Free forearm flaps for head and neck reconstruction: fewer revisions and flap failures with two venous anastomoses—a 25-year prospective study

Flap failure is a potential complication following head and neck reconstruction using free vascularized flaps. The value of a second venous anastomosis remains debated. This prospective cohort study included consecutive patients who underwent free forearm flap (FFF) surgery to repair head and neck defects between 1998 and 2023, and compared outcomes of FFF with one versus two venous anastomoses. Outcome parameters were surgical vascular revision and flap failure rates. In patients who received radial FFF for primary reconstruction, the rates of vascular revision and flap failure were significantly higher in flaps with one anastomosis (P = 0.045 and P = 0.018, respectively). Analysis of all forearm flaps (radial and ulnar) used for primary or secondary reconstruction, showed that flaps with one venous anastomosis had significantly higher rates of vascular revision (8.3% vs 2.8%, P = 0.031) and flap failure (6.7% vs 2.0%, P = 0.033) than those with two. Multivariable logistic regression confirmed that a single venous anastomosis was independently associated with increased odds of vascular revision (P = 0.039) and flap failure (P = 0.015). In conclusion, FFF with one venous anastomosis needed more surgical vascular revision and showed more flap failure than those with two venous anastomoses.