Recipient vessels in head and neck microsurgery: radiation effect and vessel access

Oculofacial plastic surgery in the cancer patient: A narrative review

With the advances in systemic therapy and radiotherapy, the life expectancy of patients battling cancer has increased. The oculofacial plastic surgeon should be aware of the potential impacts a patient in remission or one being actively treated may pose. The goal of this review is to discuss the considerations a surgeon should have in this patient population.MethodsThe authors performed a computerized search using PubMed, Embase, and Google Scholar. The search terms used were "chemotherapy AND surgery", "immunotherapy AND surgery", "radiotherapy AND surgery", "nutrition AND surgery", "(oculoplastic OR orbit OR eyelid OR lacrimal OR puncta) AND (chemotherapy OR immunotherapy OR radiotherapy)", "(facial OR facial plastic OR oculoplastic) AND (chemotherapy OR immunotherapy OR radiotherapy)", "(cancer OR malignancy) AND surgery", "(cancer OR malignancy) AND (surgery OR surgical) complications", "wound healing AND (cancer OR malignancy)", "infection AND (cancer OR malignancy)", "(bleeding OR blood loss) AND (cancer OR malignancy) AND surgery", "(chemotherapy OR immunotherapy OR radiotherapy) AND wound healing", "(chemotherapy OR immunotherapy OR radiotherapy) AND (bleeding OR blood loss)", "(chemotherapy OR immunotherapy OR radiotherapy) AND infection".ResultsA total of 89 articles, published from 1993 to 2023 in the English language or with English translations were included. Articles published earlier than 2000 were cited for foundational knowledge. References cited in the identified articles were also used to gather further data for the review.Conclusions and RelevancePatients who are being treated for cancer or are undergoing current treatment for cancer require special considerations. Systemic therapies and radiotherapy impact the physiology of patients and the integrity of tissue in ways that significantly impact surgical interventions. It is imperative for the oculofacial plastic surgeon to have a complete understanding on how a previous or current diagnosis of cancer can influence surgical outcomes.

Vastus lateralis flap for trochanteric sarcoma reconstruction following prior main pedicle dissection: A case report

The reconstruction of trochanteric defects presents a challenge to the reconstructive surgeon. There have been a number of locoregional reconstructive options described in the literature. These include flaps based on the lateral circumflex femoral artery and its branches, such as the tensor fascia lata, vastus lateralis (VL), anterolateral thigh (ALT) flaps. The present case further complicated this challenge as the patient had multiple recurrences of a sarcoma overlying the trochanteric region, with previous surgical resections, reconstruction and radiotherapy. The present case study describes an approach to harvesting the VL flap in a patient with previously harvested ALT.

Influence of Radiotherapy on Ossification of Vascularized Osseous Reconstruction of the Jaw: A Radiological Retrospective Cohort Study Based on Panoramic Radiographs

Background: The aim of this study was to evaluate the impact of irradiation and time of irradiation on the ossification of jaws reconstructed with free bone grafts. Methods: In total, 100 reconstructions of the jaw were retrospectively evaluated for ossification between bone segments by two raters based on postoperative panoramic radiographs (immediate postOP, approximately 6, 12 and 24 months follow-up). Three subgroups were divided according to the time of irradiation: preoperative radiation therapy (n = 41), postoperative radiation therapy (n = 26) and patients without any radiation therapy (n = 33) as the control group. Ossification time and influencing factors were documented. Results: The fastest ossification with a median of 304 ± 37 days was observed (p < 0.001) in the nonirradiated control group. No significant difference (p = 0.087) in ossification was found between the pre- (447 ± 136 days) and postoperative (510 ± 112 days) radiation groups. Ossification between two graft segments (336 ± 38 days) showed significantly (p < 0.001) faster ossification than between the original and grafted bone (448 ± 85 days). Moreover, closer initial contact between the segments resulted in faster ossification (p < 0.001). When analyzing cofactors, tobacco consumption was the only negative factor aggravating ossification (p = 0.006). Conclusion: Head and neck radiation corresponded with the impaired and prolonged ossification of jaw reconstructions with free bone grafts. There was no difference in ossification if radiotherapy was performed before or after reconstructive surgery. A close bony contact was particularly important for ossification between the original and grafted bone.

Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis

BACKGROUND

Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP).

METHODS

ACS-NSQIP database was accessed to identify patients treated for LE sarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index (BMI) of 57 and 27.4 kg/m,² respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes (3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications.

CONCLUSIONS

Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.

Free Flap Outcome in Irradiated Recipient Sites: A Systematic Review and Meta-analysis

The impact of previous radiotherapy on free flap outcome is still a subject of debate. Clinical investigations have come to divergent conclusions and the true effect of radiotherapy (XRT) on flap survival is not definitely known. Most studies investigating the factor often have their methodological limitations such as lack of statistical power as a consequence of the overall low failure rates together with few irradiated cases. This study will attempt to address the question whether previous radiotherapy is associated with a significantly higher incidence of flap failure or not.

