Free tissue transfers in head and neck reconstruction: Complications,outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute

Background: Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. Patients and Methods: A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20‐year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. Results: A total of 201 cases required emergent surgical re‐exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re‐exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. Conclusion: Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate. © 2013 Wiley Periodicals, Inc. Microsurgery 34:339–344, 2014.     

Reconstruction of large head and neck deformities: Experience with free gracilis muscle and myocutaneous flaps

Microvascular free flaps continue to revolutionize coverage options in head and neck reconstruction. The authors describe their experience with the gracilis free flap and the myocutaneous gracilis free flap with reconstruction of head and neck defects. Eleven patients underwent 12 free tissue transfer to the head and neck region. The reconstruction was performed with the transverse myocutaneous gracilis (TMG) flap (n = 7) and the gracilis muscle flap with skin graft (n = 5). The average patient age was 63.4 years (range, 17–82 years). The indications for this procedure were tumor and haemangioma resections. The average patient follow‐up was 20.7 months (range, 1 month–5.7 years). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. Recipient site morbidities included one hematoma. In our experience for reconstruction of moderate volume and surface area defects, muscle flaps with skin graft provide a better color match and skin texture relative to myocutaneous or fasciocutaneous flaps. The gracilis muscle free flap is not widely used for head and neck reconstruction but has the potential to give good results. As a filling substance for large cavities, the transverse myocutaneus gracilis flap has many advantages including reliable vascular anatomy, relatively great plasticity and a concealed donor area. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

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.     

Reconstruction of large composite buccal defects using single soft tissue flap—analysis of functional outcome

Resection of advanced gingivo‐buccal tumors results in a posterolateral mandibular and large soft tissue defect. Because of large soft tissue requirement, these defects are difficult to reconstruct using a single osteocutaneous flap. A double free flap reconstruction of such defects is recommended. However, double flap may not be feasible in certain situations. In this study, we objectively evaluated functional and cosmetic outcomes following single soft‐tissue flap reconstruction in a group of patients where double flap reconstruction was not feasible. Patient and defect characteristics were obtained from charts. The speech and swallowing functions of patients were prospectively assessed by a dedicated therapist. The cosmetic outcome of reconstruction was evaluated by an independent observer. Fifty‐six patients with large soft tissue and segmental posterolateral mandible defect, reconstructed with anterolateral thigh or pectoralis major flap from May 2009 till December 2010 were included. In this series, none of the flaps were lost; two patients with pectoralis major flap developed partial skin paddle loss. Most of the patients developed mandibular drift; however, majority of these patients had no postoperative trismus. All patients resumed regular or soft solid oral diet. The mean speech intelligibility was more than 70%. Majority of patients had satisfactory cosmetic outcome. The defects were classified into regions resected to develop a reconstruction algorithm for optimal reconstruction using a free or pedicle flap. In conclusion, patients with large oro‐mandibular defect undergoing single soft tissue flap reconstruction have satisfactory functional and cosmetic outcome. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Donor-Site Complications in Vascularized Bone Flap Surgery

Microvascular osteocutaneous free flaps have given reconstructive surgeons a powerful tool in the reconstruction of composite defects in head and neck surgery. Radial forearm, scapula, iliac crest, and fibula flaps have been used extensively in mandibular reconstruction. The inevitable donor-site morbidity of these osteocutaneous flaps has received less attention than the reconstructive advantages. We have reviewed the literature for each type of flap to determine the kind, incidence, and consequences of flap associated morbidity. In the future, tissue-engineered prefabricated free flaps might play an important role.     

Donor-site complications in vascularized bone flap surgery.

Microvascular osteocutaneous free flaps have given reconstructive surgeons a powerful tool in the reconstruction of composite defects in head and neck surgery. Radial forearm, scapula, iliac crest, and fibula flaps have been used extensively in mandibular reconstruction. The inevitable donor-site morbidity of these osteocutaneous flaps has received less attention than the reconstructive advantages. We have reviewed the literature for each type of flap to determine the kind, incidence, and consequences of flap associated morbidity. In the future, tissue-engineered prefabricated free flaps might play an important role.     

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

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

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.     

Simultaneous maxillary and mandibular reconstruction with a single Osteocutaneous fibula free flap: A description of three cases

Large defects that comprise both the maxilla and mandible prove to be difficult reconstructive endeavors and commonly require two free tissue transfers. Three cases are presented to discuss an option for simultaneous reconstruction of maxillary and mandibular defects using a single osteocutaneous fibula free flap. The first case describes a 16‐year‐old male with a history of extensive facial trauma sustained in a boat propeller accident resulting in a class IId maxillary and 5 cm mandibular defect status post three failed reconstructive surgeries; the second, a 33‐year‐old male with recurrent rhabdomyosarcoma of the muscles of mastication with resultant hemi‐mandibulectomy and class IId maxillary defects; and lastly, a 48‐year‐old male presenting after a failed scapular free flap to reconstruct defects resulting from a self‐inflicted gunshot wound, which included a 5 cm defect of the right mandibular body and 4.5 cm defect of the inferior maxillary bone. In all cases, a single osteocutaneous fibula free flap was used in two bone segments; one to obturate the maxillary defect and restore alveolar bone and the other to reconstruct the mandibular defect. The most recent patient was able to undergo implantable dental rehabilitation. Postoperatively, the free flaps were viable and masticatory function was restored in all patients during a follow‐up range of 2–4 years.     

