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Acta Otorrinolaringol Esp. 2014;65(1):33---42
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ORIGINAL ARTICLE
Free Flap Reconstruction in the Head and Neck.
Indications, Technical Aspects and Outcomes�
José Luis Llorente,a,∗ Fernando López,a Vanessa Suárez,a Ángel Fueyo,b
Susana Carnero,b Clara Martín,b Victoria López,c Daniel Camporro,b Carlos Suáreza
a Servicio de Otorrinolaringología, Instituto Universitario de Oncología del Principado de Asturias, Hospital Universitario Central
de Asturias, Oviedo, Asturias, Spain
b Servicio de Cirugía Plástica, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
c Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
Received 3 August 2013; accepted 7 August 2013
KEYWORDS
Free flaps;
Head and neck
reconstruction;
Hypopharynx
reconstruction;
Skull base
reconstruction
Abstract
Introduction and objectives: The use of microvascular free flaps (MFF) has become a common
method of head and neck reconstruction because of its high success rates and better functional
results. We report our experience in reconstructing complex defects with MFF.
Methods: We analysed a series of 246 patients who underwent reconstruction using MFF in our
Department from 1991 to 2013.
Results: A total of 259 interventions were performed in 246 patients. The most common reason
for surgery was tumour recurrence (46%), followed by primary tumour resection (25%). The
hypopharynx (52%) and the craniofacial region (22%) were the most frequently reconstructed
sites. The free flaps most commonly used were the radial forearm free flap (41%) and the
anterolateral thigh free flap (35%). Overall success and complication rates of 92% and 20%
respectively were reported.
Conclusions: The microvascular free flap is a reliable and useful tool for reconstructing complex
head and neck defects and continues to be the reconstructive modality of choice for these
defects.
© 2013 Elsevier España, S.L. All rights reserved.
� Please cite this article as: Llorente JL, López F, Suárez V, Fueyo Á, Carnero S, Martín C, et al. Reconstrucción de cabeza y cuello mediante
colgajos libres microvascularizados. Indicaciones, aspectos técnicos y resultados. Acta Otorrinolaringol Esp. 2014;65:33---42.
∗ Corresponding author.
E-mail address: llorentependas@telefonica.net (J.L. Llorente).
2173-5735/$ – see front matter © 2013 Elsevier España, S.L. All rights reserved.
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dx.doi.org/10.1016/j.otoeng.2014.02.011
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34 J.L. Llorente et al.
PALABRAS CLAVE
Colgajos libres;
Reconstrucción de
cabeza y cuello;
Reconstrucción de la
hipofaringe;
Reconstrucción de la
base de cráneo
Reconstrucción de cabeza y cuello mediante colgajos libres microvascularizados.
Indicaciones, aspectos técnicos y resultados
Resumen
Introducción y objetivos: La utilización de colgajos libres microvascularizados (CLM) se ha con-
vertido en un método de reconstrucción frecuente en el área de cabeza y cuello debido a sus
elevadas tasas de éxito y a sus mejores resultados funcionales. Presentamos nuestra experiencia
en la reconstrucción de defectos complejos con CLM.
Métodos: Se presenta una serie de 246 pacientes que requirieron una reconstrucción con CLM
entre 1991 y 2013.
Resultados: Se realizaron 259 intervenciones en 246 pacientes. El motivo más frecuente para la
realización de la cirugía fue la presencia de una recidiva tumoral (46%), seguido de la resección
primaria del tumour (25%). Las regiones más frecuentemente reconstruidas fueron la hipofaringe
(52%) y la región craneofacial (22%). Los CLM más usados fueron el colgajo antebraquial radial
(41%) y el anterolateral de muslo (35%). El 92% de los CLM fue un éxito y la tasa de complicaciones
fue del 20%.
Conclusiones: La utilización de CLM es un método fiable y útil para la reconstrucción de defectos
complejos de cabeza y cuello, y su uso sigue siendo la modalidad reconstructiva de elección en
estos casos.
© 2013 Elsevier España, S.L. Todos los derechos reservados.
