Timing of radiotherapy in head and neck free flap reconstruction – a study of postoperative complications

https://doi.org/10.1016/j.bjps.2008.01.005Get rights and content

Summary

The local treatment protocol of preoperative radiotherapy in head and neck cancer treatment at the Karolinska University Hospital has resulted in a unique cohort of preoperatively high dose-irradiated patients. In total 216 consecutive patients were reviewed, of whom 221 free flaps, for head and neck cancer reconstruction, were operated between 1984 and 2002. In 194 cases radiotherapy was administered preoperatively and 27 operations were performed without prior radiation. The radiation dose was 64 Gy in 147 cases, 54 Gy or less in 45 cases and uncertain in two cases. In order to study whether the time elapsed between the end of radiotherapy and surgery had any significance regarding postoperative events, the cohort was subsequently divided into three groups: patients operated on within 4 weeks (n = 27), between 4 and 6 weeks (n = 88) and more than 6 weeks (n = 78) after the last radiotherapy session. Postoperative complications were analysed in relation to preoperative dose and timing of radiotherapy.

Preoperative radiotherapy was related to an increased risk of free flap necrosis as 22 complete and eight partial flap necroses occurred in the group that had received preoperative radiotherapy and none were observed in the non-irradiated group (P < 0.05). Furthermore, a linear trend of increased flap loss (P < 0.001), infections (P < 0.001) and delayed wound healing (P < 0.001) was seen when time increased between the last radiotherapy session and surgery. The largest increase in all complication rates was seen when more than 6 weeks elapsed between last radiotherapy session and surgery. Postoperative complications were independent of the radiation dose given.

Our data show an increased morbidity in free flap surgery in the head and neck region after preoperative radiotherapy. Furthermore, time elapsed between the last radiotherapy session and surgery is associated with the risk of developing postoperative complications. We strongly suggest that free flap reconstruction should be performed within 6 weeks of the last radiotherapy session.

Section snippets

Patients and methods

From 1984 to 2002, 221 consecutive immediate free flap reconstructions were performed after head and neck cancer resection in 216 patients at the Karolinska University Hospital. All patients were operated in one stage where the tumour resection and neck dissection were performed by a head and neck surgeon and the reconstruction by a reconstructive plastic surgery team. The free radial forearm flap was the most common type of reconstruction (Table 1). Part of the radial forearm flap material up

Results

Twenty-two complete and eight partial flap necroses occurred in the group that had received preoperative radiotherapy compared to none in the preoperatively non-irradiated group. No major differences in demographic and clinical characteristics were seen between the groups (Table 2). The radial forearm flap was the most commonly used flap and also the most common flap among flap failures (Table 3). Re-explorations were performed in 39 patients, of whom 21 had a vascular compromised flap. The

Discussion

Our results consist of two main findings. First, we found an association between preoperative radiotherapy and flap failure, when partial and total flap loss were analysed together. Second, a relationship between time elapsed from the last radiotherapy session to surgery and postoperative complications could be shown. The first result is likely to be related to complications of the anastomosis, whereas the second is a result mainly related to impaired healing of the flap into the irradiated

Acknowledgements

The authors acknowledge the work of collecting data by medical student Anna-Maria Wasner, Karolinska Institutet.

References (35)

  • S. Lin et al.

    Preoperative radiation therapy and its effects on outcomes in microsurgical head and neck reconstruction

    Otolaryngol Head Neck Surg

    (2005)
  • K. Bozikov et al.

    Factors predicting free flap complications in head and neck reconstruction

    J Plast Reconstr Aesthet Surg

    (2006)
  • J. Wennerberg

    Pre versus post-operative radiotherapy of resectable squamous cell carcinoma of the head and neck

    Acta Otolaryngol

    (1995)
  • D.W. Robinson

    Surgical problems in the excision and repair of radiated tissue

    Plast Reconstr Surg

    (1975)
  • E.L. Dormand et al.

    Radiotherapy and wound healing

    Int Wound J

    (2005)
  • S.R. Baker et al.

    Radiation effects on microvascular anastomosis

    Arch Otolaryngol

    (1978)
  • S.S. Kroll et al.

    Does prior irradiation increase the risk of total or partial free-flap loss?

    J Reconstr Microsurg

    (1998)
  • Cited by (94)

    • Radiation Therapy and Soft Tissue Response

      2021, Plastic Surgery - Principles and Practice
    • Osteoradionecrosis, an increasing indication for microvascular head and neck reconstruction

      2020, International Journal of Oral and Maxillofacial Surgery
    • The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery

      2020, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
    View all citing articles on Scopus

    Presented at the 14th International Congress of the International Confederation for Plastic Reconstructive and Aesthetic Surgery (IPRAS), 29 June 2007, Berlin, Germany.

    View full text