British Journal of Oral and Maxillofacial Surgery 45 (2007) 1115

Reconstruction of defects in the head and neck with free

aps: 20 years experience

A. Eckardt

, A. Meyer, U. Laas, J.-E. Hausamen

Department of Oral and Maxillofacial Surgery, Hannover Medical School, OE7720, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
Accepted 14 December 2005
Available online 7 February 2006
Abstract
Between March 1982 and December 2002 we did a total of 534 reconstructions with free aps from various donor sites for 529 patients.
The jejunum was the donor site in 181 reconstructions (34%), followed by the radial forearm ap in 173 reconstructions (32%); 86% of the
reconstructions were immediately after excisions. Surgical re-exploration was necessary in 37 patients (7%); the failure rate from necrosis of
the ap was 5%. Factors associated with complications were American Society of Anesthesiology (ASA) class and age.
2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Free ap transfer; Reconstructive surgery; Head and neck cancer; Postoperative complication
Introduction
Extensive tissue defects in the head and neck are a chal-
lenge for reconstructive surgery. Regardless of the aetiology
of the defect, be it resection for neoplasm, infection, oste-
oradionecrosis, congenital defect, or trauma, the goals and
principles are similar; they are to restore adequate function
and aesthetics and thereby improve the quality of life. During
the past three decades, tremendous progress has been made in
the eld of reconstructive surgery, in particular as a result of
the introduction of free vascularised tissue transfer.
1,2
Con-
tinual renements in microsurgical techniques and the use
of various donor sites have increased the surgical indica-
tions for extensive resections of advanced neoplasms of the
head and neck. Large patient series with successful free ap
transfer for head and neck reconstruction have been reported
by many authors and demonstrated todays role as principal
reconstructive procedure.
36
In contrast to local and regional
aps, free aps are more effective in complex or extensive

Presentedat the 6thInternational Conference onHeadandNeckCancer,

August 711, 2004, Washington, DC, USA.

