- Email: [email protected]
Second free flaps in head and neck reconstruction
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 1165e1168
Second free flaps in head and neck reconstruction Gary Ross a, Tuija M. Yla-Kotola a, David Goldstein b, Toni Zhong a, Ralph Gilbert b, Jonathan Irish b, Patrick J. Gullane b, Stefan O.P. Hofer a,*, Peter C. Neligan a a
Division of Plastic & Reconstructive Surgery, University Health Network, 200 Elizabeth Street, 8N-865, Toronto, ON M5G 2C4, Canada b Department of Otolaryngology e Head & Neck Surgery, University Health Network, Toronto, Ontario, Canada Received 29 January 2012; accepted 22 March 2012
KEYWORDS Free flap; Reconstruction; Secondary; Outcome
Summary Introduction: Ablative surgery for head and neck cancer often results in defects that require free flap reconstruction. Improved survival after refined oncologic and adjuvant techniques has led to an increase in the number of patients undergoing a second free flap reconstruction. The objective of this study was to assess outcomes following a second free flap in head and neck reconstruction. Materials and methods: Following ablative defects in the head and neck, 1475 patients underwent reconstructive surgery over a period of 17 years. A second free flap for reconstruction was performed on 123 of these patients. In Group 1, 93 patients had a reconstruction for either tumour recurrence, second primary tumour or reconstructive complications (fractured plate, osteoradionecrosis, orocutaneous fistula). In Group 2, 30 patients had a second free flap following primary free flap reconstructive failure. Results: Flap success for Group 1 patients was 86/90 (96%) compared to group 2 patients, 22/ 30 (73%) (p < 0.05). In Group 1, partial necrosis occurred in four patients whereas in Group 2, there was only one partial necrosis (NS; p > 0.05). Conclusion: A second free flap may be required for reconstruction of head and neck defects following complications of the initial reconstruction, presence of a second primary or tumour recurrence. Success rates for second free flap reconstructions were significantly lower in those patients with initial free flap failure. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 416 340 3449; fax: þ1 416 340 4403. E-mail address: [email protected] (S.O.P. Hofer). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.03.035
1166
Introduction The goals of reconstruction following head and neck cancer ablative surgery are to achieve primary wound healing, seal contaminated cavities from sterile areas, and restore form and function. A variety of flaps ranging from local or regional flaps to more complex free tissue transfers allow primary functional and cosmetic reconstruction for post-oncologic head and neck defects.1e4 In many cases, free flaps are preferred because they offer a one-stage reconstruction with comparatively lower complication rates, better overall results, and shorter hospitalization periods.1,3,5,6 A second free flap may be required in those patients in whom the first free flap failed or in the surgical management of a second primary tumour, a treatment related complication (i.e. osteoradionecrosis) or for recurrent tumours. In these patients, secondary reconstructive options are hindered by altered anatomic relationships, availability of recipient vessels and inadvertent effects of previous lymphadenectomy and radiotherapy.1,2,5,7e9 The objective of this study was to assess surgical outcomes and complications following a second free flap in head and neck reconstruction.
Materials and methods Between August 1993 and June 2010, a total of 1475 patients underwent free flap reconstruction following ablative surgery for malignant tumours in the head and neck at the Princess Margaret Hospital (PMH), Toronto, Ontario, Canada. Following institutional ethics board approval, a retrospective chart review was performed for all patients who underwent a second free flap for head and neck reconstruction during this time period. Patients were identified through a prospective head and neck reconstructive surgery database. Patients were included if they had a second free flap as part of the management of a recurrent head and neck tumour (Group 1a), a second primary cancer of the head and neck (Group 1b) or as management of a long-term treatment related complication (Group 1c). Patients were also included if they underwent a second free flap to salvage a previous free flap failure (Group 2), including those who had a flap at another institution that failed and were referred to the PMH for a second free flap. Statistical analysis was performed using SPSS version 11 statistical software. Normally distributed ordinal data were analyzed using the student’s t test and non-Gaussian data were analyzed using the ManneWhitney test. Categorical data were analyzed using the Chi square test or the Fisher’s exact test where the expected frequency was small. Three patients had a peri-operative death (1 in Group 1a and 2 in Group 1c) and were therefore excluded from the analysis on flap survival since all had a viable flap at the time of death but did not live through the entire post-operative phase to determine if the flap would have failed. A pvalue of <0.05 was considered statistically significant.
