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BackTable / ENT / Podcast / Transcript #128

Podcast Transcript: Free Flaps 101

with Dr. Eli Gordin

In this episode of BackTable ENT, Dr. Eli Gordin, microvascular surgeon at UT Southwestern, joins hosts Dr. Gopi Shah and Dr. Ashley Agan to discuss free flap surgery. This high-yield episode walks listeners through the basics of microvascular surgery, from indications to management of surgical complications. You can read the full transcript below and listen to this episode here on BackTable.com.

Table of Contents

(1) Planning for Free Flap Surgery

(2) Managing Patient Expectations Regarding the Hospital Course

(3) History-Taking in Free Flap Patients

(4) Using Imaging & Virtual Surgical Planning

(5) Game Day: What Underlies Success in the Operating Room

(6) Vascular Supply for the Free Flap

(7) Assessing Vascular Flow Using Doppler Ultrasound

(8) Post-Operative Management of Free Flap Patients

(9) What I Wish I’d Known: Lessons for Early Career Microvascular Surgeons

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Free Flaps 101 with Dr. Eli Gordin on the BackTable ENT Podcast)
Ep 128 Free Flaps 101 with Dr. Eli Gordin
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[Dr. Gopi Shah]
This week on the BackTable podcast.

[Dr. Eli Gordin]
You simultaneously also have to realize that you don't have to do every case that comes to your door. That's a difficult position as a young faculty free flap surgeon to be in, is you get hired, especially if there are a few head and neck surgeons, whatnot, in your division or department, they send you a case, you're like, "Okay, well, they hired me to do this. They're sending me this. They obviously think that I should be able to do this case."

There are cases that you shouldn't be doing when you're fresh out. Revision, third flap, vessel depleted, midface. There's stuff that it's okay to say like, "This is not something that I, at this point in my life, want to be doing because the risk of something bad happening and then the ability to salvage the situation, the payoff there is just not favorable." It doesn't take one year of fellowship to figure out how to do this. You've got to push yourself, but you've got to be patient with it too.

[Dr. Ashley Agan]
Hi, everybody. Welcome to the BackTable ENT podcast. We're a podcast that focuses on all things otolaryngology, and we've got a really great show for you today. Thanks for stopping by. Now, a quick word from our sponsor.

Cook Medical's Otolaryngology-Head and Neck Surgery clinical specialty strives to provide otolaryngologists with minimally invasive solutions to address unmet needs. Areas of focus include head and neck, otology, and laryngology, with products ranging from a full suite of interventional sialendoscopy and the Doppler blood flow monitoring system to the Biodesign Otologic Repair Graft and the Hercules 100 Transnasal Esophageal Balloon. For more information, visit cookmedical.com/otolaryngology.

Now, back to the show. I'm one of your hosts today, Ashley Agan. I'm a general ENT.

[Gopi Shah]
My name is Gopi Shah. I'm a pediatric ENT. How are you today, Ash?

[Dr. Ashley Agan]
Hey, I'm doing good. How are you?

[Dr. Gopi Shah]
I'm excited about our guest today. The topic I'm excited about, very curious about, I don't know enough about, but the guest I'm very happy to have on the show.

[Dr. Ashley Agan]
We're very lucky to have our friend Eli Gordin on the show today. I'll introduce him and then we can get into it. Dr. Eli Gordin is an associate professor in otolaryngology at UT Southwestern in Dallas. He completed his residency at Thomas Jefferson in Philadelphia and received advanced training in facial plastic and reconstructive surgery and microvascular surgery through a fellowship at Baylor Scott & White All Saints Medical Center under Dr. Yadranko Ducic.

He is known well to Gopi and I. Gopi and Eli were in residency together. Eli was my-

[Dr. Gopi Shah]
Shout out to Jeff.

[Dr. Ashley Agan]
-fellow when I was a third-year resident. He is here today. He's going to talk to us about free flaps. Welcome to the show, Eli.

[Dr. Eli Gordin]
Hello. Thank you.

[Dr. Ashley Agan]
I'm like you're so dressed nicely today. We're in T-shirts. I'm almost like, "Man, I should have brought my own sports coat or something."

[Dr. Eli Gordin]
I told you I was under instructions that this was a black-tie affair. I do what I'm told.

[Dr. Ashley Agan]
We all go way back. It's fun to be behind the mic today and you can help share some of your insight and wisdom in free flap surgery. It's definitely been a while since I have thought about that or been involved in that.

[Dr. Eli Gordin]
Aside from the time to time when you wander through the room randomly and I'm yelling at people, but yes, sure.

[Dr. Ashley Agan]
Yes. Except when I just need to pop over and see like, "What's going on over here?" Starting out, for listeners that don't have the privilege to know you, can you tell us about yourself and your practice? How many flaps have you done? How many are you doing per month these days? How did you get here? Life story in five minutes.

[Dr. Eli Gordin]
I was born on a wintry day in March.

As far as how I got here, it was a little bit circuitous. I was a med student; I thought I was going to do neurosurgery for the longest time and then I realized it wasn't necessarily for me. Then one of my classmates, Bryan Newbrough, who also ended up being one of our co-residents at Jefferson, were at a party one day in August fourth year of med school, or July, something that's way too late to be applying to otolaryngology as a resident, he's telling me about how one day he was in the OR and they took somebody's fibula and they reconstructed their jaw with it. I was like, "Well, that sounds crazy, so I got to check this out."

I did and I thought it was interesting, the rest is history. You already gave my training background, so I'm not going to reiterate that. At this point, I do around 80 flaps a year. That's like one to two a week. Although it's pretty variable. When it rains it pours. Sometimes there's nothing. Sometimes there's like five a week, sometimes there's zero a week. Altogether, I was just tallying the numbers the other day and it's just shy of 600 total at this point. This is I guess my ninth year or so doing this.

[Dr. Gopi Shah]
That's pretty awesome.

[Dr. Ashley Agan]
Here at UT, you're covering free flaps at our county hospital, which is a very busy practice with lots of head and neck cancer, and then at our university hospital as well. I feel like when I'm on call and I'm rounding there's always free flap patients in the hospital. They're usually your patients.

[Dr. Eli Gordin]
We keep ourselves busy, I guess. I do do some other stuff besides just free flaps, do the full spectrum of facial plastic surgery. Obviously, I'm facial plastics trained, and there's some slight differences there, but I'll do the trauma, cover trauma too, do local reconstructive surgery for most defects, do rhinoplasty, do facial nerve, do some other cosmetic stuff, so kind of a little bit of everything, but this takes up pretty much at least 50% of my time.

(1) Planning for Free Flap Surgery

[Dr. Gopi Shah]
When patients are referred to you for reconstruction, how do you decide which patients are going to get the free flap versus something local? How do you start thinking about it?

[Dr. Eli Gordin]
Do they have arms or legs? If so, then free flap. If not, then local. It really just depends on the defect size and where it is. I was talking about the Mohs reconstruction, most of that ends up being local flaps nasal reconstruction, unless it's a total nasal reconstruction. The color match for tissue that comes from the face is better than the color match and texture match of tissue that's going to come from elsewhere in the body. If it's possible to get away with something that's locally sourced tissue from the head and neck region for external defects, that's always a little bit nicer cosmetically, but then sometimes the defect is just a little bit too big or too deep, too thick.

You can do free flaps in combination with local flaps. It's not like it's either/or. Usually, there's some sort of hybrid approach for these more external facial defects. It really just depends on where it is. Anything that's for the most part inside the mouth, inside the throat, bony defects of the mandible or the upper maxillary alveolus, then those are generally going to get a free flap, whether it's a fibula or scapula for the bony requirement there, but some smaller bone reconstructions like the orbital rim or things that aren't load-bearing structures, those might get bone grafts. Those may or may not be wrapped in free fascia flaps or fasciocutaneous free flaps or just standalone.

It really just depends on the type of defect.

[Dr. Ashley Agan]
They can get really complicated. Are you seeing most of these patients pre-op? Most of the time are you able to see them before they've had their ablation? What does that visit look like? What other things are you thinking about?

