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J Plast Reconstr Aesthet Surg. 2014 Sep;67(9):1186-93. doi: 10.1016/j.bjps.2014.05.012. Epub 2014 May 20.

Success of sequential free flaps in head and neck reconstruction.

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Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. Electronic address:
Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.



The need for additional free flaps following an initial free flap reconstruction sometimes arises. However, there is understandable hesitation to perform subsequent free flaps due to concerns regarding recipient vessel availability, flap loss, and other complications.


An analysis of patients undergoing one or more sequential head and neck free flap reconstructions between 2000 and 2012 was performed.


Two hundred seventy-three free flaps were performed on 117 patients over the course of 2, 3, or 4 surgeries, with 23 patients receiving 2 or 3 simultaneous free flaps in a single surgery. The success rate of subsequent free flaps was 98.7% compared to 99.1% for initial free flaps in the same patients (p = 1.00). The complication rate following subsequent free flaps was 42.9% compared to 36.8% following initial free flaps (p = 0.46). Flap success rates for double/triple simultaneous free flaps were 97.8% compared to 99.1% for single flaps (p = 0.41) and the complication rate for double/triple simultaneous free flaps was 34.6% compared to 47.8% for single flaps (p = 0.20). In patients receiving oral or pharyngeal sequential free flap reconstructions, 90.1% demonstrated at least 80% speech intelligibility and 81.6% remained feeding tube-independent. The 5-year survival of patients undergoing sequential free flaps was 75.4%.


Multiple sequential free flaps are feasible and reliable in appropriately selected patients. These findings suggest that the ability to perform free flap reconstruction should rarely limit a patient's candidacy for resection of recurrent cancers or consideration for surgery intended to improve patient aesthetics or function.


Complications; Free tissue transfer flaps; Head and neck cancer; Maxilla-mandibular reconstruction; Microsurgical free flaps

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