Single Free Flap Research Articles

Limb Salvage Using Microsurgical Free Tissue Transfer in Severe Frostbite.

Frostbite is often managed conservatively; however, in severe cases, microsurgical free tissue transfer is required for soft tissue coverage and limb salvage. Given its rarity, the techniques and outcomes of these cases are not well described. The purpose of this report is to present the largest case series, to date, of frostbite injuries requiring microsurgical reconstruction for limb salvage. A single-center retrospective review was conducted of all patients who underwent free tissue transfer by a single surgeon from 2008 to 2022. Patients of all ages were included if they suffered a frostbite injury requiring free tissue transfer. Demographics, operative details, and surgical outcomes were recorded. Eight patients with frostbite injuries were included in the report. Patients had frostbite injuries either to the lower extremities (n = 4) or to both upper and lower extremities (n = 4). Sixteen free flaps were done in total including four paired chimeric and eight single free flaps. Flap recipient sites included knees (n = 5), foot/ankle (n = 3), dorsal hands (n = 2), and thumbs (n = 2). All 16 flaps survived. Five patients had complications: four with major complications requiring operative management and two with minor complications requiring conservative management. Mean follow-up time was 505.7 days (range 115-1564). All lower extremity reconstructions were able to weight-bear at an average of 125.2 days post-injury (range 87-164). This case series demonstrates that free tissue transfer is a robust option for soft tissue coverage and functional limb salvage in patients with severe frostbite injuries to both upper and lower extremities.

Maximizing volume in autologous breast reconstruction: stacked/conjoined free flaps.

Since the first report of abdominally based tissue breast reconstruction with a free flap of rectus abdominis muscle to reconstruct mastectomy defects, autologous breast reconstruction has continually increased in popularity due to improved cosmesis, patient satisfaction, and quality of life. While abdominal tissue is frequently used as the principal donor site, other flap options are available, including from the buttocks, thighs, and back. Microsurgical advancements in recent years have continued to improve patient outcomes and decrease operative times. One innovative technique is the use of stacked or conjoined free flaps which can be used when more breast volume is needed than can be provided by one free flap alone. These stacked or conjoined free flaps can be used unilaterally or bilaterally and can include combinations of nearly every free flap depending on the volume of tissue desired for the reconstruction. Though these flaps are increasing in popularity, there is limited comparative data on the safety and efficacy of stacked or conjoined free flaps as compared to single free flaps. In this review, we aim to highlight the use of stacked/conjoined free flaps for autologous breast reconstruction, as well as highlight recent data on this technique and provide recommendations for its safe use.

Total Surface Area of a Through-and-Through Oromandibular Defect Is Associated With Thromboembolic Events for Reconstruction With a Single Fibula Free Flap

Reconstruction of through-and-through composite oromandibular defects (COMDs) has been a challenge to plastic surgeons for decades. When using a free osteoseptocutaneous fibular flap, the skin paddle is restricted by the orientation of the peroneal vessels and the inset of bone segment(s). Although the combination of double flaps for extensive COMDs is viable and reliable, the decision of single- or double-flap reconstruction is still debated, and the risk factors leading to complications and flap failure of single-flap reconstruction are less discussed. The aim of this study was to determine objectively predictive factors for postoperative vascular complications in through-and-through COMDs reconstructed with a single fibula flap. This was a retrospective cohort study in patients who underwent single free fibular flap reconstruction for through-and-through COMDs in a tertiary medical center from 2011 to 2020. The enrolled patients' characteristics, surgical methods, thromboembolic event, flap outcomes, intensive care unit care, and total hospital length of stay were analyzed. A total of 43 consecutive patients were included in this study. Patients were categorized into a group without thromboembolic events (n = 35) and a group with thromboembolic events (n = 8). The 8 subjects with thromboembolic events were failed to be salvaged. There was no significant difference in age, body mass index, smoking, hypertension, diabetes mellitus, and history of radiotherapy. The length of bony defect (6.70 ± 1.95 vs 9.04 ± 2.96, P = 0.004) and the total surface area (105.99 ± 60.33 vs 169.38 ± 41.21, P = 0.004) were the 2 factors that showed a significant difference between the groups. Total surface area was the only significant factor in univariate logistic regression for thromboembolic event (P = 0.020; odds ratio, 1.02; 95% confidence interval [CI], 1.003-1.033) and also in multivariate logistic regression analysis after adjusting confounding factors (P = 0.033; odds ratio, 1.026; 95% CI, 1.002-1.051).The cutoff level of total surface area in determining thromboembolic event development was 159 cm2 (P = 0.005; sensitivity of 75% and specificity of 82.9%; 95% CI, 0.684-0.952). Free fibula flap has its advantages and drawbacks on mandible restoration. Because there is a lack of indicators before, a large total surface area may be an objective reference for single-flap reconstruction of through-and-through COMDs due to an elevated risk of thromboembolic event.

