Management of complications and compromised free flaps following major head and neck surgery

Microvascular free flaps are preferred for most major head and neck reconstruction surgeries because of better functional outcomes, improved esthetics, and generally higher success rates. Numerous studies have investigated measures to prevent flap loss, but few have evaluated the optimal treatment for free flap complications. This study aimed to determine the complication rate after free flap reconstructions and discusses our management strategies. Medical records of 260 consecutive patients who underwent free flap reconstructions for head and neck defects between July 2006 and June 2010 were retrospectively reviewed for patient and surgical characteristics and postoperative complications. The results revealed that microvascular free flaps were extremely reliable, with a 3.5 % incidence of flap failure. There were 78 surgical site complications. The most common complication was neck wound infection, followed by dehiscence, vascular congestion, abscess, flap necrosis, hematoma, osteoradionecrosis, and brisk bleeding. Twenty patients with poor wound healing received hyperbaric oxygen therapy, which was ineffective in three patients who eventually experienced complete flap loss. Eleven patients with vascular congestion underwent medicinal leech therapy, which was effective. Among the 78 patients with complications, 44 required repeat surgery, which was performed for postoperative brisk bleeding in three. Eventually, ten patients experienced partial flap loss and nine experienced complete flap loss, with the latter requiring subsequent pectoralis major flap reconstruction. Microvascular free flap reconstruction represents an essential and reliable technique for head and neck defects and allows surgeons to perform radical resection with satisfactory functional results and acceptable complication rates.     

Geographic differences in academic promotion practices,fellowship training,and scholarly impact

Purpose

Previous literature described how clinical fellowship training impacts scholarly production among academic otolaryngologists, finding that fellowship-trained practitioners had higher research productivity than their non-fellowship-trained peers, and head and neck (H&N) surgeons and otologists had the highest scholarly impact. In this analysis we investigate whether geographic differences in academic promotion and scholarly impact exist, and whether such differences are associated with emphasis on regional fellowship training patterns.

Methods

The Scopus database was used to determine scholarly impact (as measured by the h-index) of 1109 academic otolaryngologists from 97 departments. Online faculty listings were organized by fellowship training, academic rank, and location.

Results

Fellowship-trained practitioners had greater research productivity than non-fellowship-trained otolaryngologists (H = 9.5 ± 0.26 SEM vs. 6.5 ± 0.43, p < 0.001), a finding that persisted throughout except in the Mountain and East South Central Regions. H&N surgeons and otologists had the highest h-indices. Practitioners in the West had the highest h-index, with differences persisting upon examination of junior faculty. The West (62.1%) and Midwest (60.5%) had the highest proportions of senior faculty. Regional differences in scholarly impact and academic promotion were further noted upon organizing faculty by subspecialty fellowship training.

Conclusions

Geographic differences in academic promotion and scholarly impact exist, most markedly among junior faculty. Practitioners in the West had high impact and were more represented at senior ranks. Upon examination by fellowship training status, fellowship-trained otolaryngologists had higher impact in most, but not all, geographic regions. Regional variations in promotion were noted upon organizing faculty by subspecialty, although association with scholarly impact differs by region.     

Use of the external jugular vein as the sole recipient vein in head and neck free flap reconstruction

OBJECTIVE: The selection of recipient vessels suitable for microvascular anastomosis within the head and neck region is an essential element affecting patency and outcome. Our aim was to ascertain whether the use of external jugular vein as the sole recipient vein is related to an increase in free flap failure in head and neck reconstructive surgery. METHODS: A retrospective review of all head and neck free flaps performed at an academic centre during a 3-year period was performed. Cases in which the external jugular vein was the lone recipient vein were analyzed. The same two surgeons completed all microvascular anastomosis. The outcome measure was free flap survival. RESULTS: Forty-seven of 49 flaps (96%), which used the external jugular vein as the sole recipient vein, survived. The two failures resulted from venous thrombosis but were successfully salvaged. CONCLUSION: The free flap success rate is well within the range of figures previously reported in large studies. Use of the external jugular vein as the sole recipient vein in head and neck free flap reconstruction does not increase the risk of free flap failures. This suggests that the external jugular vein is a viable option when choosing a single recipient vein in head and neck free tissue transfers.     

