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Ooms M, Winnand P, Heitzer M, Katz MS, Peters F, Bickenbach J, Hölzle F, Modabber A. Does the Anastomosis Recipient Vessel Have an Influence on Free Flap Perfusion in Microvascular Head and Neck Reconstruction-A Retrospective Analysis of 338 Cases with Comparison of Flap Perfusion between Different Arterial and Venous Recipient Vessels in Radial Free Forearm Flaps, Anterolateral Thigh Flaps, and Fibula Free Flaps. J Clin Med 2024; 13:2763. [PMID: 38792305 PMCID: PMC11122445 DOI: 10.3390/jcm13102763] [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: 04/07/2024] [Revised: 04/29/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Flap perfusion is a prerequisite for microvascular free flap survival and a parameter routinely used for flap monitoring. The aim of this study was to investigate the influence of the anastomosis recipient vessel on flap perfusion. Methods: Flap perfusion was retrospectively analyzed in 338 patients who underwent head and neck reconstruction with microvascular free flaps between 2011 and 2020. The Oxygen-to-see tissue oxygen analysis system measurements for intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 8 and 2 mm tissue depths were compared between arterial anastomosis recipient vessels (external carotid artery [ECA], facial artery [FAA], lingual artery [LIA], and superior thyroid artery [STA]) and venous anastomosis recipient vessels (internal jugular vein [IJV], combination of IJV and IJV branches, IJV branches, and external jugular vein). Results: The postoperative hemoglobin concentration at 2 mm tissue depth differed significantly between arterial anastomosis recipient vessels (ECA, 41.0 arbitrary units [AU]; FAA, 59.0 AU; LIA, 51.5 AU; STA, 59.0 AU; p = 0.029). This difference did not persist in the multivariable testing (p = 0.342). No other differences in flap blood flow, hemoglobin concentration, or hemoglobin oxygen saturation were observed between the arterial and venous anastomosis recipient vessels (p > 0.05 for all). Conclusions: The arterial and venous recipient vessels used for anastomosis did not influence microvascular free flap perfusion. This underlines the capability of the studied recipient vessels to adequately perfuse free flaps, may explain the observed indifferent flap survival rates between commonly used anastomosis recipient vessels, and implies that the recipient vessel is not a confounding variable for flap monitoring with the Oxygen-to-see tissue oxygen analysis system. Further prospective studies are needed to confirm the findings.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Barlow J, Sragi Z, Rodriguez N, Alsen M, Kappauf C, Ferrandino R, Chennareddy S, Kotz T, Kirke DN, Teng MS, Genden EM, Khan MN, Roof SA. Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta-analysis. Head Neck 2024; 46:1224-1233. [PMID: 38414175 DOI: 10.1002/hed.27684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/28/2023] [Accepted: 02/03/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Traditionally, patients undergoing free flap reconstruction for oral cavity defects have been given nothing by mouth for 6-14 days post-operatively due to concern for orocutaneous fistula development. METHODS Multiple databases were screened for studies assessing the rate of orocutaneous fistula formation in early (≤5 days) versus late (>5 days) feeding groups following oral cavity free flap reconstruction. Fixed- and random-effects meta-analyses were used. RESULTS One randomized controlled trial, one prospective cohort, and three retrospective cohort studies were included. The early feeding group displayed no significant increase in orocutaneous fistula formation (RD = -0.02, p = 0.06) or free flap failure (RD = -0.01, p = 0.39), with a significantly shorter hospital length of stay (mean difference [days] = -2.43, p < 0.01). CONCLUSIONS While further prospective trials are necessary, initiation of oral intake before post-operative day 5 may be appropriate in properly selected patients following oral reconstruction.
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Affiliation(s)
- Joshua Barlow
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Sragi
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nina Rodriguez
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mathilda Alsen
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Catharine Kappauf
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rocco Ferrandino
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Susmita Chennareddy
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tamar Kotz
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Diana N Kirke
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marita S Teng
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric M Genden
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohemmed N Khan
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Scott A Roof
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Vos DJ, Arianpour K, Fritz MA, Hadford S, Liu SW, Prendes BL, Ciolek PJ. Minimally Invasive Approach to Access Vessels for Microvascular Anastomosis in Head and Neck Reconstruction. Laryngoscope 2024; 134:2177-2181. [PMID: 37942819 DOI: 10.1002/lary.31168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/29/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To describe our technique, review indications, and evaluate the outcomes of the minimal access approach for recipient vessel identification in microvascular tissue transfer. METHODS Retrospective chart review of all patients who underwent microvascular reconstruction using the minimal access technique between 2015 and 2021. RESULTS We report 236 cases, comprising 214 patients with a mean age of 60.2 years (3-88). The most common primary defect sites were the mandible (22.6%), cranium (14%), maxilla (13.2%), skull base (12.8%), and nose/nasal cavity (10.6%). Indications for free flap reconstruction included head and neck cancer extirpation (32.2%), osteoradionecrosis (29.7%), acquired deformity (14.0%), chronic wound (11.9%) and oral motor dysfunction (7.2%). Free flap donor sites used were the anterolateral thigh (84.3%), fibula (7.2%), and radial forearm (6.4%). Vessels utilized include superficial temporal (49.8%), facial (38.3%), angular (11.1%), and transverse cervical (0.4%). The overall complication rate was 14% (n = 33), with surgical complications at the recipient site accounting for 67.6% (n = 25). Flap failure occurred in 3.4% of procedures. Prior head and neck surgery and free flaps were associated with an increased risk of major recipient site complications (n = 20, p = 0.0257 and n = 14, p = 0.0117, respectively). CONCLUSION Minimal access techniques allow consistent recipient vessel identification for microvascular-free tissue transfer. These approaches may be utilized in reconstructing a broad range of head and neck defects, are low morbidity, and contribute to an overall shorter length of stay. LEVEL OF EVIDENCE 2 Laryngoscope, 134:2177-2181, 2024.
