title: Technical considerations in patients requiring a second microvascular free flap in the head and neck.
abstract: OBJECTIVE
  To identify the difficulties associated with performing a second free flap reconstruction in the head and neck as well as the techniques used to achieve successful reconstruction.
  
  
  METHODS
  A retrospective review of a prospectively maintained patient database.
  
  
  METHODS
  The study population comprised 33 patients who required a second free flap in the head and neck.
  
  
  METHODS
  Several variables were analyzed in this cohort. Patient-related factors included the following: the availability of recipient vessels, the need to access the contralateral side of the neck, history of neck surgery, history of radiation therapy, and type of free flap used. Complications associated with the reconstruction were also reported.
  
  
  RESULTS
  In this cohort of 33 patients, 34 free flap reconstructions were performed. All were successful, and there were no flap-related complications. Owing to the paucity of good recipient vessels in many cases, the contralateral side of the neck was commonly used, but no patients required vein interposition grafts.
  
  
  CONCLUSIONS
  Second free flap reconstructions in the head and neck can be safely accomplished. We have found that the availability of recipient vessels is the most important consideration in these patients. The dissection of the contralateral side of the neck is often required, but the use of flaps with long pedicles obviates the need for vein interposition grafts. Compared with the success rate in this study, the relevant literature suggests that flap survival rates are lower when interposition grafts are used. Modifications in flap-harvesting techniques and inset geometry can also be used to facilitate insets in complicated surgical fields that have been reoperated on.
authors.affiliation: Head and Neck Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Ste A-71, Cleveland, Ohio 44195, USA. alamd@ccf.org
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Alam
authors.forename: Samir S
authors.initials: SS
authors.lastname: Khariwala
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006258:Head and Neck Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008833:Microcirculation; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000098:blood supply / Q000637:transplantation*; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult