Flap Debulking and Secondary Revisions in Head and Neck Reconstruction: A Systematic Review with Clinical Applications

Abstract

Flap debulking and secondary revisions are an integral factor in providing optimum outcomes to reconstructive patients. This review article summarizes systematically the available literature on flap debulking in head and neck reconstruction. The clinical applications of debulking techniques are discussed, including fractional direct excision, liposuction, and single-stage excision or planning with skin grafting. New technologies are also discussed.

Flap debulking and secondary revisions are commonplace in head and neck surgery. Many of these procedures are planned operations necessary to provide appropriate contour in the delicate structures of the head and neck. Despite the frequency in which these procedures are performed, there are relatively few references in the literature. Therefore, it is worthwhile to revisit this fundamental aspect of plastic and reconstructive surgery.

Recent advances in microsurgery have led to improved single stage outcomes by performing primary thinning of the flap. Radial forearm flaps remain a viable option in some populations as they provide thin, soft tissue coverage that rarely requires debulking. However, there can be significant donor morbidity and size limitations with this flap. Ultimately, the choice of flap should be determined to minimize the chance of failure and to reduce the number of revisions.

Since these tissue transfers are replacing missing tissue, a flap may often exceed the volume or contour needs of the recipient defect. These contour problems may exist for all types of flaps whether random, pedicle, perforator, or free tissue transfers. The goal of any reconstructive surgery is to maximize function while providing the best possible aesthetic outcome. Previous outcome studies have demonstrated that patients dislike bulky flap appearance, and this is a source of patient dissatisfaction after the initial surgery. ^{1 2} The purpose of this study is to systematically review flap debulking and secondary revision in the head and neck. In addition, clinical applications will be discussed.

Systematic Review

Methods

Literature Review

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. ³ Prior to literature search, a study protocol was formulated. PubMed, Web of Science, ScienceDirect, and Cochrane Library database searches of English-language publications were performed, including articles from 1975 to 2022. Search terms via each database included: PubMed: (((head and neck [MeSH Terms]) AND (surgical revision [MeSH Terms])) AND (flap)) AND (contour:).AND flap debulking; Web of Science: head and neck (topic) and surgical revision (Topic) and flap (All Fields) and contour (All Fields); ScienceDirect: “flap, contour” under “Find articles with these terms” and “head and neck, surgical revision” under “Title, abstract or author-specified keywords”; and Cochrane Library: head and neck in Title Abstract Keyword AND surgical in Title Abstract Keyword AND flap AND contour. The last literature search was performed on August 28, 2022.

Selection Criteria

The exclusion criteria were: (1) Any study that did not discuss flap revision and final outcomes, (2) studies that discussed flaps without mentioning the specific technique, (3) flap reconstructions performed for other reasons that did not include head and neck defects, and (4) any study that had a population size of less than 10. Titles and abstracts were reviewed initially to discard any studies that were deemed irrelevant for our objective. The full text of the remaining studies was then analyzed to ensure that all elements of the inclusion criteria were satisfied without any disqualifying qualities being present. Disagreements between reviewers were resolved through discussion and ultimately reaching a consensus between the reviewers. The reference lists of all selected studies were also reviewed for relevant studies that could be included in the systematic review. The process of article selection followed the PRISMA protocol as shown in Fig. 1 .

Fig. 1.

Flow diagram demonstrating the systematic review process according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol.

Quality Assessment of Information Sources

As the selected search terms were considerably focused, there were no limits applied across all databases during literature search to maximize the amount of studies available for potential inclusion in the systematic review. Studies included were case reports, case series, reviews, retrospective studies, and nonrandomized studies. Given the extensive publication period range of 47 years within the studies undergoing systematic review, there is an inherent risk of bias given advancements in surgical techniques and knowledge of human anatomy that pose different complications than faced in studies published earlier, making comparison somewhat cumbersome. Taking that into account, the quality of evidence and risks of bias of the studies included were assessed according to the MINORS (Methodological Index for Non-randomized Studies) criteria. ⁴ Twelve criteria are used to evaluate the level of evidence of comparative studies on a graded scale of 0 to 2. The following scores and their interpretations are as follows: 0 = not reported; 1 = reported but inadequate; 2 = reported and adequate. Totaling up to 24, noncomparative studies with a MINORS score of > 16 were considered to have low risk bias.

