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Original Article |

Double Free-Flap Reconstruction Indications, Challenges, and Prospective Functional Outcomes FREE

Jennifer P. Guillemaud, MD; Hadi Seikaly, MD, FRCSC; David W. J. Cote, MD, MPH; Brittany R. Barber, BSc; Jana M. Rieger, PhD; Johan Wolfaardt, BDS, MDent, PhD; Peggy Nesbitt, MA, CCC-SLP; Jeffrey R. Harris, MD, FRCSC
[+] Author Affiliations

Author Affiliations: Division of Otolaryngology–Head and Neck Surgery, University of Alberta Hospital (Drs Guillemaud, Seikaly, Cote, and Harris and Mss Barber and Nesbitt), and Institute for Reconstructive Sciences in Medicine (Drs Rieger and Wolfaardt), Edmonton, Alberta, Canada.


Arch Otolaryngol Head Neck Surg. 2009;135(4):406-410. doi:10.1001/archoto.2009.15.
Text Size: A A A
Published online

Objective  To investigate the increasing use of double free flaps in the reconstruction of large head and neck defects.

Design  A 5-year retrospective medical record review in a large tertiary care head and neck oncology program. Prospectively collected functional data were also analyzed.

Setting  Academic research.

Patients  A consecutive series of 35 patients (24 men and 11 women; mean age, 57.7 years).

Main Outcome Measures  The use of double free flaps in the reconstruction of large head and neck defects and prospective functional outcomes.

Results  The most common indication for surgery (n = 25 [71.4%]) was squamous cell carcinoma. The most common double free-flap combination (n = 22 [62.9%]) included an osteocutaneous fibular free flap with a fasciocutaneous radial forearm free flap. Objective evaluation by naive listeners demonstrated a mean single-word intelligibility score of 66.2% and a mean sentence intelligibility score of 84.8% in this group of patients. Modified barium swallow study results revealed no evidence of laryngeal penetration for swallowing liquid consistencies in 21 patients (60.0%), pudding consistencies in 30 patients (85.7%), and cookie consistencies in 32 patients (91.4%).

Conclusions  With proper patient selection and planning and the use of 2 surgical teams, the length of surgery and complication rates are not significantly increased in double free-flap reconstruction. Furthermore, by using 2 free flaps, the best osseous and soft-tissue elements may be independently selected, yielding appropriate tissue characteristics for ideal defect reconstruction.

Figures in this Article

Extensive composite defects of the upper aerodigestive tract are usually created after surgical resection of malignant tumors and can involve the bone, oral lining, external skin, and soft tissue.1 Reconstruction of such defects to acceptable functional and aesthetic quality requires complex microsurgical techniques and presents an ongoing challenge to the reconstructive surgeon.

During the past 30 years, success rates of microvascular flap transplantation have increased dramatically, and several free-flap textures and combinations have been described for various defects.26 However, in particularly extensive defects due to complexities regarding 3-dimensional anatomical boundaries, the composite nature of the resected tissues, and the specialized sensory and motor functions they execute, single free flaps may not grant an optimal aesthetic and functional outcome.7 In some patients, although the skin island of a single osteocutaneous flap may be adequate for the coverage of the inner lining and the outer face, it is often inadequate for replacement of the soft-tissue volume, which in composite oromandibular defects can have equal or greater significance for functionality than the bony reconstruction.8 By combining 2 free flaps, the best osseous and soft-tissue elements may be independently selected to yield a favorable functional and aesthetic result.

