Negative-pressure wound therapy for the treatment of pharyngocutaneous fistula

IntroductionPharyngocutaneous fistula is a well-known complication of head and neck cancer surgery. The purpose of this study was to determine the value of negative-pressure wound therapy (NPWT) for the treatment of these fistulas. NPWT is used in many fields of medicine, but its use in otorhinolaryngology has been rarely reported. NPWT is a cost-effective means to accelerate wound healing.Patients and methodsA single-centre retrospective study was conducted on 7 patients with pharyngocutaneous fistula following surgery for squamous cell carcinoma between January 2011 and April 2013. These fistulas were treated by negative-pressure wound therapy (NPWT).ResultsThis series comprised seven male patients with a mean age of 65 years and 9 months. The mean duration of treatment was 23 days (range: 11 to 42 days). Two patients had a history of radiotherapy for pharyngolaryngeal cancer. Negative-pressure wound therapy achieved cure of the fistula in all patients with satisfactory acceptability. Mean follow-up was 10 months (range: 6 months to 2 years).ConclusionNegative-pressure wound therapy represents a valuable treatment option in certain settings for the management of pharyngocutaneous fistula following head and neck cancer surgery.     

Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test

ObjectiveRecent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery.MethodsThis is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery.ResultsThere were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002).ConclusionShorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates.Level of evidenceLevel 2b.     

Pectoralis major muscle flap use in a modern head and neck free flap practice

PurposePectoralis major muscle flaps (PMMF) are a commonly used reconstructive modality to repair head and neck defects. As the use of free flap reconstruction is increasingly practiced in the head and neck, the role of the PMMF may be changing as well. This study sought to analyze indications and outcomes for PMMF following head and neck resections from one surgeon's experience.Materials and methodsRetrospective review from December 1, 2013 through September 30, 2017 at a tertiary care academic medical center. Indications for the PMMF were examined as well as surgical outcomes. Basic demographic data, patient head and neck cancer history, history of radiation and/or chemotherapy, and history of previous reconstructive procedures were obtained and compared across all subjects.ResultsForty patients underwent a PMMF within the designated time frame. The majority of patients were male (83%) and the average age was 65 years (range 55.4–74.6 years). Of the 40 cases, 9 of the PMMFs were performed as primary reconstruction of the defect. In the remaining 31 cases, these flaps were utilized as a secondary reconstructive option following fistula formation (13), dehiscence (6), need for an additional flap for recurrent disease (6) infection (4), or major bleeding (2). In every case that it was utilized, the PMMF was the definitive reconstruction. Within the same time frame, 429 free flaps were performed by the same surgeon, with an average of 125 free flaps performed yearly. The rate of total flap failure overall was 3.9%. The other failed free flap reconstructive options used besides a PMMF were secondary free flaps (11), local wound care (4), or obturator placement (2). The secondary pectoralis flaps occurred following 7.2% of free flaps with total or partial failure that were performed within the same time range. The indications for the PMMF did not change or evolve during the time frame of the study.ConclusionsAlthough free flaps were performed with far greater frequency than PMMFs at our institution, the PMMF demonstrated continued utility as a secondary reconstructive option. For a surgeon who performs a high volume of free flaps, preservation of the pectoralis muscle and associated vasculature for possible later secondary reconstruction should be considered due to its strong efficacy.     

Prophylactic fasciotomy of the anterolateral thigh donor site in head and neck reconstruction

IntroductionThe free anterolateral thigh (ALT) flap is a versatile reconstructive option for head and neck defects. Donor site complications are rare but severe; with wound dehiscence, need for secondary closure, and compartment syndrome reported.ObjectivesWe propose prophylactic thigh fasciotomy as a surgical technique to facilitate primary closure while preventing donor site complications during ALT flap harvest.MethodsWe examined donor site wound characteristics, recipient site wound characteristics, and clinical outcomes for 24 consecutive ALT flaps performed for head and neck reconstruction from 2016 to 2018. All ALT donor sites underwent prophylactic fasciotomy.ResultsThere were no incidents of thigh compartment syndrome or wound dehiscence of donor site; one patient underwent primary donor site skin grafting.ConclusionProphylactic thigh fasciotomy allows mobilization of soft tissue to facilitate primary tension-free closure of the ALT donor site even for free flaps with a large skin component, while reducing the possibility of compartment syndrome.     

