Staged Head and Neck Reconstruction: Heresy or a Reasoned Approach in a Select Group of Patients?

Abstract

Study Design: case series. Objective: The restoration of defects in a single procedure with microvascular free flap reconstruction has become a mainstay of head and neck surgery. Yet in patients with complex defects and pre-existing comorbid medical conditions, a staged-reconstructive approach can enhance the safety of the procedure and improve the patient’s outcome. Methods: We present 3 representative case examples of a larger series of patients who underwent reconstruction of major defects and discuss the usefulness of a staged-reconstructive approach in the management of complex patients. Results: All 3 patients, with an existing composite defect in the setting of prior radiation therapy, underwent successful staged-reconstructive surgery using a variety of free tissue and regional flap transfers. Conclusions: A staged approach facilitates the reconstruction of complex composite defects, increases vessel availability, and mitigates the risk of flap failure. Although this approach commits the patient to multiple procedures and a more prolonged plan of care, it is preferable to 1 operation in specific complex situations with adverse, high-risk clinical features.

A staged approach to oromandibular reconstruction using the iliac crest free flap in the setting of bilateral failed fibula free flaps

“…Secondary oromandibular free flap reconstructions introduce new levels of complexity and an increased risk of failure. 1,3 The surgeon must consider potential factors related to the anastomosis that contributed to the previous failure. These include the suitability of the recipient and flap vessels, the size match of the vessels, pedicle geometry, the anastomotic technique, and technical challenges related to the anastomosis such as exposure or ergonomics.…”

“…This is particularly advantageous in the setting of a hostile recipient bed with limited options for recipient vessels, radiation-induced tissue damage, clotting disorders, active infection, and oral contamination. 3 A multistaged reconstruction ensures that the initial soft tissue flap is successful and provides a healthy, vascularized wound bed for definitive bony reconstruction. Achieving a seal of the oral cavity helps to avoid the secondary complication of salivary contamination.…”

“…Secondary oromandibular free flap reconstructions introduce new levels of complexity and an increased risk of failure 1,3 . The surgeon must consider potential factors related to the anastomosis that contributed to the previous failure.…”

“…Despite the advantages of single stage oromandibular reconstruction, some particularly challenging cases as presented herein, may benefit from a multistaged approach. This is particularly advantageous in the setting of a hostile recipient bed with limited options for recipient vessels, radiation‐induced tissue damage, clotting disorders, active infection, and oral contamination 3 . A multistaged reconstruction ensures that the initial soft tissue flap is successful and provides a healthy, vascularized wound bed for definitive bony reconstruction.…”