With the development of more flap combinations, chimera principles, and piggybacking techniques, simultaneous double free-flap procedures have been used more prominently for the management of extensive composite head and neck defects.1,911 Each head and neck tumor requires a unique resection; therefore, by combining flaps with different textures and compositions, the optimal type and amount of tissue can be selected individually for each element of the defect.7

Arguably, the simultaneous use of 2 free flaps may have its disadvantages. More operating time is required to dissect 2 flaps and to perform 2 pairs of anastomoses. Potentially prolonged surgical time and morbidity may not be feasible for patients in suboptimal general health as a result of progressive malignant disease or malnourishment.12 However, it has been argued that the increased operating time and morbidity with 2 separate donor sites are more than compensated for by the increased level of functional return, especially for patients in whom a second free flap can increase sensation recovery and eating and speaking capabilities.10

Studies1,7,11,12 in the literature have given accounts of the techniques involved in selecting and implementing double flap reconstruction, as well as the feasibility of its use in certain patients; however, less guidance has been provided in terms of the indications for these procedures and their expected reconstructive and functional outcomes. The objectives of this study were to review the increasing use of double free flaps in our practice in terms of number and type of double flaps used and to review the indications for their use, patient length of surgery and postoperative hospital stay, complications encountered during or after surgery, and patient rehabilitation and functional outcomes.

STUDY POPULATION

The ethics review board of the University of Alberta, Edmonton, Canada, approved this study. A retrospective search of the 5-year database of a large head and neck oncology program was performed. All patients undergoing double free-flap reconstruction of head and neck defects between July 1, 2002, and September 20, 2007, were included in the study.

Information collected included patient demographics, indication for surgery, primary tumor site, free-flap donor sites, operative time, complications, and flap outcomes. In addition, prospectively collected functional outcome data for patients seen by our speech, language, and swallowing pathologists (J.M.R. and P.N.) at the Institute for Reconstructive Sciences in Medicine, Edmonton, Alberta, Canada, were collected. This included postoperative modified barium swallow assessments, level of oral intake at the most recent follow-up appointment, requirement for nutrition supplementation, and single-word and sentence comprehensibility scores.

DEFINITIONS AND VARIABLES

Patient age was noted at the time of double free-flap surgery. Indication for surgery was documented as the type of neoplasm or non–neoplasm-related reconstruction. Primary tumor site was classified according to the American Joint Committee on Cancer staging guidelines.13 The free-flap donor site was recorded as the site from which the free flap was harvested. Operative time was recorded as the time from the first skin incision to the time point when general anesthesia was reversed. For subsequent comprehensibility assessment, single words and sentences were presented to the patient to read aloud, while an objective evaluator transcribed what he or she perceived the patient to have said. Single-word and sentence comprehensibility scores were then calculated as the percentage of items properly transcribed by the evaluator.

STATISTICAL ANALYSIS

Descriptive statistics were used for all variables. Statistical analyses were performed using a commercially available statistical software program (SPSS for Windows, version 14; SPSS Inc, Chicago, Illinois). Analysis was performed on the data set to determine any significant differences in outcome measures of operative time, length of stay in hospital, complication rate, and overall free-flap success rate. An α ≤ .05 was considered statistically significant.

A consecutive series of 35 patients (24 men and 11 women; mean age, 57.7 years) treated from July 1, 2002, to September 20, 2007, was included. The most common indication for surgery was squamous cell carcinoma (n = 25 [71.4%]), followed by adenoid cystic carcinoma (n = 3 [8.6%]) and functional reconstruction (n = 2 [5.7%]). For all patients, the most common primary sites reconstructed were the oral cavity (n = 19 [54.3%]), nasal cavity and sinuses (n = 8 [22.9%]), and oropharynx (n = 4 [11.4%]) (Table). Among patients with a neoplastic indication for their surgery, 69.0% had a T4 lesion, and 93.1% had stage IV cancer based on American Joint Committee on Cancer guidelines.13 Furthermore, 31 of 35 patients (88.6%) required osseous reconstructions (16 mandibular reconstructions and 15 maxillary or nasal reconstructions).

Table Graphic Jump LocationTable. Distribution of Head and Neck Sites Reconstructed and TNM Staging According to the American Joint Committee on Cancer Guidelines13

Thirty-one patients (88.6%) required a combination of an osteocutaneous free flap with a fasciocutaneous free flap for reconstruction of their head and neck defects, while 4 patients (11.4%) received a combination of 2 fasciocutaneous free flaps for their reconstruction. Figure 1 and Figure 2 show the stages of resection and double free-flap reconstruction for 2 of our patients, one of whom required massive tissue replacement and another who had 2 flaps performed to provide a tailored reconstruction of the maxilla.

