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  • Review
  • Open Access

Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review

Journal of Otolaryngology - Head & Neck Surgery201948:13

https://doi.org/10.1186/s40463-019-0334-y

  • Received: 11 July 2018
  • Accepted: 4 March 2019
  • Published:

Abstract

Objective

The present review focuses on comparative studies of reconstruction with free flaps (FF) versus pedicled flaps (PF) after oncologic resection.

Method

A systematic review was developed in compliance with PRISMA guidelines and performed using the Pubmed, Medline, EMBASE, Amed and Biosis databases.

Results

A total of 30 articles were included. FF are associated with a longer operative time, a higher cost and a higher incidence of postoperative revisions compared to PF. FF are associated with a longer stay at the intensive care unit than the supraclavicular artery island flap (SCAIF) and with a more extended hospital stay compared to the submental island flap (SMIF). FF are associated with fewer infections and necrosis compared to the pectoralis major myocutaneous flap (PMMF).

Conclusion

The comparison of both type of flaps is limited by the inherent design of the studies included. In sum, FF seem superior to the PMMF for several outcomes. SMIF and SCAIF compare favorably to FF for some specific indications achieving similar outcomes at a lower cost.

Keywords

  • Flaps
  • Oncology
  • Reconstruction
  • Surgery
  • Outcomes

Introduction

Head and neck reconstruction surgery has considerably evolved over the past decades, along with the trend of using either a free or a pedicled flap for the reconstruction of oncologic defects. Tracing back the history of flaps, the first pedicled flap (PF) was described by Susruta in 800 BC and consisted of a forehead flap [1]. It was later popularized by McGregor in 1963 and marked a turning point in reconstructive surgery, being the first ever reliable transposition flap [2]. A decade later, the pectoralis major myocutaneous flap (PMMF), supplied by the pectoral branch of the thoracoacromial artery, was introduced by Ariyan in 1979 [3]. The PMMF became the flap of choice for head and neck reconstruction in many centers and was extensively studied. However, concerns regarding the reliability of this flap for some defects resulted in the emergence of free flaps and other regional pedicled flaps, such as the supraclavicular artery island flap (SCAIF) and the submental island flap (SMIF).

With the advent of microvascular surgery in the 1970s, harvesting free flaps became popular in head and neck reconstruction surgery. Free tissue transfer was described by various authors, such as Daniel and Taylor who described the first cutaneous free flap in 1973 [4]. Free flap (FF) reconstruction slowly gained popularity over time to become the standard of care for large head & neck defects.

Free flaps require the expertise of microvascular surgery and longer operative times, but they show more versatility and robustness than PF for some defects [5, 6]. Pedicled flaps are accessible to both academic and community surgeons and considered more reliable in specific settings but are not suitable for every defect [7, 8].

Flap selection is a complex process, with FF and PF having both their respective pros and cons. More importantly, patients pre-operative conditions, the nature of the disease, and the available resources are significant factors to consider when choosing the appropriate reconstructive technique.

Favoring one type over the other to obtain the best outcomes is a challenge and a source of debate in the literature. The purpose of this study is to review all articles explicitly comparing FF to PF for head and neck defects reconstruction regarding demographic parameters, risk factors, tumor staging, operative time, hospitalization length, cost, post-operative complications, and outcomes, in order to better characterize the benefits and disadvantages of these flaps. Regarding post-operative complications, donor and recipient sites morbidity, as well as the impact of either FF or PF reconstruction techniques on patients’ quality of life, was evaluated to facilitate the choice for clinicians in the future.

Materials and methods

Literature review

The systematic review was performed in accordance with PRISMA guidelines, and a formal PROSPERO protocol was published according to the NHS International Prospective Register of Systematic Review (PROSPERO #42017055252). The Pubmed, Ovid-MEDLINE, EMBASE, Amed and Biosis databases were used to perform a literature review of English-language publication dating from 1948 to February 2017. Keyword combination included: free flaps AND pedicled flaps AND head and neck AND reconstruction surgery. The comparative study option was used as a limit to refine the search. Additionally, references in all articles were manually searched to identify other articles.

Selection criteria

Prospective and retrospective articles explicitly comparing the use of free flap versus pedicled flaps for head and neck oncologic defects were included. The data compared had to include one of the following parameters: demographic characteristics, risk factors, radiation or chemotherapy use, operative time, length of stay, total cost, post-operative complications and outcomes concerning survival and quality of life. The paediatric population was excluded. Articles describing only revision surgery were also excluded.

Titles and abstracts were initially screened by two investigators (F.G.F and P.T) to discard irrelevant studies. All reference lists of identified studies were then further analyzed to include any additional articles of interest. (Fig. 1). Selection of relevant studies was determined independently based on inclusion criteria. Any disagreement between reviewers was solved by discussions among the authors to reach consensus or by a third party (T.A), if necessary. The selection process was conducted per PRISMA guidelines. (Fig. 1).
Fig. 1
Fig. 1

PRISMA flow diagram presenting the systematic review process

Quality assessment

The methodological quality of evidence and the risks of bias of the included studies were assessed with the MINORS criteria (Methodological Index for Non-randomized Studies) [9]. Twelve criteria are used to evaluate the level of evidence of comparative studies. Criteria are graded from 0 to 2 (0: not reported; 1: reported but inadequate; 2: reported and adequate), for a global ideal score of 24. Studies with MINORS score > 18 were considered to have low risk bias. Quality assessment was conducted independently by two investigators (F.G.F and P.T) and discrepancies were resolved through a mutual re-review.

Results

A total of 30 articles were included for qualitative analysis after selection process (Fig. 1). All studies were retrospective except for one.

Types of flaps

Of the included studies, 53.3% (n = 16) compared FF to PMMF. Ten percent compared FF to supraclavicular artery island flap (SCAIF) (n = 3) and 10% compared FF to submental artery island flap (SMIF) (n = 3). The other studies compared FF to an array of different pedicled flaps or unspecified pedicled flaps. Types of flaps of all included studies are detailed in Table 1.
Table 1

Overview of the included studies

Article

Ref

Study type

MINORS Scorea

N total

n FF

n PF

Type of free flaps

Type of pedicled flaps

Defect / tumor location

Sinha, 2017 [14]

A

Retrospective review

20

517

384

133

ALT, FibF, RFFF

PMMF, SCAIF, SMIF

N/A

Goyal, 2017 [10]

B

Retrospective review

18

797

589

208

NA

PMMF, SCAIF, SMIF, TEMP, TRPF, DELT

Cutaneous/ skull base

Oral cavity

Oropharynx

Larynx / hypopharynx

Mandibular

Sinonasal

Composite/multiple sites

Li, 2016 [15]

C

Retrospective review

19

41

24

17

RFFF

PMMF

Oral cavity

Kozin, 2016 [5]

D

Retrospective review

20

72

28

45

RFFF, ALT

SCAIF

Cutaneous defect

Parotid/temporal bone

Howard, 2016 [21]

E

Retrospective review

18

31

9

16

ALT

SMIF

Lateral skull base

6

PLDF

Geiger, 2016 [17]

F

Retrospective review

20

105

50

55

39 RFFF, 3 ALT, 4 FibF, 2 theLDF, 2 SFF, 2 ORFF

51 PMMF, 2 DIEP, 2 TPF

N/A

Gao, 2016 [49]

G

Retrospective review

16

60

34

26

RFFF

PMMF

N/A

Forner, 2016 [27]

H

Retrospective review

20

21

12

9

RFFF

SMIF

Oral cavity

Oropharynx

Zhang S, 2015 [32]

I

Retrospective review

19

37

15

12

RFFF

SCAIF

Oral cavity

Zhang X, 2014 [16]

J

Retrospective review

19

110

79

31

ALT

PMMF

Oral cavity

Oropharynx

Jing, 2014 [22]

K

Retrospective review

17

49

22

27

GFMF

PMMF

Larynx

Granzow, 2013 [7]

