Using Three Free Flaps for Reconstruction of an Advanced Head and Neck Cancer Patient

Abstract

Background: At present, there are still some head and neck cancer patients who refuse surgery because of fear. However, delayed treatment makes the operation more difficult, especially reconstructive surgery. After en bloc resection of an advanced head and neck cancer, the defect usually needs more than one flap to reconstruct. Moreover, if the recipient vessels are unavailable, high failure rates of free tissue transfer often bother reconstructive surgeons. Aim and Objectives: Complex head and neck defects after oncologic resections often require composite reconstruction of mucosal lining, skeletal support and soft tissue coverage. The reconstructive goals are restoration of the basal oromandibular function and socially acceptable appearance. Materials and Methods: A 37-year-old male patient was diagnosed with mouth floor squamous cell carcinoma. However, due to fear of surgery, he refused to undergo operation and switched into take four times of chemotherapy, but they were ineffective. One year later, he was admitted because of massive tumor bleeding. After initial assessment, he underwent en bloc tumor resection and bilateral modified radical neck dissection. The branches of the neck major vessels were almost ligated. The defect was then reconstructed with three free flaps including a jejunal flap, a fibular osteocutaneous flap and an anterolateral thigh (ALT) myocutaneous flap. Because the recipient vessels in the neck were unavailable, we utilized end-to-side microvascular anastomosis to overcome the difficulty. Results: Postoperatively, all flaps survived and the patient was recovering and doing well. At four weeks of follow-up, liquid diet was tolerated and he was satisfied with the result. Conclusion: We successfully used three free flaps with end-to-side microvascular anastomosis to reconstruct an extensive head and neck defect in a vessel-depleted neck. Moreover, the nature of the defect clearly dictates the method of reconstruction; for example, it is ideal to reconstruct the hypopharynx and cervical esophagus with a free jejunal flap to serve as a conduit and get a good swallowing function.