Introduction

The reconstruction of the large loco-regional defects resulting from the oncological margins in head and neck resections is of utmost importance. This procedure minimizes morbidity, preserves organ function (such as phonation and swallowing), protects vital structures, gives an adequate aesthetic appearance, and improves quality of life.

The use of the pectoralis major flap was first described by Ariyana in 1979 for head and neck reconstruction. Since then, there have been great advances in reconstruction. Although the first microvascular flap was performed in 1959 by Steinberg, it was only in 1970 that the technique became popular and, from the 90’s it was rapidly and progressively developed, including new proposals for microsurgical flaps that add three dimensional (3D) preoperative designs and improve aesthetic and functional results. Over those years, different and versatile pedicled and nonpedicled flaps were also developed; good examples are the submandibular and supraclavicular flaps, which efficiently achieve similar results.

In contrast to this trend of microsurgical reconstruction as an almost obligatory alternative, individualized indication in cases where the other flaps can’t achieve similar results, aiming to reduce surgical time, morbidity, and health care costs.

Different studies show similar or better benefits with pedicled or nonpedicled regional flaps in terms of functional and aesthetic results, with similar rehabilitation possibilities and a shorter surgical time, less requirement for intensive care units (ICUs), and lower health care costs. This means that regional flaps still have an important role in the era of free flaps, and should be considered when defining a reconstruction.

Materials and Methods

A retrospective, cross-sectional review study was conducted in patients who underwent reconstruction with regional and microsurgical flaps after oncological head and neck surgery to correct a surgical defect from resection. Cases from January 1^st, 2019, to December 31, 2023, were included to evaluate the results of reconstruction with both techniques. The inclusion criteria were patients over 18-years-old who underwent regional and microsurgical flaps for reconstruction for and oncological surgery, for a benign condition or trauma. Those with incomplete information were excluded. For the purposes of this work, the microsurgical propeller and regional pedicled flaps were grouped, considering that no microvascular anastomosis was performed in them. Clinical data were recorded regarding the patient and the primary tumor, its location, clinical stage, type of surgery, pathological anatomy, type of reconstruction, morbidity, and mortality. There wasn’t direct intervention to patients and the study followed the guidelines of the Declaration of Helsinki. Institutional approval was obtained and patient data were obtained from the institutional medical records, preserving their privacy.

Data were collected in a Microsoft Excel (Microsoft Corp.) spreadsheet. The IBM SPSS Statistics for Windows (IBM Corp.) software, version 22.0, was used for statistical analysis. The Shapiro-Wilk test was applied to assess the normality of quantitative variables. The quantitative variables were expressed as means and standard deviations (SD). The qualitative variables were expressed with absolute and relative frequencies. The bivariate analysis of correlation of the dependent variables was performed using Pearson’s correlation. To evaluate their association with the other variables, binary logistic regression was performed. Statistical significance was defined as p < 0.05, and 95% confidence interval (CI).

Results

A total of 269 patients were included, of whom 105 were women and 164 men. The mean age was 62.5 years; 60.2% were over 61-years-old, and most were between 51 and 79- years-old. Oncological resection for cancer (96.3%) was the main indication for flap, followed by benign and traumatic indications. Squamous cell carcinoma was the most frequent etiology, with 187 cases, followed by papillary thyroid carcinoma (6.3%), and others like sarcoma (3.7%), melanoma (3%), and cystic adenoid salivary glands (3.7%). The main locations were oral cavity and oropharynx (28.6%), followed by paranasal sinuses and orbit (20.1%), larynx (12.3%), and parotid gland (14.9%). Most patients were in the clinical stage IV (77%), the rest were III. No patients were diagnosed in early stages, and few cases were benign or trauma (►Table 1). Surgical treatment was used an initial therapy in 167 patients, and as a secondary in 102, after previous nonsurgical oncological management.

Table 1 - Characteristics of patients

The most frequent surgery was partial or total maxillectomy (14.5%), followed by pharyngeal monobloc resection, laryngectomy, glossectomy, orbital exenteration, comprehensive neck dissection, and tracheal resection. Regarding oral cavity surgeries, 20.5% required mandibular resection and 12.8% an approaching mandibulotomy.

The most frequent flaps used were the regional flaps in 70.6% of cases. Among microsurgical flaps, 48 were musculocutaneous and 12 osteocutaneous. Regarding the type of free flaps, the radial was the most used (10.4%), followed by the anterolateral thigh (ALT) , scapula, and fibula flaps. A total of 168 pedicle regional flaps were performed; the most common was the Ariyana (27.1%), followed by the supraclavicular and the submandibular ones (►Table 2). Regarding the location, defects in the oral cavity were resolved with a submandibular flap in 38.9% of cases, with musculocutaneous microsurgical in 31.9% and osteocutaneous in 15.3% of patients. Oropharyngeal defects were covered with regional flaps in 88.2% of patients. Most of orbital and SPN defects required a microsurgical flap but 31.1% could be resolved with a propeller one.