Corresponding author. Tel.: +49 511 5324878; fax: +49 511 5328879.
E-mail address: eckardt.andre@mh-hannover.de (A. Eckardt).
defects, have better blood supply, and are associated with
fewer complications.
7,8
We now report a large series of reconstructions of defects
in the head and neck with free aps over a 20-year period.
Patients and methods
We did a retrospective review of demographic and clinical
data fromall patients who had transfers of free aps to recon-
struct various kinds of defects in the head and neck in the
department of oral and maxillofacial surgery at the Univer-
sity Hospital Hannover between March 1982 and December
2002. All free vascularised tissue transfers of the head and
neck region were analyzed by reviewing the patient charts
with particular emphasis to aetiology and site of the defect,
patient co-morbidities, American Society of Anesthesiology
(ASA) class, free ap donor site and postoperative compli-
cations. Microvascular anastomoses were performed using
the largest caliber recipient vessels available. During this 20-
year period pharmacological treatment was not standardised,
but many of the patients were given low-molecular weight
dextran (Dextran-40) postoperatively for 2448 h. Postop-
eratively aps were monitored by clinical observation and
0266-4356/$ see front matter 2006 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2005.12.012
12 A. Eckardt et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 1115
occasionally also by Doppler ultrasonography. We examined
patients characteristics, choice of ap, duration of operation,
durationof anaesthesia, andpostoperative complications (dif-
ferentiating between overall, local, and medical complica-
tions). Overall complications were dened as those (local
and medical) that required additional surgical or non-surgical
treatment. Local complications were dened as complica-
tions at the surgical site including wound haematoma or
breakdown, complications at the recipient site of the ap, fail-
ure of the ap, and the need for additional operations. Medical
complications included those of a cardiovascular, pulmonary,
infective, neurological, and miscellaneous nature. Statistical
analysis of data was performed using the statistical package
for the social sciences (SPSS for Windows release 11.5) and
included descriptive analysis of the whole patient population.
Analysis of risk factors for postoperative complications was
performed by crosstable analysis and logistic regression anal-
ysis. Variables in the analysis of local and medical compli-
cations included American Society of Anesthesiology class,
use of tobacco and alcohol, preoperative radiochemotherapy,
age less than or more than 60 years, and duration of opera-
tion. A p value of 0.05 or less was regarded as statistically
signicant.
Results
Between March 1982 and December 2002, a total of 534
patients received free ap transfers to repair various kinds of
defects in the head and neck. There were 394 men and 140
women ranging in age from 7 to 88 years (mean 51 years).
There were 139 patients over 60 years old (26%). Defects
were reconstructed immediately in 457 patients (86%) and
75 patients (14%) had secondary reconstruction for func-
tional or aesthetic reasons after excisions for cancer, trauma,
or congenital defects (Table 2). Among the 534 patients there
were 433 who had tumours, 70% being squamous cell car-
cinoma; 128 (24%) had been enrolled in a chemoradiation
trial with cisplatin (12.5 mg/m
2
a day on days 15) and total
radiation dose of 36 Gy. In 101 patients, free ap reconstruc-
tions were performed for various other conditions including
trauma, osteoradionecrosis, and congenital disorders.
The most common ap was the jejunal (181 aps, 34%),
followed by the radial forearm (173 aps, 32%) (Table 1).
The recipient artery used for the anastomoses varied, the
superior thyroid (n =160) being the most common followed
by the facial (n =153) and the lingual (n =57). For venous
anastomoses the thyroid-lingual trunk (n =136), the facial
vein (n =92), and the superior thyroid vein (n =79) were the
most common. In most cases end-to-end anastomoses were
made. Starting in 1991 the jejunumwas gradually replaced as
donor site by the radial forearm ap. The donor and recipient
sites are shown in Table 1. The mean duration of anesthesia
including surgical resection was 10.4 h (range 422.8 h). Sur-
gical procedures longer than 8 h accounted for 81.5% (435
patients).
Table 1
Patients demographic and clinical data (n =534)
Sex
Male 394(74)
Female 140(26)
Age
Mean age (years) 51, range 788
<60 years 395(74)
60 years 139(26)
ASA class (n =279)
I 18(3)
II 102(19)
III 153(29)
IV 6(1)
Aetiology of defect
Tumour ablation 433(81)
Not tumour-related 101(19)
Reconstruction
Immediate 457(86)
Secondary 75(14)
Preoperative chemoradiation
Yes 128(24)
No 406(76)
Duration of operation (h)
Mean 10, range 423
<8 h 72(14)
8 h 435(82)
Donor site
Jejunum 181(34)
Radial forearm 173(32)
Fibular 46(9)
Latissimus dorsi 38(7)
Scapular 30(6)
Gracilis 19(4)
Rectus abdominis 16(3)
Iliac crest 14(3)
Upper lateral arm 8(2)
Parascapular 7(1)
Others 2
Recipient site
Oral cavity/oropharynx 397(74)
Scalp/facial skin 53(10)
Mandible 58(11)
Maxilla/midface 26(5)
Figures are number (%) unless otherwise stated.
The overall success rate of reconstructions with com-
plete ap survival was 95%. Arterial thrombosis developed
in 24 cases and venous thrombosis in 13 cases. These 37
patients were re-explored and in 10 the ap was salvaged.
A total of 27 aps failed from necrosis and these aps were
removed. When the reconstruction was immediate (n =457)
21 aps failed (5%) and when the reconstruction was sec-
ondary (n =75) 6 aps failed (8%) (Table 3). No statistical
difference regarding complete ap survival was observed
between these two groups.
Signicant factors associated with development of medi-
cal complications were age more than 60 years (p <0.001)
and ASA class III and IV compared with class I and II
A. Eckardt et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 1115 13
Table 2
Distribution of free ap donor sites (n =534)
Donor site Total
(n =534)
Immediate
reconstruction
(n =457)
Secondary
reconstruction
(n =75)
Jejeunum 181 179 2
Radial forearm 173 165 8
Fibular 46 24 22
Latissimus dorsi 38 35 3
Scapular 30 17 13
Gracilis 19 6 13
Rectus abdominis 16 16
Iliac crest 14 4 10
Lateral upper arm 8 8
Parascapular 7 3 4
Others 2 2
Table 3
Comparison between immediate and secondary reconstruction in ap
survival
Total (n =532) Immediate
(n =457)
Secondary
(n =75)
Complete survival 505 (94.9%) 436 (95.4%)
*
69(92%)
*
Total ap necrosis 27 (5.1%) 21 (4.6%) 6(8%)

