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Khan U, Hathi K, MacKay C, Corsten M. The Complications of Osseous Reconstruction in the Head and Neck: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024. [PMID: 38881407 DOI: 10.1002/ohn.793] [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: 10/21/2023] [Revised: 02/11/2024] [Accepted: 04/06/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck. DATA SOURCES PUBMED, EMBASE, Cochrane. REVIEW METHODS A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A meta-analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications. RESULTS The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29-1.11, P < .001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (-51.04 minutes, CI: -92.73 to -9.35, P = .016) and OCRFFF over FFF (66.77 minutes, CI: 52.74-80.8, P < .001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types. CONCLUSION Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long-term complications.
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Affiliation(s)
- Usman Khan
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kalpesh Hathi
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colin MacKay
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Corsten
- Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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2
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Shilo S, Muhanna N, Fliss DM, Horowitz G, Warshavsky A, Mansour J, Ianculovici C, Fliss E, Barnea Y, Zaretski A, Yanko R. Early outcomes of osteofascial versus osteocutaneous fibula free flap mandibular reconstruction. Head Neck 2024; 46:1168-1177. [PMID: 38279002 DOI: 10.1002/hed.27661] [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: 07/20/2023] [Revised: 11/23/2023] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND This study compares early outcomes of osteofascial fibula free flap (OF-FFF) with donor-site primary closure and osteocutaneous (OC) FFF with donor-site skin grafting in segmental mandibular reconstruction. METHODS A retrospective chart review of FFF mandibular reconstruction patients (2006-2022) divided into OF-FFF and OC-FFF groups. Clinical data, operative parameters, and early postoperative outcomes (≤ 90 days) were analyzed. RESULTS The study included 67 patients (39 OF-FFF, 28 OC-FFF). OF-FFF had significantly lower donor-site complications (12.8% vs. 53.6%, p < 0.001) and revision surgeries (7.7% vs. 35.7%, p = 0.004) compared to OC-FFF. Recipient-site (28.2% vs. 25%, p = 0.77) and flap (15.4% vs. 17.9%, p > 0.99) complications were comparable. CONCLUSIONS OF-FFF mandibular reconstruction with donor-site primary closure is a safe and reliable technique associated with superior donor-site and comparable flap and recipient-site outcomes to OC-FFF, thus may be considered as a viable alternative to OC-FFF for selected patients.
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Affiliation(s)
- Shahaf Shilo
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dan M Fliss
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- The University of Nicosia Medical School, Nicosia, Cyprus
| | - Gilad Horowitz
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anton Warshavsky
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Jobran Mansour
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Clariel Ianculovici
- Department of Otolaryngology - Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Fliss
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yoav Barnea
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Arik Zaretski
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Ravit Yanko
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Department of Plastic and Reconstructive Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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3
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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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4
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Fakurnejad S, Gulati A, Stanford-Moore GB, Park AM, Heaton CM, Seth R, Knott PD. The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck. Facial Plast Surg Aesthet Med 2024; 26:148-151. [PMID: 37166789 DOI: 10.1089/fpsam.2022.0395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.
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Affiliation(s)
- Shayan Fakurnejad
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Arushi Gulati
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
- UC San Francisco School of Medicine, San Francisco, California, USA
| | - Gaelen B Stanford-Moore
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
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5
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Mourgues C, Balayssac D, Mulliez A, Planeix CM, Feydel G, Biard A, Alaux-Boïko V, Irthum C, Saroul N, Dang NP. 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. J Craniomaxillofac Surg 2024; 52:291-296. [PMID: 38212165 DOI: 10.1016/j.jcms.2023.12.014] [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: 06/01/2023] [Revised: 08/08/2023] [Accepted: 12/30/2023] [Indexed: 01/13/2024] Open
Abstract
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.
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Affiliation(s)
- Charline Mourgues
- CHU Clermont-Ferrand, Délégation à la recherche clinique et à l'innovation, F-63003, Clermont-Ferrand, France.
| | - David Balayssac
- CHU Clermont-Ferrand, Délégation à la recherche clinique et à l'innovation, F-63003, Clermont-Ferrand, France; Université Clermont Auvergne, INSERM U1107, NEURODOL, F-63003, Clermont-Ferrand, France
| | - Aurélien Mulliez
- CHU Clermont-Ferrand, Délégation à la recherche clinique et à l'innovation, F-63003, Clermont-Ferrand, France
| | - Claire-Marie Planeix
- CHU Clermont-Ferrand, Délégation à la recherche clinique et à l'innovation, F-63003, Clermont-Ferrand, France
| | - Gabrielle Feydel
- CHU Clermont-Ferrand, Délégation à la recherche clinique et à l'innovation, F-63003, Clermont-Ferrand, France
| | - Adrien Biard
- CHU Clermont-Ferrand, Service Pharmacie, F-63003, Clermont-Ferrand, France
| | - Véra Alaux-Boïko
- CHU Clermont-Ferrand, Service Pharmacie, F-63003, Clermont-Ferrand, France
| | - Charles Irthum
- CHU Clermont-Ferrand, Service de chirurgie maxillo-faciale et plastique, F-63003, Clermont-Ferrand, France
| | - Nicolas Saroul
- CHU Clermont-Ferrand, Service d'Oto-Rhino-Laryngologie et chirurgie cervico-faciale, F-63003, Clermont-Ferrand, France; Université Clermont Auvergne, CHU Clermont-Ferrand, INRAE, UNH, Équipe ASMS, 63000, Clermont-Ferrand, France
| | - Nathalie Pham Dang
- Université Clermont Auvergne, INSERM U1107, NEURODOL, F-63003, Clermont-Ferrand, France; CHU Clermont-Ferrand, Service de chirurgie maxillo-faciale et plastique, F-63003, Clermont-Ferrand, France
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6
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Oglesby KR, Jefferson GD, Thomas CM, Tomblin C, Alnemri A, Curry JM, Bonaventure C, Sweeny L, Richards HW, Wax M, Kane AC. Outcomes of Head and Neck Free Tissue Transfer in Renal Failure Patients. Laryngoscope 2024; 134:688-694. [PMID: 37449944 DOI: 10.1002/lary.30862] [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: 12/19/2022] [Revised: 03/10/2023] [Accepted: 06/11/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE To assess if there is increased risk of free flap failure in renal failure patients undergoing head and neck reconstruction. We seek to primarily assess free flap outcomes based on stages of chronic kidney disease (CKD) and secondarily determine increased risk for postoperative complications. METHODS Retrospective chart review was performed at five tertiary care centers. Patients were identified that had undergone microvascular free flap reconstruction of the head and neck with diagnosis of renal failure, classified as Stage 3 CKD or higher. Demographic data was collected. Outcomes in the postoperative period were examined. RESULTS Seventy-three patients met inclusion criteria. The average patient age was 69 years with a male predominance (n = 48). The majority of patients had CKD Stage 3 (n = 52). Overall flap failure rate was 12.33% (n = 9, CKD stage 3 = 7.69%, CKD stage 4 = 30%, CKD stage 5 = 18%). There was an increased risk of flap failure on multivariate analysis for CKD stage 4/5 patients when compared to CKD 3 patients (p = 0.0095). When compared to matched controls, there was an increased risk of flap failure in CKD patients (p = 0.01) as well as an increased risk of overall complications (p < 0.0001). CONCLUSIONS Patients with CKD undergoing head and neck reconstruction are at a higher risk of flap failure and overall complications. When comparing CKD stages there may be increased risk of flap failure in later stages of CKD compared to CKD 3. Appropriate patient counseling is recommended pre-operatively in this patient population with consideration for regional flaps in the appropriate patient. LEVEL OF EVIDENCE 3 Laryngoscope, 134:688-694, 2024.
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Affiliation(s)
- Kacie R Oglesby
- Department of Otolaryngology-Head & Neck Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A
| | - Gina D Jefferson
- Department of Otolaryngology-Head & Neck Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A
| | - Carissa M Thomas
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Caitlyn Tomblin
- UAB Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Angela Alnemri
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Joseph M Curry
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Caroline Bonaventure
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A
| | - Larissa Sweeny
- Department of Otolaryngology-Head & Neck Surgery, University of Miami, Miami, Florida, U.S.A
| | - Holden W Richards
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Mark Wax
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Anne C Kane
- Department of Otolaryngology-Head & Neck Surgery, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A
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7
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Stephan D, Blatt S, Riedel J, Mohnke K, Ruemmler R, Ziebart A, Al-Nawas B, Kämmerer PW, Thiem DGE. The Impact of Transfer-Related Ischemia on Free Flap Metabolism and Electrolyte Homeostasis-A New In Vivo Experimental Approach in Pigs. J Clin Med 2023; 12:6625. [PMID: 37892763 PMCID: PMC10607031 DOI: 10.3390/jcm12206625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 10/29/2023] Open
Abstract
Free flap tissue transfer represents the gold standard for extensive defect reconstruction, although malperfusion due to thrombosis remains the leading risk factor for flap failure. Recent studies indicate an increased immune response and platelet activation in connection with pathologic coagulation. The underlying cellular and molecular mechanisms remain poorly understood, however. The presented study, therefore, aims to investigate if transfer-related ischemia alters intra-flap metabolism and electrolyte concentrations compared to central venous blood after free flap transfer in pigs to establish a novel experimental model. Free transfer of a myocutaneous gracilis flap to the axillary region was conducted in five juvenile male pigs. The flap artery was anastomosed to the axillary artery, and intra-flap venous blood was drained and transfused using a rubber-elastic fixed intravenous catheter. Blood gas analysis was performed to assess the effect of transfer time-induced ischemia on intra-flap electrolyte levels, acid-base balance, and hemoglobin concentrations compared to central venous blood. Time to flap reperfusion was 52 ± 10 min on average, resulting in a continuous pH drop (acidosis) in the flaps' venous blood compared to the central venous system (p = 0.037). Potassium (p = 0.016), sodium (p = 0.003), and chloride (p = 0.007) concentrations were significantly increased, whereas bicarbonate (p = 0.016) and calcium (p = 0.008) significantly decreased within the flap. These observations demonstrate the induction of anaerobic glycolysis and electrolyte displacement resulting in acidosis and hence significant tissue damage already after a short ischemic period, thereby validating the novel animal model for investigating intra-flap metabolism and offering opportunities for exploring various (immuno-) thrombo-hemostatic issues in transplantation surgery.
