Reconstruction of Head and Neck Cancer with Double Free Flaps: Comparison between Single and Double Recipient Vessels

In mandibular and through-and-through cheek defects, double free-flap reconstructions are often needed. However, these patients have usually received previous surgery or radiotherapy, and obtaining ideal recipient vessels is extremely difficult.

From April 2001 to May 2004, there were 47 patients with advanced buccal cancers and previous composite tumor resection. Double flaps, including a fibula osteoseptocutaneous flap for intraoral and mandibular defects and an anterolateral thigh flap for cheek defects, were used for reconstruction. Two groups, one with a single set of recipient vessels and the other with two sets, were evaluated. In Group 1, the second flap was anastomosed at the distal runoff of the fibular flap with end-to-end anastomosis; the superior thyroid arteries were the recipient vessels in most of the cases (87.5%). The branches of the internal jugular veins were most used for venous drainage (75% of cases). In Group 2, two flaps were anastomosed with two sets of recipient vessels. The first were the ipsilateral superior thyroid arteries (86.7%), the second set were the ipsilateral facial arteries (83.3%). Four patients required vein grafts for anastomosis because of contralateral recipient vessels used (26.7%).

There were 32 patients (64 flaps) in Group 1, and 15 patients (30 flaps) in Group 2. Patient ages averaged 52.2 years in Group 1 and 56.2 years in Group 2. The success rate was 91% in Group 1 and 90% in Group 2. The mean operative time was 9.75 hr in Group 1 and 10 hr in Group 2. The mean hospital stay was 30.2 days in Group 1 and 30.5 days in Group 2. There were 4 patients (6 flaps, 9.38%) who had total flap loss in Group 1 and 3 flaps (10%) were lost in Group 2. Other complications included vascular insufficiency (15.62% in Group 1, 13.33% in Group 2) needing secondary revision; wound infection (15.62% in Group 1, 10% in Group 2); and partial flap loss (3.12% in Group 1, 3.33% in Group 2). There were no statistically significant differences in success rate, ages, operative time, or length of hospital stay between the two groups.

The authors prefer to use sequentially linked flaps in double free flap transfer, with the advantages of a single set of recipient vessels, easy insetting procedure, and no necessity for vein grafts, especially for patients who have received previous neck dissection or preoperative radiotherapy.