Cost‐effectiveness of microsurgical reconstruction for head and neck defects after oncologic resection

Comparison of the microvascular anastomotic Coupler™ system with hand-sewn suture for end to end veno-venous anastomosis for head and neck reconstruction with free flap transfer: Medico-economic retrospective case-control study

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon.

A retrospective propensity score-matched analysis of oncological and functional outcomes of submental island flap versus radial forearm free flap for oral cavity cancer reconstruction

BACKGROUND

This retrospective study aims to compare the oncological and functional outcomes of the submental island flap versus the radial forearm free flap used for oral cavity cancer reconstruction after minimizing differences in baseline characteristics.

METHODS

Propensity scores for each oral cavity cancer patient who underwent surgical resection and immediate reconstruction with a submental island flap or a radial forearm free flap with a flap size ≤ 60 cm2 between October 2008 and December 2021 were generated based on the likelihood of being selected given their baseline characteristics. Patients were matched using a 1:1 nearest-neighbor approach.

RESULTS

The final matched-pair analysis included 51 patients in each group. The 5-year overall survival, disease-specific survival, and locoregional control rates were 70.1% and 64.8% (p = 0.612), 77.3% and 83.7% (p = 0.857), and 76.1% and 73.3% (p = 0.664), respectively, for the submental island flap group and the radial forearm free flap group. Speech and swallowing functions were comparable between groups. However, there were significantly lower rates of complication associated with both donor and recipient sites in the submental island flap group, and also the duration of hospital stays and hospital costs were significantly lower in these patients. A subgroup analysis of patients in which the reconstruction was carried out using the submental island flap procedure revealed that in selected cases, the presence of clinically and pathologically positive level I lymph nodes did not affect survival or locoregional control rates.

CONCLUSIONS

Although this study was not randomized, the matched-pair analysis of surgically treated oral cavity cancer patients showed that submental island flap reconstruction is as effective as radial forearm free flap reconstruction with regard to oncological and functional outcomes with lower complication rates, hospital stay, and hospital costs. This flap can be safely and effectively performed in selected cases with a clinical level I lymph node smaller than 1.5 cm and no signs of extranodal extension.

Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day

Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.

Efficacy and Safety of Microsurgical Pharyngolaryngeal and Pharyngoesophageal Reconstruction: A Systematic Review of the Literature

Restoration of function and complication management after pharyngolaryngectomy remains a challenging task. The aim of our study was to compare the functional and clinical outcomes of pharyngolaryngeal and pharyngoesophageal reconstruction using free flaps, namely jejunal (FJF), anterolateral thigh, and radial forearm, and describe a reconstructive approach for these defects following tumor resection.

Methods

We performed a systematic literature review on PubMed (Medline), Embase and Cochrane Library over the last two decades for articles reporting the surgical reconstructive modalities available after total or partial pharyngeal and/or laryngeal resection using a structured search strategy and strict inclusion and elimination criteria.

Results

Our search identified a total of 677 articles, 112 full texts were fully reviewed for eligibility, and 39 met the inclusion criteria. The use of both FJF and fasciocutaneous flaps is safe. The FJF has optimal swallowing outcomes and a low incidence of major recipient-site complications. Nevertheless, free fasciocutaneous flaps exhibit comparable functional results, while they seem linked with fewer cases of perioperative mortality and flap failure. However, none of the currently available techniques can combine all potential benefits.

Conclusions

Despite these procedures being mainly palliative in nature, the advent of microvascular techniques and utilization of fasciocutaneous free flaps has allowed optimal restoration of function combined with a reduced rate of perioperative and longterm complications. Both FJF and fasciocutaneous flaps can be viable treatment options, depending on the expertise of the surgeon and patient selection, to ensure the best outcomes.

Analysis of one- versus two-staged reconstruction in head and neck cancer patients: What are the benefits?

