A decade of reconstructive surgery: outcome and perspectives of free tissue transfer in the head and neck. Experience of a single center institution

Abstract

Purpose Free flaps have become the standard option in reconstructive surgery of the head and neck. Even though many authors have outlined the reliability of free transplants, there is an ongoing discussion about treatment options for patients bearing particular risks as previous irradiation treatment. In this analysis, we aim to address these patients with particular risk profiles by comparing different flap entity outcome parameters. Methods We retrospectively analyzed a cohort of 494 patients who underwent flap surgery between 2009 and 2018 in our department. Focusing on free microvascular transplants, we additionally analyzed the pectoralis major myocutaneous flap as the most frequently used vascular pedicled flap. Data analysis was performed by uni-and multivariate statistics. Results Overall flap success rate was 90%, with the radial forearm flap occurring to be most reliable (93%) in head and neck reconstruction. Previous radiation therapy (RT) and intraoperative revision of vascular anastomosis during primary surgery significantly resulted in impaired transplant outcome with a success rate of 91.8% (no RT) vs. 83.7% (RT), respectively. There was a negative linear correlation between incision to suture time and number of flaps per year (R 2 = 0.67). Conclusions Preoperative radiation therapy and intraoperative revision of anastomosis significantly impair outcome of microvascular flaps in the head and neck and oral cavity, whereas patient's age is not a predictor of flap failure. Increasing case number and experience reduces time of flap surgery as well as rate of complications and flap failure.

Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap

“…Free flap reconstruction currently represents the first choice in managing complex maxillofacial defects because their functional and esthetic results and donor site morbidity rates are better than those of pedicled flaps [ 11 ]. Free flaps, which can also be successfully used in elderly patients, also have similar transplant survival rates [ 3 , 12 ]. However, several publications have shown that perioperative local and systemic complications directly correlate with increased age and particularly with the presence of relevant comorbidities [ 13 ].…”

“…As described recently, free flap reconstruction represents the state of the art procedure at our department, and patients undergoing this procedure are of advanced age [ 3 ]. However, we have observed that the age at which patients require advanced maxillofacial flap reconstruction is increasing; thus, patients often present with a higher number of comorbidities.…”

“…Such failure may become critical in comorbid elderly patients who require short operating times. In patients with previous head and neck surgery or radiotherapy (RT), microsurgery may be difficult due to scarring and vessel-depleted necks [ 3 ]. For such patients, pedicled flaps such as the pectoralis major myocutaneous flap (PMMF) [ 4 , 5 ] or the submental island flap (SMIF) [ 6 ] are possible alternatives for oral and maxillofacial reconstruction.…”

Consideration in Microvascular Reconstruction during Times of Social Crises: Perspectives on Resource Utilization

“…10 A recent study by Spoerl et al reported pectoralis major myocutaneous flap closure as having a slightly lower success rate (88%; N ¼ 40) than radial forearm free flap (93%; N ¼ 230), the same as free fibula flap (88%; N ¼ 121) but higher than anterolateral thigh flap closure (82%; N ¼ 51). 12 Therefore, even though free flaps may be preferable in typical situations, in times of social crises and limited resources, the pectoralis major flap offers a viable alternative.…”

Three-Dimensional Technology Applications in Maxillofacial Reconstructive Surgery: Current Surgical Implications

“…Moreover, in defects with extensive hard and soft tissue loss in the OMF complex, loco-regional flaps and microvascular free tissue transfer is still considered as the superior reconstructive option [ 3 , 4 ]. However, despite high success rates of both vascularized and non-vascularized grafts, such reconstructive options still have critical disadvantages including, mainly, donor-site morbidity, availability in limited quantities, prolonged anesthesia time, unpredictability of bone graft resorption, total flap loss, and the need to manually sculpt the graft into the shape of the defect site [ 4 , 5 , 6 ].…”