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Multicentre evaluation of the interest in planned surgery for mandibular reconstruction with fibula free flap: a retrospective cohort study. Eur Arch Otorhinolaryngol 2021; 278:3451-3457. [PMID: 33398547 DOI: 10.1007/s00405-020-06536-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 11/30/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of this study was to determine the impact and cost-effectiveness of virtual surgical planning during fibula free flap mandibular reconstruction on peri- and postoperative data. METHODS We conducted a retrospective cohort study from January 2012 to December 2016 in four French university centres. RESULTS Three hundred fibula free flaps for mandibular reconstruction were performed in 294 patients. Surgeries were planned in 29.7% of cases (n = 89). There was no significant difference in the rate of negative-margins excision, median length of hospital stay, operative time, and early complications between planned and non-planned surgeries. Morphological analysis revealed a higher rate of centred occlusion in planned patients (satisfactory alignment of interincisal points: Planned 65.5% vs Non-Planned 33.3%, p = 0.006). CONCLUSION In mandibular reconstruction by fibula free flap, the additional cost generated by virtual surgical planning does not seem to be balanced by savings resulting from a shorter operative course, a reduced hospital stay, or a reduction in postoperative complications. However, virtual surgical planning may provide a higher rate of centred occlusion. Long-term benefits should be assessed by further studies.
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Hamill CS, Maatouk CM, Clancy K, Zender CA, Rezaee RP. Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer. Laryngoscope 2020; 131:1291-1296. [PMID: 33264425 DOI: 10.1002/lary.29267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/03/2020] [Accepted: 11/01/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES/HYPOTHESIS While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG. STUDY DESIGN Retrospective Chart Review. METHODS Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed. RESULTS The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures. CONCLUSIONS This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1291-1296, 2021.
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Affiliation(s)
- Chelsea S Hamill
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center/Case Western Reserve, Cleveland, Ohio, U.S.A
| | | | - Kate Clancy
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center/Case Western Reserve, Cleveland, Ohio, U.S.A
| | - Chad A Zender
- Department of Otolaryngology- Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio, U.S.A
| | - Rod P Rezaee
- Department of Otolaryngology- Head and Neck Surgery, University Hospitals Cleveland Medical Center/Case Western Reserve, Cleveland, Ohio, U.S.A
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Go BC, Chorath K, Frost AS, Moreira A, Cannady SB, Newman JG, Rajasekaran K. Intensive Care Versus Nonintensive Care Ward for Postoperative Management of Head and Neck Free Flaps: A Meta-Analysis. Facial Plast Surg Aesthet Med 2020; 23:408-416. [PMID: 33411570 DOI: 10.1089/fpsam.2020.0400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Although advances in surgical technique and medical management have drastically improved outcomes of free flap reconstructive surgery in head and neck patients, there is no clear consensus on appropriate level of postoperative care. Methods: The literature was searched systematically for all comparative studies of intensive care unit (ICU) and non-ICU admissions for head and neck patients. The primary outcomes were flap failure rate, flap complications, and hospital length of stay (LOS). Secondary outcomes included cost implications, medical complications, and rates of revision surgery, readmission, and mortality. Results: Nine articles (2510 patients) were included. Patients admitted to non-ICU wards were not significantly at increased risk for free flap failure, flap-related complications, or longer LOS. Total medical complications were found to have a pooled relative risk (RR) of 0.57 [95% confidence interval (CI) 0.40 to 0.83], favoring the non-ICU cohort. In particular, the non-ICU cohort was less likely to develop neuropsychiatric complications (RR 0.34 [95% CI 0.24 to 0.48]) and sepsis (RR 0.18 [95% CI 0.05 to 0.68]) with no difference in cardiovascular or pulmonary complications. Discussion: Patients admitted to non-ICU wards did not experience higher rates of adverse flap-related outcomes and had decreased risk of developing medical complications in the studies included in this meta-analysis.
