Head and Neck Reconstruction With a Second Free Flap Following Resection of a Recurrent Malignancy
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Abstract:
In Brief 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. A retrospective analysis of 12 patients whose head and neck tumors required placement of a second freeflap into a local recurrence showed an 85% survival rate for the second flaps. The same recipient artery wasreused in 38% of the flaps and the same vein in 54%.Keywords:
Free flap reconstruction
Free flap reconstruction
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Microvascular surgery
Free flap reconstruction
Reconstructive Surgeon
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SUMMARY:
Head and neck surgical reconstruction is complex, and postoperative imaging interpretation is challenging. Surgeons now use microvascular free tissue transfer, also known as free flaps, more frequently in head and neck reconstruction than ever before. Thus, an understanding of free flaps, their expected appearance on cross-sectional imaging, and their associated complications (including tumor recurrence) is crucial for the interpreting radiologist. Despite the complexity and increasing frequency of free flap reconstruction, there is no comprehensive head and neck resource intended for the radiologist. We hope that this image-rich review will fill that void and serve as a go to reference for radiologists interpreting imaging of surgical free flaps in head and neck reconstruction.Cite
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Free-flap microvascular surgery of the head and neck is now an accepted reconstructive technique. Optimal reconstruction of both function and form are achieved in selected patients by this method. We describe our experience with free-flap reconstruction of head and neck defects in 13 patients. In 5 oncologic patients reconstruction was immediate, while in 8 other oncologic and trauma patients it was delayed. The free rectus abdominis myocutaneous flap was used most often. 3 flaps required revision, but only 1 failed.
Free flap reconstruction
Form and function
Oncologic surgery
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Sir:FigureVein graft interposition is an accepted technique for microvascular reconstruction. However, in head and neck free flap reconstruction, vein grafting has rarely been addressed in the literature because of the relative infrequency of its use. In head and neck reconstruction, vein graft interposition was reportedly to be used in the following situations: (1) when the distance from the defect to the recipient vessels was greater than the length of the flap pedicle; (2) when vessel caliber mismatch existed between the recipient vessels and the flap pedicle; (3) when there were threatened or prior failed flaps; (4) when there were preirradiated graft beds; (5) for tumor recurrence; and (6) for trauma.1–3 Whether vein graft interposition increases the risk of free flap loss in head and neck reconstruction remains controversial.4 We decided to evaluate the existing literature, looking at the influence of vein graft interposition on free flap outcome in head and neck reconstruction through a systematic review. We searched the PubMed database for articles published from January of 1990 to June of 2011. Our keywords included “free flap reconstruction” or “free tissue transfer,” and “vein graft.” This search was supplemented by a review of reference lists of potentially eligible studies. We excluded non-English articles, studies from the same institute with overlapping duration, and studies that also included free flap reconstruction in other body parts. Two reviewers independently extracted data in two steps: titles and abstracts, and then full-text articles. Numerical distribution of procedures with or without vein graft and the number of flap losses were recorded (Table 1).1–3,5 The primary outcome was the flap failure rate. Relevant studies were assigned a level of evidence according to the American Society of Plastic Surgeons Evidence Rating Scale for Therapy.Table 1: The Four Retrospective Comparative StudiesThrough our electronic and reference search, we identified four retrospective comparative studies (level III evidence) that compared head and neck free flap reconstruction with and without vein graft interposition. We pooled 2102 free flaps for further survey. A total of 65 flaps (3.1 percent) used vein graft interposition and 2037 flaps (96.9 percent) did not. The overall flap failure rate was 5.2 percent. The flap failure rates were 23.1 percent in the vein graft group and 4.6 percent in the no–vein graft group. Although the pooled data showed that vein graft interposition was associated with an increased incidence of free flap failure, we could not conclude a causal relationship between vein graft interposition and flap failure. Vein graft interposition in head and neck free flap reconstruction was uncommon. The increased flap failure rates may be the result of the underlying factors that necessitated the use of vein grafts in the first place. Deliberate preoperative planning and delicate preparation for the recipient vessels and flap pedicles make it possible to avoid the use of vein grafts. Hsu-Tang Cheng, M.D. Department of Plastic Surgery, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan Fu-Yu Lin, M.D. Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan Sophia Chia-Ning Chang, M.D., Ph.D. Department of Plastic Surgery, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
Free flap reconstruction
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The purpose of this study was to determine the causes of head and neck free flap loss and to evaluate outcomes after subsequent microvascular and non-microvascular reconstruction.Patients who experienced free flap loss between 2000 and 2012 were reviewed.There were 40 flap losses out of 3090 free flaps (1.3%). Twenty-eight patients underwent subsequent free flap reconstruction of which 27 free flaps were successful (96.4%), which was not significantly different from our initial flap success rate (p = .81). Of patients who underwent subsequent free flap reconstruction for oral/pharyngeal defects, 100% had >80% speech intelligibility and 87.5% were tube feed independent. By comparison, 42.9% of patients who underwent subsequent pectoralis major flap reconstruction had intelligible speech (p = .01) and 25.0% were independent of tube feeds (p = 0.02).Subsequent free flaps after initial free flap losses can be successful in selected patients. Functional outcomes after subsequent free flap reconstruction are favorable compared to pedicled flap reconstruction.
Free flap reconstruction
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Free flap reconstruction
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Free flap reconstruction
Microvascular surgery
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Abstract The lateral arm free flap (LAFF) has been chosen by some head and neck reconstructive microsurgeons to be their fasciocutaneous free flap of choice. The qualities of this flap have been suggested to include its consistent vascular anatomy, its thin and pliable nature, and its reinnervation capabilities, as well as its low donor site morbidity and ease of closure. During the past year we have performed 14 head and neck reconstructions using the extended LAFF (ELAFF). We present our indications for its use and review its shortcomings. Although the ELAFF does have its limitations, including variability in its flap thickness and donor vessel size, it unquestionably is an important flap in head and neck reconstruction and is our flap of choice for soft tissue reconstruction.
Reinnervation
Free flap reconstruction
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