L

Retrospective review

18

34

16

18

FFF

SCAIF

Larynx / hypopharynx

Parotid

Oral cavity

Esophagus

Deganello, 2013 [11]

M

Retrospective review

18

36

16

20

RFFF

10 TEMP, 10 PMMF

Oral cavity

Oropharynx

Fang, 2013 [12]

N

Retrospective review

18

56

20

24

RFF

PLTM

Oral cavity

12

ALT

Paydarfar, 2011 [23]

O

Retrospective review

20

60

33

27

RFF

SMIF

Oral cavity

Hsing, 2011 [25]

P

Retrospective review

18

100

42

58

N/A

PMMF

Oral cavity

Chan Y, 2011 [35]

Q

Prospective review

18

202

24

92

ALT

PMMF

Hypopharynx

86

FJF

Demirtas, 2010 [18]

R

Retrospective review

20

20

12

8

10 ALT, 2 LDF

PLDF

N/A

O’Neil, 2010 [30]

S

Retrospective review

20

114

77

37

RFFF

PMMF

N/A

Mallet, 2009 [6]

T

Retrospective review

18

70

25

45

18 RFFF, 3 LD, 3 ALT, 1 PCFF, 1 FJF

PMMF

Oral cavity

Oropharynx

de Bree, 2007 [20]

U

Retrospective review – Matched cohort

19

80

40

40

RFFF

PMMF

Oral cavity

Oropharynx

Smeele, 2006 [29]

V

Retrospective – Matched cohort

20

64

32

32

N/A

PMMF

Oral cavity

Oropharynx

Chien, 2005 [26]

W

Case series

17

27

11

16

RFFF

PBFPF

Oral cavity

Chepeha, 2004 [8]

X

Retrospective review

19

179

71

108

N/A

PMMF

Oral cavity

Oropharynx

Hypopharynx

Neck

Others

Funk, 2002 [19]

Y

Case-control, matched pairs study

20

42

21

21

FTT

N/A

Oral cavity

Oropharynx

Hypopharynx

Larynx

Petruzzelli, 2002 [31]

Z

Retrospective review

18

39

24

15

FTT

N/A

N/A

Amarante, 2000 [34]

Aa

Case-series

6

117

49

68

23 RFFF, 3 ORFF, 2 CFF, 5 LDF, 5 RAFF, 3 MSA, 2 PSFF, 2 ICC, 1 GOM, 3 FJF

47 PMMF, 7 PLDF, 2 PLTM, 9 TEMP, 3 MEC

Orbit

Parotid

Skull base

Oropharynx

Larynx / hypopharynx

Mandibular

Neck

Tsue, 1997 [24]

Ab

Retrospective review

19

53

29

24

N/A

PMMF

Oral cavity

Oropharynx

Kroll, 1997 [13]

Ac

Retrospective review

17

178

145

33

89 RFFF, 56 RAFF

PMMF

Oral cavity

Oropharynx

Kroll 1992 [33]

Ad

Retrospective review

18

69

30

39

RAFF

PMMF

N/A

Ref: Reference in subsequent tables

aMINORS score ranges from 0 to 24. A value ≥20 indicates low risk of bias

Flaps abbreviatiation: ALT Anterolateral thigh, CFF Cubital forearm flap, DELT Deltopectoralis, DIEP Deep inferior epigastric perforator flap, FibF Fibular free flap, FFF free fasciocutaneous flap, FTT Microvascular free tissue transfer, FJF Free jejunal flap, GFMF Gracilis free muscle flap, GOM Greater Omentum, ICC Iliac crest, LDF Latissimus dorsi free flap, MEC musculocutaneous sternocleidomastoid flap, MSA Muscular serratus anterior, N/A Not available, ORFF Oesteocutaneous Radial free flap, PBFF pedicled buccal fat flap, PCFF Pectoralis major free flap, PLTM Platysma myocutaneous island flap, PLDF Pedicled latissiums mucocutaneous dorsi flap, PMMF Pectoralis major pedicled flap, PSFF Parascapular free flap, RFFF Radial forearm free flap, RAFF Rectus abdominis free flap, SCAIF Supraclavicular artery island flap, SMIF Submental Island flap, TEMP Temporal flap, TRPF Trapezius flap

None of the included studies compared osseous free flaps to osseous pedicled flaps. All studies compared myocutaneous or fasciocutaneous flaps with the exception of two articles comparing fibular free flaps, along with other free flaps, to a variety of myocutaneous PF.

Quality of studies

The methodological quality of each study was evaluated with the MINORS criteria [9]. (Table 1 and details in Appendix). The studies scores ranged from 6 to 20. The mean and median scores were 18.2 and 18.5 respectively. Eight studies had a MINORS score of > 20 and were considered to have low risk bias. Most studies were retrospective reviews and were deficient in categories of blinded evaluations, power calculation, and adequacy of group control. All the studies had clearly stated aims and end points were appropriate to the aim of the studies. One study had a low MINORS score of 6, but it was not excluded considering we had not established a minimum threshold for inclusion.

Defect location

Table 1 summarizes the defects location. Twenty-three studies over the 30 included mentioned the reconstruction site, with 18 studies describing defects location and 5 studies describing tumors location. The grouping of these sites differed among the studies and variable subsite divisions were used. Both categories of flaps were not used equally to reconstruct a specific defect location within the studies, except for matching cohort studies. (Table 1 and details in Appendix).

Demographic parameters

Mean, or median age of patients was mentioned in 19 articles. Groups were comparable in 14 studies. Five articles showed that patients were significantly younger in the FF group compared to PF (p <  0.05) [1014]. Gender representation was similar between both groups in the 20 studies reporting gender, as one study [15] showed fewer males in the FF group (70.8% vs 100%, p <  0.05) and another [16] showed fewer males in the PF group (88% vs 32%, p <  0.05). (Table 2).
Table 2

Demographic data, preoperative risk factors and ASA class

 

Total # of articles reporting

(total = n)

# of articles reporting differences

(total n)

Articles reporting differences

FF

PF

p-value

Age, mean ± SD

or mean (range)

16 B, D, H, K, L, M, N, O, P, R, T, W, X, Z, Aa, Ac

(n = 1855)

4

(n = 1067)

Goyal, 2017

64.0 ± 12.0

66.5 ± 12.9

0.017

Deganello, 2013

58.2 ± 6.32

69.6 ± 6.8

< 0.01

Fang, 2013

58.0 (25–78)

72.4 (55–80)

< 0.001

57.2 (46–72)

< 0.001

Kroll, 1997

56 ± 13

62 ± 12

0.0046

Age (median)

3 A, E, Ab

(n = 601)

1

(n = 517)

Sinha, 2017

65.9

(57.7–74.2)

67.9

(60.3–76.8)

0.037

Age > 50 years

4 C, F, I, J

(n = 293)

0

    

Male

20 A, D, C, F, E, H, I, J, K, L, M, N, O, P, R, T, W, X, Aa, Ab

(n = 1609)

2

(n = 151)

Li, 2016

17(70.83%)

17(100%)

0.043

Zhang X, 2014

66 (88%)

31 (32.0%)

0.018

Smoking

5 F, K, L, T, Y

(n = 300)

0

 

62.0%

61.8%

0.985

Prior head and neck surgery

4 B F X, Ab

(n = 1134)

2

(n = 902)

Goyal, 2017

189 (32.1%)

122 (58.7%)

< 0.001

Geiger, 2016a

14.0%

30.9%

0.039

Systemic diseases

(CVD, HTA, DM)

1 N

(n = 56)

1

(n = 56)

Fang, 2013

4 (20%)

20 (83.33%)

< 0.001

3 (25%)

< 0.001

COPD

2 A, T

(n = 587)

0

    

DM

3 A, L, P

(n = 651)

1

(n = 34)

Granzow, 2013

5 (31%)

0

0.02

HTA

2 F, L

(n = 139)

0

    

CAD

3 A, L, T

(n = 621)

0

    

DLP

1 F

(n = 105)

0

    

