Microsurgical Tissue Transfers for Head and Neck Reconstruction in Patients with Alcohol-Induced Mental Disorder

Background Free tissue transfer in patients with organic mental disorder has always been known to be risky. Herein, the outcomes of free tissue transfers for head and neck reconstruction in those with alcohol-induced mental disorder were analyzed. Materials and methods We retrospectively reviewed and analyzed data from the past 10 years of 1,364 patients who had undergone microsurgical tissue transfers after head and neck cancer ablation. Among them, 54 patients had been diagnosed with alcohol-induced mental disorders post-operatively. Age ranged from 33 to 71 years. Alcohol-drinking history averaged 17.5 years. Reconstructive procedures included 25 forearm flaps, 13 anterolateral thigh (ALT) flaps, 10 fibula osteocutaneous flaps, and 6 double flaps (fibula+ALT). The outcomes and complications were analyzed. Results Onset periods ranged from the first to fourth days post-operatively. Duration of alcohol withdrawal or delirium tremens was 3–10 days. All patients gradually stabilized after immediate psychiatric consultation and intensive medical treatment. The flap survival rate in patients with alcohol withdrawal was significantly decreased in comparison with patients not suffering alcohol withdrawal (83% versus 96.4%, P < 0.001). During this critical post-operative period, 28 (52%) patients with alcohol withdrawal syndrome experienced complications; 26 (48%) suffered flap-related complications, and 19 (35.2%) required additional surgery. The analytical parameters revealed that secondary operative procedures and duration of hospitalization differed significantly between the complication and non-complication groups (P < 0.001). Conclusion Higher rates of complications and level of critical care were needed in patients with alcohol-induced mental disorder after head and neck microsurgical reconstructions. Treatment requires a multidisciplinary approach, rapid diagnosis, and intensive medical care. Presented at the 21st Annual Meeting of American Society for Reconstructive Microsurgery, 14–17 January, 2006, Tucson, AZ, USA     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Combined multi-lobed flaps: A series of 39 extensive hand and multi-digit injuries one-staged reconstructions using modified designs of ALT,DPA and chimeric linking flaps

IntroductionThe use of multiple small flaps linked in a “chain-linked” flap microanastomosed chimeric system is recommended in distal hand and digital defects reconstruction. The aim of this study is to demonstrates our experience utilizing microsurgical fabrication, multi-lobed and linking combined flaps for the reconstruction of hand degloving injuries with complex multidigit soft tissue defects.MethodsMicroanastomosed chimeric flap systems using ALT and DPA modified designed flaps were combined in five selections to cover extensive soft tissue defects involving the hands and multiple digits of 39 patients (M:F − 36:3) from October 2009 to February 2013. Five different microsurgical combined chimeric flap systems utilised in extensive hand and multidigit injuries; innervated ALT flaps, multilobed DPA flaps, innervated ALT flap with multilobed DPA flap, innervated ALT flap with sensate ALT flap and bilobed ALT flap with multilobed DPA flap. All DPA donor sites were reconstructed using free ALT flap and anterior tibial artery propeller flap.ResultsThirty-nine combined free flap extremities reconstructions on 39 patients (M:F − 36:3) with average age 28.5 (18–45) years sustained traumatic degloving injuries, 24 from road traffic accidents and 15 from industrial devices. Five different designs of combined multi-lobed flaps have be successfully used without any peri-operative complications. Average follow-up of 12 months, all flaps survived without complications. Operated extremities showed favorable functional recovery with restoration of the diminished protective sensation on the flap through reinnervation. All flaps survived uneventfully with coverage matching the texture and color of the recipients. Donor sites healed without complication.ConclusionThe microsurgical fabrication of chimeric ALT flaps and multilobed DPA flaps is a valuable alternative for the reconstruction of hand degloving injury with complex multidigit soft tissue defects.Level of evidence: Level IV, therapeutic study.     

Microsurgical free flap in head and neck reconstruction

Microsurgical free flaps are today considered state of the art in head and neck reconstruction after composite tumor resections. Free flaps provide superior functional and aesthetic restoration with less donor‐site morbidity. This article details our approach to this challenging and complex procedure. Free tissue transfer can be viewed as consisting of 4 essential stages: (1) defect assessment, (2) preparation of recipient vessels, (3) flap selection and harvest, and (4) flap inset and microsurgical anastomoses. The essential details of each step are highlighted. Meticulous attention to each step is important because each plays a crucial role in the overall success of the procedure. Workhorse flaps in our practice are the anterolateral thigh, radial forearm, fibula, and jejunum flaps. Unique issues related to postoperative care and monitoring of head and neck free flaps are discussed. The management of complications, in particular those threatening flap survival, are reviewed in detail. © 2009 Wiley Periodicals, Inc. Head Neck, 2010     