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Affiliation(s)
- Derek J Vos
- Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | | | - Michael A Fritz
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Stephen Hadford
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Sara W Liu
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | | | - Peter J Ciolek
- Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, U.S.A
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Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
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Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
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Liao X, Lu H, Wei Z, Chen W, Chen L, Huang Z, Deng M, Zhou J, Liang Y, Liu R, Nie K. Construction and study of a three-dimensional visualization model of superficial temporal artery branches: With an explicatory case. Asian J Surg 2024; 47:1351-1359. [PMID: 38065731 DOI: 10.1016/j.asjsur.2023.11.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 10/26/2023] [Accepted: 11/24/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND The anatomical parameters of the superficial temporal artery branches were measured by a three-dimensional measurement method to provide anatomical reference for relevant clinical operations. METHODS Seventy original images were selected who had cranial CTA examination. The patients were aged 30-79 years, with an average of 60.0 years, including 32 females and 38 males. After reconstructing the superficial temporal artery by professional medical 3D reconstruction software, its anatomical parameters were measured. RESULTS The length of the secondary branches of the frontal branch of the superficial temporal artery were 47.6 ± 23.6 mm and 37.3 ± 21.6 mm in males and females, respectively, with a statistically significant difference. The length of the secondary branches of the parietal branch of the superficial temporal artery were 39.6 ± 20.4 mm and 49.2 ± 20.3 mm in young and middle-aged people and older people respectively, which were statistically different. The remaining measures were not statistically different across gender and age groups. The frontal branch of the superficial temporal artery was divided into three types, and the parietal branch of the superficial temporal artery was divided into two types. CONCLUSIONS The anatomical parameters of the superficial temporal artery branches can be accurately measured by means of 3D visualization, providing an anatomical reference for relevant clinical operations.
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Affiliation(s)
- Xiaoshuang Liao
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Hui Lu
- School of Medicine, Wuhan University of Science and Technology, Institute of Medical Innovation and Transformation, Puren Hospital Affiliated to Wuhan University of Science and Technology, Department of Orthopedics, Wuhan, China
| | - Zairong Wei
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Wei Chen
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Li Chen
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Zhonglu Huang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Mingfu Deng
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Jian Zhou
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Yan Liang
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China
| | - Rong Liu
- School of Medicine, Wuhan University of Science and Technology, Institute of Medical Innovation and Transformation, Puren Hospital Affiliated to Wuhan University of Science and Technology, Department of Orthopedics, Wuhan, China.
| | - Kaiyu Nie
- Department of Burns and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, The Collaborative Innovation Center of Tissue Damage Repair and Regeneration Medicine of Zunyi Medical University, Zunyi, China.
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Shaikh N, Noor K, Jafary H, Chung J, Fancy T, Stokes W. Effect of 2 Teams and Operative Time on Complications After Oral Cavity Free Flap Reconstruction. Ann Otol Rhinol Laryngol 2023; 132:1430-1437. [PMID: 37012707 DOI: 10.1177/00034894231164802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
OBJECTIVE Evaluate the effects of operative time and 2 team approach on complications after soft tissue free flap reconstruction for oral tongue cancer. METHODS Patients with oncologic glossectomy with myocutaneous or fasciocutaneous free flap reconstruction were included from the 2015 to 2018 American College of Surgery National Surgical Quality Improvement Program. The primary predictive variables assessed were operative time and 2 team approach; control variables included age, sex, body mass index (BMI), 5-question-modified frailty index (mFI-5), American Society of Anesthesiologists (ASA) class, and total work relative value units (wRVU). Outcomes assessed included 30-day mortality, 30-day reoperation, hospital length of stay beyond 30 days, readmission, medical and surgical complications, and non-home discharge. Multivariable logistic/linear regression models were used to predict surgical outcomes. RESULTS Microvascular soft tissue free flap reconstruction of the oral cavity after glossectomy was performed on 839 patients. Operative time was independently associated with readmission, prolonged length of stay, surgical complications, medical complications, and non-home discharge. A 2-team approach was independently associated with prolonged length of stay and medical complications. The mean operative time of the 1-team and 2-team approach was 8.73 and 9.13 hours. The 1-team approach did not significantly increase operative time (P = .16). CONCLUSIONS In the largest study to date of operative time on post-surgical outcomes after glossectomy and soft tissue free flap reconstruction, we found longer operative times increased rates of postoperative complications and non-home discharge. The 1-team approach is non-inferior to the 2-team approach with respect to operating time and complications.
