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Reconstruction Flaps in Neck
Patricia A. Hudgins, MD, FACR
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KEY FACTS

  • Terminology

    • Imaging

      • Diagnostic Checklist

        TERMINOLOGY

        • Definitions

          • Flap: Soft tissue ± muscle ± bone surgical site reconstruction
            • Also known as microvascular reconstruction
          • Soft tissue or autologous bone used to reconstruct postoperative resection defect in H&N
            • Fasciocutaneous flap
              • Flap constructed of deep muscle fascia with its overlying skin
              • Used for smaller surgical reconstructions in H&N
              • Allows harvesting of fasciocutaneous arterial perforators that pass along fascial septa between adjacent muscles
                • Results in larger flap size survival at reconstruction site as needed
              • Sensory cutaneous nerves also harvested when sensory reinnervation desired
              • Donor sites primarily radial forearm, lateral arm, temporoparietal, rectus, latissimus dorsi, or anterolateral thigh
            • Myocutaneous flap
              • Flap constructed of muscle, soft tissue, and overlying skin
              • Used when larger reconstruction site needs more volume (provided by muscle) to adequately fill surgical defect
              • Donor sites include pectoralis major, rectus abdominis, or latissimus dorsi muscles
            • Osteocutaneous flap
              • Flap constructed with bone, soft tissue, and overlying skin ± muscle
                • Also known as composite flap
              • Used when reconstruction requires bone replacement
                • Primarily employed in oral cavity squamous cell carcinoma (SCCa) reconstructions
                • Portion of mandible or maxilla removed during tumor treatment surgery
                • Muscle added to osteocutaneous flap if more volume needed for larger surgical defects
              • Donor site usually fibula or scapula
          • Flaps most commonly used to reconstruct tumor resection cavity
            • Also used to repair posttraumatic defects in extracranial head and neck
            • Osteocutaneous flap may be used to repair mandibular or maxillary osteonecrosis