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Affiliation(s)
- Beatrice C Go
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kevin Chorath
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ariel S Frost
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro Moreira
- Division of Neonatology, Department of Pediatrics, University of Texas Health-San Antonio, San Antonio, Texas, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G Newman
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Stewart M, Swendseid B, Hammond P, Khatiwala I, Sarwary J, Zhan T, Heffelfinger R, Luginbuhl A, Sweeny L, Wax MK, Curry JM. Anastomotic Revision in Head and Neck Free Flaps. Laryngoscope 2020; 131:1035-1041. [PMID: 33280116 DOI: 10.1002/lary.29094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/16/2020] [Accepted: 08/25/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes. STUDY DESIGN Retrospective review of 2482 consecutive patients across three tertiary institutions. METHODS Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised. RESULTS Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively). CONCLUSION Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1035-1041, 2021.
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Affiliation(s)
- Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Perry Hammond
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ishani Khatiwala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Juliana Sarwary
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University, Baton Rouge, Louisiana, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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Kim S, Lee DH, Ahn KM. Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases. Maxillofac Plast Reconstr Surg 2020; 42:29. [PMID: 32884927 PMCID: PMC7447709 DOI: 10.1186/s40902-020-00273-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Background Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery. Methods This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed. Results Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min. Conclusions The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.
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Affiliation(s)
- SeongRyoung Kim
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Dong-Hun Lee
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Kang-Min Ahn
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
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Caputo MP, Shabani S, Mhaskar R, McMullen C, Padhya TA, Mifsud MJ. Diabetes mellitus in major head and neck cancer surgery: Systematic review and
meta‐analysis. Head Neck 2020; 42:3031-3040. [DOI: 10.1002/hed.26349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/10/2020] [Accepted: 06/09/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Mathew P. Caputo
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Sepehr Shabani
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Rahul Mhaskar
- Department of Internal Medicine University of South Florida Morsani College of Medicine Tampa Florida USA
| | - Caitlin McMullen
- Department of Head and Neck and Endocrine Oncology H. Lee Moffitt Cancer Center & Research Institute Tampa Florida USA
| | - Tapan A. Padhya
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
- Department of Head and Neck and Endocrine Oncology H. Lee Moffitt Cancer Center & Research Institute Tampa Florida USA
| | - Matthew J. Mifsud
- Department of Otolaryngology—Head & Neck Surgery University of South Florida Morsani College of Medicine Tampa Florida USA
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Analysis of Selection of Recipient Vein, Number of Outflows, Style and Technique in Head and Neck Venous Anastomosis and a Proposed Algorithm. J Plast Reconstr Aesthet Surg 2020; 73:1825-1833. [PMID: 32571686 DOI: 10.1016/j.bjps.2020.05.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 04/01/2020] [Accepted: 05/09/2020] [Indexed: 11/22/2022]
Abstract
Surgeons have preferential ways of performing venous anastomosis in head and neck microsurgery. However, controversies exist regarding the superiority of each method. This study aims to determine the effects of these variables on the rates of thrombosis and flap failure, and propose an algorithm to be used as a facilitator in the decision-making process. A total of 208 microsurgical reconstructions on 199 patients from a single surgeon's data were evaluated. Selection of recipient vein (superficial vs. deep), style of anastomosis (end-to-end vs. end-to-side), number of outflows (one vs. two) and technique of anastomosis (hand-sewn vs. coupler) were compared. Selection was done according to the pre- and intraoperative plan, as well as, surgeon's clinical judgement. Outcomes were determined as rates of venous thrombosis and flap failure. Five patients (2.4%) had venous problems, leading to two partial and three total flap failures. Selection of the recipient vein, style and number of outflows did not affect the outcomes, whereas coupler use decreased the rates of venous thrombosis and flap failure (p=0.008). Although it is difficult to set dogmatic criteria to achieve consistent outcomes, coupler use in this study prevented flap failure. An algorithmic approach was proposed with the results of the data and literature to increase the success in microsurgical anastomosis. Surgeons should use algorithms and sound judgement with adherence to microsurgical principles to obtain the best results for each patient.
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