Results One hundred and twenty three patients underwent a second free flap for head and neck reconstruction and
G. Ross et al. were eligible for inclusion. There were 74 males and 49 females, with a mean age of 58 years (range 21e86 years). The majority of patients underwent surgery for a squamous cell carcinoma of the head and neck 100/123 (81%), followed by sarcoma 10/123 (8%), basal cell carcinoma 4/123 (3%), ameloblastoma 4/123 (3%), adenoid cystic carcinoma 3/123 (2%), melanoma 1/123 (1%) and a triton skull base tumour 1/123(1%). Reconstruction was most commonly performed for defects of the oral cavity (n Z 84/123, 68%) and followed in frequency by skin defects (n Z 20/123, 16%), paranasal sinus defects (n Z 7/123, 6%), oropharyngeal defects (n Z 6/123, 5%), skull base defects (n Z 3/ 123, 2%), and laryngeal defects (n Z 3/123, 2%). Ninety-three of the 123 patients (Group 1) required a second free flap following management of either a tumour recurrence (1a) (n Z 43/93), a second primary malignancy of the head and neck (1b) (n Z 23/93) or revision of long-term primary reconstructive complication (1c) (n Z 27/93) such as a fractured plate (n Z 4/27), osteoradionecrosis (n Z 19/27), orocutaneous fistula (n Z 3/27) or scar contracture (n Z 1/27). The remaining 30 patients had a second flap following primary free flap failure (Group 2). The flaps used for secondary reconstruction in both groups are presented in Table 1. The overall success rate of the 120 patients who underwent a second free flap and lived through the perioperative period was 90% (108/120). Overall flap success varied between groups; 93% (39/42) for the patients who underwent a second free flap for reconstruction tumour recurrence (Group 1a), 100% (23/23) for those who required a second free flap for reconstruction of a second primary (Group 1b), 96% (24/25) for those who underwent a second reconstruction for a treatment-related complication (Group 1c) and 73% (22/30) for the patients who a second reconstruction following an initial free flap failure (Group 2). Allowing for multiple comparisons, patients who underwent a second flap for the management of an initial flap failure had a statistically significant higher secondary failure rate than the other groups (p Z 0.004). There were no other statistically significant differences between outcomes in the other groups (NS; p > 0.05). The cause of free flap failure is presented in Table 2.
Table 1 Type and number of second free flaps in each group (n Z 123). Type of flap
Group 1 (n Z 93)
Group 2 (n Z 30)
Anterolateral thigh Radial forearm Fibular flap Rectus abdominis Scapular Latissimus dorsi Osteocutaneous radial forearm Deep inferior epigastric perforator Lateral arm Deep circumflex iliac arterial Groin flap Jejunal flap
19 20 17 13 10 6 3 2 1 1 1 0
3 11 4 2 0 6 0 1 2 0 0 1
Second free flaps
1167
Table 2 Causes for primary free flap failure in Group 2 (n Z 30). Cause for flap failure
Number of patients
Venous failure Arterial failure Infection Flap necrosis Unknown
10 6 3 1 10
There were 12 failed second free flaps; eight were reconstructed with another free flap, of which only 4 were successful. Three of the 12 patients were salvaged with a pedicled flap, and one case was managed nonoperatively. Characteristics of the failed second flaps are shown in Table 3. The aetiology for the failed second free flaps was not well documented in the patient’s charts. Of the 108 patients that had successful secondary flap reconstruction, there were 14 flap related complications. Nine patients (4 in Group 1a, 2 in Group 1b, 2 in Group 1c and 1 in Group 2) developed a venous or arterial thrombosis that required a re-exploration, all of which were successfully salvaged. Partial necrosis of skin paddle developed in five patients, all of which occurred in fibula osteocutaneous flaps. In Group 1a, two patients developed partial necrosis of the fibular skin paddle and in both cases, a pedicled pectoralis major flap was successfully used to reconstruct the defect. In Group 1c two patients developed a partial necrosis of the fibula skin paddle, which was treated nonoperatively. One patient in Group 2 developed a partial flap necrosis that was treated with a pectoralis major flap. There were three peri-operative deaths. Two patients who underwent a second free flap for reconstruction of a treatment related complication died, two from a cardiac complication and the other from respiratory failure. One
Table 3
Failure of secondary free flaps (n Z 12).
