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 onco- logical 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 combina- tion permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. V V C 2012 Wiley Periodicals, Inc. Microsurgery 00:000–000, 2012. Free flap reconstruction is now an integral part of the surgi- cal management of head and neck malignancies. 1–5 Recon- struction 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 dis- eases, which were otherwise resectable. Use of double free flaps has shown benefit in the reconstruction, in such situa- tions. The purpose of this study is to elucidate the reconstruc- tive indications of the use of simultaneous double free flaps in head and neck oncological surgery and to propose an algo- rithm 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 si- 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 tu- mor 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 32–70 years). Nineteen of 21 patients had T4 pri- mary tumor stage. The pathology was squamous cell car- cinoma in 20 patients and adenoid cystic carcinoma in one patient. Eleven patients had prior history of radio- therapy 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 1 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 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/ micr.21963 V V C 2012 Wiley Periodicals, Inc.