Second free tissue transfers in head and neck reconstruction

OBJECTIVE: As the era of free tissue transfer for head and neck reconstruction matures, more patients are requiring second resections and reconstructions. Our objective was to evaluate: patient characteristics, reconstructive options, flap survival, perioperative morbidity, and mortality. STUDY DESIGN: Retrospective chart review. SUBJECTS AND METHODS: Sixty-five patients underwent a second free tissue transfer separate from the time of the primary flap. RESULTS: The most common (53%) reason for a second flap was tumor recurrence. The most common flaps used were radial forearm and fibula in both the first and second reconstructions. Larger flaps were used in the second reconstruction. In-hospital mortality was 4.6 percent; medical complications occurred in 5 percent of patients. Flap survival was 97 percent; 13 percent of second flaps returned to the operating room for complications. Eight patients had a third free flap. CONCLUSION: A second free tissue transfer is a viable resource in head and neck reconstruction. Acceptable rates of flap survival and complications are encountered.     

Reconstruction with microvascular free flaps by visiting microsurgeons.

Twenty-two free flap reconstructions were done by one of both authors as visiting microsurgeons to a hospital a long distance away. The reconstructions were performed in the head and neck (n = 21) and the soft tissue of the lower leg (n = 1). Free flaps included: fibula (n = 8), radial forearm (n = 6), anterolateral thigh (n = 4), iliac crest (n = 1), and musculocutaneous latissimus dorsi flap (n = 3). No pedicle revision was necessary. No flap was lost completely, but one partially. Either of both microsurgeons arrived the day before reconstruction and stayed for about two days postoperatively. Preoperative investigations and postoperative care were done by the local plastic surgeons (who had no microsurgical experience), the ear, nose, and throat surgeons, and the nurses, following the regimen given by the microsurgeon. Microvascular reconstructions, done by a microsurgeon visiting from a long distance away are a reliable and safe option. This may be of advantage in remote areas where no microsurgeon is available locally, to avoid long transports for patients and the associated high costs.     

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.     

Simultaneous reconstruction of head and neck defects following tumor resection and trismus release with a single anterolateral thigh donor site utilizing a lateral approach to flap harvest

Background: An anterolateral thigh (ALT) flap has gradually become the workhorse flap of reconstructions at different anatomical locations because of its reliability and versatility. In this study, we introduced the concepts: one is the ALT flap harvest from a lateral approach and the other is the reconstruction of extensive head and neck defects with a single ALT donor site. Methods: A lateral approach ALT flap was harvested in 13 patients who had buccal cancer and/or tumors of the lower lip combined with buccal trismus. Three types of ALT flaps (type I: two skin paddles, one pedicle; type II: two skin paddles, two pedicles; type III: one skin paddle, one pedicle) were used in one‐stage reconstructions of these extensive head and neck defects. Results: In our series, there were four type I, five type II, and four type III flaps. All flaps survived and no major postoperative complication occurred. Four of the 13 donor sites were repaired with a split‐thickness skin graft harvested from the contralateral thigh. The immediate interincisor distance increase was 21.4 and 16.5 mm at 1‐year follow‐up. Conclusions: Different types of ALT flap from a single donor site can be designed by means of a lateral approach; and the satisfactory results of reconstruction for extensive head and neck defects following the tumor resection and trismus release can be achieved. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Microsurgical reconstruction for radiation necrosis: an evolving disease

We performed a retrospective chart review of a tertiary care medical center. Our objective was to report our experience with microvascular reconstruction in the head and neck in patients who presented with radiation-induced tissue damage. We will discuss the effects of radiation to soft tissues and bone in the head and neck as well as the challenges it presents for later free tissue transfer. Patients were identified who underwent free tissue transfer to the head and neck for radiation-induced tissue injury by the senior author at our institution. Data were collected to include location of the primary disease, radiation amount and zone of radiation injury, initial surgical reconstruction, time to development of radiation necrosis, type of free flap selected, recipient vessel selection, the number of sequential free tissue transfers, hyperbaric oxygen therapy, flap success rates, and minor complications. Patients were excluded if recurrent cancer was identified at any time following reconstruction. One hundred sixty-one free flaps were performed from 2000 to 2004 in the head and neck by the senior author at our tertiary care institution. Fourteen patients were identified who met the inclusion criteria and 16 (two lateral thigh, two iliac crest, one radial forearm, one transverse rectus abdominis, six fibula, two latissimus dorsi with associated rib, and two scapula) free flaps were performed for radiation-induced complications. Five patients required multiple sequential free flaps including the initial reconstruction. Anastomosis was performed within the radiation zone of injury in 14 cases (87.5%), whereas 2 (12.5%) were performed outside the zone of injury. Forty-three percent of patients ( N = 6) underwent hyperbaric oxygen therapy. After initial reconstruction, the incidence of complications requiring surgical intervention included skin breakdown ( N = 1), fistula ( N = 2), and persistent osteoradionecrosis ( N = 2). The mean time to follow-up was 17.5 months (range 1 to 49). There was one partial flap failure that was salvaged by thrombectomy. There were no total flap failures. As primary treatment for head and neck cancer moves toward radiation therapy, microsurgical reconstruction is playing an increasing role for those patients developing radiation-related complications. Radionecrosis is a progressive disease where the incidence is increasing as patients are surviving longer. Understanding the effects of radiation on soft tissue and bone and the complexity of reconstruction in the zone of injury will greatly improve the success of reconstruction.     

