A free flap is a tissue graft that contains an arterial and venous blood supply. The tissue graft, along with its artery and vein, is lifted from a donor site (usually the arm, leg, abdomen or back), and then it is transferred to the area which needs reconstruction. The surgeon then reconnects the artery and vein of the tissue graft to the carotid artery and jugular vein in your neck in order to re-establish blood flow within the flap. The operation requires meticulous technique as the surgeon re-connects blood vessels having a diameter of approximately 1/10th inch using sutures that are finer than human hair. These sutures are not usually visible to the naked eye, which require special instruments and techniques. A thin layer of skin (a skin graft) may be taken from your groin or thigh to cover the free flap donor site if the free flap is taken from the arm or the leg. If your arm or leg is the donor site, a secure dressing will be placed to protect the site from constant motion which can potentially disrupt healing.
If the lower leg is the donor site (called a fibula flap), your surgeon will require an angiogram to determine if the arteries and veins are appropriate for use. An angiogram is a special x-ray procedure and can be done as an outpatient. Likewise, if the wrist is the donor site (called a forearm flap), the physician will perform a simple, painless Allen’s test during your visit. Allen’s test is done by manually compressing the arteries in your wrist to confirm that you have adequate blood flow to your hand. If your forearm or wrist is the donor site, please do not allow any blood draws or intravenous catheters in this arm for one week before surgery.
As with any surgery, there are both potential benefits and risks. The following information will help you understand the risks of free flap surgery. As with any operation, there may be some unanticipated complications in addition to those listed here.
Bleeding: As with any surgery, bleeding is a risk. This is a major surgical procedure, and some bleeding will occur. If this bleeding is significant, blood transfusion may be necessary both for medical reasons and to maintain the perfusion to the free flap. Please let your doctor or nurse know if this is against your wishes. Because we do not want to increase the chance of heavy bleeding during the procedure, it is very important that you stop any medications that impair the ability of your blood to clot, including aspirin, ibuprofen, Aleve, Advil, Excedrin, and over the counter herbal medications. Please refer of our list of medications to discontinue prior to surgery.
Infection: Though infection is not common, it is a risk with any surgical procedure. Should infection occur, it may require prolonged treatment in or out of the hospital. Fortunately, this is not common. A wound infection occurs in less than 5% of cases and is treated with antibiotics and drainage, and is usually not a serious problem.
Thrombosis (blood clot): Surgical time is frequently between 8 to 12 hours as re-connecting the blood vessels is a painstaking process. After surgery, qualified nurses and doctors will check the blood supply to the free flap on a frequent basis, as it is crucial to the viability of the tissue graft. If a blood clot were to develop within the blood vessels of the free flap, your doctor may recommend urgent re-operation to remove the blood clot and restore blood flow. The risk of a blood clot forming is low (about 1 chance in 20). You will be given blood-thinning medications post-operatively to decrease the chances of clot formation. Given your relative state of immobility post-operatively, there is also the chance of forming what is called a deep venous thrombosis, or blood clot, in your legs. In some instances, these clots can break off and go to the lungs causing a pulmonary embolism. This is a rare but potentially fatal event.
Monitoring: Blood flow to the flap site will be checked every hour for three days after surgery. This will be done with a handheld ultrasound called a ” Doppler”. Your nurses and doctors will also be checking for color, temperature and swelling. The Doppler checks will be done on a less frequent basis after the first three days. To prevent clotting in the blood vessels of your flap, your surgeon will give you low dose Aspirin once a day after surgery during your hospitalization. You need to continue the aspirin after discharge from the hospital for a total of 14 days from the time of your surgery. You do not need to continue it for longer unless so instructed by your doctor.
Donor Site: A thin layer of skin (a skin graft) may be taken from your thigh or groin to cover the free flap donor site if the free flap is taken from the arm or the leg. Alternatively, a dermal substitute may be used as a temporary graft to fill the donor site defect. This will require skin grafting in a second stage. If your arm or leg is the donor site, a secure dressing will be placed to protect the site from constant motion which can potentially disrupt healing. If a skin graft is taken from the thigh,the site will be covered by special gauze dressing, which will dry out and become like a scab within a week after surgery. This dressing will fall off the thigh after the wound has healed after a period of 2 to 3 weeks. It is important to keep the thigh dressing dry until it falls off. Less common but possible donor site complications include pain, bleeding, infection, scarring, numbness, and temporary weakness Very rarely (less than 1/1000), limb compromise from extremity flaps have been reported.