Safety of the “incidental” neck dissection or exploration during free tissue transfer after head and neck irradiation

ImportancePatients with either local recurrence of head and neck cancer or osteoradionecrosis after prior radiation treatment often require free tissue transfer for optimal reconstruction. In this setting, neck exploration for vessels is necessary, and an “incidental” neck dissection is often accomplished despite clinically negative cervical lymph nodes. While neck surgery in the post-radiated setting is technically challenging, the safety of post-radiated elective neck dissection or neck exploration for vessels is not well-studied, especially for patients undergoing non-laryngectomy salvage resections.ObjectiveTo define intraoperative and postoperative surgical complications for patients undergoing elective neck dissection or exploration with free tissue transfer reconstruction in the post-radiated setting, with attention to complications from neck surgery.DesignRetrospective cohort study. Patient charts from May 2005 to April 2020 were reviewed.SettingTertiary care referral center.ParticipantsPatients underwent free tissue transfer after prior head and neck irradiation for non-laryngeal local cancer recurrence or second primary, osteoradionecrosis, or for sole reconstructive purposes. Patients with clinically positive neck disease were excluded.Main outcomes and measuresIntraoperative and postoperative complications including unplanned vessel or nerve injury, hematoma, chyle leak, wound dehiscence, wound infection, fistula formation, flap failure, and perioperative medical complications. Neck exploration and neck dissection patient outcomes were compared by Fisher exact test.ResultsSeventy-two patients (56 men and 16 women) of average age sixty-one (range 34–89) were identified with average follow-up 25.7 months. Most patients (78%) underwent salvage neck dissection, and the rest underwent neck exploration for vessels only. There were five intraoperative neck complications: three vessel injuries and two nerve injuries. There were twenty-six postoperative surgical complications among eighteen patients. There was no difference in surgical complications whether patients underwent neck dissection or exploration only. Two partial and two complete flap failures occurred. There were nine perioperative medical complications among six patients.Conclusions and relevanceElective neck dissection or exploration among patients undergoing free tissue transfer in the post-radiated setting carries a risk of both intraoperative and postoperative surgical complications. The present study defines risk of complications and helps to inform patient discussions for risk of complications in the post-radiated setting.     

Versatilidad del colgajo microvascularizado antebraquial radial en la reconstrucción de cabeza y cuello. Una serie de 58 casos

IntroductionThe radial forearm free flap (RFFF) is a widely used tool in head and neck reconstructive surgery. It stands out as a relatively simple flap to achieve; it is versatile and has features that enable the reconstruction of complex head and neck defects. The aim of the study was to present our results using the RFFF in the reconstruction of seated defects in the head and neck area.Material and methodsA retrospective, observational and analytical study that included 58 cases of RFFF interventions, performed between January 2002 and July 2019. The data studied were the age and sex of the patients, location of the tumour, histological type, previous radiation therapy, number of venous anastomoses performed in the surgery and body temperature in the immediate postoperative period, at 24 and 48 hours following surgery.ResultsThe percentage of viable RFFF was 82.8%. None of the variables analysed appear to be a risk factor for flap failure. The most frequent cause of flap failure was venous thrombosis.ConclusionsMicrovascularised flaps play an important role in reconstructive surgery, being the RFFF one of the most interesting for head and neck reconstruction. It is a very versatile tool that allows the reconstruction of many of the sites where the head and neck surgeon operates.     

Head and neck reconstruction using microsurgery: a 9-year retrospective study

A total of 137 patients diagnosed with head and neck cancer underwent ablative surgery and primary free flap reconstruction during a period of 9 years, 2001–2009 (men 73.7 %, women 26.3 %). Surgery included a multidisciplinary approach involving plastic, head and neck, and maxillofacial surgeons. Squamous cell carcinoma (SCC) represented the vast majority of the diagnosed tumors (91.2 %); other tumors represented in the study were malignant melanoma, sarcoma, adenocarcinoma and blastoma. The free flaps (n = 143) used for reconstructive surgery included radial forearm flap (n = 128), fibular flap (n = 13) and rectus abdominis muscular flap (n = 2). Twenty patients (15 %) needed reoperation within 48 h due to clinical signs of hematoma (n = 8) and free flap ischemia (n = 12). Furthermore, we report a total of 12 free flap failures, giving an overall free flap success rate of 92 %. Five patients were treated due to infections at donor site (4 %). The overall survival rate (OS) in male patients diagnosed with oral SCC stage II–IV after 2 and 5 years was 82 and 78 %, respectively. Female patients in the same group displayed a 2- and 5-year OS of 78 and 67 %, respectively. Furthermore, analysis of patients treated for recurrence of primary SCC displayed a 2- and 5-year OS of 70 and 55 %, respectively. We conclude that our multidisciplinary approach and treatment algorithm for head and neck cancer including primary free flap reconstruction reconstitutes a safe and reliable tool.     

