Microvascular free flap for head and neck reconstruction: our experiences with 218 free flaps for head and neck reconstructions
Keywords:Free flaps, Flap survival, Flap vascular complications
Background: Defect following radical resection for advance head and neck cancers are complex and without doubt microvascular free flap offer the best reconstructive option. The purpose of this study is to investigate the flap survival rate and review each vascular compromised flaps.
Methods: This is a reviewed of 218 microvascular free flaps done for reconstruction of 204 head and neck patients. There were 112 (51.3%) radial forearm flaps (RFF), 82 (37.6%) fibula flaps (FF) and 24 (11%) anterior lateral thigh (ALT) flaps.
Results: There were 16 complete flap loss and 3 partial flap loss, giving an overall flap survival rate 91.8% (19/218) and flap survival in turn of complete loss 92.7% (16/218). In RFF, there were 7 complete and 1 partial flap loss, giving an overall flap survival rate 92.9% (8/112) and flap survival in turn of complete loss 93.8% (7/112). In FF, there were 6 complete flap loss, giving a flap survival rate 92.7% (6/82). In ALT flap, there were 3 complete and 2 partial flaps loss, giving an overall flap survival rate 79.2% (5/24) and flap survival in turn of flap complete loss 87.5% (3/24). In our series vascular flaps complications rate was 12.3% (27/218), with a salvageable rate of 29.6% (8/27). The most salvageable flap was RFF 46.6% (7/15).
Conclusions: The study re-enforce the learning curve in microvascular free flap and RFF is a good flap for a beginner.
Zimmaro LA, Sephton SE, Siwik CJ, Phillips KM, Rebholz WN, Kraemer HC, et al. Depressive symptoms predict head and neck cancer survival: examining plausible behavioral and biological pathways. Cancer. 2018;124:1053-60.
Lydiatt WM, Moran J, Burke WJ. A review of depression in the head and neck cancer patient. Clin Adv Hematol Oncol. 2009;7:397-403.
Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg. 2014;25:868-71.
De Bree R, Rinaldo A, Genden EM, Suarez C, Rodrigo JP, Fagan JJ, et al. Modern reconstruction techniques for oral and pharyngeal defects after tumor resection. Eur Arch Otorhinolaryngol. 2008;265:1-9.
Neligan PC. Head and neck reconstruction. Plast Reconstr Surg. 2013;131:260-9.
Baj A, Beltramini GA, Demarchi M. Extended-pedicle peroneal artery perforator flap in intraoral reconstruction. Acta Otorhinolaryngol Ital. 2013;33:282-5.
Pellini R, Mercante G, Spriano G. Step-by-step mandibular reconstruction with free fibula flap modelling. Acta Otorhinolaryngol Ital. 2012;32:405-9.
Mura F, Bertino G, Occhini A. Advanced carcinoma of the hypopharynx: functional results after circumferential pharyngolaryngectomy with flap reconstruction. Acta Otorhinolaryngol Ital. 2012;32:154-7.
Dolan RT, Butler JS, Murphy SM, Cronin KJ. Health-related quality of life, surgical and aesthetic outcomes following microvascular free flap reconstructions: an 8-year institutional review. Ann R Coll Surg Engl. 2012;94:43-51.
Juan Carlos de Vicente 1, Tania Rodríguez-Santamarta, Pablo Rosado, Ignacio Peña, Lucas de Villalaín Survival after free flap reconstruction in patients with advanced oral squamous cell carcinoma. J Oral Maxillofac Surg. 2012;70(2):453-9.
Hsieh TY, Chang KP, Lee SS, Chang CH, Lai CH, Wu YC, et al. Free flap reconstruction in patients with advanced oral squamous cell carcinoma: analysis of patient survival and cancer recurrence. Microsurgery. 2012;32(8):598-604.
Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg. 2009;124(6):295-302.
Lim YS, Kim JS, Kim NG, Lee KS, Choi JH, Park SW. Free Flap Reconstruction of Head and Neck Defects after Oncologic Ablation: One Surgeon’s Outcomes in 42 Cases. Arch Plast Surg. 2014;41(2):148-52.
Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique. Plast Reconstr Surg. 1998;102:722-32.
Kansy K, Mueller AA, Mücke T, Kopp JB, Koersgen F, Wolff KD, Zeilhofer HF, Hölzle F, Pradel W, Schneider M. Microsurgical reconstruction of the head and neck - Current concepts of maxillofacial surgery in Europe. J Craniomaxillofac Surg. 2014;42:1610-3.
Jones NF. Intraoperative and postoperative monitoring of microsurgical free tissue transfers. Clin Plast Surg. 1992;19:783-97.
Hidalgo DA, Jones CS. The role of emergent exploration in free-tissue transfer: A review of 150 consecutive cases. Plast Reconstr Surg. 1990;86:492.
Pohlenz P, Klatt J, Schön G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg. 2012;41:739-43.
Suh JD, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD,Alam D, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2004;130:962-6.
Liang J, Yu T, Wang X, Zhao Y, Fang F, Zeng W, et al. Free tissue flaps in head and neck reconstruction: clinical application and analysis of 93 patients of a single institution. Braz J Otorhinolaryngol. 2018;84:416-25.
Marttila, Thoren H, Tornwall J, Vitikko A, Wilkman T. Complications and loss of free flaps after reconstructions for oral cancer. Br Oral Maxillofacial Surg. 2018;56(9):835-40.
Zhou W, Zhang WB, Yu Y, Wang Y, Mao C, Guo CB, et al. Risk factors for free flap failure: a retrospective analysis of 881 free flaps for head and neck defect reconstruction. Int J Oral Maxillofacial Surg. 2017;45(8):941-5.
Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-100.
Le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of complications of free flap reconstruction in head and neck surgery: analysis of 304 free flap reconstruction procedures. Laryngoscope. 2012;122(5):1014-9.
Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A, et al. Factors impacting successful salvage of the failing free flap. Head Neck. 2020;42(12):3568-79.
Okazaki M, Asato H, Takushima A, Sarukawa S, Nakatsuka T, Yamada A, Harii K. Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer. Plastic Reconstructive Surg. 2007;119:1223-3.
Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg. 2003;41:16-20.
28.Hyodo I, Nakayama B, Kato H, Hasegawa Y, Ogawa T, Terada A, Torii S. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope. 2006;116(11):1978-81.
Smith GI, O’Brien CJ, Choy ET. Clinical outcome and technical aspects of 263 radial forearm free flaps used in reconstruction of the oral cavity. Br J Oral Maxillofac Surg. 2005;43:199-204.
Shunyu NB, Medhi J, Laskar HA, Lyngdoh N, Syiemlieh J, Goyal A. 5th Rib Osteo-pectoralis Major Myocutaneous Flap-Still a Viable Option for Mandibular Defect Reconstruction. Indian J Otolaryngol Head Neck Surg. 2014;66(4):414-7.
Kubo T, Yano K, Hosokawa K, Kubo T, Yano K, Hosokawa K. Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction. Microsurgery. 2002;22:391-5