Place holder to copy figure label and caption
Figure 1.

A patient with T4N2bM0 squamous cell carcinoma of the buccal mucosa. A, A scapular megaflap was used, with bone for mandibular reconstruction, parascapular and scapular skin for cheek coverage, and latissimus muscle for neck vessel coverage. B, A radial forearm free flap was used to reconstruct intraoral lining.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A patient with T4N0M0 squamous cell carcinoma of the right maxillary sinus. A, A fibular free flap was used to reconstruct her alveolar ridge and the mucosa of the hard palate. B, A piece of free fibular bone was used to reconstruct the infraorbital ridge. C, A radial forearm free flap was used to reconstruct the lining of the nasal cavity and to separate the nasal cavity from the rest of the maxillary reconstruction.

Graphic Jump Location

For 31 patients who received a combination of osteocutaneous and fasciocutaneous free flaps, the most common double free-flap combination included a radial forearm free flap combined with a fibular free flap. This was the combination used in 22 (62.9%) of our patients receiving double free-flap reconstruction (Figure 3). The most common free flap used overall (77.1%) was the radial forearm free flap.

Place holder to copy figure label and caption
Figure 3.

Free-flap combinations for 31 patients who received a combination of osteocutaneous and fasciocutaneous free flaps for reconstruction of their large head and neck defects.

Graphic Jump Location

Using 2 surgical teams, the mean operative time for our patients was 13 hours and 10 minutes. The mean length of hospital stay after surgery was 20.7 days. During surgery and in the postoperative period, 2 patients experienced complications. One patient experienced a hematoma, and the other patient had a venous thrombosis in one of the flaps, resulting in flap failure. Overall, this resulted in a complication rate of 5.7% and a flap success rate of 98.6%.

During this same period, 354 single free-flap reconstructions of head and neck defects were performed by us (H.S. and J.R.H.). Therefore, patients required double free-flap reconstruction in 9.0% of all free-flap cases. Among patients receiving single free-flap reconstructions, the mean operative time (10 hours and 52 minutes, P =.06), length of hospital stay (18.8 days, P =.69), complication rate (9.3%, P = .09), and overall flap success rate (98.0%, P = .09) were not significantly different from those of the patients receiving double free-flap reconstructions.

At the time of discharge home, 3 patients in our series had a permanent tracheostomy for ventilation. All 3 had undergone total laryngectomy for advanced squamous cell carcinoma. Two of these patients attended follow-up at the Institute for Reconstructive Sciences in Medicine and were using voice prostheses, with single-word and sentence intelligibility exceeding 90%. Among other patients receiving double free-flap reconstructions, objective assessment by naive listeners demonstrated a mean single-word intelligibility score of 66.2%. The mean sentence intelligibility score was 84.8%.

Postoperative barium swallowing assessment was performed among patients to determine the safe level of oral intake for our patients. Modified barium swallowing studies of liquid, pudding, and cookie consistencies revealed no evidence of laryngeal penetration for swallowing liquid consistencies in 21 patients (60.0%), pudding consistencies in 30 patients (85.7%), and cookie consistencies in 32 patients (91.4%).

After discharge home, patients continued to undergo follow-up and rehabilitation by our team of swallowing, speech, and language pathologists. The mean length of follow-up for these patients was 18.2 months, with 18 patients still attending follow-up at the time of publication. At the most recent follow-up appointment, 31 patients (88.6%) demonstrated safe swallows with all 3 consistencies; however, 25 patients (71.4%) had insufficient oral intake to maintain adequate nutritional status. The remaining 10 patients had percutaneous endoscopic gastrostomy (PEG) tubes placed after surgery (6 used their PEG tube to supplement oral intake, and 4 used their PEG tube as the sole nutrition intake source). Five of these patients had PEG insertions after radiotherapy owing to severe xerostomia.