Table 2 - Type of flap

Overall morbidity was 16% but only 6.8% was associated with the reconstruction with a free or pedicle flap. With respect to microsurgical flaps, their morbidity was 22.5% and 13.2% for the regional flaps. Altogether, causes of morbidity were compromised of flap vascularization, surgical site infection, hematoma, and dehiscence. Postoperative pneumonia also occurred in 2 patients (0.7%). Regarding morbidity by type of flap, arterial thrombosis was found in 3.8% in the free flaps group; dehiscence in 1.3% free flaps and 2.6% regional ones; the appearance of fistula in 2.5% free flaps and 3.7% regional flaps; as well as hematoma in 5% of the free flaps and 1.6% of regional ones. When vascular compromise of the flap was detected, 46.2% could be rescued during the revision surgery with a new arterial or venous anastomosis depending on the situation. Those that couldn’t be rescued successfully underwent regional flaps, with one exception who underwent a second free flap with no success.

Mortality occurred in 18 patients (6.7%), all were in stage IV, 10 patients were over 70-years-old (55.6%), half had cancer of the aerodigestive tract. The most frequent causes were postoperative fistula and vascular complications, and the rest were nonsurgical medical causes (►Table 3).

Table 3 - Characterization and causes of morbidity and mortality in patients

Bivariate analysis was performed using Pearson correlation. There was evidence of an intermediate correlation between older patients and greater morbidity, and a low correlation between advanced clinical stages and the more frequent need for microsurgical flaps. Also, there was no correlation between the type of flap or the clinical stage with greater morbidity (►Table 4).

Table 4 - Logistic regression morbidity/mortality analysis

Similarly, there is a high correlation between ages over 70- years and higher postoperative mortality, and a significant correlation between the type of flaps and higher mortality. Additionally, logistic regression analyses were performed to evaluate whether morbidity was associated with type of flap, age, sex, clinical stage, tumor location, and mandibular approach. The results found that microsurgical flap was 2.8 times more likely to present morbidity (p = 0.010). When considering the same variables to explain mortality, male patients had a 2.7 times higher risk (p = 0.052). Furthermore, there was an 18.5-fold increased risk of mortality in postoperative morbidity cases (p = 0.001) When analyzing the type of morbidity, patients with postoperative involvement of flap vascularization had a 0.27 times higher risk of mortality (p = 0.001), as can be seen in ►Table 4.

Discussion

Flap reconstruction in head and neck surgery is an important tool to minimize the sequelae of large resections with oncological margins, aiming to achieve coverage, function, and color match, among others, to restore normalcy of the tissues. There has been a great technical evolution in the performance of head and neck flaps for reconstruction, with a higher current preference for free ones. However, reconstruction with pedicled regional flaps has been a tool of great value for the multiple head and neck subsites.

Free flaps are more time-consuming and require more training. Sometimes they must be performed in conjunction with reconstructive surgeons, who are not always accessible in all institutions. Hence, in this scenery, the importance of head and neck surgeons also being protagonists when reconstructing is highlighted.

Day et al. conducted an online cross-sectional survey of all surgeons in the American Society for Head and Neck Surgery to determine the experience characteristics of surgeons performing regional flaps; 197 replies (25%) were obtained. Surgeons performing both regional and free flaps took less time to practice, but the number of regional flaps per year was higher; 28 and 23% of surgeons performed supraclavicular and submental flaps, respectively, at least 4 to 10 times per year. The most frequent were regional flaps for reconstruction.¹

In our study, the postoperative morbidity rate was 6.1%, of which 22.5% were microsurgical and 13.2% regional flaps. These rates are a little higher compared to the study from the San Paolo Hospital (Italy) who collected 45 patients reporting the percentage of complications of 4.4% for their regional flaps, from 2009 to 2014. These, included muscle and myocutaneous flaps of the pectoralis major, trapezius, supraclavicular, latissimus dorsi, and fasciocutaneous temporalis. No flap failure was observed. One case presented complete loss of skin but retained the muscular part of the flap. One case had partial loss of the skin, and one with active bleeding.²

Similar to our work, Gabryz-Forget et al. evaluated the complications categorized according to the type of flap performed, regional or microvascular. Their systematic review showed that free flaps were associated with a higher incidence of complications compared to regional ones, 68 versus 36% respectively. Microsurgical flaps also had greater rates of arterial thrombosis and hematoma, while regional ones had greater dehiscence and appearance of fistula.³ Our cases showed similar findings but in a much lower percentage, with no cases of arterial thrombosis in the pedicled patients and minimal fistula difference between the two groups (2.5% microsurgical vs. 3.7% regional). Surgical times are longer for patients with a free flap reconstruction, with longer ICU and hospital stays. Although our study did not consider quality of life, Gabryz-Forget et al. reported similar scores in terms of swallowing and phonation with both reconstruction techniques, similar oral opening, and similar results of dependence on the feeding tube.³

On the other hand, unlike our study, Goyal et al.⁴ showed a higher rate of infection 9.1% with no difference in flap type, associated with prolonged hospital stay. The presence of fistula was also higher compared to ours, 8.2 versus 3.7%, respectively, with no significant differences between free and pedicle flaps. The pedicled ones presented with fistula in the elderly population, as well as in patients who previously underwent surgery or radiotherapy.