Anesthesia: Because you will be under anesthesia for at least 8 hours, do not eat or drink after 12 midnight on the night before surgery. This will lessen the risk of nausea, vomiting and aspiration (food and fluids that can be potentially swallowed into your lungs and cause pneumonia). If instructed by your doctor or nurse, it is OK to take your regular medications with a small sip of water on the morning of surgery. There are risks associated with any type of anesthesia including but not limited to respiratory problems, drug reaction, heart attack, stroke, brain damage, or even death. Other risks and hazards that may result from the use of general anesthetics include but are not limited to minor discomfort due to injury to the vocal cords, teeth, or eyes. You can discuss these risks with your anesthesiologist prior to surgery.
Drainage: To remove accumulated blood and fluid from the operative site, drains will be placed under the skin of your neck and sometimes within the free flap donor site wound. These drains will remain in place until fluid drainage is decreased to less than 30 cc in 24 hours or as long as your physician recommends. The nurses will measure the amount of drainage every shift. They will also assess the site for any signs of redness and tenderness. The drains will be removed at the bedside, and the procedure for drain removal causes no significant discomfort.
Scar: Scar location and extent will vary depending on the procedure you are having. Initially, this will be swollen and red. As it heals, the swelling and redness will lessen. It is a good idea not to expose the scar to direct sunlight for the first 6 months after surgery to prevent the scar from hyperpigmenting (getting dark). There will also be scars at your graft donor site.
Numbness: A lack of sensation around the area of your incision is very common and last for several months. In rare instances, the numbness can be permanent. If your flap is taken from an extremity, numbness is common and may persist for some time.
Revision Procedure: Although every attempt is made to promote survival of the donor tissue, there is a possibility of tissue death. This may require additional surgery. Additional revision procedures may be necessary for cosmetic reasons.
Fibula Free Flap:
Dr. Reilly will remove one of the bones from the lower part of your leg. The fibula bone runs on the outside of the leg from the knee joint to the ankle joint. It is a small thin bone that can be entirely removed without affecting your ability to bear weight. The fibular bone is removed (the flap) along with two blood vessels, one of which supplies blood to the flap (the artery) and one of which drains blood from the flap (the vein). Once the bone is raised it is transferred to the head and neck and secured in position with small plates and screws. The blood vessels supplying and draining the flap are then joined to blood vessels in your neck under a microscope. These blood vessels then keep the flap alive while it heals into its new place. Your leg will be placed in a bandage for a week following surgery. Often it is necessary to remove a piece of skin in addition to the fibula bone. If the piece of skin that is removed is large it will need to be replaced with a skin graft or the site will be closed directly.
Radial Forearm Free Flap:
Dr. Reilly will take a piece of skin from the inside surface of your forearm near the wrist. The skin and fat layer in this region is removed (the flap) along with two blood vessels, one of which supplies blood to the flap (the artery) and one of which drains blood from it (the vein). The vessel which supplies blood to the flap is the artery which gives rise to the pulse at the wrist at the base of the thumb. Once the flap of skin is raised it is transferred to the head and neck and sewn into the hole created by the removal of your cancer. The blood vessels supplying and draining the flap are then joined to blood vessels in your neck under a microscope. These blood vessels then keep the flap alive while it heals into its new place. Once the flap is removed from your forearm the wound created is covered with a graft of skin. This graft of skin can be taken from one of several places. Commonly a thin piece of skin is taken from the outside of your groin crease/hip.
Anterolateral Thigh Free Flap:
Dr. Reilly will take a piece of skin and fat from the upper surface of your thigh, which is known as the “donor site”. • The skin and fat layer in this region is removed (the flap) along with two blood vessels. One of the blood vessels supplies blood to the flap (the artery) and the other drains blood from it (the vein). Once the flap of skin is raised, it is transferred and sewn into the hole created by the removal of your cancer. The blood vessels supplying and draining the flap are then joined to blood vessels in your neck, under a microscope. These blood vessels then keep the flap alive while it heals into place. The donor site on your thigh is then closed, primarily with sutures (stitches) and sealed with clips. In order to remove any excess fluid or blood from the donor site, a vacuumed drain is likely to be inserted. This will be regularly monitored. The drain will be removed by the nursing staff once the area stops producing excess fluid.
Fibula Free Flap
The area of your leg where the bone has been removed is likely to be sore. Regular painkillers will be arranged for you. A small tube is also placed through the skin into the underlying wound to drain any blood that may collect. This “drain” is usually removed after a few days. All cuts made through the skin leave a scar but the majority if these fade with time. The scar on the outside of your leg runs from just below the knee joint to just above the ankle joint. The skin graft site, if performed, can take several weeks to heal in fully. Until that time, it is best to keep a lubricating ointment like aquaphor or vaseline on the incision lines as much as possible.
