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Multi-flap reconstruction after surgery for head and neck cancer led to "modest" functional and aesthetic improvement and high complication rates and costs, a meta-analysis of 24 published studies showed.

Substantial proportions of patients remained partly or fully dependent on feeding tubes at follow-up, had poor oral competence associated with drooling, or unintelligible speech. A subgroup of evaluable patients had a mean hospital length of stay exceeding 3 weeks, and more than 70% of evaluable patients had minor or major complications.

Overall survival averaged 2.36 years, Eben Rosenthal, MD, of Stanford University in California, and co-authors reported online in .

"Because of limited patient life expectancies, modest functional and aesthetic outcomes, and significant associated costs, surgeons should weigh the curative potential and palliative benefits for individual patients with a comprehensive view of the overall outcomes of extensive head and neck resections and reconstructions. Realistic expectations should be emphasized during preoperative discussions with patients."

Noting the varied patient populations, surgical skill, disease status, and quality of information from the studies included in the analysis, the author of an offered two potential interpretations:

• Patients will face a long and difficult recovery, challenging quality of life, and short survival with considerable expenditure of resources
• Most patients achieve acceptable results, including restorative form and function, given the complexity of the defects and surgical procedures

"We can argue that most patients will prefer 2 years of survival with this result than other palliative therapies," noted Neal Futran, MD, DMD, of the University of Washington in Seattle.

Regardless of the interpretation, use of multi-flap procedures should be assessed on a case-by-case basis, he continued. The surgeon, patient, and family must have an honest discussion that covers all the major goals, expectations, risks, and realities of the surgery.

"If all these aspects are all positive, the findings in the study support moving forward with multiple-flap reconstruction and provide support for other alternatives when the situation dictates," Futran added.

Multi-flap procedures following head and neck surgery confer significant morbidity and quality-of-life limitations. The procedures are complex, time consuming, and resource intensive, often requiring two surgical times, extended hospitalizations, and additional care for treatment-associated complications, Rosenthal and co-authors noted in their introduction.

The morbidity and outcomes associated with complex head and neck procedures had not been examined systematically, providing a rationale for a literature review and meta-analysis. The authors identified 24 studies, published from Nov. 1, 1992 through Sept. 1, 2016, involving a total of 487 patients, whose reconstruction procedures required a total of 978 flaps that had a survival rate of 94.9%. The patients had a mean age of 55, men accounted for 79.4% of the study population, and the indication for head and neck surgery was malignancy in 96% of cases.

Analysis of selected outcomes showed that 188 of 250 evaluable patients (75.2%) could consume an oral diet at follow-up, whereas 24.8% remained partly or fully dependent on a feeding tube. A total of 53 of 75 patients (70.7%) had postoperative oral competence associated with little or no drooling, whereas the remaining 22 patients (29.3%) had poor competence associated with moderate or severe drooling.

Of 108 patients assessed for speech function, 89 (82.4%) had intelligible speech, which was rated excellent in 44 cases and moderately intelligible in 44; one patient's speech was not rated. Only 64 patients completed surveys related to satisfaction with aesthetic results: 55 (85.9%) reported they were satisfied with the results, and nine (14.1%) were not satisfied. In 30 cases, physicians rated aesthetic results as satisfactory in 28 patients (93.3%).

Data for 380 patients showed a total of 273 perioperative complications. The total included 185 major complications, the most common being surgical re-exploration (25.9%), infection (24.3%), and total flap loss (15.1%). Of the 88 minor complications, the most common were donor-site complications (22.7%) and partial flap necrosis (21.6%).

The authors found that reports for 20 studies included survival data for 320 patients, who had a mean postoperative survival of 28.3 months.