Second failed free flap
Reason for failure
Action
Outcome
OC RFA RA FIB FIB FIB ALT RFA RFA RFA FIB LD LD
Venous thrombosis Arterial thrombosis Loss of skin island V þ A thrombosis Infection Arterial thrombosis Arterial thrombosis Venous thrombosis Unknown Unknown Venous Infection
DCIA x2 LD SCAP DCIA PECT SCAP RFA PECT RA PECT Non-op LD
Successful Successful Successful Failure Successful Successful Failure Successful Successful Successful Successful Failure
First three patients belong to Group 1, all the others to Group 2. Abbrevations: v þ a venous and arterial; ALT anterolateral thigh; RFA radial forearm; FIB fibular flap; RA rectus abdominis; SCAP scapular; LD latissimus dorsi; OC RFA osteocutaneous radial forearm; DCIA deep circumflex iliac arterial; PECT pectoralis major; non-op non-operative.
patient developed a pharyngocutaneous fistula (in Group 1A) with exposure of great vessels, that was managed successfully with a pectoralis major flap and packing. Two patients developed an oral-cutaneous fistula; one patient developed a fistula in the early post-operative period that resolved with non-operative management and the second patient who had a scapula flap for mandibular osteoradionecrosis developed a fistula in the late post-operative period that was related to osteoradionecrosis of the remaining portion of the mandible.
Discussion The objective of this study was to assess surgical outcomes and complications following a second free flap in head and neck reconstruction. Surgery remains an important initial treatment for many tumours of the head and neck and the primary treatment modality for recurrent tumours of the head and neck. The importance of clear margins at the time of resection has led to a more aggressive surgical approach that has been made possible by improvements in reconstructive options. Free tissue transfer has become a recognized standard for reconstruction of many defects in the head and neck region. Despite improvements in surgical outcomes, free flap reconstructions can fail, although the success rate for primary free tissue transfers is very high at approximately 95%.6,10e13 Most free flaps which fail can be salvaged by immediate surgical re-exploration and reanastomoses.12 In those free flaps, that cannot be salvaged, a second flap or regional flap is often required. Second free flaps are more commonly employed in patients undergoing head and neck surgery for recurrent tumour, second primary tumours or treatment related complications. This study has shown that reconstruction with a second free flap is not only feasible but also successful in the majority of patients, with a failure rate of 10%. Although this failure rate is higher than reported with primary free flaps, where failure rates are reported to range between 3% and 5% in the literature,10e13 these cases are significantly more complex. In our patient sample, free flap failure was significantly higher when a second free flap was used to salvage immediate free flap failure compared to reconstructions related to management of tumour recurrence, a second primary or treatment-related complication. In previous literature, the success rates after salvage of a compromised flap with a second free flap vary from 28% to 88%.10e12 A salvage free flap has also been found in studies to be a significant predictor of a free flap complication as well as a free flap failure.10 In a previous study from our institution, flap success decreased as the number of reconstructive procedures with free flaps increased.13 The present study confirms this finding in the subgroup of patients undergoing reconstruction with a second free flap for a salvage of a failed initial free flap. The success rate was 96% in the scheduled second flap group, which approaches the success rate in the literature for primary free flap success.12 Some of the earlier studies have presented almost similar success rates for second free flap reconstructions as for primary reconstructions. In these studies, the subgroup numbers are substantially smaller than in our study.5,8,14e17
