Perforator free flaps in head and neck reconstruction: a single-center low-volume experience

Accepted Manuscript Perforator Free Flaps in Head and Neck Reconstruction: A Single Center Low Volume Experience Annelies Weckx, MD, DMD, Natalie Loomans, MD, DMD, Olivier Lenssen, MD, DMD PII:

S2212-4403(16)30704-0

DOI:

10.1016/j.oooo.2016.11.010

Reference:

OOOO 1658

To appear in:

Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

Received Date: 11 July 2016 Revised Date:

5 November 2016

Accepted Date: 25 November 2016

Please cite this article as: Weckx A, Loomans N, Lenssen O, Perforator Free Flaps in Head and Neck Reconstruction: A Single Center Low Volume Experience, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology (2017), doi: 10.1016/j.oooo.2016.11.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Title: PERFORATOR FREE FLAPS IN HEAD AND NECK RECONSTRUCTION: A SINGLE CENTER LOW VOLUME EXPERIENCE. Author names and affiliations: Annelies Weckx, MD, DMD1, §, Natalie Loomans, MD, DMD2, Olivier Lenssen, MD, DMD1

Department of Oral & Maxillofacial Surgery, GZA Sint-Augustinus, Oosterveldlaan 24, 2610 Antwerp,

Belgium

§Corresponding

author: Annelies Weckx, MD, DMD.

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2

of Oral & Maxillofacial Surgery, ZNA Middelheim, Lindendreef 1, 2020 Antwerp, Belgium.

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1 Department

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Department of Oral and Maxillofacial Surgery, ZNA Middelheim, Lindendreef 1, 2020 Antwerp, Belgium E-mail address: [email protected] Business telephone number: +32 3 2803179 Private telephone number: +32 472 521892

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Funding:

We hereby declare that no funding was received for this research. We disclose any commercial

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associations, current and within the past five years, that might pose a conflict of interest.

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Word count abstract: 195

Complete manuscript word count: 2957 Number of references: 25 Number of figures: 3 Number of tables: 5 Supplementary materials: none

ACCEPTED MANUSCRIPT ABSTRACT

Objective: The aim of this article is to investigate the results of free flap reconstructions in the head and neck area in a secondary low-volume institution and compare these with the literature.

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Study design: A retrospective study was performed of all patients who underwent free flap reconstructive surgery in our institution (01/09/2011 - 07/12/2015) by one young surgeon in a one-team approach. The types of flaps applied, defect sites, pathology, anastomotic details, success and complication rates, length

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of stay as well as patients' age and comorbidities were analysed.

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Results: A total of 97 patients received 100 free flaps. Perforator flaps comprised 85% of the total amount (63% anterolateral thigh, 22% fibular flaps). Thirty-six percent of free flaps were performed in patients who received previous (chemo) radiation to head and neck. Free flap survival was 96%.

Conclusion: From our data, it seems that free flap surgery is not only a safe and successful technique in

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tertiary academic hospitals, but can also be performed in smaller institutions, even in the salvage situation and in patients with comorbidities. Therefore we believe that free tissue transfer is predictable in all

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centres with skilled microsurgeons and a well-trained nursing team.

ACCEPTED MANUSCRIPT INTRODUCTION

Over the past decades it is has become clear that free flap reconstructions in the head and neck area can OFFER EQUAL success rates AND functionality and HAVE A COMPARABLE economic impact AS PEDICLED OR TRANSPOSITION FLAP RECONSTRUCTIONS 1. HOWEVER, literature regarding flap outcome in low-

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volume institutions is scarce. Additionally, low-volume studies often cover a whole range of free flaps for reconstruction sites spread over the entire body. Specific results about head and neck reconstructions in small centres are not widespread. In this study we THEREFORE aim to report the results of free flap

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surgery and in particular perforator flap reconstructions in a secondary low-volume institution and

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compare this with the literature.