In head and neck oncology, surgical treatment frequently results in microvascular reconstruction. Oncologic resection followed by immediate reconstruction is often associated with prolonged working and surgical duration, challenging a surgeon's concentration level and potentially worsening patient outcome. To improve the surgeon's performance and to reduce risk of potential complications, we implemented a two-stage procedure in patients with head and neck cancer. This study critically analyzed the surgical outcomes, organizational benefits, and investigated job satisfaction among affected health care professionals. A retrospective data analysis of patients who had undergone microvascular reconstruction after oncologic head and neck surgery between 2010 and 2021 included 33 patients (n = 33). Twenty patients underwent single-stage reconstruction (group 1, n = 20) and 13 patients underwent two-stage reconstruction (group 2, n = 13) with 12.2 (± 7.4) days between surgeries. The mean surgical duration, and mean start and end time of the reconstructive surgery component differed significantly (p = 0.002). The mean total complication rate (p = 0.58) did not differ significantly, although a trend toward higher demands for blood products was observed in group 1. There was no significant difference in five-year survival (p = 0.28). A questionnaire on subjective work performance was answered by the affected health care professionals (n = 34) and it revealed that 88% preferred long surgeries to be scheduled first and that 97% work most efficiently in the morning. In conclusion, two-stage reconstruction is a suitable option in selected head and neck cancer patients offering the possibility of optimizing preoperative planning and organization. This may result in regular working hours, reduced surgeon fatigue, and improved job satisfaction without compromising patient outcomes or survival.

Microvasular Free Flap Reconstruction in Head and Neck Surgery: Complication and Outcome of 80 Flaps

Head and neck carcinoma can prompt destroying cosmetic and functional deformities with resultant mental, physical and nourishing burden. Regardless of ongoing advances in medication and surgical procedure, the general endurance for patients with head and neck malignant growth has stayed still for as long as 35 years. This endurance rate has prompted the foundation of the standards of tumor extraction with most extreme tissue saving and more up to date endoscopic laser-helped methods for auto-digestive region malignant growths targeting diminishing operational morbidity without influencing the general endurance. This retrospective and prospective study contained 80 patients who went through miniature vascular free flap remaking following a significant head and neck oncosurgery procedure from 01/01/2017-to-31/12/2019. Three kinds of free flaps were fundamentally utilized. The current study was directed to assess the clinical result in patients going through miniature vascular free flap reproduction and to decide the viability after head and neck onco-surgical procedure method. Despite the fact that miniature vascular free flaps are today viewed as cutting edge in head and neck remaking after composite resection with predominant effective and stylish rebuilding, it is as yet not basic in India at numerous focuses. This retrospective and prospective study were conducted for a time of 3 years to know the clinical result, decide the adequacy and assess the occurrence and reasons for pre- and post-surgical intricacies in patients going through miniature vascular free flap recreation after head and neck onco-surgical procedure method. It was inferred that the free flaps were dependable in accomplishing effective reproduction of the head and neck following an effective onco-surgical procedure methodology. Despite the fact that there is a critical loss of delicate tissue and bone however after an effective acknowledgment of free flap, close to ordinary anatomical and physiological capacities can be accomplished in larger part of the patients. The frequency of complexities was straightforwardly related to the co-morbidity level and specialist's working experience.

Analysis of cost and outcomes in bony versus soft tissue midface free flap reconstruction

BACKGROUND

Outcomes and cost of soft tissue versus bony midface free flap reconstruction (MR) with and without virtual surgical planning (VSP) were evaluated.

METHODS

Retrospective review of MR including ischemic time (IT), operative duration (OD), length of stay (LOS), and total cost (TC). Eighty-one soft tissue and 76 bony MR (VSP = 23) were reviewed.

RESULTS

Bony MR was used for higher complexity defects (p = 0.003) and was associated with higher IT (p < 0.001), OD (p < 0.001), LOS (p = 0.032), and TC (p < 0.001). VSP was associated with a mean 111.2 ± 37.9 minute reduction in OD (p = 0.004) compared to non-VSP bony flaps. VSP was associated with higher itemized cost, but no increase in TC (p = 0.327).

CONCLUSIONS

Bony MR was used for higher complexity MR and was associated with increased TC, LOS, OD, and IT. VSP shortened OD with no significant increase in TC.

Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes

Introduction  Free flaps have been the preferred method for reconstruction after resection of oral cavity cancer. However, pedicled flaps remain valuable alternatives in appropriate settings. Objective  The main objective of the present study was to compare surgical complications, hospital costs, and functional outcomes of oral cavity cancer patients who underwent soft tissue reconstruction with pedicled flaps or free flaps. Methods  A total of 171 patients were included in the study. Ninety-eight underwent reconstruction with a pectoralis major, submental, temporalis, or supraclavicular pedicled flap, and in 73 patients, a radial forearm or anterolateral thigh free flap had been used. The cases were retrospectively reviewed, and a comparative analysis was carried out between the two groups. Results  Recipient site and flap complications, speech, and swallowing functions did not differ between groups, but donor site complications, operative time, hospital stay, and costs were significantly reduced in the pedicled flap group compared with the free flap group. However, the pectoralis major flap reconstruction resulted in a more inferior swallowing function than the free flap reconstruction. Conclusions  With comparable complications and functional outcomes, while decreasing in costs, pedicled flaps are a useful alternative to free flaps in oral cavity cancer reconstruction. However, in an extensive defect (> 70 cm ² ), free flaps are the reconstruction of choice for the preservation of swallowing function.

Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting

BACKGROUND

 Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting.

METHODS

 A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings.

RESULTS

 Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080).

CONCLUSION

 Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.

Microvascular Reconstruction of Osteonecrosis: Assessment of Long-term Quality of Life

OBJECTIVE

Review long-term clinical and quality-of-life outcomes following free flap reconstruction for osteonecrosis.

STUDY DESIGN

Retrospective multi-institutional review.

SETTING

Tertiary care centers.

METHODS

Patients included those undergoing free flap reconstructions for osteonecrosis of the head and neck (N = 232). Data included demographics, defect, donor site, radiation history, perioperative management, diet status, recurrence rates, and long-term quality-of-life outcomes. Quality-of-life outcomes were measured using the University of Washington Quality of Life (UW-QOL) survey.

RESULTS

Overall flap success rate was 91% (n = 212). Relative to preoperative diet, 15% reported improved diet function at 3 months following reconstruction and 26% at 5 years. Osteonecrosis recurred in 14% of patients (32/232); median time to onset was 11 months. Cancer recurrence occurred in 13% of patients (29/232); median time to onset was 34 months. Results from the UW-QOL questionnaire were as follows: no pain (45%), minor or no change in appearance (69%), return to baseline endurance level (37%), no limitations in recreation (40%), no changes in swallowing following reconstruction (28%), minor or no limitations in mastication (29%), minor or no speech difficulties (93%), no changes in shoulder function (84%), normal taste function (19%), normal saliva production (27%), generally excellent mood (44%), and no or minimal anxiety about cancer (94%).

CONCLUSION

The majority of patients maintained or had advancement in diet following reconstruction, with low rates of osteonecrosis or cancer recurrence and above-average scores on UW-QOL survey suggesting good return of function and quality of life.

Risk Factors for and Cost Implications of Free Flap Take-backs: A Single Institution Review

OBJECTIVE/HYPOTHESIS

For patients undergoing microvascular free tissue transfer (MFTT), we evaluated risk factors and financial implications of operating room (OR) take-back procedures.

STUDY DESIGN

Retrospective review at a tertiary care center.

METHODS

Patients who underwent MFTT for head and neck reconstruction from 2011 to 2018 were identified. We compared hospital length of stay and overall costs associated with OR take-back procedures. Multivariable regression analysis evaluated factors associated with OR take-backs during the same hospitalization.

RESULTS

A total of 727 free flaps were reviewed, and 70 OR take-backs (9.6%) were identified. Mean total length of stay (LOS) in the ICU was 3.4 days versus 6.7 days for non-take-back and take-back flaps, respectively (P < .001). Mean total LOS on the regular floor was 6.3 days versus 13.1 days, respectively (P < .001). This resulted in a cost differential of $33,507 (94.3% increase relative to non-take-back flaps). The total cost associated with an OR take-back was $39,786. Hematomas were the most common cause of take-backs and wound dehiscence was associated with the highest costs. On multivariable analysis, higher ASA class (OR, 2.06; 95% CI, 1.11-3.99; P = .026) and shorter ischemia times (OR, 0.52; 95% CI, 0.29-0.95; P = .030) were independently associated with increased risk of take-backs.

CONCLUSIONS

OR take-backs infrequently occur but are associated with a significant increase in financial burden when compared to free flap cases not requiring OR take-back. The large majority of the cost differential lies in a substantial increase of ICU and floor LOS for take-back flaps when compared to non-take-back flaps.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1821-E1829, 2021.