1168 For most of the patients, we could identify either the arterial or venous thrombosis leading to free flap failure. However, some of the cases remained unexplained and may be related to vascular disorders which increase thrombotic risk. Factor V Leiden is the most prevalent with approximately 5% of the Caucasian population having this genetic alteration.18,19 These conditions should be taken into consideration, particularly in cases with multiple vascular problems. Vein grafts have been shown to be associated with a free flap failure or complication10,11 although some studies do not confirm the same findings.12 In secondary free flaps, vein grafts are more commonly needed when the reconstruction is necessary due to an initial free flap failure. The majority of patients in Group 2 had a second free flap within two weeks of the initial surgery, so the other contributing factors include the amount of necrotic material in the wound following debridement and the subsequent increased infection risk. In this large series, the most successful salvage procedure following both primary and secondary free flap failure was the pedicled pectoralis major flap. In only half of the cases (4/8) a third free flap was successful following both first and second free flap failure. A third free flap following two previous failures seems prone to an increased likelihood of flap failure. A third free flap was more likely to be successful if the second free flap was not performed as a salvage procedure for a flap failure. In Group 1, the success rate for the third flap was 66% (2/3) whereas in Group 2, the success rate was only 40% (2/5). However, the number of cases was too small to perform any statistical comparison. For elderly patients with underlying medical conditions, repeat anaesthesia and major surgery may increase the risk of medical complications such as pneumonia, heart disease and the risk of peri-operative mortality. Occasionally conservative management must be employed which may result in a worse functional and aesthetic outcome. Although this constituted a small number of patients in our series, it should be considered following a detailed discussion with the patient in the context of a multidisciplinary setting. In conclusion, secondary free flaps are necessary to fulfil the reconstructive goals for a variety of indications for patients with defects in the head and neck region. Success rates are lower when the secondary reconstructions are performed following primary free flap failure.
Conflict of interest None.
Funding None.
G. Ross et al.
References 1. Pickford MA, Soutar DS. Intraoral reconstruction using a second free flap for recurrent or metachronous carcinoma. Br J Plast Surg 1995;48:559e63. 2. Amin AA, Baldwin BJ, Gurlek A, et al. Second free flaps in head and neck reconstruction. J Reconstr Microsurg 1998;14:365e8. 3. Neligan P. Principles of reconstruction. In: Neligan PC, Wei FC, editors. Microsurgical reconstruction of the head and neck. St Louis: Quality Medical Publishing; 2010. p. 129e34. 4. Hofer SOP, Mureau MAM. Local flaps. In: Neligan PC, Wei FC, editors. Microsurgical reconstruction of the head and neck. St Louis: Quality Medical Publishing; 2010. p. 219e52. 5. Wei FC, Demirkan F, Chen HC, et al. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder? Plast Reconstr Surg 2001; 108:1154e60. 6. Smith RB, Sniezek JC, Weed DT, Wax MK. Microvascular surgery subcommittee of American academy of otolaryngologyehead and neck surgery. Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg 2007;137(2): 182e91. 7. Neligan PC, Ross GL. Multiple flaps in the head and neck. In: Neligan PC, Wei FC, editors. Microsurgical reconstruction of the head and neck. St Louis: Quality Medical Publishing; 2010. p. 805e14. 8. Wei FC, Demirkan F, Chen HC, et al. Management of secondary soft-tissue deficits following microsurgical head and neck reconstruction by means of another free flap. Plast Reconstr Surg 1999;103:1158e66. 9. Yazar S, Wei FC, Chen HC, et al. Selection of recipient vessels in double free-flap reconstruction of composite head and neck defects. Plast Reconstr Surg 2005;115:1553e61. 10. Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2006;59(7):737e42. 11. Podrecca S, Salvatori P, Squadrelli Saraceno M, et al. Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg 2006; 59(2):122e9. 12. Poon SW, Wei FC. Management of flap failure. In: Neligan PC, Wei FC, editors. Microsurgical reconstruction of the head and neck. St Louis: Quality Medical Publishing; 2010. p. 815e32. 13. Ross GL, Ang SW, Lannon D, et al. Ten-year experience of multiple flaps in head and neck surgery: how successful are they? J Reconstr Microsurg 2008;24(3):183e7. 