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Affiliation(s)
- Daniel Stephan
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany; (S.B.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Sebastian Blatt
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany; (S.B.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Julian Riedel
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; (J.R.); (K.M.); (R.R.); (A.Z.)
| | - Katja Mohnke
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; (J.R.); (K.M.); (R.R.); (A.Z.)
| | - Robert Ruemmler
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; (J.R.); (K.M.); (R.R.); (A.Z.)
| | - Alexander Ziebart
- Department of Anaesthesiology, University Medical Centre, Johannes Gutenberg University Mainz, Langenbeckstraße 1, 55131 Mainz, Germany; (J.R.); (K.M.); (R.R.); (A.Z.)
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany; (S.B.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Peer W. Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany; (S.B.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Daniel G. E. Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre, Johannes Gutenberg University Mainz, Augustusplatz 2, 55131 Mainz, Germany; (S.B.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
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8
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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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9
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Bollig CA, Walia A, Pipkorn PJ, Jackson RS, Puram SV, Rich JT, Paniello RC, Zevallos JP, Stevens MN, Wood CB, Rohde SL, Sykes K, Kakarala K, Bur A, Wieser ME, Galloway TLI, Tassone P, Sadeghi J, Mattingly TR, Pluchino T, Jorgensen JB. A Multi-institutional Analysis of Late Complications in Scapula, Fibula, and Osteocutaneous Radial Forearm Free Flaps. Otolaryngol Head Neck Surg 2023; 168:681-687. [PMID: 35917171 DOI: 10.1177/01945998221116061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/11/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES (1) Evaluate the association of flap type with late complications in patients undergoing osseous head and neck reconstruction with the fibula free flap (FFF), osteocutaneous radial forearm free flap (OCRFFF), and scapula free flap (SFF). (2) Compare the prevalence of late complications based on minimum duration of follow-up. STUDY DESIGN Retrospective cohort study. SETTING Multiple academic medical centers. METHODS Patients undergoing FFF, OCRFFF, or SFF with ≥6-month follow-up were stratified by type of flap performed. The association of flap type with late complications was analyzed via univariable and multivariable logistic regression, controlling for relevant clinical risk factors. Additionally, the frequency of late complications by minimum duration of follow-up was assessed. RESULTS A total of 617 patients were analyzed: 312 (50.6%) FFF, 230 (37.3%) OCRFFFF, and 75 (12.2%) SFF. As compared with the SFF, the FFF (adjusted odds ratio [aOR], 3.05; 95% CI, 1.61-5.80) and OCRFFF (aOR, 2.17; 95% CI, 1.12-4.22) were independently associated with greater odds of overall late recipient site wound complications. The SFF was independently associated with the lowest odds of hardware exposure when compared with the FFF (aOR, 2.61; 95% CI, 1.27-5.41) and OCRFFF (aOR, 2.38; 95% CI, 1.11-5.12). The frequency of late complications rose as minimum duration of follow-up increased until plateauing at 36 months. CONCLUSIONS This multi-institutional study suggests that the long-term complication profile of the SFF and OCRFFF compares favorably to the FFF. The SFF may be associated with the fewest overall late recipient site complications and hardware exposure, while the FFF may be associated with the most of these 3 options.
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Affiliation(s)
- Craig A Bollig
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Amit Walia
- Washington University in St Louis, St Louis, Missouri, USA
| | | | - Ryan S Jackson
- Washington University in St Louis, St Louis, Missouri, USA
| | | | - Jason T Rich
- Washington University in St Louis, St Louis, Missouri, USA
| | | | | | | | - C Burton Wood
- Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Sarah L Rohde
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin Sykes
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kiran Kakarala
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andres Bur
- University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | - Patrick Tassone
- University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Jairan Sadeghi
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Stevens MN, Freeman MH, Shinn JR, Kloosterman N, Carr S, Mannion K, Rohde SL. Preoperative Predictors of Free Flap Failure. Otolaryngol Head Neck Surg 2023; 168:180-187. [PMID: 35412879 DOI: 10.1177/01945998221091908] [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: 11/02/2021] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN Retrospective cohort study of 1070 patients. SETTING Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.
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Affiliation(s)
- Madelyn N Stevens
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael H Freeman
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Justin R Shinn
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern, Austin, Texas, USA
| | | | - Shane Carr
- School of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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11
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Foerster Y, Baumann L, Kafantari I, Olmos M, Wehrhan F, Kesting MR, Preidl RH. Recipient bed perfusion as a predictor for postoperative complications in irradiated patients with microvascular free tissue transfer of the head and neck area: a clinical analysis of 191 microvascular free flaps. Oral Maxillofac Surg 2022:10.1007/s10006-022-01070-1. [PMID: 35551548 DOI: 10.1007/s10006-022-01070-1] [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: 03/07/2022] [Accepted: 05/01/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite microvascular free tissue transfer being the mainstay of care in the reconstruction of larger maxillofacial defects, a significant number of patients experience postoperative complications due to impaired blood supply of the flap. In this context, the early influence of recipient bed perfusion remains unclear, but there is evidence that it is associated with free flap viability immediately after surgery. METHODS We analyzed flap and recipient bed perfusion within the first 2 weeks after surgery by using the oxygen-to-see device. One hundred ninety-one patients who underwent free flap surgery in our department were included. RESULTS Flow parameters were higher and postoperative complications were less frequent in radial forearm free flaps compared to any other type of flap. Flow parameters of the recipient bed were higher than transferred tissue at all times, implicating flap autonomization is not completed within 2 weeks. Previous radiotherapy significantly decreased flow parameters of the recipient bed but not of the flaps. Furthermore, irradiated patients with postoperative complications were found to have reduced flow parameters of their recipient bed compared to non-irradiated patients with postoperative complications. CONCLUSION We conclude that monitoring of recipient bed perfusion is useful for detecting flap compromise of irradiated patients in the early postoperative period.
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Affiliation(s)
- Yannick Foerster
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany.
| | - Laura Baumann
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
| | - Ino Kafantari
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
| | - Manuel Olmos
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
| | - Falk Wehrhan
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
| | - Marco R Kesting
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
| | - Raimund Hm Preidl
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, University of Erlangen-Nuremberg, Glückstraße 11, 91054, Erlangen, Germany
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12
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Le JM, Morlandt AB, Gigliotti J, Park EP, Greene BJ, Ying YP. Complications in oncologic mandible reconstruction: A comparative study between the osteocutaneous radial forearm and fibula free flap. Microsurgery 2021; 42:150-159. [PMID: 34792210 DOI: 10.1002/micr.30841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/31/2021] [Accepted: 10/28/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND The osteocutaneous radial forearm free flap (OC-RFFF) has been proposed as a safe and reliable free flap for head and neck reconstruction with low donor site morbidity. The purpose of this study is to compare the late complications (>30 days) associated with using the OC-RFFF versus the free fibula flap (FFF) for mandibular reconstruction following oncologic segmental resection. METHODS We conducted a single-institution, retrospective study composed of patients who underwent oncologic microvascular composite mandibular reconstruction with either the OC-RFFF or FFF. The primary predictor variable was the type of free flap used. The outcome variable was late complication postoperatively (>30 days). RESULTS A total of 93 patients (28, OC-RFFF and 65, FFF) were analyzed. The majority of patients were male (62%) and with AJCC stage T4a disease (72%). Mean hospital length of stay was comparable between the two flap groups (p = .50). OC-RFFF was associated with more late complications (p = .03) compared to FFF. Nonunion occurred in 10.7% of OC-RFFF and 0% of FFF. Partial or complete flap failure was seen in 7.1% and 0% in the OC-RFFF and FFF, respectively. Two-year disease-free survival was comparable in both groups (p > .05). CONCLUSIONS The results of this study suggest that the rate of nonunion and odds of having a late complication were significantly greater in the OC-RFFF compared to the FFF following oncologic mandibular reconstruction. However, flap success, early complications (<30 days), and length of hospital stay were comparable between the two flaps.