In many institutions the free flap of choice for head and neck reconstruction is still the radial forearm free flap (RFFF)2-7. Though, since the end of the nineties, A global TREND TOWARDS perforator flaps WAS SEEN. The anterolateral thigh flap (ALTF) was firstLY described by Song et al8 in 1984, but was in its beginnings predominantly raised in larger HOSPITALS in the Far East7, 9-11. The main reason for its recent

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global popularity was the finding that cases without a sizable perforator constitute less than 1% of cases, while it was thought before that THIS WAS THE CASE in up to 5%6, 12, 13. Additionally, technical advances allowing for a safer dissection WERE MADE and THUS INCREASED THE evidence FOR its success13. Nowadays the ALTF is becoming the workhorse for reconstructions in the head and neck area for many

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microsurgeons WORLDWIDE7, 14. Yet the RFFF is, as it is less challenging to harvest, STILL BEING USED GLOBALLY. For bony reconstructions the fibular flap (FF) is most oftenLY USED, in addition to the deep

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circumflex iliac artery flap (DCIA) and the scapula free flap.

Free flap surgery used to be performed mainly in larger, tertiary and teaching hospitals. IT IS only recently THAT smaller secondary centres are also IMPLEMENTING these procedures with a higher success rate. THEREFORE, WE REPORT ON 100 free flap reconstructions THAT were performed OVER A PERIOD OF FOUR YEARS at our regional Belgian hospital BY ONE SURGEON IN A ONE-TEAM APPROACH.

ACCEPTED MANUSCRIPT MATERIAL AND METHODS

In this retrospective analysis, we investigated the medical records of all patients who underwent free flap reconstructive surgery at the author’s institution between September 2011 and December 2015. All these

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reconstructions were performed by the same surgeon (OL) in a one-team approach.

Clinical data collected from the medical records included age at surgery, site of tumour/reconstruction, pathology, flap type, anastomotic vessels, type of anastomosis, previous radio(chemo)therapy, dose of

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previous radiotherapy, primary or secondary reconstruction, flap survival, patient survival, complications and complication rate, active smoking at time of surgery, use of anticoagulants, history of cardiovascular

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disease, diabetes, length of stay and the possibility to start adjuvant (chemo)radiotherapy within 6 weeks after surgery. Ethical approval was not applicable for this retrospective study.

Complications after free flap surgery were divided into major and minor complications, according to Singh et al15 and Bianchi et al16. Major complications were complications that needed revision surgery; minor

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complications could be resolved conservatively.

The setup of the surgical team was consistent over the investigated period. This team consisted of the head surgeon (OL) with an assisting surgeon or surgical resident. The operative procedure and

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postoperative protocol have not been altered significantly over the investigated period. For ALTF and FF, pencil Doppler was used at the beginning of the surgery to indicate the perforators. For

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FF, an additional preoperative angio-CT scan of the legs was performed to rule out anatomic abnormalities. All the FF’s were harvested with a perforator skin island: this refinement of the classic fibular flap was also described by Chana et al as the osteomyocutaneous peroneal artery perforator flap (PAP) (Chana and Odili, 2010). In cases of bony reconstruction (FF or DCIA), a 3 dimensional (3D) print of the mandible or midface region was made to visualize the region of resection. Subsequently the reconstruction plates were bent and adapted preoperatively on this 3D model to reduce the duration of the surgery and therefore also limit the ischemic time. At the start of the surgery, antibiotics (2g amoxicillin + 200mg clavulanic acid) were administered and continued for 72 hours (4 x 1g amoxicillin + 100mg clavulanic acid). Anticoagulant therapy was not

ACCEPTED MANUSCRIPT administered during surgery. The anastomosis of the artery was performed first, followed by the vein. All anastomoses were sewn manually by use of Ethilon® 9/0 (Johnson & Johnson International, Diegem, Belgium). At the end of surgery all patients were tracheotomised and the cannula was secured with a cranial suture Vicryl® 1 (Johnson & Johnson International, Diegem, Belgium). Pressure was avoided on the pedicle by correct positioning of the patient and avoiding circular bandages around the neck.

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Postoperatively, the flap was monitored every hour for the first 24 hours by capillary refill clinically and the pedicle with percutaneous Doppler ultrasound. During the following 48 hours, the flap was monitored once every 4 hours. Thereafter the flap was checked once every 12 hours. Patients received a prophylactic

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dose of low molecular weight heparin (LMWH) during the entire hospital stay (2850 I.U. anti-factor Xa).