Reconstruction of complex oro-mandibular defects by four different modifications of free fibula osteomyocutaneous flap: A prudent alternative to multiple flaps

Resection of advanced oral squamous cell carcinoma results in complex oro-mandibular defects involving external skin, oral mucosa, and bone. Reconstruction of such defects by a single free fibula flap (FFF) is limited by the lack of soft tissue bulk and adequate skin paddle for both intra- and extra-oral coverage. In this study, the reconstruction of large defects was achieved by four modifications of free fibula osteomyocutaneous flap as an alternative to multiple flaps. In this prospective study, 29 patients with complex oro-mandibular defects were reconstructed by FFF from December 2018 to October 2020. Reconstruction was done with any one of the four FFF modifications involving large proximal skin paddle from lateral leg: Strip de-epithelialization (De-Ep), chimeric bipaddle (Ch-Bp), muscle orally and skin extra-orally (Mo-Se), and double microvascular (Db-Mi). Outcome variables assessed were functional and esthetic results, early/late complications, donor site morbidity, and operative time. An algorithm based on Cordeiro's classification is proposed to assist in the selection of appropriate FFF modification. Among 29 patients, De-Ep was used in 13, Ch-Bp in 8, Mo-Se in 7, and Db-Mi in 1 case. None of the flaps underwent total loss. Two cases required re-exploration. The median operative time was 775min. Wound dehiscence and oro-cutaneous fistula were common early and late complications, respectively. Partial split skin graft loss (SSG) was the most common donor site morbidity. Functional and facial aesthetics were acceptable at the end of follow-up. Specific FFF modifications can be recommended in selected scenarios. It is reliable for single-stage reconstruction with satisfactory esthetic and functional outcomes. When used for reconstruction in first primary tumors, the second donor site is preserved, which can prove valuable in the event of a recurrence or second primary.

Anterior Neck Resurfacing Using Multiple Free Flaps in Patients With Burn Sequelae of the Anterior Neck and Chest.

It has been established that patients with burn sequelae of the anterior neck and chest have a significant degree of flap descent and deficit in neck extension when resurfaced with a single free flap. A protocol was developed to avoid flap descent in these patients by resurfacing the neck with multiple free flaps. The purpose of this article is to present our protocol for treatment and long-term results of this technique. Twenty-five 25 patients with burn sequelae of the anterior neck and anterior thorax were retrospectively identified. Ten patients were treated with a single free flap (group 1), and 15 patients were treated with multiple free flaps (group 2). Patients were followed up for an average of 7 years after their definitive reconstructive procedure at which time measurements including flap descent from sternal notch, deficit of neck extension, and subjective reports of discomfort were obtained. Patients in group 1 demonstrated 8 cm (interquartile range [IQR], 1.75 cm) of flap descent, whereas patients in group 2 demonstrated 0.5 cm (IQR, 0 cm) of flap descent. Patients in group 1 demonstrated 12.5 degrees (IQR, 10 degrees) of deficit in neck extension, whereas patients in group 2 demonstrated 0 degrees (IQR, 0 degrees) of deficit in neck extension. Analysis demonstrated significantly greater descent and deficit in neck extension in group 1 compared with group 2. Patients with burn sequelae of the neck and anterior chest experience less flap descent and deficits in neck extension when resurfaced with multiple free flaps.

VP15: Use of Single Chimeric Free Flap or a Double Free Flap for Complex Head and Neck Reconstruction

VP15: Use of Single Chimeric Free Flap or a Double Free Flap for Complex Head and Neck Reconstruction

Division of a single free flap in multiple digit reconstruction.