CHF

1 A

(n = 517)

0

    

aFIB

1 A

(n = 517)

1

(n = 517)

Sinha, 2017

7.0%

15.0%

0.0083

Alcoholism

1 T

(n = 70)

0

    

Other cancer

1 T

(n = 70)

0

    

ASA Class I-II, n (%)

6 B, L, R, T, U, Y

(n = 1043)

2

(n = 877)

Goyal, 2017

245 (41.6%)

56 (26.9%)

0.001

de Bree, 2007

32 (80%)

37 (92.5%)

0.028

ASA Class III-IV, n (%)

6 B, L, R, T, U, Y

(n = 1043)

2

(n = 877)

Goyal, 2017

343 (58.2%)

152 (73.1%)

0.001

de Bree, 2007

8 (20%)

3 (8%)

0.028

ASA mean factor

(mean ± SD)

4 A, H, R, Ac

(n = 736)

2

(n = 538)

Sinha, 2017

2.6 ± 0.03

2.8 ± 0.05

0.0007

Forner, 2016

2.3

2.4

0.05

aFIB atrial fibrillation, ASA risk factor: scored using the American Society of Anesthesiology Scale (ASA), CAD Cardiac artery disease, CHF Chronic heart failure, COPD Chronic obstructive pulmonary disease, CVD Cardiovascular disease, DM Diabetes mellitus, DLP Dyslipidemia, HTA Hypertension

Preoperative risk factors

Table 2 shows the preoperative risk factors for the FF and PF groups. Both were comparable for the incidence of smoking, chronic obstructive pulmonary disease (COPD), hypertension (HTA), cardiac atherosclerosis disease (CAD), dyslipidemia (DLP), chronic heart failure (CHF), alcoholism and the incidence of other cancer.

Prior head and neck surgery was reported in 4 studies. Two studies [10, 17] found there was a lower proportion of patients who had prior head and neck surgery in the FF group compared to the PF group (32% vs 59 and 14% vs 31%, p <  0.05). One study [12] reporting the incidence of preoperative systemic disease showed a lower regrouped incidence of diabetes, cardiovascular disease and hypertension in the FF group (25% vs 83%, p <  0.05). In contrast, another study [7] demonstrated a higher incidence of diabetes mellitus in the FF group compared to PF (31% vs 0, p <  0.05). The only study reporting the incidence of atrial fibrillation [14] showed less patient with atrial fibrillation in the FF group compared to PF (7% vs 15%, p <  0.05).

American Society of Anesthesiologists (ASA) classification

Six studies reported ASA class. Among them, four showed similar ASA classes [6, 7, 18, 19]. Two studies showed a significant difference in ASA class between FF and PF groups with contrasting results. Goyal et al. [10] showed a higher proportion of ASA class I-II in the FF group (41.6% vs 26.9%, p <  0.05) and a lower proportion of ASA class III-IV in the FF group (58.2% vs 73.1%, p <  0.05) compared to PF.

In contrast, de Bree et al. [20] demonstrated a lower proportion of patients with ASA class I-II in the FF group (80% vs 92.5%, p <  0.05) and a higher proportion of ASA class III-IV in the FF group (20% vs 8%, p <  0.05). (Table 2.)

Prior radiation or chemotherapy

Exposure to prior head and neck radiation therapy was mentioned in 11 articles, and was comparable between the FF and PF groups in 9 of them [58, 13, 17, 2123]. (Table 3) Two articles [10, 24] showed a significantly lower proportion of prior radiotherapy with FF reconstruction compared to PF (46% vs 62 and 28% vs 54% p <  0.05). No difference was seen in the incidence of prior chemotherapy between FF and PF, as it was reported in five studies [5, 7, 17, 23, 24]. The incidence of adjuvant chemoradiotherapy after surgery was higher in the FF group in one study (48% vs 44%, p < 0.05) [23].
Table 3

Staging and treatment data

 

Total # of articles

reporting

(total = n)

# of articles reporting differences

(total n)

Articles reporting difference

FF

PF

p-value

Prior radiation

11 B, D, E, F, K, L, O, T, X, Ab, Ac

(n = 1628)

2

(n = 850)

Goyal, 2017

272 (46.2%)

130 (62.5%)

< 0.001

Tsue, 1997

8 (28%)

13 (54%)

0.05

Prior chemotherapy

5 D, K, L, O, Ab

(n = 268)

0

    

T1

8 J, K, M, N, O, P, W, Y

(n = 480)

1

(n = 36)

Deganello, 2013

0

4 (20%)#

< 0.01

T2

8 J, K, M, N, O, P, W, Y

(n = 480)

1

(n = 36)

Deganello, 2013

7 (43.8%)#

5 (25%)#

< 0.01

T3

8 J, K, M, N, O, P, W, Y

(n = 480)

1

(n = 36)

Deganello, 2013

8 (50%)

8 (40%)

< 0.01

T4

8 J, K, M, N, O, P, W, Y

(n = 480)

1

(n = 36)

Deganello, 2013

1 (6.25%)

3 (15%)

< 0.01

T1-T2

4 C, H, T, Ab (n = 185)

0

    

T3-T4

4 C, H, T, Ab (n = 185)

0

    

Stage I-II

1 X (n = 179)

0

    

Stage III-IV

1 X (n = 179)

0

    

Surg + chemoradio

6 C, N, O, P, U

(n = 516)

1

(n = 60)

Paydarfar, 2011

16 (48.48%)#

12 (44.44%)#

0.03

Surg + radio

4 J, O, P, X (n = 449)

0

    

Tumor stage

1Ac (n = 178)

0

    

Tumor recurrence

1Ac (n = 178)

0

    

Surg + chemoradio: Surgical resection and adjuvant chemoradiotherapy

Surg + radio: Surgical resection and adjuvant radiotherapy

# Percentage calculated relying on the data presented. Percentage not provided by the article

Bold = Statistically significant, p-value ≤ 0.05

Tumor staging

Tumor stages were compared in 13 studies; T stage or global staging was reported (Table 3). No significant difference in cancer staging was found in the other 12 studies [6, 11, 12, 15, 16, 19, 2227]. A study comparing RFFF to PMMF and temporalis flap [11] showed a lower proportion of T1 and T4 in the FF group (T1: 0% vs 20%; T4: 6.25% vs 15%, p < 0.05) as well as a higher proportion of T2 and T3 in the FF group (T2: 43.8% vs 25%; T3:50% vs 40%, p < 0.05) when compared to PF.

Operative time

Nineteen studies compared the operative time between both reconstruction techniques. All showed that FF was associated with a longer operating time than PF. This difference was statistically significant in 14 studies (Table 4) [5, 7, 10, 1316, 20, 21, 23, 24, 2729].
Table 4

OR time, Hospital and ICU length and hospital cost

 

Total # of articles reporting

(total = n)

# of articles reporting differences

(total n)

Articles reporting difference

FF

PF

p-value

OR time, min

(mean ± SD)

12 A, B, C, E, H, I, L, M, O, R, U, Ab

(n = 1727)

9

(n = 1634)

Sinha, 2017

421.4 ± 4.4

332.7 ± 10.7

0.0001

Goyal, 2017

427.2 ± 92.3

310.8 ± 125.0

0.001

Li, 2016

405 ± 107

365 ± 48

< 0.05

Howard, 2016

683 (575–979)

544 (396–700)

0.00817

Forner, 2016

552

347

< 0.05

Granzow, 2013

816.3 ± 148.9

587.9 ± 130.5

0.0002

Paydarfar, 2011

780

506.4

0.001

de Bree, 2007

692

462

< 0.005

Tsue, 1997

684 ± 16

666 ± 20

0.003

OR time, hour

(mean ± SD)

6 D, N, T, V, Ac, Ad (n = 474)

4

(n = 384)

Kozin, 2016

8.1

6.7

0.002

Mallet, 2009

7.01 ± 1.19)