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Affiliation(s)
- John M Le
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Anthony B Morlandt
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jordan Gigliotti
- Department of Oral and Maxillofacial Surgery, McGill University, Montreal, Quebec, Canada
| | - Earl P Park
- Department of Oral and Maxillofacial Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Benjamin J Greene
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yedeh P Ying
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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13
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Camargo CP, Kubrusly MS, Morais-Besteiro J, Harmsen MC, Gemperli R. The influence of adipocyte-derived stem cells (ASCs) on the ischemic epigastric flap survival in diabetic rats. Acta Cir Bras 2021; 36:e360907. [PMID: 34755767 PMCID: PMC8580509 DOI: 10.1590/acb360907] [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: 05/23/2021] [Accepted: 08/21/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose: To assess the effects of adipocyte-derived stem cell (ASC)-injection on the
survival of surgical flaps under ischemia in diabetic rats. Methods: Diabetes was induced in 30 male Wistar rats using streptozotocin (55 mg/kg).
After eight weeks, epigastric flap (EF) surgery was performed. The animals
were divided into control (CG), medium-solution (MG), and ASC groups. The
outcomes were: the survival area (SA), the survival/total area rate (S/TR),
and expression levels (EL) of genes: C5ar1, Icam1, Nos2, Vegf-a. Results: In the ASC group, compared to CG, we observed improved flap SA (CG-420
mm2vs. ASC-720 mm2; p=0.003) was observed. The S/TR
analysis was larger in the ASC group (78%) than the CG (45%). This study
showed an increase in the Vegf-a EL in the ASC group (2.3)
vs. CG (0.93, p=0.0008). The Nos2 EL increased
four-fold in the ASC group compared to CG, and C5ar1 EL decreased almost
two-fold in the ASC group vs. the CG (p=0.02). There was no
difference among the groups regarding Icam1 EL. Compared to the MG, the ASC
group had a bigger flap SA (720 mm2vs. 301 mm2, respectively), a bigger S/TR (78%
vs. 32%, p=0.06, respectively) and increased EL of
Vegf-a (2.3 vs. 1.3, respectively). No difference between
ASC-group and MG was seen regarding Nos2 (p=0.08) and C5ar1 (p=0.05). Conclusions: This study suggests that ASCs increase the survival of EF under IR in
diabetic rats.
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14
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New Approach to the Old Challenge of Free Flap Monitoring-Hyperspectral Imaging Outperforms Clinical Assessment by Earlier Detection of Perfusion Failure. J Pers Med 2021; 11:jpm11111101. [PMID: 34834453 PMCID: PMC8625540 DOI: 10.3390/jpm11111101] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 01/18/2023] Open
Abstract
In reconstructive surgery, free flap failure, especially in complex osteocutaneous reconstructions, represents a significant clinical burden. Therefore, the aim of the presented study was to assess hyperspectral imaging (HSI) for monitoring of free flaps compared to clinical monitoring. In a prospective, non-randomized clinical study, patients with free flap reconstruction of the oro-maxillofacial-complex were included. Monitoring was assessed clinically and by using hyperspectral imaging (TIVITA™ Tissue-System, DiaspectiveVision GmbH, Pepelow, Germany) to determine tissue-oxygen-saturation [StO2], near-infrared-perfusion-index [NPI], distribution of haemoglobin [THI] and water [TWI], and variance to an adjacent reference area (Δreference). A total of 54 primary and 11 secondary reconstructions were performed including fasciocutaneous and osteocutaneous flaps. Re-exploration was performed in 19 cases. A total of seven complete flap failures occurred, resulting in a 63% salvage rate. Mean time from flap inset to decision making for re-exploration based on clinical assessment was 23.1 ± 21.9 vs. 18.2 ± 19.4 h by the appearance of hyperspectral criteria indicating impaired perfusion (StO2 ≤ 32% OR StO2Δreference > −38% OR NPI ≤ 32.9 OR NPIΔreference ≥ −13.4%) resulting in a difference of 4.8 ± 5 h (p < 0.001). HSI seems able to detect perfusion compromise significantly earlier than clinical monitoring. These findings provide an interpretation aid for clinicians to simplify postoperative flap monitoring.
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15
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Hohman MH, Vincent AG, Enzi AR, Ducic Y. Safe Free Tissue Transfer in Patients Older than 90 Years. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2021. [DOI: 10.1055/s-0041-1736419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Abstract
Objective This study aimed to evaluate the safety of microvascular free tissue transfer in the elderly patient population.
Methods We performed a 20-year retrospective review at a tertiary care private practice of patients of ≥ 90 years of age who underwent microvascular free tissue transfer and had at least 6 months of follow-up. Similarly, we reviewed patients aged 70 to 89 years who underwent free tissue transfer between 2018 and 2020 as a control group. Records were examined for type of flap, defect site, pathology, and occurrence of complications.
Results Overall 77 patients of 90 years or older met the inclusion criteria and 77 sequential patients aged 70 to 89 years were identified to serve as a control group. The overall complication rate among patients of ≥ 90 years of age was 18%, with flap-related complications in 4% (two partial flap loss and one total loss). The mortality rate was 1.3%. All patients of ≥ 90 years of age undergoing osteocutaneous reconstruction for osteoradionecrosis experienced complications, but only one was a flap complication (partial loss). Among patients aged 70 to 89 years, the overall complication rate was also 18%, with flap-related complications in 4% (two complete flap failures and one partial loss). The mortality rate in the control group was 2.6%.
Conclusion Soft tissue free flaps are a safe option in the elderly patient population and should be offered to patients who are medically optimized prior to surgery, regardless of age. Osteocutaneous reconstruction for osteoradionecrosis must be undertaken with caution. This study reflects level of evidence 4.
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Affiliation(s)
- Marc H. Hohman
- Department of Facial Plastic and Reconstructive Surgery, Madigan Army Medical Center, Tacoma, Washington
| | | | - Abdul R. Enzi
- Facial Plastic Surgery Associates, Fort Worth, Texas
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16
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Stramiello J, Nuyen B, Saraswathula A, Blumenfeld L, Divi V, Rosenthal E, Orosco R, Starmer HM. Timing of postoperative oral feeding after head and neck mucosal free flap reconstruction. Laryngoscope Investig Otolaryngol 2021; 6:1031-1036. [PMID: 34667846 PMCID: PMC8513441 DOI: 10.1002/lio2.655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/09/2021] [Accepted: 08/30/2021] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Fistula remains a common complication of upper aerodigestive tract reconstruction. Optimal timing of oral feeding is unknown and the impact of early feeding on swallow function and fistula rates remains controversial. The purpose of this study is to better understand the effects of "early feeding" on fistula rate and swallow in patients with free flap reconstruction of upper aerodigestive tract defects. METHODS Retrospective cohort study. One hundred and four patients undergoing free flap reconstruction of mucosalized head and neck defects. Two groups, early feeding (oral intake on or before postoperative day 5) and late-feeding (oral intake after postoperative day 5). Primary outcome was incidence of salivary fistula. Secondary outcomes included Functional Oral Intake Scale scores. RESULTS Fistula rate was 16.5% in late-feeding group and 0% in early-feeding group (P = .035). Patients who were fed early had an association with progression to a full oral diet by 30 days (P = .027). DISCUSSION This cohort analysis suggests that in properly selected patients with free flap reconstruction for mucosal defects, early feeding may not increase risk of salivary fistula and may improve swallow functional outcomes earlier. Level of Evidence: 3.
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Affiliation(s)
- Joshua Stramiello
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Brian Nuyen
- Department of Otolaryngology‐Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Anirudh Saraswathula
- Department of Otolaryngology‐Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Liza Blumenfeld
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Vasu Divi
- Department of Otolaryngology‐Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Eben Rosenthal
- Department of Otolaryngology‐Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
| | - Ryan Orosco
- Division of Otolaryngology‐Head and Neck Surgery, Department of SurgeryUniversity of California San Diego School of MedicineSan DiegoCaliforniaUSA
| | - Heather M. Starmer
- Department of Otolaryngology‐Head and Neck SurgeryStanford University School of MedicineStanfordCaliforniaUSA
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17
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Waligora B, Neilson JC, Brookes C. Induced Membranes for Segmental Mandibular Reconstruction: Case Series and Technique Review. J Oral Maxillofac Surg 2021; 79:1751-1759. [PMID: 33757744 DOI: 10.1016/j.joms.2021.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 02/18/2021] [Accepted: 02/18/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE This article describes the induced membrane technique (IMT) and presents 10 cases in which the technique was applied for segmental mandibular reconstruction. METHODS Ten patients requiring segmental mandibular resection were reconstructed using the staged IMT. Mandibular resection, placement of a reconstruction plate and polymethylmethacrylate spacer, was performed. At the second procedure, the spacer was removed through a small incision and particulate autograft from the ilium was placed, in some cases with bone morphogenic protein. RESULTS Nine of the 10 patients achieved bony continuity with the IMT. Spacers were designed to optimize mandibular form and future implant-based restoration. All patients have either had implants placed or have adequate bone for implant placement. The average hospital length of stay for both surgeries combined was 3.1 nights. CONCLUSIONS The IMT can be successfully used to reconstruct segmental mandibular defects, allowing surgeons to create a neomandible with optimal form both for facial contour and for dental implant-based reconstruction.