RESULTS

The files of 97 patients (m=56, f=41, mean age: 61y ± 13y, range: 19y-85y) were retrieved, accounting for

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a total of 100 free flaps.

Three patients received 2 flaps: one patient received a DCIA after a failed FF for a mandibular reconstruction. In a second patient, 2 FFs were raised for the reconstruction of a complete mandible. In a third patient, 2 free flaps had to be harvested: a FF after resection of a mandibular squamous cell

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oropharynx.

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carcinoma (SCC) and an ALTF 2 years later after resection of a second primary in the contralateral

The most commonly raised free flaps were the ALTF (63%) and the FF (PAP) (22%), resulting in 85% of perforator flaps (Table I).

The majority of reconstructed defects consisted of tongue (28%), mandible (23%) and floor of the mouth (FOM) (19%) defects. Nearly all reconstructions of the tongue and FOM were done using the ALTF (46/47). For mandibular defects the FF was predominantly used (21/23).

ACCEPTED MANUSCRIPT In 84% of cases, squamous cell carcinoma (SCC) in the head and neck region was the reason for resection and reconstruction (Table II).

Of all reconstructions 63% were performed because of a primary tumour, 26% because of a recurrent tumour (salvage surgery) and 6% after resection of a second primary. The remaining 5% were

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reconstructions after resection of ORN of the jaw or a pathologic fracture. (Summary: Table III). The free flaps were raised by primary intention in 95% of cases and by secondary intention in 5%.

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A total of 36% of reconstructions underwent preoperative (chemo)radiation therapy in the head and neck

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area.

The free flap survival rate was 96%. Failures occurred due to venous thrombosis (2%: 2 ALTF), arterial failure (1%: 1 FF) and failure of the perforator (1%: 1 ALTF). Since all failures occurred after the period of intensive flap monitoring, no flap salvage was attempted. Three out of four flap failures occurred in

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previously irradiated patients.

At the recipient site, 3 major complications were identified: 1 full skin island fail (FF) with take-back to the operating room after 2 days to remove the necrotic skin, 1 partial flap failure (ALTF) with take-back after 21 days to excise the necrotic flap ends and 1 venous congestion (ALTF) for which a surgical

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exploration was performed after 1 day. In all 3 cases the vascular pedicle appeared normal. The venous congestion was then resolved by the application of medical leeches.

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Minor recipient complications were encountered in 14% of cases: 1% full (FF) and 3% partial (1 FF + 2 ATLF) skin island necrosis, 4% partial flap dehiscence (1 ALTF + 1 DCIA + 1 FF + 1 RFFF), 2% fistulas (2 FF), 1% infection of the neck (FF) with moderate wound dehiscence (antibiotic management), 2% bleeding complication (2 ALTF) without revision surgery (flap not compromised). At the donor site we encountered 1 major complication (Lat Dorsi; bleeding with surgical revision) and 2% minor complications (2 ALTF; meralgia paresthetica).

Other technical details were that in 3% of all cases, no sizable perforator was encountered on the initiating side during raising of the ALTF. Therefore, flap harvest was performed on the contralateral side.

ACCEPTED MANUSCRIPT Except for increased donor site morbidity (scar on both legs), these patients did not experience any other complication.

The most commonly used anastomotic arteries were the facial artery (75%) and the superior thyroid artery (18%). 99% of arterial anastomoses were end-to-end (ETE) anastomoses and 1% was an end-to-

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side (ETS) anastomosis (Table IV).

The internal jugular vein (65%) and the thyrolinguofacial trunk (28%) were the most commonly used

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anastomotic veins. 26% of venous anastomoses were ETE, while 74% were ETS anastomosis (Table V).

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In 5% of the cases, an interpositional vein graft was used (in 4% to extend the venous pedicle, in 1% for the artery). None of these reconstructions failed, nor did any of them experience a postoperative complication.

Active smoking at time of surgery was seen in 44% of reconstructions, 8% had a cardiovascular history

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and 5% were diabetics. Seventeen percent used any form of anticoagulant at time of surgery (14% aspirin, 2% aspirin and clopidogrel, 1% LMWH).

