Management of Flap Failure After Head and Neck Reconstruction: A Systematic Review and Meta‐analysis

Abstract

Objective To systematically review management of flap loss in head and neck construction with free tissue transfer as compared with locoregional flap or conservative management. Data Sources Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched up to October 2019. Review Methods Candidate articles were independently reviewed by 2 authors. Articles were considered eligible if they included adequate reporting of flap management after flap loss and outcomes for survival of reconstruction, length of hospitalization, and perioperative complications. Results A total of 429 patients had acute flap failure in the perioperative period. The overall success with a secondary free flap was 93% (95% CI, 0.89-0.97; n = 26 studies, I2 = 12.8%). There was no difference in hospitalization length after secondary reconstruction between free tissue transfer and locoregional flaps or conservative management (relative risk of hospitalization ≥2 weeks, 96%; 95% CI, 0.80-1.14; n = 3 studies, I2 = 0). The pooled relative risk of perioperative complications following free tissue transfer was 0.60 when compared with locoregional flap or conservative management (95% CI, 0.40-0.92; n = 5 studies, I2 = 0). Conclusion Salvage reconstruction with free tissue transfer has a high success rate. Second free flaps following flap failure had a similar length of hospitalization and lower overall complication rate than locoregional reconstruction or conservative management. A second free tissue transfer, when feasible, is likely a more reliable and effective procedure for salvage reconstruction.

Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure

“…25 A recent meta-analysis indicated that a second free flap produced fewer perioperative complications when compared with locoregional alternatives in patients with previous free flap loss (relative risk, 0.6; 95% CI, 0.40 to 0.92; P = 0.02). 3 Remarkably, our findings indicated a higher flap success rate implementing locoregional flaps as a secondary reconstruction with a 90.9% success rate. In this setting, locoregional reconstructive options may be a valuable alternative when the wound bed is compromised or when, regardless of the physiologic status, patients need to undergo surgery because coverage is urgently required.…”

“…Although a previous meta-analysis showed a 93% success rate for a secondary free flap (95% CI, 89% to 97%), outcomes throughout the literature are highly heterogeneous. 3 The rate for reconstruction salvage with a second free flap was 71.4% in our series. Bozikov and Arnez determined that free flap failure was 4.6 times more likely to occur after salvage free flap transfer, reporting a success rate of 53%.…”

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ree tissue transfer is considered the standard treatment for oncologic reconstruction of head and neck defects, as it has been shown to offer equivalent success rates of flap survival in comparison to regional flaps, with the advantage of optimizing function. [1][2][3][4] The overall rate of a successful free flap for head and neck reconstruction in large centers has been reported to be approximately 95%. 5 Nonetheless, outcomes are generally suboptimal if flaps present vascular complications requiring reexploration after primary Background: Finite options exist to address free flap failure.

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A retrospective analysis for the management of oromaxillofacial invasive mucormycosis and systematic literature review

“…Few scientific literatures proposed treatment about the surgical technique of reconstruction for this disease. There are a multitude of considerations and perioperative measures that aim to maximize the success of tissue transfer, including acknowledgment of psychological and psychiatric factors, tight glycemic control, nutritional support, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology [ 87 ]. The defect resulted from radical surgical debridement is extensive, requiring reconstructive surgery with a pedicled than free flap.…”

Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition

“…The literature demonstrates success rates in excess of 95 per cent. 240,241 The early detection of and intervention for flap failure forms an important part of ensuring low failure rates.…”