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Affiliation(s)
- Bret Waligora
- Former Resident, Oral and Maxillofacial Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - John C Neilson
- Assistant Professor, Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Carolyn Brookes
- Private Practitioner, Adjunct Assistant Professor, Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI.
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Handheld Near-Infrared Fluorescence Imaging Device Using Modified Action Cameras for Peri-Operative Guidance of Microvascular Flap Surgery. J Clin Med 2021; 10:jcm10030410. [PMID: 33494469 PMCID: PMC7865367 DOI: 10.3390/jcm10030410] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 11/17/2022] Open
Abstract
Indocyanine green near-infrared fluorescence (ICG-NIRF) imaging has recently come into use as a novel method in peri-operative microvascular flap assessment. However, a majority of the many commercial devices launched for clinical use lack mobility, portability, and cost-efficiency and are thus unsuitable for intra-oral applications. This study introduces a cost-effective, customized, handheld NIRF device following principles of ICG-NIRF imaging. Moreover, the novel characteristics of our prototype, considered in conjunction with a literature review highlighting the significance of fluorescence devices in microvascular surgery, point to a new generation of devices for use in microvascular flap surgery.
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Chavre S, Thankappan K, Mathew J, Sharma M, Iyer S. Shape-modified radial forearm free tissue transfer in oral cavity reconstruction: Technique and a prospective comparison with the conventional technique. Head Neck 2020; 42:3345-3351. [PMID: 33196121 DOI: 10.1002/hed.26382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 06/09/2020] [Accepted: 06/26/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Donor site morbidity is a significant drawback of the radial forearm flap. The purpose of this study is to describe a new shape-modified technique. The donor site morbidity was compared to that of the conventional technique, in terms of the esthetic, functional outcomes, and quality of life (QOL). METHODS This is a prospective study of 30 patients with oral cancer who underwent reconstruction using radial forearm flaps, in two groups. RESULTS Regarding the donor site characteristics, the differences in the time for healing (P = .006), the scar score (P < .0001), and the QOL score (P < .0001) were significant. The number of patients with sensory deficit was 11 in the conventional group and 3 in the shape-modified group (P = .009). CONCLUSIONS The functional and esthetic outcomes of the donor site were better for the shape-modified technique. It is best suited for small defects. Compromise of the pedicle length is a limitation.
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Affiliation(s)
- Sachin Chavre
- Department of Head and Neck, Plastic and reconstructive surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Krishnakumar Thankappan
- Department of Head and Neck, Plastic and reconstructive surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Jimmy Mathew
- Department of Head and Neck, Plastic and reconstructive surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Mohit Sharma
- Department of Head and Neck, Plastic and reconstructive surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Subramania Iyer
- Department of Head and Neck, Plastic and reconstructive surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Microvascular anastomotic coupler devices versus hand-sewn technique for arterial anastomosis: a systematic review. Br J Oral Maxillofac Surg 2020; 59:524-533. [PMID: 33685774 DOI: 10.1016/j.bjoms.2020.10.286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/07/2020] [Indexed: 11/22/2022]
Abstract
The use of microvascular anastomotic coupling devices (MACD) is an established technique for venous anastomosis. However, literature on arterial MACD is conflicting. We report, to our knowledge, the first registered systematic review of its kind to evaluate the safety and efficiency of arterial MACD in free flaps. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. The rate of arterial thrombosis was set as the primary outcome. Secondary outcomes included flap survival, failure rates, and comparison of MACD and the conventional hand-sewn technique. From the 17 studies identified, 2672 free flap reconstructions were performed and 640 arterial anastomoses with MACD attempted (622 completed, 97.2%). The pooled incidence of arterial thrombosis was 2.1% (13/622), and overall flap failure rate 4.34% (116/2672). The total number of arterial MACD procedures performed first time, with no perioperative complications, revisions, or thrombosis, was 88.9% (569/640). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality analysis revealed low quality and significant heterogeneity. The use of arterial MACD is a safe and efficient alternative to hand-sewn anastomosis, with more recent literature showing excellent results. However, further evaluation is required with controlled trials.
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Stewart M, Hammond P, Khatiwala I, Swendseid B, Taghizadeh F, Petrisor D, Zhan T, Goldman R, Luginbuhl A, Heffelfinger R, Sweeny L, Wax MK, Curry JM. Outcomes of Venous End-to-Side Microvascular Anastomoses of the Head and Neck. Laryngoscope 2020; 131:1286-1290. [PMID: 33073859 PMCID: PMC8247029 DOI: 10.1002/lary.29134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/17/2020] [Accepted: 09/08/2020] [Indexed: 12/04/2022]
Abstract
Objectives/Hypothesis The literature on outcomes of end‐to‐side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes. Study Design Retrospective review of 2482 consecutive patients across three tertiary institutions. Methods Adult patients (> 18) who received a FTT from 2006 to 2019 were included. Results Two hundred and twenty‐one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end‐to‐end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042). Conclusions ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure. Level of Evidence 3 Laryngoscope, 131:1286–1290, 2021
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Affiliation(s)
- Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Perry Hammond
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ishani Khatiwala
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Brian Swendseid
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Farshid Taghizadeh
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Daniel Petrisor
- Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Richard Goldman
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Larissa Sweeny
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University, Baton Rouge, Louisiana, U.S.A
| | - Mark K Wax
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Joseph M Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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Stewart M, Swendseid B, Hammond P, Khatiwala I, Sarwary J, Zhan T, Heffelfinger R, Luginbuhl A, Sweeny L, Wax MK, Curry JM. Anastomotic Revision in Head and Neck Free Flaps. Laryngoscope 2020; 131:1035-1041. [PMID: 33280116 DOI: 10.1002/lary.29094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 08/16/2020] [Accepted: 08/25/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES/HYPOTHESIS Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes. STUDY DESIGN Retrospective review of 2482 consecutive patients across three tertiary institutions. METHODS Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised. RESULTS Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively). CONCLUSION Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1035-1041, 2021.
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Affiliation(s)
- Matthew Stewart
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Brian Swendseid
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Perry Hammond
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ishani Khatiwala
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Juliana Sarwary
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University, Baton Rouge, Louisiana, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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Roof SA, Perez ER, Villavisanis DF, Khan MN, Ferrandino RM, Chouake RJ, Pacheco CW, Yao M, Teng MS, Genden EM, Miles BA. 2-Octyl cyanoacrylate to prevent salivary fistula formation following oral cavity microvascular reconstruction: A prospective trial. Am J Otolaryngol 2020; 41:102552. [PMID: 32505990 DOI: 10.1016/j.amjoto.2020.102552] [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: 04/27/2020] [Accepted: 05/24/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Salivary fistulas remain a significant problem in patients undergoing major head and neck reconstructive surgery. Surgical sealants have become increasingly used in cutaneous and non-cutaneous wound closure, providing a barrier to fluids/gases and promoting healing. The purpose of this study was to determine the efficacy of a common surgical sealant, 2-Octyl Cyanoacrylate (2-OCA, Dermabond®), in the prevention of salivary fistulas following free flap reconstruction of the oral cavity. METHODS In this non-randomized, single arm prospective trial, patients undergoing free flap reconstruction of gravity-dependent oral cavity defects were recruited. Application of 2-OCA was performed along flap inset suture lines at the time of surgery. Prospectively collected trial data were propensity score matched to a control cohort to compare outcomes. Data collected include demographics, medical co-morbidities, previous treatments, primary tumor site, and subsites reconstructed. The primary outcome measure was rate of salivary fistula formation. Secondary outcomes were time to development of leak and percentage of patients tolerating oral feeding at one month post-operatively. RESULTS In the 46 propensity score matched pairs, eight (17.4%) out of 46 patients in the 2-OCA prospective cohort and seven (15.2%) out of 46 patients in the control cohort developed postoperative salivary fistulas within the one-month study interval (p = 1.00). The average time to postoperative leak in the 2-OCA group was 12.5 days versus 7.1 days in the control cohort (p = 0.10). In the 2-OCA group, 30 (65.2%) patients were tolerating regular diet at one month post-operatively compared to 33 (71.7%) in the control cohort (p = 0.65). CONCLUSION Salivary fistula rates after application of a 2-OCA surgical sealant were not improved compared to a control cohort in this single institutional trial. There are several surgical sealants available, each with varying elasticity and adhesiveness. Future studies are needed to identify surgical sealants that are able to provide sufficient strength and adhesion to seal closures and combat corrosive saliva, but elastic enough to handle motion related tension during swallowing and post-operative movements in the head and neck.