Search Results

A flow diagram of the search strategy and study selection process followed according to the PRISMA. A total of 367 studies were retrieved from database searches. Nineteen additional studies were retrieved from manually searching references in the selected articles of interest from the initial search. Records were then scanned for the possible presence of duplicate articles, in which 4 duplicates existed. Titles and abstracts were then scanned for adequate relevance to the objective. In such instances that it was unclear whether a study was to be included or excluded from scanning both the title and abstract from the established selection criteria, the full article was assessed for relevance. This initial screening of title and abstracts resulted in the exclusion of 302 articles. Upon assessing the full text of the remaining 80 articles for eligibility, 42 more articles were excluded from incorporation into systematic review due to not adequately satisfying the established inclusion criteria set forth. Thirty-eight articles were retained for analysis; however, upon further evaluation of the full text of the retained articles, 7 additional studies were excluded for reasons specified in Fig. 1 . A total of 31 articles were included for qualitative analysis after selection process.

Results

Study Types

A total of 31 articles were included in the systematic review after completion of the selection process. Study types included in the review were retrospective studies, nonrandomized studies, case series, and case reports. Table 1 provides more detail with respect to flaps used in each study and the corresponding authors of each article that were included in the systematic review.

Table 1. Overview of the studies included for systematic review with demographical data, location of head and neck defects, types of flaps used in reconstruction, mean follow-up, complication rates, and revision rates.