BackgroundSingle free flaps are a commonly used reconstructive method for multiple soft tissue defects in digits. We analyzed the flap size, division timing, and degree of necrosis in cases with various types of flap division.MethodsWe conducted a retrospective review of the medical charts of patients who had undergone single free flap reconstruction for multiple soft tissue defects across their digits from 2011 to 2020. The flap types included were the lateral arm free flap, venous forearm free flap, thenar free flap, hypothenar free flap, anterolateral thigh free flap, medial plantar free flap, and second toe pulp free flap. Flap size, anastomosed vessels, division timing, and occurrence of flap necrosis were retrospectively investigated and then analyzed using the t-test.ResultsIn total, 75 patients were included in the analysis. The success rate of the free flaps was 97.3%. All flaps were successfully divided after at least 17 days, with a mean of 47.17 days (range, 17–243 days) for large flaps and 42.81 days (range, 20–130 days) for the medium and small flaps (P=0.596). The mean area of flap necrosis was 2.38% in the large flaps and 2.58% in the medium and small flaps (P=0.935). Severe necrosis of the divided flap developed in two patients who had undergone flap division at week 6 and week 34.ConclusionsIn cases where blood flow to the flap has been stable for more than 3 weeks, flap division can be safely attempted regardless of the flap size.

Bilateral reconstruction of the mandibular body with symphyseal preservation using a single fibula free flap: operative technique

BackgroundMandibular osteonecrosis may occur in 5% of the patients who undergo radiotherapy for the treatment of head and neck malignancies. Resection and microvascular reconstruction is the treatment of choice in complicated osteoradionecrosis, however multifocal presentation may complicate the management of the disease given the poor quality and limited availability of adequate recipient vessels.Operative techniqueA 74-year-old man affected by multifocal severe osteoradionecrosis of the mandible underwent bilateral resection of the mandibular bodies while preserving the symphysis. The defects were reconstructed with a single fibula flap composed by two bony segments connected by a central segment, corresponding to the symphyseal region, in which the bone was dissected and removed. The anastomosis was performed on a single side of the neck. Healing was uneventful and the adopted technique allowed for a quick functional and esthetic recovery.ConclusionThe presented technique provided a safe and efficacious, although technically challenging, solution in a case presenting multifocal osteonecrosis of the jaw. The morbidity of the procedure was limited because the tissue resection and reconstruction processes were minimized.Graphical

Reconstruction of Extensive Oromandibular Defect With Simultaneous Dual Free Flap Transfer

Complex oromandibular defects are usually too extensive or complex to be reconstructed with a single free flap. In this situation, dual free flaps can provide an adequate amount of tissues and a three-dimensional structure for large composite defects.In our institution, a total of 6 patients underwent immediate dual free-flap reconstruction between December 2013 and February 2020. In all patients, oromandibular defects were reconstructed with a combination of a fibula free flap and a vertical rectus abdominis myocutaneous, anterolateral thigh, or radial forearm free flap. All 6 patients showed tolerable flap status without any major complications, and could transit a diet from a dysphagia diet to a general diet on the final visit. Dual free flaps can be considered an optimal reconstructive option with favorable functional and aesthetic outcomes for complex oromandibular defects involving the bone, oral lining, external skin, or soft tissue.

Reconstruction of extensive resection cavities after surgical treatment of the floor of the mouth cancer using two free flaps (ALT and peroneal) on microvascular anastomoses and a free chimeric flap (peroneal)

<br/>INTRODUCTION: The authors present two case reports of patients in whom it was possible to perform a reconstruction of an extensive postoperative cavity created during the resection of the floor of the mouth and the mandible cancer. Due to their size, the cavities had to be reconstructed with the use of specially formed flaps.<br/> <br/>CASES: In the first case, in a patient with local recurrence after previous resection of the floor of the mouth cancer and bilateral neck lymph node surgery with a sagittal flap reconstruction performed in a different clinic, there were created two separate microvascular flaps - an ALT (anterolateral thigh) flap and a peroneal flap. In the second case we present a patient diagnosed with carcinoma of the floor of the mouth and the body of the tongue with infiltration of the mandible with metastases to the lymph nodes of the neck bilaterally. Due to favorable anatomical conditions, it was possible to create a chimeric sagittal flap with two skin islands, and only one microvascular anastomosis was needed for the reconstruction of the cavity.<br/> <br/>DISCUSSION: Single free flaps used in the reconstruction of cavities after resection of cancers of the floor of the mouth are limited by their size and length of the pedicle, specific to the donor areas. These limitations result in the necessity to use two free flaps for the reconstruction of cavities after extensive resections of carcinomas of the floor of the mouth, tongue, mandible and adjacent structures. Chimeric flaps reduce the risk of complications in such a situation, allowing to perform few microvascular anastomoses and reducing the number of dose fields.<br/>

Use of Single Chimeric Free Flaps or Double Free Flaps for Complex Head and Neck Reconstruction.