Selection of recipient vessels in microsurgical free tissue reconstruction of head and neck defects

The development of microsurgical techniques has facilitated proper management of extensive head and neck defects and deformities. Bone or soft tissue can be selected to permit reconstruction with functional and aesthetic results. However, for free tissue transfer to be successful, proper selection of recipient vessels is as essential as the many other factors that affect the final result. In this article selection strategies for recipient vessels for osteocutaneous free flaps, soft tissue free flaps, previously dissected and irradiated areas, recurrent and subsequent secondary reconstructions, simultaneous double free flap transfers in reconstruction of extensive composite head and neck defects, and the selection of recipient veins are reviewed in order to provide an algorithm for the selection of recipient vessels for head and neck reconstruction.     

Microsurgical workhorse flaps in head and neck reconstruction

The aim of reconstruction after resection of head and neck tumors is to achieve acceptable functional and esthetic results with minimal donor site morbidity. Although many flaps have been developed for bone and soft tissue reconstructions, our experience in the past years has identified the anterolateral thigh flap (cutaneous or myocutaneous), the radial forearm flap, and the osteoseptocutaneous fibula flap as the most useful flaps for head and neck reconstruction. These three flaps can be used for reconstruction of almost all kinds of defects, either as a single flap or in combination. The harvest of these flaps is relatively simple and straightforward. All flaps have adequate pedicle vessel length and caliber. Donor site morbidity is negligible. As most reconstructive microsurgeons do not have enough patient volume to master many different kinds of flaps in their professional life, we recommend focusing on these three flaps as workhorse flaps instead of hunting for many other flaps for head and neck reconstruction.     

Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap

Abstract

The pectoralis major myocutaneous pedicled flap (PMMPF) – the “workhorse” for head and neck reconstruction – is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.     

Factors predicting free flap complications in head and neck reconstruction.

In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.     

Two in one: Double free flap from a single free fibula osteocutaneous unit

In the past two decades, the advancement in the microsurgical techniques has revolutionised the reconstruction of post-oncological head and neck defects. Free fibula osteocutaneous flap (FFOCF) has been considered as the treatment of choice by many for mandible reconstruction. The improvement in the surgical resection and adjuvant treatment has improved the survival rates even in patients with advanced cancer. Simultaneously the reconstruction is addressed towards more functional and aesthetic aspects to improve the quality of life in these patients. In this respect, a double free flap is advocated in certain cases of extensive composite oromandibular defects (COMDs). But in our institute, we have managed two such cases of extensive COMD with a single FFOCF unit – fibula bone with a skin paddle for inner lining and a perforator-based skin paddle from the proximal part of the FFOCF unit, anastomosed separately for outer cover. Compared to two separate free flaps, this method has the advantage of single donor site and reduction in reconstruction time. Though the technique of divided paddle, deepithelisation and supercharging has been mentioned for FFOCF, no such clinical cases of two free flaps from a single FFOCF unit have been mentioned in the literature.KEY WORDS: Composite oromandibular defect, double free flap, free fibula osteocutaneous flap     

Oromandibular reconstruction using a third free flap in sequence in recurrent carcinoma.

Successful results of a second microsurgical reconstructive attempt have been reported previously in recurrent oral carcinoma. However, the feasibility of a third free flap following a third excision has remained to be determined. Six oral carcinoma patients with multiple recurrences, surgical excisions and free flap reconstructions on three separate occasions are presented. Resections had a curative intent in all cases in the first and second ablations and in four of the six cases in the third one. Five radial forearm flaps and one double free flap were used for the first reconstruction. During the second reconstruction two radial forearm, two fibula osteoseptocutaneous, one double free flap and one rectus femoris flap were used to reconstruct the larger defects resulting from excision of the recurrent tumours. However, no vascularised bone transfers were performed following the third excision and soft tissue free flap plus plate option was used for segmental mandibular defects. There was one partial flap loss among 21 free flaps performed. Three patients died within an average of 8 months following the third reconstruction while the others remained alive, surviving an average of 6 months. In conclusion, a third free tissue transfer for reconstruction in multiply recurrent oral carcinoma was found to be feasible, safe and effective. The use of free flaps contributed to the prevention of complications in these difficult cases and enabled the patients to spend the remaining days of their lives outside hospital.     

