RECONSTRUCTIVE INDICATIONS OF SIMULTANEOUS DOUBLE

FREE FLAPS IN THE HEAD AND NECK: A CASE SERIES AND

LITERATURE REVIEW
DEEPAK BALASUBRAMANIAN, M.S., D.N.B.,1 KRISHNAKUMAR THANKAPPAN, M.S., D.N.B., M.Ch.,1*
MONI ABRAHAM KURIAKOSE, M.D., F.R.C.S.,2 SRIPRAKASH DURAISAMY, M.S.,1 RAJEEV SHARAN, M.S., M.Ch.,1
JIMMY MATHEW, M.S., M.Ch.,1 MOHIT SHARMA, M.S., M.Ch.,1 and SUBRAMANIA IYER, M.Ch., F.R.C.S.1

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge.
The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and
reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior
history of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that of
free fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of double
free flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n 5 13), (b) large oro-mandibular soft tissue
defects (n 5 4), (c) complex skull-base defects (n 5 2), and (d) dynamic total tongue reconstruction (n 5 2). Flap survival rate was 95%.
Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patients
with oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy
dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an
extensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous
use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is
C 2012 Wiley Periodicals, Inc. Microsurgery 32:423430, 2012.
proposed. V

Free flap reconstruction is now an integral part of the surgical management of head and neck malignancies.15 Reconstruction after resection of very advanced malignancies often
poses a challenge to the surgeon. They become challenging
mainly due to the extensiveness and complexity of the defects
involving multiple anatomical and functional subunits. These
reasons in the past would have limited the surgical oncologist
from offering treatment to these patients with advanced diseases, which were otherwise resectable. Use of double free
flaps has shown benefit in the reconstruction, in such situations. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps
in head and neck oncological surgery and to propose an algorithm for the right choice of flap combination.
METHODS

This is a retrospective review of consecutive cases of

head and neck malignancies treated surgically. Only the
cases treated with resection and reconstruction with si1

Department of Head and Neck Surgery and Oncology, Amrita Institute of

Medical Sciences, Kochi, Kerala, India
2
Department of Head and Neck Surgery, Mazumdar-Shaw Cancer Centre,
Narayana Hrudayalaya, Bangalore, India
*Correspondence to: Krishnakumar Thankappan, M.S., D.N.B., M.Ch.,
Department of Head and Neck Surgery, Amrita Institute of Medical Sciences,
Kochi, Kerala, India. E-mail: drkrishnakumart@yahoo.co.in
Received 23 August 2011; Revision accepted 20 December 2011;
Accepted 28 December 2011
Published online 21 March 2012 in Wiley Online Library (wileyonlinelibrary.com).
DOI 10.1002/micr.21963
C
V

2012 Wiley Periodicals, Inc.

multaneous double free flaps were included. Cases with

prior treatment with radiotherapy or chemoradiotherapy
were also included. Benign cases were excluded. The
patients who had similar defect reconstruction with a
combination of a pedicled flap and a free flap were also
excluded. An institutional review board approval was
obtained for this review. A prospectively maintained tumor board database, electronic medical records including
case records, operative details, and follow-up data were
studied. The study period was for 6 years from March
2006 to February 2011.
RESULTS

Twenty-one patients (male, 17; female, 4) underwent

reconstruction with simultaneously done double free flaps
during the study period. The mean age was 50.2 years
(range 3270 years). Nineteen of 21 patients had T4 primary tumor stage. The pathology was squamous cell carcinoma in 20 patients and adenoid cystic carcinoma in
one patient. Eleven patients had prior history of radiotherapy or chemo-radiotherapy. The primary tumor and
treatment characteristics are shown in Table 1. A total of
42 free flaps were used in these patients. Reconstructive
indications of simultaneously double free flaps were
broadly classified as: (a) large oro-mandibular bone and
soft tissue defects (n 5 13), (b) large oro-mandibular soft
tissue defects (n 5 4), (c) complex skull-base defects
(n 5 2), and (d) dynamic tongue reconstruction (n 5 2).
The predominant flap combination was that of free fibula

