Long-Term Outcomes after Double Free Flap Reconstruction for Locally Advanced Head and Neck Cancer
11 March 2018
22 May 2018
29 July 2018 (online)
Background The use of simultaneous, multiple free flaps has become a reliable reconstructive option in patients with extensive composite defects after resection of locally advanced head and neck cancer. However, some reluctance remains among reconstructive surgeons with concerns regarding flap outcomes and limited patient survival. Therefore, we evaluated complications, long-term patient survival, and patient-reported outcomes following these extensive head and neck reconstructions.
Methods All consecutive patients treated with multiple free flaps for reconstruction of extensive composite defects after resection of locally advanced head and neck cancer between 1999 and 2014 were retrospectively reviewed. Patient charts were evaluated for demographics, treatment details, complications, and patient survival. In addition, all patients alive at the start of the study were asked to complete the 10-item Eat Assessment Tool (EAT-10) and the Intelligibility Rating Scale (IRS).
Results Eighty-four simultaneous, multiple free flaps were performed in 42 patients. The predominant free flap combination consisted of a fibula with either an anterolateral thigh (n = 22) or a radial forearm flap (n = 14). Complete flap survival was 95%. Nineteen patients were still alive with a mean follow-up of 55 months. Five-year patient survival was 46.3%. Mean EAT-10 score was 8.4 (range: 0–29), with only one patient reporting problematic swallowing. Ninety percent of the patients had moderate to good speech intelligibility with the IRS.
Conclusion Multiple, simultaneous free flaps can be performed safely, leading to acceptable long-term patient survival and patient-reported functional outcomes. Our study demonstrates that it is worthwhile to perform these challenging microvascular reconstructions in patients with locally advanced head and neck cancer.
J. Nick Brinkman: Contributions to the acquisition, analysis, and interpretation of data for the work; drafting the manuscript; final approval of the version to be published.
Shoista Kambiz: Contributions to the acquisition, analysis, and interpretation of data for the work; drafting the manuscript; final approval of the version to be published.
Tim de Jong: Revising the manuscript for important intellectual content; final approval of the version to be published.
Marc A. M. Mureau: Contributions to the methodology, analysis, and interpretation of data for the work; revising the manuscript for important intellectual content; final approval of the version to be published.
* Both authors contributed equally.
- 1 Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck 2010; 32 (09) 1236-1245
- 2 Urken ML, Weinberg H, Buchbinder D. , et al. Microvascular free flaps in head and neck reconstruction. Report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg 1994; 120 (06) 633-640
- 3 Jeng SF, Kuo YR, Wei FC, Su CY, Chien CY. Reconstruction of extensive composite mandibular defects with large lip involvement by using double free flaps and fascia lata grafts for oral sphincters. Plast Reconstr Surg 2005; 115 (07) 1830-1836
- 4 Mo KW, Vlantis A, Wong EW, Chiu TW. Double free flaps for reconstruction of complex/composite defects in head and neck surgery. Hong Kong Med J 2014; 20 (04) 279-284
- 5 Ross G, Yla-Kotola TM, Goldstein D. , et al. Second free flaps in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2012; 65 (09) 1165-1168
- 6 Murphy BA, Gilbert J. Dysphagia in head and neck cancer patients treated with radiation: assessment, sequelae, and rehabilitation. Semin Radiat Oncol 2009; 19 (01) 35-42
- 7 Wei FC, Yazar S, Lin CH, Cheng MH, Tsao CK, Chiang YC. Double free flaps in head and neck reconstruction. Clin Plast Surg 2005; 32 (03) 303-308 , v
- 8 Wallace CG, Tsao CK, Wei FC. Role of multiple free flaps in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 2014; 22 (02) 140-146
- 9 Wei FC, Demirkan F, Chen HC, Chen IH. Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg 1999; 103 (01) 39-47
