# Head and neck reconstruction: the free flap, and what it gives back

Source: https://onco.cc/technologies/rejuv-recon-head-neck/  
OnCo record `rejuv-recon-head-neck` (Technology). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Removing a tongue, a jaw or a pharynx leaves a hole that will not close, so tissue is moved from the forearm, thigh or lower leg with its own artery and vein and joined under a microscope. In a series of 843 flaps the overall failure rate was 4.0 per cent, and in an older series of 1,000 flaps 7.6 per cent failed wholly or partly. Donor site disability measured years later is small.

## Summary

Microvascular free tissue transfer is the operation that made function-preserving head and neck surgery possible. A piece of skin, fascia, muscle or bone is raised from a distant site with its feeding artery and draining vein, moved to the defect, and the vessels are sewn to vessels in the neck under magnification. The commonest donors are the radial forearm for thin pliable tissue, the anterolateral thigh for bulk, and the fibula for a jaw that needs bone.

How reliable it is. A three-centre review of 843 consecutive head and neck free flaps reported overall flap failure of 4.0 per cent, with anastomotic revision needed in 5.0 per cent and a 47.6 per cent failure rate once a revision was required. An older single-institution series of 1,000 flaps in 972 patients over 23 years reported 130 failures (7.6 per cent), of which 58 were complete and 72 partial, and named venous thrombosis and neck haematoma as the commonest causes. Frailty does not appear to change flap survival: in a 112-patient cohort scored with the modified five-item frailty index, flap success, complications, reoperation and 30-day mortality were all similar between frail and non-frail patients, though one-year mortality was higher in the frail group.

What it costs the donor limb. A cross-sectional survey of patients a median 3.25 years after radial forearm free flap reconstruction found a mean QuickDASH disability score of 10.7 for the soft tissue flap and 21.6 where bone had also been taken from the radius, on a 0 to 100 scale where higher is worse. Specific tasks were harder after the bone version: opening a jar, washing the back, and recreational activities. The authors' summary is that overall donor site impairment is minimal.

What it does not restore. This is the part usually left out. A flap replaces bulk and lining; it does not replace a tongue's ability to move, a larynx's ability to close, or the salivary glands lost to radiotherapy. Swallowing and speech after head and neck reconstruction are therefore a rehabilitation problem rather than a surgical one, and are treated in the swallowing record here and in the wave one records on dry mouth. Shoulder dysfunction after neck dissection, from traction on the accessory nerve, is a separate and common impairment treated by physiotherapy.

Jaw reconstruction and teeth. A fibula flap restores the mandible's continuity and contour, and the next question is whether a person can chew. That depends on dental implants into transplanted bone that has usually been irradiated, which has its own record here.

What comes back, and when: the wound closes and the face has a contour, usually within weeks. Swallowing, speech and chewing come back over months and often incompletely, and how far they come back is determined more by how much nerve and muscle was removed, and how much radiotherapy followed, than by the reconstruction itself.

## Fields

- Kind: Technology
- Status: standard-of-care
- Last checked: 2026-10-02
- Tags: rejuvenation; survivorship; rehabilitation; evidence:moderate
- Principle: Tissue dies without perfusion, so a graft larger than a few millimetres thick cannot survive on diffusion alone. A free flap solves this by carrying its own circulation and borrowing a new inflow and outflow at the recipient site. Everything about the operation's risk profile follows from that: the failures are vascular, they happen early, and once an anastomosis needs revising the odds change sharply.
- Strengths: Flap survival above 95 per cent in modern series; Allows resection of tumours that could not otherwise be closed; Donor site disability measured years later is small
- Limitations: Restores bulk and lining, not movement, sensation or saliva; Once an anastomosis is revised, roughly half of those flaps still fail; Long operations in a population that is often frail and malnourished

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Free_flap
- Effect of perioperative antithrombotics on head and neck microvascular free flap survival after anastomotic revision (Otolaryngol Head Neck Surg 2023): https://doi.org/10.1002/ohn.295
- Microvascular free flaps in head and neck surgery: complications and outcome of 1000 flaps (Int J Oral Maxillofac Surg 2012): https://doi.org/10.1016/j.ijom.2012.02.012
- Upper extremity outcomes in radial forearm free flap reconstruction of the head and neck (OTO Open 2026): https://doi.org/10.1002/oto2.70283
- Outcomes of free-flap reconstructive microsurgery in frail head and neck patients (J Oral Maxillofac Surg 2026): https://doi.org/10.1016/j.joms.2026.05.071

## Connected records

- cancers: [Head and neck squamous cell carcinoma](https://onco.cc/cancers/head-and-neck/), [Laryngeal and hypopharyngeal cancer](https://onco.cc/cancers/laryngeal-cancer/), [Oral cavity cancer (mouth and tongue)](https://onco.cc/cancers/oral-cavity-cancer/), [Oropharyngeal cancer (tonsil and base of tongue)](https://onco.cc/cancers/oropharyngeal-cancer/)
- fronts: [Recovery & Rejuvenation](https://onco.cc/fronts/rejuvenation/), [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- technologies: [Breast reconstruction: implant and autologous, immediate and delayed, and what women report afterwards](https://onco.cc/technologies/rejuv-recon-breast/), [Cancer rehabilitation: the discipline that puts function back](https://onco.cc/technologies/rejuv-rehab-cancer-rehabilitation/), [Dry mouth, teeth and taste after head and neck radiotherapy](https://onco.cc/technologies/dry-mouth-teeth-after-head-neck-radiotherapy/), [Facial reconstruction and facial prostheses: ears, orbits and noses](https://onco.cc/technologies/rejuv-recon-facial-prosthetics/), [Scars, stiffness and contracture: shoulders, necks and jaws](https://onco.cc/technologies/rejuv-rehab-scar-contracture/), [Swallowing therapy around head and neck radiotherapy](https://onco.cc/technologies/rejuv-rehab-swallowing/), [The devices that do the restoring, and who pays for them](https://onco.cc/technologies/rejuv-rehab-assistive-devices/), [Transoral robotic surgery (TORS)](https://onco.cc/technologies/tors/), [Voice after the larynx is removed](https://onco.cc/technologies/rejuv-recon-voice-after-laryngectomy/)
- terms: [Dysphagia (difficulty swallowing)](https://onco.cc/terms/dysphagia/), [Quality of life](https://onco.cc/terms/quality-of-life/), [Skin grafts and flaps after skin cancer surgery](https://onco.cc/terms/skin-graft-and-flap-reconstruction/)
- bottlenecks: [Survivorship and late effects are neglected](https://onco.cc/bottlenecks/b-survivorship/), [Toxicity and quality of life are undervalued](https://onco.cc/bottlenecks/b-toxicity-qol/)

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