[Dr. Eli Gordin]
The goal is to see them ahead of time because there's a lot of counseling that goes into it. People have no idea what to expect, so most of my visit is just telling them what it's going to be like when they're in the hospital, what we're planning on doing. This isn't something that the general public has ever even heard of. Head and neck cancer in and of itself is fairly rare and people aren't really aware of it. Certainly not the reconstruction. They always assume we're just going to do some skin graft, so a lot of it is explaining what the difference between just a skin graft and a more robust reconstruction is.

A lot of these patients have had some minor surgeries like cutaneous malignancies and little local flap adjacent tissue rearrangements or skin grafts, so sometimes they think they know what they're in for but the main purpose of the visit is just to go over all the expectations, especially when it's something that's going to involve the upper aerodigestive tract and there's going to be trach involved or feeding tubes involved, plus the donor site morbidity, wound care instructions, just when they can expect to return to some semblance of normalcy in terms of their eating and their speaking, and of course, their appearance.

They're always very concerned about how they're going to look afterwards and whether they're going to have some kind of horrible disfigurement. It's really just hashing out all those issues. That usually takes 30/45 minutes, something in that realm.

[Dr. Gopi Shah]
What's the most common question that a patient—

[Dr. Eli Gordin]
From patients to me?

[Dr. Gopi Shah]
Yes.

(2) Managing Patient Expectations Regarding the Hospital Course

[Dr. Eli Gordin]
They like to know how long they're going to be in the hospital. People are always asking what's the recovery time. That's a complicated question. It's not really like you wait a couple of weeks and then all of a sudden you are recovered. It's a long process. That's what I tell them. I tell them it takes-- the majority of the healing occurs after the first several weeks to month, but then it's really going to be an ongoing process for really a year until they're really not noticing, not thinking about the fact that they had this surgery every day. Especially when it comes to donor site issues like fibula, they have ankle swelling, they have sore ankle issues. I tell them it's going to be like a terrible ankle sprain for potentially months. That depends on how big of a segment of bone you have to take and how low you go into the ankle, but I just prepare them that they may need, especially elderly patients who are already or not as spry as some of the younger patients, they might need assistance, they might need a walker or a cane. Some of them temporarily need a wheelchair or just can't walk. It really depends on their pre-op functional status.

Again, this conversation is tailored to the patient, depending on where they're at in their current life in terms of age. Age is not really the indicator for expecting there to be problems or complications or difficulties with their recovery, it's more their overall functional status. Sometimes we operate on 86-year-olds, 90-year-olds who do better than 60-year-olds, depending on just their other medical problems and their overall conditioning. Yes, the most common question is definitely just, "How long is it going to take for me to get back to my normal life?"

The other thing that complicates that, of course, is if they're getting radiation post-op. For the oncologic patients, most of them, if their tumor is large enough that they're going to need a free flap, most of these patients are going to end up getting radiation. Right at the point where they start to feel like they're recovering from the surgery, about a month after the surgery, then they have to start radiation, and then it sets them back. People inevitably get frustrated by that.

By the time they've started recovering after they've been in the hospital for a week and after those several weeks of additional time past post-op, the last thing they want to do is subject themselves to another treatment with pain and with losing their energy and all the side effects that come along with radiation or chemoradiation. Then the conversation shifts to trying to make sure that they do go through with it and reiterating the fact that they've already undergone all this stuff and all this surgery and all this recovery, and the purpose of the next step with the adjuvant therapy is to prevent this from recurring so that we don't have to go through this all over again.

There's a lot of just trying to encourage people and trying to keep them positive, which probably surprises you guys. People that know me would be like, "Well, you're the last person I would come to for--"

[Dr. Gopi Shah]
I know. I'm like, "Who knew Eli was so compassionate?" I'm like, "There's compassion just pouring out right now."

[Dr. Eli Gordin]
Yes. I can be very understanding and empathetic and encouraging. When that's your job, then you do. Yes, it's just a lot of just trying to tell them that what they're going through, I've never gone through it before. I can't imagine what it's like to go through it, but I've seen hundreds of people go through it and we get them through. This is pretty much what I tell them in the pre-op visit. I'm like, "I've seen people go through this a hundred times. I can't tell you I know how it feels to go through it, but we've seen pretty much all the complications. When they happen, they're usually pretty minor, just bumps in the road. We will get you through it, you have to just trust us and try not to be too frustrated."

When they're in the hospital, people are obviously apprehensive about the surgery before, at this first postoperative visit when I'm telling them all the things that we're going to be doing, especially again when it's involving trachs and feeding tubes and so on and so forth. I tell them that we'll get them through it. They're worried about pain. They're worried about breathing through a trach. I just tell them that usually people aren't in excruciating pain. It's always surprising, for the most part, how little pain the patients are having post-op.

We can control the pain with medications. A lot of times they're having tumor pain pre-op, which is much more difficult to control. Many people feel better within the first few days after having the surgery because their surgical pain is more easily controlled than their neuropathic pain from tumor that's encroaching onto various sensory nerves. The frustrating thing is that people are in the ICU, they've got a million lines on them. They've got drains, they've got trach, they've got feeding tube, they can't get out of bed, they're labeled as a fall risk, they can't go to the bathroom on their own. They literally have to depend on people for every single function that they want to do.

They can't speak most of the time temporarily. Then nurses are coming in to check them every half hour to hour. They can't sleep for days. People just get incredibly frustrated. It's not the pain, it's not the surgery, it's just the frustration and going through that, losing independence temporarily and losing all control over your life temporarily. Again, everybody is here for them and to get them through it and we do it. This is what we do.

(3) History-Taking in Free Flap Patients

[Dr. Gopi Shah]
Are there certain questions in your history in that initial visit that help you determine whether the patient is a good candidate for a free flap? What are some red flags where put them at higher risk for a flap failure or where you wouldn't necessarily-- that might disqualify them in your mind for a free flap?

[Dr. Eli Gordin]
The main thing is whether they have some hypercoagulable state or a family history thereof. I ask everybody if they've had a prior blood clot in their legs or their lungs, DVT/PE, or are aware of any clotting disorders that they have or that might run in their family. That's pretty rare to see that, at least in our patient population. The other thing would be peripheral vascular disease. I ask them if they've ever been told they have poor circulation in their legs or in general at all. A lot of people start saying that they had a blood clot in their coronary artery and they had a stent, that kind of thing. That's different than having some unexplained DVT/PE situation.

Those are the main things, just vascular disease and hypercoagulable state. Other than that, unless they've had multiple surgeries, multiple flaps before, multiple neck surgeries, vessel depleted situation, still not really a contraindication. Collagen vascular disorders like scleroderma, some of these other collagen vascular disorders, there's not a lot of patients that have these disorders and then also have free flaps. The data is sparse, but it seems to be that there is some association with increased risk of thrombosis and flaps for people that have some of these collagen vascular disorder.

[Dr. Gopi Shah]
Does nutrition play a role? Are y'all checking labs for nutrition status?

[Dr. Eli Gordin]
We do, but a lot of times there's nothing you can do about that, because they oftentimes have the malnutrition from their disease, from their tumor. Then sometimes we'll try and place a pre-op feeding tube, either NG tube or G tube, and try to boost their nutrition a little bit. You also don't want to wait too long to do the surgery. It's a balancing act between trying to optimize them in terms of nutrition and trying to expeditiously get them to the OR.

Some people, their nutrition is so poor that you know that they're going to have a major wound healing problem and it could be a life-threatening issue. Then it's worthwhile to delay for maybe several weeks to try and optimize them a little bit. That's not common.

[Dr. Gopi Shah]
Do you manage your smokers in a certain way preoperatively?

[Dr. Eli Gordin]
Counsel them that the more that they can cut back or ideally quit, then the better off their chance of avoiding complications is going to be. We have resources, smoking cessation clinics. Refer them to the smoking cessation clinic. Again, we don't have much time. A more elective reconstructive case, let's say somebody's already had treatment or had a trauma or has some other reconstructive need, but there's no urgency, there's no, let's say open wound or there's no tumor, in those cases, then I will definitely strongly counsel against proceeding to surgery until they've been able to cut down drastically or quit entirely.

