Microsurgical Reconstruction for Radiation Necrosis: An Evolving Disease

ABSTRACT

We performed a retrospective chart review of a tertiary care medical center. Our objective was to report our experience with microvascular reconstruction in the head and neck in patients who presented with radiation-induced tissue damage. We will discuss the effects of radiation to soft tissues and bone in the head and neck as well as the challenges it presents for later free tissue transfer. Patients were identified who underwent free tissue transfer to the head and neck for radiation-induced tissue injury by the senior author at our institution. Data were collected to include location of the primary disease, radiation amount and zone of radiation injury, initial surgical reconstruction, time to development of radiation necrosis, type of free flap selected, recipient vessel selection, the number of sequential free tissue transfers, hyperbaric oxygen therapy, flap success rates, and minor complications. Patients were excluded if recurrent cancer was identified at any time following reconstruction. One hundred sixty-one free flaps were performed from 2000 to 2004 in the head and neck by the senior author at our tertiary care institution. Fourteen patients were identified who met the inclusion criteria and 16 (two lateral thigh, two iliac crest, one radial forearm, one transverse rectus abdominis, six fibula, two latissimus dorsi with associated rib, and two scapula) free flaps were performed for radiation-induced complications. Five patients required multiple sequential free flaps including the initial reconstruction. Anastomosis was performed within the radiation zone of injury in 14 cases (87.5%), whereas 2 (12.5%) were performed outside the zone of injury. Forty-three percent of patients (n = 6) underwent hyperbaric oxygen therapy. After initial reconstruction, the incidence of complications requiring surgical intervention included skin breakdown (n = 1), fistula (n = 2), and persistent osteoradionecrosis (n = 2). The mean time to follow-up was 17.5 months (range 1 to 49). There was one partial flap failure that was salvaged by thrombectomy. There were no total flap failures. As primary treatment for head and neck cancer moves toward radiation therapy, microsurgical reconstruction is playing an increasing role for those patients developing radiation-related complications. Radionecrosis is a progressive disease where the incidence is increasing as patients are surviving longer. Understanding the effects of radiation on soft tissue and bone and the complexity of reconstruction in the zone of injury will greatly improve the success of reconstruction.

KEYWORDS

Osteoradionecrosis - free flap reconstruction - head and neck - hyperbaric oxygen

REFERENCES

• 1 Stone H B, Coleman C N, Anscher M S, McBride W H. Effects of radiation on normal tissue: consequences and mechanisms.  Lancet Oncol. 2003;  4 529-536
• 2 Marx R E. Osteoradionecrosis.  J Oral Maxillofac Surg. 1983;  41 283-288
• 3 Reuther T. Osteoradionecrosis of the jaws as a side effect of radiotherapy of head and neck tumour patients-a report of a thirty year retrospective review.  Int J Oral Maxillofac Surg. 2003;  32 289-295
• 4 Hao S P, Chen H C, Wei F C, Chen C Y, Yeh A R, Su J L. Systemic management of osteoradionecrosis in the head and neck.  Laryngoscope. 1999;  109 1324-1327
• 5 Marx R E. A new concept in the treatment of osteoradionecrosis.  J Oral Maxillofac Surg. 1983;  41 351-357
• 6 Gal T J, Munoz-Antonia T, Muro-Cacho C A et al.. Radiation effects on osteoblasts in vitro: a potential role in osteoradionecrosis.  Arch Otolaryngol Head Neck Surg. 2000;  126 1124-1128
• 7 Annane D, Depondt J, Aubert P et al.. Hyperbaric oxygen therapy for radionecrosis of the jaw: a randomized, placebo-controlled, double-blind, trial from the ORN96 Study Group.  J Clin Oncol. 2004;  22 4893-4900
• 8 Santamaria E, Wei F C, Chen H C. Fibula osteoseptocutaneous flap for reconstruction of osteoradionecrosis of the mandible.  Plast Reconstr Surg. 1998;  101 921-929