Flap Success Research Articles

Free flap failure in head and neck reconstruction

The purpose of this study was to determine the causes of head and neck free flap loss and to evaluate outcomes after subsequent microvascular and non-microvascular reconstruction. Patients who experienced free flap loss between 2000 and 2012 were reviewed. There were 40 flap losses out of 3090 free flaps (1.3%). Twenty-eight patients underwent subsequent free flap reconstruction of which 27 free flaps were successful (96.4%), which was not significantly different from our initial flap success rate (p = .81). Of patients who underwent subsequent free flap reconstruction for oral/pharyngeal defects, 100% had >80% speech intelligibility and 87.5% were tube feed independent. By comparison, 42.9% of patients who underwent subsequent pectoralis major flap reconstruction had intelligible speech (p = .01) and 25.0% were independent of tube feeds (p = 0.02). Subsequent free flaps after initial free flap losses can be successful in selected patients. Functional outcomes after subsequent free flap reconstruction are favorable compared to pedicled flap reconstruction.

A perspective on the role of the pectoralis major flap in oral and maxillofacial oncology surgery

AbstractIn general, the pedicled pectoralis major (PPM) flap has become a secondary choice for reconstruction in the developed world while remaining popular within the developing world. The pectoralis major flap is utilised in varying proportions as either the preferred reconstruction or for salvage reconstruction following free flap failure, further disease or complications. Refinements in surgical technique and an experienced surgeon may yield high total flap success rates with modest levels of wound complications. The pectoralis major flap is particularly useful with serious or multiple comorbidities, advanced disease, and previous surgery and/or chemoradiotherapy. It has primarily been used for reconstruction of extended radical neck dissection, posterolateral mandible, large glossectomy and oropharyngeal defects, and occasionally together with a free flap. A second free flap has increasingly been used after initial failure, particularly in the larger centres, but the PPM flap probably remains the most commonly used salvage option. The needs of the local population vary, survival outcomes are improving and patient choice may become an increasing factor in flap selection.

Onlay bone grafting simultaneous with facial soft tissue augmentation in a hemifacial microsomia patient using de-epithelialized orthograde submental flap: a technical note

Soft tissue augmentation in hemifacial microsomia patients is a challenging procedure. Free microvascular flap transfer is considered usually as the most accepted choice. On the other hand, bone grafting, simultaneous with facial soft tissue augmentation using de-epithelialized orthograde submental flap, is a suggested procedure. Moreover, preoperative evaluation of facial artery and anterior belly of the digastric muscle are essential steps for success in such flaps. Furthermore, bone suture technique helps achieve more predictable results and reduces the need for postoperative bulky dressing.

Early experiences with microvascular free tissue transfer in Lagos, Nigeria

Objectives:Microvascular free tissue transfer within our subregion is fraught with considerable challenges. We aim to highlight our experiences gained with our first fifteen cases of microvascular free tissue transfer at the Lagos University Teaching Hospital. We believe our report will be useful to colleagues embarking on such reconstructions in similar settings.Materials and Methods:The clinical records of the first 15 cases of free flaps done at our center were reviewed. The indications for surgery, choice of flap, recipient vessels, duration of surgery and complications were noted.Results:Fifteen cases were done, 10 flaps survived, ten defects occurred following trauma while remaining five followed cancer resections. Anterolateral thigh and radial forearm flaps were the most common flap used. The mean duration of surgeries was 7.1 hours SD ± 1.10 hours. Our take back rate was 13.3%, with a salvage rate of 50%. Three flaps failed on account venous congestion while remaining two failed due to arterial occlusion.Conclusion:66.67% free flap success rate recorded reflect our early experiences in our institution. We believe meticulous planning, careful vessel selection, close flap monitoring as well as improved infrastructural support can lead to much better success rates in microvascular reconstruction in our country.