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Affiliation(s)
- Noah Shaikh
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Kinza Noor
- School of Medicine, West Virginia, Morgantown, WV, USA
| | - Haseeb Jafary
- Marshall University School of Medicine, Huntington, WV, USA
| | - Jeffson Chung
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - Tanya Fancy
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
| | - William Stokes
- Department of Otolaryngology, West Virginia University, Morgantown WV, USA
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7
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Ferreira PRC, De Oliveira RIP, Vaz MD, Bentes C, Costa H. Opioid-Free Anaesthesia Reduces Complications in Head and Neck Microvascular Free-Flap Reconstruction. J Clin Med 2023; 12:6445. [PMID: 37892584 PMCID: PMC10607324 DOI: 10.3390/jcm12206445] [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: 08/24/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Head and neck free-flap microvascular surgeries are complex and resource-intensive procedures where proper conduct of anaesthesia plays a crucial role in the outcome. Flap failure and postoperative complications can be attributed to multiple factors, whether surgical- or anaesthesia-related. The anesthesiologist should ensure optimised physiological conditions to guarantee the survival of the flap and simultaneously decrease perioperative morbidity. Institutions employ different anaesthetic techniques and results vary across centres. In our institution, two different total intravenous approaches have been in use: a remifentanil-based approach and a multimodal opioid-sparing approach, which is further divided into an opioid-free anaesthesia (OFA) subgroup. We studied every consecutive case performed between 2015 and 2022, including 107 patients. Our results show a significant reduction in overall complications (53.3 vs. 78.9%, p = 0.012), length of stay in the intensive care unit (3.43 ± 5.51 vs. 5.16 ± 4.23 days, p = 0.046), duration of postoperative mechanical ventilation (67 ± 107 vs. 9 ± 38 h, p = 0.029), and the need for postoperative vasopressors (10% vs. 46.6%, p = 0.001) in the OFA group (vs. all other patients). The multimodal and OFA strategies have multiple differences regarding the fluid therapy, intraoperative type of vasopressor used, perioperative pathways, and various drug choices compared to the opioid-based technique. Due to the small number of cases in our study, we could not isolate any attitude, as an independent factor, from the success of the OFA strategy as a whole. Large randomised controlled trials are needed to improve knowledge and help define the ideal anaesthetic management of these patients.
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Affiliation(s)
- Paulo-Roberto Cardoso Ferreira
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
| | | | - Marta Dias Vaz
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Carla Bentes
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
| | - Horácio Costa
- Centro Hospitalar de Vila Nova de Gaia, 4434-502 Vila Nova de Gaia, Portugal
- Medical Sciences Department, University of Aveiro, 3810-193 Aveiro, Portugal
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Hicks MD, Vasudev M, Bishop JL, Garcia N, Chowdhury F, Pham TT, Heslop G, Greene B, Jeyarajan H, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM. Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps. OTO Open 2023; 7:e86. [PMID: 37854346 PMCID: PMC10580001 DOI: 10.1002/oto2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 07/30/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023] Open
Abstract
Objective To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects. Study Design Retrospective cohort study. Setting Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine. Methods A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma. Results A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P < .0001) and multivariate analyses (P < .0001). However, neither anticoagulation nor antiplatelet therapy were predictive of postoperative transfusion rates and hematoma formation. Conclusion Antithrombotic regimens do not increase the risk of postoperative transfusion or hematoma in head and neck microvascular reconstruction. Based on this limited data, perioperative antithrombotic regimens can be considered in patients who may otherwise be at risk for these postoperative complications.
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Affiliation(s)
- Melanie D. Hicks
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Milind Vasudev
- School of MedicineUniversity of California Irvine School of MedicineIrvineCaliforniaUSA
| | - Jessica L. Bishop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Natalie Garcia
- School of MedicineUniversity of Alabama at Birmingham Heersink School of MedicineBirminghamAlabamaUSA
| | - Farshad Chowdhury
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tiffany T. Pham
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Gabriela Heslop
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Benjamin Greene
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Hari Jeyarajan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Jessica W. Grayson
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
| | - Julie A. Goddard
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Tjoson Tjoa
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Yarah Haidar
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California IrvineIrvineCaliforniaUSA
| | - Carissa M. Thomas
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Alabama at BirminghamBirminghamAlabamaUSA
- O'Neal Comprehensive Cancer CenterBirminghamAlabamaUSA
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9
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Ooms M, Winnand P, Heitzer M, Peters F, Bock A, Katz MS, Hölzle F, Modabber A. Attached compared with unattached surface probes for monitoring flap perfusion in microvascular head and neck reconstruction: a feasibility study. Sci Rep 2023; 13:15939. [PMID: 37743387 PMCID: PMC10518317 DOI: 10.1038/s41598-023-43151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023] Open
Abstract