Extensive composite defects of the upper aerodigestive tract are usually created after surgical resection of malignant tumors that require complex microsurgical reconstructive techniques. Reconstruction of these composite defects in the head and neck not only is surgically challenging but also poses aesthetic and functional challenges. During the past 30 years, success rates of microvascular flap transplantation have increased dramatically, and several free flaps with different textures and compositions have been described for use in head and neck reconstruction.2,3,10,14 However, in particularly extensive defects due to complexities regarding the anatomical boundaries, the composite nature of the resected tissues, and the specific sensory and motor functions they perform, there may be no single free flap that combines adequate bone stock with enough thin pliable soft tissue to restore the 3-dimensional anatomical boundaries and the complex functions of the upper aerodigestive tract.

In addition to versatile and individualized reconstructive options for these extensive head and neck defects, some surgeons argue that the use of a second free flap allows easier insetting and better restoration of the 3-dimensional anatomical boundaries.7,12 It has also been stated that the increased operating time and morbidity with 2 separate donor sites are more than compensated for by the increased level of functional return.10 Furthermore, healing time can be shortened with the use of well-vascularized robust flaps, leading to earlier or timely reception of full-course adjuvant radiotherapy.7 Completion of reconstruction in a single stage is beneficial for the patient and poses less burden on health care resources.

Simultaneous use of 2 free flaps may arguably present some technical difficulties. It may be argued that more time is required to dissect 2 flaps and to perform 2 pairs of anastomoses. However, it is possible to use 2 or 3 surgical teams to harvest the flaps and to prepare the recipient vessels. Nevertheless, double free-flap reconstructions not only are surgically challenging but also are challenging to the patient and require careful selection and planning. With proper patient selection and planning and the use 2 surgical teams, the operative time, complication rate, length of hospital stay, and overall success rates were not significantly different in patients undergoing double free-flap reconstruction compared with those in patients undergoing single free-flap reconstruction. Admittedly, there were fewer double free-flap reconstructions performed compared with the number of single free-flap reconstructions during the same period at our institution, and the difference in operative times between these 2 patient populations approached statistical significance (10 hours and 52 minutes vs 13 hours and 20 minutes, P = .06).

Few surgeons have addressed the use of double free-flap reconstructions in head and neck reconstruction and demonstrated technique and feasibility. At the most recent follow-up in our series, swallowing assessment among our patients revealed that 88.6% had documented safe swallows with all oral consistencies, but only 71.4% (25 of 35) received sufficient oral intake to maintain appropriate nutritional status. However, among patients who required supplemental feedings and PEG tube insertion, half of them required these secondary to initiation and adverse effects of radiotherapy, namely, severe xerostomia. In addition, the single-word and sentence intelligibility scores seen in this series seem almost as good as those previously reported for single free-flap reconstructions.4,15 Although a direct comparison of functional outcomes between patients receiving single vs double free-flap reconstructions was not performed herein, we obtained reasonably good functional outcomes in this cohort of patients with advanced disease requiring extensive resections resulting in complicated defects necessitating double free-flap reconstruction.

In conclusion, with the use of 2 surgical teams and careful patient selection and planning, operative time and surgical complications are not increased by the use of 2 free flaps for reconstruction of large head and neck defects. In properly selected patients with complex defects, double free-flap procedures may be beneficial to provide appropriate tissue characteristics for ideal defect reconstruction.

Correspondence: Jeffrey R. Harris, MD, FRCSC, Division of Otolaryngology–Head and Neck Surgery, University of Alberta Hospital, Room 1E4.29 Walter MacKenzie Health Science Centre, 8440-112 St, Edmonton, AB T6G 2R7, Canada (jeffrey.harris@capitalhealth.ca).

Submitted for Publication: July 20, 2008; final revision received November 29, 2008; accepted December 1, 2008.

