Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection

Microvascular free tissue transfer has gained world-wide acceptance as a means of reconstructing post-oncologic surgical defects in the head and neck region. Since 1977, the authors have introduced this reconstructive procedure to head and neck reconstruction after cancer ablation, and a total of 2372 free flaps were transferred in 2301 patients during a period of over 23 years. The most frequently used flap was the rectus abdominis flap (784 flaps: 33.1 percent), followed by the jejunum (644 flaps: 27.2 percent) and the forearm flap (384 flaps: 16.2 percent). In the reported series, total and partial flap necrosis accounted for 4.2 percent and 2.5 percent of cases, respectively. There was a significant statistical difference ( p < 0.05) in complete flap survival rate between immediate and secondary reconstruction cases. The authors believe that the above-mentioned three flaps have been a major part of the armamentarium for head and neck reconstruction because of a lower rate of flap necrosis, compared to other flaps.     

Evaluation of blood flow in free microvascular flaps

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.     

Techniques of external monitoring of buried free flaps

Postoperative monitoring of free tissue transfer has proven to be crucial in enhancing the flap salvage rate in the event of thrombosis of the anastomosed vessels. Unfortunately, for buried flaps in the head and neck, direct monitoring of the flap can be extremely difficult, if not impossible. Utilizing various methods of flap exposure in a series of 55 buried free flaps of the head and neck, we demonstrate that we were able to provide a reliable means of direct postoperative assessment of the free flaps. Exteriorized components (indicator flaps) were established for 52 cases. An incision to create a skin window in the neck for monitoring was used for 3 cases. For the exteriorized flaps, in addition to clinical observation, adjunctive continuous monitoring using laser Doppler flowmetry was employed for 4-5 days. One free flap developed vascular thrombosis, which was re-explored and salvaged, giving a flap success rate of 100%. Fifty of 52 (96.2%) external components remained viable and therefore reliable for monitoring the main body of the flap. Two indicator flaps were unreliable after postoperative day 1 due to poor skin perfusion, while the subcutaneous component clinically remained viable. There was no return to the operating room for false-positive reexploration. This series reinforces the feasibility and reliability of direct monitoring of buried free flaps using the laser Doppler in practically all cases when modification is added to the flap design and inset.     

Use of single saphenous interposition vein graft for primary arterial circuit and secondary recipient site in head and neck reconstruction: a case report

BACKGROUND: Autologous vein grafts are a valuable tool in microsurgical free tissue transfer. Interposition vein grafts offer the surgeon greater freedom when placing the free flap and choosing the recipient vessels, providing valuable options in case recipient vessels are not available for those patients with large wounds. Free flaps transferred to head and neck regions carry a higher risk of failure, which may be expected to increase more with the use of vein grafts. METHODS: We present our case with the double use of a single vein graft for both primary arterial conduit in end-to-end fashion and secondary end-to-side recipient site in the microsurgical reconstruction of a complicated head and neck defect. RESULTS: All these anastomoses and flaps survived perfectly, and the patient was discharged 14 days after the transfer of the second flap. CONCLUSION: Although the anastomosis of 2 flaps to a single vein graft was successful in our case, it represents a higher risk option than different recipient vessels. We provide this alternative procedure in selected patients, as there is no other receipt vessel or recipient blood flow strong enough to supply more than 1 flap.     

Use of liposuction for secondary revision of irradiated and nonirradiated free flaps

