Free flap reconstruction of the head and neck:
Analysis of 241 cases
BRUCE H. HAUGHEY, MB, ChB, EWAIN WILSON, MD, LUCIA KLUWE, MD, JAY PICCIRILLO, MD, JOHN FREDRICKSON, MD,
DONALD SESSIONS, MD, and GERSHON SPECTOR, MD, St Louis, Missouri
OBJECTIVE: We undertook this study of free flap
reconstruction of the head and neck to stratify
patients and procedures, to determine how donor
site preference changed over time, to assess med-
ical and surgical outcomes, and to identify vari-
ables associated with complications.
METHODS: We analyzed computerized medical
records from 236 patients who underwent a total
of 241 reconstructions at a tertiary academic
medical center in St. Louis between 1989 and
1998. We created a more detailed retrospective
database of 141 of those patients by using 48
perioperative variables and 7 adverse outcome
measures. Multivariate statistical models were
used to analyze associations between variables
and outcomes.
RESULTS: The fibula became the preferred donor site
for mandibular reconstruction, and the radial fore-
arm became the preferred donor site for pharyn-
goesophageal reconstruction. For the 241
procedures, the mortality rate was 2.1%, the medi-
an length of stay was 11 days, and the flap survival
rate was 95%. Administration of more than 7 L of
crystalloid during surgery and age over 55 were
associated with major medical complications.
Blood transfusion, prognostic comorbidity, and
number of surgeons correlated with length of stay.
Cigarette smoking and receipt of more than 7 L of
crystalloid during surgery were associated with
overall flap complications, and weight loss of more
than 10% before surgery, more than one operating
From the Department of Otolaryngology–Head and Neck Surgery,
Washington University School of Medicine.
Presented at the Annual Meeting of the American Academy of
Otolaryngology–Head and Neck Surgery, New Orleans LA,
September 26-29, 1999.
Reprint requests: Bruce H. Haughey, MBChB, FRACS, FACS,
Director, Division of Head & Neck Surgical Oncology, Department
of Otolaryngology, Washington University School of Medicine,
Campus Box 8115, 660 S. Euclid, St. Louis, MO 63110; e-mail,
haugheyb@msnotes.wustl.edu.
Copyright © 2001 by the American Academy of Otolaryngology–Head
and Neck Surgery Foundation, Inc.
0194-5998/2001/$35.00 + 0 23/1/116788
doi:10.1067/mhn.2001.116788
10
surgeon, and cigarette smoking were associated
with major flap complications.
CONCLUSIONS: Risk to patients and transferred tis-
sue is low in free flap head and neck reconstruc-
tion. Age, smoking history, and weight loss should
be considered during patient selection. Fluid bal-
ance should be considered during and after
surgery. Division of labor for patient care should be
carefully delineated among surgeons in a teaching
setting. (Otolaryngol Head Neck Surg 2001;125:10-7.)
Free flap reconstruction of the head and neck was
introduced with the jejunal free flap by Seidenberg in
1959.1 Because of improved knowledge of donor site
anatomy2 and advances in microvascular surgery,3 it has
become the most reliable and efficient method for
restoring tissue to regions of the head and neck that
have been resected because of diseases such as cancer
or trauma.4,5 Advantages include the single stage proce-
dures, innervated reconstructions, the versatility of flaps
reconstructed soft tissue and bone and the ability to tai-
lor repairs to complex 3-dimensional structures such as
the tongue, and the fact that these are innervated recon-
structions and single-stage procedures.
In this article, we describe our use of this technique
for over 10 years in a teaching setting: the Department
of Otolaryngology at Washington University School of
Medicine in St. Louis. We identify variables that influ-
ence medical and surgical outcomes by analyzing our
series of 241 free flap transfers to the head and neck.
The specific objectives of this retrospective study were
to stratify patients and procedures, to determine
whether donor sites changed over time, to assess med-
ical and surgical outcomes, and to identify variables
associated with complications.
METHODS AND MATERIAL
Data from all patients who underwent free flap reconstruc-
tions at our tertiary referral teaching center between 1989 and
1998 were used for this study with approval from the
University’s Human Studies Committee. All reconstructions
were managed by the corresponding author and resections by
the corresponding author or another surgeon. Residents assist-
ed with or performed the primary resections and neck dissec-
Otolaryngology–
Head and Neck Surgery
Volume 125 Number 1 HAUGHEY et al 11

