Free flap surgery in osteoradionecrosis of the head and neck

Osteoradionecrosis (ORN) following radiation therapy is a much-feared complication of the treatment of head and neck cancer. Free flap reconstruction in the ORN patient has specific challenges for the surgeon. From 2014 to 2020 the Head and Neck Microvascular unit of the Oral and Maxillofacial Surgery Division at Jackson Health/University of Miami treated 149 ORN patients with free flap reconstruction. The fibula free flap (n=65) and anterior lateral thigh free flap (6n=1) were the workhorse flaps in our series comprising 44% and 41% of the total flap surgeries. A total of 13 cases (8.7%) involved performing 2 flaps in the same operation. Thirty cases had recorded complications with one flap loss (0.7%) and one case of partial necrosis (0.7%) of the flap. The most common complications encountered were flap congestion with 8 cases (5%), 5 cases of flap dehiscence,4 cases of neck hematoma (2.6%) and 3 cases of infection of the flap reconstruction site (3%). The average length of stay was 8.2 days. In this paper we present our approach to reconstruction in these patients and the lessons we have learned. Though this surgery is complex and has greater risks than free flap surgery in the “virgin” neck, our experience demonstrates that good outcomes can be achieved consistently with a structured approach.