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Balasubramanian et al.

osteo-cutaneous flap with free anterolateral thigh (ALT)

fascio-cutaneous flap (n 5 8). A combination of free fibula flap with free radial forearm flap was used in five
patients and ALT flap with free radial forearm flap was
used in three patients. The indications, details of the
flaps, and their combinations are depicted in Table 2. The
mean size of the skin defect in oro-mandibular defects
was 9 cm 3 7 cm. Also the mean size of the mucosal
defect in such defects was 8 cm 3 6 cm. The mean operating time was 14 hours (range 1018 hours). One patient
died in the immediate postoperative period due to systemic complications. Excluding the two flaps in this
patient, the flap survival rate was 95% (38/40). Two
patients had complete flap loss. The contralateral fibula
Table 1. Primary Tumor and Treatment Characteristics
Number
Site (n 5 21)
Tongue
Buccal mucosa/cheek
Lower alveolus
Upper alveolus
Floor of the mouth
Skullbase
T stage
T2
T3
T4a
T4b
Free flap (n 5 42)
Fibula
Radial forearm
ALT
Rectus abdominis
Gastro-omental
Flap complications
Partial flap loss
Total flap loss
Wound dehiscence
Re-exploration (venous problems)

3
7
5
1
3
2
1
1
12
7
13
11
12
2
2
0
2
3
4

flap replaced the lost fibula in a patient. ALT flap loss in

another patient was salvaged with a pectoralis major
myo-cutaneous (PMMC) flap. The histopathological examination of specimens showed that the resection was
adequate with wide margins in 16 patients, while five
patients had close or positive margins. Median follow-up
period was 11 months. Twelve patients were alive and
free of disease at the end of the follow-up. Eighteen of
19 patients with oro-mandibular and glossectomy defects
were able to resume an oral diet within 2 months while
one patient remained gastrostomy dependant till his death
due to disease not related to cancer. This patient had a
combination of free fibula flap with ALT flap, for an
extensive oro-mandibular defect. The associated large
defect involving the tongue accounted for the swallowing
difficulty. Figures 1a1c show a patient with a large oromandibular bone and soft tissue defect. The lesion was
involving lip and commissure. Only soft tissue defect
was reconstructed with a combination of free ALT flap
and free radial forearm flap. ALT flap was used for
reconstructing the outer skin defect, while radial forearm
flap was used for the mucosal lining and for reconstructing the lip. Figures 2a2d show a patient with adenoid
cystic carcinoma of the lateral skull base with intracranial
extension, involvement of the oral mucosa, and skin. A
combination of free rectus abdominis flap and ALT flap
was used. Rectus muscle with skin was used for the
skull-base defect and oral mucosal lining. ALT flap was
used for the skin cover. Figures 3a3c show an extensive
tongue lesion resected and reconstructed with a combination of free gracilis muscle flap and free gastro-omental
flap. The motorized free gracilis muscle, anchored
between the hyoid bone and the mandible worked as the
functional motor unit for providing tongue movements
and elevation, together with stomach component of gastro-omental flap, turned inside out for the mucosal sur-

Table 2. Indications and Combinations of Simultaneous Double Free Flaps

Indications
Large oro-mandibular
bone and soft tissue
defects
Large oro-mandibular
soft tissue defects

Complex skull-base
defects
Dynamic tongue
reconstruction
Total

Total number
of patients
13

Site
Oral cavity

Oral cavity
Buccal mucosa, skin
Buccal mucosa, skin,
lip commissure
Maxilla

Tongue

21

Flap combination

Number of
patients

FFF
FFF

RFFF
ALT

5
8

ALT
ALT
RFFF
Rectus
Rectus
Gracilis

RFFF
RFFF
RFFF
ALT
RFFF
Gastro-omental

2
1
1
1
1
2
21

FFF, free fibula flap; RFFF, radial forearm free flap; ALT, free anterolateral thigh flap; rectus, free rectus abdominis flap; gracilis, free gracilis muscle flap; gastro-omental, Free Gastro-omental flap.