The resident selection process in otolaryngology-head and neck surgery

This study was undertaken to characterize the objective information available about applicants to otolaryngology-head and neck surgery residency positions, and to determine the influence of these factors on obtaining a residency position. Applicants to the otolaryngology-head and neck surgery programs at University of Utah, Salt Lake City, University of Texas Medical Branch, Galveston, and University of Louisville (Ky) were studied. Thirty-one variables were examined, representing demographic and academic factors. Excellent academic performance in medical school (as represented by medical school grade-point average greater than 3.4, National Board part I score greater than 650, class percentile rank greater than 85th percentile, honors grades in both junior medicine and surgery clinical clerkships, or [5] election to Alpha Omega Alpha) was significantly correlated with success in obtaining an otolaryngology-head and neck surgery residency position.     

Outcomes in microvascular head and neck reconstruction in the setting of restricted residency hours

Background

Resident duty hour restrictions can limit the frequency of resident flap checks at smaller institutions with “home” call. Institutions are compensating with adjuvant nursing flap checks as well as incorporating technology; however, this management remains controversial.

Who Is Performing Stapedectomy Surgery? Implications for Residency and Fellowship Training

Objectives: To demonstrate that 1) recent graduates of training programs in otorhinolaryngology–head and neck surgery are less likely to recommend/perform stapedectomy than more senior otolaryngologists; and 2) when surgery is recommended, referral is most commonly made to an otologist/neurotologist. Study Design: Survey of 500 regional otolaryngologists pertaining to their treatment of patients with hearing loss secondary to otosclerosis. Methods: Otolaryngologists in community practice were provided with written surveys pertaining to their treatment of otosclerosis. Results: Data were obtained from 179 general otolaryngologists treating adults and children in solo or group private practices in our geographic region. The majority (66%) diagnosed one to five new cases per year. Ten percent of surgeons graduating in the 1970s, 25% graduating in the 1980s, 50% graduating in the 1990s, and 90% of graduates in the 2000s never performed stapedectomy as part of their practices (P < .001). Similarly, a significant number of surgeons who formerly performed stapedectomies no longer do this surgery. A trend toward greater use of hearing aids for the treatment of otosclerosis was seen in more recent graduates (P < .08). When surgery was recommended, otologists/neurotologists received the majority of referrals (75%) from the practitioners surveyed. Conclusions: Stapedectomy is performed and recommended less often by more recent graduates of otolaryngology training programs. Training requirements for both general otolaryngologists and neurotologists may need modification given current practice patterns for stapes surgery.     

Workforce Issues for the Academic Otolaryngologist

Background The current medico‐economic environment has led to profound changes in our health care system and questions of physician surplus. These issues have particularly affected the academic health care system, as research funding and departmental support have decreased, and many young otolaryngologists are questioning academic careers because of these uncertainties. The current study was undertaken to assess the workforce environment for the academic otolaryngologist, particularly the young physician. Methods Surveys were sent to the academic chairmen of all accredited otolaryngology residency programs in the United States, requesting information on faculty appointments—actual and projected—as well as subspecialty appointments and expectations of young faculty. Results The response rate was 60% (59/98). Faculty additions have been relatively stable from 1994 to 1998, with approximately 37 assistant professor and 5 associate professor positions filled yearly. Faculty additions were the result of departmental expansion in 83% of cases and spanned many subspecialties. The subspecialty positions most frequently added from 1994 to 1998 were generalists (57), head and neck oncologists (53), pediatric otolaryngologists (48), and otologists (39), with generalists filling 15 positions in 1998. Ninety‐three percent of programs anticipate faculty additions in the next 5 years; most will be at the assistant professor level (77%), with 30% of positions for generalists, 20% for head and neck oncologists, and 18% for pediatric otolaryngologists. Faculty expectations are primarily clinical, with research being least important. Conclusions Academic positions are available for the young otolaryngologist, particularly in the fields of general otolaryngology, head and neck oncology, and pediatric otolaryngology.     

