Maxillo-facial and palatal reconstructions with the deltopectoral flap

Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years

Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.

Palatomaxillary Reconstruction: Fibula or Scapula

Palatomaxillary reconstruction presents a unique challenge for the reconstructive surgeon. The maxillofacial skeleton preserves critical aerodigestive functions-it provides a stable hard palate to support mastication and separate the nasal and oral cavities, and buttress support to provide adequate midface contour. Free tissue transfer has become a routine part of the reconstructive ladder in managing palatomaxillary defects. While there is a wide variety of options for bony reconstruction within the head and neck, the fibula and the scapula, and their variations, have become two of the most commonly used options for midface reconstruction. This review will discuss the advantages and disadvantages of both in specific regard to reconstruction of the palatomaxillary area.

Obturators versus flaps after maxillary oncological ablation: A systematic review and best evidence synthesis

Maxillary defects can be resolved by prosthetic obturation, autologous tissue reconstruction, or a combination of both. However, there is still controversy in the selection of the optimal approach. Therefore, the aim of this study was to systematically review evidences comparing the performance of obturators and flaps in patients after maxillary oncological ablation. Both electronic and manual searching approaches were conducted to identify eligible evidence. Two reviewers independently assessed the risk of bias. In addition, the same reviewers independently extracted the data. Meta-analyses were performed using Revman 5.3, and best evidence synthesis was performed. Sixteen studies were included and a total of 528 participants were analyzed. All studies were assessed at low quality. Results of this meta-analysis showed weak evidence in the difference between obturators and flaps on the outcome regarding word intelligibility (P = 0.004) and masticatory efficiency (P = 0.002). However, no differences were detected regarding speech intelligibility and nasalance. All studies were compiled into the best evidence synthesis. The sum of 31 evidences was considered. Twelve evidences were evaluated at a moderate level, such as speech, mastication, pain, salivation, taste sensations, and mouth opening. Except the outcomes of word intelligibility, masticatory efficiency, and mouth pain, other moderate evidences showed no difference between obturators and flaps. In conclusion, both obturators and flaps might be effective in patients' rehabilitation functions after maxillary ablation. However, some advantages were observed when using surgical reconstruction over prosthetic rehabilitation. Additional high-quality studies are needed to provide more solid evidence before applying these results into clinical practice.

Deltopectoral flap in the era of microsurgery

Background. Our study aimed to review the role of deltopectoral (DP) flap as a reconstructive option for defects in the head and neck region in the microvascular era. Methods. All patients who received DP flap reconstruction surgery at the Department of Surgery, Queen Mary Hospital, between 1999 and 2011 were recruited. Demographic data, indications for surgery, defect for reconstruction, and surgical outcomes were analyzed. Results. Fifty-four patients were included. All but two patients were operated for reconstruction after tumour resection. The remaining two patients were operated for necrotizing fasciitis and osteoradionecrosis. The majority of DP flaps were used to cover neck skin defect (63.0%). Other reconstructed defects included posterior pharyngeal wall (22.2%), facial skin defect (11.1%), and tracheal wall (3.7%). All donor sites were covered with partial thickness skin graft. Two patients developed partial flap necrosis at the tip and were managed conservatively. The overall flap survival rate was 96.3%. Conclusions. Albeit the technical advancements in microvascular surgery, DP still possesses multiple advantages (technical simplicity, reliable axial blood supply, large size, thinness, and pliability) which allows it to remain as a useful, reliable, and versatile surgical option for head and neck reconstruction.

Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects

BACKGROUND

Palatal obturators and microvascular free flaps are both used to treat patients with maxillectomy defects, however, the optimal technique remains controversial.

METHODS

A retrospective analysis of 113 patients undergoing maxillectomy for cancer was performed. Seventy-three patients received an obturator and 40 patients were reconstructed with a free flap.

RESULTS

Speech intelligibility and postoperative diet were comparable between the obturator and free flap groups, except in cases of extensive (>50%) palatal defects, where free flap reconstruction was superior in both aspects (p = .019 and p = .043, respectively). The average time for presenting with a local recurrence in advanced cancer involving the palate was comparable in both groups (p = .33).