Average hospital stay was 18.5 days ±11d (range: 9–66) (Figure 1). The average length of stay for patients

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who underwent previous radiotherapy was 15% higher (20d ±12d) than the average length of stay of patients without previous (chemo)radiotherapy (17d ±10d). Approval for hospital discharge was based

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on decannulation and adequate resumption of oral intake.

After multidisciplinary oncologic consultation, it was decided that 51 patients (51% of all reconstructions) had to undergo postoperative (chemo)radiotherapy. One of these refused therapy and another was lost to follow-up. Of the remaining 49 patients, 41 (84%) did start postoperative (chemo)radiotherapy within a period of 6 weeks. After 8 weeks, a total of 96% had started. Delay was mostly due to prolonged hospitalisation because of postoperative delirium and poorer general condition.

ACCEPTED MANUSCRIPT DISCUSSION

This study describes data from a regional, low-volume head and neck oncologic centre performing a relatively high proportion of perforator flaps. Of importance in our series compared to other studies is that we are a secondary hospital and that all procedures are completely (neck dissection, tumour

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resection and free flap reconstruction) performed by the same surgeon in a 1-team approach. This provides a very homogenous data set.

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The most commonly raised free flaps in this study are the ALTF and the FF (PAP) accounting for 85% of all microsurgical reconstructions (Figure 2). This is high compared to other groups. Demir et al17 report a

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distribution of 31.16% perforator flaps and 68.84% axial flaps for head and neck reconstructions. The RFFF, with 3%, was the least used flap in our series. This is in contrast with many other authors who report RFFF to be their most widely raised free flap (40% (Haughey et al2), 68% (Lee et al4), 52% (le Nobel5), 56% (Zhang et al7). Lee et al4 and Zhang et al7 report to have raised mainly RFFF when starting their surgical careers, but have evolved towards proportionally more ALTF harvesting over time. The

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majority of free flaps raised by Kim et al18 are also ALTFs, similar to our data.

Our preference for these perforator flaps is FIRSTLY explained by the reduced donor site morbidity compared to RFFF. A SECOND ADVANTAGE IS THAT they offer a sufficient volume of tissue for larger and

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functional reconstructions. A DRAWBACK OF perforator flaps IS THAT THEY tend to be more difficult to harvest, because of their varying anatomy. In 3 patients, no perforator could be detected at the initiating

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side REQUIRING the surgery TO BE converted to the contralateral side.

EACH FREE FLAP WAS DESIGNED ACCORDING TO THE DESIRED FORM, DICTATED BY THE DEFECT, AND DISSECTED ACCORDINGLY. FOR EVERY ALTF, CAUTIOUS DISSECTION OF THE MOST SIZEABLE PERFORATOR WAS PERFORMED. SMALLER PERFORATORS, IF PRESENT, WERE SACRIFICED SINCE THERE WAS NO NEED FOR CHIMERIC FLAPS. MOST OF THE PERFORATORS IN ALTF WERE MUSCULOCUTANEAOUS PERFORATORS. TO ACQUIRE SUFFICIENT LENGTH, THE PEDICLE WAS DISSECTED UP TO THE LATERAL FEMORAL CIRCUMFLEX ARTERY AND IF NECESSARY UP TO THE FEMORAL ARTERY. ALMOST ALL PERFORATORS IN THE FF’s WERE SEPTOCUTANEOUS PERFORATORS,

ACCEPTED MANUSCRIPT USUALLY LOCATED IN THE THIRD QUARTER OF THE FIBULA. IN 3 FF’S (13.5%) THE PERFORATOR WAS LOCATED IN THE DISTAL QUARTER OF THE FIBULA, IN 2 FF’S (9%) A MUSCULOCUTANEOUS PERFORATOR HAD TO BE DISSECTED. PEDICLE LENGTH EXCEEDED 6CM IN ALL PERFORATOR FLAPS AND THERE WAS ALMOST ALWAYS A GOOD COAPTATION OF THE ARTERIAL PEDICLE TO THE FACIAL RECIPIENT ARTERY. AN

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INTERPOSITIONAL VEIN GRAFT WAS USED IN 5% OF RECONSTRUCTIONS TO EXTEND THE VENOUS (4%) OR ARTERIAL (1%) PEDICLE.