Burnout in academic faculty of otolaryngology-head and neck surgery

Objective/Hypothesis: To characterize burnout in academic faculty of otolaryngology—head and neck surgery. To identify associated modifiable factors to reduce burnout and improve the health of the field. Study Design: Mailed survey. Methods: A cross section of US academic otolaryngologists was sampled through a mailed survey. Content included the Maslach Burnout Inventory‐Human Services Study (MBI‐HSS) and questions assessing potential burnout predictors such as demographic information, professional stressors, satisfaction, self‐efficacy, and support systems. Results: Burnout was common among academic otolaryngologists. High burnout was observed in 4% of faculty, moderate burnout in 66%, and low burnout in 30%. Women experienced a statistically higher level of emotional exhaustion than men. In addition, associate professors were significantly more burned out than full professors and microvascular surgeons were notably more burned out than all other subspecialists. The strongest predictors of burnout were dissatisfaction with the balance between personal and professional life, low self‐efficacy, inadequate research time, and inadequate administration time. A significant association was seen between high burnout and likelihood to leave academic medicine within the next 1 to 2 years. Conclusions: Burnout was prevalent among US academic otolaryngologists, although levels were lower than those of otolaryngology chairs and residents. Modification of risk factors, such as allowing sufficient faculty time for research and administrative activities, should be undertaken to curb the development of burnout and its deleterious sequelae.     

Unsurpassed reliability of free flaps for head and neck reconstruction

OBJECTIVE: To review the outcome and incidence of perioperative complications in patients undergoing microvascular free flaps for reconstruction of the head and neck region. DESIGN: A prospective case series. SETTING: An academic tertiary care otolaryngology-head and neck surgery program. PATIENTS: One hundred fifteen patients who underwent 119 consecutive free flaps performed by 1 surgeon during a 32-month period. INTERVENTIONS: Reconstruction primarily by means of radial forearm, fibula, and rectus abdominis flaps (95% of the flaps selected for reconstruction). MAIN OUTCOME MEASURE: The incidence of perioperative reconstructive and medical complications. RESULTS: There was 1 perioperative death (0.8%). Among the surviving patients, there was 1 case of complete flap failure, resulting in an overall flap survival of 99.2%. There were 2 additional cases (1.8%) of partial flap necrosis. Perioperative reconstructive complications occurred during 10.1% of the hospitalizations, half of which required additional surgical intervention. Notable perioperative medical complications occurred in 17.1% of the patients. CONCLUSIONS: Despite their reliance on small-vessel anastomoses for survival, free flaps are extremely reliable with regard to the incidence of flap necrosis, which contributes to a low incidence of perioperative complications. Selection of flaps that have proven dependability contributes to a successful outcome. While this technique frequently requires lengthy surgery in an elderly patient population, the perioperative mortality) and morbidity are acceptable. Because of their unsurpassed reliability, free flaps have become the preferred method of reconstruction for most patients with major defects in the head and neck region.     

Matching graduate education with societal need

OBJECTIVES/HYPOTHESIS: A number of prior Ogura lecturers have focused on the need to change residency education in otolaryngology-head and neck surgery; nothing has changed. The present discussion is based on the notion that graduate medical education should reflect societal need. STUDY DESIGN: Lecture. METHODS: Information on graduate medical education is presented. RESULTS: The information presented substantiates the maldistribution of otolaryngologists and the mismatch of the design and output of our programs from the perspective of public need. CONCLUSION: It is proposed that the American Board of Otolaryngology should take the lead in substantive change with the targets being 1) providing flexibility in program design, 2) a 1-year reduction in core training in otolaryngology, and 3) expanded interaction with family medicine.     

Flap outcomes when training residents in microvascular anastomosis in the head and neck

Objective

Microvascular anastomosis is generally performed by attending surgeons or fellows, with published success rates > 95%. Since otolaryngology residents do not typically perform microvascular anastomosis, it is unknown if they achieve similar results. The objective of this study is to determine the success rate and complication rate during free flap reconstruction when microvascular anastomosis is performed in part by otolaryngology chief residents.

Study Design

Multi-institutional retrospective review.

Setting

Academic, tertiary-care referral centers.

Subjects and Methods

Consecutive patients who underwent microvascular reconstruction by the Department of Otolaryngology from 2004 through 2011. All patients had > 50% of the arterial and venous anastomoses performed by the chief resident.

Results

The study included 93 consecutive free flaps in 88 patients: 43 radial forearm, 14 anterolateral thigh, and 36 fibula. There were 71 males and 22 females with mean age of 53. The pre-operative diagnosis was squamous cell carcinoma in 78%, with 27% of patients having previously received radiotherapy and 13% of patients having had previous neck surgery. There were no instances when resident-placed sutures required revision, nor was there a perceived need to revise such an anastomosis intraoperatively. Overall flap success rate was 97%. The anastomotic complication rate was 4.3%, with venous thrombosis in three cases and arterial hemorrhage in one case.