Author Contributions: Dr Harris had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Seikaly, Wolfaardt, and Harris. Acquisition of data: Guillemaud, Cote, Barber, Rieger, Nesbitt, and Harris. Analysis and interpretation of data: Guillemaud, Cote, and Harris. Drafting of the manuscript: Guillemaud, Barber, Wolfaardt, Nesbitt, and Harris. Critical revision of the manuscript for important intellectual content: Guillemaud, Seikaly, Cote, Rieger, and Harris. Statistical analysis: Cote. Obtained funding: Harris. Administrative, technical, and material support: Guillemaud, Rieger, Wolfaardt, Nesbitt, and Harris. Study supervision: Seikaly, Rieger, and Harris.

Financial Disclosure: None reported.

Funding/Support: This study was supported by the Head and Neck Oncology Program Fund from the Division of Otolaryngology–Head and Neck Surgery, University of Alberta Hospital.

Previous Presentation: This study was presented at the Seventh International Conference on Head and Neck Cancer of the American Head and Neck Society; July 22, 2008; San Francisco, California.

Wei  FCYazar  SLin  CHCheng  MHTsao  CKChiang  YC Double free flaps in head and neck reconstruction. Clin Plast Surg 2005;32 (3) 303- 308, v
PubMed Link to Article
Hidalgo  DA Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84 (1) 71- 79
PubMed Link to Article
Yim  KKWei  FC Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 1994;15 (4) 245- 249
PubMed Link to Article
Uwiera  TSeikaly  HRieger  JChau  JHarris  JR Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap. J Otolaryngol 2004;33 (6) 356- 359
PubMed Link to Article
Soutar  DSScheker  LRTanner  NSMcGregor  IA The radial forearm free flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36 (1) 1- 8
PubMed Link to Article
Swartz  WMBanis  JCNewton  EDRamasastry  SSJones  NFAcland  R The osteocutaneous scapular flap for mandible and maxillary reconstruction. Plast Reconstr Surg 1986;77 (4) 530- 545
PubMed Link to Article
Wei  FCDemirkan  FChen  HCChen  IH Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg 1999;103 (1) 39- 47
PubMed Link to Article
Urken  MLWeinberg  HVickery  CBuchbinder  DLawson  WBiller  HF Oromandibular reconstruction using microvascular composite free flaps: report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117 (7) 733- 744
PubMed Link to Article
Koshima  IYamamoto  HHosodo  MMoriguchi  TOrita  YNagayama  H Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92 (3) 411- 420
PubMed Link to Article
Urken  MLWeinberg  HVickery  C  et al.  The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects. Laryngoscope 1992;102 (5) 543- 558
PubMed Link to Article
Nakatsuka  THarii  KYamada  AUeda  KEbihara  S Dual free flap transfer using forearm flap for mandibular reconstruction. Head Neck 1992;14 (6) 452- 458
PubMed Link to Article
Posch  NAMureau  MADumans  AGHofer  SO Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg 2007;120 (1) 124- 129
PubMed Link to Article
Greene  FLPage  DLFleming  ID  et al.  American Joint Committee for Cancer Staging Manual.  New York, NY Springer-Verlag2002;
Smith  RBSniezek  JCWeed  DTWax  MKMicrovascular Surgery Subcommittee of American Academy of Otolaryngology–Head and Neck Surgery, Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg 2007;137 (2) 182- 191
PubMed Link to Article
Seikaly  HMaharaj  MRieger  JHarris  J Functional outcomes after primary mandibular resection and reconstruction with the fibular free flap. J Otolaryngol 2005;34 (1) 25- 28
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

A patient with T4N2bM0 squamous cell carcinoma of the buccal mucosa. A, A scapular megaflap was used, with bone for mandibular reconstruction, parascapular and scapular skin for cheek coverage, and latissimus muscle for neck vessel coverage. B, A radial forearm free flap was used to reconstruct intraoral lining.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A patient with T4N0M0 squamous cell carcinoma of the right maxillary sinus. A, A fibular free flap was used to reconstruct her alveolar ridge and the mucosa of the hard palate. B, A piece of free fibular bone was used to reconstruct the infraorbital ridge. C, A radial forearm free flap was used to reconstruct the lining of the nasal cavity and to separate the nasal cavity from the rest of the maxillary reconstruction.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Free-flap combinations for 31 patients who received a combination of osteocutaneous and fasciocutaneous free flaps for reconstruction of their large head and neck defects.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Distribution of Head and Neck Sites Reconstructed and TNM Staging According to the American Joint Committee on Cancer Guidelines13