Free flaps have become the preferred reconstructive approach to restore form and function for patients presenting with complex head and neck defects. For composite, complex defects for which a regular free flap might not meet all reconstructive demands, adequate coverage can be achieved with either a single chimeric free flap or a double free flap. We performed a single-center retrospective chart review of patients who underwent either single chimeric free flap or double free flap reconstruction. Indications for reconstruction included defects resultant from head and neck tumor or osteoradionecrosis resections. We extracted the following variables: tumor location, defect, flap(s) performed, and postoperative complications. Unpaired t-tests were performed to evaluate for statistically significant differences in complications encountered between the single chimeric versus the double free flap patient groups. In our series of 44 patients, a total of 55 single chimeric and double free flaps were performed. We found no significant difference in overall complications (p = 0.41) or flap/skin paddle loss (p = 0.45) between the groups. There were three total flap losses; two patients underwent successful salvage procedures and one patient died. The anterolateral thigh (ALT) was the most common free flap (70%) used in our series, and 98% of our patients completed successful reconstruction. As the initial reconstructive effort is critical for achieving favorable long-term outcomes in complex head and neck cases, effective and safe techniques should be employed to ensure optimal delivery of care. We believe that single chimeric and double free flap techniques should be appropriately utilized as part of the armamentarium of head and neck reconstructive microsurgeons.

Single Free Flap for Large Defects in Head and Neck Reconstruction, Double Paddle Anterolateral Thigh Flap

Abstract The purpose of the study is to evaluate the efficacy of double skin paddle anterolateral thigh flap (ALT) to reconstruction of through and through oral cavity defect due to cancer surgery. A prospective review was performed of patients referred to Firoozgar and Erfan hospitals with oral cavity defects with two or more oral cavity subunits and skin simultaneously involvement and immediate reconstruction using double-skin paddle ALT flap at the same time of tumor ablation from January 2019 to November 2020. A total number of 6 patients was evaluated. The mean area of skin paddle was 110.4 cm2 and 92.8 cm2 in distal and proximal paddle respectively. Except one patient was complicated and expired in hospital admission, the remaining 5 patients got fully oral intake and completely survived flaps with primarily closed donor site. Tumor recurrence was not found in the mean follow-up time of 12 months. The double skin paddle anterolateral thigh flap serves as an efficient reconstruction technique in complex and perforating oral cavity defects with the same functional outcome and the same flap related complications as conventional ALT flap.

The perforator-centralizing technique for super-thin anterolateral thigh perforator flaps: Minimizing the partial necrosis rate.

BackgroundDespite the wide demand for thin flaps for various types of extremity reconstruction, the thin elevation technique for anterolateral thigh (ALT) flaps is not very popular because of its technical difficulty and safety concerns. This study proposes a novel perforatorcentralizing technique for super-thin ALT flaps and analyzes its effects in comparison with a skewed-perforator group.MethodsFrom June 2018 to January 2020, 41 patients who required coverage of various types of defects with a single perforator-based super-thin ALT free flap were enrolled. The incidence of partial necrosis and proportion of the necrotic area were analyzed on postoperative day 20 according to the location of superficial penetrating perforators along the flap. The centralized-perforator group was defined as having a perforator anchored to the middle third of the x- and y-axes of the flap, while the skewed-perforator group was defined as having a perforator anchored outside of the middle third of the x- and y-axes of the flap.ResultsNo statistically significant difference in flap thickness and dimension was found between the two groups. The arterial and venous anastomosis patterns of patients in both groups were not significantly different. Only the mean partial necrotic area showed a statistically significant difference between the two groups (centralized-perforator group, 3.4%±2.2%; skewed-perforator group, 15.8%±8.6%; P=0.022).ConclusionsThe present study demonstrated that super-thin ALT perforator flaps can be elevated safely, with minimal partial necrosis, using the perforator-centralizing technique.