14. Demirkan F, Wei FC, Chen HC, et al. Microsurgical reconstruction in recurrent oral cancer: use of a second free flap in the same patient. Plast Reconstr Surg 1999;103:829e38. 15. Alam DS, Khariwala SS. Technical considerations in patients requiring a second microvascular free flap in the head and neck. Arch Otolaryngol Head Neck Surg 2009;135(3):268e73. 16. Varvares MA, Lin D, Hadlock T, et al. Success of multiple, sequential, free tissue transfers to the head and neck. Laryngoscope 2005;115(1):101e4. 17. Demirkan F, Wei FC, Chen HC, et al. Oromandibular reconstruction using a third free flap in sequence in recurrent carcinoma. Br J Plast Surg 1999;52:429e33. 18. Esmon CT. Basic mechanisms and pathogenesis of venous thrombosis. Blood Rev 2009;23(5):225e9. 19. Dahlback B. Advances in understanding pathogenic mechanisms of thrombophilic disorders. Blood 2008;112(1):19e27.
Second free flaps in head and neck reconstruction Gary Ross a, Tuija M. Yla-Kotola a, David Goldstein b, Toni Zhong a, Ralph Gilbert b, Jonathan Irish b, Patrick J. Gullane b, Stefan O.P. Hofer a,*, Peter C. Neligan a a
Division of Plastic & Reconstructive Surgery, University Health Network, 200 Elizabeth Street, 8N-865, Toronto, ON M5G 2C4, Canada b Department of Otolaryngology e Head & Neck Surgery, University Health Network, Toronto, Ontario, Canada Received 29 January 2012; accepted 22 March 2012
KEYWORDS Free flap; Reconstruction; Secondary; Outcome
Summary Introduction: Ablative surgery for head and neck cancer often results in defects that require free flap reconstruction. Improved survival after refined oncologic and adjuvant techniques has led to an increase in the number of patients undergoing a second free flap reconstruction. The objective of this study was to assess outcomes following a second free flap in head and neck reconstruction. Materials and methods: Following ablative defects in the head and neck, 1475 patients underwent reconstructive surgery over a period of 17 years. A second free flap for reconstruction was performed on 123 of these patients. In Group 1, 93 patients had a reconstruction for either tumour recurrence, second primary tumour or reconstructive complications (fractured plate, osteoradionecrosis, orocutaneous fistula). In Group 2, 30 patients had a second free flap following primary free flap reconstructive failure. Results: Flap success for Group 1 patients was 86/90 (96%) compared to group 2 patients, 22/ 30 (73%) (p < 0.05). In Group 1, partial necrosis occurred in four patients whereas in Group 2, there was only one partial necrosis (NS; p > 0.05). Conclusion: A second free flap may be required for reconstruction of head and neck defects following complications of the initial reconstruction, presence of a second primary or tumour recurrence. Success rates for second free flap reconstructions were significantly lower in those patients with initial free flap failure. ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ1 416 340 3449; fax: þ1 416 340 4403. E-mail address: [email protected] (S.O.P. Hofer). 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2012.03.035
1166
Introduction The goals of reconstruction following head and neck cancer ablative surgery are to achieve primary wound healing, seal contaminated cavities from sterile areas, and restore form and function. A variety of flaps ranging from local or regional flaps to more complex free tissue transfers allow primary functional and cosmetic reconstruction for post-oncologic head and neck defects.1e4 In many cases, free flaps are preferred because they offer a one-stage reconstruction with comparatively lower complication rates, better overall results, and shorter hospitalization periods.1,3,5,6 A second free flap may be required in those patients in whom the first free flap failed or in the surgical management of a second primary tumour, a treatment related complication (i.e. osteoradionecrosis) or for recurrent tumours. In these patients, secondary reconstructive options are hindered by altered anatomic relationships, availability of recipient vessels and inadvertent effects of previous lymphadenectomy and radiotherapy.1,2,5,7e9 The objective of this study was to assess surgical outcomes and complications following a second free flap in head and neck reconstruction.