- 10 Ross GL, Ang S W EE, Lannon D. , et al. A ten-year experience of multiple flaps in head and neck surgery: how successful are they?. J Reconstr Microsurg 2008; 24 (03) 183-187
- 11 Guillemaud JP, Seikaly H, Cote DW. , et al. Double free-flap reconstruction: indications, challenges, and prospective functional outcomes. Arch Otolaryngol Head Neck Surg 2009; 135 (04) 406-410
- 12 Balasubramanian D, Thankappan K, Kuriakose MA. , et al. Reconstructive indications of simultaneous double free flaps in the head and neck: a case series and literature review. Microsurgery 2012; 32 (06) 423-430
- 13 Bianchi B, Ferrari S, Poli T, Bertolini F, Raho T, Sesenna E. Oromandibular reconstruction with simultaneous free flaps: experience on 10 cases. Acta Otorhinolaryngol Ital 2003; 23 (04) 281-290
- 14 Bianchi B, Ferri A, Ferrari S. , et al. Reconstruction of lateral through and through oro-mandibular defects following oncological resections. Microsurgery 2010; 30 (07) 517-525
- 15 Hanasono MM, Weinstock YE, Yu P. Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg 2008; 122 (06) 1739-1746
- 16 Schiavetti N, Metz DE, Sitler RW. Construct validity of direct magnitude estimation and interval scaling of speech intelligibility: evidence from a study of the hearing impaired. J Speech Hear Res 1981; 24 (03) 441-445
- 17 Belafsky PC, Mouadeb DA, Rees CJ. , et al. Validity and reliability of the Eating Assessment Tool (EAT-10). Ann Otol Rhinol Laryngol 2008; 117 (12) 919-924
- 18 Serletti JM, Coniglio JU, Tavin E, Bakamjian VY. Simultaneous transfer of free fibula and radial forearm flaps for complex oromandibular reconstruction. J Reconstr Microsurg 1998; 14 (05) 297-303
- 19 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 (06) 1553-1561
- 20 Posch NA, Mureau MA, Dumans AG, Hofer SO. Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg 2007; 120 (01) 124-129
- 21 Lin PY, Kuo YR, Chien CY, Jeng SF. Reconstruction of head and neck cancer with double flaps: comparison of single and double recipient vessels. J Reconstr Microsurg 2009; 25 (03) 191-195
- 22 Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: complications, outcomes and strategies for management of flap failure: analysis of 2019 flaps in single institute. Microsurgery 2014; 34 (05) 339-344
- 23 Wei FC, Celik N, Chen HC, Cheng MH, Huang WC. Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plast Reconstr Surg 2002; 109 (01) 45-52
- 24 Pignon JP, Bourhis J, Domenge C, Designé L. Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-NC Collaborative Group. Meta-analysis of chemotherapy on head and neck cancer. Lancet 2000; 355 (9208): 949-955
- 25 Chaput B, Vergez S, Somda S. , et al. Comparison of single and double venous anastomoses in head and neck oncologic reconstruction using free flaps: a meta-analysis. Plast Reconstr Surg 2016; 137 (05) 1583-1594
- 26 Andrades P, Bohannon IA, Baranano CF, Wax MK, Rosenthal E. Indications and outcomes of double free flaps in head and neck reconstruction. Microsurgery 2009; 29 (03) 171-177
- 27 Las DE, de Jong T, Zuidam JM, Verweij NM, Hovius SE, Mureau MA. Identification of independent risk factors for flap failure: a retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction. J Plast Reconstr Aesthet Surg 2016; 69 (07) 894-906
- 28 Cheriex KC, Nijhuis TH, Mureau MA. Osteoradionecrosis of the jaws: a review of conservative and surgical treatment options. J Reconstr Microsurg 2013; 29 (02) 69-75
- 29 Krijgh DD, Mureau MA. Reconstructive options in patients with late complications after surgery and radiotherapy for head and neck cancer: remember the deltopectoral flap. Ann Plast Surg 2013; 71 (02) 181-185
- 30 Arrese LC, Carrau R, Plowman EK. Relationship between the Eating Assessment Tool-10 and objective clinical ratings of swallowing function in individuals with head and neck cancer. Dysphagia 2017; 32 (01) 83-89
- 31 Balm AJ, Rasch CR, Schornagel JH. , et al. High-dose superselective intra-arterial cisplatin and concomitant radiation (RADPLAT) for advanced head and neck cancer. Head Neck 2004; 26 (06) 485-493
- 32 Albers AE, Grabow R, Qian X. , et al. Efficacy and toxicity of docetaxel combination chemotherapy for advanced squamous cell cancer of the head and neck. Mol Clin Oncol 2017; 7 (01) 151-157