Introduction
The progressive development of microsurgical techniques,
the variety of available flaps, the high success rates and the
optimal results obtained have helped to establish microvas-
cular free flaps (MFF) as the standard method for the
reconstruction of complex defects in the head and neck
region.1
Reconstructive surgery represents a major challenge for
head and neck surgeons due to the varying characteristics
of patients, the associated morbidity and the defects that
must be corrected. MFF represent the first choice for
the reconstruction of most defects in the head and neck
region following cancer surgery. Defects related to osteora-
dionecrosis, trauma and sequelae of facial paralysis are also
susceptible to being treated with MFF. One of the advan-
tages of MFF compared to local and regional flaps is their
versatility in terms of surface, volume, composition and
vascularisation. MFF allow surgeons to successfully address
most reconstructive needs, so they are used for a variety of
defects and in multiple anatomical regions. As a result, they
enable the immediate reconstruction of defects that could
not previously be reconstructed and allow broader oncolo-
gical resections, improving local control of the disease and
the prognosis of patients, and reducing sequelae and patient
morbidity, compared to the period before the routine use of
MFF.1
The number of interventions requiring the use of MFF has
increased in our hospital in recent years, making it a routine
and normalised procedure in cases where it is necessary to
perform complex head and neck reconstructions. The effec-
tiveness of the procedure, the teamwork between surgeons
and anaesthesiology specialists and the standardised peri-
operative care of these patients have been highlighted as
crucial factors in the implementation and consolidation of
this technique. The purpose of this study was to present our
experience in the reconstruction of head and neck defects
using MFF.
Materials and Methods
We reviewed the surgical registry of our Otolaryngology
Service between 1991 and January 2013, and gathered data
from 246 patients who required reconstruction with MFF.
We excluded from the study those patients with less than
6 months of postoperative follow-up.
The indications for performing a reconstruction with
MFF were as follows: (a) complex defect of the head and
neck region not susceptible to reconstruction using local
or regional flaps; (b) reconstruction in patients in whom
other local or regional flaps had failed; (c) patients with
severe sequelae after (chemo)radiotherapy (RT) in whom
the upper aerodigestive tract had to be reconstructed;
(d) failure of a prior MFF; and (e) choice of treatment by
the surgeon.
The primary objective was to carry out a descriptive
study of the sample. The secondary objectives were to cal-
culate the rates of MFF viability and complications.
The mean follow-up period was 26 months (range: 6---
337 months).
Surgical Procedure
All patientswere administered prophylactic antibiotic ther-
apy, which was subsequently continued for at least 7---
10 days. Likewise, thromboprophylaxis with low molecular
weight heparins was administered until ambulation. Gener-
ally, patients underwent an Allen test prior to surgery (to
assess the integrity of the ulnar artery), to confirm if in case
it was advisable to use a radial forearm free flap (RFFF). If
an anterolateral thigh free flap (ATFF) was used, the perfo-
rating vessels and the vascular axis were located previously
using a Doppler probe.
The surgery was performed by 2 teams (otolaryngologists
and plastic surgeons). Except for special situations, surgery
was performed sequentially, as follows:
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Free Flap Reconstruction in the Head and Neck 35
30
25
20
15
10
5
0
1991 1992 19931994 1995 19961997199819992000 2001 20022003 20042005 20062007 2008 2009 20102011 2012 2013
125
100
75
50
25
0
35-4919-34 50-64
Age (years)
65-75 >75
P
a
ti
e
n
ts
 (
n
)
F
re
q
u
e
n
c
y
 (
%
)
Years
BA
Figure 1 (A) Annual evolution of the number of interventions performed. (B) Patient distribution by age.
(1) Initially, otolaryngologists performed excision surgery
and prepared the defect. In addition, they found, diss-
ected and marked the MFF receptor vessels.
(2) Plastic surgeons proceeded to extract the MFF, which,
once in ischaemia, was maintained at a low tempera-
ture.
(3) The team of otolaryngologists reconstructed the defect
created by adapting the extracted MFF to it. Occasion-
ally, it was necessary to remodel the MFF in order to
obtain a correct adaptation.
