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A Review of 30 Years of Head and Neck Flap Reconstructions at a Single Institution
Alexander Sun, BS, Xiaolu Xu, PhD, Saiyara Fahmi, Clarence Sasaki, MD, Stephan Ariyan, MD, Derek Steinbacher, MD, DMD.
Yale School of Medicine, New Haven, CT, USA.

Background. Head and neck (HN) defects after tumor extirpation are challenging to repair and may require flap reconstruction. Historically, pedicled flaps were the mainstay for HN reconstruction; but in recent decades, free tissue transfer has come into vogue as another reconstructive option. This study examines a single institution’s experience with HN reconstruction over a 30-year period with the objective of comparing pedicled and free flap outcomes and patient characteristics. We hypothesize that reconstructive preferences have shifted toward free flaps with time.
Methods. This is an HIC approved retrospective analysis. HN cancer patients receiving flap reconstruction from 1983 – 2013 were included. Records from the senior resecting surgeon (CS) were reviewed for demographic, perioperative, and postoperative data. Information was stratified based on flap type and time-point. Statistical analysis involved chi-square tests, z-test for proportions, and Fisher-exact tests. All tests were two-tailed with a significance level of 0.05.
Results. Over 3000 cases were queried and 861 fulfilled criteria. 91.6% of primary reconstructions were for squamous cell carcinoma. Pedicled reconstruction was preferred in the early years (96.3%), while free flaps predominated in later years (69.5%). Choice of flap type was significantly associated with gender, past irradiation, past chemotherapy, hypertension, dyslipidemia, tobacco use, and intraoperative brachytherapy. Free flaps were associated with significantly longer operative times (643.5 min vs. 429.7 min, p < 0.0001), postoperative critical care stay (4.23 nights vs. 1.43 nights, p < 0.0001), and postoperative hospital stay (16.89 nights vs. 14.01 nights, p = 0.0005). Free flaps also had higher rates of emergent reoperation, total flap loss, hematoma, and donor site morbidity (p < 0.001). By univariate analysis, pedicled flaps were more significantly associated with major complication (reoperation and total flap loss) in the setting of past local surgery and diabetes, while no factors were found to significantly affect rate of major complication for free flaps. Previously irradiated patients were much more likely to receive pedicled flaps; additionally, previous irradiation did not affect the rate of major complication for either pedicled or free flaps.
Conclusions. Head and neck reconstruction has shifted from pedicled flaps to free tissue transfer over the last 30 years. While free tissue transfer has been reported in literature to approach very low rates of complication, this study found pedicled flaps to have fewer complications and shorter operations and hospital stays. This is the largest single-center study that includes both pedicled and free flaps. Thus, it has the advantage of using the same outcome metrics to directly compare procedures with less variability than a multi-center study. This study focused on perioperative data and flap complications; as such, it does not account for any of the cosmetic or functional benefits of free tissue transfer. As free tissue transfer becomes the workhorse for HN reconstruction, there may still be a role for pedicled flaps in the armamentarium of the head and neck reconstructive surgeon.

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