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In selected cases, AN ALTF was thinned during flap elevation because of excessive flap thickness. In 4 reconstructions ALTF-THINNING WAS NECESSARY after radiation therapy, because of persisting volume

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excess. IN THE OTHER TYPES OF FLAPS, THINNING WAS NOT NEEDED PER- OR POSTOPERATIVELY. Dental rehabilitation for optimal patient function and comfort WAS pursued IN ALL CASES. SINCE DENTAL IMPLANTS ARE NOT REIMBURSED BY THE BELGIAN HEALTH INSURANCE, ONLY A FEW PATIENTS COULD AFFORD TO BE DENTALLY REHABILITATED WITH AN IMPLANT-SUPPORTED PROSTHESIS. WHENEVER POSSIBLE, this WAS PLANNED after a period of 3 months after finishing OF the

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postoperative radiation therapy. In selected cases of upper jaw reconstruction using an ALTF, zygomatic implants trough the ALTF WERE used for dental rehabilitation (Figure 3), BECAUSE OF A LACK OF LOCAL BONY RECONSTRUCTION. BESIDES FLAP DEBULKING AND IMPLANT PLACEMENT, NO OTHER FLAP

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REVISION SURGERY WAS PERFORMED.

Success rate in our study is 96% which is similar to other larger and smaller studies (95% (Haughey et

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al2), 92.6% (Klosterman and Tatum3), 98% (le Nobel et al5), 97.6% (Zhang et al7), 90.7% (Kim et al18), 91% (Ryan and Hochman19), 96% (Gao and Loo20), 92.4% (Pohlenz et al21), This shows that success rates in low-volume institutions can be as good as those of large centres, as was already described by other authors3, 18.

Half of our failures were due to venous thrombosis and this finding is consistent with literature18, 22, 23. The perioperative mortality in our study was 2% which is comparable with rates reported in literature (2.1% (Haughey et al2), 0.7% (Klosterman and Tatum3), 4.7% (Simpson et al24), 1.3% (Suh et al25).

Despite the extensive co-morbidities of our patients, we report a relatively low complication rate with few

ACCEPTED MANUSCRIPT major complications. Recipient site complications in other studies vary between 9.4% and 35%, but because of different complication reporting systems, it is difficult to compare complication rates between different studies3,7,19,20,25.. WHEN USED AS AN OSTEOCUTANEOUS FLAP, FF’S ARE OFTEN PRONE TO DONOR SITE COMPLICATIONS. IN OUR STUDY, THIS DONOR SITE COMPLICATION RATE WAS FAIRLY LOW. ALL PATIENTS RECEIVED AN ANKLE SPLINT FOR 10 DAYS, AFTER THIS PERIOD PHYSIOTHERAPY

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WAS PRESCRIBED DURING THEIR REMAINING HOSPITAL STAY. AT DISCHARGE, NO ADDITIONAL PHYSIOTHERAPY WAS PRESCRIBED SINCE. NO SINGLE PATIENT EXPERIENCED GAIT PROBLEMS OR ANKLE INSTABILITY. THIS WAS PROBABLY ARCHIEVED BECAUSE CARE WAS TAKEN TO LEAVE AT

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LEAST 7CM (AND IF POSSIBLE 8CM) OF FIBULAR BONE TO THE ANKLE JOINT. SKIN GRAFTS WERE USED IN 86.5% OF FF’S. IN ALL OTHER CASES THE DONOR SITE COULD BE PRIMARLY CLOSED. MINOR

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MARGINAL HEALING PROBLEMS OCCURRED IN 5 PATIENTS (26%). FOR THESE CASES, HEALING WAS OBTAINED AFTER 4 WEEKS. SKIN GRAFT FAILURE OCCURUD IN TWO PATIENTS (10%) WHO EXPERIENCED PROLONGED HEALING PROBLEMS FOR MORE THAN 3 MONTHS.

Radiation therapy does not affect flap survival or complication rates5, 18: in our series three out of our 4

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failures occurred in patients who underwent previous radiation therapy, but due to small sample size, no correlations could be calculated.