CONCLUSION

Moderate-sized maxillectomy defects involving the palate can be successfully treated with either an obturator or free flap reconstruction. Extensive defects have a better functional outcome with free flaps. Evidence does not suggest that free flap reconstructions delay diagnosis of local recurrences.

Midfacial reconstruction and radiation: case report and review of the literature

Midfacial radiation-induced defects usually involve the bony structures and require composite reconstruction. A 36-year-old male patient with a midfacial defect due to radiation and failure of local flaps was referred to us and treated successfully with a microvascular flap. This case is reported in correspondence with a literature review of the classification of midfacial defects, choice of treatments, and outcomes of different reconstructive options. The deleterious effects of radiation on tissue healing and the functional and aesthetic outcome of reconstruction are discussed. Midfacial defects that are refractory to treatment with local flaps are best treated with microvascular free tissue transfer.

Gunshot wounds to the head and neck

PURPOSE OF REVIEW

Gunshot wounds to the head and neck result in significant bone and soft tissue loss. These defects pose a challenge to the facial reconstructive surgeon. This paper reviews the current literature on the management of ballistic injuries to the head and neck and outlines a treatment algorithm.

RECENT FINDINGS

With recent advances in free tissue transfer, early definitive reconstruction of bone and soft tissue deficits with vascularized flaps has become the treatment of choice. Computed tomography angiography of the neck has been shown to be a sensitive, specific, and safe technique in screening for vascular injuries.

SUMMARY

Management of ballistic injuries to the head and neck begins with advanced trauma life support protocols. Computed tomography angiography is now widely available and provides an accurate and rapid evaluation of head and neck vasculature. The initial operation aims to establish occlusion, stabilize bone and close soft tissue defects. Serial debridement of wounds with delayed reconstruction has given way to early definitive repair with vascularized tissue. This has led to improved function, fewer operations, and shorter hospital stays.

Osteomyocutaneous peroneal artery perforator flap for reconstruction of composite maxillary defects

BACKGROUND

Composite maxillary defects often involve the maxilla, nasal mucosa, palate, and maxillary sinus. We presented the surgical techniques and outcome of the osteomyocutaneous peroneal artery perforator (PAP) flap for reconstruction of composite maxillary defects.

METHODS

Six patients underwent an osteomyocutaneous PAP flap reconstruction of composite maxillary defects. The average age was 52 years. The defects were Cordeiro type II in three patients and type IV midfacial defects in another three patients.

RESULTS

No total or partial flap failures occurred. At a mean 12-month follow-up, five patients had a normal speech and were able to eat a regular diet. One patient tolerated a soft diet and had intelligible speech. One patient had ectropion develop. Excellent cosmesis was found in five patients.

CONCLUSIONS

The osteomyocutaneous PAP flap represents a further refinement of the fibula flap and increases its versatility, with multiple skin paddles, bone segments, and soleus muscle independently isolated. It is a comparable reconstruction option for composite maxillary defects.

Paranasal Sinus and Midfacial Reconstruction

Midface defects pose the most difficult of the facial reconstruction problems. Current reconstruction relies heavily on microsurgical techniques, among which there are numerous possibilities. Although midface defects frequently extend to the upper and lower face, often an awareness of the midface subunits most involved can be of critical importance. This article presents an approach that will help the surgeon to identify the defect-related problems, prioritize the reconstructive goals, and select the best surgical option in the total patient context.

Definitive management of severe facial trauma utilizing free tissue transfer

OBJECTIVE

Severe ballistic or avulsion injuries to the face create complex, composite defects. We report the results of an aggressive management algorithm to optimize facial form and function: (1) the initial encounter, (2) definitive reconstruction with vascularized tissue, and (3) aesthetic and prosthetic refinement.

STUDY DESIGN AND SETTING

Retrospective case series of 49 patients in 2 tertiary care institutions. Patients were evaluated for age, gender, mechanism of injury, anatomic subsites involved, surgical procedures, flaps utilized, complications, and functional outcomes.