End-to-Side Versus End-to-End Venous Anastomosis Using Couplers in Mandibular Reconstruction: A Comparative Study

Purpose

This study compares the advantages of end-to-side technique over end-to-end technique for venous anastomosis using couplers.

Methods

Patients were divided into group I and group II based on end-to-side and end-to-end techniques, respectively. Intraoperative anastomotic time, flap ischemic time, and postoperatively flap vitality were the parameters evaluated.

Results

Thirty-eight patients were randomly allocated to two groups with 19 patients in each group. The mean anastomotic time with standard deviation in group I was 391.84 ± 49.052 s and in group II was 354.47 ± 46.365 s with p value 0.021. The mean flap ischemic time with standard deviation in group I was 180.68 ± 35.773 min and in group II was 161.21 ± 32.418 min with p value 0.087. All the flaps in group I were vital, whereas 78.9% of flap vitality was observed in group II with p value 0.105.

Conclusion

Based on this study, end-to-side venous anastomosis using couplers is a better technique over end-to-end venous anastomosis.

Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience

BACKGROUND

Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients.

METHODS

Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated.

RESULTS

Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient.

CONCLUSIONS

The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Balancing Training Opportunities and Patient Outcomes: A Single Surgeon's Experience

ABSTRACT

Microvascular free tissue transfer is the criterion standard of reconstruction post-oncological resections of the head and neck region. We present a consultant's first 200 consecutive microvascular head and neck reconstructions in independent practice. A retrospective analysis of a prospectively collected database of all head and neck reconstructions performed in the first 3 years of practice was performed. These included 200 consecutive microvascular head and neck reconstructions performed by a single surgeon at a tertiary referral center. We review the results and complications in this series and discuss factors significant for successful outcomes in head and neck reconstruction. We also highlight that different parts of the surgery in the majority of cases were performed by a trainee under the supervision of the senior surgeon and thus discuss the need for training future plastic surgeons with an interest in head and neck reconstruction.

Transverse cervical vessels as a recipient site for microvascular reconstruction in vessel-depleted necks: a safe option

Background

Free flap reconstruction is the gold standard in complex head and neck reconstruction. The branches of the external carotid vessels (ECVs) are considered the most suitable recipients, but they may be unavailable in patients presenting “frozen necks” or “vessel-depleted necks” due to previous treatments. We report our experience using the transverse cervical vessels (TCV) in these situations.

Methods

Retrospective chart review of microsurgical head and neck reconstructions from 2005 to 2017. We focused our analysis on secondary procedures and compared the complication rate according to whether the TCV or the ECVs were used.

Results

A total of 97 free flaps were performed for secondary procedures in 89 patients, mainly due to oncological recurrence and fistulae. TCV were used in 14 procedures when external carotid vessel branches were unavailable. The overall complication rate (all grade III Dindo-Clavien) was of 21% versus 35%, respectively, in the TCV and ECVs group. Grade IIIb Dindo-Clavien complications, i.e., microsurgical complications (10%) and flap loss (1%), were only recorded in the ECVs group. Other complications recorded were seroma (7% versus 1%) and hematoma (17% versus 6%) in the TCV and ECVs groups, respectively, and corresponded to grade IIIa Dindo-Claviens.

Conclusions

The use of TCV is a safe second-line recipient site for microsurgical head and neck reconstruction in vessel-depleted necks. Major advantages are their anatomical position outside the previous surgical and radiation zone, lower affinity for atherosclerotic damage, and similar diameter to the pedicles of the most used flaps.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Postoperative morphological changes over time of vascularized scapular bone used for mandibular reconstruction: A retrospective cohort study

BACKGROUND

Currently, sequential morphological changes of vascularized scapular bone for mandibular reconstruction have remained unreported.

METHODS

We retrospectively analyzed 18 patients with defects on the lateral segment of the mandible who underwent postoperative computed tomography (CT) scanning at 1, 6, 12, and 24 months postoperatively. Using the cross-sectional coronal CT images during each assessment, we measured the height and thickness of the grafted scapular bone at points 10 and 30 mm away from the mesial segment and evaluated their differences over time. Then, the relationship between the morphological changes of the grafted scapular bone and the distance from the mesial bone segment, the number of occlusal supports on the contralateral side of the mandible, and the correlation of sex and age were evaluated.

RESULTS

The height of the grafted scapular bone decreased by approximately 11% and its thickness increased by 14% within 24 months postoperatively. The bone thickness increase was greater at point 30 mm from the mesial bone segment. Patients with two occlusal contacts (premolar and molar) on the contralateral side had a significantly higher rate of bone thickness increase. Furthermore, the graft morphology was not associated with age or sex.

CONCLUSION

A vascularized scapular bone thickens over time, which depends on the distance from the mesial bone segment and the occlusal contact regions on the contralateral side of the mandible.

Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature

BACKGROUND

Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures.

METHODS

A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications.

RESULTS

The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases.

CONCLUSIONS

Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.