(4) Plastic surgeons performed microvascular sutures.
(5) Finally, otolaryngologists proceeded to the final closure
of the surgical defect.
After surgery, the patients remained in the recovery room
between 24 and 48 h. It was important not to put pressure
on the flap and pedicle area, as well as to avoid arterial
hypotension. Flap viability was monitored approximately
every 4 h, by direct inspection (colour, filling, temperature)
in cases in which it was possible or by fibreoptic evaluation.
Close attention was also paid to any signs of haemorr-
hage. Once in the ENT hospitalisation ward, the patients
were controlled by the otolaryngologist and the donor area
was controlled by the plastic surgeon.
Results
The sample consisted of 246 patients: 206 males (84%) and
40 females (16%), with a mean age of 58 years (range: 21---
84 years) (Fig. 1A). A total of 11 patients required a sec-
ond MFF, while 1 patient required a third. Altogether, 259
surgical interventions were performed.
Since the completion of the first MFF procedure in 1991,
the number of interventions has increased steadily, becom-
ing more frequent after the year 2000, with 15 annual cases
(Fig. 1B). The mean duration of the interventions was 10 h
(range: 7---15 h), mainly varying according to the type of
resection surgery.
The most common reason for the use of MFF was the
presence of tumoural recurrence (46% of all interventions)
(Fig. 2). Squamous cell carcinoma was the most com-
mon histological subtype (80% of patients) (Table 1), with
the hypopharynx being the most common location (43%
of patients) as well as the most frequently reconstructed
region (52% of interventions) (Table 2). In total, 57 inter-
ventions (22%) involved the reconstruction of the skull base,
and MFF were used in 22 (8%) cases for reconstruction after
orbital exenteration. By tumoural stages (Table 3), most
patients who presented neoplastic disease at the time of
surgery (n = 202) were in stage IVA (84%).
In 53 of the 246 patients (22%), reconstruction with
MFF was part of the initial treatment. A total of
170 patients (69%) had undergone prior interventions, 154
(63%) had received prior RT and 39 (15%) had received prior
chemotherapy (CT) (Table 4). Of the 236 cases, 95 (40%) had
undergone neck dissection prior to the surgical intervention
requiring the use of MFF (Table 5). The mean number of
surgical procedures prior to MFF surgery was 4 (range: 1---7).
Total pharyngolaryngectomy was the most common pro-
cedure (20%), followed by complex anterior facial and
anterior skull base approaches (17%) (Table 6). In 60 patients
250
200
150
100
50
0
Tumours Pharyngostomas Complex
defects
Rescue of prior
MFF
18 SPT
119 R
65 PT
38
14 5
Figure 2 Reasons to perform the surgical procedure. MFF:
microvascular free flap; PT: primary tumour; R: recurrence; SPT:
second primary tumour.
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36 J.L. Llorente et al.
Table 1 Primary Diagnosis in the 236 Patients.
Diagnosis Number of patients
(%) (n = 236)
Epidermoid carcinoma 198 (81)
Adenoid-cystic carcinoma 9 (4)
Basal cell carcinoma 8 (3)
Adenocarcinoma 7 (3)
Sarcoma 4 (2)
Melanoma 3 (1)
Undifferentiated carcinoma 3 (1)
Malignant fibrohistiocytoma 3 (1)
Neuroesthesioblastoma 2 (1)
Mucoepidermoid carcinoma 1 (1)
Triton tumour 1 (1)
Carcinoma ex-pleomorphic adenoma 1 (1)
Trauma 1 (1)
Cerebrospinal fluid fistula 1 (1)
(24%) we performed the surgical treatment of the neck
simultaneously (Table 5).
Of the 259 MFF performed, the most commonly used were
RFFF (41%), followed by ATFF (35%) (Table 7). As seen in
Fig. 3, the use of ATFF was more frequent in recent years,
whereas in the beginning of this type of surgery, the most
commonly used MFF were RFFF and jejunum. In 4 patients
we performed a second MFF as rescue procedure following
necrosis of a previous MFF, in another 5 as rescue proce-
dure following tumour recurrence, in 2 to reconstruct a
defect following a prior MFF and in 1 patient we conducted
a second MFF due to necrosis of the prior procedure, and
subsequently a third due to dehiscence of the second.