Table 1. Diagnoses Table 3. Donor sites

Diagnosis N Site N %

Squamous cell carcinoma 184 Radial forearm ± radius 96 40%

Other malignancy 30 Fibula 46 19%
Osteoradionecrosis 14 Jejunum 27 11%
Trauma 5 Iliac crest 22 9%
Congenital 2 Rectus abdominus 19 8%
Fibrous dysplasia 1 Latissimus dorsi 19 8%
Mengioma 1 Serratus/rib 5 2%
Other 4 Lateral thigh 5 2%
Total 241 Scapula 2 1%
Total 241 100%

Table 2. Recipient sites

Table 4. Variables associated with major medical
Site N %
complications: univariate analysis (N = 141)
Oromandibular 73 30% Variable P
Oral soft tissue 43 18%
Oropharyngeal 41 17% Major comorbidity 0.007
Pharyngoesophageal 35 15% Age >55 0.009
Midface 14 6% Volume of crystalloid >7 L 0.017
Facial soft tissue 14 6% Reason for flap (bone reconstruction) 0.028
Skull base 8 3% Intraoperative pressors 0.077
Other 13 5%
Total 241 100%

tions under supervision, isolating blood vessels at the recipi-
ent sites. A microvascular fellow took progressive responsi-
bility for free tissue transfer over a 1-year training period.
Because this study focused on perioperative outcomes, we
followed patients for at least 30 days, entering records into a
computerized database. We conducted a more detailed analy-
sis, based on medical records, of the patients treated between
1992 and 1997. This smaller database provided comprehen-
sive preoperative, intraoperative, and postoperative data for
139 patients and 141 free flap transfers.
We studied 48 variables in these 141 cases. Demographic
variables were age, race, gender, weight, and height. Clinical
variables included defect site, tumor stage, reason for the flap,
prior treatments such as radiation or surgery, donor site, recip-
ient site, recent weight loss, medical comorbidity (assessed
with the Kaplan-Feinstein scale6), tobacco and alcohol use,
hematology values, serum biochemistry, and medication his-
tory. Intraoperative variables included the number of sur-
geons, length of anesthesia, volume and type of intravenous
fluids, blood transfusions, and use of pressors.
The database also contained postoperative outcome mea-
sures. These included 30-day survival, length of stay (which
correlates with cost in our hospital), and medical complica-
tions. Surgical outcomes included flap survival, flap com-
plications such as ischemia and flap loss, and donor site
complications. A flap complication was defined as major if
further surgery was necessary for that complication. Data
was captured on a coding form and entered into a personal
computer.
It should be noted that we recorded minor medical compli-
cations, such as rashes and urinary tract infections, as well as
life-threatening complications, such as myocardial infarction,
infection, and gastrointestinal bleeding. Also, we defined flap
complications broadly to include any condition at the recipient
or donor site that possibly could be attributed to the flap, even
though some (eg, hematomas, infections, and pharyngocuta-
neous fistulas) could have originated in the recipient site.
One of the authors (JSP) performed the statistical calcula-
tions with the χ2 test for univariate analysis and the logistic
regression model for multivariate analysis.
RESULTS
Between 1989 and 1998, 236 patients underwent free
flap reconstructions on the corrresponding author’s ser-
vice at our center. There were 155 men and 81 women.
However, 5 of the patients (3 men and 2 women) under-
went a second resection and reconstruction during this
period because their cancer recurred, increasing the total
number of free flap reconstructions to 241. Therefore,
66% of the reconstructions were performed on males
and 34% on females. Sixty-one percent of the recon-
structions involved patients 55 years of age or younger;
the remaining 94 (39%) were over 55. The age range
was 16 to 91, with a median age of 62.

