Late Free Flap Failure in Head and Neck Reconstruction: Unusual Etiology in Two Case Studies and Literature Review
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CLINICAL REPORT
Late Free Flap Failure in Head and Neck Reconstruction: Unusual Etiology in Two Case Studies and Literature Review Mohamed Zahran1 Ahmed Youssef1
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Gary Hoffman2 • Robert Eisenberg2 • Andrew Tan2
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Received: 26 August 2020 / Accepted: 31 October 2020 Ó Association of Otolaryngologists of India 2020
Abstract The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates. However, devastating consequences of partial or total flap failure and subsequent loss may occur. This usually occurs in the first 48–72 h post-operatively. It is rare for flaps to fail in the late post-operative period and it remains poorly understood why flaps fail after day seven. We presented two patients in whom flap failure occurred after the seventh post-operative day (POD). Complete flap failure occurred after POD 9 and 27 in our cases. During the postoperative period, there was no evidence of early occlusion or insult to the vascular integrity such as venous/arterial compression. The cause of late flap failure was due to thrombophlebitis secondary to infection from the tracheostomy-neck fistula. This assumption was supported by recurrent failure of anastomoses revision. Keywords Free tissue flaps Head and neck cancer Flap failure
& Mohamed Zahran [email protected] 1
Department of Otolaryngology, Alexandria University School of Medicine, Champllion Street, El-Azareeta, Alexandria, Egypt
2
Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, Newcastle, NSW, Australia
Introduction Surgical resection continues to remain the mainstay of treatment for patients with head and neck cancer (HNC). The resulting defect is often complex and functional reconstruction requires the insertion of robust tissue with appropriate constituents. The development of microvascular free flap reconstruction in this context has made one stage surgery possible and reliable in the majority of HNC cases. ‘‘Microsurgery for the reconstruction of macro defects’’ [1] provides repair for extensive soft and/or hard tissue defects that require elements of lining, cover and/or separation, considered either in isolation or combination [2]. The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates (94–97%) [3–5]. However, as with any surgery, procedural complications can occur. In such circumstances, devastating consequences of partial or total flap failure and subsequent loss occur. This usually occurs in the first 48–72 h postoperatively. Anastomotic failure may be due to either primary venous outflow obstruction (thrombosis) or primary or secondary (to venous obstruction) arterial inflow failure [3, 6–9]. However, it is rare for flaps to fail in the late postoperative period and it remains poorly understood why flaps fa
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