Flap classification	Article	MINORS score	Population size	Age range; gender (male or female)	Location	Any complications? (%)/Any revisions? (%)	Mean time range of follow-up	Type of flap(s) used (cm, cm x cm, cm 2 )
Soft tissue	Hanasono et al 5	21	40	13–79 years old; 25 male and 15 female	Temporal fossa, face	Yes, 30% (3 infections, 1 wound dehiscence, 1 CSF leak, 5 seromas, 3 infections); 50% revision rate	17.6 months	Adipofascial perforator flaps (ALT, DIEP) (14 × 6.5 cm, 8.2 × 6.1 cm, 12.9 × 6.6 cm)
	Tan et al 6	16	11	38–68 years old; 2 female, 9 male	Oral cavity	No complications reported; 100% revision rate	6 months	Myocutaneous free flap (N/R)
	Lai et al 7	14	12	43–69 years old; 0 female, 12 male	Oral cavity	No complications reported; 100% revision rate	5 months	ALT flap (N/R)
	Cigna et al 8	21	45	34–68 years old; 13 female, 32 male	Oral cavity	No flap complications reported; 30% revision in group 1, 100% revision rate in group 2	62.4 months	ALT flap (9 × 6 cm – 18 × 9 cm)
	Spyriounis and Lutz 9	16	23	32–85 years old; 6 female, 17 male	Head and neck (face)	Yes, 4%, (partial skin regraft); 9% revision rate	45 months	Vastus lateralis flap (24 cm 2 –225 cm 2 )
	Wolff et al 10	14	187	9–82 years old; 43 female, 144 male	Oral cavity, neck,	Yes, 13% (flap loss, fistula, partial flap necrosis, donor site seromas); 31% revision rate	133.5 months	ALT flap (3 × 5 cm – 21 × 10 cm)
	Liu et al 11	22	32	No preop CTA (group 1), 46–69 years old; 0 female, 17 male / pre-op CTA (group 2), 39–75 years old; 0 female, 15 male	Cheek (face)	Group 1, yes, 65% (flap necrosis, fistula, venous thrombosis, flap dehiscence, delayed wound site healing, muscle necrosis, partial skin graft loss); 56% revision rate Group 2, yes, 20% (hematoma, venous congestion, flap dehiscence, delayed wound healing); no revisions reported	16.8 months	ALT flap (group 1, ∼165 cm 2 ; group 2, 170.55 cm 2 )
	Park 12	12	10	N/R	Nose (face)	Yes, 10% (epidermolysis); no revisions reported	N/R	Forehead island flap (N/R)
	Gharb et al 13	18	20	9 months old – 18 years old; 6 female, 14 male	Head and neck (face)	Yes, 35% (venous thrombosis, flap necrosis, skin necrosis, donor site hypertrophic scar); 40% revision rate	36 months	ALT flap (4 × 8 cm – 25 × 8 cm)
	Sadigh et al 14	15	60	28–78 years old; 3 female, 57 male	Head and neck (face)	Yes, 7% (wound infection, flap necrosis); 100% revision rate	10 months	Random pattern, pedicled perforator with skeletonization, without, free perforator flap); mean flap size = 7.4 × 4.8 cm
	Ozkan et al 15	12	11	18–82 years old; 1 female, 10 male	Scalp, temporal fossa, face	Yes, 18% (vascular compromise, pedicle torsion); no revisions reported	N/R	ALT flap (6 × 15 cm – 18 × 24)
	Goh et al 16	16	210	4–80 years old; 92 female, 118 male	Oral cavity, trunk	Yes, 24% (flap necrosis, venous congestion, arterial thrombosis, venous thrombosis, hematoma, negative exploration, traumatic injury, partial flap loss, BKA); 12% revision rate	54.6 months	SCIAP flap (17.5 cm 2 –216 cm 2 )
	Hanasono et al 17	20	117	49.8–78.4 years old; 22 female, 95 male	Temporal fossa	Yes, 23.0% (wound infection, CSF leak, hematoma, arterial thrombosis, seroma, donor site morbidity, wound dehiscence, pneumonia); 12.1% revision rate	48.6 months	Regional flap: Temporalis flap Free flap: ALT flap, rectus abdominis flap, latissimus flap, serratus anterior flap, gracilis flap, groin flap, lateral arm flap, RFFF (cutaneous defects: regional flaps = 0–42 cm 2 , free flaps = 0–225 cm 2 ; regional flap defects: entire temporalis used, free flaps = 63–223 cm 2 )
	Higgins et al 18	18	13	37–89 years old; 2 female, 11 male	Face, neck	Yes, 15% (pulmonary embolism, hematoma); no revisions reported	22 months	ALT flap (8 × 5 cm – 14 × 8.5 cm)
	Yu 19	14	69	38–91 years old; 18 women, 50 men	Face, oral cavity	Yes, 9% (donor site morbidity, seroma, hematoma, wound dehiscence, flap necrosis)	N/R	ALT flap (N/R)
	Soutar and McGregor 20	13	60	54–85 years old; 21 female, 39 male	Oral cavity	Yes, 10% (arterial thrombosis, venous thrombosis, flap ischemia); 7% revision rate	25 months	RFFF (N/R)
	El-Marakby 21	11	25	N/R	Oral cavity, face, neck	Yes, 60% (wound dehiscence, infection, hematoma, seroma, partial flap failure, fistula, donor site morbidity); no revisions reported	N/R	PMMPF (N/R)
	Hu et al 22	16	23	13–32 years old; 17 female, 6 male	Face, temporal fossa	Yes, 4% (partial fat necrosis); 100% revision rate	30.8 months	ALT flap (9 × 18 cm), latissimus flap (N/R)
	Haddock et al 23	11	346	N/R	Face	No complications reported; 89% revision rate	N/R	Parascapular flap
	D'Souza et al 24	18	12	5–13 months old, gender N/R	Neck	Yes, 44% (hypertrophic scar, wound dehiscence); 33% revision rate	6 months	Double z-plasty (3 cm)
	Song et al 25	12	13	17–42 years old; 9 female and 4 male	Face, temporal fossa	Yes, 8% (VTE); 100% revision rate	N/R	Dorsal thoracic adipofascial free flap (∼9 cm)
	Disa et al 26	14	18	16–75 years old; 5 female and 13 male	Temporal fossa	Yes, 33% (wound dehiscence, hematoma, VTE); 33% revision rate	N/R	ALT flap, latissimus flap, rectus abdominis flap, lateral arm free flap (6 × 12 cm, 115 cm 2 , 161 cm 2 , 10 × 20 cm, respectively)
Osteocutaneous	Fan et al 27	19	51	Group 1, 27–69 years old/ group 2, 19–71 years old; 17 female, 11 male/14 female, 9 male, respectively	Maxilla and mandible	Group 1 = Yes, 4% (flap necrosis; no revisions reported Group 2 = Yes, 30% (flap necrosis, skin necrosis); 63% revision rate	3 months	Osteomyofascial free fibula flap [group 1], osteocutaneous free fibula flap [group 2] (3.5 × 4.0 cm – 10.5 × 7.5 cm, 2.5 × 3.0 - 9.5 × 7.2, respectively)
	Rüegg et al 28	16	50	1–23 years old; 33 female and 17 male	Maxilla, mandible, malar cheek	Yes, 40% (wound healing, soft tissue necrosis, bone necrosis, wound dehiscence, infection); 24% revision rate	312 months	Prefabricated vascularized calvarium flap (N/R)
	Dornhoffer 29	17	38	12–70 years old; 12 female, 8 male	Temporal fossa	No complications reported; 100% revision rate	24 months	Palva flap, cartilage-perichondrium island flap
Mixed	Wooden et al 30	17	12	N/R	Face, neck	No complications; 86% revision rate	21 months	RFFF, scapular fasciocutaneous flap, axillary fascial-fat free flap, gracilis flap, omental flap transfer (N/R)
	Garg et al 31	21	186	Mean = 64.4 years old for patients that underwent revision, mean = 62.7 years old for those that did not; 9 female, 10 male and 46 female, 121 male, respectively	Oral cavity (face)	No complications reported; 10.2% revision rate	23.4 months for patients that underwent revision, 12.7 months for patients that did not	ALT, RFFF, fibula flap, scapula flap, rectus abdominis flap (N/R)
	Cigna et al 32	9	11	N/R	Face	No complications reported; 100% revision rate	N/R	N/R
	Parrett et al 33	16	32	16–62 years old; 11 female, 21 male	Neck	Yes, complications reported by flap (flap loss, tip necrosis, infection, donor site seroma, dehiscence), only three flaps (groin, lower abdominal, rectus) without a complication reported (67%); 100% revision rate	12 months	Parascapular flap, ALT flap, RFFF, latissimus flap, rectus flap, groin flap, lower abdominal flap, prefabricated flap, prelaminated flap (N/R)
	Howard et al 34	19	31	44–89 years old; 3 female, 28 male	Temporal fossa	Yes, 6% (hematoma); 100% revision rate	99 months	Submental flap, latissimus flap, ALT flap (N/R)
	Schusterman et al 35	16	288	14–89 years old; 98 female, 190 male	Face, oral cavity	Yes, 36% (hematoma, infection, fistula, seroma, donor site morbidity); no revisions reported	14.2 months	Deep circumflex iliac artery flap, lateral thigh flap, free jejunal transfer flap, RFFF, latissimus flap, fibula flap (N/R)

