Journal of Surgical Oncology 2009;99:80–81

HOW I DO IT

A Simplified Technique of Free Flap Pedicle Transfer for Reconstruction of

Defects Following Head and Neck Cancer Ablation

RAJEEV SHARAN, MCh, MOHIT SHARMA, MCh, SUNDEEP VIJAYARAGHAVAN, MCh, P.R. SASIDHARAN, MCh,MONI ABRAHAM KURIAKOSE, MD, FRCS, AND SUBRAMANIA IYER, MCh, FRCS*

Head and Neck Institute, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India

Free flaps are being widely used for reconstruction of defects following head and neck cancer ablation. The pedicle of the flap is usually tunneled

into the neck wound for anastomosis to the neck vessels. This transfer of the pedicle can be technically difficult to execute and associated with

difficulties of torsion and kinking. No effective method has been so far reported to make this procedure easy and safe. A very easy and effective

method for the pedicle transfer is described in this report, which has been practiced successfully in our head and neck service in more than 175 free

flaps.

J. Surg. Oncol. 2009;99:80–81. � 2008 Wiley-Liss, Inc.

KEY WORDS: free flap; pedicle transfer; head neck reconstruction; microvascular surgery

INTRODUCTION

Free microvascular flap reconstruction has become the standard of

care in head and neck reconstruction after tumor resection, resulting in

a predictable functional and aesthetic outcome [1–3]. In majority of

the microvascular free flap reconstruction in the head and neck region,

main sources of recipient vessels are the neck vessels. This necessitates

transfer of the free flap pedicle through a tunnel to reach the neck

vessels. It is essential that there should not be any distortion or twisting

of the pedicle during transfer of the pedicle through the tunnel. If flap is

being used for maxilla or skull base, the tunneling has to be long in the

subcutaneous plane and the transferring the pedicle through that long

tunnel becomes cumbersome. Generally two methods are used to

transfer the pedicle through the tunnel: (a) the hemostat forceps is

introduced from the neck wound to the defect and the same hemostat

forceps catches the tip of the pedicle and pulls it into the neck. (b) Pass

a thread or string along the tunnel and then attach the end of the pedicle

to pull it into the neck wound. Both of these have inherent problems.

Most importantly, twisting and rotation of the pedicle that might occur

within the tunnel could not be obvious while inspecting the end

delivered in the neck wound. The pedicle might slip off from the suture

or forceps within the tunnel while transferring, requiring repetition of

the whole procedure. This might cause damage to the ends of the

pedicle, requiring trimming which might shorten the pedicle length.

Once the pedicle has reached the neck wound, it may retract into the

tunnel unless anchored to the surrounding tissues, prior to the

anastomosis. To circumvent all these problems, we have developed a

simple and effective technique of railroading the pedicle inside a red

rubber catheter. We have used this simple technique in the last 175 free

flap transfers in the head and neck region during the past one and

half year.

METHODS

After resection of the tumor and isolation of the neck donor vessels,

a tunnel is created in the standard fashion extending from the defect to

the neck. Hemostasis is achieved within the tunnel. It is essential that

the tunnel should be made broad enough to prevent compression of the

pedicle. The wider proximal part of a red rubber catheter 10 or 12

French size is caught hold by the end of this hemostat forceps and then

pulled out through the primary defect. The flap is transferred to the

defect and the tip of the pedicle is pushed inside the wide proximal part

of the catheter. The perivascular tissue is sutured to the catheter with

3–0 silk suture (Fig. 1), ensuring that the pedicle end is well inside the

catheter and protected. Traction is now applied to the end of the

Fig. 1. Free flap pedicle sutured to the wider part of the red rubbercatheter.

No financial support or funding required for this study.

The authors have no financial relationship to disclose.

*Correspondence to: Subramania Iyer, MCh, FRCS, Professor and Head,Department of Plastic and Reconstructive Surgery; Consultant, Head andNeck Institute, Amrita Institute of Medical Sciences, Amrita Lane,Elamakkara PO, Cochin 682026, Kerala, India. Fax: 91-484-280-2028.E-mail: subu@aims.amrita.edu

Received 26 August 2008; Accepted 2 September 2008

DOI 10.1002/jso.21162

Published online 20 October 2008 in Wiley InterScience(www.interscience.wiley.com).

� 2008 Wiley-Liss, Inc.

catheter that is in the neck wound, bringing the pedicle in the neck

(Fig. 2). Skin paddle of the flap is anchored at different points to the

defect edges to inset the flap. While insetting the flap even if pedicle

length is slightly less, catheter supports the pedicle preventing its

retraction into the tunnel. Once the pedicle position found to be

satisfactory, suture holding the catheter is cut and catheter is removed.

The vascular anastomosis is then carried out.

DISCUSSION

Kinking or distortion of the vascular pedicle during free flap

reconstruction is a potential cause for flap complication. Herein, we

report a simple and effective technique to prevent this complication.

Pedicle transfer is especially important in the reconstruction of defects

of oral cavity, soft palate, maxilla and skull base where a long tunnel

needs to be created either over or under the mandible to pass the

pedicle into the neck. Tunneling becomes more complex and difficult

in reconstruction of maxilla and skull base due to uneven surface of the

facial bone where the tunnel to be made, is not in a single plane.

Transferring flap pedicle to the anastomotic site requires meticulous

attention and patience, especially when the pedicle has to take a long or

curved course to reach the donor vessels. The methods currently used

in transferring the pedicle through the tunnel, has the inherent

problems of crush injury to the tip of the pedicle, twisting of the pedicle

within the tunnel and slippage of the pedicle while transferring due to

loss of grip. The technique reported is a very simple, time saving and

reliable way of transferring pedicle avoiding all these pitfalls. It

stabilizes the pedicle without retraction into the tunnel while the flap is

insetted, in cases where the pedicle length is just adequate. We have

used this technique in over 175 free flap transfers in head and neck

region with perfect ease and devoid of problems. This can be used

anywhere in the body where the pedicle needs to be transferred through

the tunnel.

REFERENCES

1. Su WF, Hsia YJ, Chang YC, et al.: Functional comparison afterreconstruction with a radial forearm free flap or a pectoralis majorflap for cancer of the tongue. Otolaryngol Head Neck Surg2003;128:412–418.

2. Soutar DS, Scheker LR, Tanner NS, et al.: The radial forearm flap: aversatile method for intraoral reconstruction. Br J Plast Surg1983;36:1–8.

3. Swartz WM, Banis JC, Newton ED, et al.: The osteocutaneousscapular flap for mandibular and maxillary reconstruction. PlastReconstr Surg 1986;77:530–545.

Journal of Surgical Oncology

Fig. 2. Red rubber catheter pulled out from the neck wound, bringingthe flap pedicle in the neck.

Free Flap Pedicle Transfer 81