4.19 ± 0.57

< 0.001

Smeele, 2006

12.5 ± 1.9

9.9 ± 1.5

< 0.0001

Kroll, 1997

10.49 ± 2.06

9.39 ± 2.59

0.029

OR time of > 600 min

1 J

(n = 110)

1

(n = 110)

Zhang X, 2014

59 (74.68%)

3 (9.68%)

0.001

Hospit length, days

(mean ± SD)

17 D, E, H, I, L, M, O, R, S, T, U, V, X, Z, Ab, Ac, Ad (n = 1104)

7

(n = 634)

Howard, 2016

9.8 (7–22)

4.75 (2–14)

0.004

Zhang S, 2015

17 ± 2.5

12 ± 1.7

< 0.05

Paydarfar, 2011

14.0

10.6

0.008

de Bree, 2007

24

28

0.005

Chepeha, 2004

12

14

0.006

Kroll, 1997

13.2 ± 5.4

19.8 ± 11.5

0.003

Kroll, 1992

11.3

21.2

0.003

ICU length, days

(mean ± SD)

4 H, L, V, Ab

(n = 172)

1

(n = 34)

Granzow, 2013

5.6 (4–9)

1.8 (0–5)

0.0001

Hospital cost

9 D, H, M, R, U, V, Z, Ab, Ac

(n = 563)

4

(n = 339)

Kozin, 2016

SCAIF 32% less expensive than FTT

0.0001

Deganello, 2013

22,924

19,872

0.043

Tsue, 1997

50,026 ± 4340

38,246 ± 1440

0.003

Kroll, 1997

28,460 ± 8435

40,992 ± 1958

0.001

Hospitalization and ICU length of stay

Seventeen studies compared the duration of hospital stay. (Table 4). Ten studies showed a similar hospitalization stay with FF compared to PF [57, 11, 18, 24, 27, 2931]. However, when FF were compared to SMIF and SCAIF specifically the results differed. FF patients had a longer hospitalization stay than SMIF patients for skull base (9.8 days vs 4.75, p < 0.05) [21] and oral cavity (14.0 days vs 10.6, p < 0.05) defects [23]. SCAIF patients had a shorter length of stay than FF patients for oral cavity defects (12 ± 1.7 vs 17 ± 2.5, p < 0.05) [32]. On the other hand, four studies [8, 13, 20, 33] showed a shorter hospitalization stay with FF compared to PMMF (p < 0.05).

Four studies assessed the ICU length of stay [7, 24, 27, 29]. One study comparing FF to SCAIF for larynx/pharynx reconstruction [7] concluded in a longer stay for FF reconstruction (p < 0.05).

Cost

Nine studies compared hospital costs between FF and PF [5, 11, 13, 18, 24, 27, 29, 31]. As reported by three studies, FF was associated with a significantly higher cost compared to PF. Of these, Kozin et al. [5] showed that SCAIF was 32% less expensive than FF for total laryngectomy, parotid/temporal bone, and cutaneous defect reconstruction. Reconstruction for oral cavity and oropharynx were also less expensive with PMMF compared to FF. (38,246$ vs 50,026, p < 0.05) [24]. A study comparing temporal flap (TEMP) and PMMF reconstruction to RFFF for oral cavity and oropharyngeal defects to RFFF led to similar findings (19,872$ vs 22,924$, p < 0.05) [11]. In contrast, one study [13] showed a lower hospital cost with FF compared to PMMF for the reconstruction of oral and oropharyngeal defects. (28,460 ± 8435 vs 40,992 ± 1958, p < 0.05) (Table 4).

Post-operative complications

Articles differed in the definitions of their studied complications. (Table 5). For example, some studies grouped recipient and donor site complications, as other separated them. Some studies were less specific and only reported the incidence of any complications. Others were selectively reporting the incidence of infection, fistula, abscess, dehiscence, hematoma, and others. Articles and results were grouped according to the definition of their studied complications.
Table 5

Post-operative complications and outcomes

 

Total # of articles reporting

(total = n)

# of articles reporting differences

(total n)

Articles reporting difference

FF

PF

p-value

Any complications

7 F, J, K, L, O, Aa, Ad

(n = 544)

3

(n = 284)

Geiger, 2016

68.0%

36.4%

0.001

Zhang X, 2014

13 (16.46%)

14 (45.16%)

0.002

Kroll, 1992

4 (13%)

17 (44%)

0.0145

Infection

3 F, L, T

(n = 209)

0

    

Recipient site infection

6 B, D, O, S, T, X

(n = 1292)

1

(n = 179)

Chepeha, 2004

2 (3%)

18 (17%)

< 0.004

Donor site infection

3 B, D, S

(n = 983)

0

    

Donor site morbidity

1 Q

(n = 202)

0

    

Fistula

11 B, F, K, O, Q, S, R, T, V, X, Aa

(n = 1777)

2

(n = 902)

Goyal, 2017

18 (3.1%)

17 (8.2%)

0.005

 

Geiger, 2016

22.0%

7.3%

0.039

Abscess

1 F

(n = 105)

0

    

Dehiscence recipient or donor site

4 F, K, S, V

(n = 332)

1

(n = 105)

Geiger, 2016

44.0%

23.6%

0.029

Dehiscence recipient site

5 D, L, O, V, X

(n = 409)

1

(n = 179)

Chepeha, 2004

0

11 (10%)

< 0.008

Dehiscence donor site

8 D, I, L, O, V, K, L, R (n = 370)

0

    

Hematoma

2 X, S

(n = 293)

0

    

Hematoma Donor site

2 E, V

(n = 95)

0

    

Hematoma recipient site

2 O, V

(n = 124)

0

    

Partial flap necrosis

6 I, O, V, X, Aa, Ad

(n = 526)

1

(n = 179)

Chepeha, 2004

2 (2.82%)#

12 (11%)#

< 0.006

Total flap necrosis

2 V, Aa

(n = 181)

0

    

Partial or total flap necrosis

1 T

(n = 70)

1

(n = 70)

Mallet, 2009

1 (4%)

14 (31%)

0.02

Osteonecrosis

2B, F

(n = 902)

1

(n = 105)

Geiger, 2016

24.0%

3.6%

0.007

Deep Vein Thrombosis (Inferious member)

2 A, S

(n = 631)

0

    

Venous obstruction (At site)

1 O

(n = 60)

0

    

Late anastomotic stricture

1Q

(n = 202)

0

    

Operative revision surgery

8 E, F, L, O, S, R, X, Aa (n = 660)

2 (n = 136)

Howard, 2016

1.6 (1–3)

0.6 (0–1)

< 0.00001

Geiger, 2016

34%

9.1%

0.003

Flap failure

8 E, I, K, L, O, T, U, V (n = 425)

1 (n = 70)

Mallet, 2009

1 (4%)

14 (31%)

0.02

Mortality at 30 days

2 (n = 228)K, X

     

Mortality at 1-year

2 (n = 76)L, Y

     

Mortality at 2-year

1 (n = 80)U

     

# Percentage not provided by the original article, calculated by the authors from the data presented

Seven articles reported the incidence of “any complications” [7, 16, 17, 22, 23, 33, 34]. One article [17] showed that FF was associated with a higher incidence of any complication (68.0% vs 36.4%, p < 0.05). This article included various types of flaps in both FF and PF groups. Two studies [16, 33] showed the opposite with a lower incidence of “any complication” in the FF group compared to PF. Of those, Zhang X et al. [16] showed a significantly lower rate of complications in the FF group compared to PMMF. (16.5% vs 45.2%, p < 0.05).

Infections at large, recipient site infection and donor site infection were reported in some studies. In one study [8], the rate of infection at the recipient site was lower in the FF group compared to the PMMF group (3% vs 17%, p < 0.05).

Two studies showed significant differences in the incidence of fistula. Goyal et al. [10] showed a lower rate of fistula in the FF group compared to PF (3.1% vs 8.2%, p < 0.05). The exact defect location was not specified in this study including multiple reconstruction sites, i.e. skull base, sinonasal cavities, oral cavity, and larynx. However, in a study focusing on intraoperative brachytherapy [17], the rate of fistula was higher in the FF group (22% vs 7.3%, p < 0.05). Neither the defect location nor the exact type of flaps was mentioned in this study.