Single‐stage preputial skin flap urethroplasty for long‐segment urethral strictures: evaluation and determinants of success

To determine the overall efficacy and predictors of success of the penile preputial flap in the management of complex urethral strictures >2.5 cm in length. We performed a retrospective and prospective study of 58 patients undergoing single-stage penile preputial flap urethroplasty for complex long-segment urethral strictures, without lichen sclerosus, repaired between May 2005 and April 2012 at our institution. For obvious reasons circumcised patients were excluded from the study. Results were assessed by univariate analysis of various patient characteristics, preoperative and postoperative patient satisfaction (based on symptoms), and urethral ultrasonography, retrograde urethrography and uroflowmetry. The median (range) follow-up was 42 (6-90) months, the median (range) intra-operative stricture length was 48.5 (26-85) mm and the median (range) operating time was 90 (85-125) min. A total of 87.93% of patients had a satisfactory outcome, with an overall success rate of 81.03%. Diabetes mellitus (relative risk [RR] 5.21, confidence interval [CI] 2.31-64.68, P = 0.003) and smoking (RR 4.19, CI 1.54- 45.0, P = 0.01) were predictors of failure, while postinfective aetiology (RR 2.19), panurethral stricture (RR 2.73), stricture length >70 mm (RR 3.25), previous urethroplasty (RR 2.4) and severe peri-urethral fibrosis (RR 2.37) were also associated with a higher risk of failure. A urologist should try to gain experience of all the methods of urethroplasty as the techniques may vary according to the circumstances. Single-stage preputial skin flap urethroplasty, in experienced and expert hands, has results equivalent to all other methods of urethroplasty in complex urethral strictures. We prefer this technique in this part of the world where buccal mucosa cannot be used because of dyskeratotic changes as a result of consumption of gutkha, tobacco, pan masala, betel nut.

Microsurgical Reconstruction for Head and Neck Cancer in Elderly Patients

The purpose of this study is to review our group of elderly patients and examine whether microsurgical reconstruction is safe to perform in these cases. From October 2006 to October 2009, 747 patients with head and neck cancer who underwent free flap reconstruction were divided into two groups: patients younger than 70 years (n = 714) and patients older than 70 years (n = 33). The two groups of patients were compared regarding medical comorbidities, medical/surgical complications, smoke, and alcohol consumption and outcomes. Two deaths occurred in the "elderly" (6% mortality rate) group of patients and two deaths in the "young" group of patients (0.28% mortality rate) in the immediate postoperative period (15 days postoperatively). Thus, mortality rate had a significant difference (p = 0.011) between these two groups. There was no significant difference in morbidity between these two groups of patients regarding the rate of medical complications, surgical complications, flap failure, and reexploration during our 3-month follow-up period. Mortality risk is higher in the elderly group of patients. However, there is no significant difference regarding the free flap success rate between these two groups. Thorough preoperative evaluation and preparation are critical to achieve a favorable outcome in elderly patients.

Free tissue transfers in head and neck reconstruction: Complications, outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute

Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute. A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20-year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed. A total of 201 cases required emergent surgical re-exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re-exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses. Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate.

Jejunal free flap for reconstruction of pharyngeal defects in patients with head and neck cancer—the Birmingham experience

We retrospectively audited operative complications, success of flaps, and speech and swallowing outcomes in patients with head and neck cancer who had reconstruction with jejunal free tissue transfer to the pharynx. A total of 104 patients had jejunal free flaps between 1987 and 2009 at University Hospital, Birmingham. Management was by a multidisciplinary team, and the same vascular surgeon did all the anastomoses. We investigated the relations between patients, operative factors, and postoperative complications, and noted the ischaemic time of the flaps and coexisting conditions of the patients. Outcomes measured included initial and final survival rates of flaps, donor and recipient site complications, and speech and swallowing outcomes on discharge and up to 2 years postoperatively. Of the 104 patients, 14 (13%) had initial flap complications but overall flap survival was 97%. A total of 11 (11%) patients developed a fistula at a mean of 15 days postoperatively and 11 (11%) had minor donor site complications. A total of 95 (91%) were able to resume oral diet on discharge. Of the 44 who were followed up on discharge, 32 (73%) were able to maintain oral intake at 2 years and 31 (70%) could use their voice in everyday situations. The jejunal free flap enables the tumour to be removed, and reconstruction and restoration of function to be done in a single operation using tissue that is versatile. The operation is associated with low morbidity at the donor and recipient sites, and results in good speech and swallowing outcomes. The flap can also be used to reconstruct pharyngolaryngeal defects.