The Umbilicus Free Flap.

The morbidly obese patient has few reliable options if a single free flap is required for large surface area coverage. Usually, a latissimus dorsi muscle would be the primary option. If unavailable, a transverse-oriented abdominal flap based on deep inferior epigastric perforators as either a perforator flap or a muscle sparing type 2 transverse rectus abdominis musculocutaneous flap would be an alternative. A central panniculectomy type approach allows primary donor site closure by the cephalad advancement of the intentionally retained ptotic portion of the panniculus. Inclusion of the umbilicus with the free flap, which in this patient subgroup often is at risk for complications if excluded, mitigates against the need for undermining of the upper abdomen. The umbilicus free flap, as part of a panniculectomy, not only minimizes intrinsic flap risks, but also those of the abdominal donor site.

Reconstruction of composite leg defects post-war injury.

In a high conflict region, war injuries to the distal lower extremity are a major source of large composite defects involving bone and soft tissues. These defects are at the edge between using a single free flap [osteo-(+/-myo) cutaneous] vs double free flap reconstruction (bone and soft tissue). In this paper, we present our experience and outcomes in treating patients with leg war injury reconstructed using a single free fibula flap. Fifteen patients with distal leg composite defects secondary to war injuries were treated between January 2015 and March 2016. All patients were reconstructed using single barrel free fibula osteo-(+/-myo)cutaneous flap where single or double skin paddles were used according to the soft tissue defect requiring coverage. There were no cases of total or partial flap loss. Complications were limited to three cases including traumatic fibula fracture, venous congestion with negative findings, and residual soft tissue defect requiring coverage. There were no cases of wound dehiscence or infection. Mean follow-up time was 418.8 days. Mean bone healing time was nine months after which patients were allowed full weight bearing. A single barrel free fibula osteo-(+/-myo)cutaneous flap is a valid and reliable tool for reconstruction composite lower extremity defects post-war injury. Adequate planning of fibula flap soft tissue components (skin, muscle) rearrangement is essential for success in such challenging reconstructions.

Clinical application of single or bilobed free anterolateral thigh flaps with fascia lata in repair of dorsal skin and tendon defects of hand and foot

Objective To explore the clinical efficacy of single or bilobed free anterolateral thigh flaps with fascia lata in repair of dorsal skin and tendon defects of hand and foot. Methods From January 2014 to March 2018, 18 patients with dorsal skin and tendon defects of hand and foot were repaired with single or bilobed free anterolateral thigh flaps with fascia lata, including 14 cases of dorsal hand wound and 4 cases of dorsal foot wound. Among them, 1 case was accompanied with 1 tendon defect, 5 cases with 2 tendon defects, 8 cases with 3 tendon defects, 3 cases with 4 tendon defects, and 1 case with 5 tendon defects. There were 12 cases of single lobed flaps and 6 cases of bilobed flaps. 6 cases underwent secondary flap plastic surgery and tenolysis after operation. Results All the 18 flaps survived and the wound achieved primary healing. The donor site of thigh healed well with only linear scar. The follow-up period was 6 to 24 months with an average of 13 months. 14 cases of dorsal skin defects in hand were evaluated according to the criteria issued by the Hand Surgery Society of the Chinese Medical Association with the results being excellent in 6 cases, good in 7 cases, poor in 1 case. 4 cases of dorsal skin defects in foot had good functional recovery, no toe droop and no limitation of walking function. The appearance and texture of the flaps were excellent in 11 cases. No re-rupture or adhesion of extensor tendon occurred. 6 cases underwent second operation to thin the skin flaps 3 months after operation because of unsatisfactory shape. 4 of them had tendon adhesion after hand wound repair. The tenolysis was performed at the same time of skin flaps thinning. The appearance and function of the flaps recovered satisfactorily. Conclusion The single or bilobed free anterolateral thigh flaps with fascia lata in repair of dorsal skin and tendon defects of hand and foot have little damage to donor site. It is an ideal method for repairing such injuries for good recovery of hand and foot function. Key words: Surgical flaps; Treatment outcome; Fascia lata; Skin defects; Tendon defects

Complications and Outcomes of Chimeric Free Flaps: A Systematic Review.

Ablations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making. The librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997). Candidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates. A total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively. Chimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.