Unattached surface probes are commonly used with the O2C analysis system (LEA Medizintechnik, Germany) to monitor microvascular free flap perfusion. This study compared attached and unattached surface probes for extraoral free flaps. The study included 34 patients who underwent extraoral microvascular head and neck reconstruction between 2020 and 2022. Flap perfusion was monitored postoperatively using the O2C analysis system at 0, 12, 24, 36, and 48 h, with an attached surface probe at 3 mm tissue depth and an unattached surface probe at 2 mm and 8 mm tissue depths. Clinical complications, technical errors, and perfusion measurement values were compared. No clinical complications (attachment suture infections) or technical errors (probe detachment) occurred. Flap blood flow values of the probes were partially different (3 mm vs. 2 and 8 mm: p < 0.001; p = 0.308) and moderately correlated (3 mm with 2 and 8 mm: r = 0.670, p < 0.001; r = 0.638, p < 0.001). Hemoglobin concentration and oxygen saturation values were generally different (3 mm vs. 2 and 8 mm: all p < 0.001) and variably correlated (3 mm with 2 and 8 mm: r = 0.756, r = 0.645; r = 0.633, r = 0.307; all p < 0.001). Both probes are comparable in terms of technical feasibility and patient safety, with flap perfusion values dependent on tissue measurement depth.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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10
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Ooms M, Winnand P, Heitzer M, Peters F, Bock A, Katz M, Hölzle F, Modabber A. Flap perfusion monitoring with an attached surface probe in microvascular reconstruction of the oral cavity. Clin Oral Investig 2023; 27:5577-5585. [PMID: 37522990 PMCID: PMC10492739 DOI: 10.1007/s00784-023-05177-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Postoperative flap monitoring is essential in oral microvascular reconstruction for timely detection of vascular compromise. This study investigated the use of attached surface probes for the oxygen-2-see (O2C) analysis system (LEA Medizintechnik, Germany) for intraoral flap perfusion monitoring. MATERIALS AND METHODS The study included 30 patients who underwent oral reconstruction with a microvascular radial-free forearm flap (RFFF) or anterolateral thigh flap (ALTF) between 2020 and 2022. Flap perfusion was measured with attached (3-mm measurement depth) and unattached surface probes (2- and 8-mm measurement depths) for the O2C analysis system at 0, 12, 24, 36, and 48 h postoperatively. Flap perfusion monitoring with attached surface probes was evaluated for cut-off values for flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation indicative of vascular compromise and for accuracy and concordance with unattached surface probes. RESULTS Three RFFFs were successfully revised, and one ALTF was unsuccessfully revised. The cut-off values indicative of vascular compromise for flap perfusion monitoring with attached surface probes were for RFFF and ALTF: blood flow < 60 arbitrary units (AU) and < 40AU, hemoglobin concentration > 100AU and > 80AU (both > 10% increase), and hemoglobin oxygen saturation < 40% and < 30%. Flap perfusion monitoring with attached surface probes yielded a 97.1% accuracy and a Cohen's kappa of 0.653 (p < 0.001). CONCLUSIONS Flap perfusion monitoring with attached surface probes for the O2C analysis system detected vascular compromise accurately and concordantly with unattached surface probes. CLINICAL RELEVANCE Attached surface probes for the O2C analysis system are a feasible option for intraoral flap perfusion monitoring.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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11
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Uehara M, Habu M, Sasaguri M, Tominaga K. Post-reconstruction Free Flap Complications After Oral Cancer Ablation. J Maxillofac Oral Surg 2023; 22:20-27. [PMID: 37041939 PMCID: PMC10082861 DOI: 10.1007/s12663-023-01854-2] [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: 06/11/2021] [Accepted: 01/14/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Microvascular free flap transfer is considered a standard reconstruction after the ablation of oral cancer. Although the success rate is high, flap complications occasionally occur. This study investigated the reasons for and local factors involved in complications of free flap transfer and explored how to salvage the flaps. Patients and Methods The cases of 53 patients who underwent a free flap transfer [radial forearm flaps (n = 36), abdominis musculocutaneous flaps (n = 6), scapular osteocutaneous flaps (n = 10), and fibular osteocutaneous flap (n = 1)] were analyzed: flap complications were observed in five of the cases. Results In the all five cases, a salvage operation was performed under general anesthesia. The flap complications occurred within 33 h after anastomosis. In the salvage operation, thrombotic occlusion in veins of flap feeders was observed in three of the five cases. The possible reasons for flap complications were a twisting of the anastomosed vein where two veins were united, pressure to the feeder due to subcutaneous hematoma, and edema of adjacent tissue and/or drain tube; the reason was not clear in one case. The flaps were successfully salvaged in four cases by thrombectomy in veins, release of pressure at the veins, and/or interposition of the vein graft. Conclusion Surgeons should pay close attention to the pressure and/or twisting in the feeder as well as the hemostasis in the surgical field, and a salvage operation should be carried out immediately when a flap complication is identified.
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Affiliation(s)
- Masataka Uehara
- Unit of Oral and Maxillofacial Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho, Shimonoseki City, Yamaguchi 750-8520 Japan
| | - Manabu Habu
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Masaaki Sasaguri
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Kazuhiro Tominaga
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
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12
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Scarabosio A, Tel A, Contessi Negrini F, Albanese R, Robiony M, Parodi P. The shark flap: a modified internal mammary artery perforator flap for composite defects in head and neck reconstruction. Case Reports Plast Surg Hand Surg 2023; 10:2178924. [PMID: 36818191 PMCID: PMC9937011 DOI: 10.1080/23320885.2023.2178924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
This report describes a multi-vector variant of IMAP flap which allows to reconstruct composite head and neck defects. It was named the 'shark flap' because of its shape: a main body (the regular IMAP) and a superior 'fin' based on a randomic vascular pathway.