A Successful Free Fibula Transfer in the Patient With Chronic Peroneal Vein Thrombosis

Despite the rare incidence, occult chronic thrombosis of peroneal veins of the fibula graft during the flap harvest presents a challenge to produce a successful reconstruction. In this article, we present a case of a 54-year-old man with chronic thrombosis of peroneal veins found during the harvest of the free fibula osteocutaneous flap for reconstruction of the mandible defect after tumor ablation. With near-total obliteration of the lumens, a small lumen with residual blood outflow was identified under microscopic magnification. A successful flap transfer was made possible by using the recanalized lumen around the chronic thrombus of the vein for microanastomosis. The pathological analysis of the vein revealed that the recanalized lumens and the endothelial cells-specific CD31 immunohistochemical stain highlighted the endothelium of regenerative lumen around the chronic thrombus. The abundant deposition of thick collagen fibers also suggested a chronic nature of the thrombus. However, although a successful microsurgical free osteocutaneous flap transfer might be possible in the patient with lower-limb chronic peroneal vein thrombosis, a careful preoperative evaluation with imaging study is recommended for high-risk patients.

Identification of perioperative risk factor by laser-doppler spectroscopy after free flap perfusion in the head and neck: a prospective clinical study.

The aim of this study was to evaluate perioperative flap perfusion using noninvasive monitoring with a laser-Doppler flowmetry and spectrophotometry unit (O2C) and identify whether perioperative blood flow, velocity, hemoglobin level (Hb), and oxygen saturation (SO2 ) measured could be used as indicators of free flap success. Measurements of blood flow, velocity, Hb, and SO2 were performed in 196 microvascular flaps, which had been transferred into the oral cavity to reconstruct ablative defects after surgery for oral cancer. The values were calculated superficially on the skin surface and at a depth of 8 mm. The results showed that perioperative absolute values measured were not associated with an increased rate of microvascular revisions or free flap failure. Independent predictors of microvascular revisions at the first postoperative day were the development of a falling trend in superficial and deep blood flow, and velocity in comparison with baseline values of variables measured. On day 2, all superficial and deep values of Hb, flow, and velocity were independent prognostic factors (P < 0.01), demonstrated as a downward trend were associated with a need for revision. The superficial and deep values of SO2 (P = 0.59 and 0.43, respectively) were not associated with ultimate free flap failure. This is the first clinical study to demonstrate that during early free flap integration to the recipient site different parameters of perfusion and oxygenation play an important role at different points of time. Within the first two postoperative days, changes in these parameters can help influence the decision to revise microvascular anastomoses.

Sexual Function and Long-Term Results Following Vaginal Reconstruction with Free Vascular Jejunal Flap

Sexual adjustment and long-term results following vaginal reconstruction with free vascular jejunal flap are not well known. The study aims to investigate sexual adjustment and long-term results among patients who underwent vaginal reconstruction with free vascular jejunal flap. A total of 34 women, aged 16-31 years (mean 23.5), who underwent vaginal reconstruction with a vascular jejunal flap between 2005 and 2011 were evaluated. Indications for reconstruction included the following: Mayer Rokitansky Kuster Hauser syndrome (29 patients), isolated vaginal agenesis (2 patients), androgen insensitivity syndrome (2 patients), and (1) history of gynecologic-oncologic surgery. The study evaluates the perioperative results, complications, satisfaction with sexual function, length and width of the neovagina. All of the surgeries were completed without any intraoperative complications. Three patients required reoperation because of postoperative venous compromise in the grafts. The flap success rate was 100%, and no infection was observed for any case. The mean follow-up was 50 months (between 20 and 87 months). The mean vaginal depth and diameter were satisfactory for all cases. Postoperatively, six patients complained of jejunal hypersecretion, one patient complained of mucosal prolapse, and one patient complained of vaginal constriction. The neovaginal prolapse was repaired via minor surgery. Twenty-seven were married and sexually active. Twenty patients completed the questionnaire on sexual function. Sexual function was assessed using the Female Sexual Function Index (FSFI). Eleven patients were satisfied with their sexual lives after surgery (FSFI scores≥25). Based on our results, satisfactory sexual function was achieved using the free jejunal vascular flap.