Reconstruction of soft tissue defects of the Achilles tendon with rotation flaps,pedicled propeller flaps and free perforator flaps

Introduction. Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back‐up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves. Methods. Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler‐ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction. Results. One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. No complications were seen with free tissue transfer. Conclusion. Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps. © 2010 Wiley‐Liss, Inc. Microsurgery 30:608–613, 2010.     

RECONSTRUCTION WITH MICROVASCULAR FREE FLAPS BY VISITING MICROSURGEONS

Twenty-two free flap reconstructions were done by one of both authors as visiting microsurgeons to a hospital a long distance away. The reconstructions were performed in the head and neck ( n &#114 = &#114 21) and the soft tissue of the lower leg ( n &#114 = &#114 1). Free flaps included: fibula ( n &#114 = &#114 8), radial forearm ( n &#114 = &#114 6), anterolateral thigh ( n &#114 = &#114 4), iliac crest ( n &#114 = &#114 1), and musculocutaneous latissimus dorsi flap ( n &#114 = &#114 3). No pedicle revision was necessary. No flap was lost completely, but one partially. Either of both microsurgeons arrived the day before reconstruction and stayed for about two days postoperatively. Preoperative investigations and postoperative care were done by the local plastic surgeons (who had no microsurgical experience), the ear, nose, and throat surgeons, and the nurses, following the regimen given by the microsurgeon. Microvascular reconstructions, done by a microsurgeon visiting from a long distance away are a reliable and safe option. This may be of advantage in remote areas where no microsurgeon is available locally, to avoid long transports for patients and the associated high costs.     

Sequential chimeric medial femoral condyle and anterolateral thigh flow‐through flaps for one‐stage reconstructions of composite bone and soft tissue defects: Report of three cases

Small recalcitrant non‐unions with poor perfusion require reconstruction with vascularized bone flaps. Cases with concomitant large soft tissue defects are especially challenging, since vascularized soft tissue transfer is often indicated and distant microvascular anastomoses may be required. We introduce a sequential chimeric free flap composed of a medial femoral condyle corticoperiosteal flap anastomosed to an anterolateral thigh flow‐through flap (MFC‐ALT flap) and report its use for reconstruction of small non‐unions with concomitant large soft tissue defects in three exemplary patients. Two female and one male patients ages 39–58 years suffered from composite bone and soft tissue defects of the lower extremity and clavicle caused by tumor resection and postoperative radiation resp. infected tibial pilon fracture. The sizes of the soft tissue defects ranged from 15–23 × 4.5–6 cm and the sizes of the bone defects ranged from 1.5–4 × 2–4 cm. Defect reconstructions were performed in all cases with sequential chimeric MFC‐ALT flaps with sizes ranging from 2–4 × 1.6–4 cm for the MFC and 21–23 × 7–8 cm for the ALT skin paddles. Functional reconstructions were achieved in all cases resulting in stable unions and soft tissue coverage enabling the patients to bear full weight without assistance on 5‐months follow‐up. Postoperative course was uneventful and complications were restricted to a small skin necrosis at the suture line in one case. MFC‐ALT flaps may be a safe, and effective procedure for one‐stage reconstructions of small, irregularly shaped bone defects with concomitant large soft tissue loss or surrounding instable scarring, particularly in cases of recalcitrant non‐unions after radiation exposure.     

Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India

Introduction:

Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India.

Materials and Methods:

This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed.

Results:

We performed 22 cases of free flaps in a six-month period (2008-2009). Majority (17) of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9) and anterolateral thigh flap (ALT: 9) were the most commonly used flaps. A fibula flap (1) was done for an anterior mandible defect, whereas a jejunum free flap (1) was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps.

Conclusion:

Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.KEY WORDS: Free flap, head and neck cancer, microvascular surgery, reconstruction, resource constrained, reconstruction of head and neck     

Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta‐analysis

We performed a systematic review and meta‐analysis to determine whether diabetic patients have an increased rate of postoperative complications compared to nondiabetic patients after head and neck free flap reconstruction. A systematic review of PubMed Database between 1966 and 2012 was performed. RevMan 5.0 was used for meta‐analysis. A retrospective medical chart review of 7890 patients to identify those who had a failed microsurgical reconstruction of the head and neck region at Chang Gung Memorial Hospital was also carried out. The result revealed that patients with diabetes mellitus have a 1.76 increased risk of complications (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.11–2.79) with minimal heterogeneity (I ² = 22%; p = .28). The prevalence of diabetes mellitus in patients with failed free flaps for head and neck reconstruction is 15%. The incidence of diabetes mellitus in these patients with failed free flaps is 2.3 times higher than in the general population.<copy;2013> © 2014 Wiley Periodicals, Inc. Head Neck 37 : 615–618, 2015