Again, if there's no urgency, then there's no reason to not do it under the best circumstances, because those are usually challenging cases anyway, if they have some sort of chronic problem that requires this kind of reconstruction.

[Dr. Ashley Agan]
Just bouncing back to the patients who have a history of clots or are hypercoagulable, that doesn't exclude them from having a free flap. It just changes the way you think about it. Let's say it's a patient that now they have to take-- they're on warfarin or Eliquis or they're on something because of this history, you just manage that, correct? It doesn't necessarily mean they can't have a free flap.

[Dr. Eli Gordin]
Yes. If they have a hypercoagulable state like let's say a Leiden Factor V or something like that, it's not a contraindication to doing a free tissue transfer, but it certainly puts them at higher risk for having thrombosis and a complete flap failure. Then it means that we're going to put them on some degree of anticoagulation during the case and then continuing that post-op until they can transition back to their regular anticoagulation, if they normally take it, or even if they don't take it. If there is a diagnosed hypercoagulable state, then they'll be on some heparin during the case in the first several weeks post-op.

Again, the numbers are small, so it's hard to quote them specific risks. Patients who don't have any of those risk factors or medical comorbidities, we don't give them any aspirin. We just give them routine DVT prophylaxis as you would to any patient in the hospital, so they're not getting anything. Somebody who has a defined and real hypercoagulable state, then they will get heparin. It depends on what the exact condition is, how the case is going, and the appearance of everything intraoperatively, but we'll generally start them on heparin while they're having surgery.

(4) Using Imaging & Virtual Surgical Planning

[Dr. Gopi Shah]
For your pre-op workup for the donor site, do you get MRAs of the legs or are you getting any ultrasounds or anything specific on your exam to help you know that the perfusion is good or the artery is good? Is that routine or how do you—

[Dr. Eli Gordin]
For fibula, CTA ends up being a CT angiogram abdomen pelvis, and then we're just writing in the comments that we're trying to evaluate the three vessel runoff to the lower extremity bilaterally. We get CTA for fibula patients. Forearm, we don't do any imaging. We just clinically do Allen tests, and then scapula, no imaging. Unless we're doing virtual surgical planning, then we'll get imaging just of the scapula itself, but not of any angiography. It's a non-contrast CT chest. Thigh flaps don't require any imaging. It's really just fibula.

[Dr. Ashley Agan]
You mentioned the virtual surgical planning. I feel like that's a lot more common than when I was a resident. Are you doing that a lot more than you used to and what does that entail?

[Dr. Eli Gordin]
Yes, I did not train with virtual surgical planning. It's something that I slowly adopted over time. I tried it out a little bit when I first completed my training because one of my partners was interested in using it and I didn't like it that much, but then it's improved over the years. There is a certain amount of learning curve that is required in terms of learning how to design the cutting guides and design the plates and just the way you're going to position bone segments. It's a little bit different. You get on this session with an engineer, depending on the vendor that you're using. Usually, it's Stryker or KLS Martin or Synthes are the main three that we use. You get on a call with an engineer and they're controlling the computer-assisted design software and manipulating things and you're trying to direct them what you want exactly. They do this with many other surgeons. They don't really suggest stuff, which I wish they would early on because sometimes you're just not sure how most people would do X, Y, or Z defect.

There's a little bit of a learning curve that was required as far as designing the shape of the cutting guides because they have a lot of different options and sometimes it's hard to physically fit the cutting guide into the space that you're working in. You have to know what works and what doesn't. After I got the hang of it, I realized it did just help-- It does save some time in the OR, granted you're using that time elsewhere. A simple case is about 10 minutes to plan, but sometimes they can take 30 minutes or even 40 minutes if it's something complex. You still are spending that time, but at least you're saving the patient a little bit of anesthetic time.

The main reason why I like it is just because it forces you to think about what you're going to do ahead of time. You have a definitive plan and you pin down the person that's doing the resection and you communicate more thoroughly than you otherwise would. Think of contingency plans and plan A and plan B, which of course you should normally, but it just requires it to be more precise because you have to know exactly what tooth on the mandible you're going to make your osteotomy.

Then you can see it in three dimensions. You can see how the different segments are going to fit together and what degree of asymmetry. Because you're taking straight bone segments, it's never going to be perfectly the same shape as a native mandible, which is curved. You can play with things and see what works better, especially with very long fibula segments. If you're reconstructing more than half a mandible, you want to see how much fibula is available, and you might be pushing the boundary of how much fibula you can resect. Then that might affect the resecting surgeon's margins.

Sometimes they just want to take an extra centimeter or two because it doesn't really affect the patient at all. If you can't reconstruct that as well, then that might influence that decision. That's something you wouldn't really know ahead of time unless you were really, really good at just looking at the images and being able to tell those small distances in your mind. The fact that it forces you to plan the case out in your mind ahead of time is really why I like it. Because then you're just executing on the day of surgery. You're not really thinking about how you're going to solve the problem. You're just doing the technical things. Unless the plan changes, and occasionally, it does.

[Dr. Gopi Shah]
This is on the computer or are you wearing an Oculus?

[Dr. Eli Gordin]
No, it's just on the computer.

[Dr. Gopi Shah]
Okay.

[Dr. Eli Gordin]
I have a holodeck and I go inside it.

[Dr. Gopi Shah]
Are you in the metaverse at this point? Where are we?

[Dr. Eli Gordin]
I just text my friend Zuck and he just pulls it up on Facebook and then we go to town.

[Dr. Gopi Shah]
Okay. Cool.

[Dr. Ashley Agan]
Mostly you're talking mandibles. Fibula reconstruction of mandibles is mostly when you're using the virtual planning?

[Dr. Eli Gordin]
Bony?

[Dr. Ashley Agan]
Anything bone.

[Dr. Eli Gordin]
-reconstruction cases of mandible or midface. I find it pretty helpful for the midface because of the fact that it's more complex, especially like a total maxillectomy with orbital preservation is one of the more complex bony reconstructions that we do, just because we're trying to maintain the position of the eye. If you drop the eye by a couple of millimeters, they might start getting diplopia. It's more cosmetically sensitive. It's just like a more complex shape. Then you also have dentition that you have to worry about as far as dental rehabilitation, and then the nasal airway too. Those are more challenging. A few millimeters makes more of a difference than it does on a mandible.

The other thing that I didn't mention before is when we do the virtual surgical planning, we can create a model of the defect. Then we can plate our construct in the model and we can put all our little plates on, especially for the midface.

[Dr. Ashley Agan]
Physically or virtually?

[Dr. Eli Gordin]
Physically. In surgery, we have a plastic model of the bony facial skeleton with the resection done already. It's missing the resection. You have basically a plastic model of your defect. If it's a three, four-segment midface bony reconstruction, we can then plate all the bone fragments together and cut them and shape them and plate them to the plastic model using the plastic model as the fake inset. Then you have all your bony fragments plated together and you can just take that whole thing as an already prefabricated construct. Then you can bring that up to the face and just pop it in.

That allows us to do more of a minimally invasive approach for total maxillectomy where we can just do a midfacial degloving and transoral incisions and transnasal incisions and avoid making incisions on the face. Whereas if you don't do that, it's just very hard to get the screwdrivers in the angles that you need. You can't just control the segments and get them into position. This makes it a little easier to work through a smaller cavity when we're doing the plating.

(5) Game Day: What Underlies Success in the Operating Room

[Dr. Gopi Shah]
Yes, that makes sense. Intra-op, tell me the sequence of, and may vary, maybe case to case or what your day is like, but in terms of the harvest, and then when you come back to put the flap in. Tell me about that. How do you harvest or prepare the donor site and are you able to do it at the same time that ablation is happening or do you wait until they're done, or?