The most frequently used anastomoses were between
MFF vessels and the superior thyroid artery (35%) and the
external jugular vein (40%) (Table 8). In general, the donor
regions were closed primarily. However, sometimes the fore-
arm region was adequately closed with a skin graft or using
an ulnar flap (16), as previously described.2
Reconstruction with MFF did not limit the applica-
tion of RT or CT after surgery. Postoperative RT was
Table 3 Tumoral Stage in the 202 Patients Who Presented
Tumours at the Time of Surgery.
Category n (%)
T
Without local tumour 4 (2)
T1 0 (0)
T2 5 (3)
T3 32 (16)
T4 131 (80)
N
N0 151 (75)
N1 1 (1)
N2a 6 (3)
N2b 30 (15)
N2c 8 (4)
N3 6 (3)
M
M0 201 (99)
M1 1 (1)
Stage
I 0 (0)
II 5 (2)
III 20 (10)
IVa 170 (84)
IVb 6 (3)
IVc 1 (1)
Table 4 Prior Treatment in the 246 Patients.
n (%)
Initial treatment 53 (22)
Surgery 35 (14)
Radiotherapy 13 (5)
Surgery and radiotherapy 106 (43)
Surgery and chemoradiotherapy 25 (10)
Surgery and chemotherapy 4 (2)
Chemoradiotherapy 10 (4)
Table 2 Reconstructed Region According to Primary Location of the Region (n = 259 Interventions).
Origin vs reconstruction Complex
craniofacial a
Premaxilla Oropharynx Tongue Hypopharynx Mandible Soft parts Total
Sinonasal---skullbase 38 14 0 0 0 0 0 52
Cavum 4 0 0 0 0 0 0 4
Oropharynx 0 0 15 16 3 6 3 43
Mouth floor 0 0 0 0 0 2 0 2
Lip 0 1 0 0 0 0 3 4
Palate 2 0 0 0 0 0 0 2
Hypopharynx 0 0 0 0 108 0 0 108
Larynx 0 0 0 0 24 0 1 25
Temporal---skull base 3 0 0 0 0 0 0 3
Lachrymal sac 1 0 0 0 0 0 0 1
Cervicofacial soft parts 9 0 0 0 0 1 5 15
Total 57 15 15 16 135 9 12 259
a All these reconstructive procedures involved, in one way or another, the reconstruction of the skull base and, in some cases, the
orbit.
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Free Flap Reconstruction in the Head and Neck 37
Table 5 Cervical Treatment in the 246 Patients.
n (%)
No 91 (37)
Prior to surgery with free flap
Unilateral functional dissection 31 (13)
Bilateral functional dissection 52 (21)
Functional dissection and radical dissection 7 (3)
Radical dissection 5 (2)
Simultaneously with surgery with free flap
Unilateral functional dissection 11 (4)
Bilateral functional dissection 31 (13)
Functional dissection and radical dissection 16 (6)
Radical dissection 2 (1)
administered after 74 of the 254 (29%) viable MFF, and adju-
vant chemotherapy was administered in 29 cases (11%). Both
RT and CT were administered in 16 cases (6%). There were
no cases of necrosis or dehiscence complications following
postoperative radiotherapy.
The complications associated with surgery are shown in
Table 9. There were complications of some type after 50
interventions (20%), with the most frequent being local hae-
morrhage, although only 12 cases (5%) required surgical
reoperation. In 7 cases (3%), patients died in the perioper-
ative period due to medical complications. We observed no
significant difference in the complication rate regarding the
type of MFF used. A total of 92% MFF were viable (239/259).
