A Simplified Approach to Microvascular Head and Neck Reconstruction: A 17‐Year Experience with 1416 Cases

Abstract

Objectives: Free flap failure is a dreaded complication that significantly affects both patient postoperative morbidity and surgeon anguish. This presentation aims to 1) familiarize the audience with a simplified and highly reliable approach to microvascular head and neck reconstruction; and 2) discuss the surgical principles and perioperative management fundamental to achieving flap success greater than 99%. Methods: Retrospective chart review performed at a tertiary care academic center. 1416 consecutive free flaps were performed for head and neck defect reconstruction between 1995 and 2012. Patient demographics, defect and free flap characteristics, and postoperative flap survival were examined. Results: Fibula, radial forearm, subscapular system, anterolateral thigh, and rectus abdominis flaps accounted for 99% of procedures performed. Since 2005, the anterolateral thigh flap largely replaced the rectus abdominis flap. The rate of successful free flap transfer was 99.5%, with only 8 flap failures. Increased risk of free flap failure was encountered in fibula flaps (8 out of 614, 1.8%) versus all others (0 out of 802, 0%), p<0.01. Flap failures occurred more frequently in women (7 out of 478, 1.5%) than in men (1 out of 938, 0.1%), p<0.01. Conclusions: A simplified approach to microvascular reconstruction of the head and neck facilitates success rates in excess of 99%. Surgical principles attentive to selecting reliable flap donor sites, large caliber recipient vessels, non-redundant and kink-free pedicle geometry, and use of simple perioperative care measures enable high success. These principles are paramount in reducing flap loss, associated patient morbidity, and microvascular surgeon burnout.