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Page 2 of 15 Ali et al. Plast Aesthet Res 2021;8:35 https://dx.doi.org/10.20517/2347-9264.2021.29

Keywords: Free tissue transfer, head and neck reconstruction, perforator mapping, technology, microvascular
couplers, three-dimensional exoscope, fluorescent angiography, postoperative monitoring

INTRODUCTION
Free tissue transfer (FTT) has become a cornerstone of modern head and neck surgery, as it offers a unique
means of reconstructing complicated skin, soft tissue, and osseous defects. As overall success rates continue
to improve, head and neck surgeons are increasingly turning to FTT as a means of restoring form and
[1]
function for patients with operative and traumatic head and neck defects . Since its inception, significant
advances in the operation and technological practice of the field have greatly reduced surgical duration and
[2]
length of inpatient stay, two key metrics in sustaining a high-volume FTT practice . In particular, the
coordination of a two-team approach, the advent of the microvascular coupling device, and the exploration
of easily accessible, reliable donor site options have significantly reduced operative time. As technological
advancements become more widely accessible, every aspect of the care provided to head and neck cancer
patients has evolved, from the preoperative planning to postoperative monitoring. This chapter will explore
recent technological advancements and their impacts on the modern FTT practice. An overview of the
various technologies can be found in Table 1.

PREOPERATIVE
Preoperative planning, including flap donor site selection, is imperative to decrease operative duration and
optimize patient outcomes. Planning typically starts with a complete history and physical to determine the
anticipated defect and patient specific factors that will influence flap selection such as body habitus and
prior surgery. Flap selection is also often drived by the surgeon’s prior experience and preferred donor sites.

Certain flaps have reliable anatomy and require minimal preoperative planning. For example, a physical
exam is adequate when planning to do a radial forearm, ulnar, lateral arm, or latissimus. However with the
use of perforator-based flaps with variable anatomy such as the anterolateral thigh (ALT), thoracodorsal
artery perforator (TDAP), and deep inferior epigastric perforator (DIEP) some surgeons find preoperative
planning helpful. Studies have also shown decreased operative duration when preoperative perforator
mapping is utilized . The use of various imaging modalities in perforator mapping may be valuable in
[3,4]
cases where the skin paddle must be thinned or split. It can also be considered in cases where larger skin
paddles are required, to assist with better centering the perforator within the skin paddle and capture its
respective angiosome. Here we will discuss some imaging options for perforator mapping in the
preoperative setting.

Computer tomography angiography
Head and neck surgeons commonly use computer tomography angiogram (CTA) for fibula flap planning to
rule out vascular disease and anatomic variants in vascular supply to the foot. This also allows for perforator
[5]
mapping when designing the fibula skin paddle . A lesser-used alternative to CTA for perforator mapping
in the fibula free flap is magnetic resonance angiography (MRA) . In a comparative study, Rozen et al.
[6]
[7]
found that CTA is able to identify perforators as small as 0.3 mm, smaller than the 1 mm perforators
detectable by advancements in MRA technology. CTA is also commonly used in DIEP flap planning by
breast reconstructive surgeons where its utility has been well documented. CTA for other types of perforator
flaps are less commonly used by head and neck surgeons.

[8]
Chen et al. showed significantly decreased operative duration in ALT harvest by adopting preoperative
CTA. Interestingly, they did not witness a significant difference in the number of perforators identified