There were 20 cases of complete necrosis, which forced the
removal of the MFF, and 6 cases of subtotal necrosis, which
did not prevent the viability of the MFF and evolved suc-
cessfully with conservative measures. Most cases of necrosis
occurred 48 h after the surgery, due to venous thrombosis. Of
the 20 cases with complete necrosis that required removal
of the MFF, a second MFF was performed in 5 cases, fail-
ing again in 2 cases and with both patients dying within a
short period of time due to disease progression. In 5 cases,
after removing the necrotic MFF, the patient died due to
sepsis/massive haemorrhage. The remaining 8 cases were
resolved by scarring by secondary intervention (2 cases), a
local flap (2 cases) and a pectoralis major myocutaneous flap
(4 cases). In 14 of the 20 total necrosis cases (70%) patients
Table 6 Surgical Interventions Performed (n = 254).a
n (%)
Total pharyngectomy 41 (16)
Subtotal pharyngectomy and total
laryngectomy
3 (1)
Total pharyngolaryngectomy 51 (20)
Subtotal pharyngectomy 9 (4)
Total glossectomy 11 (4)
Partial glossectomy 5 (2)
Command of oropharynx
(+mandibulectomy)
12 (+11) (9)
Pharyngoplasty 30 (12)
Extended maxillectomy 20 (8)
Complex anterior facial approach and
anterior skull baseb
43 (17)
Craniofacial resection 5 (2)
Complex lateral approach and skull basec 13 (5)
a The number of interventions in which an ablation or plasty
procedure was employed was 254. In the 5 remaining cases, up
to a total of 259 interventions were performed, the objective
was to place a rescue free flap due to necrosis of the previous
flap.
b Including anterior facial translocation, lateral, orbital
approach, fronto-zygomatic and/or orbital exenteration.
c Includes parotidectomy, infratemporal approach, subtem-
poral-preauricular approach, resection of cervical soft parts
and/or total/lateral resection of the temporal.
had received prior RT. However, no significant association
was observed between the administration of RT prior to
surgery and the development of severe complications. Nei-
ther did we observe a significant relationship between the
rate of complications and age, tumour histology, location,
associated surgical procedure, administration of postopera-
tive RT or the type of MFF employed. We noted complications
susceptible to surgery in the donor area in 8 cases, of which
50% were related to 1 RFFF, 1 ATFF, 1 jejunum and 1 TRAM
(transverse rectus abdominis myocutaneous).
Overall, at the end of the follow-up period, 69 patients
(28%) remain currently alive. Of the 177 deaths (72%), 148
(60%) were due to disease progression (24 due to local pro-
gression, 96 due to locoregional progression, 28 due to the
Table 7 Microvascular Free Flaps Used According to the Reconstructed Region (n = 259).
Complex
craniofaciala
Premaxilla Oropharynx Tongue Hypopharynx Mandible Soft parts Total
Anterolateral 23 2 4 11 41 2 7 90
Forearmb 20 10 7 3 65 1 2 108
Parascapular 10 0 3 1 7 4 3 28
Scapular-parascapular 3 2 1 0 3 1 0 10
Jejune 0 0 0 0 19 0 0 19
Fibula 0 1 0 0 0 1 0 2
TRAM 1 0 0 1 0 0 0 2
Total 57 15 15 16 135 9 12 259
TRAM: transverse rectus abdominis myocutaneous.
a All these reconstructive procedures involved in some manner the reconstruction of the skull base and, in some cases, the orbit.
b In 2 cases, the forearm flap included a radial bone fragment.
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38 J.L. Llorente et al.
1
9
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9
9
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9
9
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1
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Anterolateral thigh
20
15
10
N
u
m
b
e
r 
o
f 
fl
a
p
s
5
0
Forearm
Parascapular
Scapular–parascapular
Jejune
Fibula
TRAM
3 3
4 4
2
5
2
4
5
6
8
7
4 4 4 4
5
9
6
1 1
1
1
1
1
1 1 1 1 1 1111111
1
1
1111111
1
1
2
2
7 7
9
222
8
9
5
6
2
1
3 3 3 3
Years
Figure 3 Annual evolution of the type of free flap. TRAM: transverse rectus abdominis myocutaneous.
development of distant metastases) and 29 (12%) due to
unrelated reasons. Given the heterogeneity of the patients
in our sample, we only calculated the rates of locoregional
control and specific survival at 5 years in the 2 groups with
more patients (Fig. 4).