A number of patients with free tissue transfer require secondary revision to improve contour and regional definition to maximize function or appearance. However, there is controversy with regard to whether irradiated free flaps can be revised safely using liposuction. The purpose of this study was to compare the outcomes of revisionary procedures requiring liposuction in irradiated versus nonirradiated flaps. From December 1992 to July 2001, office and hospital records were reviewed retrospectively to identify patients who had undergone free tissue transfer and subsequent flap revision at a single institution. The number of revisions, amount of fat aspirated, timing of revision and the postoperative complications including infection, hematoma, wound dehiscence, and flap loss were reviewed. A total of 41 flap revisions using liposuction alone or with direct excision were performed on 33 free flaps (31 head and neck, 1 chest wall, and 1 extremity). The rectus musculocutaneous flap was the most commonly revised (88%). The average length of time to secondary revision of patients who had received postoperative radiotherapy to their flaps was significantly higher that those whose flaps had not been irradiated (P < 0.05). There were no postoperative complications except for 1 partial (20%) flap loss in a patient whose flap was irradiated. The difference in complication rates between the irradiated and nonirradiated group was not statistically significant. Secondary free flap revision using liposuction and direct excision is a safe technique for recontouring free flaps. There was no significant difference in complication rates for irradiated and nonirradiated flaps. Postoperative radiation therapy is therefore not a contraindication to secondary revision. However, these procedures should be delayed for several months after the acute effects of radiation have resolved.     

Internal jugular vein versus external jugular vein anastamosis: implications for successful free tissue transfer

BACKGROUND: Microvascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems. METHODS: Retrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion. RESULTS: On hundred fifty-six free flaps were performed during this time period. Sixty-five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end-side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p =.03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%). CONCLUSIONS: Although the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

Use of the internal mammary vessels as recipient vessels for an omental flap in head and neck reconstruction

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.     

Free tensor fascia lata perforator flap as a backup procedure for head and neck reconstruction

Free tissue transfer is an essential part of the head and neck reconstruction. Despite several flap options, free perforator flaps have become very popular for head and neck. Anterolateral thigh perforator flap has multiple advantages among other options and is preferred by most of the reconstructive microsurgeons. Besides its advantages, sometimes it is impossible to harvest an anterolateral thigh perforator flap, and the surgeon has to shift to another option. Between January 2002 and June 2005, 5 tensor fascia lata perforator flaps were used for head and neck reconstruction because anterolateral thigh perforator flap could not be elevated due to absence or insufficient musculocutaneous perforators. Only 1 flap was reexplored and salvaged by redoing the venous anastomosis. All flaps survived without any other problem. Donor sites were covered by split-thickness skin grafts in 4 patients and closed directly in 1 of them. Doppler examination is important in planning of anterolateral thigh perforator; if the signals of the perforators are absent or very weak, the surgeon can shift to another flap. This decision may also be made during the operation when insufficient perforators are seen. Based on our experience, tensor fascia lata perforator flap is a safe alternative when anterolateral thigh perforator harvest is not possible. Tensor fascia lata perforator flap can be harvested from the same anatomic region with almost same morbidity.     

Usefulness of vascular bundle interposition of the descending branch of the lateral circumflex femoral vessels for free flap reconstruction of the calvarial defect

Usefulness of the descending branch of the lateral circumflex femoral vessels as a vascular bundle interposition graft was introduced. Large calvarial defect with no recipient vessel for direct anastomosis was successfully covered with free flap nourished by the cervical vessels through the vascular bundle interposition graft of the descending branch of the lateral circumflex femoral artery and its venae comitantes. The vascular bundle interposition has remarkable advantages over the venous graft regarding its patency and durability, especially in the head and neck region in which grafted vessels is difficult to be set on the straight. The descending branch of the lateral circumflex femoral vessels can be harvested up to 20 cm, and its diameter is suitable for interposition between conventional free flaps and recipient vessels in the head and neck region.     

Head and neck reconstruction with a second free flap following resection of a recurrent malignancy

A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.     

Free flaps for head and neck reconstruction in non-oncological patients: experience of 200 cases

Two hundred free flaps for reconstructing the head and neck regions in 192 patients with non-oncological pathology were studied. Pathological entities included Romberg's disease, hemifacial microsomia, acquired facial palsy, trauma, and burn sequelae. Indications for selecting a specific free flap for reconstructing each case, details of anastomoses, reexploration, flap success, operative time, length of hospitalization, and complications were studied. The long-term results of cosmetic and function were also obtained. Patient age ranged from 6 to 40 years. The most common diagnosis was Romberg's disease 39% (n = 75), followed by hemifacial microsomia 20% (n = 40). The free flap most frequently used was the scapular 32% (n = 64), followed by the groin free flap 21% (n = 42). A total of 190 flaps (95%) were successful, whereas only 10 (5%) were lost. The mean operative time was 5:30 h and the average hospital stay was only 6 days. There were no major complications and no deaths in the study group. The patients were followed for at least 1 year in all cases. It is concluded that free flaps are safe and reliable procedures for reconstructing complex head and neck non-oncological defects.     

Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction

This article presents the authors' experience with the anterolateral thigh free flap for lower extremity reconstruction. Twenty-one consecutive anterolateral thigh flaps were transferred for reconstruction of soft-tissue defects of the lower extremity from March 2000 to May 2002. Total flap survival was 90.5 percent, with two partial failures. Venous congestion was observed in one flap (4.7 percent) and the venous anastomosis was revised immediately in the postoperative second hour. The mean follow-up time was 13.4 months (range: 5 to 26 months). The cutaneous perforators were consistently found and presented as musculocutaneous in 19 patients (90.5 percent) or septocutaneous in two other patients (9.5 percent). A thinned anterolateral thigh flap was used in 11 patients. Sensate flaps were used in four patients (19.05 percent) for the reconstruction of amputation stumps. Five flaps (23.8 percent) were used also as flow-through flaps. All patients were satisfied with the cosmetic and functional results. The anterolateral thigh flap has many advantages over other free flap donors in lower extremity reconstruction. These include a long and large caliber vascular pedicle, large and pliable skin paddle, good color and texture matching, and minimal donor-site morbidity. Moreover, the flap can be used successfully and safely as a sensate, thin, or flow-through flap. The anterolateral thigh flap can be accepted as an ideal free flap choice for lower extremity reconstruction because it has maximal reconstructive capacity and produces minimal donor-site morbidity.     

Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction

Background.

The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction.

Methods.

We retrospectively reviewed 1310 free flap reconstructions for head and neck defects performed between July 1995 and June 2006.

Results.

Forty‐nine cases of flap compromise due to vascular obstruction (3.7%) were identified, and 27 flaps were lost (2%). Arterial occlusions occurred in 12 flaps, with a salvage rate of 33%. Eight flaps failed within the first 24 hours, and only 1 of these was salvageable. Five of the 8 flaps had intraoperative thrombosis due to technical difficulties. Venous occlusions occurred in 31 flaps, with a salvage rate of 58%. Twenty‐two venous occlusions occurred within the first 72 hours. The main reason for venous failure was mechanical obstruction due to compression, twisting, kinking, or stretching of the vein. The most common cause of late failures (after 7 days) was unrecognized failure of a buried flap owing to the lack of reliable monitoring. Overall, there was no correlation between surgeon experience and flap failure, but the flap failure rate was lower in surgeons who had performed more than 70 free flap procedures.

Conclusion.

Precise surgical techniques, avoidance of mechanical obstruction, and better monitoring of buried flaps may further improve the success rate of free tissue transfer in complex head and neck reconstruction. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

Venous flow-through flap as an external monitor for buried radial forearm free flap in head and neck reconstruction.

Postoperative monitoring of buried free flaps in head and neck reconstruction can be extremely difficult or impossible. The authors describe a series of 11 cases over a 21-month period, of buried radial forearm free flaps used in head and neck reconstruction. To monitor the main buried flap a small venous flow-through flap is supplied by and attached to the cephalic vein of a radial forearm free flap. This small venous skin flap is inset separately from the main paddle, so that it is visible at the external surface of the neck, furnishing information about the perfusion of the entire flap.     