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Affiliation(s)
- Anna Scarabosio
- Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy,CONTACT Anna Scarabosio Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Alessandro Tel
- Maxillo-Facial Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | | | - Roberta Albanese
- Plastic Surgery Consultant at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Massimo Robiony
- Maxillo-Facial Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
| | - Piercamillo Parodi
- Plastic Surgery Resident at Santa Maria della Misericordia Hospital, Udine, Italy
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13
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Tu CH, Hong SF. Preoperative anemia: Predictor of free flap reconstruction complications in head and neck cancer. CHINESE J PHYSIOL 2023; 66:21-27. [PMID: 36814153 DOI: 10.4103/cjop.cjop-d-22-00115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Free flap reconstruction has been the mainstay among reconstruction surgeries for head and neck cancer. Intraoperative and postoperative hemoglobin (Hb) levels were both possible risk factors of flap failure and had been discussed widely. However, few investigations of preoperative Hb were seen in the previous study with its effect to flap condition remain uncertain and no conclusions in the literature. Patients who underwent free flap reconstruction after head and neck surgery in our institution between May 2014 and May 2019 were enrolled. The postoperative flap condition was observed carefully, and re-exploration was performed if necessary. We then retrospectively collected patient data with several intraoperative and postoperative indices. A total of 598 patients were enrolled in our study. The total major flap complication rate was 10.6%, with an overall success rate of 89.4%. They were predominantly male (95%), and most of them underwent free flap reconstruction for the first time (91%). A total of 81 (13%) patients received radiotherapy before reconstruction. Among all factors, the preoperative Hb level and free flap type showed significance in univariate and multivariate analyses. A previous history of radiotherapy, body mass index, nutrition status, or poorly controlled diabetes mellitus showed no significant results in either univariate or multivariate analysis. Our study showed that a lower preoperative Hb level affects free flap survival. Meanwhile, preoperative radiotherapy history has no significant influence in either univariate or multivariate analysis.
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Affiliation(s)
- Cheng Hung Tu
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - San Fu Hong
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
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14
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Choi JW, Alshomer F, Kim YC. Evolution and current status of microsurgical tongue reconstruction, part II. Arch Craniofac Surg 2022; 23:193-204. [PMID: 36373253 PMCID: PMC9663260 DOI: 10.7181/acfs.2022.00857] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 08/18/2022] [Accepted: 10/11/2022] [Indexed: 01/25/2023] Open
Abstract
Tongue reconstruction remains a major aspect of head and neck reconstructive procedures. Surgeons planning tongue reconstruction should consider several factors to optimize the overall outcomes. Specifically, various technical aspects related to tongue reconstruction have been found to affect the outcomes. Multidisciplinary teams dedicated to oncologic, reconstructive, and rehabilitative approaches play an essential role in the reconstructive process. Moreover, operative planning addressing certain patient-related and defect-related factors is crucial for optimizing functional speech and swallowing, as well as quality of life outcomes. Furthermore, tongue reconstruction is a delicate process, in which overall functional outcomes result from proper flap selection and shaping, recipient vessel preparation and anastomosis, surgical approaches to flap insetting, and postoperative management. The second part of this review summarizes these factors in relation to tongue reconstruction.
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Affiliation(s)
- Jong-Woo Choi
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Feras Alshomer
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Chul Kim
- Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Ooms M, Puladi B, Winnand P, Heitzer M, Steiner T, Bickenbach J, Hölzle F, Modabber A. Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation. Int J Oral Maxillofac Surg 2022; 52:640-647. [PMID: 36253245 DOI: 10.1016/j.ijom.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.
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16
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Park JH, Park JU. Flap monitoring with incisional negative pressure wound therapy (NPWT) in diabetic foot patients. Sci Rep 2022; 12:15684. [PMID: 36127377 PMCID: PMC9489718 DOI: 10.1038/s41598-022-20088-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/08/2022] [Indexed: 11/24/2022] Open
Abstract
Various types of flaps are considered as reconstructive options for patients with diabetic foot ulcer. However, flap reconstruction for diabetic foot ulcer treatment is particularly challenging because of the relatively limited collateral perfusion in the distal lower extremity. This study evaluated the efficacy and safety of a novel postoperative monitoring procedure implemented in conjunction with negative pressure wound therapy immediately after flap operations for treating diabetic foot. A retrospective analysis was performed on diabetic foot patients who underwent free flaps and perforator flaps from March 2019 through August 2021. The surgical outcomes of interest were the rates of survival and complications. On the third postoperative day, patients underwent computed tomography angiography to check for pedicle compression or fluid collection in the sub-flap plane. Monitoring time, as well as comparisons between NPWT and conventional methods, were analyzed. Statistical analysis was performed between the two groups. This study included 26 patients. Among patients, the negative pressure wound Therapy treated group included 14 flaps and the conventional monitoring group included 12 flaps. There was no significant intergroup difference in flap survival rate (p = 0.83). In addition, there was no significant intergroup difference in the diameters of perforators or anastomosed vessels before and after negative pressure wound therapy (p = 0.97). Compared with conventional monitoring, flap monitoring with incisional negative pressure wound therapy was associated with a significantly lower mean monitoring time per flap up to postoperative day 5. Although conventional monitoring is widely recommended, especially for diabetic foot ulcer management, the novel incisional negative pressure wound therapy investigated in this study enabled effortless serial flap monitoring without increasing complication risks. The novel flap monitoring technique is efficient and safe for diabetic foot patients and is a promising candidate for future recognition as the gold standard for flap monitoring.