[Dr. Eli Gordin]
Depends on the case. If it's thigh flap cases, generally you can do the vast majority of the harvest without committing to the size of the actual skin paddle. That's more difficult to do with forearm and fibula cases. Usually, we want to make the reconstruction no larger than it has to be because they end up having a skin graft in those donor site locations when it comes to forearm and fibula. Usually, for those two locations, I'll wait until the resection is done, but then they still usually have a neck or two to do and we can get the harvest done while we're waiting for frozens and waiting for them to complete the neck dissections.

For thigh reconstructions, I'll just start pretty much immediately unless I have something else going on in a different room. For scapula, it's challenging to simultaneously work, any of the subscapular system like lat or serratus or scapula, because the arm has to be up and extended. You can do it, but everybody is uncomfortable. I usually just wait until they're completely done to start doing any of those subscapular system flaps.

[Dr. Gopi Shah]
For the thigh, I recall dopplering out where you think the artery is going to be. Do you still do that at the thigh and what other, for the different donor sites, are you still dopplering out or other ways that you prepare when you're thinking for the harvest?

[Dr. Eli Gordin]
Yes, we Doppler the thigh just to get a sense of the perforators. It doesn't really matter that much unless you're trying to make an extra thin thigh and just raise it in a subcutaneous plane instead of subfascial or immediately superfascial plane, because sometimes where the perforator goes through the fascia lata doesn't exactly correspond to where it comes through the skin or a very small flap, I guess.

We do Doppler for thighs to get a sense of where those perforators are going to be. It's not the main pedicle vessel that we're looking for. It's the little branches that come up through the muscle and through the intermuscular septi and terminate in the skin. That's what we're looking for. We do that for fibula also. For forearm, there's no dopplering. For scapula, tip and lat, we don't generally Doppler.

[Dr. Ashley Agan]
Special considerations when you're raising the flap, are there certain things that are particular that need to be happening in regards to, I don't know, anesthesia or the setup or anything like that?

[Dr. Eli Gordin]
Not specific to when we're physically raising the flap. We use tourniquet for fibula flaps and for forearm flaps. You don't have to, but it makes it easier. There's a little bit of a time constraint when you're using the tourniquet. Otherwise, there's nothing, no really different management from an anesthesia perspective, just because we're raising the flap. Aside from the fact that we're going to be stimulating the patient more because they're working on the head and they've already made incisions. When we go down and start to make incisions on the leg or the arm, then it stimulates the patient more. Anesthesia has to be ready for that additional anesthetic requirements. Other than that, there's not really anything.

[Dr. Ashley Agan]
There's not like a certain MAP? Blood pressure or fluid, do you limit them on fluid or?

[Dr. Eli Gordin]
For the entire case, we try to stay below 5 liters of crystalloid for the entire case. Not specific to the harvest but part of our time out when we're discussing antibiotics. Usually, we're doing just Ancef for cutaneous cases and we're doing Unasyn for mucosal cases. Then if it's some sort of chronic wound situation, we might be doing something different based on cultures. As far as pressors, some people are pretty adamant that they don't want to use pressors on any free flap cases.

From my perspective, I think there's sufficient evidence. There's not that much evidence for most things in microvascular reconstruction, but for pressors, it seems like there are a decent number of studies at this point, including meta-analyses that show that using pressors at normal, reasonable doses do not adversely affect the flap outcomes. I just tell anesthesia, "Look, we need to use pressors." If the patient is euvolemic and they're still not maintaining adequate blood pressure, then I'd rather that they give them some pressors as opposed to start flooding them with fluids.

For blood transfusions, we usually use around eight as a cutoff. There is a little bit of a upper limit to what you want the hemoglobin to be, just theoretically speaking in terms of blood viscosity. If you're going to be transfusing, it's not like we would intentionally blood-let a patient to get them below nine. Unless there's some sort of medical reason to transfuse them, we certainly wouldn't do it for anything that's above nine just because of viscosity issue and therefore flow.

Of course, there's no reason to give people transfusions unless there's a real indication for it, because there's a small risk of reaction to transfusion. There's a risk of immunosuppression with transfusion. We usually use 7.5 as a cutoff for transfusion, unless there's some other medical issue that requires that they have a higher hemoglobin, cardiac-wise or otherwise. 5 liters for crystalloid. We let them use albumin. If they need a little bit more of a volume resuscitation, then the colloid is fine.

[Dr. Ashley Agan]
What's the rationale for limiting the volume, it's just like you're going to get too much edema in the flap or?

[Dr. Eli Gordin]
Yes. It's associated with adverse outcomes in terms of the wound healing and also the flap survival rate.

[Dr. Ashley Agan]
Because that volume moves out of the vascular circulation?

[Dr. Eli Gordin]
The flap is completely cut off from all lymphatic drainage. The flaps always have edema disproportionate to the rest of the surgical site because they have no lymphatic drainage. I think theoretically, it's just that the flap is going to swell to a greater degree than the rest of the body. Therefore, it could have microcirculatory injury because of the pressure that's being exerted on it or just macroscopic pressure against the pedicle. Therefore, it could restrict flow through the pedicle and then thrombose in that way. There is an association between excessive fluid resuscitation and adverse outcomes.

[Dr. Gopi Shah]
You've harvested the flap and they've done the ablation. When you say harvest, and this might be a dumb question, let's say, for example, fibula, you've exposed your vessels in terms of which artery and vein you're going to take from the donor site, you expose the bone. When do you make the actual cuts for—

[Dr. Eli Gordin]
For the bone cuts?

[Dr. Gopi Shah]
The bone cuts as well as the vascular cuts at the donor site. Do you wait until the ablation's done and then you look at it and then you go back and then finish those cuts to then take everything or do you have everything out and on the back table and then you go in once the ablation's done?

[Dr. Eli Gordin]
Again, for fibula, usually, I will wait until the primary specimen is resected. Then if the ablating surgeon feels good about the margins, then we'll proceed. Though it's nice to have the actual frozen margins back before you go ahead and make the skin paddle design. They can't get frozens on the bone, obviously, so the bone is wherever they've decided to make those cuts, which hopefully are corresponding to where we planned with the VSP.

When we're harvesting the fibula, first we come along the anterior side of the bone and come through the anterior musculature, just isolating the bone. Then we make cuts at the inferior-most aspect. We leave about 7, 8 centimeters of bone by the ankle and 6, 7 centimeters of bone by the knee just to maintain stability in those locations. We'll just remove the rest of the fibula. We'll cut inferiorly and superiorly then, and that helps us retract the bone and then access the peroneal vessels, which are the pedicle for the fibula. We make those bone cuts just as we're harvesting.

Then as we isolate the flap and trace the pedicle approximately, it's just hanging on by its artery and two veins at that point. Then depending on the type of reconstruction, we might start making the actual osteotomies for the reconstructive segments at that point while it's still perfusing, or we might just wait until they're completely done, the ablation, and then do it on the back table. In some instances like when we do dental implants at the time of surgery, then that just takes too long to do that on ischemia time. We put the cutting guide on the fibula while it's still attached by its pedicle and it's still perfusing. We make the fibula osteotomies. We plate it on the model like I was talking about earlier.

[Dr. Ashley Agan]
All before cutting the fibula?

[Dr. Eli Gordin]
Yes.

[Dr. Ashley Agan]
Okay.

[Dr. Eli Gordin]
Yes. Then the oral surgeons will put in the dental implants or at least the-

[Dr. Ashley Agan]
Posts.

[Dr. Eli Gordin]
-yes, the posts and some form of abutment. That can take like an hour or so. There's no reason to do that on ischemia time. We want to keep the total ischemia time to less than three hours is my general guideline. Usually, it's significantly less than that for fibula, maybe like two hours. Typically I'll inset the soft tissue or the majority of the soft tissue before reperfusing it just so it's not bleeding and you can see a little bit better in the posterior oral cavity. I have no qualms about two hours of ischemia time. I really try and keep it below three. We would struggle with that for these complex cases with dental implants if we were going ischemic and then doing all those cuts on the back table.

