The preferred mode of reconstruction of large defects involving the orbitomaxillary region involves free tissue transfer. Our preferred mode of reconstruction is with the rectus abdominis myocutaneous free flap. The skin paddle is often used for reconstruction of an external skin defect and/or palatal defect. Unfortunately, in many cases use of the skin paddle is difficult, unsightly or not possible due to the large amount of adipose tissue in some patients. We have recently begun to use tumescent liposuction of the adipose tissue following dissection of the rectus flap in order to debulk the flap. We describe a representative case (fig 1). The patient underwent a left orbito-maxillectomy with removal of the left side of her hard palate (fig 2). The rectus abdominis flap was elevated in the usual standard fashion with a skin island, which measured 14cm in length and 6 cm in width (fig 3). The adipose tissue was then infiltrated with 40cc of ½ percent lidocane with 1:200,000 epinephrine, with a tumescent cannula. The amount of fat removed was greater than 200 cc (fig 4, 5), which allowed us to use the skin paddle to reconstruct the palate (fig 6) and to use a de-epithelialized portion over the cheek area to improve contour (fig 7, 8). Insetting of this flap would not have been possible without debulking of the flap with tumescent liposuction. The traditional way to debulk the adipose tissue of a free flap prior to inset is with direct excision. This method, however, can be dangerous due to inadvertent injury to the perforators feeding the flap resulting in ischemia. The perforators appear to be better visualized and palpated following suction lipectomy. There have been a number of animal studies showing the safety of suction lipectomy following elevation of flaps^1,2 and liposuction of free flaps is routinely done postoperatively³. Intraoperative tumescent liposuction of a free flap allows for contouring and successful insetting of the flap. We believe that use of this method can become part of the armamentarium for the reconstructive microsurgeon.

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