The Multiple Osteotomized Free Iliac Osteocutaneous Flap for Reconstructions of Complex Maxillofacial and Oromandibular Defects

The vascularized iliac osteocutaneous flap has been used successfully for jaw reconstruction. To obtain a better contour of the reconstructed area in large upper and lower jaw resections, the transferred bone actually needs to be osteotomized. Single closing-wedge osteotomy of the iliac flap for mandibular reconstruction has been previously described. In this article, the modified multiple osteotomized perforator-based versatile free iliac osteocutaneous flap is described. Eleven cases were enrolled. Seven patients had wide anterior mandibular resections due to oral cavity and mandibular tumors; 3 patients had a defect due to explosive injury and 1 patient had complicated orbitomaxillary defect due to blast injury. Skin paddle was based on the perforators. In 8 patients, the bony segment was divided into 3 segments by 2 osteotomies, whereas in 2 patients the bony segment was divided into 4 segments by 3 osteotomies. In 10 cases, the flap was used for anterior mandibular defects, whereas in 1 case the flap was customized to fit an L-shaped defect at the naso-orbito-maxillary region. The overall flap success rate was 100%. No resorption or morbidity related to the osteotomy of the bony segments was observed. The size of perforator skin paddle was 6 to 8 × 15 to 18 cm. Physical and radiologic examinations showed proper bone healing without any additional complications. The modified multiple osteotomized free osteocutaneous iliac flap can provide a safe and versatile bony segment to be arranged and adapted to reconstruct complex mandibular and maxillofacial defects.

Large Prefabricated Skin Flaps Based on the Venous System in Rabbits

Flap prefabrication offers a bridging role between traditional reconstructive surgery and tissue engineering; however, because flap prefabrication is based on the concept of implanting a nourishing vascular pedicle in the target tissues before transfer, survival remains unreliable. Furthermore, the extended period required for neovascularization hampers its clinical application. Based on two different venous angiosomes involving two sides of thoracoepigastric veins (taken as the vascular carrier) in rabbits, a large abdominal flap measuring 12 × 13 cm was designed by anastomosing the transferred femoral artery with the thoracoepigastric vein distally and prefabricated by incision of the proximal and distal ends of the flap for 1 week. Traditional arterial flaps, arterialized venous flaps, and composite skin grafts of the same size were used as control groups. Flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite in each group were assessed. The large prefabricated flaps achieved results similar to the traditional flaps in terms of flap viability, status of vascular perfusion and microvasculature, and level of epidermal metabolite. Large skin flaps with good quality can be prefabricated within a shorter period for aesthetic and plastic surgery reconstruction using the inherent venous system. This technique may prove to be a viable alternative for successful flap prefabrication.

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

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&lt;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&lt;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.

Venous Anastomosis with Microvascular Coupler in Head and Neck Reconstruction: Experience in 200 Consecutive Procedures