The incidence of dehiscence either at the recipient, donor, or recipient and/or donor sites was reported by several studies. Dehiscence at “recipient and/or donor” site was higher with FF reconstruction compared to PF, according to Geiger et al. (44% vs 23.6%, p < 0.05) [17].

Dehiscence at recipient site was lower in FF group compared to PMMF in one study (0 vs 10%, p < 0.05) [8]. As for dehiscence at the donor site, no significant difference was observed between FF and PF in the eight studies reporting this complication [5, 7, 18, 22, 23, 29, 32].

The incidence of hematomas either at the recipient, donor, or recipient and/or donor site was analyzed by very few studies [8, 21, 23, 29, 30], without statistically significant differences between both techniques.

One study [8] showed a lower incidence of partial flap necrosis with FF reconstruction compared to PMMF (2.8% vs 11%, p < 0.05) for various defect locations (oral cavity, oropharynx, hypopharynx, neck, and others). The same was revealed by the Mallet et al. [6] study where “partial or total flap” necrosis was higher with PMMF for oral tongue and base of tongue reconstruction (4% vs 31%, p < 0.05).

Post-operative outcomes

Operative revision surgery was significantly higher in the FF group in two studies [21] (Table 5). One compared FF to SMIF (1.6 vs 0.6, p < 0.05) for lateral skull base defects [21] and the other compared various FF to PF (34% vs 9.1%, p < 0.05) without specifying the defect location [17]. Although not being statistically significant, six other studies also showed a higher occurrence of revision with FF reconstruction [7, 8, 18, 23, 29, 30, 34]. One study [6] showed that flap failure was more frequent with PMMF compared to FF (4% vs 31%, p < 0.05) for oral tongue and base of tongue reconstruction. No difference between both groups was reported for mortality at 30 days [8, 22], at 1 year [7, 19] and at 2 years [20].

Quality of life

Table 6 shows the quality of life of patients after surgical reconstruction with either FF or PF. The University of Washington Quality of Life Questionnaire (UW-QOL), including 14 items, was used by three studies [15, 16, 25] to measure the quality of life after surgical reconstruction with either FF or PMMF. Differences were seen in speech. Zhang X. et al. [16] showed a lower quality of speech with FF (57.5 ± 20.1 vs 76.1 ± 13.3, p < 0.05) with a mean follow-up of 5.9 years. Hsing et al. showed a better quality of speech with FF compared to PMMF (66.7 ± 27.2 vs 44.7 ± 35.0, p < 0.05) from data of patients operated 2 to > 10 years earlier.
Table 6

Quality of Life data

 

Article

FF

PF

p-value

UW-QOL Global

Li, 2016#

55.14 ± 9.24

54.36 ± 8.13

0.965

Zhang X, 2014$

70.5 ± 16.7

67.3 ± 12.9

0.860

Hsing, 2011&

66.0 ± 18.5

57.8 ± 18.2

0.090

UW-QOL: Pain

Li, 2016

71.63 ± 9.91

72.94 ± 11.13

0.751

Zhang X, 2014

86.2 ± 10.8

89.9 ± 11.4

0.425

Hsing, 2011

76.8 ± 23.0

68.1 ± 27.2

0.138

UW-QOL: Swallowing

Li, 2016

44.00 ± 16.27

43.78 ± 4.95

0.741

Zhang X, 2014

49.4 ± 14.7

51.3 ± 21.7

0.840

Hsing, 2011

49.3 ± 37.2

48.6 ± 32.7

0.962

UW-QOL: Chewing

Li, 2016

42.45 ± 6.15

43.43 ± 12.37

0.817

Zhang X, 2014

52.6 ± 17.1

59.4 ± 12.9

0.498

Hsing, 2011

34.5 ± 39.0

33.6 ± 36.7

0.973

UW-QOL: Speech

Li, 2016

51.27 ± 11.24

52.63 ± 12.43

0.461

Zhang X, 2014

57.5 ± 20.1

76.1 ± 13.3

0.017

Hsing, 2011

66.7 ± 27.2

44.7 ± 35.0

0.002

UW-QOL: Apparence

Li, 2016

57.47 ± 11.44

68.54 ± 13.24

0.0001

Zhang X, 2014

76.4 ± 18.6

70.3 ± 17.1

0.308

Hsing, 2011

67.3 ± 25.0

69.8 ± 25.5

0.535

UW-QOL: Activity

Li, 2016

64.23 ± 9.52

63.73 ± 8.41

0.641

Zhang X, 2014

71.9 ± 11.5

74.8 ± 10.2

0.710

Hsing, 2011

67.9 ± 24.2

66.8 ± 27.9

0.760

UW-QOL: Recreation

Li, 2016

66.59 ± 11.62

67.26 ± 9.23

0.445

Zhang X, 2014

72.1 ± 10.2

78.9 ± 11.2

0.590

Hsing, 2011

69.1 ± 32.6

62.5 ± 32.2

0.221

UW-QOL: Shoulder

Li, 2016

61.52 ± 7.83

54.65 ± 11.24

0.0001

Zhang X, 2014

87.1 ± 14.4

65.6 ± 20.0

< 0.001

Hsing, 2011

81.4 ± 14.7

50.5 ± 29.8

< 0.001

UW-QOL: Taste

Li, 2016

50.91 ± 10.64

51.24 ± 11.23

0.673

Zhang X, 2014

48.4 (18.3)

52.9 (19.6)

0.713

Hsing, 2011

55.0 ± 43.2

45.9 ± 39.6

0.226

UW-QOL: Salive

Li, 2016

45.48 ± 16.92

44.17 ± 12.78

0.723

Zhang X, 2014

70.9 ± 9.5

72.3 ± 23.1

0.813

Hsing, 2011

71.7 ± 34.8

73.8 ± 28.1

0.964

UW-QOL: Mood

Li, 2016

69.94 ± 9.51

68.31 ± 14.72

0.474

Zhang X, 2014

76.0 ± 14.7

71.6 ± 18.8

0.114

Hsing, 2011

76.2 ± 24.7

60.8 ± 32.8

0.022

UW-QOL: Anxiety

Li, 2016

70.57 ± 15.11

72.55 ± 15.19

0.219

Zhang X, 2014

78.5 ± 9.64

86.4 ± 17.5

0.775

Hsing, 2011

75.9 ± 26.3

68.9 ± 33.9

0.423

UW-QOL: Composite score

Hsing, 2011

66.0 ± 18.5

57.8 ± 18.2

0.090

Speech

Excellent

Zhang S, 2015§

12 (80.0%)#

11 (91.7%)#

0.62

Good

3 (20%)

1 (8.3%)

Poor

0

0

Always understandable

O’Neil, 201

17 (53.1)

4 (22.2)

0.014

Usually understandable

14 (43.8)

9 (50.0)

Difficult to understand

1 (3.1)

5 (27.8)

Swallowing full/regular diet at follow-up

(vs soft, liquid)

n (%)

Zhang S, 2015§

13 (86.7%)#

10 (83.3%)#

1.00

Paydarfar, 2011%

19

20

0.60

Chan Y, 2011*

8 (38.2%)

24 (35.8%)

ND

52 (61.9%)

ND

O’Neil, 2010**

17 (59.4%)

6 (33.3%)

0.202

Tsue, 1997***

8 (34%)

4 (17%)

0.02

Preoperative mouth-open width distance (mean) cm

Fang, 2013

1.5–6.2 (4.6)

1.2–6.2 (4.8)

ND

0.9–6.0 (3.5)

ND

Chien, 2005

6.3–3.5 (5.7)

6.1–2.5 (5.1)

0.384

Postoperative mouth-open width

Fang, 2013

1.4–5.8 (4.3)

1.1–4.7 (3.2)

ND

0.8–5.8 (3.3)

ND

Chien, 2005

5.9–3.2 (5.2)

5.6–1.6 (3.6)

0.384

Mouth-open width change (%)

Fang, 2013

4.0–9.1%

8.3–47.5%

< 0.001

3.3–11.1%

<0.001

Chien, 2005

4.8–9.8%

5–45.5%

< 0.001

G-tube at 6 months postoperatively

Smeele, 2006

21.8%

34.3%

NS

G-tube dependence, n (%)

Chepeha, 2004

10 (16%)

40 (42%)

0.001

Feeding tube for >21 days

Mallet, 2009

8 (36%)

17 (42%)

0.84

Feeding tube at discharge

Tsue, 1997

20 (69%)

20 (83%)

NS

Feeding tube at follow upe

11 (39%)

17 (85%)

0.002

# Follow up ranging from 13 to 108 months

$ Mean-follow up = 5.9 years

& Follow up ranging from 2 to >10 years

§ Follow-up = 6 months

% at most recent follow-up

* Regular PO follow-up, median follow-up period was 82 months

** Follow-up period not mention

*** Median follow-up was 298 days

# Percentage calculated relying on the data presented. Percentage not provided by the article

Bold = Statistically significant, p-value ≤ 0.05

Speech quality was also specifically assessed by two other studies not using the UW-QOL. O’Neil et al. [30] found a difference in speech quality (p < 0.05), with RFFF patients being more often “always understandable” than PMMF patients (53.1%vs 22.2%, follow-up period not mentioned). Additionally, Zhang S. et al. [32] graded the speech quality as excellent, good or poor, and found no difference in the speech quality of reconstruction with either FF or SCAIF flaps 6 months after the surgery.

Shoulder function, evaluated with UW-QOL, was significantly better in the FF group compared to the PMMF group in all three studies [15, 16, 25]. Follow-up time was ranging from 1 to over 10 years. One study [25] showed that FF was associated with a better mood compared to PMMF (76.2 ± 24.7 vs 60.8 ± 32.8, p < 0.05).

In addition, looking at studies using the UW-QOL, FF and PMMF scored similarly on global quality of life, pain, swallowing, chewing, speech, activity, recreation, taste, saliva, anxiety and composite score [15, 16, 25].

Recovery to a normal diet was reported in five studies [23, 24, 30, 32, 35]. According to one study [24], the incidence was higher in the FF group compared to the PMMF for reconstruction of oral or base of tongue defects (34% vs 17%, p < 0.05).

Preoperative and postoperative mouth opening were reported by two studies, one comparing RFFF and ALT to platysma myoctuaneous island flap (PMIF) [12] and the other comparing RFFF to pedicled buccal fat pad flap [26]. Mouth opening was similar between FF and PF groups.

The incidence of feeding tube dependence was reported by some studies and different postoperative timepoints were evaluated. One study [8] showed a lower incidence of feeding tube dependence in the FF group compared to PMMF (16% vs 42%, p < 0.05) for reconstruction of various defects. The FF group was also associated with a lower rate of incidence of feeding tube at follow up, with a median follow-up of 298 days, compared to PMMF (39% vs 85%, p < 0.05) for oral cavity and oropharynx reconstruction [24]. Feeding tube dependence at 21 days [6] and at discharge [24] was similar between the PF and FF groups in two studies.

Discussion

Choosing between FF and PF in head and neck reconstruction is a challenge for some defects, especially with the recent resurgence of PF and their expanding indications. In this era of economic awareness in the healthcare system, use of microvascular reconstruction needs to be justified if other comparable and less expensive alternatives are available. The present study aimed to review the literature comparing FF to PF for reconstruction of oncologic head and neck defects and determine the relative benefits and drawbacks of both flap types. To our knowledge, this is the first systematic review of studies comparing the postoperative complications and outcomes of FF and PF for head and neck reconstruction of oncologic defects.

The major findings of the present study are that: (a) FF was associated with a longer operating time and, in general, a higher cost compared to PF, including compared to SCAIF. (b) FF was associated with a lower hospitalization stay compared to PMMF, but a higher hospitalization stays when compared to SCAIF and SMIF. (c) Recipient site morbidity was lower with FF reconstruction compared to PMMF, including a lower incidence of infection, dehiscence, and necrosis. The incidence of hematoma and fistula were equivocal. (d) Donor site morbidity was equivocal between FF and PF reconstruction, with no distinction in the rate of infection, dehiscence, and hematoma. (e) Revision surgery was higher with FF reconstruction compared to PF and SMIF. (f) Speech quality was better with FF than with PMMF for oral cavity defects, and FF and PMMF scored similarly on global quality of life, pain, swallowing, chewing, speech, activity, recreation, taste, saliva, anxiety and composite score.

Those conclusions are drawn from retrospective studies lacking methodological homogeneity, thus limiting a truly valid comparison between FF and PF reconstruction. The main issues that need to be further address are the inherent differences among the studied groups in term of patients’ preoperative characteristics and defect locations. The findings of the studies included in this review can result from surgeon’s bias itself opting for either a FF or a PF based on patient’s characteristics and considering it more suitable for a certain location. In fact, patients in the FF group were younger than patients in the PF group with more than a 10-year age difference noted in some studies [11, 12]. Distal extremity reconstruction donor sites are thought to be affected by the patients’ health status and age in relation to the condition of peripheral vessels. However, according to several studies age is not considered a risk factor for FF failure [36]. FF reconstruction was also considered with favorable long-term outcomes in patients of 90 years old in a study by Wester et al. [37].

Overall, only a minority of studies showed significant differences in the preoperative characteristics of FF and PF groups. The patients characteristics and T stage were similar between FF and PF groups in most of the studies with a few exceptions. In those, some even showed opposite findings, as it is the case for the ASA class and the incidence of diabetes mellitus [7, 10, 12, 20]. Thus, in front of a majority of studies with similar baseline characteristics between the PF and FF groups, we could extrapolate with caution that the intrinsic flaps characteristics have an essential contribution to the surgical outcomes depicted in these studies.

A unanimous finding among all studies in this review was the longer operative (OR) time necessary for FF reconstruction which was frequently explained by the microvascular anastomosis. Interestingly, four distinct articles mentioned longer hospitalization time for PF when compared to PMMF [8, 13, 20, 33]. The higher complication rate in PMMF and the poorer patients’ preoperative health status in two of those studies may explain this finding [25, 33]. In contrast, SMIF and SCAIF showed a shorter hospitalization and ICU length of stay when compared to FF in similar patients groups [7, 21, 23, 32].

Cost analysis favour PF over FF in a study focusing on the SCAIF [5]. The study by Forner et al. also showed a favorable cost-analysis for SMIF over RFFF but no statistical analysis was provided to be able to conclude on a significant difference [27]. Conclusions on the relative cost of PMMF are harder to draw because studies are showing divergent results [11, 13, 24]. The differences in costs for the PMMF between studies can be explained by the different indications for the use of this flap by the authors. In an era of limited resources and increased attention to health economics, cost analysis studies should be encouraged.

Studies demonstrating significant differences in complication rates were all specifically comparing PMMF to FF. In fact, there was a higher incidence of overall complications, recipient site infection, dehiscence of recipient site, necrosis and flap failure with PMMF reconstruction in all articles except one. Geiger et al. [17] presented different results with regards to fistula, dehiscence and osteonecrosis rates. It is important to note, however, that the authors compared RFFF to PMMF only in the presence of intraoperative brachytherapy implants. These implants, which supplied high doses of radiation, may have led to direct tissue damage in the thinner free flaps, subsequently leading to a higher risk of fistula and dehiscence. The authors themselves associated the lower complication rate of the PMMF group to their increased bulk.

When comparing ALT to SMIF, Howard et al. [21] showed a higher complication rate as well as higher operative revision rates when using the ALT. Similarly, Zhang et al. [23] demonstrated higher rates of donor site complications in the RFFF when compared to SCAIF. Paydarfar et al. [23] demonstrated higher recipient and donor site complications when comparing RFFF to SMIF (no p-values were available); this latter flap has previously been cited as having a low donor site morbidity in another study [38].