Abbreviations: ALT, anterolateral thigh; BKA, below-the-knee amputation; CSF, cerebrospinal fluid; CTA, computed tomography angiography; DIEP, deep inferior epigastric perforator flap; MINORS, Methodological Index for Non-randomized Studies ; N/A, not applicable; N/R, not reported; PMMPF, pectoralis major myocutaneous pedicle flap; RFFF, radial forearm free flap; SCIAP, superficial circumflex iliac artery perforator flap; VTE, venous thromboembolism.

Quality Assessment

As discussed earlier, the MINORS criteria were used as the measurement tool to assess the quality of evidence and the risk of bias within the studies included for systematic review. The study scores ranged from 9 to 22. The mean and median scores were 15.7 and 16, respectively. Seventeen of the 31 studies had a MINORS score of 16 or greater. Most studies were retrospective studies and case series that were deficient in the categories of blinded evaluations, power calculations, and adequate group control. Most of the studies had clear and well stated aims with endpoints that were appropriate to the aim of the studies. Only one study had a low MINORS score of 9; however, it was still included in the systematic review as there was no minimum MINORS score established in the protocol for inclusion.

Demographic Parameters

Age and gender were part of the baseline demographics mentioned in most studies. Most of the studies consisted of adult patient populations, whereas only two studies looked at pediatric populations exclusively. The number of patients included in a study ranged anywhere from 10 to 346. Based on the type of flap reported for use in reconstruction, studies were categorized into the flap classifications of soft tissue, osteocutaneous, and mixed. The “soft tissue” classification consisted of musculocutaneous and cutaneous flaps only whereas the “osteocutaneous” classification consisted of osteocutaneous flaps only. For a study to be classified as “mixed,” both osteocutaneous and soft tissue flaps were included in the study. Additional demographic details can be found in Table 1 .

Revision Rates

Of all studies included in the systematic review, only one study did not employ the use of a flap within their revision process of head and neck reconstruction. The location of defects and types of flaps used in each study along with its size dimensions can be found in detail in Table 1 . Rates of complication and revision were also reviewed for each study. Out of the 31 studies, 8 studies did not report any complications that developed during reconstruction or postop. As for revisions, 7 studies in the systematic review reported no revision procedures performed after initial flap reconstruction. Further details regarding the different kinds of complications that developed in each study, in addition to the percentages of complication and revision experienced are also explored in Table 1 . All revisions performed were for correction of a complication of prior surgery or for secondary debulking of a flap to achieve adequate contour.

Outcomes

The etiologies of the reported defects along with the time range of follow-up after reconstruction and revisions if performed, were reviewed. As stated before, most studies were deficient in establishing adequate protocols for blinded evaluations to be recorded. Some of the included studies spoke to patient satisfaction and recurrence of said defects within their evaluation of outcomes while some studies did not. Ultimately, only 9 studies reported an experience of flap loss in their overall outcomes. The pooled mean complication rate of all included studies was 19%. The pooled mean revision rate was 46%. Mean complication rates recorded for the flap classifications of soft tissue, osteocutaneous, and mixed were 19, 19, and 18%, respectively. Mean revision rates recorded for the flap classifications for soft tissue, osteocutaneous, and mixed were 41, 47, and 66%, respectively. Further details regarding the associated mean complication and revision rates for each flap classification can be found in Table 2 .

Table 2. Overall analysis of complication rates and revision rates reported in the studies included in the systematic review.

Flap classification	Mean age (y)	Gender (male/female)	Mean follow-up (mo)	Mean complication rate	Mean revision rate
Total ( soft tissue)	84	Female = 275; Male = 688	23.6 mo	19%	41%
Total ( osteocutaneous )	70	Female = 76; Male = 45	113 mo	19%	47%
Total ( mixed )	75	Female = 167; Male = 370	27.4 mo	18%	66%

This systematic review has some significant limitations. The heterogeneity and abundance of recipient defects and the variety of flap choices make the task of trying to pool revision rates almost an impossible task. In addition, the variation of individual patient body habitus and comorbidities also make the pooling of studies extremely difficult. However, the list of articles included in Table 1 provides a summary of the significant published literature on the topic of head and neck flap debulking.