        IMAGING

        • General Features

          • Imaging Recommendations

            • CT Findings

              • MR Findings

                DIFFERENTIAL DIAGNOSIS

                  PATHOLOGY

                  • General Features

                    • Staging, Grading, & Classification

                      CLINICAL ISSUES

                      • Presentation

                        • Demographics

                          • Natural History & Prognosis

                            DIAGNOSTIC CHECKLIST

                            • Consider

                              • Image Interpretation Pearls

                                • Reporting Tips

                                  Selected References

                                  1. Patel SA et al: Principles and practice of reconstructive surgery for head and neck cancer. Surg Oncol Clin N Am. 24(3):473-489, 2015
                                  2. Glastonbury CM et al: Ossification of the vascular pedicle in microsurgical fibular free flap reconstruction of the head and neck. AJNR Am J Neuroradiol. 35(10):1965-9, 2014
                                  3. Wehage IC et al: Complex reconstructions in head and neck cancer surgery: decision making. Head Neck Oncol. 3:14, 2011
                                  4. Chan JW et al: Three- and four-dimensional computed tomographic angiography studies of the supraclavicular artery island flap. Plast Reconstr Surg. 125(2):525-31, 2010
                                  5. González-García R et al: Transport osteogenesis in the maxillofacial skeleton: outcomes of a versatile reconstruction method following tumor ablation. Arch Otolaryngol Head Neck Surg. 136(3):243-50, 2010
                                  6. Jacobson AS et al: Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope. 120(2):273-5, 2010
                                  7. Kalavrezos N et al: Current trends and future perspectives in the surgical management of oral cancer. Oral Oncol. 46(6):429-32, 2010
                                  8. Kruse AL et al: Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery. 30(3):242-8, 2010
                                  9. Lee JT et al: Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps. J Reconstr Microsurg. 26(3):145-51, 2010
                                  10. Nelson JA et al: The vastus lateralis muscle flap in head and neck reconstruction: an alternative flap for soft tissue defects. Ann Plast Surg. 64(1):28-30, 2010
                                  11. Pattani KM et al: What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope. 120(4):717-23, 2010
                                  12. Sader C et al: Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 125(3):893-5, 2010
                                  13. Smith JE et al: Temporalis muscle flap for reconstruction of skull base defects. Head Neck. 32(2):199-203, 2010
                                  14. Abdel-Galil K et al: Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques--part I. Non-invasive techniques. Br J Oral Maxillofac Surg. 47(5):351-5, 2009
                                  15. Chien SH et al: Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg. 124(1):318, 2009
                                  16. Corten EM et al: Clinical outcome after pedicled segmental pectoralis major island flaps for head and neck reconstruction. Ann Plast Surg. 63(3):292-6, 2009
                                  17. Ethier JL et al: Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes. J Otolaryngol Head Neck Surg. 38(6):632-41, 2009
                                  18. Iseli TA et al: Functional outcomes following secondary free flap reconstruction of the head and neck. Laryngoscope. 119(5):856-60, 2009
                                  19. Nuara MJ et al: Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions. Arch Facial Plast Surg. 11(4):235-9, 2009
                                  20. Sumer BD et al: Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation. Arch Otolaryngol Head Neck Surg. 135(8):801-6, 2009
                                  21. Ayad T et al: Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck. 30(4):437-45, 2008
                                  22. Cordeiro PG: Frontiers in free flap reconstruction in the head and neck. J Surg Oncol. 97(8):669-73, 2008
                                  23. Dassonville O et al: Head and neck reconstruction with free flaps: a report on 213 cases. Eur Arch Otorhinolaryngol. 265(1):85-95, 2008
                                  24. Kramer M et al: Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography. J Oral Maxillofac Surg. 66(2):302-7, 2008
                                  25. Murray DJ et al: Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg. 61(10):1148-56, 2008
                                  26. Oliver C et al: Interpretability of PET/CT imaging in head and neck cancer patients following composite mandibular resection and osteocutaneous free flap reconstruction. Head Neck. 30(2):187-93, 2008
                                  27. Thorwarth M et al: Free flap transfer in cranio-maxillofacial surgery: a review of the current data. Oral Maxillofac Surg. 12(3):113-24, 2008
                                  28. Bokhari WA et al: Tongue reconstruction: recent advances. Curr Opin Otolaryngol Head Neck Surg. 15(4):202-7, 2007
                                  29. Kelly AM et al: Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making. AJR Am J Roentgenol. 188(1):268-74, 2007
                                  30. Resto VA et al: Pectoralis major flap in composite lateral skull base defect reconstruction. Arch Otolaryngol Head Neck Surg. 133(5):490-4, 2007
                                  31. Richmon JD et al: Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg. 15(4):208-12, 2007
                                  32. Smith RB et al: Scapula osteocutaneous free flap reconstruction of the head and neck: impact of flap choice on surgical and medical complications. Head Neck. 29(5):446-52, 2007
                                  33. Spiegel JH et al: Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope. 117(3):485-90, 2007
                                  34. Podrecca S et al: Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg. 59(2):122-9, 2006
                                  35. Morimoto Y et al: Instability of background fat intensity suppression using fat-saturated (FS) MR imaging techniques according to region and reconstruction procedure in patients with oral cancer. Oral Oncol. 40(3):332-40, 2004
                                  36. Hudgins PA: Flap reconstruction in the head and neck: expected appearance, complications, and recurrent disease. Semin Ultrasound CT MR. 23(6):492-500, 2002
                                  37. Tomura N et al: MR imaging of recurrent head and neck tumours following flap reconstructive surgery. Clin Radiol. 57(2):109-13, 2002
                                  38. Chong J et al: MR imaging of the muscular component of myocutaneous flaps in the head and neck. AJNR Am J Neuroradiol. 22(1):170-4, 2001
                                  Related Anatomy
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                                  Related Differential Diagnoses
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                                  References
                                  Tables