Microsurgery DOI 10.1002/micr

Simultaneous Double Free Flaps in the Head and Neck

425

face, as an added source of secretion. The attached omentum provided adequate bulk.
DISCUSSION

In the head and neck, when the resection involves

complex multiaxial subunits, it may not be possible to
reconstruct the defect with single flap. The subunits may
be of skin, bone, or large mucosal defects. Simultaneous
use of double free flaps will be helpful in these situations. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double
free flaps in head and neck cancer surgery. Previous studies have brought about the efficacy and outcome of double free flaps in head and neck reconstruction.68 Some
reports have also dealt with the oncological indications of
such surgery.9,10 The goals, indications, and functional
results of reconstruction in these different subsites would
be different. However, at the same time, there are situations in these areas that demand a complex simultaneous
double free flap reconstruction.
Large Oro-Mandibular Bone and Soft
Tissue Defects

Figure 1. (a): Patient with a large oro-mandibular bone and soft tissue defect. The lesion involving lip and commissure. (b): Computed
tomography scan. (c): Reconstructed outcome. Only soft tissue
defect was reconstructed with a combination of free ALT flap and
free radial fore arm flap. [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]

They include through and through defects after the

composite resection of the mandible, maxilla, part of the
tongue, floor of mouth, and the cheek skin. Fibula free
osteocutaneous flap is the commonest choice for combined bony and soft tissue reconstruction. Unfortunately,
there is a limit for the soft tissue and skin that can be
taken along with the fibula. They may not always be sufficient enough to replace all the resected tissue. Also
there are limitations due to the orientation of the fibula
skin paddle and muscular tissue in relation to the bone. If
the skin paddle is used for an extensive oral cavity lining,
it necessitates the use of a simultaneous soft tissue flap
for the skin cover. The choice would be to combine a
free radial forearm flap or free ALT flap along with fibular bone. This is the commonest indication of the present
series (n 5 13). Free fibula flap with free radial forearm
flap combination was used in five patients and free fibula
flap with ALT flap was used in eight patients. Wei et al.6
has described the use of double free flaps for this purpose
in 36 oral cancer patients with good results. Free fibula
flap with free radial forearm flap was the commonest
combination used (n 5 20) by them. In a separate paper,
Wei et al. describes the use of combined ALT flap and
vascularized fibula osteo-septocutaneous flap in reconstruction of 22 extensive composite mandibular defects
with good esthetic and functional results.11 Jeng et al.12
has described the reconstruction of extensive composite
mandibular defects with large lip involvement by using
double free flaps and fascia lata grafts for oral sphincters.
Recent work by Posch et al. has noted a modest improveMicrosurgery DOI 10.1002/micr

426

Balasubramanian et al.

Figure 2. (a): Patient with adenoid cystic carcinoma of the lateral skull base. (b): Surgical defect involving the skull base, dura, oral mucosal defect, and skin. (c): A combination of free rectus abdominis and ALT flap was used. Rectus muscle with skin was used for the skullbase defect and oral mucosal lining. (d): Reconstructed outcome. ALT was used for the skin cover. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]

ment in function and esthetics in double free flap reconstruction in through and through defects.13
Large Oro-Mandibular Soft Tissue Defects

These defects are similar to the above category but

include those where a bony reconstruction is not planned.
Presence of severe trismus is an instance when a bony
reconstruction may not be done. Replacement of bone may
hinder adequate mouth opening postoperatively. Presence
of large skin defects including that of the neck along with
mucosal effects of the oral cavity is also included in this
category. These kinds of defects can be effectively dealt
with the use bipaddling of soft tissue flaps like ALT flaps
or PMMC pedicled flap. However, such bipaddling may be
difficult if the defects are too big or may be not suitable
because of the bulkiness that would lead to a functionally
compromise. Use of double free flaps may suit better in
these defects. This study includes two patients where a
combination of ALT flap with free radial forearm flap was
performed as bipaddling of the ALT flap would have been
Microsurgery DOI 10.1002/micr