The advantage of doing it on the back table is that you have a little bit more freedom of movement and you're not potentially pulling on the pedicle. It's just easier to manipulate things. Other than that, it's definitely doable to do all the osteotomies and plating while it's still attached to the leg and perfusing. Again, if I'm waiting for the ablative team to finish, then I might do that, even though it takes a little bit longer for me to do that and it's a little bit more difficult to do it while it's attached to the leg. At least then I save the 20 minutes later on in the case for the anesthetic time if I get that done before we go ischemic.

[Dr. Ashley Agan]
You're doing your entire inset most of the time prior to your anastomosis. You get that all set how you like it and then you do your anastomosis most of the time.

[Dr. Eli Gordin]
Yes. Anything that looks like it would be challenging to access, specifically in terms of oral cavity stuff, we'll do. Anything that's posterior. The anterior area we might leave just so we can see a little bit of the flap edge and we can assess it for bleeding and we can access anything that's bleeding underneath the flap to get hemostasis afterwards. A little bit of access is good, but I'll try and get as much of it done as possible in any challenging, hard-to-reach areas. Then if it's something that's just on the scalp or a cutaneous defect, then no. Then we'll just do the anastomosis and re-perfuse the flap before we really do any inset. We'll just put a few tacking sutures.

The other issue is you want to know where the flap is going to inset before you do your anastomosis because you don't want to have to change something or commit to something that you're not going to be happy with in terms of the position of the flap after you've already done the anastomosis. That would be counterproductive. You want to know exactly where it's going to sit and then you don't want it to fall off the face while you're under the microscope. That would be suboptimal as well.

(6) Vascular Supply for the Free Flap

[Dr. Gopi Shah]
For the veins, do you use a coupler, or do you hand with suture, or does it—

[Dr. Eli Gordin]
Coupler.

[Dr. Gopi Shah]
A coupler?

[Dr. Eli Gordin]
Yes, I use the coupler 99% of the time. The only instance where we might hand sew is sometimes for an end-to-side to the internal jugular vein, although usually you can use the coupler for that too unless it's a previous radiation and there's zero elasticity or a very small internal jugular vein. Otherwise, you can use the coupler end-to-side or some other end-to-side situations to smaller veins or a really large vessel mismatch, something like that. These situations are pretty rare. It's been years since I've sewn a vein, I think.

[Dr. Ashley Agan]
Do you have a strong preference for having more than one vein? Do you usually have multiple?

[Dr. Eli Gordin]
Yes, I do all the veins that are there. I acknowledge the fact that you probably only need one vein and it maybe does not add anything. That being said, I did have a situation years ago where there was a flap that ended up getting congested, like late postoperative course, post-op day 9 or 10 or something like that. We took her to the OR. The veins were thrombosed. We ended up taking down one of them and we flushed TPA through it. We managed to get it going.

I can't remember, but I remember being happy about the fact that I had two veins and the one I ended up just sacrificing at that point. That was one situation that ever happened that actually felt beneficial to have two veins. I'm not saying that it's really something that you need to do. Plenty of people just routinely do one vein, but my feeling is that it takes five minutes to put a coupler on, so I just couple all the veins.

There are times when there've been three veins in a fibula and I've just coupled all three because it's just easy to do and I just sleep a little better at night. Then there's also a contrary school of thought that's like, "Well, if you only do one, then the flow is higher through the veins, therefore you're less likely to get thrombosis because you have a higher rate of flow through the vein. I don't know. It probably doesn't matter, but I just do two.

[Dr. Gopi Shah]
If you have a valve, do you just trim proximal to that or do you ever run into valves?

[Dr. Eli Gordin]
Yes, we run into valves a lot. I know they say that there are no valves in the neck, but there are valves in the neck, but there are definitely valves in the extremity circulation. The valves should all be oriented in the way that is allowing the blood to drain from proximal to distal or reverse for veins actually. If it's right in the area of the anastomosis, then either we'll cut it back a little bit, but that might then change the caliber of the vein.

It really depends on whether or not you can tolerate cutting it back in terms of length or caliber. Otherwise, you could just pin it to the coupler so that it's pinned open, but there are times when I just leave it because the directionality is appropriate anyway. They don't bother me too much.

[Dr. Gopi Shah]
I was going to ask about the artery. Do you have a preference for what type of suture you use for the artery? Is there a certain number of sutures that you put in or do you space them out in a certain way? How do you think about that?

[Dr. Eli Gordin]
The suture we use is 9-0 nylon. It's on a needle that's called a BV130-4, which is just the needle that I like to use, but there's plenty of other needles. That's a taper needle that's semicircular, but then it has a little bit of a straight back to it. It's just a little thicker and shorter, which is just a little easier to control, I think, but that's just personal preference.

Then sometimes if you have a significant atherosclerosis, then you need what's called a taper cut needle, which is a V130 or 100, I forget the exact number, but it's got a little bit of a cutting edge to it. It can break through a plaque a little bit more easily. It's pretty rare that we need to use that maybe once a year or twice a year or something like that. Then for spacing them out, there's nothing hard and fast. It's really just how it looks. I've never really measured how much my just internal—

[Dr. Gopi Shah]
Do you have a caliper?

[Dr. Eli Gordin]
Yes. it's not a bad question though. Sometimes it leaks when, not when I do it, obviously only if the fellow's doing it, but sometimes it leaks afterwards. We just put in a rescue stitch if we need to, if it's really shooting out, otherwise, it just stops on its own generally. Then the way I do it is, I use the little double approximator, Heifetz clamp or Eklund clamp, however, you describe the mini-vascular, microvascular bulldog apparatus that we use to hold the two vessels together. Not everybody likes using the double approximator, but we did that in residency. We did that in fellowship.

Some of them have this little cage on them that you can wrap sutures around, which people like. I don't like that just because it gets in the way when you're trying to suture and tie, and I just don't find the extra tension and retraction helpful. Then I'll put stitches on either side, like 180 degrees circumferentially around. Two stitches, just one on either side of the vessel, and then we'll sew the front side, and we'll flip it over and sew the backside.

[Dr. Gopi Shah]
Do you use papaverine or flushes routinely, or is that only if you see a plaque?

[Dr. Eli Gordin]
We always use heparinized saline irrigation. I think our concentration is 20 units per cc. I may not be remembering that accurately, but so we use just heparin in saline. That's just to wash out the vessels as you're doing the anastomosis. I don't flush it all the way through and look for a return. Some people like to do that, but it's 50-50, I think. That's also to prevent desiccation. We put a few wet laps around the field.

We make a little triangle just because the light from the microscope can desiccate the tissue and it's sitting there. When your veins start getting dried out, they become all leathery, and it's disconcerting. We want to keep everything moist as we're doing it and to flush out any clot, tiny little bits of clot or little bits of blood. Then as far as papaverine, we'll use that if it's smaller vessels, if they look like they're spasming a little bit. We don't use it 100% of the time. If they're very robust vessels that are large caliber, then sometimes I don't papaverine them.

[Dr. Gopi Shah]
Can you remind me what papaverine is?

[Dr. Eli Gordin]
It's a smooth muscle relaxant. I think it's a phosphodiesterase inhibitor or something like that. My biochemistry is lacking at this point in my life.

[Dr. Gopi Shah]
Do you ever use that for veins? Do you have to flush with heparin, saline, or papaverine in your veins before you coupler them?

[Dr. Eli Gordin]
We flush both sides with the saline. We wash the blood out of the portion of the vessel.

[Dr. Gopi Shah]
It sits there?

[Dr. Eli Gordin]
Yes, that's immediately adjacent.


[Dr. Gopi Shah]
Oh, okay.

[Dr. Eli Gordin]
We wash that out. Again, some people like to flush the artery until saline come out the vein. That's not something that I do. I just wash the segment that's near the anastomosis until it runs clear, flush the artery until the fluid that's back flowing out of the artery is clear, which takes about three seconds usually. Then the same thing for the vein.

[Dr. Gopi Shah]
For the hypercoagulable patient, you had mentioned using intraop heparin. When is that turned on? Is that turned on at the start of the case, or is it just when you're ready to start taking vessels? Because there's probably a time at which it gets therapeutic?

