Analytic Review of 2372 Free Flap Transfers for Head and Neck Reconstruction Following Cancer Resection

ABSTRACT

Microvascular free tissue transfer has gained world-wide acceptance as a means of reconstructing post-oncologic surgical defects in the head and neck region. Since 1977, the authors have introduced this reconstructive procedure to head and neck reconstruction after cancer ablation, and a total of 2372 free flaps were transferred in 2301 patients during a period of over 23 years. The most frequently used flap was the rectus abdominis flap (784 flaps: 33.1 percent), followed by the jejunum (644 flaps: 27.2 percent) and the forearm flap (384 flaps: 16.2 percent). In the reported series, total and partial flap necrosis accounted for 4.2 percent and 2.5 percent of cases, respectively. There was a significant statistical difference (p < 0.05) in complete flap survival rate between immediate and secondary reconstruction cases. The authors believe that the above-mentioned three flaps have been a major part of the armamentarium for head and neck reconstruction because of a lower rate of flap necrosis, compared to other flaps.

KEYWORDS

Head and neck reconstruction - free flaps - post-oncologic defects - complications

REFERENCES

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Dr. Nakatsuka and colleagues should be congratulated for reviewing a large series of free tissue transfers for head and neck reconstruction. The nice feature of this series is that it is a long- term experience spanning more than 20 years and a wide variety of microsurgeons at different levels of revision. This experience also comes from a variety of different hospitals within the University of Tokyo system. The total flap necrosis rate of 4.2 percent is certainly comparable to other large series of head and neck free flaps during a similar time period. It is interesting that the Tokyo experience finds that the frequently utilized flaps-the rectus, forearm, and jejunum-had better survival rates than other less commonly used flaps. The authors note that osteocutaneous flaps, such as the fibula and iliac crest, have a significantly lower survival rate. Although they attribute this to unreliable vascular supply and mismatches in recipient neck vessels, the experience at Memorial Sloan-Kettering Cancer Center with these tissue transfers has been very different.

Over a ten-year period, between 1991 and 2001, we reconstructed 883 defects of the head and neck using free tissue transfers. The overall flap success rate in this series was 97.8 percent. The five most common flaps used were the radial forearm flap (29 percent), rectus flap (29 percent), fibula (25 percent), jejunum (13 percent), and latissimus flap (2 percent). There was no difference in flap loss based on flap type within the major flap types, with flap loss rates ranging from 0.4 to 2.2 percent. On the other hand, our less commonly used flaps, which made up less than 2 percent of the total number of reconstructions, had a 14 percent flap loss rate, which was significantly higher than the four commonly used flaps. Thus, it is not likely that osteocutaneous flaps per se would have a higher flap loss rate than non-osseous flaps. It is much more likely that the reason for loss of a flap is a lack of familiarity with dissection and technique. The Tokyo experience with osteocutaneous flaps is relatively small, and it appears to constitute about 5 percent of their overall flap experience. We have had extensive experience with osteocutaneous free tissue transfer (30 percent of total volume), and these flaps do not have a higher loss rate. Although Nakatsuka and colleagues do not specifically evaluate flap loss with very experienced compared with less experienced microsurgeons, it is very likely that those surgeons with less experience would have a higher flap loss rate.

Thus, familiarity with a particular flap and microsurgeons' experience significantly contribute to flap outcome. In our previous series of free tissue transfers, buried flaps appear to have a higher flap loss rate than non-buried flaps.[1] Our current review of the overall series shows no significant difference, and there is no other variable that significantly correlates with flap loss. It makes sense that success in microsurgery remains directly related to experience and familiarity with a particular flap. Esoteric and more complicated flaps should, therefore, be reserved only for situations where the much more reliable flaps could not otherwise be used.

REFERENCES

• 1a Hidalgo D A, Disa J J, Cordeiro P G, Hu Q Y. A review of 716 consecutive free flaps for oncologic surgical defects: refinements in donor-site selection and technique.  Plast Reconstr Surg . 1998;  102 722-732