12 HAUGHEY et al
Fig 1. Medical complications among 141 patients who underwent reconstructive
head and neck surgery between 1992 and 1997. Eighty of these patients devel-
oped a total of 124 medical complications.
The 241 cases included 223 reconstructions after
cancer surgery (93%). The remaining 18 reconstruc-
tions (7%) were performed after trauma, osteora-
dionecrosis, or removal of benign tumors such as large
mandibular ameloblastomas. Table 1 lists the diagnoses.
One hundred one (45%) of the cancer cases had
received preoperative radiation therapy.
One hundred twenty-nine (58%) of the 223 cancer
cases underwent primary treatment, whereas 111 (46%)
were reconstructed after salvage resection because a
tumor had recurred or osteoradionecrosis had devel-
oped. The remaining 8% had been resected during pre-
vious surgery, often at another institution.
Neck dissections were performed in 150 (62%) of
the 241 cases: unilateral in 118 cases and bilateral in 32
cases. Table 2 indicates the recipient sites in the head
and neck; they were predominantly the oral cavity and
oropharynx.
The major donor sites were the radial forearm (40%)
and fibula (19%), although a range of other sites also
were used (Table 3). Over time, however, donor site
preferences changed. For mandibular reconstructions (N
= 72) during the first half of the series (cases 1-120),
45% (14/31) of the reconstructions were performed with
bone and soft tissue taken from the deep circumflex
DCIA system (iliac crest), and 52% were performed
with fibular material. During the second half of the
Otolaryngology–
Head and Neck Surgery
July 2001
series (cases 121-241), the proportions changed to 15%
(iliac crest) and 80% (fibula). There was also a distinct
shift from using jejunal flaps to using tubed fasciocuta-
neous flaps for pharyngoesophageal reconstruction (N =
35): 88% jejunal and 12% fasciocutaneous during the
first half of the series and 17% jejunal and 83% fascio-
cutaneous during the second. In most cases, the fascio-
cutaneous flaps were taken from the radial forearm,
though some came from the lateral thigh.
Outcome measures obtained from the complete data
set of 241 cases were 30-day mortality, length of stay,
and flap loss. Five patients (2.1%) died during the 30-
day postoperative period. Causes of death were a perfo-
rated bleeding duodenal ulcer, myocardial infarction, a
sudden death that possibly resulted from tracheal tube
plugging, hyperosmolar diabetic hyperglycemia, and
adult respiratory distress syndrome. The median length
of stay was 11 days, with a 5-day minimum and a 41-
day maximum. Two hundred twenty-eight (95%) of the
241 flaps survived completely. Ten flaps (4%) were
completely lost, and 3 (1%) were partially lost. Of these
13, there were 6 repeat flap transfers for tissue loss and
7 that were managed without returning the patients to
the operating room.
The 141-case data set enabled us to analyze outcomes
in more detail. It showed that 65 (46%) of these cases
were managed entirely by the corresponding author
Otolaryngology–
Head and Neck Surgery
Volume 125 Number 1 HAUGHEY et al 13

Table 5. Variables associated with major medical complications: multivariate analysis (n = 141)
95% CI

Variable Category Adjusted odds ratio Lower Upper P

Volume of crystalloid <7 L 1 Reference 0.006

>7 L 5.08 1.60 16.20
Age ≤55 1 Reference 0.02
56-66 14.15 1.65 121.26 0.01
>66 20.52 2.37 177.93
Major comorbidity No 1 Reference 0.067
Yes 4.34 0.90 20.78

Table 6. Variables associated with increased Table 7. Variables associated with increased
length of stay: univariate analysis (n = 141) length of stay: multivariate analysis (n = 141)
Variable P Variable P

Perioperative blood transfusion 0.001 Number of surgeons 0.002

Recipient site (hypopharynx>oropharynx>oral cavity) 0.009 Blood transfusion 0.004
Two or more surgeons 0.02 Prognostic comorbidity 0.013
Administration of albumin 0.031 Type of colloid 0.340

