Free Flaps

One of the most important changes to occur in plastic surgery during the last few decades is the development of advanced microsurgical techniques. This is perhaps seen most clearly in the use of free flaps, one of the surgeons’ most challenging yet effective reconstructive tools. The procedure is done to replace other tissues missing from a variety of causes, including trauma, cancer surgery, and congenital defects.

The term “free flap” refers to the complete removal of a piece of body tissue from one area and the transfer to another area, along with the reattachment of the blood vessels providing the nutrient supply to the tissue. Free flaps are different from “grafts,” in which the blood supply is not reattached in the new position, but rather is gradually restored through the healing tissue. “Free” flaps are also different from “local” flaps or “pedicle” flaps, in which there is repositioning of the tissue without complete separation from a source of blood supply.

The types of tissue moved in a free flap are determined by the structures missing at the site to be reconstructed. They can include skin, fat, muscle, supportive fascia, bone, or combinations of these tissues. Breast reconstruction after a mastectomy is often done with pedicle or free TRAM (transverse rectus abdominus muscle) flaps, which include an abdominal muscle and its overlying fat and skin. Other tissues from the buttock, hip, and thigh may be options for breast reconstruction in selected cases. Free muscle flaps are sometimes used to restore movement in cases of congenital defects, trauma, or nerve disorders. A good example is the gracilis muscle in the thigh, which can be used as a free flap in the forearm to restore finger movement. In cases of trauma or diseases affecting bone, free flaps can be done from the fibula (lower leg), scapula (shoulder blade), iliac crest (pelvis), or radius (forearm), depending on the size and shape of the missing bone. A common example is the use of the fibula to reconstruct the mandible (lower jaw) after extensive cancer resections.

The operations usually require general anesthesia, and may require an extensive amount of time. Sometimes more than one surgeon is involved in order to minimize the operative time and reduce the associated operative risks. The surgical approach generally involves addressing the damaged tissues first. At least one artery and vein are identified as attachment sites for the flap. The free flap is then removed from its original site. At least one artery and vein are identified at the flap site during this part of the surgery, and are divided as the last portion of the flap to be disconnected from the original site. The flap is then brought to the defect site, and the blood vessels are sewn together under the microscope. After reestablishing the blood supply, the remainder of the flap is attached at its new site.

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