Clinical Applications

Preoperative Planning

The choice of donor flap directly impacts the likelihood of revision or debulking procedures. ³⁶ The five main considerations in choosing a flap are (1) size, (2) location, (3) composition, (4) hair bearing recipient or donor, and (5) patient characteristics.

First, the dimensions of the flap should ideally match the dimensions of the recipient defect. While this seems obvious on first glance, the delicate structure and function of the head and neck do not always allow a perfect match. But through a combination of flap selection, prefabrication, and secondary procedures acceptable outcomes are usually achievable.

The location of the recipient defect in the head and neck also determines the choice of donor flap. If a circumferential oropharyngeal defect is present either a thin enough flap that can be fashioned into a tubular structure or a free jejunal flap would be appropriate reconstruction.

Composite defects including maxilla or mandible are challenging to reconstruct. Virtual surgical planning has increased in popularity and improved patient outcomes. Although secondary procedures are still occasionally required.

The presence of hair on cutaneous flaps also may be a consideration. While a radial forearm flap or medial sural cutaneous perforator flap might provide thin coverage for the floor of mouth or tongue defect. The presences of a significant amount of hair growth intraorally can be distressing to the patient. Hair reduction lasers and postoperative radiation may reduce hair growth but these issues are best avoided if possible with good planning.

Finally, patient characteristics such as body habitus, prior surgery, and comorbidities also influence flap choice. Published studies need to be evaluated based on the study population. A series of anterolateral thigh (ALT) flap outcomes will be much different in a patient population with a low body mass index (BMI) compared with higher BMI in terms of the debulking and secondary revision rates. Also, prior surgery and radiation may demonstrate the necessity of extended arteriovenous loops for vascular access, which also may impact outcomes.

The achievable outcomes are variable based on the amount and location of tissue missing. No head and neck review article would be complete without referencing the multistage forehead flap debulking refinements for nasal reconstruction as described by Menick. ³⁷ However, massive tissue loss due to facial shot gun blasts or burn injuries may only be amenable to composite tissue allografts.

It is also important to recognize in some areas adequate bulk is needed for long-term function. For example, total glossectomy defects require bulk to allow lateralization of fluids and saliva to swallow. A lack of bulk leads to pooling of secretions in the floor of the mouth. Coverage of calvarial exposure frequently requires large flaps such as latissimus dorsi muscle and split-thickness skin graft or ALT flaps. If a flap is required to cover the jaw, the flap must be thin enough to allow denture or osseointegrated implant fixation. If muscle-only free flaps are used for coverage of defects, the shrinkage over time due to denervation of the muscle needs to be considered before performing primary or early debulking.

Primary Thinning

As the understanding of flap perfusion has improved, plastic surgeons are becoming more comfortable with primary thinning or debulking of myocutaneous or fasciocutaneous flaps. This is to reduce or eliminate the number of secondary revisions. While this is certainly possible, these techniques should be individualized and applied according to the experience of the surgeon. Patient safety should always be the primary goal. The senior author's experience has been that overaggressive primary debulking may lead to partial flap loss especially in the obese American population with comorbidities.

Secondary Flap Debulking Techniques

Three basic techniques exist for debulking flaps. These are staged fractional excision, liposuction, and single-stage excision (planing) with or without skin grafting. In addition, there are innovative techniques with advanced technology that have been described.

Direct Fractional Excision

Excess tissue in bulky flaps can be excised directly, assuming proper delay has been given from initial flap reconstruction. Staged fractional excision is the elevation of a portion (usually ⅓ to ½) of the flap with direct subcutaneous excision and then suture repair of the skin. The incision should be made along the long axis of the flap. Excising along the tip of the flap in “U” or “V” fashion is not recommended, as both are associated with greater risks for flap necrosis and loss. ^{38 39} If multiple excisions are needed, a two-staged approach is recommended and still proven useful to practicing surgeons all over; however, this approach can require a 3- to 6-month period in between subsequent debulking procedures before finally achieving overall patient satisfaction. It is important to ensure proper delay and be extremely careful in excision of perforators because if adequate care is not taken with subfascial layers, flap necrosis can ensue.