p =0.25, Fishers exact test

(p =0.024); signicant factors for local complications were
also age more than 60 years (p =0.027) and ASAclass III and
IV(p =0.002) (Table 4). Logistic regression analysis showed
that ASA class (p =0.002), alcohol consumption (p =0.021),
Table 4
Factors associated with (a) local and (b) medical complications after free
ap reconstruction (n =534)
Factor Rate of complication p
*
(a)
ASA
I (n =18) 17%(3) 0.010
II (n =102) 17%(17)
III (n =153) 35%(53)
IV (n =6) 17%(6)
ASA
I/II (n =120) 17%(20) 0.002
III/IV (n =159) 34%(54)
Age
<60 years (n =395 21%(82) 0.027
60 years (n =139) 30%(42)
(b)
ASA
I/II (n =120) 7%(8) 0.02
III/IV (n =159) 16%(25)
Age
<60 years (n =395) 8%(31) <0.001
60 years (n =139) 22%(31)
Tobacco use
Yes (n =367) 8%(13) 0.063
**
No (n =167) 13%(49)

Fishers exact test.

Pearson
2
.
and preoperative chemoradiation (p =0.01) were signicant
factors for local complications and ASA class (p =0.05) and
age more than 60 years (p =0.002) were signicant factors
for medical complications. Fifteen patients died within 30
days of operation (3%).
Discussion
Afundamental change in ways of reconstruction of defects in
the head and neck was the introduction of free vascularised
tissue transfer in the 1970s and 1980s, which enabled pri-
mary reconstruction for extensive defects. Since that time
microvascular free tissue transfer has gained world-wide
acceptance and is the option of choice for large and complex
defects.
1,4,6,9
This procedure has largely replaced traditional
surgical concepts of multiple stage reconstruction using pedi-
cled and local aps. Our data represent clinical experience
over a 20-year period with 534 microvascular free ap recon-
structions of various kinds of head and neck defects in 534
patients. The majority of patients (81%) suffered from head
and neck tumours of various histology. Our series is rela-
tively unbalanced as 74% of the recipient sites were soft
tissue defects of the oral cavity and oropharynx. Evaluat-
ing the results of diverse reconstruction modalities following
head and neck defect reconstruction is extremely difcult,
particular when location and extent of defect varies. The lack
of functional assessment at a standard time-point for each ap
may be a limitation of the comparative analysis; due to the
retrospective nature of our reviewroutine functional outcome
assessment was not available.
Inagreement withother surgeons we have preferredimme-
diate reconstruction after radical resection of tumours.
3,6,10,11
Inthis series immediate reconstructionwas performedin86%
of the cases. Arguments in favour of immediate reconstruc-
tion are the ease of access to recipient veins and arteries in
the vicinity of the defect, soft tissues not subject to secondary
brosis and distortion, and the patient not left with a con-
siderable functional disability. During the 20-year period it
became apparent that there is an optimal ap for each site
in the head and neck. Our preferred donor site for restoring
large mucosal defects of the oral cavity and oropharynx was
the jejunal ap for many years.
12
However, today the radial
forearm ap has become our choice for reconstruction of
intraoral soft tissue.
1,13,14
The radial forearm ap provides
thin, pliable tissue that helps the tongue to move. Another
appealing feature of the radial forearm ap is the fact that
the ap can be harvested simultaneously with the resection.
In recent years there has also been an increasing interest in
restoration of sensation in radial forearm aps
15
indicating
that reinnervation of the ap by nerve coaptation is successful
and warrants further clinical investigation.
15,16
For reconstruction of the mandible four donor sites (bula,
iliac crest, radial forearm, and scapula) have become the
sources of vascularised bone and soft tissue.
1720
We prefer
the bular osteocutaneous ap rather than the iliac crest and
14 A. Eckardt et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 1115
scapular aps. It provides an excellent length of bone with
sufcient cross-section for subsequent insertion of osseoin-
tegrated implants, can tolerate multiple osteotomies, and can
be well adapted to mandibular defects. For large mandibular
defects, particularly when they are anterior or large lateral
including the ascending ramus, the osteocutaneous bular
ap has become the ap of rst choice.
3,19,2025
Cordeiro et
al.
25
developed an algorithm for mandibular reconstruction
based on a systematic analysis of 150 patients and came to
the conclusion that the bular donor site should be the rst
choice for most mandibular defects. These ndings were sup-
