What is a Free Flap?

Patients who are diagnosed with cancer of the head and neck are often treated with surgery. Removal of tumors in the mouth and the throat can significantly inhibit speech and swallowing.  Similarly, removal of the bone involved with cancers of the jaw affects appearance and function of patients. In some cases, the wounds, left as a result of cancer surgery, can be allowed to heal or be covered with the surrounding tissues. Often, however, the wounds are too big, and the tissue removed with the tumor must be replaced. In such circumstances, a “free flap” may be a sound option for repairing the defect.

Local Flaps Versus Free Flaps

A flap is any piece of tissue that is moved to cover a wound.  A free flap is a piece of tissue that is disconnected from its’ original blood supply, and is moved a significant distance to be reconnected to a new blood supply.  Let us use a lamp as an example. When a lamp has to be moved from one part of the table to another it may not need to be unplugged. This is similar to a “local” flap that is “rotated” into the wound.  The electric cord is analogous to the blood vessels delivering blood to the flap. When the lamp must be moved from one side of the room to another, the cord cannot stretch the required distance. In these cases the lamp is unplugged (“free”), brought to its’ new location and plugged into another outlet.

Similarly, a free flap is taken from the body of the patient; the blood vessels that bring the blood in and out of the tissue are cut, and then reconnected to another source of blood (usually in the neck). The artery that comes with the flap is sewn to the artery in the neck to bring the blood in, and the vein is sutured to a vein in the neck, re-establishing the blood flow. The blood vessels feeding the flap are usually very small and the “re-plugging” of the flap is done through microvascular surgery.  Microvascular surgery is a technique of sewing two small blood vessels together under a microscope.

The surgeon has to select tissue in the body that will do the best job of restoring the function and the appearance of head and neck tissues destroyed by the tumor.  The commonly used free flaps include: forearm or thigh skin (thin skin that can be used to rebuild the inside of the mouth and throat), muscles from the abdomen or the back, and fibula bone (bone on the outer side of the leg).

The success of using a free flap in reconstruction after head and neck cancer surgery is 95-98 percent.  The goal of the reconstructive surgeon is to return the patient to a state where they can enjoy eating, swallowing and speaking.  With the advancements in the field of microvascular and reconstructive surgery, this goal is often achieved.

Mohemmed Nazir Khan, MD

Mohemmed Nazir Khan, MD

Assistant Professor, Department of Otolaryngology at Mount Sinai-Union Square

Dr. Khan’s clinical interests and expertise include the medical and surgical management of benign head and neck tumors; thyroid and parathyroid disorders; salivary gland disorders; head and neck cancers; and reconstructive surgery involving the head and neck. In addition to his professorship, he is the Associate Director of the Head and Neck Cancer Research Program at the Icahn School of Medicine at Mount Sinai. Dr. Khan is available for rapid referrals and same day appointments.

Could Your Sore Throat Be Caused by Acid Reflux?

Have you had a cough, tickle in the throat, itchy throat, or raspy voice that will not go away despite not having a cold or feeling sick? Is excess mucus causing you to clear your throat so often that it is annoying and, at times, embarrassing?  Many who suffer from these symptoms are treated by doctors and urgent care physicians with allergy medications, nasal sprays, decongestants, and even antibiotics. Despite this, symptoms do not get better. Often these symptoms are not caused by allergies, a sinus infection, or a cold, but by laryngopharyngeal reflux (LPR). Also called airway reflux, reflux laryngitis, or atypical reflux, LPR is one of the most common diseases of the 21st century. Unlike gastroesophageal reflux disease (GERD), which primarily affects the esophagus, LPR will affect the larynx and pharynx—your voice production system.  Lissette Giraud, MD, provides insight into and answers common questions about this widespread condition.  

What causes LPR?

It is commonly accepted that this condition is caused by reflux of acid or bile. GERD symptoms like heartburn are not typical of the condition but may appear. The most common symptoms of LPR are hoarseness, sore throat, excess mucus in the throat, persistent cough, asthma-like, symptoms (wheezing, chest tightness, and difficulty breathing), postnasal drip, sensation of a lump in the throat, difficulties swallowing, and ear pain. However, LPR presents differently in each person.

When should I see a doctor?

If you have a sore throat, painful swallowing, cough, difficulty swallowing, or hoarseness for 10-14 days, you should seek medical attention, preferably from an ENT.

What is the treatment for LPR?

Treatment will vary in accordance with the severity of symptoms. It can be as simple as making changes to your diet, like avoiding spicy foods, tomatoes, chocolate, caffeine, citrus beverages or foods, and alcohol.

Other solutions include:

  • Avoiding large meals
  • Eating three hours or more prior to going to bed
  • Elevating the head eight inches when sleeping
  • Smoking cessation
  • Losing weight if you are overweight

Your doctor may also recommend a medication to reduce acid production in the stomach, like Zantac or Pepcid, for a few weeks or longer.Stronger medications may be recommended if diet and life style changes have not worked.

Do I need any tests like CT scans, X-rays, or MRI’s to diagnose LPR?

The diagnosis of LPR is mostly based on symptoms and an office procedure called flexible laryngoscopy—an endoscopic exam of the voice box and throat performed by an ENT—and response to treatment. In some cases an upper endoscopy examination to evaluate the stomach and esophagus for inflammation, ulcers, or any abnormal lesion may be recommended. More advanced tests like pH testing and esophageal manometry are less frequently recommended and are typically done for difficult cases.

What are the complications from untreated LPR?

If LPR is left untreated, patients may experience vocal cord lesions like polyps or granulomas, chronic laryngitis, or asthma.

If you or a loved one suffers from the above symptoms, visit an ENT doctor, who will be prepared to do a complete evaluation and determine if you have LPR and recommend treatment.

Photo of Lissette GiraudLissette Giraud, MD, is a board certified otolaryngologist at New York Eye and Ear Infirmary of Mount Sinai and Mount Sinai Doctors Tribeca with more than 15 years of experience. She treats both pediatric and adult patients with an emphasis in management of sinus disease/surgery, laryngopharyngeal reflux, thyroid surgery, dizziness, and ear diseases. Dr. Giraud is fluent in English and Spanish.

What's the difference between LPR and GERD?

Both LPR and GERD are caused by acid reflux. GERD, the more well known condition, occurs when stomach acid backs up into the esophagus. Patients with this condition may experience nausea and heartburn. LPR occurs when stomach acid reaches the back of the throat or, in some cases, the nasal passage.

Frequently, primary care physicians correctly make the diagnosis of LPR. Patients may be reluctant to start treatment since the typical “acid reflux” symptoms—like heartburn, belching, and regurgitation of acid contents—are not present. Additionally, when patients see a gastroenterologist after a referral by their primary care provider or otolaryngologist (ear, nose, and throat physician, also known as ENT), they are frequently told they do not have “acid reflux.” This confuses many patients and creates further frustration.

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Edward Yang, MD, a board certified orthopedic surgeon and Chief of Orthopaedics at Mount Sinai Queens

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