Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Abstract

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that of free fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n = 13), (b) large oro-mandibular soft tissue defects (n = 4), (c) complex skull-base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patients with oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Influence of neck dissection and preoperative irradiation on microvascular head and neck reconstruction-Analysis of 853 cases

“…Few reports have been found with regards to previous radiotherapy and neck dissection in head and neck free tissue transfers, and selection of recipient vessels. Balasubramanian et al reported double free flap reconstructions in patients receiving previous radiotherapy without complications . Hanasono et al examined 261 free flaps in 237 head and neck reconstructive surgeries which were divided into four groups: those who had a history of prior neck dissection and radiation therapy, radiation therapy alone, neck dissection alone, and no history of prior neck dissection or radiation therapy.…”

Effects of Vascular Endothelial Growth Factor on Survival of Surgical Flaps: A Review of Experimental Studies

“…Inadequate blood perfusion and ischemia-reperfusion injury are believed to be the major factors. [3][4][5][6] Various methods have been proposed to address these problems. However, until recently, the surgical delay procedure was the only proven technique to improve tissue survival at and beyond standard flap territory margins.…”

Single versus dual venous anastomoses of the free fibula osteocutaneous flap in mandibular reconstruction: A retrospective study

“…Since Hidalgo firstly reported the use of free fibula flap for repair and reconstruction of mandibular defects in 1989, the free fibula flap has gradually become the primary graft of choice for the reconstruction of the mandible. Several clinical studies indicated the use of free fibula flap for mandibular reconstruction with a success rate of 95–98% . However, microsurgeons are constantly exploring different ways to improve the success rates of the transplantation.…”