Conclusion

Overall free flap success rate and anastomosis-related complications with residents performing portions of the microvascular anastomosis are comparable to published studies. Otolaryngology chief residents can safely participate in microsuturing, which is a single facet in the broader skill set of a microvascular surgeon.     

Effects of aspirin and low-dose heparin in head and neck reconstruction using microvascular free flaps

Objective: The success of microvascular free‐tissue transfer to the head and neck has been greatly increased secondary to increased experience, yet postoperative anticoagulation continues to be routinely used to prevent pedicle thrombosis. However, there is currently no consensus as to what the ideal regimen, if any, is recommended for postoperative anticoagulation. This study reviews the outcome and incidence of perioperative complications in patients undergoing free flaps for head and neck reconstruction, using a simple postoperative anticoagulation regimen of aspirin and subcutaneous heparin (SQH). Design: Retrospective chart review. Methods: With institutional review board approval, the charts of 261 patients undergoing free flap reconstruction from January 2000 to January 2004 were retrospectively reviewed. Patients who received a standard postoperative anticoagulation regimen of SQH (5000 U SC bid) and aspirin (325 mg PO qd) were included in the study (216 patients). Charts were reviewed for postoperative complications, specifically for free flap failure, vascular compromise (arterial insufficiency/venous congestion), and hematoma. Results: There were six flap failures (2.8%), resulting in an overall free flap survival rate of 97.2%. There were six patients with venous congestion of the flap that required neck exploration (2.8%), and 12 patients with postoperative hematoma (5.6%), requiring surgical intervention. Conclusion: The free flap survival rate in patients undergoing head and neck reconstruction using this simple anticoagulation regimen of aspirin and SQH appears to be equivalent to the free flap survival rate in patients using other anticoagulation agents. In addition, aspirin and SQH do not increase the incidence of postoperative hematoma when compared with the other anticoagulation agents. Therefore, aspirin and SQH appear to be reliable postoperative anticoagulation agents for patients undergoing head and neck reconstruction using free flaps.     

Myocardial infarction after microvascular head and neck reconstruction

OBJECTIVE/HYPOTHESIS: Microvascular flap transfer is a popular method for immediate reconstruction of defects in the head and neck resulting after the treatment of head and neck cancer. Head and neck cancer occurs most commonly in elderly patients with a high prevalence of heavy smoking. Surgery in this patient population is frequently prolonged and is associated with significant intraoperative blood loss. The present study seeks to identify factors contributing to perioperative myocardial infarction and to determine the best course of management. STUDY DESIGN: Retrospective analysis of 193 consecutive free flap surgeries.METHODS A series of 193 microvascular free flaps performed over a 5-year period for reconstruction of defects in the head and neck was retrospectively analyzed to identify the incidence, management, and outcome of perioperative myocardial infarction in this patient population. RESULTS: Myocardial infarctions occurred in seven patients, for an overall incidence of 3.6%. Statistical analysis using logistic regression failed to demonstrate any significant relationship between age, sex, total operative time, operative blood loss, net intraoperative fluid shifts, tumor stage, American Society of Anesthesiology (ASA) preoperative classification, type of free flap, and the occurrence of perioperative myocardial infarction. Hemodynamic instability manifested by hypotension occurred in four patients who had perioperative myocardial infarction. Three of these patients underwent urgent coronary artery bypass surgery, whereas one patient underwent urgent endovascular therapy with subsequent stabilization of the hemodynamic instability. All free flaps survived despite myocardial infarction and hemodynamic instability. Two patients (29%) died after postoperative intervals of 74 and 99 days, never having left the hospital. CONCLUSIONS: Systemic hypotension is a well-recognized risk factor for free flap failure. Our experience suggests that aggressive intervention to reverse coronary ischemia associated with hemodynamic instability has a favorable outcome on free flap survival, and free flap thrombosis is not an inevitable outcome of the low-flow state associated with perioperative cardiopulmonary bypass. Although the overall incidence of perioperative myocardial infarction in patients undergoing microvascular head and neck reconstruction is low, patient mortality is high, so emphasis should be placed on preoperative identification of patients with coronary artery disease.     