Materials and methods Between August 1993 and June 2010, a total of 1475 patients underwent free flap reconstruction following ablative surgery for malignant tumours in the head and neck at the Princess Margaret Hospital (PMH), Toronto, Ontario, Canada. Following institutional ethics board approval, a retrospective chart review was performed for all patients who underwent a second free flap for head and neck reconstruction during this time period. Patients were identified through a prospective head and neck reconstructive surgery database. Patients were included if they had a second free flap as part of the management of a recurrent head and neck tumour (Group 1a), a second primary cancer of the head and neck (Group 1b) or as management of a long-term treatment related complication (Group 1c). Patients were also included if they underwent a second free flap to salvage a previous free flap failure (Group 2), including those who had a flap at another institution that failed and were referred to the PMH for a second free flap. Statistical analysis was performed using SPSS version 11 statistical software. Normally distributed ordinal data were analyzed using the student’s t test and non-Gaussian data were analyzed using the ManneWhitney test. Categorical data were analyzed using the Chi square test or the Fisher’s exact test where the expected frequency was small. Three patients had a peri-operative death (1 in Group 1a and 2 in Group 1c) and were therefore excluded from the analysis on flap survival since all had a viable flap at the time of death but did not live through the entire post-operative phase to determine if the flap would have failed. A pvalue of <0.05 was considered statistically significant.
Results One hundred and twenty three patients underwent a second free flap for head and neck reconstruction and
G. Ross et al. were eligible for inclusion. There were 74 males and 49 females, with a mean age of 58 years (range 21e86 years). The majority of patients underwent surgery for a squamous cell carcinoma of the head and neck 100/123 (81%), followed by sarcoma 10/123 (8%), basal cell carcinoma 4/123 (3%), ameloblastoma 4/123 (3%), adenoid cystic carcinoma 3/123 (2%), melanoma 1/123 (1%) and a triton skull base tumour 1/123(1%). Reconstruction was most commonly performed for defects of the oral cavity (n Z 84/123, 68%) and followed in frequency by skin defects (n Z 20/123, 16%), paranasal sinus defects (n Z 7/123, 6%), oropharyngeal defects (n Z 6/123, 5%), skull base defects (n Z 3/ 123, 2%), and laryngeal defects (n Z 3/123, 2%). Ninety-three of the 123 patients (Group 1) required a second free flap following management of either a tumour recurrence (1a) (n Z 43/93), a second primary malignancy of the head and neck (1b) (n Z 23/93) or revision of long-term primary reconstructive complication (1c) (n Z 27/93) such as a fractured plate (n Z 4/27), osteoradionecrosis (n Z 19/27), orocutaneous fistula (n Z 3/27) or scar contracture (n Z 1/27). The remaining 30 patients had a second flap following primary free flap failure (Group 2). The flaps used for secondary reconstruction in both groups are presented in Table 1. The overall success rate of the 120 patients who underwent a second free flap and lived through the perioperative period was 90% (108/120). Overall flap success varied between groups; 93% (39/42) for the patients who underwent a second free flap for reconstruction tumour recurrence (Group 1a), 100% (23/23) for those who required a second free flap for reconstruction of a second primary (Group 1b), 96% (24/25) for those who underwent a second reconstruction for a treatment-related complication (Group 1c) and 73% (22/30) for the patients who a second reconstruction following an initial free flap failure (Group 2). Allowing for multiple comparisons, patients who underwent a second flap for the management of an initial flap failure had a statistically significant higher secondary failure rate than the other groups (p Z 0.004). There were no other statistically significant differences between outcomes in the other groups (NS; p > 0.05). The cause of free flap failure is presented in Table 2.
