Free tissue transfer is a very effective reconstructive technique for challenging defects of the head and neck and in many cases the gold standard for congenital facial paralyses and composite defects. Although its use in the pediatric population is not new and the success rates are comparable to those in adults, there is still a lack of information about its applications in children. This study aims to review the indications for use and discuss the anatomic considerations that may influence surgical complexity and long-term outcomes in the developing craniofacial skeleton.

Microvascular free flap surgery has become the gold standard for head and neck reconstruction. There is significant variability in the technical aspects of this type of surgery, but commonalities can be found regarding general workflow and practice setup. This text will highlight several strategies to help the reconstructive head and neck surgeon improve efficiency, outcomes, and surgeon wellness.

Microvascular free tissue transfer in head and neck surgery has evolved through technological advancements, focusing on enhancing surgical outcomes and reducing complications. The strategic process involves preoperative planning for perforator mapping, intraoperative devices for microvascular anastomoses and patient positioning, and innovative postoperative monitoring techniques ensuring flap viability. This workflow has led to a high flap success rate, although revision surgery can still be necessary. This article aims to explore recent advances in microvascular free tissue transfer technology utilized across the preoperative, intraoperative, and postoperative domains for enhanced surgical efficacy.

This article aims to provide an update on techniques related to head and neck reconstruction using microvascular free tissue transfer, focusing on strategies for donor vessel selection in the vessel depleted neck, use of vein grafting and mechanical arterial coupling, estimating flap volume loss, and utilization of virtual planning and medical modeling for midface and mandibular reconstruction.

Microvascular free-flaps have changed reconstructive surgery. For patients undergoing maxillomandibular resections, free-flap surgery, especially use of the osseocutaneous fibula free-flap (FFF) has dramatically altered the ability to provide patients with good functional and aesthetic outcomes despite a large resection. The use of endosseous dental implants along with free-flaps has helped patients return to eating and speaking relatively quickly postoperatively. Implants can be placed primarily or secondarily depending on specific criteria. The Jaw in a Day concept has revolutionized providing patients with a rapid aesthetic and functional outcome for those undergoing maxillomandibular resections.

The complexity of the midface structure and its importance to a multitude of functions present the reconstructive surgeon with unique challenges. The midface is an area that is crucial both functionally and esthetically. Midface reconstructions can make profound differences in form and function. This review focuses on complex midface and maxillary reconstructions requiring free tissue transfer.

Reconstruction of the oropharynx plays a critical role in preserving quality of life after surgical resection of oropharyngeal carcinoma. Free tissue is one of several reconstructive options, which can closely approximate native oropharyngeal anatomy and lead to favorable functional outcomes in carefully selected patients. Here, the authors provide an overview of the indications, treatment options, functional outcomes, potential complications, and future considerations for free flap reconstruction of the oropharynx.

This article describes the background and importance of scalp reconstruction. The relevant anatomy and neurovasculature will be discussed. Finally, the entire reconstructive ladder will be examined in its relation to scalp reconstruction and how to optimally reconstruct scalp defects.

Facial paralysis severely impacts a person's ability to interact with the world. Advances in microsurgery, especially free neurotized muscle transfers, have greatly improved reanimation outcomes. The gracilis free muscle transfer, introduced in 1971, is the most widely used procedure for long-standing flaccid paralysis. This review covers recent innovations in gracilis reanimation, including vector design and neurotization options, and introduces the free strap muscle for dynamic facial reanimation.

Enhanced recovery after surgery (ERAS) protocols facilitates a standardized patient care regimen with a goal of reducing the metabolic stress of surgery. Adapted to head and neck free flap reconstructive surgery in 2017, these protocols focused on several key domains such as perioperative nutritional optimization, multimodal pain control, and early mobilization. Studies have shown that in addition to ERAS implementation, the maintenance and improvement of ERAS protocol compliance rates improve perioperative outcomes such as hospital length of stay and decrease major postoperative complications.

Donor site morbidity has become a major focus in free tissue transfer as flap success rates have approached 98%. Emphasis is placed on minimizing the morbidity and optimizing cosmetic and functional outcomes at the donor site. This article reviews techniques to mitigate the donor site morbidity of commonly used free flaps in head and neck reconstruction.

Stabilizing the nasal base is important before working on the nasal tip lobule. This will help define the nasolabial angle, the alar columellar relationship and nasal tip projection and rotation. Columellar struts and septal extension grafts are techniques that balance the nasal base and create a stable structure to modify the nasal tip. The type of graft used, and its design will depend on the patient's needs, cartilage availability and surgical techniques used. An endonasal or open approach can be used. In this chapter, authors will share their experience using columellar struts and the different types of septal extension grafts.

Controversies in Preservation Rhinoplasty" explores the nuanced indications, techniques, and challenges in preservation rhinoplasty (PR), featuring contributions from JC Neves, D Toriumi, and A Göksel. Neves recounts his early career under Wilson Dewes and describes the evolution of PR techniques. Toriumi, having started PR in 2019, discusses his initial cautious approach and subsequent expansion to include patients with more diverse nasal deformities. Göksel highlights the critical role of surgical expertise and individualized patient assessment, advocating for methods like dorsum-plasty osteotomies and the Ballerina maneuver to enhance PR's effectiveness.

Autologous cartilage can be easily and safely harvested as a reliable source of cartilage in rhinoplasty through a small, well-hidden incision. Rib cartilage can be utilized during a primary rhinoplasty when there is insufficient cartilage from the septum or often in revisional nasal surgeries where the initial septal cartilage has previously been used or removed. Rib cartilage carving can be done on a cutting board prior to the beginning of the rhinoplasty in order to allow time for the cartilage to present any warping while it is soaked in saline. Overall autologous rib cartilage is a good source of copious and often good quality cartilage.

Structure rhinoplasty and preservation rhinoplasty are 2 popular philosophies that can be used alone or in combination to provide a hybrid approach. Structure rhinoplasty is the leading option for revision rhinoplasty and utilizes cartilage grafting techniques to support and reconstruct the nose. Preservation rhinoplasty spares bone, cartilage, ligaments, and soft tissues to minimize the need for grafting and preserves the favorable features of the nose. Structural preservation rhinoplasty uses dorsal preservation in the upper two-thirds of the nose and structure rhinoplasty in the lower third. This hybrid approach has great utility in primary, revision, and reconstructive rhinoplasty.

Reprojecting the severely damaged nose is a challenging operation fraught with pitfalls. This panel discussion covers 6 fundamental questions answered by 3 surgeons, each with decades of experience. Discussion points include management of the 3 components necessary for successful reconstruction-the soft tissue envelope, the support structure, and the internal lining. The authors also discuss how their practices have changed in the last few years.

Alloplastic materials are well suited for use in rhinoplasty in the right clinical scenarios, specifically in patients with platyrrhine noses and in challenging revision cases. The most commonly used materials today are silicone and high-density porous polyethylene. Both implant materials carry a unique set of properties and offer various advantages and disadvantages for use. Complications can be minimized with appropriate utilization of implants and using proper technique.

Rhinoplasty is one of the most popular operations in the world. Despite its popularity, rhinoplasty complications are common and stem from a myriad of issues both subjective and objective in nature. Complications of rhinoplasty include scar, asymmetries, irregularities, imperfections, nasal airway obstruction, skin ischemia or necrosis, nasal collapse, nasal deformity, and overcorrection or undercorrection of a perceived nasal irregularity. A thorough understanding of these potential complications, along with strategies for avoidance and management, is critical for ensuring patient safety and optimizing surgical outcomes.