Effect of salivary fistulas on free flap failure: a laboratory and clinical investigation

OBJECTIVES: Infection is associated with free flap failure in patients undergoing microvascular flap reconstruction. This study investigates the association between infection arising from salivary fistulas, microvascular thrombosis, and free flap failure. STUDY DESIGN: Prospective laboratory investigation and retrospective clinical investigation. METHODS: The effect of saliva-induced infection on the patency of microvascular thrombosis was studied in an experimental animal model and in a clinical series of patients undergoing free flap reconstruction of the head and neck. In the laboratory phase of this study, rat femoral artery anastomoses were inoculated with freshly collected rat saliva to simulate a postoperative salivary fistula. The incidence of femoral artery thrombosis was determined. In the clinical arm of this study, the incidence of salivary fistulas and resulting clinical outcome in 588 head and neck free flap reconstructions were examined. RESULTS: In the animal experiment, arterial patency was 95% after 10 days for both the control group and the salivary contamination group. In the clinical series, 24 patients developed salivary fistulas during the postoperative period. No cases of microvascular thrombosis were attributed to salivary fistula formation. CONCLUSIONS: Postoperative salivary fistulas do not appear to be strongly associated as a contributory factor toward free flap failure in head and neck reconstruction. On the basis of our current understanding of this condition, we describe a rational approach for management of patients who develop salivary fistulas after microvascular head and neck reconstruction.     

Emerging trends in the performance of parathyroid surgery

OBJECTIVE: The management of hyperparathyroidism has evolved rapidly in the past decade with the introduction of intraoperative parathyroid hormone testing, radioguided surgery, and endoscopic surgery. Not surprisingly, there is a corresponding movement toward specialization of surgeons providing increasingly sophisticated treatments for head and neck endocrine disorders. We sought to identify trends in the disciplines performing parathyroid surgery. DESIGN: Nonrandomized, controlled comparison of surgical caseloads and publication volumes. METHODS AND MATERIALS: Two metrics designed to reflect the proportion of parathyroidectomies being performed by otolaryngologist-head and neck surgeons (OHNS) and general surgeons (GS) were chosen: the operative case logs of graduates from American training programs in OHNS and GS from 1996 through 2005 and the number of scientific papers published relating to parathyroid surgery during two timeframes (1991-1995 and 2001-2005). RESULTS: There was a gradual increase in the mean number of parathyroid surgeries performed by GS residents from 6.0 in 1996 to a peak of 9.2 in 2004; this volume has begun to decline (to 8.5 in 2005). During the same timeframe, the mean number of parathyroidectomies performed by OHNS residents rose sharply and steadily from 1.8 in 1996 to 10.9 in 2005. The number of American GS parathyroid publications from 1991 to 1995 was 41, compared with 108 in the period 2001 to 2005. During the same timeframe, the number of American OHNS parathyroid papers increased from 1 to 27. The relative proportion of parathyroid publications authored by American otolaryngologists rose from 2.4% to 20.0% (P = .006). CONCLUSIONS: Increasingly, otolaryngologists are the primary surgeons in parathyroid operations as indicated by two surrogate metrics. Graduating chief residents in otolaryngology now perform more parathyroid procedures than chief residents in general surgery, and a growing proportion of parathyroid publications are being authored by otolaryngologists.     

Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction

OBJECTIVE: Microvascular free-tissue transfer is essential for functional reconstruction in head and neck cancer surgery. The risk of free flap failure depends on venous thrombosis rather than arterial thrombosis, and any type of failure caused by venous thrombosis is often diagnosed late. In this study, we studied the flap survival rate achieved by this technique depending on the recipient vein. Further, the risk factor was analyzed for venous thrombosis with regard to preservation of recipient vein during neck dissection. METHODS: This study is a retrospective review of 102 consecutive free flaps performed by a single head and neck surgical team from 2000 to 2006 at the Department of Otolaryngology, Head and Neck Surgery at Kagoshima University Hospital. The recipient vessels such as the external jugular (EJ) vein and internal jugular (IJ) system were carefully preserved during neck dissection. All patients received 80 microg of prostaglandin E1 (Alprostadil) for 5 days after surgery. RESULTS: The overall success rate was 94.1%. All the six cases of unsuccessful free flap transfer were caused by venous thrombosis. Microvascular free flaps anastomosed to the EJ vein failed at a significantly higher rate (13.3%) than those anastomosed to the IJ system (2.8%) (p<0.05). On studying the failed cases after IJ system anastomosis, we found that all complications were caused by internal jugular vein thrombosis (IJVT) and not by microvascular anastomotic thrombosis. In all the three cases of flap failure with IJVT, the dissected IJ vein was patently ballooning because of the remaining connective tissue, including the adventitia around the IJ vein in the supraclavicular lesion. CONCLUSIONS: Although the IJ system is the ideal recipient vessel when compared with EJ vein, there is another risk of flap failure due to IJVT. To improve the survival rate, IJVT should be prevented by a careful manipulation of IJ system during neck dissection to avoid ballooning of the IJ vein in head and neck cancer surgery.     