Surgical Techniques for Head and Neck Reconstruction in the Vessel-Depleted Neck

The vessel-depleted neck presents a unique and challenging scenario for reconstructive surgery of the head and neck. Prior surgery and radiation often result in significant scarring and damage to the neck vasculature, making identification of suitable recipient vessels for microvascular free tissue transfer exceedingly difficult. Therefore, alternative reconstructive techniques and/or vessel options must be considered to obtain a successful reconstructive outcome for a patient. In this article, we discuss our experience and approach to the management of the vessel-depleted neck, emphasizing the importance of preoperative planning and having multiple backup options prior to surgery. The various preoperative imaging modalities and available options for recipient arteries and veins are presented in detail. Additionally, we discuss modifications of select free flaps to maximize their utility in successful reconstruction. Together with thoughtful preoperative planning, these techniques can help aid the reconstructive surgeon in addressing the complex decisions associated with the vessel-depleted neck.

Pedicled Latissimus Dorsi Myocutaneous Flap-an Effective Reconstructive Option for Extensive Buccal Cancer Resection in Resource Constrained and Salvage Settings

Free flaps are the gold standard for reconstruction of extensive buccal cancer resections. However, salvage surgeries in previously operated and radiated necks, cost, increased operating time, and patient co-morbidities limit their routine use in high volume and resource-constrained settings. Pectoralis major myocutaneous (PMMC) flap is the mainstay of reconstruction of large buccal defects. However, reconstruction becomes a challenge during salvage of recurrences where PMMC has been utilized in previous reconstruction and in female patients where PMMC harvest results in major donor site morbidity. A retrospective analysis of clinical data of 13 consecutive patients (eight male and five female) with through and through buccal cancer resection defects reconstructed using pedicled latissimus dorsi (LD) flap from July 2018 to September 2019 was performed. The indications of using an LD flap were salvage surgeries for recurrences where PMMC was used in earlier reconstruction, medical co-morbidities, vessel depleted necks, and financial constraints precluding use of free flaps. The mean follow-up period was 9.84 months. The mean operating time post-resection was 2 h and 26 min. The mean hospital stay was 12.61 days. All patients could be decannulated successfully (mean duration 9.69 days) and 12 could be weaned off feeding tube. None of the patients had any major flap related or donor site complications. Pedicled LD flap has a limited but an effective reconstructive role for extensive buccal cancer ablation as an alternative to free flaps and PMMC in salvage and resource-constrained situations.

Salvage surgery in head and neck cancer

Salvage surgery after failed organ preservation treatment offers challenges for both the patient and the surgeon. The outcome is often uncertain and even today, 5‐year overall survival does not exceed 50 per cent. The chemoradiotherapy induced toxicity asks for meticulous discussion and planning in a multidisciplinary manner in a changing environment of increasing incidence of human papillomavirus induced oropharyngeal tumours, evolving surgical techniques and patient participation. Herein, we discuss the latest literature on salvage surgery and the need for identifying the proper prognosticators to ensure for an optimal treatment plan in potentially salvageable patients.

Neck involvement and disease recurrence in adenoid cystic carcinoma of the minor salivary glands: the role of surgery in primary and progressive disease

The aim of this study was to analyse the rates of metastatic events and clinical outcomes of patients with adenoid cystic carcinoma (ACC) of the minor salivary glands and to critically evaluate the role of surgical therapy. A retrospective cohort study was designed including all patients with ACC of the oral minor salivary glands treated in the study department during the years 2010-2017. Relevant clinicopathological data were analysed to determine factors with an impact on overall survival (OS) and progression-free survival (PFS). Forty-one patients with primary ACC of the oral cavity and the oropharynx were included. Cervical metastases were found in 14 patients (34.1%) and were shown to have a significant negative impact on OS (P=0.009) and PFS (P=0.03). Sixteen patients developed disease recurrence during follow-up (39.0%) and most patients exhibited local disease recurrence with or without regional or distant metastases (14/16, 87.5%). Local recurrence was treated successfully with surgery in five cases. We recommend surgical therapy for patients with ACC of the minor salivary glands, including elective neck dissection and microvascular reconstruction, to optimize the planning of adjuvant therapy.

Non-suturing microvascular anastomosis in maxillofacial reconstruction- a comparative study

AIM

The aim of the study is to compare the advantages and disadvantages of non-suturing anastomotic methods over conventional microsuturing for microvascular venous anastomosis.

MATERIALS AND METHODS

All patients reporting to the institute for hard and soft tissue reconstruction (Primary/secondary) were enrolled in the study. Patients with systemic comorbidities, peripheral vascular diseases, or anatomical aberration of the indicated donor site were excluded from the study. The patients selected for the study were randomly allocated to five groups of different techniques of venous anastomosis, namely Group I (conventional microsuturing), II (fibrin sealant reinforced microsuturing), III (couplers), IV (staplers), V (Laser Assisted Vascular Anastomosis (LAVA)). Intraoperative anastomotic time, flap ischaemic time, patency and leakage were the parameters that were assessed for all five groups.