RESULTS

Forty defects were gunshot wounds, 9 resulted from major avulsive trauma. Involved sites included 13 oromandibular, 21 midface/upper face, and 15 combined sites; 54 free flaps were utilized, 21 were soft tissue and 33 contained bone. No flap failures occurred. Function and cosmesis were best in the oromandibular only group, and worst in the combined group with nasal and/or orbital tissue loss.

CONCLUSION

Treatment of severe facial trauma requires early tissue debridement with bony repair and/or stenting to minimize scar contracture. Free tissue transfer techniques allow simultaneous reconstruction of the bony framework and overlying tissues. Multiple secondary procedures are frequently required for optimal aesthetic restoration.

EBM RATING

C.

The Thoracodorsal Artery Perforator-Scapular Osteocutaneous (TDAP-SOC) Flap for Reconstruction of Palatal and Maxillary Defects

Despite technical advances over the past 3 decades, subtotal, total, and extended total maxillectomy defects remain challenging reconstructive problems. In particular, postoncologic resection of the maxilla results in complex 3-dimensional defects of the midface, which cause severe functional and esthetic deformities. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and maxilla is especially challenging because it requires reconstitution of the facial buttresses, occlusion, replacement of bony hard palate, and the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue-bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. Osteocutaneous and osteomuscular flaps such originating from the scapular, iliac, peroneal, and radial vascular systems have been attempted with good success. We devised an osteocutaneous flap based on the scapular vascular system, which provided bone and soft tissue to successfully reconstruct the palate and maxilla in 2 patients. The skin paddle received its blood supply from the major perforating vessels of the thoracodorsal artery, and the scapular bone was nourished by the angular vessels. Although free tissue transfer using thoracodorsal perforator flaps has been described, this flap has not been previously reported in the literature as an osteocutaneous tissue transfer. With the use of rigid fixation, excellent results have been obtained with this technique for palatal and maxillary reconstruction.

Tracheal Reconstruction With a Prefabricated Deltopectoral Flap Combined With Costal Cartilage Graft and Palatal Mucosal Graft

We have created an alternative method for tracheal reconstruction. Our new surgical procedure using a deltopectoral flap combined with a costal cartilage graft and mucosal graft for tracheal reconstruction allows us to achieve reconstruction of the tracheal mucosa, the tracheal cartilage, and the covering skin with adequate subcutaneous tissue. In one case, a tracheostenosis was reconstructed with a deltopectoral flap combined with a costal cartilage graft. In the other case, a tracheal defect was reconstructed with a deltopectoral flap combined with a costal cartilage graft and palatal mucosal graft. Although the operation is a multistage procedure, our method provides satisfactory clinical results. Thus, we believe that our method is useful for the surgical treatment of large tracheal defects.

Lining the mouth floor with prelaminated fascio-mucosal free flaps: clinical experience

Soft-tissue defects of the mouth floor need thin, foldable, and pliable tissues able to preserve local anatomy as well as chewing, phonation, and deglutition. The oral mucosa is made of a stratified, nonkeratinized, epithelium-secreting mucus, which lubricates the oral cavity and facilitates tongue movements. No flap exists that can reproduce the physiology of the oral mucosa better than the oral mucosa itself. Prefabrication of mucosal flaps may represent the best solution. Therefore, 10 consecutive cases of mouth floor cancer were treated with prelamination of the fascia antibrachialis with mucosal grafts obtained from the healthy cheek, and with subsequent transplantation 3 weeks later. A significant increase in mucosal graft surface was seen in all cases, with a mean size twice the original. All flaps healed uneventfully. Follow-up time ranged between 2-60 months (average, 26.6 months). Morphological and functional results were excellent. Tongue motility, speech intelligibility, and swallowing were reestablished in all treated cases. Mucosal prelamination of the forearm fascia is feasible and allows physiological reconstruction of oral cavity defects up to 6 x 4 cm.