Based on our current small experience we advocate that free flap reconstructions can be performed with a

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high success rate, even in older patients, smokers and in patients with a history of cardiovascular disease.

Since overall success rates are increasing worldwide, analysis of additional parameters has become more

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important in gauging patient impact. Besides the overall complication and mortality rate, length of hospital stay (LOS) and the timing of the start of radiation therapy can also estimate the quality of care and impact on the patient. Moreover, a reduced LOS and a rapid start of radiation therapy could reduce the financial burden of our current healthcare system. Average length of stay in our data (18.5d ± 11d) seems to be in the same range as that of others (11 days (Haughey et al2); 55 days (Klosterman and Tatum3); 5-41 days (Ryan and Hochman19)), however comparison is difficult since not many studies report on this topic and the considered reconstructions vary widely in size and location. Our patients are admitted until after decannulation and usually until they are able to swallow without risk of aspiration. Administration of IV antibiotics and flap monitoring are

ACCEPTED MANUSCRIPT other reasons for hospital stay, but those are usually completed after 1 week. Furthermore, every complication prolongs hospitalization. Studies with shorter LOS usually discharge their patients before decannulation and resumption of oral intake19. Patients who underwent previous (chemo)radiation therapy have a longer hospital stay of 2.8 days on average compared to patients who did not. Ryan and

flap-related complicated cases.

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CONCLUSION

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Hochman19 also report a longer LOS in this previously irradiated group, but only for those patients with

Our findings and success rates are comparable to what other authors describe, but with the difference that

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we perform relatively more perforator flaps17, a relatively high proportion of our patient population underwent previous (chemo)radiation, resulting in stiff necks and more difficult surgical procedures, and all procedures were performed by one young surgeon in a low-volume regional institution. Still, complication rates are fairly low and success rates and length of stay are comparable to those reported in

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literature.

We believe that the best functional and aesthetic results can be obtained using perforator flaps for head and neck reconstructions. Perforator flaps have few disadvantages. They are technically more challenging but there is enough evidence from large-volume institutions and growing evidence from low-volume

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centres that they can be performed reliably in both settings as long as they are performed by a skilled

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microsurgeon. Particularly the reduced donor site morbidity and their versatility are major advantages.

Because of our positive experience with free flap reconstructions, even in patients with multiple comorbidities, we have a low threshold for these procedures. We think our data show that free flap reconstructive surgery is not only a safe and successful technique in tertiary referral centres, but can also be reliably performed in smaller secondary hospitals. Regardless of the size of the centre, the key values for a successful reconstruction are the skills of the surgeon and the training and commitment of the nursing and intensive care team.

ACCEPTED MANUSCRIPT Acknowledgements

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None

ACCEPTED MANUSCRIPT List of references

1) Kakarala K, Emerick KS, Lin DT, Rocco JW, Deschler DG. Free flap reconstruction in 1999 and 2009:

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changing case chararcteristics and outcomes. Laryngoscope 2012;122(10):2160-2163.

2) Haughey HH, Wilson E, Kluwe L, Piccirillo J, Fredrickson J, Sessions D, Spector G. Free flap

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reconstruction of the head and neck: Analysis of 241 cases. Otolaryngol Head Neck Surg. 2001;125 (1): 10-

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17.

3) Klosterman T, Tatum S. Free flap reconstruction experience and outcomes at a low-volume institution

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over 20 years. Otolaryngol Head Neck Surg. 2015;152(5): 832-837.

4) Lee JT, Chen PR, Cheng LF, Wang, CH, Wu MS, Huang CC, Chien SH, Hsu H. A comparison between proximal lateral leg flap and radial forearm flap for intraoral reconstruction. Ann Plast Surg. 2013;71(1):

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S43-S47.

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5) le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of complications of free flap reconstruction in head and neck surgery: analysis of 304 free flap reconstruction procedures. Laryngoscope 2012;122(5):10141019.

6) Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg. 2006;35(3):199-207.

