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Shuck JW, Chang EI. Discussion: Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure. Plast Reconstr Surg 2024; 153:1400-1401. [PMID: 38810164 DOI: 10.1097/prs.0000000000010863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Affiliation(s)
- John W Shuck
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Center
| | - Edward I Chang
- From the Department of Plastic Surgery, University of Texas MD Anderson Cancer Center
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Musmann RJ, Andree C, Munder B, Hagouan M, Janku D, Daniels M, Aufmesser-Freyhardt B, Becker K, Oramary A, Bromba A, Stockhausen N, Wolter A, Fertsch S. Secondary solution for breast reconstruction following total DIEP flap loss: A single-center experience after 3270 DIEP flaps. J Plast Reconstr Aesthet Surg 2024; 92:11-25. [PMID: 38489983 DOI: 10.1016/j.bjps.2024.02.059] [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: 10/10/2023] [Revised: 02/02/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND Total deep inferior epigastric perforator (DIEP) flap failure is a significant concern in autologous breast reconstruction. Literature on secondary reconstruction options following total flap failure is limited. This study outlines the outcomes of patients who underwent reconstruction post-DIEP flap failure at our institution. METHODS We conducted a retrospective analysis of patients receiving autologous breast reconstruction between 2004 and 2021. We aimed to identify causes of total DIEP flap failure, outcomes of revision surgery, and outcomes of secondary breast reconstruction procedures. RESULTS From 2004 to 2021, 3456 free flaps for breast reconstruction were performed, with 3270 being DIEP flaps for 2756 patients. DIEP flap failure was observed in 40 cases (1.22%). Bilateral reconstructions had a higher failure rate (2.31%) than unilateral (0.72%). The primary cause was intraoperative complications during flap harvest (18 cases), followed by insufficient arterial perfusion (seven cases). Other causes included postoperative hematoma (seven cases), venous congestion (six cases), and late-onset fat necrosis (two cases). Post-failure, five patients received a second free flap with three cases of repeated flap failure. Twenty patients received implant-based reconstruction with two cases of reconstruction failure, while seven patients received a pedicled latissimus dorsi (LD) flap reconstructions with no cases of reconstruction failure. Eight patients declined further reconstruction. CONCLUSION A second free flap post-DIEP failure was associated with a high risk of reconstruction failure, suggesting the need for careful patient selection. Implant-based and pedicled LD flap seem to be reliable secondary reconstruction options.
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Affiliation(s)
- R J Musmann
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany.
| | - C Andree
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Heinrich-Heine-Universität Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf
| | - B Munder
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Hagouan
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - D Janku
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - M Daniels
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - B Aufmesser-Freyhardt
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - K Becker
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Oramary
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Bromba
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - N Stockhausen
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany
| | - A Wolter
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
| | - S Fertsch
- Dept. of Plastic and Aesthetic Surgery, Sana Krankenhaus Gerresheim, Gräulinger Straße 120, D-40625 Düsseldorf, Germany; Universität Witten-Herdecke, Fakultät für Gesundheit, Alfred-Herrhausen-Straße 45, 58455 Witten, Germany
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Biswas G, Mathew JG, Kaur A, Panchal KB. Utilizing a Second Flap to Address the Effect of Postradiotherapy Soft Tissue Fibrosis in Head and Neck Malignancy. Indian J Plast Surg 2024; 57:31-38. [PMID: 38450016 PMCID: PMC10914542 DOI: 10.1055/s-0044-1779476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Background Late effects of adjuvant radiation therapy (RT) on soft tissues can lead to hair loss, pigmentary changes, loss of tissue volume, and fibrosis, which appear months to years after the treatment. These changes are often progressive and are because of tissue hypoxia due to radiation-induced capillary endothelial damage. Tissue hypoxia may be compounded by subclinical infection following minor trauma, exposed hardware, or associated osteoradionecrosis. The combined effect of these factors causes significant deformities in soft tissue, affecting both function and appearance. Such changes are also seen in primarily transferred flaps, which have been radiated, resulting in severe, progressive soft tissue fibrosis, compromising function and aesthetics. In selected cases, a second flap may be needed to restore function and volume. Methods Data of patients who underwent secondary soft tissue transfers for postradiotherapy-related soft tissue changes were collected from the hospital electronic medical records, from January 2019 to 2023. Details regarding the primary surgery, dose, duration of adjuvant RT, time interval between adjuvant RT and secondary soft tissue transfer, indications, and the choice of the second flap were analyzed. Results Twenty-one patients had undergone secondary soft tissue transfer for extensive soft tissue fibrosis. In addition, associated compounding features like exposed implant and volume loss were observed. Two patients with osteoradionecrosis also had associated extensive soft tissue fibrosis necessitating replacement. Out of these 21 patients, 13 had undergone free tissue transfers, while 7 locoregional tissue transfers. Conclusion Late sequelae of adjuvant RT changes usually present from 6 months onwards. The radiated hypoxic tissue, due to capillary damage, leads to a chronic progressive fibrotic stage, causing loss of soft tissue volume and fibrosis. Replacing this tissue with a vascularized flap helps to restore volume and correct these secondary changes, improving overall quality of life.
