Most patients with advanced head and neck cancers now undergo microvascular free flap reconstruction. This is mainly as flaps facilitate complete tumour and margin removal by providing reliable wound coverage and better restoration of form and function. However, despite this, loco regional recurrence remains the dominant form of treatment failure. Furthermore these patients are at risk of developing a second primary malignancy and complications of multimodality treatment, notably osteoradionecrosis, strictures and fistulae. The optimal treatment for these might involve further microvascular free flap reconstruction. There is understandable hesitation in performing sequential head and neck free flaps, mainly for fear of lack of suitable vessels and other postoperative complications. In this retrospective study the authors analyse patients that underwent one or more sequential flaps reconstructions between 2000 and 2012. A total of 278 flaps were performed on 117 patients and 23 patients had two or three simultaneous flaps. Patients had up to four sequential free flaps and one patient a total of five free flaps. This is an impressive series of flaps including a wide variety of flaps, receipt vessels and veins. Complications for subsequent free flaps (22.2-43.1%) were reported and were not significantly different from those of primary flap surgery. Also survival and good function was demonstrated. The authors demonstrate that in a selected patient cohort with the possibility of long-term good quality of life it is worth considering sequential flap reconstruction. This is an impressive series of flaps for reconstruction in a difficult set of patients and gives the surgeon confidence to think about sequential free flaps.

Success of sequential free flaps in head and neck reconstruction.
Hanasono MM, Corbitt CA, Yu P, Skoracki J.
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