Discussion
In the last 2 decades, increasingly sophisticated recon-
struction techniques have been used in an attempt
to cure disease, improve functional outcomes, prevent
complications and reduce the delay of postoperative RT. The
use of locoregional flaps, mainly pectoralis major myocuta-
neous flaps, remains the main reconstructive option at most
centres.3 However, nowadays the use of MFF has become the
Table 8 Receptor Vessels.
Arteries (n = 259) Veins (n = 394)a
Superior thyroid 91 (35) 38 (10)
Facial 84 (32) 99 (25)
Lingual 33 (13) ---
Transverse cervical 25 (10) 9 (2)
Temporal 14 (5) 13 (3)
External carotid 9 (3) ---
Occipital 2 (1) ---
Auricular posterior 1 (1) ---
External jugular --- 106 (27)
Thyrolinguofacial trunk --- 82 (21)
Internal jugular --- 38 (10)
Middle thyroid --- 9 (2)
a In 124 (48%) free flaps we conducted 1 venous anastomo-
sis and in 135 (52%) we conducted 2 anastomoses. We did not
perform venous grafts in any case.
method of choice for reconstructions, especially for complex
defects.4,5
The choice ofreconstruction type is influenced by the
general condition of the patient, the nature of the defect
to be reconstructed and the experience of the surgical
team. The indications have been detailed previously.6 In
our experience, like other authors,7,8 we have not found a
prior condition that is related to the success of the recon-
struction, so each decision must be individualised for each
case. Each location has its own characteristics (size, three-
dimensional complexity, required tissue components) which
dictate what type of MFF is most suitable. As can be observed
Table 9 Complications.
Postoperative complications Number of flaps (n = 249)
Interventions 50 (20%)
Local bleeding 21 (8%)
Local infection 3 (1%)
Delay in scarring in the donor region 8 (3%)
Complications related to the flapa
Necrosisb 20 (8%)
<6 h 2
6---24 h 1
24---48 h 3
>48 h 14
Partial necrosis 6 (2%)
24---48 h 1
>48 h 5
a In 6 cases, the necrosis of the flap was accompanied by local
haemorrhage (5 cases) or infection (1 case).
b Three patients suffered necrosis of 2 flaps consecutively.
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Free Flap Reconstruction in the Head and Neck 39
1.0
0.8
0.6
0.4
0.2
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1.0
0.8
0.6
0.4
0.2
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0.0
0 12 24 36 48 60 0 12 24 36 48 60
0 12 24 36 48 600 12 24
Months Months
MonthsMonths
Reconstruction of hypopharynx
Reconstruction of skull base
S
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36 48 60
A B
C
 D 
Figure 4 Kaplan---Meier curves representing survival without locoregional recurrence and disease-specific survival in the recon-
struction of the hypopharynx (A and B) and the skull base (C and D).
in the series presented, the reconstruction of the hypophar-
ynx and complex facial and skull base defects represents
the main indications for the use of MFF. Moreover, MFF
also tends to be the technique of choice whenever vas-
cularised tissue is required, especially in relapses and in
previously irradiated patients. Despite being shared by other
authors,9,10 these indications are not absolute and should
not be regarded as dogma. It is very important to avoid
overindication and to opt, whenever possible, for simple
and quick solutions which offer the same functional result.
The experience of the surgical team will lead it to opt for
a specific reconstruction technique. Having a broad array of
reconstructive solutions available (MFF, local and regional
flaps) that can address different needs should be the ulti-
mate goal. It is important to consider the learning curve of
this technique in order to achieve reliable results. Although
there are no exact figures, the experience gained after
performing 30---50 MFF allows for optimal results.11 In our
series, the number of procedures increased steadily over
the years until it stabilised, allowing us to incorporate the
technique into our therapeutic arsenal and expand its indi-
cations.