Pharyngocutaneous fistula

The occurrence of pharyngocutaneous fistula after oncologic head and neck surgery is a serious complication. It is the most common complication after major hypopharyngeal and laryngeal ablative surgery. The cause and management guidelines are still controversial. Contributing risk factors of impaired wound healing should be recognized in preoperative planning. Perioperative technical issues and preventive postoperative care play a major role in the prevention of fistulae, limiting the severity of the fistula and minimizing secondary complications. Surgical salvage of cancers treated with organ preservation approaches is associated with higher rates of postoperative complications, particularly in cases in which mucosal membranes are transgressed and surgically closed. Patients who require surgical repair are best treated by the use of regional myocutaneous flaps or free tissue transfers. This subset of patients is likely best treated in regional centers of excellence with well developed multidisciplinary programs for ablative and reconstructive head and neck surgery.     

Reconstrucción de cabeza y cuello mediante colgajos libres microvascularizados. Indicaciones,aspectos técnicos y resultados

Introduction and objectivesThe use of microvascular free flaps (MFF) has become a common method of head and neck reconstruction because of its high success rates and better functional results. We report our experience in reconstructing complex defects with MFF.MethodsWe analysed a series of 246 patients that underwent reconstruction using MFF in our Department from 1991 to 2013.ResultsThere were 259 interventions performed in 246 patients. The most common reason for surgery was tumour recurrence (46%), followed by primary tumour resection (25%). The hypopharynx (52%) and the craniofacial region (22%) were the most frequently reconstructed sites. The free flaps most commonly used were the radial forearm free flap (41%) and the anterolateral thigh free flap (35%). Overall success and complication rates of 92% and 20% respectively were reported.ConclusionsThe microvascular free flap is a reliable and useful tool for reconstructing complex head and neck defects and continues to be the reconstructive modality of choice for these defects.     

Unusual uses of the deltopectoral flap.

For the past decade the deltopectoral flap has become the premier reconstructive tool in oncologic head and neck surgery. It has achieved a level of reliability that has not been approached by any other single flap. Its most common application has been replacement of lost skin either from planned surgical resection or necrosis following ablative surgery. This paper illustrates a few unusual clinical settings in which the deltopectoral flap was used instead of other conventional methods: 1. Use of the same delopectoral flap in two different locations. 2. Employment of the base of the deltopectoral tube for skin coverage. 3. Successful application of bilateral simultaneous deltopectoral flaps. 4. Three-stage reconstruction of the cervical esophagus in a tenuous metabolic setting. 5. Two-stage technique for soft palate replacement. 6. An alteration of the design of the conventional deltopectoral flap because of an upper pectoral abscess.     

2-Octyl cyanoacrylate to prevent salivary fistula formation following oral cavity microvascular reconstruction: A prospective trial

BackgroundSalivary fistulas remain a significant problem in patients undergoing major head and neck reconstructive surgery. Surgical sealants have become increasingly used in cutaneous and non-cutaneous wound closure, providing a barrier to fluids/gases and promoting healing. The purpose of this study was to determine the efficacy of a common surgical sealant, 2-Octyl Cyanoacrylate (2-OCA, Dermabond®), in the prevention of salivary fistulas following free flap reconstruction of the oral cavity.MethodsIn this non-randomized, single arm prospective trial, patients undergoing free flap reconstruction of gravity-dependent oral cavity defects were recruited. Application of 2-OCA was performed along flap inset suture lines at the time of surgery. Prospectively collected trial data were propensity score matched to a control cohort to compare outcomes. Data collected include demographics, medical co-morbidities, previous treatments, primary tumor site, and subsites reconstructed. The primary outcome measure was rate of salivary fistula formation. Secondary outcomes were time to development of leak and percentage of patients tolerating oral feeding at one month post-operatively.ResultsIn the 46 propensity score matched pairs, eight (17.4%) out of 46 patients in the 2-OCA prospective cohort and seven (15.2%) out of 46 patients in the control cohort developed postoperative salivary fistulas within the one-month study interval (p = 1.00). The average time to postoperative leak in the 2-OCA group was 12.5 days versus 7.1 days in the control cohort (p = 0.10). In the 2-OCA group, 30 (65.2%) patients were tolerating regular diet at one month post-operatively compared to 33 (71.7%) in the control cohort (p = 0.65).ConclusionSalivary fistula rates after application of a 2-OCA surgical sealant were not improved compared to a control cohort in this single institutional trial. There are several surgical sealants available, each with varying elasticity and adhesiveness. Future studies are needed to identify surgical sealants that are able to provide sufficient strength and adhesion to seal closures and combat corrosive saliva, but elastic enough to handle motion related tension during swallowing and post-operative movements in the head and neck.     

