Examqo › Examqo library › Otolaryngology – Head and Neck Surgery › Thyroid surgery, reconstruction and trauma · IMLE

Head and neck reconstruction: local, regional and free flaps

Reconstruction after head and neck tumour resection is chosen along the "reconstructive ladder" — from primary closure, through skin graft and local or regional flap (such as pectoralis major), up to a microsurgical free flap; the free flap is today the first choice for large defects, and close monitoring in the first days rescues failing flaps.

לקריאה בעברית

Why it matters in the exam

The common free flaps: radial forearm — thin and pliable, based on the radial artery, suited to the tongue, floor of mouth and pharynx (before surgery hand perfusion is checked with the Allen test); anterolateral thigh (ALT) — supplied by the lateral circumflex femoral artery's descending branch, suited to large defects; fibula — based on the peroneal artery, the choice for mandibular reconstruction after segmental resection (before surgery leg vessel imaging confirms the foot does not depend on the peroneal artery); scapula and iliac crest — bony alternatives; jejunum — for tubular reconstruction of the pharynx. The classic regional flap is pectoralis major, based on the thoracoacromial artery, and a good choice when a free flap is not possible.

The success rate of free flaps is about 95%. Failure comes from venous thrombosis more often than arterial; venous congestion (a bluish, swollen flap with fast, dark bleeding on pinprick) usually appears in the first 24 to 72 hours. Salvage chances are best with return to theatre within hours. Key factors during and after surgery: short ischaemia time, appropriate fluid balance, avoiding pressure on the neck vessels (for example from tracheostomy tube ties), and close monitoring of colour, capillary refill, temperature and Doppler.

Repair of cleft lip and palate is part of the reconstruction topics in the exam. Cleft lip is repaired with the rotation-advancement technique (Millard), usually around age 3 months. Cleft palate is repaired at age 9 to 12 months, before speech develops; the Furlow operation is a double-opposing Z-plasty that lengthens the palate and turns the levator veli palatini muscle to lie transversely. Children with cleft palate are at high risk of middle ear effusion and hypernasal speech.

Key points

• Reconstructive ladder: from primary closure to free flap.
• Radial forearm — thin; ALT — large; fibula — mandible.
• Success about 95%; venous failure is commoner.
• Venous congestion → immediate return to theatre.
• Cleft palate: 9 to 12 months, Furlow.

Summary table

Free exam questions

In the full version for subscribers

• A simple algorithm
• Memory aid
• Exam traps
• 5 review cards
• Enough for IMLE

The full version is open to subscribers of: ENT and head and neck surgery, Medical licensing exam (IMLE), General surgery, Plastic surgery.

Subscriber? Read the full topic Plans and prices 25 free questions

Sources

• Cummings Otolaryngology: Head and Neck Surgery, 7th edition (2021) — Free tissue transfer; regional and local flaps
• Urken ML. Atlas of Regional and Free Flaps for Head and Neck Reconstruction, 3rd edition (2023) — Radial forearm, fibula and anterolateral thigh flaps
• Neligan PC. Plastic Surgery, 5th edition (2023) — Cleft lip and palate repair

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.