[Dr. Eli Gordin]
Yes. I would turn that on. We would probably give them a dose. We don't necessarily routinely give them pre-op DVT prophylaxis, but in those cases I would give them pre-op DVT, just the prophylactic 500 SubQ heparin dose. Then if it's a flap that we're going to use a tourniquet on, then I would probably start the systemic heparin infusion about half an hour before we want to go on tourniquet. Otherwise, about half an hour before we go ischemic so it has some time to kick in because the blood's going to be sitting in that flap.

Once you go ischemic, even if you flush it through, my concern is that there would just be some amount of blood that could clot within the flap from stasis at that point. You want the heparinization to be on board before you go on ischemia time. Usually, we'll do a bolus. It depends the patient's weight and what our goal is, but we'll do a bolus, and then start an IV infusion, and then just keep that infusion running till probably about a week until we can start to transition to something that's a once a day dosing, but it's more difficult to reverse. The rationale being if there's a hematoma, we want something that we can reverse pretty easily like heparin by just stopping it.

(7) Assessing Vascular Flow Using Doppler Ultrasound

[Dr. Ashley Agan]
Then with your arterial anastomosis, are you doing implantable Dopplers?

[Dr. Eli Gordin]
No, I was using them for a while. In residency, we did not use them. In fellowship, we did use them. Then they're nice because you know that you're listening to the right vessel. Sometimes when you put a Doppler, a stitch on the neck, on a flap, especially a buried flap, then that you can't monitor, and you can't see, then you don't necessarily know if you or the nurse or the resident are Dopplering the real pedicle versus just some other artery in the neck. It's not really been shown to actually give people a better outcome in terms of flap salvage rates. There's some data that it does a little bit. Again, you can use the implantable Doppler for the artery or the vein. Then again, there's conflicting data depending on the study that you look at, whether it's more common to have an arterial or a venous thrombosis as the cause of a perfusion issue post-op.

Some people prefer to use the venous. There's a coupler that has an implantable Doppler attached to it. Some people prefer that. Some people prefer the arteries. Some people like to use both. On the Doppler box, there's two channels, so you can plug two Dopplers into it. I've stopped using it over the last couple years just because I just felt like it wasn't really adding anything. It makes you feel nice that you hear it, but we just had situations where it was either malfunctioning, or it was not interpreted properly. Ultimately, if you have a tool, then it's only as useful as the people who are interpreting it.

We had one case where it was a post-op day seven after a laryngectomy and a thigh flap just for a patch on the pharynx. Then in the morning the nurses told us that they had turned off the Doppler overnight because it was just giving static signal, but that was the thrombosis that occurred because of a occult fistula that we had not yet clinically ascertained, so then the flap ended up dying. We took it back, but it was too late at that point. If that's happening with an implantable Doppler, then I don't know what's the point, and that was. It's pretty rare too.

[Dr. Ashley Agan]
I remember being nervous about when you pull it and cut it off.

[Dr. Eli Gordin]
Yes, pulling it out.

[Dr. Ashley Agan]
That always made me super nervous as a resident.

[Dr. Eli Gordin]
I have heard of instances where there's been an injury by pulling out the Doppler. Usually, I would pull them out myself, just not that-- There's nothing really to it. You just pull on it, but that way I can't blame somebody else if something bad happens after it gets pulled out. Then it was one more thing to worry about. Then the wire and then physical therapy is working with the patient and the wires are getting pulled on, and then we're worried that maybe there's going to be a hematoma in 15 minutes. It just was causing a little bit more stress in many situations than it was alleviating. I gravitated away from it unless, again, maybe a buried flap or something where it's hard to monitor otherwise.

[Dr. Ashley Agan]
Do you do the little skin paddle indicator part for your buried flaps? I've seen sometimes there's a little just square of flap tissue that's made external so that you can monitor the flap? I may not be describing that well.

[Dr. Eli Gordin]
Yes, if it's feasible to do it without creating a lot of extra work, then yes. Laryngectomy cases, usually you can just put a little small fusiform-shaped paddle, just superior to the stoma. That's a nice thing to just be able to see it. Sometimes, the other issue with doing a little monitoring paddle is there are times when your monitoring paddle will locally have perfusion issues, but it doesn't necessarily mean that the flap is globally ischemic. You can have false reads. I think if the reverse could be true too, although I think usually if the monitoring paddle looks good, the odds of the main flap being ischemic or whatnot having a problem is extremely low.

I usually do try to create a little monitoring paddle if it's feasible. Then if it looks sad as we're closing, but the main flap looks good, I might get rid of it because I don't want to have a false positive scarce in terms of flap perfusion.

(8) Post-Operative Management of Free Flap Patients

[Dr. Gopi Shah]
Tell us about post-op. Do you, one, have a protocol or anything like that? Two, are we doing Q1 flap checks the first 24 hours still? Then Q2, is that still happening? Then what are some signs? Do you have an algorithm if somebody is concerned for whether it's venous congestion versus an arterial problem?

[Dr. Eli Gordin]
Yes, we've got a protocol. We just revised it actually. It's now 24 pages or 25 pages long.

[Dr. Gopi Shah]
We don't have to go through all 25 pages.

[Dr. Eli Gordin]
Good, because it takes an hour and a half. I did that yesterday.

[Dr. Eli Gordin]
We're trying to create a document that's both tells people what happens on each day, post-operative day, and things to look out for when preparing for a case and pre-op preparations and things like that. Then also filling in the rationale behind different things and all kinds of stuff like who might be appropriate to decannulate and how you decide if somebody is maybe ready to start PO intake or capping their trach or whatever. There's just a lot of background information in there too. It's not all just day-to-day do this at this point in time.

As far as flap checks, we do Q1 hours for almost 72 hours. We have them go to the ICU. We don't have an intermediate or a step-down unit, unfortunately. Q1 hour checks can't be done on the floor. They can do Q4 hour, I believe is the most frequent checks that they can do.

[Dr. Ashley Agan]
“They” being like, nursing, right? It's nursing doing the checks?

[Dr. Eli Gordin]
Correct. It's a nursing order. Yes, nurses can't because of the number of patients they have. They're restricted by the frequency of different orders that can be carried out on patients on the floor relative to the ICU. ICU can do Q1 hour nursing flap checks. That's what we do.

[Dr. Ashley Agan]
What does that entail, Eli? Is that just them Dopplering the stitch, or what are you asking?

[Dr. Gopi Shah]
They document the color, the warmth?

[Dr. Eli Gordin]
Everything. As long as it's visible, then flap check entails looking at the flap. Does the color look normal? It should just look like normal, healthy skin. Unfortunately, a lot of times the flap is more pale than the surrounding tissue, especially when it's coming from the leg and it's going to the face or the thigh. It's pretty pale relative to the face. It's always going to look pale relative to the surrounding tissue, but it's really more of a change than anything else. Whether it looks pale, extra pale, whether it starts looking purple, which might be a sign of congestion—

Edema, like I mentioned, is pretty normal and flaps, especially perforator-based flaps, they tend to get pretty edematous slowly over the course of the first three days. That's the peak I think is around day three. Then it starts slowly tapering off again, but a sudden change in flap edema or swelling that might signify hematoma under the flap or hematoma in the neck or wherever else.

The temperature is not the easiest thing to assess. A lot of time the flap does feel more cool relative to the surrounding skin, but you palpate it. You feel the temperature, you feel the general turgor or just how tight it feels. It again should feel pretty normal, but it does get swollen. Then the Doppler check. Usually, we have some degree of donor site extremity checks too. Just doing the same thing with the hand. If it's a forearm, just look at the hand, and especially thumb and forefinger, which are the distal most in the circulation.

If you're getting your circulation from your ulnar artery now and you have no radial artery, making sure that the cap refill and sensation and motor are all intact on the donor site, and there's no evidence of compartment syndrome developing. Then if there's any concern, then they call our resident team, and then the residents would assess. If they agree that there's something questionable on the flap check, then the next step is to scratch it or stick it with a needle, depending on your preference.