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Affiliation(s)
- Scott A Roof
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA.
| | - Enrique R Perez
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | | | - Mohemmed N Khan
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Rocco M Ferrandino
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Robert J Chouake
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Caitlin W Pacheco
- Department of Otolaryngology Head and Neck Surgery, Kaiser Permanente Oakland, Oakland, CA, USA
| | - Mike Yao
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Marita S Teng
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Eric M Genden
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
| | - Brett A Miles
- Department of Otolaryngology Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA
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Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A, Heffelfinger R, Krein H, Petrisor D, Bender-Heine A, Wax MK. Factors impacting successful salvage of the failing free flap. Head Neck 2020; 42:3568-3579. [PMID: 32844522 DOI: 10.1002/hed.26427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/25/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Science Center - New Orleans, New Orleans, Louisiana, USA
| | - Joseph Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Meghan Crawley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Taylor Cave
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Petrisor
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Adam Bender-Heine
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Mark K Wax
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Carta F, Quartu D, Mariani C, Tatti M, Marrosu V, Gioia E, Gerosa C, Zanda JSA, Chuchueva N, Figus A, Puxeddu R. Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System. Front Oncol 2020; 10:984. [PMID: 32760667 PMCID: PMC7372302 DOI: 10.3389/fonc.2020.00984] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/19/2020] [Indexed: 11/13/2022] Open
Abstract
Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.
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Affiliation(s)
- Filippo Carta
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Daniela Quartu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Cinzia Mariani
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Melania Tatti
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Valeria Marrosu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Edoardo Gioia
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Clara Gerosa
- Unit of Pathology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Jacopo S A Zanda
- Unit of Pathology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Natalia Chuchueva
- ENT Department, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Andrea Figus
- Unit of Plastic Surgery, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
| | - Roberto Puxeddu
- Unit of Otorhinolaryngology, Department of Surgery, Azienda Ospedaliero-Universitaria di Cagliari, University of Cagliari, Cagliari, Italy
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Delayed Reconstruction of Palatomaxillary Defect Using Fibula Free Flap. J Clin Med 2020; 9:jcm9030884. [PMID: 32213855 PMCID: PMC7141519 DOI: 10.3390/jcm9030884] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction. The objective of this study was to evaluate a surgical technique and to present the results of delayed reconstruction of palatomaxillary defects using fibula free flap (FFF). Methods. A review was conducted for nine patients who underwent palatomaxillary reconstruction using FFF. Primary disease, type of reconstruction, defect area, fibula segment length and number of osteotomies, radiotherapy, and implant installation after FFF reconstruction were analyzed. Results. All nine patients underwent delayed reconstruction. The fibula shaft was osteotomized into two segments in seven patients and three segments in one patient with bilateral Brown’s revised classification IV/d defect. One case was planned by using a computer-aided design computer-aided manufacturing (CAD/CAM) system with a navigation system. The mean length of the grafted fibula bone was 68.06 mm. Dental implant treatment was performed in six patients. Six patients received radiation therapy, and there were no specific complications related to the radiation therapy. In one case, the defect was reconstructed with FFF flow-through from a radial forearm free flap. Conclusion. This clinical study demonstrated that the fibula flap is an ideal donor-free flap in a palatomaxillary defect. Delayed reconstruction using an FFF can reduce the complication and failure rates.
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Swendseid B, Kumar A, Sweeny L, Wax MK, Zhan T, Goldman RA, Krein H, Heffelfinger RN, Luginbuhl AJ, Curry JM. Long-Term Complications of Osteocutaneous Free Flaps in Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2020; 162:641-648. [PMID: 32204662 DOI: 10.1177/0194599820912727] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the frequency at which patients with osteocutaneous free flap reconstruction of the head and neck develop long-term complications and identify predisposing perioperative factors. STUDY DESIGN A prospectively maintained database of free flaps performed at a single institution over a 10-year period was queried. SETTING Single tertiary care referral center. SUBJECTS AND METHODS In total, 250 osseous or osteocutaneous free flaps (OCFFs) for mandibular or maxillary reconstruction were analyzed. Data were collected on demographics, preoperative therapy, resection location, adjuvant treatment, complications, and subsequent surgeries, and multivariate analysis was performed. Subgroup analysis based on perioperative factors was performed. RESULTS The median follow-up time was 23 months. In 185 patients with at least 6 months of follow-up, 17.3% had at least 1 long-term complication, most commonly wound breakdown, fistula or plate extrusion (13.5%), osteoradionecrosis or nonunion (6.5%), and infected hardware (5.9%). Prior chemoradiotherapy and cancer diagnosis predisposed patients to long-term complications. At the 5-year follow-up, 21.7% of patients had experienced a long-term complication. CONCLUSIONS Long-term complications after OCFF occurred in 17% of patients. In this series, a preoperative history of chemoradiation and those undergoing maxillary reconstruction were at high risk for the development of long-term complications and thus warrant diligent follow-up. However, OCFFs can often enjoy long-term viability and survival, even in the case of perioperative complications and salvage surgery.
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Affiliation(s)
- Brian Swendseid
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ayan Kumar
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Larissa Sweeny
- Department of Otolaryngology-Head & Neck Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana, USA
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Tingting Zhan
- Department of Pharmacology, Division of Biostatistics, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Richard A Goldman
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Ryan N Heffelfinger
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Adam J Luginbuhl
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
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Hanick A, Meleca JB, Fritz MA. Early discharge after free-tissue transfer does not increase adverse events. Am J Otolaryngol 2020; 41:102374. [PMID: 31883753 DOI: 10.1016/j.amjoto.2019.102374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/08/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Demonstrate that carefully selected free flap patients may be discharged early after surgery without increasing the rates of postoperative complications or readmissions. METHODS Based on a published article in Laryngoscope 2016 of 51 free-tissue transfers, a retrospective chart review was performed on an expanded cohort who underwent free-tissue transfer for head and neck reconstruction between February 2010 and May 2018 and discharged by postoperative day 3. RESULTS 101 patients who underwent 104 free flaps with average age of 56 (3-84) years old were reviewed. Free flap indications included orbital and maxillary defects (n = 22), palatal defects (n = 16), nasal and septal defects (n = 16), cranioplasty and scalp defects (n = 16), mandibular defects due to osteoradionecrosis (n = 14), facial contouring and parotid defects (n = 12), and complex postsurgical and radiotherapy wounds or fistula closure (n = 8). Free flaps performed were anterolateral thigh (n = 97), radial forearm (n = 2), serratus (n = 2), latissimus (n = 1), fibula (n = 1) and supraclavicular (n = 1). The recipient vessels used via minimal access approaches were facial (n = 43), superficial temporal (n = 29), angular (n = 20) and others. There were 3 flap failures (2.9%) recognized in follow-up. No flap failures or perioperative complications were associated with early discharge. There were only 2 patients readmitted and 1 watched in observation within 30 days postoperatively. CONCLUSION An updated review of our institutional experience with more than double the cohort size substantiates previous conclusions that early discharge after free-tissue transfer is a safe option in select patients. Moreover, earlier discharge is a critical management choice that reduces cost and decreases hospital-related adverse events.
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Affiliation(s)
- Andrea Hanick
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
| | - Joseph B Meleca
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA.
| | - Michael A Fritz
- Cleveland Clinic, Head and Neck Institute, Cleveland, OH, USA
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Chen Z, Yu M, Huang S, Zhang S, Li W, Zhang D. Preliminary report of the use of a microvascular coupling device for arterial anastomoses in oral and maxillofacial reconstruction. Br J Oral Maxillofac Surg 2019; 58:194-198. [PMID: 31859103 DOI: 10.1016/j.bjoms.2019.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/11/2019] [Indexed: 10/25/2022]
Abstract
Our aim was to record our preliminary use of a microvascular coupler for arterial anastomoses with free flap transfer in the reconstruction of oral and maxillofacial defects in 45 patients with defects that were repaired with anterolateral thigh, fibular, and radial forearm flaps. The microvascular coupler was used for both the venous and the arterial anastomoses. The site of the defect, type of flap, recipient artery, duration of operating time for the anastomosis, size of coupler, and survival of the flap were recorded and analysed. A total of 45 consecutive patients had microsurgical reconstructions in the head and neck, including 16 radial forearm, 18 fibular, and 11 anterolateral thigh free flaps. The sizes of coupler required ranged from 1.5-2.5 mm, with most flaps (n = 30) requiring a 2.0 mm coupler. The mean (SD) operating time for arterial anastomoses was 7 (2) mins. One arterial crisis occurred during an operation, and required a sutured anastomosis instead. There were no complications related to the technical performance of the coupler. The coupler is reliable for arterial anastomoses of free tissue transfers in reconstructions of the head and neck. With proper selection of vessels and enough experience in using the microvascular coupler, it may be used in an expeditious, safe, and reliable fashion with minimal morbidity. Though not common, the use of the coupler for arterial anastomoses saves a lot of time, and is a viable alternative to a sutured anastomosis.
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Affiliation(s)
- Z Chen
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China
| | - M Yu
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China
| | - S Huang
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China
| | - S Zhang
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China
| | - W Li
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China
| | - D Zhang
- Department of Oral and Maxillofacial Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, China.