Objectives: There is a scarcity of data on outcomes when GEM microvascular coupler is used for head and neck reconstruction. We sought to review our experience in a large, contemporary series. Methods: Retrospective chart review of 201 consecutive flaps performed in 193 patients between September 2009 and January 2013 in a tertiary academic setting. Results: The cohort consisted of 125 males with a mean age of 64 years (range 3-83). A double free flap was performed in 8 cases. The most common defect locations were mandible (n = 62, 30.8%); oral cavity (n = 27, 13.4%), and cutaneous (n = 24, 11.9%). Flaps included anterolateral thigh (n = 85, 42.3%); fibula (n = 53, 26.4%); radial forearm (n = 37,18.4%); scapula, latissimus, and rectus (n=5, 2.5% respectively); iliac crest and vastus (n = 4, 2% respectively); and other (n = 3, 1.5%). A double venous anastomosis was performed in 26 flaps. The entire range of couplers (1-4mm) was used, but the 2.5mm was the most commonly used (n = 83, 36.6%) followed by the 2.0mm (n = 47, 20.7%). Facial (n = 134, 59%), External jugular (n = 32, 14.1%), and superficial temporal (n = 22; 9.7%) were the most common recipient vessels. Seven cases underwent microvascular revision yielding arterial thrombosis in 1 case, pedicle torsion in 1 case, and venous thrombosis in 5 cases. The flap was successfully salvaged in 3 cases. A delayed failure in another patient yielded an overall flap success rate of 97.5%. None of the tested variables reached statistical significance for venous thrombosis or flap survival. Conclusions: The microvascular coupler is a reliable alternative for venous anastomosis in head and neck flaps. Given the low failure rate, a multi-institutional study could help elucidate outcome predictors in this setting.

Plate Failure in Microvascular Osseous Recontructions

Osseous microvascular free flap reconstruction is a long accepted treatment following resection of the jaws. Different vascularized osseous free flaps allow for adequate tissue and bone for reconstruction of defects from various causes and sizes.1 Continued improvements in both surgical techniques and treatment planning, such as computer modeling and template design, improve the success of osseous microvascular flaps for facial reconstruction.2 Although success rates of osseous free flaps are high, at our institution we have noted multiple instances of hardware failures occurring at different time periods from the original reconstruction.

Outcomes following Microvascular Free Tissue Transfer in Reconstructing Skull Base Defects

Objective Successful resection of complex tumors involving the skull base (SB) depends on the ability to reconstruct the resulting defects. The objective of this study was to assess the outcomes of patients undergoing reconstruction after resection of SB tumors with free flaps. Methods From 1995 to 2010 a retrospective review of cases was undertaken. Demographics, histology, surgical management, complications, locoregional control, and survival were analyzed. Results We performed 62 flaps in 57 patients. There was a preponderance of sinonasal malignancies (45%), and most lesions involved the anterior SB (81%). A total of 94% of patients underwent radiotherapy. Reconstruction was undertaken mainly with anterolateral thigh (37%) or radial forearm (34%) flaps. Complications occurred in 17% of patients, and the flap's success rate was 94%. Conclusion Free flaps are versatile and highly reliable for reconstructing defects resulting from resections of the SB. They should be considered for SB reconstruction of large three-dimensional defects as well as defects involving an irradiated field. Successful reconstruction of the SB can be performed using a small number of highly dependable flaps.

Applications of the Medial Femoral Condyle Free Flap for Foot and Ankle Reconstruction

Avascular necrosis (AVN) or persistent nonunion occurs in situations of poor vascular supply. Some specific situations that plague the foot and ankle surgeon are talus nonunion, talus AVN, navicular AVN, and failed ankle arthrodesis with bone loss. The medial femoral condyle (MFC) flap has emerged as a popular source of vascularized corticocancelous bone. We present a series of cases demonstrating the versatility of the MFC flap in complex foot and ankle pathology. A retrospective review was completed of all MFC flaps used in the foot and ankle over the past 5 years. Five patients were identified (average age 48). Surgical indications included talar AVN and ankle arthritis, talar nonunion, and navicular AVN. All patients had undergone conventional bone grafting techniques, which failed, prior to being treated with a MFC free flap; this series of patients did not possess significant medical comorbidities. Fixation techniques included compression screw fixation, plate osteosynthesis, or fine wire external fixation. The average follow-up was 20 months (range 8 to 40 months). There was a 100% flap success rate with no returns to the operating room for thrombosis. The volume of the bone flaps was 5.6 cm(3) (range 1 cm(3) to 12 cm(3)). The average follow-up time was 20 months (range 8 to 40 months). All cases resulted in union, and full weight bearing status was achieved at a mean of 23.8 weeks (range 10 to 52 weeks) postoperatively. Vascularized bone transfer in the form of the MFC free flap was a valuable method for foot and ankle reconstruction. The MFC flap provided an alternative for those defects that were smaller then 3 cm in length. In our experience, for small bone defects requiring vascularized bone, the MFC flap is currently the ideal donor location supplanting the iliac crest. Level IV, retrospective case series.

