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Free-Flap Reconstruction in the Doubly Irradiated Patient Population

Cohn, Alvin B. M.D.; Lang, Patrick O. M.D.; Agarwal, Jayant P. M.D.; Peng, Stephanie L. M.S.; Alizadeh, Kaveh M.D.; Stenson, Kerstin M. M.D.; Haraf, Daniel J. M.D.; Cohen, Ezra E. W. M.D.; Vokes, Everett E. M.D.; Gottlieb, Lawrence J. M.D.

Plastic and Reconstructive Surgery: July 2008 - Volume 122 - Issue 1 - p 125-132
doi: 10.1097/PRS.0b013e3181773d39
Reconstructive: Head and Neck: Original Articles

Background: The standard of care for previously irradiated, unresectable, recurrent head and neck cancer has been chemotherapy alone. High-dose reirradiation with concomitant chemotherapy represents a more aggressive approach to these tumors and has afforded encouraging results with an increased fraction of long-term survivors. After reirradiation, these patients commonly present with extensive tissue loss, nonhealing wounds, contractures, and fistulas, and free-flap reconstruction is often necessary to correct the perils of oncologic treatment.

Methods: A 9-year retrospective review of 35 patients who required surgical intervention following a second round of chemoradiation was performed. Thirty-three free flaps were performed on 24 patients, and total radiation given before free tissue transfer ranged from 100 to 200 Gy. Indications for free-flap reconstruction included soft-tissue necrosis (15 of 33), tumor ablation (seven of 33), osteoradionecrosis (six of 33), oral incompetence (three of 33), tracheal perforation (one of 33), and esophageal stricture (one of 33).

Results: Free tissue transfer was successful in 94 percent (31 of 33) of flaps, with an overall major complication rate of 66 percent (23 of 35). Wound dehiscence (15 percent), infection (15 percent), hematoma (12 percent), fistula formation (12 percent), partial flap necrosis (9 percent), and total flap necrosis (6 percent) were the most commonly seen complications.

Conclusions: Although complications are common, free tissue transfer offers the difficult reirradiated patient a successful means of wound rehabilitation. The ultimate success of closing these wounds allows for aggressive oncologic treatment, which possibly will facilitate improved survival in this patient population that struggles with a dismal overall prognosis.

Chicago, Ill.

From the Sections of Plastic and Reconstructive Surgery and Otolaryngology, Head and Neck Surgery, the Department of Radiation and Cellular Oncology, and the Section of Hematology/Oncology, Department of Medicine, University of Chicago.

Received for publication March 22, 2007; accepted November 8, 2007.

Presented in part at the 43rd Annual Meeting of the Midwestern Association of Plastic Surgeons, in Chicago, Illinois, April 23, 2005.

Lawrence J. Gottlieb, M.D.; University of Chicago Hospitals; 5841 South Maryland Avenue; Chicago, Ill. 60637;

Disclosure: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

©2008American Society of Plastic Surgeons