BACKGROUND: Free Flap is now considered as the gold standard method of reconstruction in head and neck cancer patients with a 95% reported success rate. The management of cases with free flap failure, however, remains a topic of debate. Although, there have been a few case series published that justify the use of secondary free flap, the results are inconsistent and varied. This study aimed to analyze the outcomes of salvage procedures performed on patients following free flap failure and the various patient factors that correlate with postoperative results. These data were used to derive an algorithm to aid in surgical management in such patients.
MATERIALS: The study was conducted by performing a retrospective chart review of patients who were surgically treated following free flap failures for head and neck cancers between 2010 and 2020. A total of 50 flaps performed on 48 patients were included in this study and assessed for their demographic details, smoking, comorbidities, steroid use, type of tumor, stage at presentation, neoadjuvant therapy, type of failed free flap, donor and recipient vessels, postoperative complications, type of salvage procedure, complications after salvage procedure, and management after failure of a salvage procedure.
RESULTS: Of the 50 primary free flap failures included in this study, 22 were salvaged by a pedicled flap with a 90% (20/22) success rate. In total, 28 primary free flap failure patients who underwent reconstruction by a secondary free flap were placed in three groups depending on which day the secondary procedure was performed: group A: 0–5 days, group B: 6–30 days, group C: >30 days. A significantly higher rate of survival of salvage free flap was observed in group A (Flap survival: 87.5%; 7/8) and C (Flap survival: 90%; 9/10), whereas group B (Flap survival: 40%; 4/10) showed a high incidence of flap failure (P = 0.023). Smoking and tobacco use was associated with a higher incidence of failure rates, although this was not statistically significant (P = 0.094, P = 0.791). A significantly higher rate of free flap failures was seen with diabetes mellitus (P = 0.004), hypertension (P = 0.023), and chronic steroid use (P = 0.019).
CONCLUSIONS: Reconstruction by a secondary free flap after a failed primary free flap in the head and neck region remains a challenging task for a plastic surgeon owing to high complications and secondary failure rates. Timing and the type of reconstruction plays the most important role in this scenario as best results with secondary free flaps are observed with early reconstruction within 5 days; alternatively, a waiting period of at least 1 month should be offered to a patient to achieve optimum results. Further, patient factors such as smoking, diabetes mellitus, hypertension, and steroid use should preclude free flap reconstructions; such patients are best benefitted by pedicled flap reconstruction. Our algorithm aids the surgeon to make the best decision for these patients.