Value of Intensive Care Unit-Based Postoperative Management for Microvascular Free Flap Reconstruction in Head and Neck Surgery

Importance: Although routine postoperative care for microvascular free flap reconstruction typically involves admission to the intensive care unit (ICU), few studies have investigated the effect of postoperative care setting on clinical outcomes and institution cost. Objectives: To determine the value of non-ICU-based postoperative management for free tissue transfer for head and neck surgery, in terms of clinical outcomes and cost-effectiveness. Design, Setting, and Participants: This is a retrospective cohort study of two groups of adults who underwent vascularized free tissue transfer from October 2013 to October 2017 at an academic tertiary care center and community-based hospital, respectively. Postoperative management differed such that the first group recovered in a protocol-driven non-ICU setting and the second group was cared for in a planned admission to the ICU. A single surgeon performed all tissue harvest and reconstruction at both centers. Main Outcomes and Measures: Descriptive statistics and cost analyses were performed to compare clinical outcomes and total surgical and downstream direct cost to the institution between the two patient groups. Categorical variables were compared using χ² test where appropriate. Results: Among a total of 338 patients who underwent microvascular free flap reconstruction for head and neck surgical defects, there was no significant difference in patient characteristics such as demographics, comorbidities, history of surgical resection, prior free flap, and locoradiation between the postoperative ICU cohort (n = 146) and protocol-driven non-ICU cohort (n = 192). There were 16 patients in the non-ICU group who spent >3 days in the ICU postoperatively secondary to patient comorbidities and patient care priorities. Still, the average ICU length of stay was 7 days (interquartile range [IQR] 6-9 days) for the planned ICU cohort versus 1 day (IQR 0-1) for the non-ICU group (p < 0.00001). There was no difference in operative variables such as donor site, case length, or total length of stay, and postoperative management in the ICU versus non-ICU setting resulted in no significant difference in terms of flap survival, reoperation, readmission, and postoperative complications. However, average cost of care was significantly higher for patients who received ICU-based care versus non-ICU postoperative care. Specifically, room and board were 239% more costly for the planned ICU care group than the non-ICU setting (p < 0.00001). Conclusions and Relevance: This study demonstrates that postoperative management after vascularized free tissue transfer in a non-ICU setting is equivalent to standard ICU-based management, in terms of clinical outcomes, while being less costly.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.

METHODS

Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey.

RESULTS

Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.

CONCLUSION

The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

Consideration in Microvascular Reconstruction during Times of Social Crises: Perspectives on Resource Utilization

Reconstruction of head and neck surgical defects can be a complicated, costly process. While the era of cost-effective medicine has begun to broadly question the necessity of high-cost care, times of extraordinary sociomedical demand bring increased scrutiny to even routine costs and resource utilization. Within this context, we reviewed the advantages, drawbacks, and financial costs of both regional and free flap reconstructions, namely the decreased costs and hospital resource utilization that may be associated with reconstruction using regional flaps. Although beset by reports of partial necrosis in certain regional flaps-particularly the submental island, cervicofacial advancement, and supraclavicular artery island flaps-many reports have demonstrated complication and flap failure rates equivalent to those of free flaps. Additionally, regional flaps have been associated with decreased costs for hospital stay, most notably in cases of postoperative complications. In cases necessitating free flap reconstruction, cost-savings strategies such as bypassing postoperative intensive care unit admissions have been shown to provide satisfactory, safe outcomes. As the head and neck surgeon continues to adapt to the medical pressures of a global pandemic, resource-sparing approaches to oncologic care will persist in their newfound importance.

Maxillo-facial reconstruction following cancer ablation during COVID-19 pandemic in southern Italy

In COVID-19 pandemic era, one major concern is related to ensure optimal management to oncologic patients, even though a context of radical uncertainty. The aim of our effort is to guarantee high-quality and timely care, minimizing COVID-19 infection risk, according to our head and neck (HN) reconstructive mission, still more challenging because of the criticality of the period. Thus, our reconstructive decision algorithm is changed. Microvascular free flaps, reported to be the gold standard for surgical reconstruction, represent extremely specialized procedures necessitating an extended resource allocation not affordable in the adversities of the period. Therefore, we are obliged to define a paradigm shift in our approach, based on free-style reconstructive surgery principles of propeller flap concept. According to our experience, we believe that this viable and feasible surgical technique could represent a reconstructive landmark in this pandemic era, since any guideline is missing, besides HN reconstructive surgery is most likely heading towards a new reconstructive approach.