Table 1 Type and number of second free flaps in each group (n Z 123). Type of flap
Group 1 (n Z 93)
Group 2 (n Z 30)
Anterolateral thigh Radial forearm Fibular flap Rectus abdominis Scapular Latissimus dorsi Osteocutaneous radial forearm Deep inferior epigastric perforator Lateral arm Deep circumflex iliac arterial Groin flap Jejunal flap
19 20 17 13 10 6 3 2 1 1 1 0
3 11 4 2 0 6 0 1 2 0 0 1
Second free flaps
1167
Table 2 Causes for primary free flap failure in Group 2 (n Z 30). Cause for flap failure
Number of patients
Venous failure Arterial failure Infection Flap necrosis Unknown
10 6 3 1 10
There were 12 failed second free flaps; eight were reconstructed with another free flap, of which only 4 were successful. Three of the 12 patients were salvaged with a pedicled flap, and one case was managed nonoperatively. Characteristics of the failed second flaps are shown in Table 3. The aetiology for the failed second free flaps was not well documented in the patient’s charts. Of the 108 patients that had successful secondary flap reconstruction, there were 14 flap related complications. Nine patients (4 in Group 1a, 2 in Group 1b, 2 in Group 1c and 1 in Group 2) developed a venous or arterial thrombosis that required a re-exploration, all of which were successfully salvaged. Partial necrosis of skin paddle developed in five patients, all of which occurred in fibula osteocutaneous flaps. In Group 1a, two patients developed partial necrosis of the fibular skin paddle and in both cases, a pedicled pectoralis major flap was successfully used to reconstruct the defect. In Group 1c two patients developed a partial necrosis of the fibula skin paddle, which was treated nonoperatively. One patient in Group 2 developed a partial flap necrosis that was treated with a pectoralis major flap. There were three peri-operative deaths. Two patients who underwent a second free flap for reconstruction of a treatment related complication died, two from a cardiac complication and the other from respiratory failure. One
Table 3
Failure of secondary free flaps (n Z 12).
Second failed free flap
Reason for failure
Action
Outcome
OC RFA RA FIB FIB FIB ALT RFA RFA RFA FIB LD LD
Venous thrombosis Arterial thrombosis Loss of skin island V þ A thrombosis Infection Arterial thrombosis Arterial thrombosis Venous thrombosis Unknown Unknown Venous Infection
DCIA x2 LD SCAP DCIA PECT SCAP RFA PECT RA PECT Non-op LD
Successful Successful Successful Failure Successful Successful Failure Successful Successful Successful Successful Failure
First three patients belong to Group 1, all the others to Group 2. Abbrevations: v þ a venous and arterial; ALT anterolateral thigh; RFA radial forearm; FIB fibular flap; RA rectus abdominis; SCAP scapular; LD latissimus dorsi; OC RFA osteocutaneous radial forearm; DCIA deep circumflex iliac arterial; PECT pectoralis major; non-op non-operative.
patient developed a pharyngocutaneous fistula (in Group 1A) with exposure of great vessels, that was managed successfully with a pectoralis major flap and packing. Two patients developed an oral-cutaneous fistula; one patient developed a fistula in the early post-operative period that resolved with non-operative management and the second patient who had a scapula flap for mandibular osteoradionecrosis developed a fistula in the late post-operative period that was related to osteoradionecrosis of the remaining portion of the mandible.