Usually I take a scalpel and just make a tiny little, paper cut depth thing, just through the epidermis and barely into the dermis. Not anything that needs to be sutured up, but just a little-- Literally, it looks like a paper cut. I just find that easier to ascertain whether or not there's blood return than if you stick it with a little needle, then you look at the blood, and if it's not bleeding, then obviously that's concerning for ischemia. If it's bleeding real dark red blood that comes out extremely quickly, then that's concerning for venous congestion because you have backflow of blood into the flap. Then there's everything in between, which is usually where it is. Then you're trying to figure out what you should do at that point.

[Dr. Ashley Agan]
Normal would be a little bit of bright red blood, if everything is that reassuring?

[Dr. Eli Gordin]
Yes. Sometimes it's pretty brisk. It can be hard sometimes. Going back to the paper cut analogy, if you cut your finger like that, oftentimes it'll bleed pretty briskly for a little bit until you hold pressure and it stops. Sometimes a normal flap will bleed quite briskly, but as long as it's bright red blood, then I'm not too concerned about that. Then it might be something to just monitor and go back for the resident to check themselves every hour or a little bit more frequently just to make sure it's not something that's progressing.

Because a lot of times the goal is to catch things as early as possible, but that also means that in these situations where you're not sure, then you're trying to rule out whether or not it's a progressive perfusion problem. If you're catching it early, venous outflow obstruction, meaning the flap is now bleeding more than it ought to be, then over time that's going to worsen and the flap's going to start getting purple, and it's going to start getting blue. Arterial thrombosis that follows that is extremely difficult to salvage at that point because that means the entire flap has become static and clotted off.

If they come back and they can just scratch with a needle the cut that we already made there, and illicit bleeding from the cut that we already put there, that way you don't have to be stabbing the flap over and over again with needles because that ends up causing bruising if the flap's not dead. Then that becomes more difficult to interpret because now you have a bruised flap that may have a perfusion problem. Yes, you're just looking for the speed of bleeding, but again, as long as it looks bright red, even if it's pretty slow, as long as it's present—

When it's starting to get ischemic you see this weird serous component to the blood, you might see a tiny little drop of blood, and then there's this serous fluid that also starts coming out and that's usually a bad sign.

[Dr. Ashley Agan]
Is imaging ever helpful if you're not sure? Does CT, or ultrasound, or I don't know, are there any objective studies that help you decide?

[Dr. Eli Gordin]
The problem is if there's really a problem you need to act on it more quickly. You can't really wait around for trying to get a CT. Theoretically, I would think a CT angio you could look at it at the pedicle, you could do it like a duplex ultrasound and look at the pedicle. i think there are times when we've tried that when we were like, "I really don't think this is a true problem, but I just want to be able to sleep better tonight."

The classic teaching is if you're in doubt, just go back to the OR and just open it up and check because worst case scenario, you had an unnecessary take back and you spent a couple hours mobilizing the OR, and then half an hour to actually look in the neck and assess the pedicle. The patient's had a little extra anesthesia but a lot of times they have a trach anyway, so it's pretty easy to induce anesthesia in them. If they don't, and it's a difficult airway, then that factors into your decision making too because it's all just risk-benefit analysis, but really if you have a doubt about the circulation of the flap then going back to the OR is the gold standard thing to do at that point.

[Dr. Gopi Shah]
In terms of let's say you caught it early, we're going to do more frequent checks, and we're going to try the scratch thing, what do you use temporizing measures? Are we still doing things like nitrous or leeches? How do whether to do those things versus we need to go back?

[Dr. Eli Gordin]
It can be difficult to figure that out sometimes. Again, going back is usually the first line. Sometimes you go back and it looks fine, and the macro circulation looks fine, the artery looks fine, the vein looks fine, but the flap looks weird, so then that's some local or microvascular issue. For that, there's not really an operative intervention that you can do. Usually, in this situation it's some partial flap issue. You might have a very large flap and a portion of it is unhappy for one reason or another. Then you might consider using nitro paste in that situation.

Theoretically, you could use hyperbaric oxygen, which may help for small amounts of ischemic tissue although that's pretty difficult to do on inpatients who are ICU, post-op day one. Head and neck resection free flap, that's probably not practical. Then we do sometimes use leeches for cases where there's a local area that looks congested or flap looks congested. We've taken it back, we've done everything we can, and it seems like it's holding on, but it's still congested for some reason.

Sometimes these little perforator based flaps, you might have somehow an injury to the tiny little vein as it enters the skin, so you can have transient perfusion issues in perforator flaps that might be temporized with leeching, but if it's a real venous clot, then leeching it is not really the way to go. You need to try and take it to the OR and fix the issue. These are really just in situations where it's a local flap, part of a flap perfusion problem, or you've already tried everything that you possibly can in terms of salvage operatively and it's not worked.

[Dr. Ashley Agan]
When you're going to the OR to troubleshoot, what does that look like? Are you taking down your anastomosis? Can you get an idea of how it's doing just by looking at it or I’m Dopplering it? What does it look when you're doing that OR take back?

[Dr. Eli Gordin]
You can get a sense of how it looks like. If you open the neck and it looks normal, after you've been doing it for a little while, you can get a sense for what a normal artery looks like. If there's a clot, usually, there's a bit of a discoloration, a purpleness. Arteries are usually white light pink shade. It gets a discoloration usually when there's a clot in there but depending on the wall thickness of the artery, you may or may not see that.

Certainly, you would see when you have a pedicle, and it's flowing properly, especially in cases where it's geometrically curving or looping on itself, you don't want to have it kinked, but sometimes we create a gentle curvature in the pedicle, so that it's going to where it needs to go, but not kinking, but then the whole thing expanding as it pulsates. It's not just rocking back and forth, which is more indicative of there being some obstruction and you're just getting a transmitted pulsation appearing thing from the fact that it's attached to a vessel that at some point does have some flow in it until that flow hits the obstruction.

You can just look and see whether or not it's expanding. You can Doppler it. If the neck is open, then you're able to lift the pedicle up and Doppler it with air underneath it such that you're not potentially picking up the signal of a deeper artery, which you can if you're just Dopplering it while it's flat against the neck. For the vein, likewise, you can probably more easily tell when there's a clot inside a vein because it's a thinner-walled structure, and then you can palpate a vein a little bit more easily. You take your little micro jeweler forceps and you can palpate artery, palpate vein. You can feel when there's a clot in there, especially for the vein it's pretty obvious most of the time.

You can do what's called a strip test, where you take two jewelers and you just gently you hold. For the vein you would be holding towards the flap upstream of where the venous drainage is coming from and then you milk with the other pickup. You draw your hand down towards the anastomosis and then you let go of the first one. You try and see whether or not there's venous blood passing through that area.

Then if you're not sure, then you have to take it down or cut a side branch. Sometimes there's little side branches that you clipped when you're doing the harvest, and then sometimes you can cut one on the artery and see whether or not there's brisk blood pulsatile arterial blood shooting out of the side branch or likewise with the vein and look for appropriate venous bleeding, but again, if you can't tell or you're not sure then the next step is you just have to take it down.

Unless it's a very late failure from venous thrombosis in which case the entire thing is clotted off, usually it's one or the other. In my experience, it's most commonly been the artery. Unless it's a late complication because of fistula or infection that affects everything, then you don't necessarily have to take down the vein. You might just take down the artery and the clot is going to be right at the anastomosis.

Unless there was some injury to the vessel downstream of the anastomosis, it's pretty much right there, so you just cut right next to your suture line or through your suture line you can just see the clot, pull it out, and then try and figure out why the clot happens because that's really the next step. Are we going to be able to salvage this? How long has it been? How long do we think it's been since we really detected the ischemia and what we need to change? Why did this happen? Is it a patient intrinsic factor? Do they have some hypercoagulable state that we missed or was it a technical error, which is oftentimes, especially early in your career is usually what it is.

You just redo it and then it's fine, but those usually occur 20 minutes, half an hour after you finish the original anastomosis. Just going back to the implantable Doppler, the one nice thing about the implantable Doppler, was you put that on right after you finish your anastomosis. Then it's there and you're listening to it as you're closing. Then it gets slowly quieter over time, and then you're like, "Oh," and you wait and you wait and it goes away. Then you have to reopen the neck, but you're already right there, and you're still in the OR, and the drapes are still up, so you find it immediately.