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Fernandez D. Cryopreserved amniotic membrane and umbilical cord for a radiation-induced wound with exposed dura: a case report. J Wound Care 2019; 28:S4-S8. [PMID: 30767634 DOI: 10.12968/jowc.2019.28.sup2.s4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
An 87-year old male received surgical excision of scalp melanoma and subsequent radiotherapy due to metastasis to the skull. A radiation-induced wound developed with osteoradionecrosis that required necrotic bone excision resulting in a 7.5x8.5cm wound over the exposed dura, which remained non-healing despite many attempts by local wound care management. Due to the refractory nature of the wound, strips of cryopreserved umbilical cord (cUC) allograft were applied over the exposed dura resulting in significant vascular granulation tissue formation in the central wound bed within four weeks. Re-epithelialisation around the wound perimeter was further promoted by injection of particulate amniotic membrane umbilical cord matrix (AMUC) at the 16th week, and completed by another application of cUC strips and injection of AMUC proximal to the necrotic bone at the 21st week. Vascularisation of the necrotic bone was further promoted by application of cUC and AMUC injection directly into the bony margins at 29 weeks and 34 weeks, respectively, followed by application with an AMUC-hydrogel paste, applied four times over an eight week interval. By 96 weeks, healthy re-epithelialised tissue had formed under the necrotic bony margins. This report highlights the unique regenerative capabilities of cUC and AMUC in promoting wound healing over exposed dura in a long-standing full-thickness, radiation-induced scalp and skull wound.
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Brady JS, Desai SV, Crippen MM, Eloy JA, Gubenko Y, Baredes S, Park RCW. Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck. JAMA FACIAL PLAST SU 2019; 20:188-195. [PMID: 28983575 DOI: 10.1001/jamafacial.2017.1607] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking. Objective To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck. Design, Setting, and Participants The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016. Exposures Microvascular reconstructive surgery of the head and neck. Main Outcomes and Measures Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality. Results A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16). Conclusions and Relevance Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery. Level of Evidence 3.
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Affiliation(s)
- Jacob S Brady
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Stuti V Desai
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Meghan M Crippen
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Department of Ophthalmology, Rutgers New Jersey Medical School, Newark
| | - Yuriy Gubenko
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - Richard Chan Woo Park
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
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Trojanowski P, Szymański M, Trojanowska A, Andrzejczak A, Szczepanek D, Klatka J. Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection. Eur Arch Otorhinolaryngol 2019; 276:3487-3494. [PMID: 31515663 PMCID: PMC6858904 DOI: 10.1007/s00405-019-05627-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/30/2019] [Indexed: 01/13/2023]
Abstract
Purpose Evaluation of the utility of the free anterolateral thigh flap reconstruction of the defects resulting from radical temporal bone resection in the management of lateral skull base malignancies in a single institution. Methods An analysis of 17 en bloc subtotal petrosectomies for removal of malignant tumours was performed. There were 12 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenoid cystic carcinoma. The tumours were staged with the University of Pittsburgh TNM system. In all patients, the lateral temporal bone with the preservation of the petrous apex and carotid artery was performed. All patients had parotid gland resection. The post-resection defect was reconstructed with an ALT free flap. Results Tumour radical resection and defect reconstruction with an ALT flap was achieved in all patients without intraoperative complications. The transplants were harvested as fasciocutaneous flaps, 11 perfused by musculocutaneous and 6 by septocutaneous perforators. The ALT flaps had a mean pedicle length of 8 cm (6–12 cm), and the flap size ranged between 6 × 15 cm and 15 × 30 cm. The flaps were supplied by nine facial, five occipital and three maxillary arteries. Recipient-site veins included eight internal jugular, seven facial, one retromandibular and one external jugular vein. All arterial pedicles were anastomosed in an end-to-end manner. The veins were anastomosed with interrupted sutures and in 11 cases with Synovis-Coupler® devices. All the flap transfers were performed successfully. Three patients experienced postoperative complications. Conclusions The ALT flap proved to be effective for covering large temporal skull base defects resulting from the radical removal of temporal bone malignancies. The functional and cosmetic results were acceptable with a low complication rate.
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Affiliation(s)
- Piotr Trojanowski
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland.
| | - Marcin Szymański
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
| | | | - Adrian Andrzejczak
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
| | - Dariusz Szczepanek
- Department of Neurosurgery and Paediatric Neurosurgery, Medical University of Lublin, Lublin, Poland
| | - Janusz Klatka
- Department of Otolaryngology and Laryngological Oncology, Medical University of Lublin, Jaczewskiego 8, 20 954, Lublin, Poland
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Jehn P, Zimmerer R, Dittmann J, Winterboer J, Gellrich NC, Tavassol F, Spalthoff S. Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery. Int J Oral Maxillofac Surg 2019; 48:1163-1168. [DOI: 10.1016/j.ijom.2019.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/02/2019] [Accepted: 02/13/2019] [Indexed: 11/25/2022]
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Sweeny L, Topf M, Wax MK, Rosenthal EL, Greene BJ, Heffelfinger R, Krein H, Luginbuhl A, Petrisor D, Troob SH, Hughley B, Hong S, Zhan T, Curry J. Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction. Laryngoscope 2019; 130:347-353. [PMID: 31287566 DOI: 10.1002/lary.28177] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/06/2019] [Accepted: 06/19/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction. STUDY DESIGN Retrospective multi-institutional review of prospectively collected databases at tertiary care centers. METHODS Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history. RESULTS Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002). CONCLUSION This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures. LEVEL OF EVIDENCE 4 Laryngoscope, 130:347-353, 2020.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana
| | - Michael Topf
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Eben L Rosenthal
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Benjamin J Greene
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Petrisor
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Scott H Troob
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon
| | - Brian Hughley
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Steve Hong
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, California
| | - Tingting Zhan
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Yan D, Zhang J, Min X. Modified Infrahyoid Myocutaneous Flap for Laryngopharyngeal Reconstruction. EAR, NOSE & THROAT JOURNAL 2019; 99:15-21. [PMID: 31079475 DOI: 10.1177/0145561319849947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The laryngopharyngeal reconstruction in patients with pyriform sinus carcinoma continues to be a challenge for surgeons. In this article, we describe our experience with laryngopharyngeal reconstruction in patients with pyriform sinus carcinoma using the modified infrahyoid myocutaneous flap (IHMCF). The modified incision design for the modified IHMCF and clinical outcomes are also detailed here. Between January 2012 and February 2018, 10 patients with hypopharyngeal squamous cell carcinoma who underwent laryngopharyngeal reconstruction using the modified IHMCF after hemicricolaryngopharyngectomy were included in this study. The drainage vessels of the modified IHMCF, oncological outcomes, and functional reservation of the larynx were recorded. All of the flaps survived well. No flap necrosis or other major complications occurred during follow-up. None of the patients remained on nasogastric feeding for more than 4 weeks postoperatively. The follow-up period ranged from 12 to 73 months (mean, 36 months). In our series, 6 patients were successfully decannulated and 5 had received radiation therapy. We roughly assessed the speech and swallowing functions, and the outcomes seemed acceptable in all of the patients after surgery. Laryngoscopic examination showed that the modified IHMCF survived well and the new glottis provided excellent function and good ventilation results. In our experience, the modified IHMCF is a safe and viable procedure that can serve as a valid alternative to free flaps and the pectoralis major myocutaneous flap to reconstruct laryngopharyngeal defects.
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Affiliation(s)
- Danqing Yan
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Jian Zhang
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
| | - Xiang Min
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, People's Republic of China
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Lang DM, Danan D, Sawhney R, Silver NL, Varadarajan VV, Balamohan S, Bernard SH, Boyce BJ, Dziegielewski PT. Discharge Delay in Head and Neck Free Flap Surgery: Risk Factors and Strategies to Minimize Hospital Days. Otolaryngol Head Neck Surg 2019; 160:829-838. [DOI: 10.1177/0194599819835545] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Length of stay (LOS) includes time medically necessary in the hospital and time waiting for discharge (DC) afterward. This DC delay is determined in head and neck free flap patients. Reasons for and factors leading to DC delay, as well as associated adverse outcomes, are elucidated. Methods Retrospective chart review was performed for all head and neck free flap surgeries from 2012 to 2017. Data including demographics, comorbidities, and perioperative factors were collected. Regression analyses were performed to identify factors associated with DC delay. Results In total, 264 patients were included. Mean total LOS was 13.1 days. DC delay occurred in 65% of patients with a mean of 4.8 days. Factors associated with DC delay on univariate analysis included Medicaid/self-pay insurance, DC to a facility, and not having children ( P < .05). Multivariate analysis showed prolonged medically necessary LOS and surgery on a Monday/Friday ( P < .05) were associated with DC delay. Top reasons for DC delay included case management shortages, rejection by facility, and awaiting supplies. Eleven percent experienced complications during the DC delay. Discussion DC delay can add days and complications to the LOS. Prevention begins preoperatively with DC planning involving the patient’s closest family. Understanding limitations of the patient’s insurance may help plan DC destination. Optimizing hospital resources when available should be a focus. Implications for Practice Head and neck free flap patients require a team of teams unified in optimizing quality of care. DC delay is a novel quality metric reflecting the team’s overall performance. Through strategic DC planning and capitalizing on available resources, DC delay can be minimized.
