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PURPOSE:
Even as head and neck reconstruction with free flaps has become routine, there is a hesitation to perform multiple sequential free flaps in the same patient. Our goal was to determine the success rate of sequential free flaps, and also to compare outcomes of sequential flaps performed soon after an initial free flap to those performed after a delay.
METHODS:
A review of patients undergoing sequential free flap reconstruction of head and neck defects between 1997 and 2010 was performed. Sequential free flap reconstructions were divided into two groups: “early” flaps, which were performed within 15 days of the initial free flap, and “late” flaps, which were performed after 15 days of the initial free flap.
RESULTS:
A total of 199 free flaps were performed on 86 patients, including 64 patients who had 2 sequential free flaps, 18 patients who had 3 sequential free flaps, 3 patients who had 4 sequential free flaps, and 1 patient who had 5 sequential free flaps. Five of these patients received two simultaneous sequential free flaps during one operation. Twenty patients received 20 early sequential free flaps. The indication for performing an early free flap was loss of an initial free flap in all cases. Sixty-six patients received 90 late sequential free flaps. The indications for performing a late free flap included: 30 recurrent cancers, 18 osteoradionecroses, 30 wound dehiscences or fistulae, 3 flap losses, and 1 stricture. Additionally, 8 cases were performed to augment the contour of an initial flap. The mean time from the initial free flap to the sequential free flap was 7.0 days in the early group and 801.8 days in the late group.
Adequate recipient vessels were found in every case, although 25 flaps required use of contralateral neck vessels, 3 flaps required use of internal mammary vessels, and 1 flap required use of thoracoacromial vessels. The early and late sequential free flap success rates were 95.0% and 96.7%, respectively (p=0.56). Complications occurred following 50.0% and 29.0% of early and late free flap reconstructions, respectively (p=0.11). There were no significant differences in complication rates following second, third, fourth, and fifth sequential free flaps (p=0.13). Intensive care unit stays averaged 7.5 days following early sequential free flaps and 2.9 days following late sequential free flaps (p<0.0001). Hospital stays averaged 16.3 days following early free flaps and 8.9 days following late flaps (p=0.0001).
CONCLUSION:
Multiple sequential free flaps are feasible in appropriately selected patients. The relatively high success rates of sequential free flaps suggests that loss of an initial free flap can often be treated with another free flap. Although indications for performing sequential free flaps were different, success rates for early flaps were equivalent to late flaps. However, because the morbidity was greater, consideration might be given to performing sequential free flaps in a delayed fashion, whenever possible. This is the largest series of patients undergoing sequential free flaps to date, and also the first series of patients who underwent 4 and 5 sequential head and neck free flaps.