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.