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Affiliation(s)
- Jun Ho Park
- Department of Plastic and Reconstructive Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Ji-Ung Park
- Department of Plastic and Reconstructive Surgery, SMG-SNU Boramae Medical Center, Seoul National University College of Medicine, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea.
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17
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Ooms M, Puladi B, Houschyar KS, Heitzer M, Rashad A, Bickenbach J, Hölzle F, Modabber A. Smoking and microvascular free flap perfusion in head and neck reconstruction: radial free forearm flaps and anterolateral thigh flaps. Sci Rep 2022; 12:13902. [PMID: 35974131 PMCID: PMC9381556 DOI: 10.1038/s41598-022-18216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
Head and neck reconstruction with microvascular free flaps is frequently performed in smokers. Smoking causes various alterations in the cardiovascular system. The aim of this study was to investigate the effects of smoking on flap perfusion as a critical factor for flap survival. A total of 370 patients reconstructed with a radial free forearm flap (RFFF) or anterolateral thigh flap (ALTF) in the head and neck region between 2011 and 2020 were retrospectively analyzed. Flap perfusion measurements with the O2C tissue oxygen analysis system were compared between nonsmokers, light smokers (< 20 pack-years), and heavy smokers (≥ 20 pack-years). The blood flow was intraoperatively equal in RFFFs (84.5 AU vs. 84.5 AU; p = 0.900) and increased in ALTFs (80.5 AU vs. 56.5 AU; p = 0.001) and postoperatively increased in RFFFs (114.0 AU vs. 86.0 AU; p = 0.035) and similar in ALTFs (70.5 AU vs. 71.0 AU; p = 0.856) in heavy smokers compared to nonsmokers. The flap survival rate was similar in nonsmokers, light smokers, and heavy smokers (97.3%, 98.4%, and 100.0%). Smoking partially increases rather than decreases microvascular free flap perfusion, which may contribute to similar flap survival rates in smokers and nonsmokers.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Khosrow Siamak Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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18
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Raghavan P, Vakharia K, Morales RE, Mukherjee S. Surgical Free Flaps and Grafts in Head and Neck Reconstruction: Principles and Postoperative Imaging. Neuroimaging Clin N Am 2021; 32:75-91. [PMID: 34809845 DOI: 10.1016/j.nic.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review article discusses the basic principles behind the use of flaps and grafts for reconstructive surgery in the head and neck, with a special emphasis on the types of commonly used free flaps, their imaging appearance as well as some frequently encountered postoperative complications. Given the ubiquity and complexity of these reconstructive techniques, it is essential that head and neck radiologists be familiar in distinguishing between the expected evolving findings, complications, and tumor recurrence.
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Affiliation(s)
- Prashant Raghavan
- Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA.
| | - Kalpesh Vakharia
- Department of Otorhinolaryngology-Head and Neck Surgery, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, 419 West Redwood Street, Suite 370, Baltimore, MD 21201, USA
| | - Robert E Morales
- Neuroradiology, Diagnostic Neuroradiology Fellowship, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Sugoto Mukherjee
- Department of Radiology and Medical Imaging, University of Virginia Health System, PO Box 800170, 1215 Lee Street, Charlottesville, VA 22908-1070, USA
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19
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Kim TH, Park JH. A novel negative pressure wound therapy (NPWT) monitoring system for postoperative flap management. Medicine (Baltimore) 2021; 100:e27671. [PMID: 34871244 PMCID: PMC8568380 DOI: 10.1097/md.0000000000027671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 10/11/2021] [Indexed: 01/05/2023] Open
Abstract
Various types of flaps are widely utilized as reconstructive options for patients with soft tissue defects. However, the postoperative monitoring of the flap requires a large amount of time and effort. The aim of this study was to evaluate the efficacy and safety of this novel monitoring procedure using negative pressure wound therapy (NPWT) immediately after the flap operations.A retrospective analysis was performed on patients who underwent free flaps and perforator flaps from March 2019 to December 2020. The flaps were managed by either novel NPWT method or conventional dressing. Among NPWT group, computed tomography angiography was performed in randomly selected 5 flaps on the third postoperative day for evaluation of pedicle compression. Statistical analysis was performed between the 2 groups.A total of 54 flaps were included in this study. Twenty seven flaps were managed using novel NPWT method and 27 flaps were managed using conventional dressing. There was no statistically significant difference in flap survival rates between the 2 groups (P = .91). The patency of flap pedicles in the NPWT group was confirmed by comparing the computed tomography angiography findings. The estimated total flap monitoring time and cost for 5 days was significantly decreased by the application of the novel NPWT monitoring system.Through the application of the novel postoperative monitoring system using NPWT, there is efficient evaluation of the flap. Furthermore, safe flap monitoring is possible with the reduced risk of infection by the avoidance of multiple manual dressing performed in the conventional method.
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20
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Molteni G, Gazzini L, Albi C, Fior A, Nocini R, Marchioni D. Donor site aesthetic and functional outcomes: comparison between radial forearm free flap and anterolateral thigh free flap. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01889-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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21
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Katsnelson JY, Tyrell R, Karadsheh MJ, Manstein E, Egleston B, Deng M, Baltodano PA, Shafqat MS, Patel SA. Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database. J Reconstr Microsurg 2021; 38:343-360. [PMID: 34404103 DOI: 10.1055/s-0041-1733922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years. METHODS Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay. RESULTS A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps. CONCLUSION Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.