Reconstruction of hypopharyngeal defects with anterolateral thigh free flap: A single-center retrospective analysis

IntroductionReconstruction of expanded hypopharyngeal defects following laryngo-hypopharyngectomy for surgical treatment of primary is still a challenge for head and neck surgeons. Tradiotionally, jejunal or radial forearm flaps are the common reconstructive choice. Recently, the anterolateral thigh (ALT) free flap has served for pharyngoesophageal reconstruction. The goal of this work is to describe a retrospective analysis about a five-year single-center experience in the reconstruction of post-operative hypopharyngeal defects with ALT free flap.MethodsA single-center retrospective study was performed, including patients treated for patients who underwent tumor surgery involving hypopharynx with ALT free flap reconstruction from 2015 to 2020. Exclusion criteria were paediatric (0–18 years) patients, and the absence of follow-up.ResultsThe study included 23 adult patients. The mean size of the flap was 90 cm² (range 60–130 cm²). The mean time required to harvest the antero-lateral tight flap was 70 min (range 35–120 min). The median age was 46.3 years (SD 15.81, range: 19–84 years), with a gender female prevalence (F = 48, M = 33). Mean follow-up was 77.7 months (min 4–max 361, SD 72.46). One patient (4.4 %) showed a hypopharyngeal stenosis.ConclusionALT free flap represents a successful and versatile reconstructive option for hypopharyngeal defects extended to oropharynx and/or larynx following total laryngectomy with circumferential or partial hypopharyngectomy, regardless of the functional and aesthetic results, with minimal donor-site complication.     

Microvascular free flap reconstruction for head and neck defects

In a three-year period, 53 microvascular free-tissue grafts were performed on 51 patients to repair defects following major head and neck ablative surgery or trauma. The vast majority were done at the time of tumor resection. The remainder were done as secondary operations after resection or injury. The choice of free flap was dictated by the reconstructive needs of the patient and donor site availability. Fifty-two (98%) of 53 free-tissue transfers were successful with one failure resulting from venous thrombosis. Complications were noted in 16 of 53 flaps. The majority of these complications were in flaps used to replace bony defects or oropharyngeal resections. Although free flaps may appear to be more risky than traditional forms of reconstruction, they offer the surgeon a greater spectrum of reconstructive options. Limitations of the use of free flaps result only from lack of technical skills and specialized equipment.     

Colgajo antebraquial radial en cabeza y cuello: nuestra experiencia

IntroductionOncologic surgery leads to important defects and sequelae, as well as notable cosmetic and functional alterations. In this aspect reconstructive surgery has an essential role, allowing more radical excision and lower associated functional and cosmetic morbidities. The aim of this study was to present and evaluate the experience and results of the reconstructive microsurgery unit in our centre's ENT department.MethodsRetrospective study of procedures performed between 2006 and 2012.ResultsA total of 36 cases were reviewed. The primary tumour was found in the oropharynx (58%) in the majority of cases. In 5 cases the procedure was performed for reconstruction and fistula closure (4 pharyngostoma and 1 tracheoesophageal fistula). Failure from total necrosis was 16% (6/36). No associated mortality has been reported. The most common postoperative complications were wound dehiscence in 5 patients and pharyngostoma (fistula) in 5 cases. Prior radiotherapy significantly influenced the increase in the overall incidence of complications (P < 05).ConclusionsReconstructive surgery currently plays an important role in surgery for head and neck cancer. The radial forearm flap is a safe, reliable method for reconstruction of most defects in the ENT field. This type of intervention provides greater autonomy and safety in surgical oncology.     

Deltopectoral flap revisited in the microvascular era: a single-institution 10-year experience

