Background: Understanding factors impacting successful salvage of a compromised free flap. Methods: Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764). Results: Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04). Conclusions: There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision. K E Y W O R D S free flap, free flap salvage, head and neck reconstruction, outcomes, surgical complications 1 | INTRODUCTION Microvascular free flap reconstruction of head and neck defects was first introduced in the 1970s and has resulted in superior aesthetic and functional results and improved patient quality of life. 1-3 Free flap survival rates in recent years are consistently cited as greater than 95%, 4-10 with still a small percentage of free flaps experiencing vascular compromise. Salvage of a compromised free flap is often attempted as complete failure of a free flap results in significant morbidity for the patient, increased length of hospitalization, and increased health care cost. 7,11-15 The ability to salvage a compromised free flap has been cited as high as 60% to 80%. 9,16-19 Therefore, great efforts are undertaken to salvage a compromised free flap. Most academic centers, which perform high volume free tissue transfer, are prepared to rapidly intervene once a compromised free flap is identified. A timely recognition of a

Objectives/Hypothesis To review the management of failed free tissue transfers among four large institutions over a 13‐year period to provide data and analysis for a logical, algorithmic, experience‐based approach to the management of failed free flaps. Study Design Retrospective case series. Methods A multi‐institutional retrospective chart review of free tissue transfers to the head and neck region between 2006 and 2019 was performed. Patients with a failed free flap during their hospitalization after surgery to the head and neck were identified and reviewed. Patient age, co‐morbidities, risk factors, flap characteristics, tumor specifics, and length of hospital stay were reviewed, collected, and analyzed. Results One hundred eighteen flap failures met criteria. The most common failed flap in this review was the osteocutaneous flap 52/118 (44%). The recipient site of the initial free flap (P < .001) was the only statistically significant parameter strongly correlated with management. Osteocutaneous flap failures, fasciocutaneous, bowel, and muscle‐only flaps tended to be managed most commonly with a second free flap. Myocutaneous flap failures were managed equally with either a second free flap or a regional flap. Conclusions The most important factor in management of a failed free flap is the recipient site. A second free flap is often the preferred treatment, but in the acute setting, local or regional flaps may be viable options depending on the recipient site, circumstances of flap loss, and patient‐ specific comorbidities. An algorithm for management of the acute flap loss is presented in this review. Level of Evidence 4 Laryngoscope, 131:518–524, 2021

Objective To demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery. Methods Single institution retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient‐specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed. Results Forty‐one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P‐value of .003478. Conclusion Use of the Spider Limb Positioner allows for a simultaneous two‐team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation. Level of Evidence 3 Laryngoscope, 131:525–528, 2021

The mylohyoid (MH) musculature separates the sublingual and submandibular spaces and is, therefore, important with regard to the spread of infection and space occupying lesions. Moreover, the MH may be elevated and included in the myocutaneous submental island flap or sutured in conjunction with the platysmas and the anterior bellies of the digastric muscles (ABDMs) to add stability to submental muscular medialization procedures. Therefore, variation in the anatomy of the MH musculature must be considered in the management of the spread of infection and space occupying lesions as well as in surgical planning. This report reviews mylohyoid variations and documents a unique case in which several suprahyoid muscular variations occurred concurrently. The variations included isolated anterior bellies of the mylohyoid inserting into the geniohyoid thereby forming mylo-geniohyoid muscles as well as isolated posterior bellies of the mylohyoid inserting into the ABDM and the intermediate tendon of the digastric muscle thereby forming mylo-digastric muscles. Surgeons operating in the suprahyoid region should be aware of potential anatomical variation of the mylohyoid to develop contingency plans.

The purpose of our study is to test the feasibility of transoral thyroid chondrolaryngoplasty using a similar approach to transoral thyroidectomy. This approach would allow for gender-affirming surgery while avoiding an external neck scar. We carried out our cadaveric feasibility study in an anatomy laboratory at an academic center. Five fresh cadavers were used for this study. We used a lower oral vestibular incision, along with retractors and an endoscope to dissect and gain access to the laryngeal prominence of the thyroid cartilage. Portions of the laryngeal prominence were then removed using scissors to achieve a satisfactory neck contour. Endoscopic as well as extracorporeal photographs were taken to demonstrate the approach. We were able to remove the laryngeal prominence successfully in all of our cadaveric specimens with this transoral approach.