Indications and outcomes of double free flaps in head and neck reconstruction

Objective. This study describes the clinical setting and operative outcomes for simultaneous double free flap treatment of extensive composite head and neck cancers. Methods. A retrospective review at two tertiary referral centers was performed. Patient demographics, cancer characteristics, reconstruction methods, and postoperative course were recorded. All patients were assessed for diet, speech, esthetics, socialization, and satisfaction using specific evaluation scales. Results. A total of 30 patients underwent double free flap reconstruction between 2001 and 2007. There were 19 men and 11 women, mean age of 62 years (range, 42–79). Comorbidities were present in 67% of the cases and 70% smoked. Most frequently the cancer was a squamous cell carcinoma (90%), in advanced stage (87%), and recurrent (67%), affecting the oral cavity (43%), larynx (23%) or pharynx (20%). The fibula osteoseptocutaneous/radial forearm fasciocutaneous flap combination was most commonly used (n = 13), followed by the jejunum‐radial forearm flap (n = 10). Three flaps required early anastomosis revision and only two partial flap losses were observed. In 11 cases, there was a severe recipient site complication: wound dehiscence (n = 3), oral incompetence (n = 4), fistula (n = 2), and stenosis (n = 2). Two patients died in the postoperative period due to medical problems (7%). The mean follow up was 15.3 months. Patient satisfaction was poor to moderate and the overall functional evaluation score was low. Conclusions. Double free flaps for one‐stage reconstruction of extensive head and neck defects should be used in selected cases. Although a reliable procedure, immediate postoperative morbidity and mortality is high, and the long‐term functional and esthetic results are modest. Realistic outcomes should be discussed with patients during planning and consent. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction.

Free flaps are frequently used to reconstruct the defect following radical resection of pharyngoesophageal malignancy but postoperative monitoring of buried flaps is difficult. We have designed a monitoring-muscle flap using the short head of the biceps femoris muscle when using a free lateral thigh flap. The third and fourth perforators of the profunda femoris artery, the main vascular pedicle of the lateral thigh flap, pass through the short head of the biceps femoris. Partial excision of the short head of the biceps femoris muscle does not result in any functional disturbance of the leg, and the viability of the buried lateral thigh flap can be monitored by observing the exposed muscle through a small window in the neck. Between April and October 1998 five patients underwent pharyngoesophageal reconstruction by this method. The short head of the biceps femoris was used to monitor the main flap in three patients and to obliterate the dead space after neck dissection in two patients. There were no recipient-site complications such as fistula or infection and no disturbance of thigh function.     

Head and neck reconstruction with the deep inferior epigastric perforator flap: A report of two cases

Rectus abdominis musculocutaneous (RAMC) free flaps are preferred for head and neck reconstruction because of the abundant blood supply to the rectus abdominis musculocutaneous. In contrast, the indications for deep inferior epigastric perforator (DIEP) free flaps in head and neck reconstruction are limited. In this report, two cases of oral cavity reconstruction with DIEP free flaps are described. In both cases, the defect was reconstructed with a DIEP free flap because it could avoid functional damage to the donor site. Successful reconstruction with a two skin‐island method was performed in both patients. Furthermore, donor site morbidity was minimal in both patients. When a DIEP free flap is used for head and neck reconstruction, elimination of dead space is the most difficult problem, because a DIEP free flap does not contain well‐vascularized muscle tissue. We compensate for this disadvantage with a flap designed to include a de‐epithelialized skin flap. Although this technique is not always the first choice for head and neck reconstruction, it is suitable for patients who wish to avoid donor site morbidity. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Head and neck reconstruction with antebrachial flap concerning 100 patients

We studied the files of head and neck reconstruction with antebrachial flap used in 100 patients between May 1996 and March 2007 in the department of Maxillofacial Surgery of the CHU of Bordeaux. Flap harvesting and vascular anastomosis were performed by the same operator. Antebrachial flap was used to cover the defect after resection of head and neck cancer in 89 patients and after shotgun injuries of the face in 11 patients. This flap, by its smoothness and its plasticity, makes it possible to rebuild all the oral cavity localizations, even the most complex, by covering the defects without blocking deglutition and enunciation. It brings to the patient a better quality of life by decreasing the functional after-effects that can be seen with the traditional myocutaneous flaps. This flap is highly reliable, not requiring specific care after the operation as other micro-surgeries, which simplifies the postoperative quality of life of the aged and debilitated patients.     

Upper extremity reconstruction using free SCIA/SIEA flap

The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft‐tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft‐tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.