OBJECTIVES: In 1965, Bakamjian described the deltopectoral (DP) flap as a reconstructive option in head and neck surgery. It served as the premier flap for reconstructing complex head and neck defects until the late 1970s. Today, the DP flap is often overlooked; although its role has diminished, its use is still warranted in certain select clinical situations. METHODS: A retrospective patient chart review of 25 DP flap procedures performed at the University of Iowa Hospitals and Clinics and Iowa City Veterans Administration Hospital between January 1, 1991, and June 1, 2002, was undertaken. The data collected included patient demographics and assessment of DP flap survival and its ability to accomplish established preoperative reconstructive goals. RESULTS: The DP flap was used for the following situations: vascularized skin coverage of the neck, carotid arteries, and face (16 cases), including simultaneous coverage of other reconstructive flaps in 6 cases; controlled orocutaneous fistula development (3 cases) or fistula closure (5 cases); and pharyngoesophageal reconstruction (4 cases). In 3 cases the flap was used for more than one of the preoperative goals described above (n = 25). Minor flap-related complications that required local wound treatment developed in 5 cases (20.0%), but the flaps were successfully salvaged and no subsequent reconstructive procedure was required. In an additional 5 cases (20.0%), the flap failed in some measure to accomplish its preoperative goal, necessitating further surgical reconstruction. Sixteen patients (64%) had undergone previous or simultaneous reconstructive procedures that limited other available reconstructive options. CONCLUSIONS: The technical simplicity of the DP flap, coupled with its predictable vascular supply, has allowed it to maintain a niche role in contemporary reconstructive surgery. The DP flap provides an excellent method of reconstruction in select cases in which vascularized skin coverage of the neck is needed. The DP flap also provides a valuable salvage option in situations in which other reconstructive techniques are not possible.     

Three-dose vs extended-course clindamycin prophylaxis for free-flap reconstruction of the head and neck

BACKGROUND: Twenty-four hours of perioperative antibiotics provides effective prophylaxis for most head and neck cancer resections. Many reconstructive surgeons have been hesitant to apply this standard to free-flap reconstruction of the head and neck. This prospective clinical trial compared short-course and long-course clindamycin prophylaxis for wound infection in patients with head and neck cancer undergoing free-flap reconstruction. METHODS: Seventy-four patients were randomized to receive short-course (3 doses) or long-course (15 doses) clindamycin perioperatively. Wound infections, fistulas, and other postoperative complications were documented by faculty surgeons who were blinded as to treatment group. RESULTS: The differences in wound infections and other complications were statistically insignificant. No other independent predictors of wound complications emerged in this series of patients. CONCLUSIONS: Short-course clindamycin is as effective as long-course clindamycin in preventing wound infections after free-flap surgery for head and neck ablative defects.     

Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction.

PURPOSE: To review our experience and results with the use of pedicled latissimus dorsi myocutaneous flap (LDMF) for secondary reconstruction in head and neck surgery. METHODS: Twenty-two patients had LDMF, 17 of them for secondary reconstruction. Data were collected regarding the primary surgery, primary method of reconstruction, indication for secondary reconstruction, and outcome. RESULTS: Seventeen LDMF procedures were performed for secondary reconstruction. Flap success rate was 100%. Reconstructive goals were achieved immediately in 16 (94.1%) patients. CONCLUSION: LDMF is a thin flap with a large surface area and a long pedicle that allows it to reach any region in the head, neck, and scalp. Its main disadvantages are the need for lateral positioning of the patient and the fact that its pedicle is not protected with muscle. In our experience, LDMF provides an excellent reconstructive option especially in complicated cases of secondary reconstruction. It may be used in cases where a free flap is usually used, but with significantly reduced surgical time.     

Pulmonary Atelectasis After Reconstruction With a Latissimus Dorsi Myocutaneous Flap

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm² (mean, 128 cm²). The flap size ranged from 7 × 10 to 15 × 15 cm. The majority of flaps were 10 × 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on their flaps (>120 cm²) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.     

Designing an evidence‐based free‐flap pathway in head and neck reconstruction

BackgroundThe use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center''s approach to standardized free‐flap care.Data SourcesThis article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology.ConclusionFree‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.     

Gracilis free flap in head and neck reconstruction beyond facial palsy reanimation

IntroductionThe gracilis muscle free flap has gained popularity in head and neck reconstruction due to minimal donor-site morbidity, reliable vascular pedicle, strong muscular component, and possibility to perform nerve coaptation. However, almost all the existing evidence in the literature is related to its use for facial palsy reanimation. The aim of this study was therefore to review and provide a comprehensive summary of all the possible indications and outcomes of this versatile free flap in head neck reconstructive surgery.Materials and methodsA systematic review of the literature was conducted including articles from 1970 to 2019. All articles were examined and described.ResultsTwenty-seven papers published between 1994 and 2019 were identified for analysis. The evidence highlights the use of the gracilis muscle free flap for parotid, forehead and midface defects, oral tongue, oral sphincter, lower and upper lip, cheek, and oral commissure defects, among others, as the most common defects reconstructed.ConclusionThis flap represents an easy to harvest and versatile free flap with low donor-site morbidity and multiple proven uses in head & neck reconstruction. We therefore encourage reconstructive surgeons to include this flap in their armoury, either as a first or as a second-line option.