Italian cost analysis of free flap surgery in head and neck reconstruction using the activity-based costing (ABC)

The aim of the study is to evaluate costs of free flap surgery for head and neck (H & N) reconstructions using the time-driven activity-based costing (ABC) method and to compare them with the refund provided by the Italian National Health System (NHS) amounting to 11,891€. We retrospectively selected 29 consecutive patients underwent free flap reconstruction in 2013 at IRCCS Casa Sollievo della Sofferenza. Patients were divided into three groups: Group 1 (n = 10) included patients receiving radial forearm free flap (RFFF), Group 2 (n = 10) receiving anterolateral thigh (ALT) free flap, and Group 3 (n = 9) composed of patients having fibular free flap. For each patient, costs were calculated using the ABC and divided into instay, surgical, and services costs. We observed an overall mean total cost of 27,802.40€. The mean costs related to hospital stay were 9,800.70€. The mean costs for surgery were 13,097.60€ and amounted to 4,904.10€ for services. RFFF appears to be less costing (25,175.40€) compared with ALT (29,191.60€) and fibula free flap (29,040.20€). ABC is an appropriate method to determine actual costs of free flap surgery by correctly allocating the resources used. The Italian NHS tariff seems to be inadequate to cover the real cost of this type of surgery.

Modified submental platysmal adipomyofascial flap: is it a reliable alternate reconstructive option for small- to mid-sized defects especially in male patients with oral/oropharyngeal cancer?

Purpose

To introduce modified submental platysmal adipomyofascial flap as a new and viable hairless locoregional option for reconstruction of small- to mid-sized defects after ablative surgery in oral/oropharyngeal cancer patients keeping in mind the present pandemic situation.

Methods

An observational retrospective study was conducted using modified submental platysmal adipomyofascial flap as a locoregional reconstructive option for both intraoral and oropharyngeal defects in early-stage oral/oropharyngeal cancer patients, from Jan 2016 to May 2020 in a tertiary care hospital. All patients in this study were male and the overall flap outcome was evaluated with post-operative follow-up.

Results

Out of 18 patients, in 4 patients modified submental platysmal adipomyofascial flap was used as a combination of flaps for reconstruction. Six patients (33.33%) underwent adjuvant radiation therapy/radiation chemotherapy. The long-term functions (speech and swallowing) and cosmetic outcomes were good in the majority of the patients. One patient (5.55%) had pinhole oroantral fistula. No patient had any major flap failure.

Conclusion

Modified submental platysmal adipomyofascial flap can be considered as a good alternative in male patients for reconstruction of small- to mid-sized oral cavity/oropharyngeal defects post-resection, especially during the prevailing pandemic crisis. It is an oncologically safe procedure with the major advantage of providing a hairless flap for oral cavity, tonsillar and BOT resection defects with lesser donor site morbidity.

Reconstruction with Free Flaps of Head and Neck Cancer Defects: A National Cohort Study

The purpose of this study was to determine the perioperative mortality rate, reintervention rate, and total healthcare costs for head and neck cancer patients who underwent free tissue transfer (FTT) in Colombia. The prognostic factors associated with those results were estimated.

Factors impacting successful salvage of the failing free flap

BACKGROUND

Understanding factors impacting successful salvage of a compromised free flap.

METHODS

Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764).

RESULTS

Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04).

CONCLUSIONS

There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision.

Are contralateral submental artery perforator flaps feasible for the reconstruction of postoperative defects of oral cancer?

BACKGROUND

We evaluated the clinical applications of the reconstruction of postoperative defects of the oral cavity using contralateral submental artery flaps.

METHODS

A retrospective study of 18 patients with postoperative intraoral cancer defects reconstructed with contralateral submental artery perforator flaps between October 2018 and October 2019 in our department was conducted. The defect area, flap size, and complications were evaluated.

RESULTS

All patients were diagnosed based on pathological examinations: 2 with adenoid cystic carcinoma and 16 with squamous cell carcinoma. The submental artery perforator flap used for simultaneous repair was 8 to 15 cm in length and 4 to 6.5 cm in width. The survival rate of flap reconstruction was 100% with no donor site complications.

CONCLUSIONS

Contralateral submental artery flap reconstruction is a suitable alternative for moderate to large intraoral defects, postoperative mouth floor defects, and oral cavity composite defects of oral malignant tumors without contralateral lymph node metastases.

Facial Plastic and Reconstructive Surgery During the COVID-19 Pandemic: Implications in Craniomaxillofacial Trauma and Head and Neck Reconstruction

BACKGROUND

The global COVID-19 pandemic has had a profound impact on facial plastic and reconstructive surgery. Our review serves as a safety resource based on the current literature and is aimed at providing best-practice recommendations. Specifically, this article is focused on considerations in the management of craniomaxillofacial trauma as well as reconstructive procedures after head and neck oncologic resection.