ACCEPTED MANUSCRIPT 7) Zhang C, Sun J, Zhu H, Xu L, Ji T, He Y, Yang W, Hu Y, Yang X, Zhang Z. Microsurgical free flap reconstructions of the head and neck region: Shanghai experience of 34 years and 4640 flaps. Int J Oral Maxillofac Surg. 2015;44(6): 675-684.

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8) Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous

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artery. Br J Plast Surg. 1984;37:149–159.

9) Demirkan F, Chen HC, Wei FC, Chen HH, Jung SG, Hau SP, Liao CT. The versatile anterolateral thigh flap:

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a musculocutaneous flap in disguise in head and neck reconstruction. Br J Plast Surg. 2000;53(1): 30-36.

10) Koshima I, Fukuda H, Yamamoto H, Moriguchi T, Souda S, Ohta S. Free anterolateral thigh flaps for

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reconstruction of head and neck defects. Plast Reconstr Surg 1993; 92(3): 421-430.

11) Shieh SJ, Chiu HY, Yu JC, Pan SC, Tsai ST, Shen CL. Free anterolateral thigh flap for reconstruction of

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head and neck defects following cancer ablation. Plast Reconstr Surg 2000;105(7):2349-2360.

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12) Celik N, Wei FC, Lin CH, Cheng MH, Chen HC, Jeng SF, Kuo YR. Technique and strategy in anterolateral thigh perforator flap surgery. An analysis based on 15 complete and partial failures in 439 cases. Plast Reconst Surg. 2002;109(7):2211-2216.

13) Chana JS and Odili J. Perforator flaps in head and neck reconstruction. Semin Plast Surg 2010;24:237254.

ACCEPTED MANUSCRIPT 14) Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg 2005;32:421-430.

15) Singh B, Cordeiro PG, Santamaria E, Shaha AR, Pfister DG, Shah JP. Factors associated with

403-411.

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complications in microvascular reconstruction of head and neck defects. Plast Reconstr Surg 1999;103:

16) Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E. Free flaps: Outcomes and complications in head and

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neck reconstructions. J Cranio-Maillofac Surg. 2009;37,438-442.

17) Demir A, Kucuker I, Keles MK, Demirtas Y. The effect of learning curve on flap selection, reexploration, and salvage rates in free flaps; a retrospective analysis of 155 cases. Microsurgery 2013;33,

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519-526.

18) Kim H, Jeong WJ, Ahn SH. Results of free flap reconstruction after ablative surgery in the head and

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neck. Clin Exp Otorhinolaryngol 2015;8(2): 167-173.

19) Ryan MW, Hochman M. Length of stay after free flap reconstruction, of the head and neck. Laryngoscope 2000;110(2): 210-210.

20) Gao R, Loo S. Review of 100 consecutive microvascular free flaps. N Z Med J 2011;124(1345): 49-56.

ACCEPTED MANUSCRIPT 21) Pohlenz P, Klatt J, Schön G, Blessmann M, Li L, Schmelzle R. Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps. Int J Oral Maxillofac Surg 2012;41: 739-743.

22) Hidalgo DA, Jones CS. The role of emergent exploration in free-tissue transfer: a review of 150

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consecutive cases. Plast Reconstr Surg 1998;102(3): 722-732.

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23) Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BL. Choice of flap and

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incidence of free flap success. Plast Reconstr Surg 1996;98(3):459-463.

24) Simpson KH, Murphy PG, Hopkins PM, Batchelor AG. Prediction of outcomes in 150 patients having

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microvascular free tissue transfers to the head and neck. Br J Plast Surg 1996;49(5): 267-273.

25) Suh DS, Sercarz JA, Abemayor E, Calcaterra TC, Rawnsley JD, Alam D, Blackwell KE. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Otolaryngol Head

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Neck Surg 2004;130:962-966.

ACCEPTED MANUSCRIPT Captions to illustrations.

Figure 1. Length of Stay. Overview of the number of patients (y-axis) per length of stay (in days, x-axis). A distinction is made between patients who underwent preoperative radiation therapy (in red) and patients

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were not irradiated preoperatively (in blue).