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Affiliation(s)
- Jacob Y Katsnelson
- Department of Surgery, Abington-Jefferson Health, Abington, Pennsylvania
| | - Richard Tyrell
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Murad J Karadsheh
- Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Ely Manstein
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Mengying Deng
- Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Pablo A Baltodano
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - M Shuja Shafqat
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania.,Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Sameer A Patel
- Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania.,Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania.,Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
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22
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Kushida-Contreras BH, Manrique OJ, Gaxiola-García MA. Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature. Ann Surg Oncol 2021; 28:2882-2895. [PMID: 33550502 DOI: 10.1245/s10434-021-09590-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures. METHODS A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications. RESULTS The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases. CONCLUSIONS Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.
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Affiliation(s)
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY, USA
| | - Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children Hospital (Hospital Infantil de México "Federico Gómez"), Mexico City, Mexico.
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Head and neck free tissue transfer in a patient with factor V Leiden: case report and review of the literature. Oral Maxillofac Surg 2021; 25:571-574. [PMID: 33471220 DOI: 10.1007/s10006-021-00939-x] [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: 10/28/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
Hypercoagulable disorders can compromise success of free flap reconstruction. Factor V Leiden is one such disorder for which only one previously reported case of successful free tissue transfer in the head and neck has been described. We report a 70-year-old woman with factor V Leiden treated for stage IVA squamous cell carcinoma of the mandible with a composite resection and reconstruction with an osteocutaneous scapular free tissue transfer. The free tissue transfer occurred without complications, in the setting of intraoperative heparin, postoperative aspirin, and enoxaparin. The free tissue transfer continues to be viable at her most recent follow-up appointment. The hypercoagulable patient represents a diverse presentation of increased coagulation risk in the perioperative period. Considering a patient's history and understanding available treatment adjuncts can factor heavily in a patient with factor V Leiden successfully undergoing free tissue transfer for head and neck defects.
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McLean A, Lowe D, Rogers SN. Administration of intravenous iron and tranexamic acid in the management of postoperative iron deficiency anaemia following free flap reconstruction: re-audit. Br J Oral Maxillofac Surg 2020; 59:97-101. [PMID: 33168366 DOI: 10.1016/j.bjoms.2020.08.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022]
Abstract
Following free tissue transfer, intravenous iron (IVI) has a role in reducing the rates of blood transfusion and more rapidly restoring haemoglobin (Hb) levels. Anaemia has a detrimental effect on survival, postoperative complications, fatigue, and health-related quality of life, therefore early correction is recommended. The aim of this re-audit is to assess the use of IVI, of tranexamic acid intraoperatively, and of perioperative blood transfusions. A total of 148 consecutive patients who underwent ablative surgery and free flap reconstruction between May 2018 and September 2019 were audited. The median (IQR) age was 66 (59,72) years and 36% were female. For two-thirds, surgery was for cancer located in the oral cavity and two-thirds of the free flaps were soft tissue. Tranexamic acid (TXA) was used intraoperatively for 30%, red blood cells (RBC) were transfused for 20% and 55 patients (37%) received IV iron. This compares with 4%, 26%, and 0, respectively, in the initial audit. Those having IVI were more likely (56%) to have had a composite flap, a lower postoperative haemoglobin and lower discharge Hb. The Hb between four and twelve weeks' follow up, known for 40, was a median (IQR) of 122 (104,138). There were no adverse reactions to IV iron. Although it is straightforward to administer IVI postoperatively, this re-audit demonstrates that it can be a challenge to embed change in protocols. Through raised awareness of the benefits of IVI, lack of adverse events and clarification of selection criteria, it is hoped that rates of IVI use will increase.
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Affiliation(s)
- A McLean
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool L9 7AL, UK.
| | - D Lowe
- Astraglobe Ltd., Congleton, Cheshire.
| | - S N Rogers
- Regional Maxillofacial Unit, Aintree University Hospital, Liverpool L9 7AL, UK.
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Giovacchini F, Bensi C, Paradiso D, Docimo R, Tullio A. Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2020; 278:2171-2185. [PMID: 32870364 DOI: 10.1007/s00405-020-06286-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery. METHODS The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale. RESULTS A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81). CONCLUSIONS The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.
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Affiliation(s)
- Francesco Giovacchini
- Maxillo-Facial Surgery Unit, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Caterina Bensi
- Paediatric Dentistry Post-Graduate School, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy.