While it may sometimes be possible to work in 2 fields in
an attempt to reduce the duration of the intervention, in our
experience this is not always the case and the mean duration
of surgery is fairly constant (9 h). This is possible due to an
ordered sequence of intervention by the surgical teams, as
well as the experience gained. Working sequentially allows
the team extracting the MFF to adapt it to the recons-
tructive needs following tumour excision. Although many
reconstructions are well-defined, occasionally the complex-
ity and uniqueness of the defects to be repaired make it
necessary to innovate along the way and even abort the
performance of a MFF, if it turns out not to be necessary. Hav-
ing extensive experience in microsurgery enables surgical
teams to have a variety of MFF available, manage microvas-
cular complications optimally and be capable of instantly
performing a second MFF.
The choice of type of MFF is significant. Each type of MFF
has different characteristics and is suited to specific needs
(Fig. 5).10 The ease of removal and previous experience are
relevant factors. The selection of the best reconstructive
option should be individualised. The RFFF and rectus femoris
flaps are the easiest MFF to extract and the most reliable. In
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40 J.L. Llorente et al.
Subscapular
system
Long pedicle and
good calibre Simple extraction
Long pedicle
Possibility of 
bone
Abundant tissue
Compound: skin, 
fascia, muscle, bone
Patient positionDisadvantages
Advantages
Morbidity at 
donor site Morbidity at
donor site
Excessive volume
Anatomical variability
Provides volume
Subcutaneous, fasciocutaneous, myofasciocutaneous
Fascia
Chimeral flaps
Pedicle with good calibre and length
Work with 2 teams
Versatility
Complex extraction
Does not provide 
volume
No fascia
Radial flap
Lateral circumflex
femoral arterial
system
Rectus abdominis
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Figure 5 Characteristics of the most commonly used free flaps.
contrast, compound MFF, chimeral MFF and ATFF, are more
complex and require greater experience. Fasciocutaneous
flaps offer a reconstructive solution in most cases.12 RFFF
are the most commonly used flaps, as well as the easiest to
extract, and can be used in multiple situations. In our case,
these were the MFF of choice for small, facial, skull base and
pharyngolaryngeal defects. Their failure rate is less than 2%,
but the sequelae at the donor site are not negligible (<10%).
ATFF also have a high success rate and leave scarce sequelae
at the donor site.10,13 According to the current trend,14 ATFF
are the MFF of choice in most head and neck reconstruct-
ions and the most frequently used at present.15,16 For special
situations, other MFF, such as those from the subscapular sys-
tem and rectus abdominis, as well as fibular, iliac crest and
jejunal flaps may also be used with good results.
The 2 regions that were most frequently reconstructed in
our series were the hypopharynx and the skull base. In previ-
ous articles15---17 we discussed our experience in these cases
considering the specific characteristics of the anatomical
region. The use of MFF, mainly ATFF, achieved satisfactory
functional results in the reconstruction of the hypopharynx,
with figures of 15% and 9% for pharyngocutaneous fistulas
and stenosis, respectively. These figures were lower than
those obtained with RFFF (20% and 11%, respectively) and
comparable to those obtained with jejunal MFF. The phona-
tory and swallowing functions obtained with ATFF were
superior to those achieved with other MFF.10 In recent years,
we have abandoned the use of the jejunum for fasciocu-
taneous flaps. The main reason is that MFF have a better
tolerance to ischaemia and greater versatility of the vascular
pedicle, and occasionally allow pharyngeal and cutaneous
reconstruction witha single flap (especially ATFF). Regarding
the reconstruction of the skull base, the use of MFF enables
large resections to be conducted, in order to obtain disease-
free margins with fewer complications. MFF help to achieve
an effective dural closure, isolate and fill cavities (pre-
venting infections and herniation of intracranial structures),
restore the airway and/or digestive tract, and rebuild the
orbit and the osteocutaneous craniofacial surface.17,18
The choice of recipient vessels is a critical step in these
procedures. It should be noted that, occasionally, due to
previous treatments, the potential recipient vessels are very
scarce. Having different options available is very important
to solve complex situations.19 The superior thyroid and facial
vessels and the external jugular vein were the most com-
monly used vessels in our series. These data are consistent
with those offered by Yazar,20 who proposed an algorithm
to select the recipient vessels based on the location of the
defect to be reconstructed. In general, it is advisable to
perform the anastomosis manually and with great care, in
order to correct any discrepancies and, if possible, using
1 artery and 2 veins. There are devices available which help
to perform the anastomosis, as an alternative to a manual
anastomosis.8 The use of venous grafts may be necessary,
although it increases the rate of complications.