Retrospective case series of primary and secondary microvascular free tissue transfer reconstruction of midfacial defects

STATEMENT OF PROBLEM

Midfacial defects arising from tumor extirpation or trauma may involve any portion of the central area of the face, including the palate, maxilla, orbit, lip, and/or nose. Speech, mastication, swallowing, and cosmesis are significantly impaired and present a unique challenge to the reconstructive surgeon.

PURPOSE

This study evaluated the functional and cosmetic success of both soft tissue and osteocutaneous free flap reconstruction of the midface.

MATERIAL AND METHODS

A retrospective chart review of 34 patients who underwent primary and secondary free flap reconstruction of the midface was conducted. The main outcome measures were perioperative complications, diet, speech intelligibility, type of dental restoration, and cosmetic result.

RESULTS

Fifteen patients underwent soft tissue free flap reconstruction of the midface. Six of these patients also had additional nonvascularized free cranial bone grafts to improve restoration of the orbitozygomatic region. Nineteen patients who might have required osseointegrated implants to anchor a dental prosthesis underwent osteocutaneous free flap reconstruction. Thirty-three of 34 free flaps survived, and wound complications were minimal. After surgery, 20 patients were able to eat a regular diet and 14 a soft diet. All patients had intelligible speech over the telephone. Ten patients used a dental prosthesis (5 conventional and 5 implant-borne). Cosmesis was judged to be excellent in 12 patients, good in 15 patients, fair in 5 patients, and poor in 2 patients.

CONCLUSION

In the patients reviewed, free flap reconstruction of the midface was completed in a single stage and created a reproducible, permanent separation of the oral and sinonasal cavities with adequate speech and swallowing.

Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects

OBJECTIVE

To evaluate and discuss the free flap reconstructive options for patients with partial and total maxillectomy defects.

DESIGN

Retrospective review of cases.

SETTING

Two tertiary referral centers.

PATIENTS

Fifty-one patients had partial or total maxillectomy defects resulting from oncologic surgical resection, and 7 had partial maxillectomy defects resulting from trauma. Inferior or partial maxillectomy defects included 10 anterior arch and hemipalate defects and 12 subtotal or total palate defects. Total maxillectomy defects with and without orbital exenteration included 36 maxilla defects with hemipalate and malar eminence.

INTERVENTION

There were 11 fibula, 14 rectus abdominis, 9 scapular, 10 radial forearm, 5 latissimus dorsi, and 13 combination latissimus dorsi and scapular flaps.

MAIN OUTCOME MEASURES

Separation of the oral cavity from the sinonasal cavities, diet, type of dental restoration, type of orbital restoration, speech intelligibility, and complications.

RESULTS

Only 1 flap failure was reported. There was loss of bone in 2 flaps and loss of the skin paddle in 1 flap. All palatal defects were sealed by the separation of the oral and sinonasal cavities. Thirty-eight patients were able to eat a regular diet while the remaining patients maintained a soft diet. All patients conversed on the telephone without difficulty in intelligibility. Eight patients had an implant-borne dental prosthetic, and 30 patients had a conventional partial prosthetic. Orbit restoration was achieved in 2 patients with an implant-borne prosthetic, and 6 patients retained a standard orbit prosthetic.

CONCLUSIONS

Free flap reconstruction of the maxilla creates reproducible permanent separation of the oral and sinonasal cavities in a single-stage procedure. In addition, there exists the potential for dental rehabilitation with restoration of masticatory and phonatory function. Free flap reconstruction also provides a good cosmetic result, which improves patients' outlook and contributes to their overall well-being. Reconstructive flaps are designed to fit specific maxillary defects and patient needs to provide optimally functional and cosmetic results.