RESULTS

80 Patients were randomly allocated to five groups and each group comprised 16 patients. The mean ischaemic time and standard deviation of Group I and Group II were 256.19 ± 10.622 min and 255.19 ± 11.083 min, and for groups III, IV, and V were 193.38 ± 9.972 min, 139.06 ± 6.413 min, and 139.31 ± 6.364 min respectively (p < 0.001). Mean anastomotic time and standard deviation were 19.813 ± 1.5366 min in Group I and 20.281 ± 1.6514 min in Group II. The non-sutured anastomosis groups III, IV, and V showed a mean anastomotic time of 5.375 ± 0.9876 min, 4.175 ± 0.7664 min, and 3.856 ± 0.867 min respectively (p value < 0.001). In Groups I and II, 18.8% of patients had delayed patency and in Groups III, IV and V, immediate patency was observed in all subjects (p value 0.030). In Groups I and II, 18.8% and 6.3 % of patients respectively had leakage, whereas all patients in Groups III, IV, V had no leakage from the anastomotic site (p value 0.119).

CONCLUSION

Based on the results of the study, non-suturing techniques should be preferred over microsuturing technique whenever appropriate for venous anastomosis.

Influence of preoperative radiotherapy on head and neck free-flap reconstruction: Systematic review and meta-analysis

The effect of preoperative external radiotherapy (XRT) on head and neck free-flap reconstruction is still controversial. In this study, we aimed to determine the impact of preoperative XRT on the outcomes of head and neck microvascular free-flap reconstruction. A systematic review and meta-analysis was conducted in concordance with the Systematic reviews and Meta-Analyses protocol. We searched several databases (PubMed, EMBASE, Web of Science, and Cochrane Library) to find published papers on the topic. The R program was used for data synthesis and statistical heterogeneity evaluation; then, fixed effect or random effect models were used. A total of 37 studies, involving 12 408 patients with 12 668 flaps, were included in this meta-analysis. The overall flap success rate for all studies was 94.4%. Pooled analysis showed that patients with preoperative XRT were significantly associated with an increased risk of total flap failure (odds ratio [OR] = 1.80, 95% confidence interval [CI] = 1.45-2.23, P < .001), partial flap failure (OR = 1.90, 95% CI = 1.07-3.38, P = .029), and postoperative complication rates (OR = 2.22, 95% CI = 1.64-2.72, P < .001). Our study suggests that preoperative XRT is associated with an increased risk of developing free-flap failure and an increased postoperative complication rate.

Is sequential free flap safe in oral cancer reconstruction in the same patient? An outcome and complication analysis

BACKGROUND

Sequential free flap reconstruction in patient with head and neck cancer can provide reliable and effective wound coverage. Only a few studies have reported on the outcome and complications analysis but without consensus on the recipient vessels and flap chosen. Herein, we presented the outcome and analysed the risk factors for complications in sequential free flap reconstruction.

PATIENTS AND METHODS

Patients who had sequential free tissue transfers due to cancer recurrence, second primary cancer, or secondary correction of the soft tissue contractures and volume deficits were all included. Variables extracted included demographics, comorbidities, free flap characteristics, infection, dehiscence and flap necrosis rates.

RESULTS

In total, 40 patients with 92 free flaps were analyzed; 42 initial and 50 sequential free flaps. The most common recipient vessels for sequential flap were contralateral superficial thyroid vessels (68%). The most common flap for both initial and sequential free flap was anterolateral thigh flap (64.3 and 62%). The success rate of sequential free flap was 92.0 compared to 92.9% for initial free flap, which showed no significant difference. Female was independently associated with delayed wound healing with an odds ratio of 90.91 (95% confidence interval 0.001-0.17, P = 0.001), as well as diabetes with an odds ratio of 31.14 (95% confidence interval 2.60-373.19, P = 0.007). Sequential free flap was not a risk factor for any complication.

CONCLUSIONS

Sequential free flap is a reliable method for head and neck surgery without more complication rate comparing to initial free flap reconstruction. More attentions should be paid on patients with preferential risk for certain complications.

Transverse cervical vascular pedicle: It's extended use as 'second-line' recipient vessels in thoracic and upper arm reconstructions in addition to head-and-neck reconstructions

Background:

Selection of recipient vessels is one of the key factors for a successful microvascular reconstruction. Non-availability of primary recipient vessels in the vicinity necessitates surgeon to approach a remote second-line vascular access. Transverse cervical vessels (TCV) have been described as second-line vascular access for head-and-neck reconstructions. Due to its location, their use can be extended to the proximal chest and upper arm reconstructions.

Aim:

The aim of the study is to analyse the reliability of TCV as second-line recipient vessels for the upper arm and chest reconstructions in addition to the head-and-neck reconstructions.

Materials and Methods:

During 2010–2017, 14 TCV were explored as the choice of second-line recipient pedicle for specific indications. Clinical experience with different reconstructions discussed.

