Background: Free flap tissue transfer has become a key technique for head and neck reconstruction following tumor resection. As factors associated with flap loss have been studied, description of secondary reconstructive efforts in the setting of flap loss have been less reported. Flap failure can require reoperation and has been reported to increase hospital length of stay, readmission rate, and delay initiation of adjuvant therapy. Flap failure can be a devastating complication for patients and surgeons alike and subsequent management and decisions may be hampered by fear of losing additional flaps. The purpose of this study is to review and analyze management of free flap failure at our own institution and describe outcomes following secondary free flaps, regional flaps or conservative management.
Methods: A single institution retrospective review was performed. Approval for the study was obtained from the Washington University School of Medicine Institutional Review Board. Patients were included if they underwent free flap at our institution between January 1st, 2004, and January 1st, 2021. Patient information regarding flap type, indication, length of stay, 30-day readmission, and start date of adjuvant therapy was extracted from the electronic medical record. Mann-Whitney U and Chi squared tests were used for analysis. Median differences and corresponding 95% CI were used to assess for clinically meaningful differences.
Results: A total of 1148 patients were included in the review. 74.6% of patients were Caucasian, 63.1% were male, 32.3% reported active tobacco use, 39.3% report current alcohol use, 28.1% had prior head and neck radiation. 1083 flaps were determined to be healthy with no failure. 25 flaps had partial failure (2.17%). 40 flaps had total failure (3.48%). Among patients who experienced flap loss, the most common type of flap was fibular osteocutaneous free flap (30.8%). Oral cavity and oropharynx comprised of 86.2% of flap recipient sites. 80% of flaps were used after oncologic resection. Of the 65 patients with flap failure, data on second treatment for tissue defect was available for 60 patients; 27 were managed with conservative treatment, 23 were managed with a regional flap, and 10 were managed with a second free flap. Of the 10 second free flaps, 9 flaps were successful, 1 flap had partial failure, and no flaps had total failure.
The median difference in length of stay (days) and time to adjuvant therapy (days) for patients with healthy flap compared to those with flap loss was 6 days (95%CI 4-8 days) and 8 days (95% CI 1-15 days), with no statistically or clinically meaningful difference in 30-day readmission rate (21.0% versus 28.3%, p=0.153)
Comparing failed flaps that were managed conservatively to flaps managed with a regional flap or second free flap (Figure 2), the median difference in length of stay and time to adjuvant therapy were not significant: -5 days (95% CI -11 to 0 days) and 1 day ( 95% CI -13 to 17 days) nor was 30-day readmission rate (32% versus 32.3%, p=0.984).
Conclusion: Free flaps can safely be performed in a setting of first flap failure without significant increase of failure from baseline risk. Second free flap reconstruction was not associated with an increased length of stay or delay in start of adjuvant therapy compared to conservative management of initial flap loss. Careful examination of indication, patient wishes, and surgeons' comfort will still need to guide decision making in these challenging situations.
