Examination of the patient
1. Patients medical history
The preoperative assessment starts with a thorough history taken from the patient. The nature of the problem is discussed (traumatic, post-tumor removal, etc.) as is the time course of the process. If the planned repair is a secondary reconstruction, the timing of when the defect was created should be determined, as well as the details of the primary operative procedure and any associated treatments (radiation, chemotherapy, previous neck dissections, prior dental implants, etc).
A review of the patient's medical/surgical history and a physical examination should pay special attention to:
- Conditions that compromise wound healing
- Overall health status
- Ability to sustain anaesthesia
- History of peripheral vascular disease (especially for patients undergoing free tissue transfer)
- Previously harvested local flaps and available donor vessels
- The extent of the defect
- Quality/quantity of remaining dentition
- Involvement of overlaying facial skin/soft tissues
- Involvement of eye (midface and skull base defects)
- Cranial nerve function
2. Imaging
CT
Imaging of the primary site should start with CT scan of the:
- sinuses and neck with contrast (midface defects)
- mandible and neck with contrast (mandible defects)
This will provide better detail with regards to bony and dental involvement.
MRI
An MRI may also be necessary to provide improved soft tissue detail, as well as additional information if orbital, skull base or parapharyngeal involvement is suspected.
Panorex
In dentate patients, a panorex may be beneficial to assess the quality of the remaining teeth.
3. Workup of donor site
For individuals where plans are made to perform reconstruction with free tissue transfer, work-up specific for the donor site should be performed.
Radial forearm free flap
In patients scheduled to receive a radial forearm free flap, a preoperative Allen’s test should be performed to assess the adequacy of the ulnar and palmar arch circulation.
Fibula free flap
If a fibula free flap is planned, circulation to the feet should be assessed to ensure three vessel run-off by way of patent anterior and posterior tibial arteries as well as the peroneal artery. This is usually accomplished with a CTA or MRA study of the lower extremities.
Rectus abdominis
Evaluate patient for prior abdominal surgery over the rectus muscle
Anterolateral thigh
Use a hand held Doppler to identify the dominant perforating vessel to the skin half way between the anterior iliac spine and the lateral aspect of the patella.
Scapula free flap
There are no recommended preoperative studies but the patient should be directly questioned and examined to rule out prior axillary/shoulder surgery or radiation therapy.
Iliac crest, Pectoralis major myocutaneous flap
There are no recommended preoperative studies.
