Free flap
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The terms free flap, free tissue transfer, and free muscle transfer describe a variety of procedures which all have share a common purpose, order, and complications. Free flaps are surgical procedures that involve the transfer of tissue which includes muscle and/or fat and its vein and artery supply from one part of the body and attaching that tissue to another part of the body and reconnecting the blood supply.
Free flaps may be done for a number of reasons, including:
- Cosmetic reconstruction: Most commonly creating a breast after a mastectomy. This may happen at the time of mastectomy or at a later date. Free flaps are usually only done if a TRAM flap is not possible. See rotational flap for more information on TRAM flap. Plastic surgeons usually perform these surgeries.
- Traumatic reconstruction: Some area of the body has missing tissue either from a trauma or from some existing wound. This may include areas on the leg where bone is exposed or any other area on the body which needs soft tissue coverage prior so that a skin graft will be successful. Plastic surgeons usually perform these surgeries.
- Removal of cancer of the mouth, jaw, or neck: Some ENT and Oral and Maxillofacial surgeons with microvascular training will remove the cancer and then proceed with the free flap. If the cancer involves a part of the lower jaw (mandible) then sometimes a part of the lower leg smaller bone called the fibula will be removed along with the muscle to replace the removed mandible.
Free flaps all have common steps. These do not necessarily occur in order.
- If cancer is involved it is removed.
- An incision is made over the area identified where the flap will be taken from.
- The flap is dissected and freed from the surrounding tissue.
- The blood supply including at least one vein and one artery is dissected. This segment is called the pedacle.
- The vein and artery are either tied off or clamped and then cut.
- Before the pedacle is clamped the area the flap is going to is prepared and blood supply is identified and released from surrounding tissue.
- The free flap is brought up to the defect area and the vein and artery are reanatamosed (connected) to the existing vein and artery supply. This step is the "microsurgery" part and is done under a large microscope placed over the patient.
- The free flap is sutured to the defect area while it is monitored to assure the blood supply patency.
- The donor site area is sutured closed.
- A Split Thickness Skin Graft (STSG) may be performed and placed on top of the defect site and/or the donor site.
Most common complications of free flaps include of loss of arterial supply which may cause necrosis (death) of the flap or loss of venous return which may cause congestion and also loss of the flap. Close monitoring of the flap both by nurses and by the surgeon is important postoperatively to monitor for this. If caught early, loss of blood supply may be corrected either medically or surgically. Many times an implantable doppler probe can be installed during surgery to provide better monitoring postoperatively. This doppler probe can be removed before discharge from the hospital.
Usually donor sites are selected which will cause the least amount of disability but this may occur. Other complications which may occur with any surgery are also possible including infection and pain.
Free flap vs. rotational flap Rotational flaps involve the same movement of usually muscle but differ from free flaps in that the pedacle (blood supply) to the flap as not cut. Instead the pedacle is dissected long enough so that the flap can be moved directly or through a tunnel created under the skin to the defect area. Rotational flaps usually are faster and have less complications but are not always possible.
Free flaps can be very complex and lengthy surgeries. Length commonly ranges from 6 to 12 hours but can take longer based on the complexity.
Finger and hand reattachments use the same microvascular techniques.
The suture used to reattach blood vessels is made of nylon and is so fine that it almost floats.
Many successful free flap surgeries are performed every day.