Results:

Out of 14 transverse cervical arteries, 13 were of adequate size for anastomosis. About 12 successful reconstructions were performed involving the head and neck (7), proximal thorax (3) and upper arm (2) for indications such as scarring from different aetiology (8), previous free flaps (2) and sacrificed vessels (2). In one case, the arterial anastomosis was shifted to superior thyroid artery. All the chest and upper arm reconstructions needed a realignment of the pedicle without any kink. Transverse cervical vein (TCv) could be used only 5/14 times either alone or along with external jugular vein (EJV). In other cases, EJV alone was used. All the 12 flaps survived without any vascular event.

Conclusions:

Transverse cervical vessels are reliable second-line recipient vessels in the head and neck; in addition, they are of use in the upper arm and proximal chest defects.

Superficial temporal vessels, both anterograde and retrograde limbs, are viable recipient vessels for recurrent head and neck reconstruction in patients with frozen neck

BACKGROUND

Reconstruction of recurrent head and neck malignancy especially in the presence of a frozen neck is challenging. The superficial temporal vessels would be ideal as recipient vessels because they lie out of the previous surgical and radiation field.

METHODS

We conducted a retrospective case-control study based on our database between January 2013 and June 2016. A total of 581 primary cases were selected as controls. The 60 test group patients had (a) recurrent head and neck reconstruction, (b) previous surgery and irradiation, (c) frozen neck, and (d) superficial temporal vessels as recipients.

RESULTS

There was no significant difference between vascular compromise rates of superficial temporal vessels (anterograde and retrograde limbs) and controls (P > .05). Flap success rate of the test and control group is comparable, 95% vs 98% respectively.

CONCLUSION

Superficial temporal vessels, both anterograde and retrograde, should be the first consideration for recurrent intraoral, facial, and scalp reconstruction with frozen necks.

Microsurgery in musculoskeletal oncology

Sarcomas are rare mesenchymal bone and soft tissue tumors of the musculoskeletal system. In the past, the primary treatment modality was amputation of the involved limb and the 5-year survival was very low for high-grade tumors. During the last three decades, limb salvage has become the rule rather than the exception and the use of neoadjuvant and adjuvant therapies (radiation and chemotherapy) has dramatically increased disease-free survival. Reconstruction of large bone and soft tissue defects, though, still remains a significant challenge in sarcoma patients. In particular, vascularized tissue transfer has proved extremely helpful in dealing with complex bone and soft tissue or functional defects that are frequently encountered as a result of the tumor or as a complication of surgery and adjuvant therapies. The principles, indications and results of microsurgical reconstruction differ from trauma patients and are directly related not only to the underlying disease process, but also to the local and systemic therapeutic modalities applied to the individual patient. Although plastic reconstruction in the oncological patients is not free of complications, usually these complications are manageable and do not jeopardize oncological outcome. The overall treatment strategy should be tailored to the patient's and sarcoma profile.

Determinants of Free Fasciocutaneous Flap Outcomes in Partial Hypopharyngeal Defects

BACKGROUND

Most of the patients with hypopharyngeal cancer are still diagnosed with advanced stage, and total or partial pharyngectomy with free flap reconstruction is the mainstay of treatment. The aim of this study was to find out the possible risk factors related to surgical complications after free fasciocutaneous flap reconstruction for partial pharyngeal defect and its sequelae in the follow-up.

PATIENTS AND METHODS

We retrospectively reviewed the charts of patients with advanced hypopharyngeal cancer who received free fasciocutaneous flaps for partial pharyngeal defects reconstruction. From 2005 to 2015, 79 free fasciocutaneous flaps (59 free fasciocutaneous flaps and 20 anterolateral thigh flaps) were performed in our department. The risk factors for free flap outcome and complications were evaluated with multivariant linear regression model.

RESULTS

The mean age of patients was 60.8 years with male predominance. The mean follow-up duration was 39.6 months. Most of the cases (97.5%) were in stage III or IV. Patients with comorbidities showed significant correlation to flap failure (95% confidence interval [CI] = 0.038 to 0.264, P = 0.10). Anastomosis style (end-to-side vs end-to-end) was the only operation-related factors significantly related to flap failure rate (18.8% vs 3.2%, 95% CI = 0.031 to 0.32, P = 0.18). Flap size was significantly associated with fistula formation (95% CI = -0.005 to 0.000, P = 0.38).

CONCLUSIONS

In our experience, patients with comorbidities and end-to-side anastomosis illustrate significantly higher flap failure rate in free fasciocutaneous flap reconstruction of partial hypopharyngeal defect. Reconstruction with smaller flap size had higher possibility of fistula formation.

Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma

Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.

A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction

PURPOSE

Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in 'vessel-depleted neck' and 'frozen neck' respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery.

METHODS

The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis.

RESULTS

The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm.

CONCLUSION

The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.

Multiple Free Flap Reconstructions of Head and Neck Defects Due to Oral Cancer

Objective:

We studied complications following multiple free flap reconstructions in the head and neck.

Methods:

In this cohort, 26 patients (14 men and 12 women) who underwent multiple microvascular free flap reconstructions were included in the study. The reasons for secondary reconstruction were recurrence of tumor (12 cases), necrosis of transferred skin and/or bone (6 cases), reconstruction plate fracture or exposure (4 cases), and others (4 cases). A third reconstruction in 4 cases and a fourth reconstruction in 1 case were performed.