References

Wei  FCYazar  SLin  CHCheng  MHTsao  CKChiang  YC Double free flaps in head and neck reconstruction. Clin Plast Surg 2005;32 (3) 303- 308, v
PubMed Link to Article
Hidalgo  DA Fibula free flap: a new method of mandible reconstruction. Plast Reconstr Surg 1989;84 (1) 71- 79
PubMed Link to Article
Yim  KKWei  FC Fibula osteoseptocutaneous flap for mandible reconstruction. Microsurgery 1994;15 (4) 245- 249
PubMed Link to Article
Uwiera  TSeikaly  HRieger  JChau  JHarris  JR Functional outcomes after hemiglossectomy and reconstruction with a bilobed radial forearm free flap. J Otolaryngol 2004;33 (6) 356- 359
PubMed Link to Article
Soutar  DSScheker  LRTanner  NSMcGregor  IA The radial forearm free flap: a versatile method for intra-oral reconstruction. Br J Plast Surg 1983;36 (1) 1- 8
PubMed Link to Article
Swartz  WMBanis  JCNewton  EDRamasastry  SSJones  NFAcland  R The osteocutaneous scapular flap for mandible and maxillary reconstruction. Plast Reconstr Surg 1986;77 (4) 530- 545
PubMed Link to Article
Wei  FCDemirkan  FChen  HCChen  IH Double free flaps in reconstruction of extensive composite mandibular defects in head and neck cancer. Plast Reconstr Surg 1999;103 (1) 39- 47
PubMed Link to Article
Urken  MLWeinberg  HVickery  CBuchbinder  DLawson  WBiller  HF Oromandibular reconstruction using microvascular composite free flaps: report of 71 cases and a new classification scheme for bony, soft-tissue, and neurologic defects. Arch Otolaryngol Head Neck Surg 1991;117 (7) 733- 744
PubMed Link to Article
Koshima  IYamamoto  HHosodo  MMoriguchi  TOrita  YNagayama  H Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of the head and neck regions: an introduction to the chimeric flap principle. Plast Reconstr Surg 1993;92 (3) 411- 420
PubMed Link to Article
Urken  MLWeinberg  HVickery  C  et al.  The combined sensate radial forearm and iliac crest free flaps for reconstruction of significant glossectomy-mandibulectomy defects. Laryngoscope 1992;102 (5) 543- 558
PubMed Link to Article
Nakatsuka  THarii  KYamada  AUeda  KEbihara  S Dual free flap transfer using forearm flap for mandibular reconstruction. Head Neck 1992;14 (6) 452- 458
PubMed Link to Article
Posch  NAMureau  MADumans  AGHofer  SO Functional and aesthetic outcome and survival after double free flap reconstruction in advanced head and neck cancer patients. Plast Reconstr Surg 2007;120 (1) 124- 129
PubMed Link to Article
Greene  FLPage  DLFleming  ID  et al.  American Joint Committee for Cancer Staging Manual.  New York, NY Springer-Verlag2002;
Smith  RBSniezek  JCWeed  DTWax  MKMicrovascular Surgery Subcommittee of American Academy of Otolaryngology–Head and Neck Surgery, Utilization of free tissue transfer in head and neck surgery. Otolaryngol Head Neck Surg 2007;137 (2) 182- 191
PubMed Link to Article
Seikaly  HMaharaj  MRieger  JHarris  J Functional outcomes after primary mandibular resection and reconstruction with the fibular free flap. J Otolaryngol 2005;34 (1) 25- 28
PubMed Link to Article

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