                                  Tables

                                  KEY FACTS

                                  • Terminology

                                    • Imaging

                                      • Diagnostic Checklist

                                        TERMINOLOGY

                                        • Definitions

                                          • Flap: Soft tissue ± muscle ± bone surgical site reconstruction
                                            • Also known as microvascular reconstruction
                                          • Soft tissue or autologous bone used to reconstruct postoperative resection defect in H&N
                                            • Fasciocutaneous flap
                                              • Flap constructed of deep muscle fascia with its overlying skin
                                              • Used for smaller surgical reconstructions in H&N
                                              • Allows harvesting of fasciocutaneous arterial perforators that pass along fascial septa between adjacent muscles
                                                • Results in larger flap size survival at reconstruction site as needed
                                              • Sensory cutaneous nerves also harvested when sensory reinnervation desired
                                              • Donor sites primarily radial forearm, lateral arm, temporoparietal, rectus, latissimus dorsi, or anterolateral thigh
                                            • Myocutaneous flap
                                              • Flap constructed of muscle, soft tissue, and overlying skin
                                              • Used when larger reconstruction site needs more volume (provided by muscle) to adequately fill surgical defect
                                              • Donor sites include pectoralis major, rectus abdominis, or latissimus dorsi muscles
                                            • Osteocutaneous flap
                                              • Flap constructed with bone, soft tissue, and overlying skin ± muscle
                                                • Also known as composite flap
                                              • Used when reconstruction requires bone replacement
                                                • Primarily employed in oral cavity squamous cell carcinoma (SCCa) reconstructions
                                                • Portion of mandible or maxilla removed during tumor treatment surgery
                                                • Muscle added to osteocutaneous flap if more volume needed for larger surgical defects
                                              • Donor site usually fibula or scapula
                                          • Flaps most commonly used to reconstruct tumor resection cavity
                                            • Also used to repair posttraumatic defects in extracranial head and neck
                                            • Osteocutaneous flap may be used to repair mandibular or maxillary osteonecrosis