PMMF was associated with poorer QoL outcomes when compared to FF [15, 16, 25, 32]. Tsue and al [24]. even demonstrated a lower capacity to progress to a regular diet following oral cavity and oropharyngeal reconstruction. This was corroborated by Chepeha et al. [8] who showed a higher incidence of gastrostomy tube dependence after PMMF which they attributed to the flap’s downward pull, small size, a limited axis of rotation and inability to fold.

Thereby, PMMF seem to be inferior to FF or other pedicled flaps on many different levels. However, we must remember that higher ASA classes were more common in the PMMF groups representing a considerable bias in the literature. It is our opinion that PMMF should still be considered a reliable and useful flap, especially in a salvage surgery setting.

The present review did not allow us to find any comparative study between osseous or composite FF and osseous or composite PF. Composite head and neck defects have previously been reconstructed with PF including a bony component such as the pectoralis major osteomyocutaneous flap with rib or sternum, the sternocleidomastoid flap with part of the clavicle, or the trapezius flap with the scapular spine. These flaps did not withstand the test of time because of their lack of robustness, reliability and versatility in comparison to their homologue free flaps [3943]. The more recent SMIF has also been used as a composite flap for mandible, maxilla and orbital defects reconstruction [10]. Yet, its role in osseous reconstruction remains to be defined in an era dominated by FF. Despite the lack of comparative studies, we can safely state that FF are superior to PF for bony reconstructions, especially in radiated patients.

This review suggests that SMIF and SCAIF can be considered reasonable alternatives to free flaps for the reconstruction of head and neck tissue defects given the similar functional outcomes and better performance in OR time, hospitalization/ICU length, and cost. Some articles described their use more frequently in higher ASA classes which further highlights their utility. They can usually be closed primarily and do not typically require skin grafting [38]. Furthermore, SMIF has also been cited as having superior color matching for cervicofacial skin defects [44]. Nonetheless, SMIF and SCAIF are not suitable for all head and neck defects. Patients with previous history of radiation or ipsilateral neck dissection are not optimal candidates [21]. Additionally, reconstruction of the midface or upper face can sometimes be limited by the length of their respective pedicles. Finally, the use of SMIF in patients requiring level I neck dissection is still debated [21], as its oncological safety and the potential risk to transfer cervical neoplastic cells to the recipient site is controversial in the literature [45]. However, recurrence is thought to be due to the aggressively of the resected tumor than the flap itself [46]. A careful flap dissection, at the subplatysmal plane, after completing the neck dissection, helps minimize the risk of tumor spread [47]. The SMIF is a reliable reconstruction technique if level 1, A and B, nodes are thoroughly removed, as supported by Howard et al. 11-years case-series study, where no recurrences related to the SMIF transfer of metastatic tissue were noted [21]. Still, SMIF should not be performed in the presence of clinical or radiographic evidence of level 1 cervical lymph node disease [48].

Limitation

Of the thirty studies reviewed, some do not specify the primary tumor location and consequently the defect site. Many articles did not mention the specific flaps used and lacked standard definitions for post-operative complications and outcomes. Furthermore, retained articles were for the majority retrospective studies and comprised risk bias, as assessed by the MINORS criteria. These factors limited the authors ability to analyze specific discordant results between articles and to draw robust conclusions from this systematic review.

Conclusion

The articles included in this review are lacking of methodological homogeneity. Their retrospective nature and the inherent disparities in term of preoperative characteristics between the groups in some studies are limiting. Although the conclusions should be interpreted with caution, it is safe to assume that free flaps are an excellent choice for reconstruction in relatively healthy subjects with low ASA classes. It appears that FF are superior to the PMMF for several postoperative outcomes. However, other pedicled flaps such as the SMIF and SCAIF compare favorably to FF for some specific indications achieving similar outcomes at a lower cost.

Notes

Declarations

Acknowledgments

Not applicable.

Funding

No funding to declare.

Availability of data and materials

This review is using data from published articles to portrayed the current literature on head and neck reconstruction surgery with either a free or a pedicled flap. All the references are properly listed as they are being used in the manuscript.

Authors’ contributions

TA designed and directed the study. FGF and PT wrote the manuscript with support from TA. AR, EB, AC and TA were involved in the critical revision of the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
Faculty of Medicine, Université de Montreal, Montreal, QC, Canada
(2)
Division of Otolaryngology - Head & Neck Surgery service, Université de Montréal, Montreal, QC, Canada
(3)
Department of Surgery, Centre Hospitalier de l’Université de Montréal, 900, Saint-Denis St. pavillon R, H2X 0A9, Montreal, Canada