(BHH) and that two or more surgeons were present dur-
ing the remaining 76 cases (54%). When multiple sur-
geons were involved, the senior author performed only the
free flap reconstruction.
Subsequent surgery during the first 30 days was
performed in 33 (23%) of the 141 cases. Of the 15 sec-
ondary reconstructions the most common type was a
pedicled myocutaneous flap, usually the pectoralis
major. Wound healing and/or carotid protection was
successful in all of these procedures. The most com-
mon donor site complications were skin graft losses
and infection: two required repeat surgery, one
for debridement and application of a second skin
graft (forearm), and the other for hematoma drainage
(fibula).
(Kaplan-Feinstein level 3) age over 55, and adminis-
tration of more than 7 L of crystalloid during anes-
thesia (Table 4).
Using multivariate analysis, we determined that
administration of more than 7 L of crystalloid during
surgery was significantly associated with major medical
complications (Table 5). The odds ratio was 5:1. Age
was also a significant variable, and subjects between
ages 56 and 66 were 14 times more likely to have a
major medical complication develop than those 55 and
under. The odds were more than 21:1 when patients 67
or older were compared with those 55 and under.
Comorbidity did not reach statistical significance,
though its presence appeared to increase the absolute
risk more than 4-fold.

Medical complications Length of stay

Eighty (57%) of the 139 patients developed one or
more medical complications within 30 days of recon-
structive surgery, and they had 124 complications in
all. The most common were cardiovascular, respirato-
ry, and central nervous system complications, as shown
in Fig. 1. We classified medical complications on a 4-
point (0-3) scale, which assigns a score of 3 to life-
threatening complications.
Using the χ 2 test, we compared frequencies of
complications when a variable was either present or
absent. When we considered major (severity level 3)
medical complications, variables that reached statis-
tical significance (P < 0.05) were major comorbidity
The median length of stay was 11 days, with a min-
imum of 5 days and a maximum of 41 days. The χ2 test
associated perioperative blood transfusions, recipient
site (hypopharynx vs oral cavity, oropharynx, or oth-
ers), number of surgeons, and administration of albumin
during surgery with length of stay (Table 6). For exam-
ple, patients who underwent reconstruction of the
hypopharynx stayed longer (median of 17 days) than
the other sites (medians of 10-12 days).
The multivariate analysis indicated independent
association of blood transfusion, “prognostic” comor-
bidity (K-F = 3), and number of surgeons with
increased length of stay (Table 7).