Maxillary reconstruction: functional and aesthetic considerations

Maxillary reconstruction is a challenging endeavor in functional and aesthetic restoration. Given its central location in the midface and its contributions to the key midfacial elements--the orbits, the zygomaticomaxillary complex, the nasal unit, and the stomatognathic complex--the maxilla functions as the keystone of the midface and unifies these elements into a functional and aesthetic unit. Maxillary defects are inherently complex because they generally involve more than one midfacial component. In addition, most maxillary defects are composite in nature, and they often require skin coverage, bony support, and mucosal lining for reconstruction. In the reconstruction of maxillary defects secondary to trauma, ablative tumor surgery, or congenital deformities, the following goals must be met: (1) obliteration of the defect; (2) restoration of essential functions of the midface, such as mastication and speech; (3) provision for adequate structural support to each of the midfacial units; and (4) aesthetic reconstruction of the external features. This review will discuss the pertinent anatomic considerations, the historical approaches to maxillary reconstruction, and the merits of the techniques in use today, with an emphasis on state-of-the-art reconstruction and dental rehabilitation of extensive maxillary defects.

Functional dental rehabilitation of massive palatomaxillary defects: cases requiring free tissue transfer and osseointegrated implants

BACKGROUND

Mandibular reconstruction with functional dental rehabilitation using a free tissue transfer bone flap as the substrate for osseointegrated implant-borne or implant-retained dental prostheses is well described. Similar use of these techniques in maxillary dental rehabilitation is less frequent and has received less attention in the literature. However, in selected cases of extensive composite defects of the maxilla, free tissue transfer reconstruction of the maxillary arch and the use of implant-borne or implant-retained dental prostheses is the only satisfactory method of achieving functional dental rehabilitation.

METHODS

Three cases of maxillary reconstruction and dental rehabilitation using free tissue transfer with implant-borne or implant-retained prostheses are presented. Patient selection, reconstructive technique, and the biomechanical considerations in maxillary dental rehabilitation of large palatomaxillary defects are presented.

RESULTS

The patients in this report were restored to full maxillary dental functioning. One implant of 17 implants placed in free flap bone was lost due to failure of osseointegration; 94% of the implants placed are stable an average of 18 months after dental rehabilitation was complete.

CONCLUSIONS

In selected patients with extensive palatomaxillary defects due to ablative surgery or trauma, the use of free tissue transfer and osseointegrated implant-borne or implant-retained dentures may be the only method possible to restore maxillary dental function. Dental rehabilitation of large maxillary defects presents a number of biomechanical challenges which must be clearly understood and overcome to achieve a long-term, functional dental rehabilitation.

Deep circumflex iliac artery free flap with internal oblique muscle as a new method of immediate reconstruction of maxillectomy defect

BACKGROUND

A wide range of pedicled and free tissue transfer flaps have been described in the reconstruction of the complex maxillofacial defect, but no preferred reconstructive technique has so far emerged. The previous methods described may effectively close the oronasal fistula but reliable support for the cheek and orbit while providing a basis for an implant retained prosthesis is less likely to be achieved.

METHODS

The methods of using the flap in low, high, and central maxillectomy defects as well as cases requiring orbital exenteration are described.

RESULTS AND CONCLUSIONS

The deep circumflex iliac artery (DCIA) flap with internal oblique provides a reliable reconstruction for the maxillectomy as the fistula is closed with muscle which becomes epithelialized with minimal bulk. The large volume of bone available from the iliac crest can restore the facial contour, support the orbital contents, reconstruct the orbital rim, and provide sufficient bulk of bone for the placement of implants.

Cancrum oris: functional and cosmetic reconstruction in patients with ankylosis of the jaws

Advances in reconstructive surgery allow treatment of established cases of Cancrum oris with total ankylosis of the jaws to produce a satisfactory functional and cosmetic result. This is achieved by radical excision of scar tissue followed by two layered flap closure of the defect. It is recommended that a cervical flap is used for lining and a deltopectoral flap for cheek cover. Ten patients with Cancrum oris are presented to demonstrate the techniques used.