suboptimal. The other indication for the use of double free

flaps for soft tissue reconstruction alone is the significant
simultaneous involvement of lip, commissure, and soft tissues of the cheek. Using a single free flap does not allow
proper reconstruction of a competent lip. The combination
used was ALT flap and free radial forearm flap, with
bipaddled ALT flap for providing the skin and buccal mucosal lining and radial forearm flap with palmaris longus
tendon for lip and the commissure. Two patients were
included in the present series, where double free flaps were
used to reconstruct combined cheek skin, buccal mucosa,
and lip defects.
Complex Skull-Base Defects

Large defects after anterolateral and lateral skull-base

resections usually require a muscle flap like free rectus
abdominis muscle for reconstruction.14 However, when
such defects are associated with complex defects involving bone, skin, and mucosal lining, tissue available with
a single flap may not be sufficient. The present series

Simultaneous Double Free Flaps in the Head and Neck

427

Figure 3. (a): Tongue carcinoma involving near total tongue. Computed tomography scan showing the lesion. (b): The scheme of reconstruction with double free flaps. Inverted gastric mucosa over the omentum. Free gracilis muscle was hitched between the hyoid and the
mandible. (c): Reconstructed tongue. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

include two such patients. We have used a combination

of free rectus abdominis muscle along with free radial
forearm flap or ALT flap. Free rectus abdominis flap was
used for the skull-base defect. Radial forearm flap or
ALT flap was used for the skin cover.
Dynamic Tongue Reconstruction

Total glossectomy and near total glossectomy defects

are often reconstructed with free soft tissue flaps like free

rectus abdominis or ALT flaps.15,16 The use of gastroomental free flap along with free gracillis muscle flap to
achieve functional dynamic reconstruction of the tongue
is reported earlier.17 The free gracilis muscle flap worked
as functional motor unit for providing tongue movements
and elevation, together with free stomach component of
gastro-omental flap, turned inside out for the mucosal
surface, as an added source of secretion. The attached
omentum provided adequate bulk.17 The hypoglossal
Microsurgery DOI 10.1002/micr

428

Balasubramanian et al.

nerve end was anastomosed to obturator nerve, the motor

supply to gracillis muscle. Two patients underwent such
reconstruction with successful outcome.
With the exception of functional reconstruction of
tongue, in all other indications, one of the free flaps
could be substituted by a pedicled flap like PMMC flap
or a forehead flap. Although not included in this report,
we had on six occasions, used a pedicled flap for the
outer cover with a free flap for the lining; five PMMC
flaps and one forehead flap (data not shown). However,
they are useful in limited coverage of skin or mucosal
defects. Use of these pedicled flaps along with the free
flaps is more demanding technically to position and protect the pedicle. They also carry with them the inadequacy of being less pliable to suit the three-dimensional
defects.
The surgical management of advanced through and
through tumors of the oral cavity poses a challenge in
the surgical reconstruction. Urken et al.18 and Jewer
et al.19 reported the multiunit reconstruction of oro-mandibular defects using a single iliac crest flap. The iliac
crest has the advantage of being either an osseous or an
osseo-cutaneous flap. The addition of the internal oblique
muscle permitted the reconstruction of mucosal and pharyngeal defects. Boyd et al.20 compared the osseo-cutaneous radial forearm flap with the iliac crest flap for oromandibular reconstruction. In Boyds study, majority was
the iliac crest transfers and this group had a higher incidence of intraoral breakdown and bone exposure. They
also reported good function with regard to speech and
swallowing in extensive T4 lesions with through and
through defects with composite oro-mandibular reconstruction. All the above papers related to the use of a single flap reconstruction for oro-mandibular defects. However, in extensive T4 lesions, there is a need for a large
and robust skin and soft tissue component that is seldom
available with the fibula or the iliac crest. The earliest
reports of double free flap transfer was for oro-mandibular reconstruction.8,2123 The radial forearm flap when
used, is thin, pliable, does not add to excess bulk and can
be used to reconstruct the lip in combination with palmaris longus tendon.22 However, in certain cases of oromandibular defects, a larger soft tissue component is
required. Ao et al.21 first reported the use of the ALT
flap in combination with a free fibula flap. Wei et al.6
reported the first large series of 36 patients who underwent double free flap transfer. In Weis series, a wide variety of flaps were used, the most common being free radial forearm flap with free fibula flap. The flap success
rate was 93%. Forty-four percentage of the patients in his
series survived for 36 months. In a subsequent publication, Wei et al.11 reported the use of an ALT flap in
combination with the free fibula flap in 22 patients.
According to the author, the radial forearm flap does not
Microsurgery DOI 10.1002/micr