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.     

头颈部肿瘤术后缺损游离组织瓣的供区选择

目的应用游离组织瓣修复头颈部肿瘤术后缺损,探讨较简便合适的方法。方法回顾并分析1999年1月~2002年1月,采用游离组织瓣修复头颈部肿瘤术后缺损86例。缺损部位:口腔32例,下咽27例,下颌骨12例,颅底5例,中面部4例和头皮/皮肤6例。供区:腹直肌皮瓣32例,股前外侧皮瓣10例,空肠瓣25例,腓骨瓣11例,背阔肌皮瓣4例,前臂皮瓣3例和肩胛皮瓣1例。其中皮瓣或肌皮瓣大小4 cm×5 cm~14 cm×24 cm,腓骨瓣长度4~16 cm,空肠瓣长度9~20 cm。结果游离组织瓣术后成活79例,成活率为92%。其中口腔缺损采用腹直肌肌皮瓣22例(69%)和股前外侧皮瓣10例(31%)修复;下咽缺损主要用空肠瓣修复25例(93%),下颌骨缺损则用腓骨瓣修复11例(92%),颅底缺损由腹直肌皮瓣修复4例(80%)。腹直肌、股前外侧、空肠和腓骨4种组织瓣修复头颈部缺损78例,占同期游离组织瓣的91%。结论头颈部肿瘤术后缺损复杂,利用腹直肌肌皮瓣、股前外侧皮瓣、空肠瓣和腓骨瓣可解决大多数修复重建的难题。     

吻合血管的腓骨瓣移植一期重建双侧下颌骨

目的探讨下颌骨巨大肿瘤截骨切除后应用游离腓骨复合组织瓣一期重建双侧下颌骨方法和疗效。方法2000年7月至2002年10月,分别对波及双侧下颌骨的4例巨大成釉细胞瘤、2例牙龈癌施行截骨切除,手术造成跨中线的双侧下颌骨巨大缺损。根据下颌骨缺损的特点,以腓动静脉为血管蒂切取腓骨肌(皮)瓣,经截骨塑形后,用微形钛板将移植骨与双侧下颌骨残端坚固内固定,腓动、静脉与颈部小血管吻合,形成血管化腓骨复合组织瓣一期重建双侧下颌骨。结果6例移植腓骨复合组织瓣全部成活。随访6个月-2年,面下部外形恢复良好,移植腓骨与上颌骨相对位置正常,接受活动义齿修复后咬合关系和咀嚼功能均较满意。结论腓骨复合组织瓣节段性的骨膜供血和骨髓滋养动脉的双重供血特点十分适合塑造成下颌骨的弓状形态,是修复下颌骨巨大肿瘤导致的跨中线双侧下颌骨巨大缺损的理想材料。     

Parascapular free flaps for head and neck reconstruction

We report our experience with single-stage, primary reconstruction of the head and neck in 29 consecutive patients using parascapular free flaps. The commonest indications were for craniofacial defects (9), oropharyngeal soft tissue defects (10), and combined mandibular and soft tissue losses (4). Ablative surgery was performed for squamous carcinoma (22), melanoma (2), and malignant fibrous histiocytoma (2). Seven patients died of recurrent disease during a 3 1/2 year follow-up. Seven patients are alive with recurrence. Flap complications included total loss (2) due to unsalvageable microvascular thrombosis, wound breakdown with oropharyngeal fistula (2), mandibular osteomyelitis (1), trismus (2), neck contracture (1), and donor site wound dehiscence (1). The overall success of this reconstruction was 93%. Primary wound healing was the general rule with lower morbidity than with other reconstructive techniques. The flap is thin, pliable, and conforms well to three-dimensional defects. The lateral border of the scapula can be incorporated on the same vascular pedicle for single-stage mandibular reconstruction. No muscle is sacrificed, and the posterior donor defect is an added advantage. The parascapular flap is our first choice for reconstruction of major defects in the head and neck.     

The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.