References

  1. Robertson MS, Robinson JM. Pectoralis major muscle flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1986;112(3):297–301.PubMedGoogle Scholar
  2. McGregor IA. The temporal flap in intra-oral cancer: its use in repairing the postexcisional defect. Br J Plast Surg. 1963;16:318–35.PubMedGoogle Scholar
  3. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction of the head and neck. Plast Reconstr Surg. 1979;63(1):73–80.PubMedGoogle Scholar
  4. Daniel RKTG. Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr Surg. 1973;52(2):111–7.PubMedGoogle Scholar
  5. Kozin ED, Sethi RK, Herr M, Shrime MG, Rocco JW, Lin D, et al. Comparison of perioperative outcomes between the supraclavicular Artery Island flap and Fasciocutaneous free flap. Otolaryngol Head Neck Surg. 2016;154(1):66–72.PubMedGoogle Scholar
  6. Mallet Y, El Bedoui S, Penel N, Ton Van J, Fournier C, Lefebvre JL. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol. 2009;45(12):1028–31.PubMedGoogle Scholar
  7. Granzow JW, Suliman A, Roostaeian J, Perry A, Boyd JB. Supraclavicular artery island flap (SCAIF) vs free fasciocutaneous flaps for head and neck reconstruction. Otolaryngol Head Neck Surg. 2013;148(6):941–8.PubMedGoogle Scholar
  8. Chepeha DB, Annich G, Pynnonen MA, Beck J, Wolf GT, Teknos TN, et al. Pectoralis major myocutaneous flap vs revascularized free tissue transfer: complications, gastrostomy tube dependence, and hospitalization. Arch Otolaryngology Head Neck Surg. 2004;130(2):181–6.Google Scholar
  9. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–6.PubMedGoogle Scholar
  10. Goyal N, Yarlagadda BB, Deschler DG, Emerick KS, Lin DT, Rich DL, et al. Surgical site infections in major head and neck surgeries involving Pedicled flap reconstruction. Ann Otol Rhinol Laryngol. 2017;126(1):20–8.PubMedGoogle Scholar
  11. Deganello A, Gitti G, Parrinello G, Muratori E, Larotonda G, Gallo O. Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital. 2013;33(6):380–7.PubMedPubMed CentralGoogle Scholar
  12. Fang QG, Safdar J, Shi S, Zhang X, Li ZN, Liu FY, et al. Comparison studies of different flaps for reconstruction of buccal defects. J Craniofac Surg. 2013;24(5):e450–1.PubMedGoogle Scholar
  13. Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP, Miller MJ, et al. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps. Plast Reconstr Surg. 1997;99(5):1282–6.PubMedGoogle Scholar
  14. Sinha S, Puram SV, Sethi RK, Goyal N, Emerick KS, Lin D, et al. Perioperative deep vein thrombosis risk stratification. Otolaryngol Head Neck Surg. 2017;156(1):118–21.PubMedGoogle Scholar
  15. Li W, Zhang P, Li R, Liu Y, Kan Q. Radial free forearm flap versus pectoralis major pedicled flap for reconstruction in patients with tongue cancer: assessment of quality of life. Med Oral Patol Oral Cir Bucal. 2016;21(6):e737–e42.PubMedPubMed CentralGoogle Scholar
  16. Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg. 2014;25(3):868–71.PubMedGoogle Scholar
  17. Geiger EJ, Basques BA, Chang CC, Son Y, Sasaki CT, McGregor A, et al. Pedicle versus free flap reconstruction in patients receiving intraoperative brachytherapy. J Plast Surg Hand Surg. 2016;50(4):227–32.PubMedGoogle Scholar
  18. Demirtas Y, Yagmur C, Kelahmetoglu O, Demir A, Guneren E. Transaxillary-subclavian transfer of pedicled latissimus dorsi musculocutaneous flap to head and neck region. J Craniofac Surg. 2010;21(3):771–5.PubMedGoogle Scholar
  19. Funk GF, Karnell LH, Whitehead S, Paulino A, Ricks J, Smith RB. Free tissue transfer versus pedicled flap cost in head and neck cancer. Otolaryngol Head Neck Surg. 2002;127(3):205–12.PubMedGoogle Scholar
  20. de Bree R, Reith R, Quak JJ, Uyl-de Groot CA, van Agthoven M, Leemans CR. Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol. 2007;32(4):275–82.PubMedGoogle Scholar
  21. Howard BE, Nagel TH, Barrs DM, Donald CB, Hayden RE. Reconstruction of lateral Skull Base defects: a comparison of the submental flap to free and regional flaps. Otolaryngol Head Neck Surg. 2016;154(6):1014–8.PubMedGoogle Scholar
  22. Jing SS, O'Neill T, Clibbon JJ. A comparison between free gracilis muscle flap and pedicled pectoralis major flap reconstructions following salvage laryngectomy. J Plast Reconstr Aesthet Surg. 2014;67(1):17–22.PubMedGoogle Scholar
  23. Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg. 2011;137(1):82–7.PubMedGoogle Scholar
  24. Tsue TT, Desyatnikova SS, Deleyiannis FW, Futran ND, Stack BC Jr, Weymuller EA Jr, et al. Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx. Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg. 1997;123(7):731–7.PubMedGoogle Scholar
  25. Hsing CY, Wong YK, Wang CP, Wang CC, Jiang RS, Chen FJ, et al. Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients--a quality of life analysis. Oral Oncol. 2011;47(6):522–7.PubMedGoogle Scholar
  26. Chien CY, Hwang CF, Chuang HC, Jeng SF, Su CY. Comparison of radial forearm free flap, pedicled buccal fat pad flap and split-thickness skin graft in reconstruction of buccal mucosal defect. Oral Oncol. 2005;41(7):694–7.PubMedGoogle Scholar
  27. Forner D, Phillips T, Rigby M, Hart R, Taylor M, Trites J. Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis. J Otolaryngol Head Neck Surg. 2016;45:11.PubMedPubMed CentralGoogle Scholar
  28. Angel MF, Narayanan K, Swartz WM, Ramasastry SS, Kuhns DB, Basford RE, et al. Deferoxamine increases skin flap survival: additional evidence of free radical involvement in ischaemic flap surgery. Br J Plast Surg. 1986;39(4):469–72.PubMedGoogle Scholar
  29. Smeele LE, Goldstein D, Tsai V, Gullane PJ, Neligan P, Brown DH, et al. Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer: matched control study. J Otolaryngol. 2006;35(2):102–7.PubMedGoogle Scholar
  30. O'Neill JP, Shine N, Eadie PA, Beausang E, Timon C. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci. 2010;179(3):337–43.PubMedGoogle Scholar
  31. Petruzzelli GJ, Brockenbrough JM, Vandevender D, Creech SD. The influence of reconstructive modality on cost of care in head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg. 2002;128(12):1377–80.PubMedGoogle Scholar
  32. Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular Artery Island flap versus free radial forearm flap for tongue reconstruction following Hemiglossectomy. J Craniofac Surg. 2015;26(6):e527–30.PubMedGoogle Scholar
  33. Kroll SS, Reece GP, Miller MJ, Schusterman MA. Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck. Am J Surg. 1992;164(6):615–8.PubMedGoogle Scholar
  34. Amarante J, Reis J, Costa-Ferreira A, Malheiro E, Silva A. Head and neck reconstruction: a review of 117 cases. Eur J Plast Surg. 2000;23(8):404–12.Google Scholar
  35. Chan YW, Ng RW, Liu LH, Chung HP, Wei WI. Reconstruction of circumferential pharyngeal defects after tumour resection: reference or preference. J Plast Reconstr Aesthet Surg. 2011;64(8):1022–8.PubMedGoogle Scholar
  36. Zhou W, Zhang WB, Yu Y, Wang Y, Mao C, Guo C-B, Yu G-Y, Peng X. Risk factors for free flap failure: a retrospective analysis of 881 free flaps for head and neck defect reconstruction. Int J Oral Maxillofac Surg. 2017;46:941–5.PubMedGoogle Scholar
  37. Wester JL, Lindau RH, Wax MK. Efficacy of free flap reconstruction of the head and neck in patients 90 years and older. JAMA Otolaryngol Head Neck Surg. 2013;139(1):49–53.PubMedGoogle Scholar
  38. Lee JC, Lai WS, Kao CH, Hsu CH, Chu YH, Lin YS. Multiple-parameter evaluation demonstrates low donor-site morbidity after submental flap harvesting. J Oral Maxillofac Surg. 2013;71(10):1800–8.PubMedGoogle Scholar
  39. Bhathena H, Kavarana NM. One-stage total mandibular reconstruction with rib, pectoralis major osteomyocutaneous flap. Head Neck Surg. 1986;8(3):211–3.PubMedGoogle Scholar
  40. Leclere FM, Vacher C, Benchaa T. Blood supply to the human sternocleidomastoid muscle and its clinical implications for mandible reconstruction. Laryngoscope. 2012;122(11):2402–6.PubMedGoogle Scholar
  41. Bem C, O'Hare PM. Reconstruction of the mandible using the scapular spine pedicled upon trapezius muscle; description of the posterior approach to the transverse cervical vessels. Br J Plast Surg. 1986;39(4):473–7.PubMedGoogle Scholar
  42. Garcia-de Marcos JA, Arroyo-Rodriguez S, Rey-Biel J. Submental Osteocutaneous Perforator Flap for Maxillary and Mandibular Reconstruction Following Tumor Resection. J Oral Maxillofac Surg. 2016;74(4):860 e1–9.PubMedGoogle Scholar
  43. Al Felasi MA, Bissada E, Ayad T. Reconstruction of an inferior orbital rim and cheek defect with a pedicled osteomyocutaneous submental flap. Head Neck. 2016;38(3):E64–7.PubMedGoogle Scholar
  44. Hayden RE, Nagel TH. The evolving role of free flaps and pedicled flaps in head and neck reconstruction. Curr. 2013;21(4):305–10.Google Scholar
  45. Sagüillo K, García-Serrano G, Almeida F, Núnez J, Picón M, Acero J. Submental flap in reconstruction of orofacial defects. Revista Española de Cirugía Oral y Maxilofacial. 2015;37(4):196–201.Google Scholar
  46. Chow TLCT, Chow TK, Fung SC, Lam SH. Reconstruction with submental flap for aggressive orofacial cancer. Plast Reconstr Surg. 2007;120(2):431–6.PubMedGoogle Scholar
  47. Amin AASM, Khalil AA, Rifaat MA, Zayed SB. The submental flap for oral cavity reconstruction: extended indications and technical refinements. Head Neck Oncol. 2011;51(3).Google Scholar
  48. Howard BE, Nagel TH, Donald CB, Hinni ML, Hayden RE. Oncologic safety of the submental flap for reconstruction in Oral cavity malignancies. Otolaryngol Head Neck Surg. 2014;150(4):558–62.PubMedGoogle Scholar
  49. Gao LL, Basta M, Kanchwala SK, Serletti JM, Low DW, Wu LC. Cost-effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection. Head Neck. 2017;39(3):541–7.PubMedGoogle Scholar

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