Head and Neck Reconstruction with a Second Free Flap Following Resection of a Recurrent Malignancy

Head and neck malignancies are frequently aggressive with high recurrence rates. These tumors are usually treated with surgical resection and/or radiation therapy. Patients treated initially with a free tissue transfer may require resection of the free flap if involved with recurrent tumor. This may result in a defect that requires a second free tissue transfer. These reconstructions may be technically difficult, and sometimes impossible, because of post-radiation changes, scarring from previous neck dissections, the presence of the initial free flap, or absence of quality recipient vessels for microvascular anastomosis.

The authors reported their experience with second free tissue transfers in 12 patients with recurrent head and neck malignancy who previously underwent free flap reconstruction of the same region over a 15-year period at the Mayo Clinic, Rochester, from 1988 to 2003. All recurrences involved the original free flap which, therefore, needed resection. The patients included 5 men and 7 women, with an average age of 55 years (35–73), who underwent 25 free flaps for this indication. The most common pathologic diagnosis was squamous cell carcinoma (n =ߙ7). The most common free flap used for the second reconstruction was the rectus abdominis muscle (n =ߙ4). The overall flap survival rate was 92%, with a 100% survival rate in the first free tissue transfer and 85% survival rate in the second transfer. The overall complication rate in the second free flaps was 23% (3 of 13 flaps). There was one minor complication (8%) which was a wound infection at a fibula harvest site; and two major complications (15%), including a failed fibula osteocutaneous flap in one patient and a myocardial infarction in another. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 (38%) of the cases the same artery, and in 7 of 13 (54%) the same vein were utilized for both the first and second free flaps.

Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective, with the original recipient vessels often being used for the second reconstruction.