Increasing the success of reverse sural flap from proximal part of posterior calf for traumatic foot and ankle reconstruction: Patient selection and surgical refinement

In this report, we present our experience on the use of the reverse sural flap for traumatic foot and ankle reconstruction. The patient selection and surgical refinement are discussed. From 2007 to 2010, 11 consecutive patients underwent modified reverse sural flap at the Chang Gung Memorial Hospital. The defects were located at the ankle (three cases), foot (two cases), and heel (six cases). Particular attention was paid to precise patient selection and surgical refinements. Patient selection was based on the lower limb vascular status by palpable distal pedal pulses and ankle brachial index ranging from 0.9 to 1.2. Surgical techniques were refined as precisely locating the perforators of peroneal artery, placing the skin paddle in upper third of leg for a distal region coverage, designing a 7-cm-wide adipofascial pedicle with a 2 cm skin paddle on it, preserving the mesentery structure of sural nerve and concomitant artery with or without including gastrocnemius muscles cuff, no tunneling when inset this flap and supercharging with lesser saphenous vein whenever needed. All the flaps survived completely. Only one patient required immediate anastomosis of lesser saphenous vein to local vein around defect in order to relieve the venous congestion during operation. Patients felt diminished but adequate recovery of sense of touch and temperature at the flap. Following the precise patient selection and surgical refinements, the modified reverse sural flap seemed to be a reliable and effective local flap for reconstruction of the soft tissue defects on ankle and foot.

OP105: Intraoperative fluorescent angiography analysis for head and neck micro-vascular free flap reconstruction – A preliminary experience

Reconstruction of complex defects of the head and neck region utilizing micro-vascular free tissue transfer reconstruction has become invaluable. Early detection of vascular compromise and its prompt correction is critical to its success. The use of intra-operative fluorescent angiography (ICG) may facilitate surgeons in being objective when assessing micro-vascular anastamosis patency and flap perfusion. 201 head and neck free tissue transfer cases on 198 patients performed by a single surgeon between 2003 and 2012 were reviewed for type of flap, flap success and complications. In 32 of the head and neck free tissue transfer cases, intra-operative ICG was performed with SPY Elite (Lifecell) for assessment of micro-vascular anastomosis patency and analysis of adequacy of blood supply to all zones of the inset flap. Conventional subjective patency test and clinical inspection were performed for the remaining 169 cases. Overall success rate was 95% (191/201) with eight flap failures and two partial flaps necrosis. When intra-operative ICG analysis was performed, the success rate was 97% (31 out of 32) with 1 partial flap necrosis. In the conventional subjective analysis group, the success rate was 94% (160/169) with eight flap failures and one partial flap necrosis. Overall complication rate was 12% (25/201). Post-operative complications included hematoma, venous thrombosis, infection, partial flap necrosis, and hemorrhage. In the intraoperative ICG analysis cases, the overall complication rate was 6% (2/32 cases) with 3% (1/32) hematoma and 3% (1/32) partial flap necrosis. In the conventional subjective analysis group, the overall complication rate was 16% (23/169) with post op complications of hematoma 7% (12/169), venous thrombosis 4% (7/169), infection 1% (2/169), partial flap necrosis 1% (2/169) and hemorrhage 0.6% (1/169). Routine implementation of intraoperative ICG analysis can further increase the reliability of free tissue transfer reconstruction of the head and neck region.