In cases that involve the oropharynx, a nasal ray endotracheal tube is obligatory. The tube can be secured to the caudal septum with a heavy silk stitch. To avoid alar rim skin necrosis, the entire tubing apparatus should be brought inferiorly and secured to the patient’s foam-padded forehead with tape. A straight accordion tube extender is often useful to lengthen the circuit and avoid kinks. The tubing closer to the anesthesia machine can also be secured to the back of the headrest for additional security. Once this process is complete, the surgeon should check the integrity of this construct by turning the head in either direction.

The positioning of the patient will depend to some extent on the reconstructive plan. In the case of pedicled flaps and most free tissue flaps, supine positioning is adequate. If a large defect is anticipated and a latissimus flap is considered for reconstruction, it may be prudent to harvest the muscle flap first in a lateral decubitus position, then partially close the donor site and turn the patient supine for the extirpative operation.

Hemodynamic instability is rare during resection and reconstruction of most pediatric head and neck tumors . The main exception to this is in large vascular malformations, especially arteriovenous malformations. As such, invasive monitoring is typically limited to an arterial line and at least one and usually two peripheral intravenous lines. If postoperative chemotherapy or frequent blood sampling is anticipated postoperatively, a central venous catheter may be placed at the outset of the procedure. In patients coming to the operating room with a previously placed port-a-cath™ or long-term indwelling central venous catheter, special care must be taken to ensure appropriate handling and interrogation of these sites if they are to be used. The use of such devices should be cleared with the oncology team, parents, and the surgical team caring for the line. A nasogastric or orogastric tube is usually needed—initially for decompressing the stomach and potentially following surgery for nutrition.

A broad-spectrum antibiotic that covers oral/nasal flora is routine and should be continued in the perioperative period. Other medications to consider for postoperative comfort are antiemetics and pain medications. The surgeon should communicate early with the anesthesiologist about the use of vasopressors. Too often, a wide-open arterial anastomosis has been redone only to find that the agent responsible for the pale flap was the vasopressor. Fluid, colloid, or blood product administration should be the first line of treatment in these cases.

One of the most difficult complications of oropharyngeal reconstruction is the dreaded fistula [3–12]. Fistulas may develop between the oropharynx and the nasal cavity or the skin. Typically, they occur at the flap and native mucosa juncture. To minimize the risk of fistulas, one should consider the causative factors: poor healing and inadequate seal. Poor healing may result from ischemia, infection, or a suboptimal environment (such as bathing in saliva or a radiated tissue bed). Ischemia can be controlled by bringing healthy, well-vascularized tissue to the defect and by resecting all poorly perfused tissues. Inadequate seal is almost always a result of poor surgical planning or execution. The most problematic areas for obtaining a tight seal are at the gingiva, the palate, and posterior mouth. Patients with intraoral tumor involvement, radiation, or poor oral hygiene may present with mucosa that is friable. The right approach is to remove all of the friable and suboptimal tissue from the area so that a tight seal can be created with the newly transferred flap and the surrounding tissues.

When reconstructing defects that involve the cranial base, it is critical to obtain a good seal to separate the brain from the mucosa [13]. Tumor extirpation operations that involve the cranial base typically leave a large soft tissue defect. Obliteration of the resulting dead space is paramount to avoid cerebrospinal fluid leakage and infection. It is not uncommon to have to utilize a muscle flap in addition to a fasciocutaneous flap in these cases—the former for obliteration of the dead space and the latter for mucosal reconstruction.

The importance of adequate vessels for microvascular anastomosis cannot be overstated—the larger the vessels, the higher the likelihood of success . Source vessels found in the neck have reliable anatomy and flow. These vessels may be too distant for more cephalic defects such as the scalp or orbit; in which case, the facial or superficial temporal vessels may be substituted [14]. In head and neck reconstruction , one rarely encounters difficulty in finding a suitable artery. However, finding an appropriate vein can sometimes be challenging. Good communication between the extirpative team and the reconstructive team from the outset of the procedure may allow for the identification and preservation of useful recipient vessels later in the procedure. In situations where the area is heavily scarred or has been previously radiated, one should consider (a) vein grafting to the opposite side or (b) use of the ipsilateral cephalic vein. It is rarely worth the risk to use less than optimal vessels in a zone compromised by scarring or radiation, to avoid the additional effort of vein grafting, using the contralateral side or the ipsilateral cephalic vein. We have found the cephalic vein quite useful in difficult outflow situations. A long segment can be harvested from the ipsilateral arm using multiple stab incisions. Minimal morbidity, anatomic consistency, and long length make this vein a perfect “bail out” strategy in difficult situations. There is ongoing debate in the literature about immediate versus delayed use of arteriovenous loops. The most recent literature suggests that staging of arteriovenous loops is not necessary [15].