Results:

No flap necrosis occurred. Postsurgical infections occurred at only secondary reconstructions in 7 patients. Although 4 cases with a history of external radiation therapy were anastomosed at contralateral side, those 4 cases suffered from severe pre-and postsurgical infection of the ipsilateral side. Postsurgical infection occurred in 2 cases with anastomoses at the ipsilateral side of the neck and required drainage after secondary surgery.

Conclusions:

A history of external radiation therapy and the existence of severe preoperative infection affected complications after multiple reconstructions.

Arteriovenous fistulas for microvascular head and neck reconstruction

BACKGROUND

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

METHODS

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

RESULTS

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

CONCLUSIONS

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

The value of perioperative antibiotics on the success of oral free flap reconstructions

The subject of the presented study was to monitor and compare problems and outcomes of reconstructive surgery with microvascular free flaps in the head and neck region between groups of patients treated with perioperative antibiotics and a group of patients without antibiotics. Patients requiring oral reconstructive surgery following cancer resections with microvascular free flaps were prospectively evaluated (2007-2012). Antibiotic therapy was started 30 min before the operation and administered for 10 days. Three hundred and fifty patients were included (208 male, 59.4%; 142 female, 40.6%; mean age 59.8 ± 13.2 years). 330 patients received perioperative antibiotics. Twenty patients (5.7%) who received no antibiotics for specific reasons served as the control group. Wound infections developed in 33 of 122 patients (27%) who received benzylpenicillin, 17 of 88 patients (19.3%) who received amoxicillin combined with sulbactam and 25 of 120 patients (20.8%) who received cefuroxime. Ten patients (50%) who did not receive antibiotics developed wound infections. Receiving no antibiotics or penicillin showed no benefit (P = 0.11). Those receiving cefuroxime showed significantly lower incidence of wound infections (P = 0.034; risk decreased by the factor 2.88). The use of amoxicillin combined with sulbactam showed the lowest rate of wound infections (P = 0.018; risk decreased by the factor 3.46). The use of amoxicillin combined with sulbactam appears to be the most appropriate prophylactic antibiotic followed by cefuroxime in oral microsurgical free flap reconstructions. These data may serve as a guide until a controlled multicenter prospective trial is performed comparing newer antibiotics against current standards.

Arteriovenous fistulas for microvascular head and neck reconstruction

Background

In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks.

Methods

The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula.

Results

The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported.

Conclusions

Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

Recipient vessel selection in the difficult neck: Outcomes of external carotid artery transposition and end-to-end microvascular anastomosis

BACKGROUND

Selection of recipient vessels for head and neck microvascular surgery may be limited in the previously dissected or irradiated neck. When distal branches of the external carotid artery (ECA) are unavailable, additional options for arterial inflow are needed. Here we propose high ligation of the ECA and transposition toward the lower neck as an alternative.

METHODS

After obtaining institutional approval, patients who underwent head and neck tumor resection and simultaneous free flap reconstruction were identified over a 5-year period. Patients whose recipient artery was listed in the operative report were included. Chart review was performed to identify patient demographics, operative details, and patient and flap complications. In cases where the ECA was used, the artery was traced distally with care taken to protect the hypoglossal nerve. The ECA was then divided and transposed toward the lower neck where an end-to-end microvascular anastomosis was performed.

RESULTS

The recipient artery used for head and neck microsurgery was available for 176 flaps, and the facial (n = 127, 72.2%) and external carotid (n = 19, 10.8%) arteries were most commonly used. There were 0 flap thromboses in the ECA group compared to 3 flap thromboses that occurred with other recipient arteries (P = 1.00). No cases of first bite syndrome or hypoglossal nerve injury were identified.

CONCLUSIONS

The ECA may be transposed toward the lower neck and used for end-to-end microvascular anastomosis without complication of hypoglossal nerve injury or first bite syndrome. This method may be considered an alternative in patients with limited recipient vessel options for head and neck microsurgery. © 2015 Wiley Periodicals, Inc. Microsurgery 37:96-100, 2017.

The use of short segment free jejunal transfer as salvage surgery for cervical esophageal and hypopharyngeal cancer

Background

Salvage surgery after definitive chemoradiotherapy for cervical esophageal cancer and hypopharyngeal cancer remains a challenge because of the high rate of complications. The purpose of this study was to evaluate the safety and efficacy of free jejunal transfer as salvage surgery for cervical esophageal cancer and hypopharyngeal cancer after definitive chemoradiotherapy.

Methods

We enrolled eight patients with cervical esophageal cancer and 11 patients with hypopharyngeal cancer who underwent free jejunal transfer as salvage surgery following radiotherapy or chemoradiotherapy. In this study, we reviewed the surgical procedures, perioperative complications, and survival rates.