ported in another prospective analysis and a similar algorithm
for mandibular reconstructionwas developed.
20
However, the
iliac crest donor site can still be used in patients who have
vascular compromise of the extremities, although morbidity
at the donor site can be substantial and the bulky skin paddle
is not optimal for some mandibular defects.
During our analysis we realised that this retrospective
evaluationof various types of reconstructionat different times
is probably a weakness of our study. However, each ap was
at that particular time the most commonly used method for
reconstruction in our institution and we developed a similar
expertise with each procedure. Nevertheless, given the large
number of 534 microvascular reconstructions, we are con-
dent that we can draw some valid conclusions from this
retrospective study. By overlooking a 20-year period with
accumulation of extensive clinical experience in microvas-
cular reconstruction techniques, it has become obvious that
limitation to a relatively small number of donor sites will
lead to improved ap harvesting and ap insetting. Increas-
ing the clinical experience, will also decrease the operating
time, a fact which contributes by itself to a further decrease
of complications. Disa and Cordeiro
19
stressed the fact that a
simplied approach using a small number of well-established
aps, leads to reliable surgical outcomes with fewer compli-
cations.
Our complication rate of 5% with regard to ap necro-
sis compares favorably with reported failure rates in recently
published series (Table 5).
2,6,14,2833
The surgical mortality
rate of our series was 3%; this is comparable with other pub-
lishedreports.
14,34
Causes of deathinour 15patients included
multiple organ failure, adult respiratory distress syndrome,
Table 5
Free ap failure rates in head and neck reconstruction
Author Patients Total ap loss (%)
Vaughan
27
120 7.5
Schustermann et al.
2
308 5.5
Urken et al.
28
200 6.5
Jones et al.
3
305 8.8
OBrien et al.
29
250 4
Blackwell
30
119 0.8
Singh et al.
31
200 2
Haughey et al.
14
241 4
Wei et al.
32
1235 3.4
Bizeau et al.
33
165 9
Nakatsuka et al.
6
2372 4.2
myocardial infarction, and peritonitis. Patients undergoing
extensive oncological operations and free ap reconstruc-
tions often have serious comorbidities that increase the risk
of postoperative complications.
31,35,36
Consequently, many
authors argue in favor of an optimized preoperative patient
assessment as a prerequisite to prevent and minimize post-
operative complications and point out that careful patient
selection certainly is a critical issue.
8,31,34,36
An improved
outcome might be closely related to the identication of pre-
dictive factors for perioperative complications.
37
Our analysis revealed age 60 years (p =0.027/p <0.001)
and ASA class III/IV (p =0.002/p =0.024) as signicant risk
factors for local and medical complications, respectively.
Tobacco use shows a trend towards signicance (p =0.063)
and seems to be related with an increase of medical complica-
tions. We were not able to show any correlation between the
duration of the procedure and postoperative complications,
although an increased risk has long been debated. Haljamae
38
reported that the duration of anaesthesia inuences the inci-
dence of postoperative complications, but suggested that this
might reect the severity of the underlying disease and the
extent of the operation instead of some unique characteris-
tic of a prolonged exposure to anaesthetics. Likewise, longer
operations are commonly associated with more extensive dis-
ease, which might cause a higher rate of complications. Singh
et al.
31
identied duration of anaesthesia (p =0.02) as a sig-
nicant risk factor for medical complications and increased
age (p =0.02) as a signicant factor for complications at the
recipient site. They also identied by multivariate analysis a
severe Charlson comorbidity index as the single most impor-
tant risk factor for medical complications.
31
In conclusion, free ap transfer for reconstruction of large
defects in the head and neck is a highly successful and rel-
atively safe method with success rates between 92% and
98% and can be regarded as the principal reconstructive
procedure for extensive post-oncological as well as post-
traumatic defects in the head and neck.
2,3,6,26,29,31
However,
as most patients with head and neck tumours often have med-
ical comorbidities a proper and critical preoperative assess-
ment of the risk of postoperative complications is essential
before such patients are selected for extensive oncological
and reconstructive surgery.
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