Figure 2. 68-year old woman with a recurrent SCC (T4N0M0) of the anterior mandible. a) Preoperative image shows invasion in the soft tissue and skin of the chin b) Resection specimen: the mandible was

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removed from angle to angle, including the skin and lower lip c) Postoperative image after reconstruction of the mandible and chin with a FF with skin island d) Postoperative panoramic radiograph of the

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reconstructed mandible.

Figure 3. 78-year old woman with a primary SCC (T4N0M0) of the left maxilla. a) Preoperative image of the left maxillary SCC (T4N0M0). The tumor was removed and reconstruction was done with an ALTF b) Image immediately after placement of zygoma implants through the healed ALTF left, and regular tooth

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implants in the right maxilla. c) Panoramic x-ray after implantation.

ACCEPTED MANUSCRIPT Table I: Overview of the raised free flaps.

Number performed (%)

ALTF

63

FF

22

DCIA

7

Lat Dorsi

5

RFFF

3

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Flap donor site

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ALTF = anterolateral thigh flap; FF = fibular flap; DCIA = deep circumflex iliac artery flap; Lat Dorsi = Latissimus Dorsi flap; RFFF = radial forearm free flap

ACCEPTED MANUSCRIPT

Squamous Cell Carcinoma (SCC)

84

Osteoradionecrosis (ORN)

4

Sarcoma

3

Adenoid Cystic Carcinoma

2

Ameloblastoma

2

Mucoepidermoid Carcinoma

2

Clear Cell Carcinoma

1

Desmoplastic malignant melanoma Primary Extranodal Extralymphatic Hodgkin

1

1

AC C

EP

TE D

Lymphoma with pathologic fracture

SC

Number (%)

M AN U

Pathologic diagnosis

RI PT

Table II: indications for flap reconstruction

ACCEPTED MANUSCRIPT Table III: Site of reconstruction with type of free flap used and the division between primary or recurrent tumor and ORN.

Defect (n)

Type of

n

free flap

Primary

Recurrent

Second

ORN or

tumor

tumor

primary

pathologic

ALTF

27

21

5

(28)

RFFF

1

1

0

Mandible

FF

21

14

1

(23)

DCIA

2

1

FOM

ALTF

19

15

ALTF

(11)

DCIA

0

0

0

5

1

0

0

1

3

0

M AN U

1

5

4

1

0

0

4

2

2

0

0

Lat Dorsi

2

1

1

0

0

ALTF

7

0

6

1

0

BOT (3)

ALTF

3

0

3

0

0

Midface (3)

Lat Dorsi

1

0

1

0

0

DCIA

1

0

1

0

0

(7)

AC C

Oropharynx

EP

Maxilla

TE D

(19)

1

SC

Tongue

RI PT

fracture

ACCEPTED MANUSCRIPT 1

0

1

0

0

ALTF

2

2

0

0

0

Facial Skin (2) Lat Dorsi

2

1

1

0

0

Retromolar

FF

1

1

0

RFFF

1

1

0

trigonum (1)

Cheek

AC C

EP

TE D

M AN U

mucosa (1)

0

SC

Soft Palate (2)

RI PT

RFFF

0

0

0

ACCEPTED MANUSCRIPT

n

Type

Facial artery

75

ETE

Superior thyroid artery

18

ETE

Occipital artery

3

ETE

Ascending pharyngeal artery

2

ETE

Angular artery

1

ETE

External carotid artery

1

SC

Artery

RI PT

Table IV: Overview of the anastomotic arteries

M AN U

ETS

AC C

EP

TE D

n = number

ACCEPTED MANUSCRIPT Table V: Overview of the anastomotic veins

n

ETE

ETS

Internal jugular vein

65

1

64

Thyrolinguofacial trunc

28

19

9

Retromandibular vein

2

2

Facial vein

2

1

Anterior jugular vein

1

1

External jugular vein

1

1

Lingual vein

1

1

RI PT

Vein

0

1

M AN U

SC

0

AC C

EP

TE D

n = number; ETE = end to end; ETS = end to side

0 0

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT Statement of Clinical Relevance

Free (perforator) flap reconstructive surgery is not only a safe and successful technique in tertiary referral centres, but can also be reliably performed in smaller secondary hospitals when microsurgeons

AC C

EP

TE D

M AN U

SC

RI PT

and nursing staff are properly trained.