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Affiliation(s)
- Dustin M. Lang
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Deepa Danan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Raja Sawhney
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Natalie L. Silver
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
| | | | - Sanjeev Balamohan
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Stewart H. Bernard
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Brian J. Boyce
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
| | - Peter T. Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, Florida, USA
- University of Florida Health Cancer Center, Gainesville, Florida, USA
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Moreno MA, Bonilla‐Velez J. Clinical pathway for abbreviated postoperative hospital stay in free tissue transfer to the head and neck: Impact in resource utilization and surgical outcomes. Head Neck 2019; 41:982-992. [DOI: 10.1002/hed.25525] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Mauricio A. Moreno
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
| | - Juliana Bonilla‐Velez
- Department of Otolaryngology – Head and Neck SurgeryUniversity of Arkansas for Medical Sciences Little Rock Arkansas
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Taufique ZM, Daar DA, Cohen LE, Thanik VD, Levine JP, Jacobson AS. The medial sural artery perforator flap: A better option in complex head and neck reconstruction? Laryngoscope 2018; 129:1330-1336. [DOI: 10.1002/lary.27652] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Zahrah M. Taufique
- Department of Otolaryngology–Head and Neck Surgery New York New York U.S.A
| | - David A. Daar
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Leslie E. Cohen
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Vishal D. Thanik
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Jamie P. Levine
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Adam S. Jacobson
- Department of Otolaryngology–Head and Neck Surgery New York New York U.S.A
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Comparison of two different laser photobiomodulation protocols on the viability of random skin flap in rats. Lasers Med Sci 2018; 34:1041-1047. [PMID: 30565200 DOI: 10.1007/s10103-018-2694-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/22/2018] [Indexed: 01/20/2023]
Abstract
To identify the best low level laser photobiomodulation application site at the same irradiation time to increase the viability of the skin flap in rats. Eighteen male rats (Rattus norvegicus: var. Albinus, Rodentia Mammalia) were randomly distributed into three groups (n = 6). Group I (GI) was submitted to simulated laser photobiomodulation; group II (GII) was submitted to laser photobiomodulation at three points in the flap cranial base, and group III (GIII) was submitted to laser photobiomodulation at 12 points distributed along the flap. All groups were irradiated with an Indium, Galium, Aluminum, and Phosphorus diode laser (InGaAlP), 660 nm, with 50 mW power, irradiated for a total time of 240 s in continuous emission mode. The treatment started immediately after performing the cranial base random skin flap (10 × 4 cm2 dimension) and reapplied every 24 h, with a total of five applications. The animals were euthanized after the evaluation of the percentage of necrosis area, and the material was collected for histological analysis on the seventh postoperative day. GII animals presented a statistically significant decrease for the necrosis area when compared to the other groups, and a statistically significant increase in the quantification of collagen when compared to the control. We did not observe a statistical difference between the TGFβ and FGF expression in the different groups evaluated. The application of laser photobiomodulation at three points of the flap cranial base was more effective than at 12 points regarding the reduction of necrosis area.
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40
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Parr JM, Chouhan P, Wagels M. Anterolateral thigh versus pectoralis major flaps in reconstruction of the lateral temporal bone defect. ANZ J Surg 2018; 89:E132-E136. [PMID: 30485644 DOI: 10.1111/ans.14922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/12/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Free tissue reconstruction is reliable in suitable patients but patient selection remains a challenge for the reconstructive surgeon. The anterolateral thigh (ALT) free flap and pedicled pectoralis major myocutaneous flap (PMMF) are two common reconstructive options for a lateral temporal bone resection defect. The threshold at which free tissue reconstruction should be considered over locoregional reconstruction is not defined. We sought to define reconstructive flap choice in the setting of medical comorbidities that may dissuade free tissue transfer. METHODS A retrospective analysis of lateral temporal bone defects at a single institution was undertaken. The primary outcomes were flap survival, surgical complications and durations of surgery and stay. Data regarding medical comorbidities and potential confounders were examined. RESULTS Sixty patients with lateral temporal bone defects were identified. Twenty-four (40%) patients underwent PMMF reconstruction and 36 (60%) were reconstructed with ALT. The former were significantly older (73 versus 62 years), though with similar Anesthesiologists Risk Classification System status. Free-flap reconstruction resulted in significantly less flap loss (two versus six) but a longer operating time (790 versus 671 min). CONCLUSION Patients suffering head and neck cancer with medical comorbidities can make selection of a suitable reconstruction difficult. We found that while patients undergoing ALT reconstruction were typically younger, the comorbidity profile of those patients was similar to patients undergoing PMMF reconstruction. ALT flaps were more reliable than the PMMF, lending credence to the view that free tissue transfer should be the preferred reconstructive option in suitable candidates and defects.
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Affiliation(s)
- Justin M Parr
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Prem Chouhan
- Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, Imperial College London, London, UK
| | - Michael Wagels
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Plastic and Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Farquhar DR, Masood MM, Pappa AK, Patel SN, Hackman ATG. Predictors of Adverse Outcomes in Free Flap Reconstruction: A Single-Institution Experience. Otolaryngol Head Neck Surg 2018; 159:973-980. [DOI: 10.1177/0194599818787801] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Objective Understanding the independent predictors of poor outcomes in free flap surgery is essential for patient selection. We aim to determine the independent predictors of major complications, flap survival, and extended hospital stays. Study Design Retrospective cohort study. Setting Tertiary medical center. Subjects and Methods We reviewed medical records from all vascularized tissue transfers in the head and neck between 2007 and 2014 at our institution. We recorded demographics, medical comorbidities, disease characteristics, flap characteristics, and intraoperative events. We defined outcomes as major complications in the 30-day postoperative period, flap death or partial flap survival, and a length of stay ≥14 days. We used bivariate and multivariate methods to test for associations. Results Of 170 free flap operations, 44% had major complications; 11% fully or partially failed; and 27% required an extended hospital stay. Independent predictors of major complications were age ≥60 years (odds ratio [OR], 3.7; P = .001), revision surgery (OR, 3.5; P = .004), and a prior neck dissection (OR, 3.5; P = .004). Independent predictors of flap failure were revision surgery (OR, 4.1, P = .01) and the use of a plate (OR, 3.7; P = .03). Revision surgery was independently associated with a longer stay (OR, 3.0; P = .01), and the use of a radial forearm flap was associated with a shorter stay (OR, 0.3, P = .047). Conclusion These results underscore that caution is warranted in revision flap surgery, patients with prior neck operations, and patients aged ≥60 years.
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Affiliation(s)
- Douglas R. Farquhar
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Maheer M. Masood
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Andrew K. Pappa
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Samip N. Patel
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - and Trevor G. Hackman
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
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Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Have a basic understanding of virtual planning, rapid prototype modeling, three-dimensional printing, and computer-assisted design and manufacture. 2. Understand the principles of combining virtual planning and vascular mapping. 3. Understand principles of flap choice and design in preoperative planning of free osteocutaneous flaps in mandible and midface reconstruction. 4. Discuss advantages and disadvantages of computer-assisted design and manufacture in reconstruction of advanced oncologic mandible and midface defects. SUMMARY Virtual planning and rapid prototype modeling are increasingly used in head and neck reconstruction with the aim of achieving superior surgical outcomes in functionally and aesthetically critical areas of the head and neck compared with conventional reconstruction. The reconstructive surgeon must be able to understand this rapidly-advancing technology, along with its advantages and disadvantages. There is no limit to the degree to which patient-specific data may be integrated into the virtual planning process. For example, vascular mapping can be incorporated into virtual planning of mandible or midface reconstruction. Representative mandible and midface cases are presented to illustrate the process of virtual planning. Although virtual planning has become helpful in head and neck reconstruction, its routine use may be limited by logistic challenges, increased acquisition costs, and limited flexibility for intraoperative modifications. Nevertheless, the authors believe that the superior functional and aesthetic results realized with virtual planning outweigh the limitations.
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Wilkman T, Husso A, Lassus P. Clinical Comparison of Scapular, Fibular, and Iliac Crest Osseal Free Flaps in Maxillofacial Reconstructions. Scand J Surg 2018; 108:76-82. [DOI: 10.1177/1457496918772365] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: This study compared the three most used composite flaps in maxillofacial reconstructions in our institute. Patients and Methods: Between 2000 and 2012, a total of 163 patients with mandibular, maxillary, and orbital defects received either scapular, fibular, or iliac crest osseal reconstructions in Helsinki University Hospital, Departments of Plastic Surgery and Maxillofacial Surgery. Data regarding the patient demographics, complications, and outcomes were analyzed. Results: There were 92 deep circumflex iliac artery flaps (56%), followed by 42 scapular (26%) and 29 fibular flaps (18%). The rate of flap loss was the highest in the deep circumflex iliac artery group (p = 0.001). Reconstructions using fibula were fastest (p = 0.001) and had lowest perioperative blood loss (p = 0.013). There were no significant differences in the number of early or late complications between the flaps, but donor site complications were more severe in deep circumflex iliac artery. Osteotomies as well as dental implants were safely performed in all flaps with equal results. Conclusion: All three flaps of this study can be performed with awareness of the deep circumflex iliac artery flap being the least reliable alternative. The knowledge of the advantages and disadvantages of several osseal-free flap alternatives is beneficial in selecting the best suitable method for each individual patient requiring maxillofacial osseal reconstruction.