METHODS

Relevant clinical data were obtained from peer-reviewed journal articles, task force recommendations, and published guidelines from multiple medical organizations utilizing data sources including PubMed, Google Scholar, MEDLINE, and Google search queries. Relevant publications were utilized to develop practice guidelines and recommendations.

CONCLUSIONS

The global COVID-19 pandemic has placed a significant strain on health care resources with resultant impacts on patient care. Surgeons operating in the head and neck are particularly at risk of occupational COVID-19 exposure during diagnostic and therapeutic procedures and must therefore be cognizant of protocols in place to mitigate exposure risk and optimize patient care.

Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits

The simultaneous use of two different free flaps, harvested from distinct donor sites, has demonstrated a reasonable degree of safety and success rates in head and neck composite defects reconstruction. Unfortunately, their relatively low frequent use, together with the lack of proper statistics on their management strategies, make their indications weak of robust conclusions to better define their role in common practice. The aim of the present study was to review the literature of the last 15 years regarding simultaneous free flap transposition, presenting advantages, disadvantages, and results of this technique, with the final purpose to propose an up-to-date panorama for the use of double free flap for complex head and neck defects reconstruction. Depending on which factors are present, surgeons may choose to select an approach that is theoretically safer, but yields less-than-ideal functional outcomes, such as local flap. Two free flaps may be necessary when the defect contains both a large, complex bony defect, large soft tissue needs, and proper surgical planning and meticulous monitoring continues to be the cornerstone of success.

High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)

Background

There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors.

Methods

A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation.

Results

We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood.

Conclusions

The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.

Choice of Regional Flaps for Oral Cancer Defects: Relevance in Current Era

Introduction

Microvascular free flaps (MVFF) are the current standard of care for reconstruction of oral ablative defects; however, pedicled myocutaneous flaps (PMCF) are still used widely in India. The rationale behind the preference for selecting PMCF in the present era is not well understood. The associated complications and swallowing outcomes are variable.

Methods

We retrospectively analysed the records of patients who underwent reconstructive surgery for oral cancer ablative defects over a 3-year period.

Results

Ninety-seven pedicled myocutaneous flaps [89 pectoralis major myocutaneous (PMMC) flaps, eight lower trapezius island myocutaneous (TMC) flaps] and 113 MVFFs were performed. The reasons for selecting PMCF were financial constraints 38.7%, MVFF salvage 22.5%, medically compromised 10.7%, vessel-depleted neck 6.4%, old age with PS2 + 5.3%, early recurrence 5.3%, borderline resectable 4.3%, palliative resection 2.1%. Overall complication rate was 20.4%. Of patients, 50.7% and 34.7% were on regular and semisolid diet, respectively; 66.6% had acceptable swallowing-related social well-being.

Conclusion

PMCFs have an important role in developing countries with patients having financial constraints. The other potential reasons driven by patient factors were discussed. The swallowing outcomes are good, with majority of the people having socially acceptable swallowing function.

Clinical Factors Associated With Reoperation and Prolonged Length of Stay in Free Tissue Transfer to Oncologic Head and Neck Defects

Importance

Prolonged hospitalization and reoperation after free tissue transfer may be associated with certain clinical factors.

Objective

To determine patient and surgical factors associated with length of stay (LOS) and reoperation following surgical procedures for malignant neoplasm of the head and neck involving microvascular free tissue transfer reconstruction.

Design, Setting, and Participants

This was a retrospective review of American College of Surgeons National Surgical Quality Improvement Program data from 2012 to 2014 using International Classification of Diseases, Ninth Revision (ICD-9), codes for malignant neoplasms of the head and neck. Multivariable logistic regression modeling was used to examine correlation of patient and surgical variables with reoperation and LOS. The national retrospective database included outcomes from community and academic participant hospitals (517 member institutions in 2014). A total of 1115 cases of head and neck malignant neoplasm ablation with microvascular free tissue transfer flap were reviewed retrospectively.

Main Outcomes and Measures

Incidence of reoperation within 30 days of index operation and hospitalization equal to or longer than 13.0 days, which is equal to being in the top quartile for duration of stay.