offer enough tissue to cover the bone, reconstruction

plate, and the soft tissue defect. The flap success rate
was 90.9% in this series. Gabr et al.24 in a series of 40
patients used a single flap (17 patientsosseo-musculocutaneous fibula flap) and double flap (23 patientsiliac
crest and ulnar free flap) for complex oro-mandibular
defects. Overall flap survival was 96.8% (100% of fibular
flaps and 95.65% of iliac/ulnar flaps). A distinct advantage of using simultaneous double free flaps is in reconstructing lip defects. Jeng et al.12 reported the use of a
fascia lata sling in combination with ALT flap and free
fibula flap. This neo" oral sphincter allows for return of
some function and provides better results.
Posch et al.13 attempted to study the functional and
esthetic results following double free flap reconstruction.
More than half of the patients in his series had functional
problems following surgery (deteriorated speech, oral
incontinence, color mismatch, and flap contracture of
flaps). Hanasono et al.25 reported a group of 39 patients
who received double free flaps for a variety of defects
(mandible, cheek, tongue, and palate). Functionally, out
of 29 patients who were feeding tube dependant prior to
surgery, 23 resumed oral diet following surgery. This
indicates a good functional result with regard to swallowing after double free flap transfer. One of the issues with
double free flap transfer is the availability of recipient
vessels in the neck for anastamosis especially in radiation
failure or previously operated cases. Lin et al.26 reported
a series of 55 patients, out of which 39 had the second
anastamosis to the distal run off of the fibula flap. The
rest of the patients underwent two vessel anastamosis.
There was no difference between the outcomes between
the two groups. In certain cases, one may need to combine a free flap and a local flap for defect closure. Bianchi et al.27,28 reported such a combination with good esthetic results even in anterior mandible defects.
The outcome of double free flap reconstruction in our
series was good. The flap survival rate was 95%. Nineteen of 21 patients were of T4 clinical T stage. Seven
(33%) patients were staged as T4b, the very advanced
lesions. Simultaneous free flap reconstruction had aided
the reconstruction after such extensive resections. The
functional outcome was also satisfactory. All but one
patient were able to resume oral diet. All of the tumors
were T4 stage (14 T4a and seven T4b). Majority of our
patients were buccal mucosa tumors. Twelve out of 21
patients (52.4%) were alive and disease free at the end of
the follow-up. Considering the extensiveness of the
tumors, these oncological results were good. Also the
buccal mucosal tumors are chewing tobacco related and
show a better outcome. Although locally advanced, they
did not have nodal metastasis at presentation and remain
disease free after appropriate local surgery and adjuvant
treatment. The complex reconstructions have aided this.

Simultaneous Double Free Flaps in the Head and Neck

429

Figure 4. An algorithm for the choice of flap combination for the appropriate indications. ALT (free ALT flap) and RFFF (radial forearm free
flap). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

CONCLUSIONS

Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and
neck oncologic resections. Such combinations permit better complex multiaxial subunit reconstruction. The outcome in terms of flap survival, oncological results, and
functional results in such patients with extensive tumors
was good. This retrospective analysis has elucidated the
reconstructive indications of the use of simultaneous double free flaps in head and neck cancer surgery and proposes an algorithm for the right choice of flap combination (Fig. 4).

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Microsurgery DOI 10.1002/micr

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