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Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution’s 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction (p < 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.
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Neck dissection
Reconstructive Surgery
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Abstract This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The reconstructive needs following ablative surgery for head and neck cancer are unique and require close attention to both form and function. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. This paper discusses the options for reconstruction available following ablative surgery for head and neck cancer and offers recommendations for reconstruction in the various settings. Recommendations • Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer. (R) • Free flaps should be offered as first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction. (R) • Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R) • Composite free tissue transfer should be offered as first choice to all patients needing mandibular reconstruction. (R) • Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce pharyngocutaneous fistula rates. (R)
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With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.
Salvage Surgery
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Free flap reconstruction
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Facial reconstruction
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The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.
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Debridement (dental)
Reconstructive Surgeon
Conservative Management
Free flap reconstruction
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Abstract Background Reverse‐flow flaps rely on retrograde or reverse flow for drainage and have shown success in reconstructive surgery. However, limited studies have been conducted on the use of reverse‐flow recipient veins. Our study proposed bidirectional venous anastomoses within a single recipient vein to optimize venous outflow and evaluated the outcomes of an additional retrograde venous anastomosis group in traumatic extremity reconstruction. Methods We performed a retrospective analysis of 188 patients with traumatic extremity free flap using two venous anastomoses, which were divided into the antegrade and bidirectional venous anastomosis groups. We analyzed the basic demographic information, flap type, duration between injury and reconstruction, recipient vessels, postoperative flap outcomes, and complications. Propensity score matching was used for the additional analysis. Results Of the 188 patients analyzed, 63 free flaps (126 anastomoses, 33.5%) and 125 free flaps (250 anastomoses, 66.5%) were included in the bidirectional venous anastomosis and antegrade groups, respectively. In the bidirectional vein group, the median time between trauma and reconstruction was 13.0 ± 1.8 days and the mean flap area was 50.29 ± 7.38 cm 2 . Radial artery superficial palmar branch perforator flap was most frequently performed (60.3%). In the antegrade vein group, the median time until surgery was 23.0 ± 2.1 days and the mean flap area was 85.0 ± 8.5 cm 2 . Thoracodorsal artery perforator flap surgery was the most frequently performed surgery. The two groups were similar in terms of basic characteristics, but the bidirectional group demonstrated significantly higher success rate (98.4% vs. 89.7%, p = .004) and lower complication rate (6.3% vs. 22.4%, p = .007) than the antegrade group. However, these results were not observed after propensity score matching. Conclusions Our study demonstrated successful results with the recipient vein using reverse flow. Additional retrograde venous anastomosis is a useful option for augmenting venous drainage for reconstruction of distal extremities in cases where dissection of additional antegrade vein is not feasible.
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Osteoradionecrosis
Free flap reconstruction
Reconstructive Surgery
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We have found that the pectoralis major myocutaneous flap is so reliable a flap that in seven selected patients we completely re-elevated, isolated, and transposed it to a new reconstructive site in the head and neck. This may be accomplished safely, despite full courses of external-beam radiation therapy to the flap. We discuss the principles of this and propose that it can be extended and applied to other island, pedicle, or free flaps. The manner in which the flap can be reused and integrated with microvascular transfer or other regional pedicle flaps in complex secondary operations must be determined by the individual reconstructive surgeon on the basis of the requirements of the reconstruction. This technique will make one more tool available to the surgeon for reconstruction.
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