Page 14 - Read Online

Page 2 of 8 Hussaini et al. Plast Aesthet Res 2022;9:30 https://dx.doi.org/10.20517/2347-9264.2021.132

anatomical location, patient-specific factors, and health system resources, there is no standardized algorithm
for reconstruction, and treatment must be tailored on a case-by-case basis. Furthermore, given that
functional rehabilitation often requires a prolonged course, patient “buy-in” and adherence are additional
factors that must be considered on an individual basis for long-term success.

Generally speaking, the primary goal of reconstruction involves restoration of both function and form,
while at the same time minimizing donor site morbidity. Options for reconstruction generally include
locoregional pedicled flaps (LRPF) and microvascular free tissue transfer (FTT). Over the past several
decades, the treatment paradigm has shifted several times in the United States. Although the concept of a
reconstructive ladder historically provided a systematic manner to approach surgical techniques from
simplest to most complex based on defect and pathology, reconstruction in the modern era is less stringent
and FTT is often employed for defects across the spectrum of complexity.

Historically, the use of LRPF in head and neck reconstruction was first popularized by McGregor in the
[1]
1960s with the axial-pattern forehead flap supplied by the superficial temporal artery. This flap provided a
robust option for reconstruction of many sites including the oral cavity, face, and pharynx, and was
[2]
considered the workhorse flap for head and neck reconstruction up until the late 1970s . During this
period, increasing concern regarding donor site morbidity and cosmesis led to anatomic studies into
independent myocutaneous vascular territories in the body, which ultimately paved the way for the first
localized myocutaneous rotational flaps . Since its inception in 1979, the pedicled myocutaneous pectoralis
[3]
[4]
major flap, as described by Ariyan, remains a popular option today for locoregional reconstruction .

Although the first report of end-to-end microvascular anastomosis dates back to 1887 by Eck , it was not
[5]
until the 1970s that free tissue transfer gained traction as a viable option for reconstruction . McLean and
[2,6]
Buncke described the use of vascularized omentum for scalp reconstruction in 1972 and the first
[7]
cutaneous free flap was described in 1973 by Daniel and Williams . In addition, Chinese surgeons during
[8]
this period are often credited for the development of the radial forearm free flap; however, their work
remained unknown to the western hemisphere for a number of years due to political isolation . Despite
[9]
these advances, the momentum and surgical trend towards FTT in head and neck reconstruction somewhat
stagnated with the introduction of the previously described pectoralis major flap, which provided reliability
without the need for special microvascular skills.

It was not until the mid-1980s that there was renewed interest in FTT. The radial forearm free flap, which
had been described more than a decade prior, gained popularity amongst head and neck surgeons owing to
its pliability and ease of harvest, and was widely considered the workhorse of soft tissue reconstruction by
the 1990s. In addition, the introduction of the composite fibular flap by Hidalgo in 1989 solved many of
[10]
the problems with hardware exposure with pedicled myocutaneous flaps. This, along with the
osteocutaneous flaps of the subscapular system, vastly improved the functionality aspect of head and neck
reconstruction.

As of the present, the current paradigm in head and neck reconstruction is being challenged. Although FTT
represents the state-of-the-art standard for addressing substantial defects of the head and neck, nearly three
decades of experience with LRPF has led to technical advances and a better understanding of maneuvers to
improve outcomes. Furthermore, increasing economic pressures have strained healthcare systems in the
United States and have challenged surgeons to improve efficiency and cost-effectiveness. With these factors
in mind, it is important to reconsider the utility of LRPF in an era where FTT is often considered the gold
standard for composite defects. Herein we describe and discuss two high-yield options for LRPF and