Gracilis musculotendinous free flap for lower extremity reconstruction after surgical removal of malignant tumors: A report of five cases.

Lower extremity reconstruction is challenging because of the need to restore form and function. Despite the many options for soft-tissue coverage, little research has addressed combined tendon and soft-tissue reconstitution. We present a series of patients undergoing lower extremity tendon reconstruction and wound coverage with a single free gracilis flap and its tendon. We studied five patients (age range, 51-81 years) undergoing lower limb reconstruction for defects involving soft tissue and tendon between 1998 and 2016 in the senior author's practice. Wounds (all in the foot and ankle region) were caused by sarcoma (n = 4) and Merkel cell carcinoma (n = 1) and ranged from 6.5-10 × 8-12 cm. Donor tendons, 2-18 cm long, were used to reconstruct the tibialis anterior, extensor hallucis longus, extensor digitorum longus, and extensor retinaculum. Patient characteristics and outcomes were reviewed retrospectively. Reconstructions used a gracilis muscle free flap and its tendon. Flap sizes ranged 5-6.5 × 11-14 cm. Complications were one case of cellulitis and one case of reoperation for flap thinning and tenolysis. All patients had at least 7 months of follow-up (mean: 37 months; range: 7-104 months). At latest follow-up, all patients were ambulatory. On average, patients resumed assisted ambulation 27 days postoperatively and unassisted ambulation 62 days postoperatively. For complex wounds with soft-tissue and tendinous defects, the gracilis muscle free flap may be a reconstructive option. We recommend it be considered as a single-donor incision option for lower extremity reconstruction.

Single Versus Simultaneous Double Free Flaps for Head and Neck Reconstruction: Comparison of Flap Outcomes and Donor-Site Morbidity.

Ablative procedures of the head and neck often result in substantial defects that require large-volume tissue transfer for restoration of form and function. Multiple simultaneous free flaps may be required for complex defects, but these procedures are often avoided because of the perception of an increase in associated surgical complications and morbidity. We present our experience with the use of simultaneous multiple free flaps as compared with single free flaps (SFFs) for head and neck reconstruction. Thirty-seven patients with a history of head and neck malignancy underwent SFF reconstruction, and 21 patients underwent double free flap (DFF) reconstruction. Statistical analysis was conducted comparing demographics, comorbidities, etiology of disease, and surgical outcomes between the 2 patient groups. Operative time and length of hospital stay were both significantly longer in the DFF group versus the SFF group. Despite significantly higher rates of preoperative radiation, osteoradionecrosis, and operation for secondary malignancy in DFF group, no significant differences in flap survival, partial flap loss, recipient site complications, or donor site complications were found. Overall flap-related reoperation rates were low, as were total flap losses. There were 10 complications (24%) that required reoperation in the DFF group, and 1 total flap loss (2.4%), on per-flap basis. There were 10 complications (27%) that required reoperation in the SFF group and 3 total flap losses (8.1%). Per-flap incidence of donor site morbidity in the DFF group was significantly lower than that in the SFF group (23.8% vs 56.8%, respectively, P = 0.011). The use of multiple free flaps for reconstruction of major head and neck tissue defects is sometimes necessary to achieve adequate reconstructive results. These procedures have no significant associated increase in overall flap-related complications. Our findings suggest that donor site morbidity can be minimized in double-flap reconstructions by thoughtful flap selection.

Challenges in multi-unit reconstruction: a framework perspective

Locally advanced or recurrent head and neck cancer can present both oncologic and reconstructive challenges. There are no current guidelines for reconstruction of multi-unit defects, yet reconstructive goals should serve the purpose of providing a safe healing environment for both adjuvant therapy and functional rehabilitation. In light of a younger head and neck cancer population, reconstructive methods aimed at preserving form and function over a long survivorship period are optimal. The review of the literature regarding use of single or double free flaps, with or without locoregional reconstructive options, and new techniques for multi-unit defects is described. Managing complex defects with multiple units involves determining a framework of critical, optimal, and optional elements for each reconstruction with consideration of the medical tolerance of the patient and long-term functional rehabilitation. Multi-unit reconstruction should involve distinction of critical, optimal, and optional aspects to provide a safe healing environment for both adjuvant therapy and functional rehabilitation fit for long-term survivorship.