14 HAUGHEY et al
Fig 2. Flap complications among 141 patients who underwent reconstructive head and neck surgery
between 1992 and 1997. Forty of these patients developed a total of 64 complications.
Flap complications
These complications developed in 40 of 139 (29%)
patients. The most common flap complications were fis-
tula, wound dehiscence, and hematomas or seromas
(Fig 2). There was no significant decrease in complica-
tion rate within the 5 years over which they were
recorded. Table 8 summarizes the significant variables
with the χ2 tests. Multivariate analysis of variables asso-
ciated with any type of flap complication identified cig-
arette smoking during the 2 weeks before surgery as a
significant variable. A large volume of crystalloid (>7
L) administered during surgery was also significant, but
the involvement of more than one surgeon just failed to
reach significance (Table 9).
Loss of more than 10% of body weight before
surgery was associated significantly with a major
flap complication developing (one that required a
return to the operating room), along with having
more than one surgeon and smoking cigarettes. For
major flap complications, multivariate analysis iden-
tified the same significant variables as univariate
analysis: weight loss, having more than one surgeon,
and smoking cigarettes (Table 10).
DISCUSSION
We conclude that free tissue transfer is a reliable tech-
nique for head and neck reconstruction in a tertiary refer-
ral and teaching center. The perioperative mortality in our
series of 241 patients was 2.1%, which is comparable
with rates reported for other large series of free flap trans-
fers to the head and neck (7.0%7, 2.0%8, 4.7%9, 6.3%10).
Otolaryngology–
Head and Neck Surgery
July 2001
The donor sites in our series changed significantly
over a decade. For mandibular reconstructions, we came
to prefer the fibula over the iliac crest, mainly because
it can be harvested easily under tourniquet control with
little loss of blood. Also, its versatile cutaneous unit can
be used for lining the aerodigestive tract and/or for skin
coverage. It is, however, more prone to atherosclerosis
in the arterial pedicle than the iliac crest or scapula. For
repairing pharyngoesophageal defects, we now prefer
fasciocutaneous flaps over jejunal flaps because, in our
clinical judgment, there is less donor site morbidity. The
possibility of surgically related abdominal hemorrhage
or peritonitis is eliminated.
Our detailed study of complications and statistical
analyses identified several variables that associate with
less satisfactory medical or surgical outcomes (Table
11). Administering a large volume of crystalloid during
surgery was a risk factor for developing major medical
complications and/or for any level of flap complication.
Reasons for crystalloid administration include fluid
replacement, transfusion with packed cells, and
hypotension during surgery; interestingly, duration of
anesthesia, which might co-vary with volume of crys-
talloids given, did not predict for complications, nor did
the use of blood tranfusions or pressors. The pathologic
results of increased crystalloid administration could
include fluid overload and its cardiorespiratory conse-
quences. Administration of a large volume of crystalloid
during surgery was also associated with flap complica-
tions. One hypothesis is that excessive edema in the flap
and/or the recipient site promotes swelling and mechan-
Otolaryngology–
Head and Neck Surgery
Volume 125 Number 1 HAUGHEY et al 15

Table 8. Variables associated with all flap complications: univariate analysis (n = 141)
P P
(Any complication) (Major complications)
Variable 60/141 Variable 8/141

Cigarette smoking 2 weeks before surgery 0.001 Weight loss >10% 0.023
More than 1 surgeon 0.041 More than 1 surgeon 0.030
Major (level 3) medical complications 0.042 Cigarette smoking 2 weeks before surgery 0.036
Alcohol during the 2 weeks before surgery 0.057 Large volume of crystalloid (>7 L) 0.138
Intraoperative pressors 0.083 Intraoperative pressors 0.164
Large volume of crystalloid (>7 L) 0.149 Alcohol 2 weeks before surgery 0.585
Weight loss >10% 0.419 Major (level 3) medical complications

Table 9. Variables associated with any flap complication: multivariate analysis (n = 141)
95% CI

Variable Category Adjusted odds ratio Lower Upper P

Cigarette smoking No 1 Reference 0.002

Yes 5.33 1.84 15.42
Volume of crystalloid <7 L 1 Reference 0.025
>7 L 2.75 1.13 6.69
Number of surgeons 1 1 Reference 0.053
2 or more 2.19 0.99 4.84
Volume of blood lost <1 L 1 Reference 0.098
>1 L 0.48 0.20 1.15
Intraoperative pressors No 1 Reference 0.121
Yes 2.32 0.88 6.70
Alcohol consumption No 1 Reference 0.814
Yes 1.14 0.37 3.49