Results

Of the 1115 patients, 370 (33.2) were female, and the mean (SD) age was 66.8 (3.9) years. Predictors of prolonged length of stay included return to the operating room (odds ratio [OR], 4.8; 95% CI, 3.3-6.9), smoking (OR, 2.1; 95% CI, 1.5-3.1), clean-contaminated wound (OR, 2.2; 95% CI, 1.3-4.0), bony flap (OR, 1.8; 95% CI, 1.2-2.8), age (OR, 1.5; 95% CI, 1.2-1.7), and operative time (OR, 1.2; 95% CI, 1.1-1.3). Reoperation occurred 298 times for 225 patients (20.2%). Mean (SD) time to reoperation was 8.0 (7.7) days, with 180 (80%) occurring before discharge from the primary operation. The most common indications for reoperation were neck exploration (37 [12.4%]) or incision and drainage of neck (35 [11.7%]).

Conclusions and Relevance

American College of Surgeons National Surgical Quality Improvement Program data allow for large database analysis of free flap transfer to the head and neck. The data herein provide information to help guide surgeons on which patients will require longer stay in hospital and the most common reasons for return to the operating room. Wound class of index operation, subsequent wound-related complications, and long duration of the index operation were the primary drivers of increased risk for reoperation and, therefore, prolonged hospitalization. These same factors were also associated with prolonged hospitalization without reoperation.

Level of Evidence

NA.

Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review

Objective

The present review focuses on comparative studies of reconstruction with free flaps (FF) versus pedicled flaps (PF) after oncologic resection.

Method

A systematic review was developed in compliance with PRISMA guidelines and performed using the Pubmed, Medline, EMBASE, Amed and Biosis databases.

Results

A total of 30 articles were included. FF are associated with a longer operative time, a higher cost and a higher incidence of postoperative revisions compared to PF. FF are associated with a longer stay at the intensive care unit than the supraclavicular artery island flap (SCAIF) and with a more extended hospital stay compared to the submental island flap (SMIF). FF are associated with fewer infections and necrosis compared to the pectoralis major myocutaneous flap (PMMF).

Conclusion

The comparison of both type of flaps is limited by the inherent design of the studies included. In sum, FF seem superior to the PMMF for several outcomes. SMIF and SCAIF compare favorably to FF for some specific indications achieving similar outcomes at a lower cost.

Taking Free Flap Surgery Abroad: A Collaborative Approach to a Complex Surgical Problem

Accessibility to health care, especially complex surgical care, represents one of the major health care disparities in developing countries. While surgical teams may be willing to travel to these areas to help address these needs, there are many logistical and ethical dilemmas inherent in this pursuit. We reviewed our approach to the establishment of the team-based surgical outreach program, wherein we perform head and neck free tissue transfer surgery in Haiti. We describe the challenges encountered in the delivery of surgical care as well as ethical dilemmas relevant to surgical outreach trips, highlighting an approach reliant on strong local cooperation. Despite the obstacles in place, our experience shows that free flap surgery can be successfully and ethically performed in these areas of great need.

A Clinical Care Pathway to Reduce ICU Usage in Head and Neck Microvascular Reconstruction

Objective

To design and implement a postoperative clinical care pathway designed to reduce intensive care usage on length of stay, readmission rates, and surgical complications in head and neck free flap patients.

Methods

A postoperative clinical care pathway detailing timelines for patient care was developed by a multispecialty team. In total, 108 matched patients receiving free tissue transfer for reconstruction of head and neck defects in the year before (prepathway), year after (early pathway), and second year after (late pathway) pathway implementation were compared based on postoperative length of stay, 30-day readmission rate, intensive care unit (ICU) admission, and rates of medical/surgical complications.

Results

Median length of stay decreased from 10 to 7.5 and 7 days in the pre-, early, and late-pathway groups, respectively ( P = .012). Readmission rate decreased from 16% in the prepathway group to 0% and 3% in the early and late-pathway groups. The number of patients admitted to the ICU postoperatively decreased from 100% to 36% and 6% in the pre-, early, and late-pathway groups, respectively ( P = .025). The rates of surgical and medical complications were equivalent.

Discussion

This pathway effectively reduced ICU admission, length of stay, and readmission rates, without increasing postoperative complications. These outcomes were sustainable over 2 years.

Implications for Practice

Free flap patients may not require routine ICU admission and may be taken off ventilatory support in the operating room. This effectively reduces costly resource use in this patient population. Similar pathways could be introduced at other institutions.

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

OBJECTIVE

Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed.

DATA SOURCES

PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies.

RESULTS

A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively.

CONCLUSIONS

There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.