Flap selection, harvest and anastomosis
Pedicled or free flap! what should be the choice of reconstruction? This question comes to the mind of a reconstructive surgeon. Again, this will depend upon the resources, availability of operating rooms, time, and the defect. Both free and pedicle flaps have their roles, usually, the workhorse flaps like Free fibula, free anterolateral thigh flap, free radial artery forearm flap, and Latissimus dorsi should be done as a routine. Some cases of lateral mandibular defect can be reconstructed with a pectoralis major flap instead of free flaps. The deltopectoral flap should be avoided for perioral defects, as continuous drooling of oral secretions may occur. In cases of mandibular reconstruction with the fibula, putting primary dental implants can be avoided.
To decrease the operative time, the flap should be preferentially harvested by the senior surgeons. This will also decrease the error rate of the procedure. Some reports have suggested to reduce intraoperative surgical smoke, as it can be a potential source of infection. Hence special consideration like, using bipolar electrocautery favorably, or monopolar electrocautery with low power settings to reduce surgical smoke, use of suture materials and clips is encouraged. Care should be given to adequate smoke dispersal in the operating room25. The most experienced surgeon must do the critical steps of surgery, like harvest and vascular anastomosis to get optimal success18. During anastomoses near the head and neck region putting a transparent adhesive surgical drape to cover the aerodigestive tract will provide some protection. While operating an N95 mask or powered air-purifying respirator (PAPR) is a must.
A generalized plan for the type of reconstruction, will depend on the extent of oncological clearance, the general condition of the patient, and the presence of comorbidities (Table 1). A region-wise consideration may depend on the risk vs benefits of the reconstruction and an individualized clinical judgment on a case to case basis.