Posterior scalping flap revisited

OBJECTIVE: To report our experience in a case series of 5 posterior scalping flaps. DESIGN: Retrospective review of a case series. SETTING: A tertiary academic care otolaryngology-head and neck surgery referral center. PATIENTS: Five patients having undergone posterior scalping flap reconstruction of cutaneous midface defects. METHODS: Reconstruction was performed for 4 cheek defects, 1 of which included the lateral third of the upper and lower lips, and 1 combined midfacial and lateral nasal wall defect. RESULTS: All 5 patients had excellent cosmetic and functional results. The only complication was a single case of partial-thickness distal flap necrosis. CONCLUSION: The posterior scalping flap offers a reliable source of skin with appropriate color and texture and minimal donor-site morbidity.     

Head and neck reconstruction with free flaps: a report on 213 cases

The aim of this retrospective study is to review the experience of our institution in performing microvascular head and neck reconstruction between 2000 and 2004. During this period, 213 free flaps, including 146 radial forearm free flaps, 60 fibular flaps and 7 scapular flaps, were performed. Free flap success rate and complications were reported. The pre-treatment factors influencing these results were subsequently analyzed. Functional and aesthetic outcomes were evaluated by the same clinician. There were 14 free flap failures, giving an overall free flap success rate of 93.4%. Salvage surgery for recurrent cancer was the only factor correlated with a higher risk of free flap failure (P = 0.0004). The local complication rate was 20.9%. High level of comorbidity (P = 0.009), salvage surgery for recurrent cancer (P = 0.03) and hypopharyngeal surgery (P = 0.002) were associated with a higher risk of local complications. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results.     

Reconstruction of the hypopharynx: current trends

PURPOSE OF REVIEW: Reconstruction of the hypopharynx continues to present a clinical challenge for the reconstructive surgeon. Trends continue to evolve as many viable options exist, depending on individual patient characteristics and institutional preferences. The article reviews the most current literature available on the subject. RECENT FINDINGS: Surgical resections resulting in pharyngoesophageal defects require timely reconstruction to minimize patient morbidity while optimizing quality of life, specifically in regards to speech and swallowing. Contemporary reconstructive options include various gastrointestinal flaps, pedicled myocutaneous flaps, and fasciocutaneous free flaps. Institutional trends often depend on the availability, training, and expertise of the reconstructive surgeon. The current options available differ in their complication rate and overall morbidity, and must take into account each patient's general medical health. Increased availability of surgeons trained in microvascular reconstruction and the continued high published success rates have made free flaps an attractive option for hypopharyngeal reconstruction. Functional outcome regarding swallowing and speech rehabilitation after free flap reconstruction is promising. SUMMARY: With continued publication of overall high success rates coupled with superior functional outcome and increased availability of surgeons trained in microvascular reconstruction, fasciocutaneous free flap reconstruction of the hypopharynx will probably surpass intestinal flaps in reliability and popularity.     

Assessment of patency of the internal jugular vein following neck dissection and microvascular flap reconstruction by power Doppler ultrasound

The objective of this study was to assess patency of the internal jugular vein following modified radical or selective neck dissection and microvascular flap reconstruction by power Doppler ultrasound and its impact on free flap survival. In 23 patients who underwent selective or modified radical neck dissection and microvascular flap reconstruction the patency of the internal jugular vein was examined by power Doppler ultrasound on the first post-operative day and after follow-up of at least four months. On the first post-operative day in one patient partial thrombosis was found, while in the other 22 patients the internal jugular vein was normal patent. During follow-up in 17 (74 per cent) patients a normal patent internal jugular vein was found, while partial and complete thrombosis were found in three (13 per cent) patients each. On the first post-operative day 22 of the 23 (96 per cent) free flap veins were visualized. There was no free flap loss during follow-up. Power Doppler ultrasound is a valuable diagnostic technique for determination of internal jugular vein patency and may be useful as screening method or in case of clinical suspicion of thrombosis to determine internal jugular vein patency. Late internal jugular vein thrombosis may probably not effect free flap survival due to neovascularization.