Radial Forearm Free Flap
Your forearm will be placed in a bandage and sometimes your arm held with the hand up in a special sling for a few days. The bandage is removed after around 10 days and replaced with a lighter dressing. The blood vessels lifted with the flap run from the inside of the wrist as far as the inside of the elbow so there will be a row of stitches along this line which will be taken out when the bandage is removed. The nerve which supplies feeling to the skin over the base and side of the thumb is sometimes bruised when the flap is raised. This can mean that the area ends up tingly or numb for several months following surgery. Occasionally it can be permanent. Rarely a bruised nerve can give rise to feelings of pain. You may also notice that your hand does not feel as strong as it was after the operation and sometimes it will feel more cold than it used to in the winter months.
Anterolateral Thigh Free Flap
Your thigh will be bandaged for protection and comfort and this will be monitored regularly by nursing staff. The dressing will be removed after approximately two to three days, once the wound has sufficiently closed. It will then be covered with ointment regularly. The staples or sutures in the wound will be left in place for approximately 10 days, during which time you can wash the area normally. In the immediate post-operative period, it is likely that you will find the movement of your leg, from which the flap has been taken, quite uncomfortable. You will receive regular painkillers. It is generally recommended that only gentle movement is undertaken for the first few days, after which point your Physiotherapist will advise you on an appropriate exercise plan. The operation will leave you with a scar on your thigh and a slight indentation. However, the scar does fade over time, gradually becoming less visible. If scarring is of concern to you, please discuss with Dr. Reilly what can help once the wounds have fully healed.
General Information for Free Flaps
The routine hospital stay after free flap surgery is 7-10 days.
The first three days are spent in the ICU. Blood flow to the flap site will be checked every hour for three days after surgery. This will be done with an ultrasound probe called a “Doppler”. Your nurses and doctors will also be checking for color, temperature and swelling. You will then be transferred to a routine surgical floor for the remainder of your stay.
If the free flap involves the mouth or oral cavity, you will usually have a temporary tube in your trachea or windpipe to help you breathe without difficulty. This tube is called a tracheostomy tube or ” trach”. Because of swelling that is expected after surgery, your airway will be compromised without a trach. Your trach tube is frequently removed before you go home, and the hole in the windpipe will heal within a few days without any stitches.
To reduce swelling in your face and neck, we will elevate the head of your bed at a 35-degree angle. There will not be any constricting ties or dressings placed around your neck as this may prevent blood flow through the arteries and veins of your free flap. We may ask you to avoid certain head positions during the first week after surgery, as certain head positions might pinch off blood flow to your free flap.
If your surgery affects your mouth or throat, you will be unable to eat by mouth immediately after surgery. To maintain your nutrition and to hasten healing, you will be fed through a tube. This tube, called a nasogastric or NG feeding tube, will be inserted through your nose into your stomach while you are under anesthesia. Your feeding tube will remain in place until you are able to swallow food and fluids by mouth.
To remove accumulated blood and fluid from the operative site, drains will be placed under the skin of your neck and sometimes within the free flap donor site wound. These drains will remain in place until fluid drainage is decreased to less than 30 cc in 24 hours. The drains will be removed at the bedside, and the procedure for drain removal causes no significant discomfort.
You will be transferred to a standard surgical unit, and will be encouraged to get moving as much as possible. If a tracheostomy is placed, this will typically be changed to a smaller caliber tube on the 5th day after surgery. If you are able to breathe freely with this smaller tube covered for 24 continuous hours, the tracheostomy tube will be removed on the 7th day after surgery. On the 7th day following most free tissue reconstruction of the mouth and/or throat, you are typically given a trial of eating/swallowing. If this is successful, the feeding tube in the nose will be removed and you will be prescribed a liquid diet to gradually advance to more solid foods over the following days.
Once you are getting enough calories by mouth and no longer requiring any specialized care, you will be discharged home with a follow up appointment within a week. At home, it is important to continue to move as much as possible in order to minimize the risk of a blood clot. You will be given instructions for taking care of the surgical sites, which generally involves keeping incisions moist with a petroleum-based jelly such as aquaphor or vaseline. Any sutures or staples that are not removed prior to discharge will be removed at the follow up visit. Your swelling and bruising will gradually fade over this time period, but it may persist for up to 3 weeks.
1. Rest and good nutrition are important healing factors, especially during the first 6 weeks.
2. Numbness, tingling, hardness, tightness, and bumpiness of the surgical area are common occurrences. If any of these things do occur, they will gradually subside over several months.
Dr. Michael Reilly is double board-certified by the American Board of Otolaryngology--Head & Neck Surgery and The American Board of Facial Plastic & Reconstructive Surgery. He specializes in facial plastic surgery.
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