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Affiliation(s)
- T. Wilkman
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A. Husso
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P. Lassus
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Wu H, Liu F, Ji F, Guo M, Wang Y, Cao M. Identification of Independent Risk Factors for Complications: A Retrospective Analysis of 163 Fibular Free Flaps for Mandibulofacial Reconstruction. J Oral Maxillofac Surg 2018; 76:1571-1577. [PMID: 29391160 DOI: 10.1016/j.joms.2017.12.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Revised: 12/03/2017] [Accepted: 12/26/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE Fibular free flap transfer is a powerful tool available to the reconstructive surgeon when treating oral and maxillofacial defects, but complications still occasionally occur and predictive analysis focusing on this specific flap is limited in terms of risk factors for complication. The purpose of this study was to identify key variables associated with complications in patients undergoing fibular free flap transfer. PATIENTS AND METHODS The data of 163 consecutive patients who underwent fibular free flap surgery at the Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, between 2012 and 2015 were reviewed retrospectively. Patient demographic data, laboratory data, surgical data, and fluid infusion-related data that may have an influence on free flap outcomes were recorded. Univariate and multivariate logistic regression analyses were used to identify relevant risk factors. RESULTS A total of 163 fibular free flaps were transferred for mandibulofacial reconstruction in 163 patients with a mean age of 50.9 years. Postoperative complications developed in 33 (20.2%). Multivariate analysis showed that free flap complications were significantly associated with radiotherapy history (odds ratio [OR], 5.12; P = .001), postoperative anemia (OR, 1.048; P = .041), postoperative hypoalbuminemia (OR, 0.844; P = .002), and prolonged operative time (OR, 1.005; P = .004). CONCLUSIONS Radiotherapy history, decreased postoperative hemoglobin and albumin levels, and prolonged operative time are potential predictors of postoperative complications after fibular free flap reconstruction for mandibulofacial defects.
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Affiliation(s)
- Haixuan Wu
- Resident, Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Funing Liu
- Attending, Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Fengtao Ji
- Professor, Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mingyan Guo
- Attending, Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Youyuan Wang
- Professor, Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Minghui Cao
- Department Head, Department of Anesthesiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
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Arnaoutakis D, Kadakia S, Abraham M, Lee T, Ducic Y. Locoregional and Microvascular Free Tissue Reconstruction of the Lateral Skull Base. Semin Plast Surg 2017; 31:197-202. [PMID: 29075158 DOI: 10.1055/s-0037-1606556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The goals of reconstruction following any oncologic extirpation are preservation of function, restoration of cosmesis, and avoidance of morbidity. Anatomically, the lateral skull base is complex and conceptually intricate due to its three-dimensional morphology. The temporal bone articulates with five other cranial bones and forms many sutures and foramina through which pass critical neural and vascular structures. Remnant defects following resection of lateral skull base tumors are often not amenable to primary closure. As such, numerous techniques have been described for reconstruction including local rotational muscle flaps, pedicled flaps with skin paddle, or free tissue transfer. In this review, the advantages and disadvantages of each reconstructive method will be discussed as well as their potential complications.
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Affiliation(s)
| | - Sameep Kadakia
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Manoj Abraham
- Department of Otolaryngology-Head and Neck Surgery, New York Medical College, Valhalla, New York
| | - Thomas Lee
- Department of Otolaryngology-Head and Neck Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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Akashi M, Kusumoto J, Sakakibara A, Hashikawa K, Furudoi S, Komori T. Literature Review of Criteria for Defining Recipient-Site Infection after Oral Oncologic Surgery with Simultaneous Reconstruction. Surg Infect (Larchmt) 2017; 18:755-764. [PMID: 28792850 DOI: 10.1089/sur.2017.101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The lack of uniformity of criteria for defining recipient-site infection after oral oncologic surgery with simultaneous reconstruction is problematic despite numerous studies on this issue. This study aimed to investigate the difference in the criteria for defining recipient-site infection after oral oncologic surgery with reconstruction. METHODS A Medline search was performed via PUBMED using the following combinations of key terms that were tagged in the title, abstract, or both: "surgical site infection-head neck," "surgical site infection-oral cancer," "antibiotic prophylaxis-head neck," and "surgical site infection-oral carcinoma." Search results were filtered between 2005 and 2017. Articles in which there was no mention of the criteria for definition of surgical-site infection were excluded. RESULTS The number of articles that met the inclusion criteria was 24. The lack of uniformity in the criteria for defining recipient-site infection in each article appeared to be attributable mainly to differences in whether an orocutaneous fistula and superficial incisional infection were regarded as recipient-site infection. CONCLUSION Reconsideration of the categorization of orocutaneous fistula as infection, regardless of the etiology, and differentiation of superficial and deep incisional infections are necessary for correct assessment of recipient-site infection in oral oncologic surgery.
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Affiliation(s)
- Masaya Akashi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Junya Kusumoto
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Akiko Sakakibara
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Kazunobu Hashikawa
- 2 Department of Plastic Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Shungo Furudoi
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
| | - Takahide Komori
- 1 Department of Oral and Maxillofacial Surgery, Kobe University Graduate School of Medicine , Kobe, Japan
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Kang SY, Spector ME, Chepeha DB. Perforator based rectus free tissue transfer for head and neck reconstruction: New reconstructive advantages from an old friend. Oral Oncol 2017; 74:163-170. [PMID: 28739194 DOI: 10.1016/j.oraloncology.2017.06.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 06/26/2017] [Accepted: 06/30/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To demonstrate three reconstructive advantages of the perforator based rectus free tissue transfer: long pedicle, customizable adipose tissue, and volume reconstruction without muscle atrophy within a contained space. MATERIALS AND METHODS Thirty patients with defects of the head and neck were reconstructed with the perforator based rectus free tissue transfer. RESULTS Transplant success was 93%. Mean pedicle length was 13.4cm. Eleven patients (37%) had vessel-poor necks and the long pedicle provided by this transplant avoided the need for vein grafts in these patients. Adipose tissue was molded in 17 patients (57%). Twenty-five patients (83%) had defects within a contained space, such as the orbit, where it was critical to have a transplant that avoided muscle atrophy. CONCLUSIONS The perforator based rectus free tissue transfer provides a long pedicle, moldable fat for flap customization, and is useful in reconstruction of defects within a contained space where volume loss due to muscle atrophy is prevented.
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Affiliation(s)
- Stephen Y Kang
- The Ohio State University, Department of Otolaryngology-Head and Neck Surgery, Columbus, OH, USA
| | - Matthew E Spector
- University of Michigan, Department of Otolaryngology-Head and Neck Surgery, Ann Arbor, MI, USA
| | - Douglas B Chepeha
- University of Michigan, Department of Otolaryngology-Head and Neck Surgery, Ann Arbor, MI, USA; University of Toronto, Department of Surgical Oncology, Toronto, Ontario, Canada.
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Validity of the American College of Surgeons' National Surgical Quality Improvement Program risk calculator in South Australian glossectomy patients. The Journal of Laryngology & Otology 2017; 132:173-179. [DOI: 10.1017/s0022215117001451] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractBackground:Appropriate selection of tongue cancer patients considering surgery is critical in ensuring optimal outcomes. The American College of Surgeons' National Surgical Quality Improvement Program (‘ACS-NSQIP’) risk calculator was developed to assess patients' 30-day post-operative risk, providing surgeons with information to guide decision making.Method:A retrospective review of 30-day actual mortality and morbidity of tongue cancer patients was undertaken to investigate the validity of this tool for South Australian patients treated from 2005 to 2015.Results:One hundred and twenty patients had undergone glossectomy. Predicted length of stay using the risk calculator was significantly different from actual length of stay. Predicted mortality and other complications were found to be similar to actual outcomes.Conclusion:The American College of Surgeons' National Surgical Quality Improvement Program risk calculator was found to be effective in predicting post-operative complication rates in South Australian tongue cancer patients. However, significant discrepancies in predicted and actual length of stay may limit its use in this population.
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Ciolek PJ, Clancy K, Fritz MA, Lamarre ED. Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction. Am J Otolaryngol 2017; 38:433-437. [PMID: 28476441 DOI: 10.1016/j.amjoto.2017.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 03/31/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Limited data exists on cardiac complications following head and neck free flaps. DESIGN A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015. RESULTS 368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay. CONCLUSIONS There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.
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Barton BM, Riley CA, Fitzpatrick JC, Hasney CP, Moore BA, McCoul ED. Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review. Laryngoscope 2017; 128:412-421. [PMID: 28581030 DOI: 10.1002/lary.26703] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2017] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Blair M Barton
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles A Riley
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Christian P Hasney
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Brian A Moore
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
| | - Edward D McCoul
- Department of Otolaryngology-Head and Neck Surgery, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otorhinolaryngology, Ochsner Clinic Foundation, New Orleans, Louisiana.,Ochsner Clinical School, University of Queensland School of Medicine, New Orleans, Louisiana, U.S.A
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