                                        IMAGING

                                        • General Features

                                          • Imaging Recommendations

                                            • CT Findings

                                              • MR Findings

                                                DIFFERENTIAL DIAGNOSIS

                                                  PATHOLOGY

                                                  • General Features

                                                    • Staging, Grading, & Classification

                                                      CLINICAL ISSUES

                                                      • Presentation

                                                        • Demographics

                                                          • Natural History & Prognosis

                                                            DIAGNOSTIC CHECKLIST

                                                            • Consider

                                                              • Image Interpretation Pearls

                                                                • Reporting Tips

                                                                  Selected References

                                                                  1. Patel SA et al: Principles and practice of reconstructive surgery for head and neck cancer. Surg Oncol Clin N Am. 24(3):473-489, 2015
                                                                  2. Glastonbury CM et al: Ossification of the vascular pedicle in microsurgical fibular free flap reconstruction of the head and neck. AJNR Am J Neuroradiol. 35(10):1965-9, 2014
                                                                  3. Wehage IC et al: Complex reconstructions in head and neck cancer surgery: decision making. Head Neck Oncol. 3:14, 2011
                                                                  4. Chan JW et al: Three- and four-dimensional computed tomographic angiography studies of the supraclavicular artery island flap. Plast Reconstr Surg. 125(2):525-31, 2010
                                                                  5. González-García R et al: Transport osteogenesis in the maxillofacial skeleton: outcomes of a versatile reconstruction method following tumor ablation. Arch Otolaryngol Head Neck Surg. 136(3):243-50, 2010
                                                                  6. Jacobson AS et al: Reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular free flap. Laryngoscope. 120(2):273-5, 2010
                                                                  7. Kalavrezos N et al: Current trends and future perspectives in the surgical management of oral cancer. Oral Oncol. 46(6):429-32, 2010
                                                                  8. Kruse AL et al: Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery. 30(3):242-8, 2010
                                                                  9. Lee JT et al: Reconstruction of extensive composite oromandibular defects with simultaneous free anterolateral thigh fasciocutaneous and fibular osteocutaneous flaps. J Reconstr Microsurg. 26(3):145-51, 2010
                                                                  10. Nelson JA et al: The vastus lateralis muscle flap in head and neck reconstruction: an alternative flap for soft tissue defects. Ann Plast Surg. 64(1):28-30, 2010
                                                                  11. Pattani KM et al: What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope. 120(4):717-23, 2010
                                                                  12. Sader C et al: Fat graft pedicle stabilization in head and neck microvascular reconstruction. Plast Reconstr Surg. 125(3):893-5, 2010
                                                                  13. Smith JE et al: Temporalis muscle flap for reconstruction of skull base defects. Head Neck. 32(2):199-203, 2010
                                                                  14. Abdel-Galil K et al: Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques--part I. Non-invasive techniques. Br J Oral Maxillofac Surg. 47(5):351-5, 2009
                                                                  15. Chien SH et al: Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg. 124(1):318, 2009
                                                                  16. Corten EM et al: Clinical outcome after pedicled segmental pectoralis major island flaps for head and neck reconstruction. Ann Plast Surg. 63(3):292-6, 2009
                                                                  17. Ethier JL et al: Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes. J Otolaryngol Head Neck Surg. 38(6):632-41, 2009
                                                                  18. Iseli TA et al: Functional outcomes following secondary free flap reconstruction of the head and neck. Laryngoscope. 119(5):856-60, 2009
                                                                  19. Nuara MJ et al: Prospective analysis of outcomes and complications of 300 consecutive microvascular reconstructions. Arch Facial Plast Surg. 11(4):235-9, 2009
                                                                  20. Sumer BD et al: Microvascular flap reconstruction of major pharyngeal resections with the intent of laryngeal preservation. Arch Otolaryngol Head Neck Surg. 135(8):801-6, 2009
                                                                  21. Ayad T et al: Reconstruction of floor of mouth defects by the facial artery musculo-mucosal flap following cancer ablation. Head Neck. 30(4):437-45, 2008
                                                                  22. Cordeiro PG: Frontiers in free flap reconstruction in the head and neck. J Surg Oncol. 97(8):669-73, 2008
                                                                  23. Dassonville O et al: Head and neck reconstruction with free flaps: a report on 213 cases. Eur Arch Otorhinolaryngol. 265(1):85-95, 2008
                                                                  24. Kramer M et al: Vascular mapping of head and neck: computed tomography angiography versus digital subtraction angiography. J Oral Maxillofac Surg. 66(2):302-7, 2008
                                                                  25. Murray DJ et al: Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature. J Plast Reconstr Aesthet Surg. 61(10):1148-56, 2008
                                                                  26. Oliver C et al: Interpretability of PET/CT imaging in head and neck cancer patients following composite mandibular resection and osteocutaneous free flap reconstruction. Head Neck. 30(2):187-93, 2008
                                                                  27. Thorwarth M et al: Free flap transfer in cranio-maxillofacial surgery: a review of the current data. Oral Maxillofac Surg. 12(3):113-24, 2008
                                                                  28. Bokhari WA et al: Tongue reconstruction: recent advances. Curr Opin Otolaryngol Head Neck Surg. 15(4):202-7, 2007
                                                                  29. Kelly AM et al: Preoperative MR angiography in free fibula flap transfer for head and neck cancer: clinical application and influence on surgical decision making. AJR Am J Roentgenol. 188(1):268-74, 2007
                                                                  30. Resto VA et al: Pectoralis major flap in composite lateral skull base defect reconstruction. Arch Otolaryngol Head Neck Surg. 133(5):490-4, 2007
                                                                  31. Richmon JD et al: Reconstruction of the hypopharynx: current trends. Curr Opin Otolaryngol Head Neck Surg. 15(4):208-12, 2007
                                                                  32. Smith RB et al: Scapula osteocutaneous free flap reconstruction of the head and neck: impact of flap choice on surgical and medical complications. Head Neck. 29(5):446-52, 2007
                                                                  33. Spiegel JH et al: Microvascular flap reconstruction by otolaryngologists: prevalence, postoperative care, and monitoring techniques. Laryngoscope. 117(3):485-90, 2007
                                                                  34. Podrecca S et al: Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg. 59(2):122-9, 2006
                                                                  35. Morimoto Y et al: Instability of background fat intensity suppression using fat-saturated (FS) MR imaging techniques according to region and reconstruction procedure in patients with oral cancer. Oral Oncol. 40(3):332-40, 2004
                                                                  36. Hudgins PA: Flap reconstruction in the head and neck: expected appearance, complications, and recurrent disease. Semin Ultrasound CT MR. 23(6):492-500, 2002
                                                                  37. Tomura N et al: MR imaging of recurrent head and neck tumours following flap reconstructive surgery. Clin Radiol. 57(2):109-13, 2002
                                                                  38. Chong J et al: MR imaging of the muscular component of myocutaneous flaps in the head and neck. AJNR Am J Neuroradiol. 22(1):170-4, 2001