BACKGROUND: A variety of free flaps have been successfully used for mandible reconstruction. This study compared the short- and long-term results of using the free iliac crest and fibula flaps. METHODS: We conducted a retrospective analysis of 117 patients who underwent mandibular reconstruction, 59 patients with iliac crest and 58 with free fibula. Accurate long-term functional assessment was possible in 31 cases in the iliac crest group and in 48 patients with fibular reconstruction. Anterior or combined anterolateral defects formed 72% and 64% in the iliac crest and fibula groups, respectively. The remainder were pure lateral defects. In both series, a skin paddle was included to provide either lining, skin cover, or both in 77% of the cases, whereas in 23% bone only was used. RESULTS: Complications included two perioperative deaths and three flap losses in the iliac crest group and five flap losses in the fibula group. Long-term functional and cosmetic assessment showed no statistically significant differences in oral continence (p > 0.9), speech (p = 0.57), and contour results (p = 0.80) between the two groups. However, oral deglutition was statistically significantly better in the fibula free flap group (p = 0.009). CONCLUSION: Although the fibula free flap is the flap of choice, the iliac crest is an excellent and reliable complementary flap for mandibular reconstruction.     

Elective free flap revision in the head and neck cancer patient: Indications and outcomes

Elective free flap revision among head and neck cancer patients remains poorly characterized. This study evaluates patients who underwent flap revision and their surgical outcomes. Patients who underwent tumor extirpation with free flap reconstruction were identified over a 5‐year period. Elective flap revision was defined as debulking or redraping of the original free flap for functional or cosmetic reasons. Patient demographics, surgical indications, and outcomes were reviewed. One hundred and eighty‐six patients were identified, and 19 (10.2%) underwent flap revision. Revision of oral cavity flaps (n = 9, 47.4%) was performed to address excessive flap bulk compromising lip competence, speech, swallowing, mastication, or placement of a dental prosthesis. Revision of flaps resurfacing the face or neck (n = 10, 52.6%) was performed to address facial ptosis after facial nerve sacrifice, facial asymmetry, or soft tissue redundancy. Revisions were performed at an average of 7.3 months postoperatively and there was no age or gender bias toward undergoing flap revision. Patients whose flap skin paddles were used to resurface the facial or neck skin were significantly more likely to undergo elective revision than patients with an external paddle designed for flap monitoring (p < 0.01). We identified a 10% elective revision rate for head and neck free flaps in cancer patients, approximately half of which were performed to improve oral cavity function and half of which were performed to address facial ptosis or asymmetry. While there was no age or gender preference for flap revision, extensive facial or neck resurfacing was significantly associated with eventual flap revision. © 2015 Wiley Periodicals, Inc. Microsurgery 35:591–595, 2015.     

The application of 3-D biomodeling technology in complex mandibular reconstruction��experience of 47 clinical cases

3-D biomodeling technology associated with stereolithography has become a fundamental tool in reconstructive surgery in recent years as it enables a highly accurate definition of the defect to be reconstructed. In complex mandibular reconstruction using free flaps, the exact 3-D characteristics of the flap are decisive to restore symmetry and structural integrity, which enables a good functional and aesthetic result. This paper reports the application of an innovative 3-D biomodeling approach for the calculation of the exact contours, angles, length, and general morphology of iliac crest and fibula free flaps for mandibular reconstruction. Between 2003 and 2009, we managed 47 complex mandibular reconstruction cases using this technology. The free flaps used were fibula (n = 29) and iliac crest (n = 18) transferred as osseous or osteocutaneous flaps. From computer tomography scans, virtual 3-D images of the patient's anatomy were converted into 3-D physical models using first Freeform Modeling? software and then selective laser stereolithography technology. Intra-operative bone osteotomies and modeling were guided by these biomodels. Functional and aesthetic end results were at least considered satisfactory in 95.7% of the patients. The majority (80.8%) were in the good and very good end-result categories. This personalized designing of free flaps enabled optimization of pre-operative planning, reduced operative time, and significantly improved the aesthetic and bio-functional outcome. We found it to be particularly useful in major secondary defects (oncological, osteoradionecrosis, trauma) with important distortion of craniofacial structure, congenital malformations, and primary tumor surgery when the dimensions of the tumor have altered normal anatomy considerably.     

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

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

Free flap reconstruction of oral composite defect complicated by intraoperative cardiac arrest: A case report

We report the case of intraoperative cardiac arrest of a patient undergoing free tissue harvest for an oral composite defect and subsequent completion of reconstruction with simultaneous double flaps. A 54‐year‐old man with advanced carcinoma of the tongue underwent near‐total glossectomy, segmental mandiblectomy, and bilateral neck dissections. We planned a fasciocutaneous anterolateral thigh flap to reconstruct the glossectomy defect, and a fibula osteocutaneous flap for the mandible defect. After the fibula flap harvest, the patient suffered a cardiac arrest. After a 4‐min code, the patient regained a sinus rhythm and became hemodynamically stable. We completed the cancer resection and banked the pedicled, osteotomized fibula flap in the lower extremity. We took the patient back to the operating room on postoperative day number 5 for successful reconstruction with simultaneous fibula and ALF flaps. The microvascular surgeon must always be poised to rapidly address intraoperative complications that may critically compromise the success of the free flap or, more seriously, jeopardize the patient's life. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

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     

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects.

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.