Results

The median duration of surgery was 514 min, and the median blood loss was 439 ml. In surgical procedures, the recipient vessels for the anastomosis of the free jejunum consisted of one artery and one vein (63 %), one artery and two veins (5 %), and two arteries and two veins (31 %). The postoperative morbidity rate was 57.9 % (11 patients), with six cases of partial necrosis of the tracheal margin and no cases of graft necrosis or postoperative in-hospital death. The overall 5-year survival rate after surgery was 58.1 %.

Conclusions

Our findings suggest that with careful attention to the potential development of necrosis of the tracheal margin, pharyngolaryngoesophagectomy and free jejunal transfer can be safely performed, even in patients who received radiotherapy or chemoradiotherapy.

Free Flap Reconstruction of Head and Neck Defects after Oncologic Ablation: One Surgeon's Outcomes in 42 Cases

Background

Free flap surgery for head and neck defects has gained popularity as an advanced microvascular surgical technique. The aims of this study are first, to determine whether the known risk factors such as comorbidity, tobacco use, obesity, and radiation increase the complications of a free flap transfer, and second, to identify the incidence of complications in a radial forearm free flap and an anterolateral thigh perforator flap.

Methods

We reviewed the medical records of patients with head and neck cancer who underwent reconstruction with free flap between May 1994 and May 2012 at our department of plastic and reconstructive surgery.

Results

The patients included 36 men and 6 women, with a mean age of 59.38 years. The most common primary tumor site was the tongue (38%). The most commonly used free flap was the radial forearm free flap (57%), followed by the anterolateral thigh perforator free flap (22%). There was no occurrence of free flap failure. In this study, risk factors of the patients did not increase the occurrence of complications. In addition, no statistically significant differences in complications were observed between the radial forearm free flap and anterolateral thigh perforator free flap.

Conclusions

We could conclude that the risk factors of the patient did not increase the complications of a free flap transfer. Therefore, the risk factors of patients are no longer a negative factor for a free flap transfer.

Introducing the tibial-dorsalis pedis osteocutaneous shin flap: a new option for oromandibular reconstruction

BACKGROUND

The authors investigated the possibility of incorporating a well-vascularized, partial corticotomy of the anterolateral aspect of the tibia "in-series" with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction.

METHODS

A cadaveric injection study was performed to characterize the vascular territory of the anterior tibial artery with regard to the surrounding osseous and soft tissue. The two-point breaking strength of the tibia (twist) was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathologic fracture. Finally, the authors performed an in vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap.

RESULTS

The perfusion study revealed that the anterior tibial artery provided a rich matrix of musculofascial periosteal blood supply to the anterolateral cortex of the tibia that could potentially support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to pathologic fracture of the remaining tibia was greater than 30 percent. The osteocutaneous shin flap was performed in eight patients. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation.

CONCLUSIONS

The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with bone stock that replicates mandibular bone dimensions, facilitating primary osseointegration or denture rehabilitation.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Reconstruction of sarcoma defects following pre-operative radiation: free tissue transfer is safe and reliable

BACKGROUND

Neoadjuvant radiotherapy followed by surgical resection and soft tissue reconstruction provides the best possibility of achieving superior limb function in soft tissue sarcomas. The aim of this study was to report our experience of free flap microsurgical reconstruction of recently irradiated soft tissue sarcoma defects.

METHODS

A retrospective study of microsurgical outcome in consecutively treated extremity and trunk sarcoma patients undergoing free tissue transfer between 2007 and 2012 was conducted from a prospectively collected database. Outcomes in pre-operatively irradiated patients were compared with non-irradiated patients. Demographic data, operative details, limb salvage rate, post-operative including microsurgical complications, and long-term limb function (Toronto Extremity Salvage score, TESS; Musculoskeletal Tumour Society Rating Scale, MSTS) were recorded and analysed for differences between the two study groups.

RESULTS

Forty-six patients underwent 46 free flaps (pre-irradiated n = 32, non-irradiated n = 14) over the study period. Microvascular complications (intra-operative revision, flap re-exploration, flap loss) were uncommon and similar between the two groups (4/32 and 2/14 respectively, p > 0.05). Recipient site wound healing complications (i.e. not flap related) occurred more frequently in pre-irradiated patients (16 events) compared with the control group (2 events, p = 0.03). There was no significant difference in limb salvage rate, or TESS/MSTS functional outcome scores between the two patient groups.

CONCLUSIONS

Free tissue transfer is safe and effective in patients undergoing surgical resection and reconstruction following neoadjuvant radiotherapy.

The role of the internal mammary vessels as recipient vessels in secondary and tertiary head and neck reconstruction

BACKGROUND

Successful microsurgical free tissue transfer for head and neck reconstruction highly depends on the quality of the recipient vessels. In most cases, vessels near the site of resection are available; however, when the bilateral vascular network in the neck is compromised or inaccessible due to prior surgery and/or irradiation, alternatives have to be sought.