| | - Daniele Paradiso
- S.S.D. of Oral Surgery and Ambulatory, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Raffaella Docimo
- Paediatric Dentistry, Department of Surgical Sciences, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy
| | - Antonio Tullio
- Maxillo-Facial Surgery, University of Perugia, Perugia, Italy
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Zaid W, Schlieve T. The Early Effects of Coronavirus Disease-2019 on Head and Neck Oncology and Microvascular Reconstruction Practice: A National Survey of Oral and Maxillofacial Surgeons Enrolled in the Head and Neck Special Interest Group. J Oral Maxillofac Surg 2020; 78:1859-1868. [PMID: 32745533 PMCID: PMC7366104 DOI: 10.1016/j.joms.2020.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The coronavirus disease-2019 (COVID-19) pandemic has affected healthcare systems across the nation. The purpose of this study is to gauge the early effects of the COVID-19 pandemic on head and neck oncology and reconstructive surgery (HNORS) practice and evaluate their practice patterns especially ones that might be impacted by COVID-19 and compare them to the current literature. METHODS This study is a cross-sectional study that surveyed fellowship-trained oral and maxillofacial surgeons in HNORS. This cohort of surgeons was contacted via a generated email list of surgeons enrolled in the American Association of Oral and Maxillofacial Surgeons pathology special interest group. An electronic survey contained 16 questions to assess the COVID-19 effect on HNORS practice and capture their practice patterns from mid-March to mid-April 2020. Statistical analysis was performed to analyze counts, percentages, and response rates. RESULTS We had a 60% response rate (39 of 64); 72% of our responders worked at academic institutions, 18% marked themselves as hybrid academic/private practice, and only 10% were considered hospital-based surgeons. Only 8% of the survey respondents were requested to pause head and neck cancer surgery, whereas 24% were requested to pause free flap surgery during the pandemic. Fifty-five percent agreed that the head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks was a reasonable delay for head and neck cancer cases, whereas 29% thought they should not be delayed for any amount of time. Regarding practice patterns, microvascular reconstruction was the favored method (100%). Respondents generally admitted patients to an intensive care unit postoperatively (92%) and were kept on a ventilator (53%). CONCLUSION The COVID-19 pandemic had a small impact on the surgical treatment of patients with head and neck oncology. Most HNORS surgeons are practicing in accordance with recently published literature.
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Affiliation(s)
- Waleed Zaid
- Associate Professor, Department of Oral and Maxillofacial Surgery, Site Director of Oral and Maxillofacial Surgery - Baton Rouge, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA.
| | - Thomas Schlieve
- Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Dallas, TXl, Residency Program Director, Division of Oral and Maxillofacial Surgery, Dallas, TX, Director of Oral and Maxillofacial Surgery, Parkland Memorial Hospital, Dallas, TX, Director of Oral and Maxillofacial Surgery, Texas Health Presbyterian- Dallas, Dallas, TX
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27
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Augmented Reality-Assisted Periosteum Pedicled Flap Harvesting for Head and Neck Reconstruction: An Anatomical and Clinical Viability Study of a Galeo-Pericranial Flap. J Clin Med 2020; 9:jcm9072211. [PMID: 32668591 PMCID: PMC7408700 DOI: 10.3390/jcm9072211] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022] Open
Abstract
Head and neck reconstructive surgeons have recently explored new perspectives in bone restoration using periosteum carrier flaps. Following this idea, we explored the possibility of harvesting a galeo-pericranial flap. The present work studies the vascular supply of the pericranial temporo-parietal region in order to assess the possibility of harvesting a galeo-pericranial flap based on the superficial temporalis vascularization. Anatomical dissections were performed at the Anatomical Institute of the University of Bologna on eight donor cadavers. Then we performed the harvesting of the flap in vivo on eight patients. We introduced augmented reality (AR) to facilitate anatomical visualisation during free flap harvesting. Augmented reality merges virtual and actual objects, allowing direct observation of patient anatomy and the surgical field. No post-operative major or minor complications occurred. We encountered no post-operative functional issues on the donor or recipient sites, and good clinical healing was observed in all patients. In conclusion, we believe that the galea-pericranium flap could represent a new donor site for the harvesting of a periosteum carrier flap.
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Kanatas AN, Lowe D, Rogers SN. Free flap donor site during early review consultations: is it really an issue? Br J Oral Maxillofac Surg 2020; 58:e115-e118. [PMID: 32620300 DOI: 10.1016/j.bjoms.2020.06.007] [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: 11/24/2019] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
Donor site complications, following microvascular free tissue transfer, can limit recovery in patients treated for head and neck cancer, with a curative intent. The Patient Concerns Inventory (PCI-HN) is a prompt list that provides patients with repeated opportunities to raise issues they feel are important and want to discuss. Here, we look at baseline results from a cluster preference randomised control trial with consultants either "using" or "not using" the PCI package in clinic to identify patient concerns. UWQOL results were presented from 67 consecutive patients having reconstruction with free tissue transfer and PCI results from 25 of these patients in the PCI arm of the trial. During early review consultations patients most wanted to discuss issues related to dental health, dry mouth, and chewing. Donor site morbidity, in our patient sample, did not appear to be an issue that patients wanted to discuss.
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Affiliation(s)
- A N Kanatas
- Leeds Teaching Hospitals and St James Institute of Oncology and Leeds Dental Institute.
| | - D Lowe
- Director Astraglobe Ltd, Congleton, Cheshire, UK.
| | - S N Rogers
- Evidence-Based Practice Research Centre (EPRC), Faculty of Health and Social Care, Edge Hill University, St Helens Road, Ormskirk, L39 4QP, UK; Consultant Regional Maxillofacial Unit, University Hospital Aintree, Liverpool, L9 1AE, UK.
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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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Mannelli G, Gazzini L, Comini LV, Parrinello G, Nocini R, Marchioni D, Molteni G. Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits. Oral Oncol 2020; 104:104637. [PMID: 32217459 DOI: 10.1016/j.oraloncology.2020.104637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/02/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Giuditta Mannelli
- Head and Neck Oncology and Robotic Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Luca Gazzini
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Lara Valentina Comini
- Otorhinolaryngology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Riccardo Nocini
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Daniele Marchioni
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Gabriele Molteni
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
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