Anaesthesia is also an essential part of the process. The
complication rate seems to be higher among procedures last-
ing more than 11 h.21 It is crucial to maintain a low arterial
pressure during ablation and, after performing microanas-
tomosis, the pressure should be slightly elevated in order
to facilitate perfusion of the flap. So far, there is no evi-
dence to support an absolute contraindication of vasopressor
agents during this surgical procedure.22 The use of antibi-
otic therapy (repeating doses every 4---6 h during surgery)
and the use of anticoagulants may favour the success of the
procedure.23
Postoperative care is vital, especially in the first hours.24
There are various methods to monitor MFF, which are more
complex in cases where it is hidden. However, no differ-
ences in failure rates were noted between hidden flaps and
those that can be monitored.25 Several authors advocate
externalising a segment of the MFF temporarily for moni-
toring. The use of Doppler probes does not appear to be
an entirely reliable method.26 As in our case, clinical signs,
although sometimes difficult to assess, are often the pre-
ferred method.
The success rate in our series was 92%, which was simi-
lar to the figures reported in the literature, with rates over
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Free Flap Reconstruction in the Head and Neck 41
90%.1,8 These figures are global and should be taken with
caution, as they group reconstructions performed in differ-
ent locations and under very different conditions. However,
we believe that they may serve as a reference to accept
the validity of the technique applied. Venous thrombosis is
still the main reason for loss of the flap. Most failures in
the literature take place within the first 48 h. Suspicion and
early intervention are essential to maximise the possibility
of rescue. A mean time of 60 min has been estimated to opti-
mise results. After identifying the MFF problem, there is a
75% chance of rescue in MFF, which are not hidden. Hidden
MFF have a lower possibility of rescue, since their problems
are usually identified belatedly. Overall, rates of successful
recovery range between 28% and over 90%.4 Following MFF
failure, the salvage therapeutic option seems to be a sec-
ond MFF or, if this is not possible, a regional flap.3 Contrary
to what has been described in the literature, the highest
rate of MFF necroses in our series occurred due to venous
thrombosis, 48 h after the procedure, which appears to be
associated with an infection of that region.27
The overall complication rate in our series was 20%, and
5% of cases required reoperation. These figures are similar
to those found in the literature.28 There is no evidence of
an association between the development of complications
and factors such as tumour histology, type of flap and pre- or
postoperative RT. However, Halle et al.29 did find an increase
in complications in patients with prior RT. The presence of
preoperative comorbidities could increase the number
of complications, so certain risk factors should be
controlled.30 The use of a limited range of MFF could be
related to fewer complications, due to experience with and
improvement of the technique.31
The administration of postoperative RT (when indicated)
is not a contraindication after performing MFF. Moreover,
along with other authors,32 we believe that reconstruction
with MFF would decrease complications related to high doses
of postoperative RT by providing well-vascularised tissue.
Our results indicate that these procedures could be carried
out safely.
In terms of disease control, the results obtained at the
level of the skull base and hypopharynx lead us to conclude
that MFF allow a certain degree of control of the disease
at a locoregional level.8,15---18 However, given the poor prog-
nosis of most patients requiring MFF for reconstruction, the
survival rates at 5 years are low.
Conclusions
The use of MFF represents a reliable and useful method for
the reconstruction of complex defects in the head and neck
region and remains the reconstructive method of choice
in these cases. Its use has enabled the resection of large
tumours, enhancing survival and improving the quality of
life of patients. MFF reconstructions should be performed
at centres with expertise in oncological and reconstructive
pathology.
Conflict of Interest
The authors declare no conflict of interest.
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