Microvascular approach to function and appearance of large orbital maxillary defects

Forty-three patients with major three-dimensional orbitomaxillary defects underwent 48 free-tissue transfers for defects arising from resection of a neoplasm or trauma. Defects were complex, involving the malar skin, mandible, lateral nasal wall, orbit, palate, and brain. A three-dimensional approach attempting to recreate the midface by folding the flaps was the usual method, with subsequent revisions if necessary. Ten patients had simultaneous free bone grafts and 6 had vascularized bone grafts. There were three flap failures and four perioperative deaths. Excluding the 4 deaths, the results were assessed as excellent in 25 patients, good in 12, and poor in 2. Free-tissue transfer is a reliable method of providing enough tissue at one initial operation to satisfy complex three-dimensional defects of the orbitomaxillary region. Followed by minor revision, it provides a means of restoring function and appearance without multiple staged procedures with a high risk of failure.

Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Limitations and refinements in 56 cases

The transaxillary latissimus dorsi musculocutaneous flap is suitable whenever a large volume of tissue is required for head and neck reconstruction. Fifty-six transaxillary latissimus dorsi musculocutaneous flap reconstructions were performed in 55 patients. There were two cases of complete flap necrosis and eight cases of partial flap necrosis. The latissimus dorsi vascular pedicle is separate from the irradiated field. The pedicled latissimus dorsi flap provides coverage of the orbitocranium, including the supraorbital region and central portion of the upper face. In the event that the pedicled latissimus dorsi flap does not reach far enough cephalad, the nutrient vessels may be separated from the axillary artery and anastomosed to vessels in the neck. Combined defects of the esophagus, mandibulofacial region, and neck may be reconstructed with a single large latissimus dorsi flap. Hairless skin particularly suitable for oral cavity reconstruction is usually available. Aesthetic and functional deficits are minimal after latissimus dorsi reconstruction. Disadvantages of this technique include repositioning of the patient, increased blood loss, and longer operating time. Permanent brachial plexus injury may occur. The latissimus dorsi musculocutaneous flap should not be used when defects can be reconstructed by simpler methods.

Primary malignant melanoma of the oral cavity. A review of 20 cases

Twenty patients with primary malignant melanoma of the oral cavity have been described. They formed 3.9 percent of the total number of patients with malignant neoplasms of the oral cavity. The upper gingiva was most commonly affected. In this series, there were 14 male patients and 6 female patients who ranged in age from 26 to 80 years (average 58 years). The first symptom of melanoma was hyperpigmentation of the mucosa in 10 patients, tumor in 7, and pain in 3 edentulous patients with prostheses. Radical surgery was performed in 13 patients, followed by chemotherapy and radiotherapy in 9 cases. Only 1 patient survived 9 years. The remaining 12 died 11 to 18 months after radical treatment. Palliative therapy was applied in three patients, two patients were treated symptomatically, and two patients refused treatment. Early detection of melanoma is an indication for radical treatment and may increase the survival rate of patients with this disease, which is still very low.

Reconstruction of massive orbito-maxillary-cheek defects

The problem of soft-tissue reconstruction in patients who must undergo radical resection of the maxilla, orbit, and cheek is discussed. This problem is greatly complicated by previous radiation therapy or by the need for postoperative radiation therapy. Restoration of oral competence is of primary importance and usually cannot be satisfactorily accomplished with prosthetic appliances when a stable support base is lacking. An orderly reconstructive plan with a high success rate is of the utmost help to the surgeon facing this problem. A multistaged procedure utilizing a deltopectoral flap that has been successful in 7 patients is presented.

The deltopectoral flap: a historical review with comments on its role in neurovascular reconstruction

The history of the clinical, anatomical and haemodynamic aspects of the deltopectoral flap is reviewed, with some comments on its use as a neurovascular flap.

Experience with the deltopectoral flap

One hundred and three non-delayed deltopectoral flaps were used for head and neck reconstruction in 86 patients. A retrospective analysis to detect factors with negative influence on the reconstruction resulted in two significant risk factors (p less than 0.05): irradiated recipient site and internal location of recipient site. The flap failure rate was not significantly affected by variations in flap length, age, sex or concomitant diseases. The mean stay in hospital was 10 weeks and was significantly prolonged for patients having had radiotherapy, internal reconstructions or flap failure (p less than 0.05).