I think sometimes there's probably some degree of not noticing it until the patient's in the ICU. Then maybe the last thing you want to do is come back, especially if it was a hard case and it's late at night. Finding these things intraoperatively and Dopplering, like to Doppler, find the area that we're going to put a Doppler stitch on the neck or wherever it's going to be before we close the neck so that we are as sure as possible that we're Dopplering the appropriate thing, and then Doppler before we take the drapes down. Doppler before we leave the OR room. If there's going to be a problem you should find it within the first hour.

After doing the anastomosis, if there's a technical problem, or sometimes there's a plaque that's a little bit downstream of your anastomosis that just slowed things down enough to create a clot, so then just going back to what you're doing to try and salvage the situation. You're cutting back the vessels till the area looks clean and there's no more clots stuck in there.

If it's a localized clot, then you're not having to do TPA or flush the flap through with any thrombolytic agent if it's just at the anastomosis, then you assume first and foremost that there's either a technical problem with your suturing or perhaps your neck artery didn't have good enough flow, so you might check that again. Does it look like the facial artery or the superior thyroid or whatever you're using does that look like it's still two men as they say, or does it look like it's trickling out?

Then what's the blood pressure? Is the blood pressure 80 and it's trickling out or is the blood pressure 150 and it's still trickling out because that's a different situation too. Then maybe you want to pivot to a different neck vessel, whatever it may be, whether lingual or just something else, or just cut the vessel back more until you get good flow. Because step one is find a source of blood that's appropriate for your flap. Then once you have that, then it's looking into the lumen of the flap artery and trying to ascertain whether there's any indication that there could be atherosclerosis in there. Could there be a plaque more downstream?

You can tell usually just externally looking at the vessel if it looks irregular, if there's a marble appearance where you see yellow plaques and stuff like that through the wall and you can palpate it gently. You don't want to crack these things, so you have to be pretty careful. You don't want to squeeze a very atherosclerotic vessel and cause la crack in the plaque that then is going to become a thrombogenic stimulus.

Then just cutting back the flap artery. If that's not working to the extent that you can, just if you hook the vessel back up again and it thrombosis again, then you keep cutting the artery back until you can't anymore, and then at some point if too much time has passed, then you've reached what's called the no-reflow phenomenon where enough microcirculatory damage has occurred to the flap because of ischemia that it's just never going to come back again and all the microcirculation is thrombosed and it's over.

[Dr. Ashley Agan]
How much time do you have until then?

[Dr. Eli Gordin]
Theoretically, for a skin flap, six hours is,what's quoted as the upper limit of normal and it decreases with muscle and decreases a lot with a visceral, a jejunum type of flap. The problem is you never know when the ischemia occurred unless it's intra-op. You don't know if it's post-op day two, and you got called in the morning that the flap didn't look right. You have no idea if it's been eight hours or what.

[Dr. Gopi Shah]
Then for a flap that is salvageable, you take it back, you're able to cut back and re-anastomose, do you ever then put these patients on aspirin or Heparin afterwards or is there any rule for that post-op?

[Dr. Eli Gordin]
As far as evidence-based rule, I don't think so. The only evidence-based anticoagulation scenario is patients with hypercoagulable states, but I do usually put them on, if I thought it was an isolated anatomic or technical thing that we fixed, and I feel good about it, then no. If it's something that I just am not sure why this happened, but we managed to get things flowing again, then yes, usually we'll put them on heparin infusion at that point just because I have no idea why this happened in the first place and we want to obviously prevent it from happening again, but then it's trade-off between hematoma risk versus risk of re-thrombosis.

One thing I failed to mention is doing the thrombolysis and using TPA or something else like that. If you think that the clot has propagated pretty extensively throughout the flap or the last thing that you do, if your other stuff isn't working then you have to disconnect the flap from the patient's circulation because you can't inject TPA into the patient's systemic circulation. You can, but then you're risking a stroke or bleeding event where you don't have to. If you can just either disconnect the vein or clamp the vein and open a side branch and let all the TPA just out so that you can suction it up.

Sometimes you can use Fogarty catheters, these little vascular catheters with a little balloon on it to try and snake some clot out of there, but that, you're also potentially damaging the vessel when you're putting that in, and the vessel is narrowing, the more distal it goes. That oftentimes isn't a great solution, but it's another trick to just have.

[Dr. Gopi Shah]
As we are rounding it out, I feel like we've only scratched the surface.

[Dr. Ashley Agan]
We made a paper cut into this topic!

[Dr. Gopi Shah]
In the interest of time, any final thoughts about just how you think about free flaps and things that you would want listeners to know as the big take home points.

(9) What I Wish I’d Known: Lessons for Early Career Microvascular Surgeons

[Dr. Eli Gordin]
Things that I wish I knew earlier that I know now, number one, is not being afraid to just take the flap back to the OR to take a look because it's always, you take it as a personal affront to your skill and ability when there's potentially a problem. You don't want to believe that there's a problem. You don't want to rely on hope as a strategy. I was telling the residents yesterday that hope as a concept is completely and utterly worthless when it comes to free flap surgery.

If you think that there's a problem, you might as well just look and see, and then you'll feel better if you open up the neck and see that everything looks fine, then great. You have to force yourself to just do the right thing because it only gets harder the further along the timeline you get when bad things are happening. The last thing you want to have to do is then do a whole new flap. This applies to intraoperative situations too. I've had cases where you're doing, let's say a fibula, and then the skin paddle doesn't look good, but the bone looks fine, and you didn't find a nice skin perforator.

Now, it's seven o'clock at night and you're like, "Well, the skin paddle doesn't look right. Should I just close it up and see what happens or should I just now put a thigh flap on top of this and remove the skin and do a second flap?" At some point you learn that it's just easier to take care of things immediately, as soon as possible, and not hope that something that looks wrong is going to just right itself at some point in the future. That's probably the main thing.

Then also just not being afraid to ask for help, especially as this becomes more commonplace and spreads to more non-large academic medical centers. This is stuff that people now do more in the private practice, or quasi, “priva-demic” situation where you don't have a big residency program. You may be the only person who's doing this at your institution and that's a tough position to be in.

You definitely have whoever you trained under that you can call, but you simultaneously also have to realize that you don't have to do every case that comes to your door. That's a difficult position as a young faculty free flap surgeon to be in is you get hired, especially if there are a few head and neck surgeons, whatnot in your division or departments. They send you a case and you're like, "They hired me to do this. They're sending me this, so they obviously think that I should be able to do this case," but there are cases that you shouldn't be doing when you're fresh out, revision revision, third flap, that vessel depleted mid face. I don't know.

There's stuff that it's okay to say like, "This is not something that I, at this point in my life want to be doing because the risk of something bad happening." Then the ability to salvage the situation, the payoff there is just not favorable. Maybe this patient needs to travel to some other medical center where there's somebody with more experience. You have to get your experience and you can't just-- It doesn't take one year of fellowship to figure out how to do this. It really takes years till you can start to-- You got to go push yourself, but you got to be patient with it too. Those are the two wisdoms that I would impart.

[Dr. Gopi Shah]
Very well said.

[Dr. Ashley Agan]
Some good wisdoms.

[Dr. Gopi Shah]
It's great to talk to you, Eli. I learned a ton. Thanks for coming on.

[Dr. Eli Gordin]
Absolutely. Anytime. Let's do this again.

Podcast Contributors

Dr. Eli Gordin discusses Free Flaps 101 on the BackTable 128 Podcast

Dr. Eli Gordin

Dr. Eli Gordin is an otolaryngologist, head and neck surgeon, facial plastic surgeon, and assistant professor with the department of otolaryngology at UT Southwestern in Dallas, Texas.

Dr. Ashley Agan discusses Free Flaps 101 on the BackTable 128 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses Free Flaps 101 on the BackTable 128 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, September 12). Ep. 128 – Free Flaps 101 [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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