Liposuction

Liposuction is a very well-established technique that is used for removal of excess subcutaneous tissue, which has great utility in flap debulking. Its utility is greatly limited when the flap is complicated with fibrotic tissue. Options for liposuction cannulas will depend upon the size of the flap and amount of tissue to be removed and the tolerance for contour irregularity. Generally a 3- to 4-mm blunt-tipped cannula is used with multiple points of access and preinjection with tumescent fluid. Pretunneling is performed after infiltration and before fat extraction. This technique allows easier removal of fat in adipofascial flaps that require debulking. Muscle flaps usually do not respond to liposuction and require direct surgical excision as the most straightforward debulking technique. It is generally recommended that a minimum of 3 months elapsed from initial flap reconstruction before beginning liposuction, as that is when it is believed the flap is viable without its main pedicle and initial operative edema has resolved. Salgarello et al demonstrated liposuction does not inflict injury to most perforating vessels and proving to be a very safe technique, recent studies have shown that it is still important that careful technique be used when around the pedicles after 3 months has passed as it is still possible to inflict damage to the pedicles and increase risk for flap necrosis. ⁴⁰ Ultrasound-assisted liposuction and power-assisted liposuction are options that can provide good outcomes, as it decreases chance of tissue damage from mechanical stimulation; however, it does come with slight risk of damage to flap from thermal injury. ⁴¹ Excision of resulting excess skin should be delayed by approximately 2 to 3 months after liposuction to allow subsequent postliposuction skin contraction to take effect. It is recommended to apply gentle compressive dressing after completion of the procedure to prevent seroma and hematoma formation.

Liposuction can reduce the amount of subcutaneous tissue of the flap while protecting the vascular pedicle. ⁴¹ It is uncommon to injure the vascular pedicle with liposuction and for the most clinical situations enough vascular ingrowth has occurred that there is no need to maintain a dominant pedicle to the free flap. This is due to the extensive blood supply ingrowth from the wound base and periphery. Specifically in the head and neck with exposed calvarium there may be a need to preserve the dominant pedicle due to the lack of vascular ingrowth from denuded or radiated exposed calvarium.

Single Stage Debulking with or without Skin Graft

This technique involves shaving or planing a flap to the desired thickness and then resurfacing the resulting wound base as a single stage. This technique is useful for muscle flaps that fail to atrophy and also for skin flap that have excess hair growth. Intraoral flaps that have been debulked in this manner can be allowed to reepithelialize which generally occurs in a few weeks. ²⁷ Spare parts usage of the areas of the flap to be discarded should also be considered. If a cutaneous skin paddle is present consider using this as a donor site before utilizing other autograft donors such as the thigh, abdomen, or scalp. While these are frequently required it is preferred to utilize the skin on the debulked flap first. This can be harvested with an air or electric dermatome with preinjection with tumescent fluid since the sound base is then thinned to appropriate depth. A thicker split graft at 16–181000th makes harvesting easier. Meshing the graft for expansion also helps minimize any additional donor site requirements.

Finally, advanced techniques utilizing power assisted liposuction and arthroscopic shavers have been described. However, these technologies do not obviate the need to follow basic principles of flap perfusion and patient safety. ⁴² The main drawback of this debulking method is its limited ability to remove fibrotic tissue, for which arthroscopic cartilage shaver may serve as a better technique in this setting. ⁶

Conclusion

Flap debulking and secondary procedures are common in head and neck reconstructive surgery. Proper patient selection and flap choice can reduce the number of additional procedures but does not eliminate the need for debulking. Primary flap thinning may also reduce or eliminate the need for debulking procedures but overaggressive primary thinning may risk partial flap loss. Patient safety should always be the prime consideration.