Head and Neck Free Flaps: Monitoring, Salvage, and Reconstruction

Free flap success depends on much more than a patent anastomosis. In this lecture, head and neck surgeon David Choi explains how microcirculatory failure, reperfusion injury, and the no-reflow phenomenon shape postoperative decisions—and why a reassuring Doppler signal can still be misleading.

Using clinical cases and literature data, the session compares arterial insufficiency with venous congestion, shows how flap color, capillary refill, turgor, bleeding, and temperature should be interpreted together, and outlines when immediate return to the operating room matters most. It also covers buried-flap monitoring, leech therapy as a rescue option, the role of nursing teams, and practical ways to reduce critical secondary ischemia time.

The second half challenges common perioperative habits around anticoagulation, aspirin, vasopressors, fluids, and antibiotics, then moves into reconstructive planning for mandibular and maxillary defects. Fibula, scapular, and osteocutaneous radial forearm flaps are compared through operative anatomy, donor-leg selection, vessel geometry, skin-paddle orientation, imaging, and technical pitfalls—including several details that can determine whether a seemingly good reconstruction remains reliable after the operation.