METHODS

Secondary or tertiary head and neck reconstruction was performed using the internal mammary vessels (IMVs) as recipient vessels in seven patients who had undergone previous neck dissection and radiation therapy. Indications were: tracheal-oesophageal fistula or stenosis (n = 4), oesophageal-cutaneous fistula (n = 1), saliva fistula (n = 1) and oral cancer (n = 1). Free flaps used for reconstruction were radial forearm flap (FRFF) (n = 5), anterolateral thigh flap (ALT) (n = 3) and transverse rectus abdominis myocutaneous flap (TRAM) (n = 1). Within two patients an additional ALT flap was necessary for soft-tissue coverage and resurfacing of the neck. The IMVs were separately exposed in a standard fashion over the second or third rib. The pedicle of the flap was anastomosed anterograde and end-to-end to the recipient vessels in all cases. Mean pedicle length was 14.3 cm (11-20 cm), with a mean distance of 9.8 cm (7-13 cm) between the resection and recipient vessel site.

RESULTS

All patients were tumour free at time of re-operation and no sign of radiation injury was observed in the recipient vessels. All flaps survived and all patients healed without major complications. Mean follow-up time was 18 months. Four patients died of local recurrence or distant metastases during follow-up.

CONCLUSION

In the vessel-depleted neck, the IMVs are a reliable and easy accessible recipient area for microsurgical reconstruction of the head and neck. Surgical management and technique refinements for dissection of the vessels are discussed. In combination with free flaps with a long pedicle, especially perforator flaps, vein grafts are unnecessary and microsurgery can safely be performed outside the zone of injury.

Influence of irradiation and oncologic surgery on head and neck microsurgical reconstructions

Despite the refinement of microsurgical techniques, microsurgical free flap transfer in patients with a history of previous radiotherapy, neck dissection or free flaps remains a challenge in oncologic reconstructive surgery. Previous studies on the prognostic factors for postoperative complications have been largely retrospective and shown conflicting results. Our aim was to design a prospective study to identify negative outcome predictors of free flap surgery in previously treated oral cancer patients. Prospective study including all patients who required microsurgical free flap transfer for reconstruction of the oral cavity between July of 2007 and June of 2010 with subset analysis of those cases in whom previous surgical or nonsurgical oncological treatment for head and neck cancer had been carried out. A total of 360 free flaps were performed in 358 patients, of whom 61 had previous neck dissection and 58 had undergone radiation therapy. Operation time was significantly found to be longer in irradiated patients. The need for microsurgical revision, postoperative wound infection and free flap loss were significantly associated with the ASA score and a previous neck dissection. Wound infection was seen significantly more often after radiotherapy. Previous neck dissections and radiotherapy as well as the ASA score are significant negative predictors for success in free flap transfer. For patients with prior oncologic treatments in their medical history, we recommend detailed preoperative assessment of the vascular status and an intensified postoperative care to reduce complication rates to improve outcome in oncologic reconstructive surgery.

Reconstruction techniques in skull base surgery

One of the major challenges of cranial base surgery is reconstruction of basal dural defects. Ineffective reconstruction may result in potentially life-threatening complications such as cerebrospinal fluid leak, meningitis, and tension pneumocephalus. Goals of reconstructive procedures are to repair the dural defect and to separate intracranial contents from bacteria-laden secretion of the mouth, nose, and sinus. Different reconstructive techniques have been reported. Multiple factors may influence the surgical choice of reconstructive technique and its outcome. Regional pedicled flap and vascular free flaps represent the best reconstructive options because vascularized tissues promote fast and complete healing. A variety of endoscopic pedicled mucosal flaps within the nasal cavity have also been described. The different reconstruction techniques are described and discussed in terms of indications, advantages, and drawbacks.

Free flap reconstruction in the head and neck region following radiotherapy: a cohort study identifying negative outcome predictors

BACKGROUND

With the increased use of radiotherapy in the treatment of head and neck cancers, free tissue transfer in an irradiated field is now common. Reported outcomes with free tissue transfer reconstructions in irradiated areas are often unclear and contradictory. This is attributable in part to small sample size and heterogeneity in patients and procedures. The goals of this study were, first, to determine the outcome of head and neck reconstructions in an irradiated field using a large retrospective cohort and, second, to identify negative outcome predictors that could potentially be modified to reduce the morbidity in these procedures.

METHODS

Patients undergoing free flap reconstruction in irradiated head and neck regions between July of 2005 and July of 2007 were identified. Charts, including operative and radiotherapy records, were reviewed. Multiple logistic regressions were performed to identify negative outcome predictors.

RESULTS

During the study period at the authors' institution, 984 patients underwent head and neck free flap reconstruction. Of these, 137 had free tissue transferred to irradiated fields. Patients received an average radiotherapy dose of 64.5 Gy. The overall flap success rate was 96.4 percent. The postoperative complication rate was 47 percent. There was an overall 22 percent reoperation rate and a 28 percent infection rate. Segmental mandibulectomy, larger flap size, and infection were found to be significant negative outcome predictors.

CONCLUSIONS

This study confirms that free flap transfer to previously irradiated head and neck areas has a success rate comparable to that of transfer to nonirradiated zones. However, previously irradiated patients have a high risk of complications. Infection, as a modifiable risk factor, should be treated aggressively.