In the patients with morbidity related to vascular involvement due to ischemia or thrombosis, 46.2% had successful revision of the flap. This rate is a little lower compared to other rescue publications regarding rescue techniques of free flaps. Kucur et al.⁵ presented loss of the free flaps in 3.5% of their patients; 12% of their flaps needed a revision surgery, with a successful rescue in 57%. Ross et al.,⁶ in their series of 1,473 patients, required rescue in 2.8% of cases with a second free flap, with a success rate of 73%. In our work, only one patient required a second rescue flap, which wasn’t successful.

Bozikov and Arnez⁷ obtained a success rate of 85% in 162 patients, observing that the failure of free flaps was 5 times higher in the presence of diabetes and 4.6 times higher after salvage surgery, especially if an interposition venous graft was used.

The systematic review by Mooney et al.⁸ compared the submental and free flaps, and included 7 studies, most of which were retrospective. Although the groups evaluated had moderate heterogeneity, the regional flap reduced the surgical time by an average of 193 minutes, as well as the length of hospital stay by 2.1 days compared to the free flaps. Total flap loss, hematoma, surgical site infection, dehiscence, and venous congestion rates were similar in both groups, with no statistically significant differences. Tumor recurrence was under 10% in both groups. On the other hand, Vitkos et al.⁹ also compared the supraclavicular and free flaps. They found 8 studies with no significant difference in terms of flap loss, necrosis, fistula, and dehiscence, proposing these flaps are alternatives of similar utility to the microvascular one.

The multivariate analysis found a high correlation between older patients and higher morbidity, as well as between those over 70-years-old and higher postoperative mortality. There are several authors who have reported that age should not be considered an independent risk factor for performing a free flap. Ferrari et al.¹⁰ had a success rate of 96.5% in 54 flaps performed in patients over 75-years-old with a complication rate of 30.9%, similar to that of younger patients, noting an association with the American Society of Anesthesiologists (ASA) classification’s physical status rather than age. Similarly, Tarsitano et al.¹¹reportedthatthe complication rate was similar in patients older (11%) and younger (9%) than 75 years, with a high ASA score being related to a higher probability of complication.

Our results could not be compared with the systematic review by Fancy et al. since their cut-off point of greatest risk of perioperative morbidity and mortality was 80-years, finding serious complications at 30 days in up to 51% of cases, and mortality of 8% at 90 days, especially associated with greater frailty, low body mass index (BMI), long duration of surgery and subsites such as oral cavity, oropharynx and maxilla. Similar to our study, in the presence of morbidity, mortality was even higher in patients under 80-yearsold. The type of flap, free or pedicled, was not associated with morbidity and mortality, and it did not contrast with the surgical time, which is obviously longer in microsurgical patients.¹²

With respect to sex-related mortality, which in our study was higher in men, the Global Burden Cancer¹³ data shows similar findings, where the mortality is higher in men 241,585(95% uncertaintyinterval [UI]: 207,546-279,188) compared to women with 148,189 (95% UI: 124,242- 175,146). The higher incidence for men was 2:1 in that study, and in ours 1.5:1. Mortality was also higher in the group between 70 and 79-years-old.

Finally, the postreconstruction mortality observed in our study was 6.8%, similar to Ali et al.,¹⁴ who showed a 30-day mortality for free flaps of up to 6.3%, especially related to anemia, age over 80 years, malnutrition, and poor functional status.

Conclusion

The reconstruction of large and complex surgical defects after oncological resection of advanced head and neck tumors requires good clinical judgment of the pedicled, microsurgical, or regional flap techniques. Currently, there is a preference for free flaps, based on the application of novel techniques that improve aesthetic and functional results. However, regional and pedicled flaps should not be dismissed, since they are similarly useful in terms of coverage, function, and even aesthetics. With the exception of the bone component in reconstruction, they should be considered relevant surgical tools, since they offer similar results, lower morbidity, and reduced surgical time, which also reduces health care costs. The age of 70 years seems to be the cut-off point in which morbidity and mortality increase in those undergoing microsurgical flaps for reconstruction in head and neck surgery. These rates are even higher for men, and a less demanding type of reconstruction should always be considered as an alternative in these cases.