ically stresses the pedicles. The 5 patients in the
detailed, 141-case database whose flaps failed had a
median of 9.5 (3.7-11.0) L of crystalloid given. The low,
3.7-L value was in a patient whose flap failed because
of mechanical separation of the vein in an alcoholic
withdrawal crisis. Edema in recipient sites and flaps
might also disrupt the closure lines. In response to this
association, we recommend to our anaesthetist col-
leagues that crystalloid volume be minimized within the
limits of adequate vital organ perfusion. It is plausible
that >7 L of crystalloid was a marker for anesthetic
practice, a variable not included in our study.
Another statistically significant variable for medical
complications, advancing age, suggests that extra atten-
tion should be paid to the preoperative and postopera-
tive management of older patients. A careful presurgical
medical evaluation, preferably with the internal medical
surveillance postoperatively, would be ideal in patients
over 55 in view of the likelihood that major surgery will
unmask physiologic vulnerability. Our study differs
from an Australian study11 that failed to find a signifi-
cant difference in postoperative complication rates
between patients over and under 70 who were stratified
for preoperative comorbidity. However, in that study the
absolute numbers of medical complications were still
29% in the under-70 group and 54% in the over-70
group. A British study found that older men were at risk
for postoperative chest infection.9
Cigarette smoking within 2 weeks of surgery was
also associated with flap complications. In this respect,
our findings differ from those of several other series9,12
in which smoking did not appear to be a risk factor for
flap complications; however, these series did not speci-
fy proximity of smoking to surgery. There is evidence,
however, from other clinical literature and laboratory
work that tobacco products inhibit healing and promote
tissue loss in flaps.13 Therefore we recommend physi-
cians discourage smoking in patients who are about to
undergo free flap head and neck reconstruction.
The finding that both length of stay and major flap
complications increase significantly when more than
one surgeon is involved is open to several interpreta-
tions. One possibility is that outcomes improve when
the responsibility for preoperative selection and post-
operative management decisions rests with one per-
son. This finding encourages improved
 Otolaryngology–
Head and Neck Surgery
16 HAUGHEY et al July 2001

Table 10. Multivariate analysis of association with major flap complications (n = 8/141)
95% CI

Variable Category Adjusted odds ratio Lower Upper P

Weight loss >10% No 1 Reference 0.022

Yes 3.62 1.21 10.83
Number of surgeons 1 1 Reference 0.023
2 or more 4.22 1.22 14.78
Cigarette smoking No 1 Reference 0.036
Yes 3.23 1.08 9.68
Volume of crystalloid <7 L 1 Reference 0.138
>7 L 2.33 0.76 7.23

Table 11. Summary of multivariate analyses

Outcome

Variable Flap complication (any) Flap complication (major) Medical complication (major) Length of Stay

Cigarette smoking ** **
Volume crystalloid >7 L ** **
Two of more surgeons ** **
Weight loss (> 10%) **
Prognostic
co-morbidity **
Blood transfusion **
Age >55 years **

communication and peer review of cases selected for
this type of surgery. Because there is no other study
that controls for this variable, we cannot compare our
results with other institutions. However, other centers
do report comparable flap success rates with multiple
surgeon teams.10
The association of patient weight loss with major
flap complications may be explained by the effect of
nutritional deficits on wound healing14; this continues
to be a variable we try to eliminate by hyperalimenta-
tion before surgery.
Pertinent negative findings were that preoperative
irradiation had no association with medical or surgical
outcomes even though radiotherapy is known to damage
blood vessels and delay healing. A negative effect of
irradiation has been reported in some studies9,15,16 but
not in others.17 Duration of surgery did not influence
medical or surgical outcomes; therefore, the adverse
medical effects associated with high crystalloid vol-
umes and two or more surgeons were unlikely to have
resulted from prolongation of procedures. Our finding
that age fails to affect flap outcomes agrees with sev-
eral previous studies,7,17,18 but we demonstrated the
significant effect of advancing age on major medical
complications. Finally, the failure of all but major
comorbidity using the Kaplan-Feinstein scale to pre-
dict complications probably speaks to case selection
and our routine practice of seeking an internal medical
consultation before free flap operations. This is at vari-
ance with another study that used different (Charleson)
comorbidity index; this study did not distinguish com-
plications as medical or surgical, as we did, but rather
grouped complication severity and types.16
CONCLUSION
We will continue to offer microvascular free tissue
transfer as the preferred method of reconstruction in
appropriately selected patients with head and neck dis-
ease. Cognizance of potentially significant variables
uncovered by this study should help optimize future
outcomes and generates hypotheses for future investi-
gation. Microvascular free flap transfers to the head
and neck are known to be safe, but enhanced attention
to patient selection, preparation of patients for surgery,
fluid balance, and coordination between members of
the care team should increase effectiveness and safety
even further.
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Head and Neck Surgery
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