Staged inset of free flaps for complex microsurgical head and neck reconstruction to ensure total flap survival

Abstract

Introduction Microsurgical reconstruction of complex head and neck defects often requires reliable tissue in multiple spatial configurations to achieve good functional and aesthetic outcomes. In addition to robust perforators, flap inset and wound closure require great caution to minimize complications especially in the presence of trismus with limited space for inset. This report describes the technique and results of our staged approach to flap inset which increases the chance of total flap survival in complex head and neck reconstructions. Methods From February 2010 to August 2016, a total of 53 patients were identified via a retrospective chart review. Patients who were suspected to have a high risk of vascular compromise and subsequently underwent complex head and neck reconstruction with staged inset of anterolateral thigh (ALT) flaps were included. The flap was inset only partially at the recipient site initially with fewer sutures. At a second stage, after neovascularization from surrounding tissue was established, the flap was partially elevated, divided and mobilized on its own pedicle for definitive inset. Results Fifty‐one patients had complete survival of flaps and had uneventful postoperative course. Six cases required immediate re‐exploration to release wound tension or reposition the pedicle. Of these, 4 flaps were salvaged, 2 failed due to small perforators despite anastomosis revision. The flap survival rate was 96.2% and the average time between 2 stages was 24 days (range, 21–28). Conclusion Staged flap inset can improve free flap survival in complex head and neck reconstructions.

Three salvage strategies in microvascular fibula osteocutaneous flap for mandible reconstruction with vascular compromise and establishment of an algorithm

“…The loss of mandibular integrity causes an imbalance between the bone and the associated soft tissue, which can lead to an impaired quality of life (Wallace et al, 2010). Therefore, successful complex mandibular reconstruction depends on the transfer of a composite tissue, which involves the skin and muscle of the extraoral and intraoral lining as well as a bone for a reliable inset (Huang et al, 2018).…”

Use of Single Chimeric Free Flaps or Double Free Flaps for Complex Head and Neck Reconstruction

“…1 Such reconstructive endeavors are complex and require a reliable inset of the flap components respecting the spatial orientation and volume distribution in this particular anatomic region. 2 Following wide local resection of advanced-stage tumors, patients are frequently left with extensive defects involving skin, soft tissue, oral mucosal lining, and bone. While local pedicled flaps have the advantages of reduced cost, decreased operative time, and faster patient recovery, these can be inadequate for treating complex, potentially radiated defects.…”

“…4 Some surgeons critique the increased operative time and potential for donor site morbidity, while others highlight the challenges of reconstruction and increased complexity of the procedure. 2,5 Nonetheless, a carefully executed free flap reconstruction can minimize vascular complications, effectively address soft tissue and bony defects, and allow for more favorable functional outcomes in patients undergoing resection of extensive head and neck tumors. 1 As a result, the objective of this manuscript is to describe our experience with the use of single chimeric free flaps and double free flaps for the reconstruction of complex defects after head and neck tumor and osteoradionecrosis resections.…”