Discussion The objective of this study was to assess surgical outcomes and complications following a second free flap in head and neck reconstruction. Surgery remains an important initial treatment for many tumours of the head and neck and the primary treatment modality for recurrent tumours of the head and neck. The importance of clear margins at the time of resection has led to a more aggressive surgical approach that has been made possible by improvements in reconstructive options. Free tissue transfer has become a recognized standard for reconstruction of many defects in the head and neck region. Despite improvements in surgical outcomes, free flap reconstructions can fail, although the success rate for primary free tissue transfers is very high at approximately 95%.6,10e13 Most free flaps which fail can be salvaged by immediate surgical re-exploration and reanastomoses.12 In those free flaps, that cannot be salvaged, a second flap or regional flap is often required. Second free flaps are more commonly employed in patients undergoing head and neck surgery for recurrent tumour, second primary tumours or treatment related complications. This study has shown that reconstruction with a second free flap is not only feasible but also successful in the majority of patients, with a failure rate of 10%. Although this failure rate is higher than reported with primary free flaps, where failure rates are reported to range between 3% and 5% in the literature,10e13 these cases are significantly more complex. In our patient sample, free flap failure was significantly higher when a second free flap was used to salvage immediate free flap failure compared to reconstructions related to management of tumour recurrence, a second primary or treatment-related complication. In previous literature, the success rates after salvage of a compromised flap with a second free flap vary from 28% to 88%.10e12 A salvage free flap has also been found in studies to be a significant predictor of a free flap complication as well as a free flap failure.10 In a previous study from our institution, flap success decreased as the number of reconstructive procedures with free flaps increased.13 The present study confirms this finding in the subgroup of patients undergoing reconstruction with a second free flap for a salvage of a failed initial free flap. The success rate was 96% in the scheduled second flap group, which approaches the success rate in the literature for primary free flap success.12 Some of the earlier studies have presented almost similar success rates for second free flap reconstructions as for primary reconstructions. In these studies, the subgroup numbers are substantially smaller than in our study.5,8,14e17
1168 For most of the patients, we could identify either the arterial or venous thrombosis leading to free flap failure. However, some of the cases remained unexplained and may be related to vascular disorders which increase thrombotic risk. Factor V Leiden is the most prevalent with approximately 5% of the Caucasian population having this genetic alteration.18,19 These conditions should be taken into consideration, particularly in cases with multiple vascular problems. Vein grafts have been shown to be associated with a free flap failure or complication10,11 although some studies do not confirm the same findings.12 In secondary free flaps, vein grafts are more commonly needed when the reconstruction is necessary due to an initial free flap failure. The majority of patients in Group 2 had a second free flap within two weeks of the initial surgery, so the other contributing factors include the amount of necrotic material in the wound following debridement and the subsequent increased infection risk. In this large series, the most successful salvage procedure following both primary and secondary free flap failure was the pedicled pectoralis major flap. In only half of the cases (4/8) a third free flap was successful following both first and second free flap failure. A third free flap following two previous failures seems prone to an increased likelihood of flap failure. A third free flap was more likely to be successful if the second free flap was not performed as a salvage procedure for a flap failure. In Group 1, the success rate for the third flap was 66% (2/3) whereas in Group 2, the success rate was only 40% (2/5). However, the number of cases was too small to perform any statistical comparison. For elderly patients with underlying medical conditions, repeat anaesthesia and major surgery may increase the risk of medical complications such as pneumonia, heart disease and the risk of peri-operative mortality. Occasionally conservative management must be employed which may result in a worse functional and aesthetic outcome. Although this constituted a small number of patients in our series, it should be considered following a detailed discussion with the patient in the context of a multidisciplinary setting. In conclusion, secondary free flaps are necessary to fulfil the reconstructive goals for a variety of indications for patients with defects in the head and neck region. Success rates are lower when the secondary reconstructions are performed following primary free flap failure.
Conflict of interest None.
Funding None.
G. Ross et al.
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