Management of radial forearm free flap failure in head and neck reconstruction due to COVID-19 infection

Abstract

Free flap surgery is a largely diffuse technique that allow to reconstruct various complex tissue defects. In head and neck surgery, they allowed reconstruction of an important variety of defects such extensive resection in treatment of malignant and benign tumors, defects as trauma consequence, congenital defects, and others. We present the case of 69-year-old Caucasian male admitted to the Department of Head and Neck for a cT2 N2b M0 squamous cell carcinoma of oral cave extended to the oral pharynx and treated with extended resection and radial forearm free flap reconstruction. No early postsurgery complication was detected. After 10 days from surgery, patient resulted positive for SARS-CoV-2. In the days after positivization, free flap started to show signs of ischemia, which lead to necrosis flap itself. A second surgery with palatal rotation flap and Bichat fat pad flap was necessary. Failure of free flap reconstruction is associated to vascular failure. In particular, venous thrombosis is the most common cause of vascular failure. Anterolateral thigh free flap was the one associated with the highest incidence of complications. Clinical comorbidity, smoking, age, and surgeon experience have been described as the mean risk factors. Actual knowledge as confirmed an increased risk of venous and arterial thromboembolic events in patients with SARS-CoV-2 infections. Nowadays there is no evidence of a correlation between SARS-CoV-2 diseases and free flap failure. Our case, about the patient with a tardive vascular free flap failure consequent to SARS-CoV-2 infection, suggests how COVID-19 could be a new risk factor for reconstructive surgery that surgeon community must keep in mind.