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Affiliation(s)
- Gautam Biswas
- Department of Plastic Reconstructive and Microsurgery, Tata Medical Centre, Kolkata, West Bengal, India
| | - Jovin George Mathew
- Department of Plastic Reconstructive and Microsurgery, Tata Medical Centre, Kolkata, West Bengal, India
| | - Amrita Kaur
- Department of Plastic Reconstructive and Microsurgery, Tata Medical Centre, Kolkata, West Bengal, India
| | - Karnav Bharat Panchal
- Department of Plastic Reconstructive and Microsurgery, Tata Medical Centre, Kolkata, West Bengal, India
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Preudhomme R, Veyssière A, Bildstein AC, Chatellier A, Garmi R, Bénateau H. Management after fibula free flap necrosis in maxillofacial reconstruction. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101586. [PMID: 37562713 DOI: 10.1016/j.jormas.2023.101586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/26/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Few articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction. MATERIAL & METHODS Between 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy. RESULTS In Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days. DISCUSSION Based on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.
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Affiliation(s)
- Renaud Preudhomme
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France.
| | - Alexis Veyssière
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France
| | - Anh-Claire Bildstein
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France
| | - Anne Chatellier
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France
| | - Rachid Garmi
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France
| | - Hervé Bénateau
- Caen University Hospital. Oral and Maxillofacial Surgery Department, Address: Avenue de la Côte de Nacre, 14033 Caen France
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Zahran M, Hoffman G, Eisenberg R, Tan A, Youssef A. Late Free Flap Failure in Head and Neck Reconstruction: Unusual Etiology in Two Case Studies and Literature Review. Indian J Otolaryngol Head Neck Surg 2022; 74:2527-2532. [PMID: 36452744 PMCID: PMC9702170 DOI: 10.1007/s12070-020-02256-3] [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: 08/26/2020] [Accepted: 10/31/2020] [Indexed: 11/30/2022] Open
Abstract
The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates. However, devastating consequences of partial or total flap failure and subsequent loss may occur. This usually occurs in the first 48-72 h post-operatively. It is rare for flaps to fail in the late post-operative period and it remains poorly understood why flaps fail after day seven. We presented two patients in whom flap failure occurred after the seventh post-operative day (POD). Complete flap failure occurred after POD 9 and 27 in our cases. During the postoperative period, there was no evidence of early occlusion or insult to the vascular integrity such as venous/arterial compression. The cause of late flap failure was due to thrombophlebitis secondary to infection from the tracheostomy-neck fistula. This assumption was supported by recurrent failure of anastomoses revision.
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Affiliation(s)
- Mohamed Zahran
- Department of Otolaryngology, Alexandria University School of Medicine, Champllion Street, El-Azareeta, Alexandria, Egypt
| | - Gary Hoffman
- Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - Robert Eisenberg
- Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - Andrew Tan
- Department of Otolaryngology-Head and Neck Surgery, John Hunter Hospital, Newcastle, NSW Australia
| | - Ahmed Youssef
- Department of Otolaryngology, Alexandria University School of Medicine, Champllion Street, El-Azareeta, Alexandria, Egypt
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Multiple Sequential Free Flap Reconstructions of the Head and Neck: A Single-Center Experience. Plast Reconstr Surg 2021; 148:791e-799e. [PMID: 34586092 DOI: 10.1097/prs.0000000000008432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Free flap reconstruction is the standard of care in extensive defects of the head and neck area, and although most patients may be treated sufficiently with one flap, recurrence of a malignant tumor or failure of a previous reconstruction may make the use of a second (or more) flap necessary. The aim of this study was to evaluate the indications and success rates of multiple consecutive reconstructive procedures in a large cohort of patients. METHODS Nine hundred ninety-six free flap reconstructions were retrospectively analyzed and cases of sequential reconstructions in the same patient were identified. Indications, success rates, perioperative procedures, and frequently used flaps were evaluated. RESULTS Two hundred twenty cases of sequential microvascular reconstructions were identified, ranging from two to six flaps per patient. The overall flap success rate was 89.1 percent. A history of diabetes was identified as a risk factor for flap failure (p = 0.029). There was no association of flap loss with the number of reconstructive procedures per patient. CONCLUSIONS The use of several free flaps in the same patient is a feasible option for patients suffering from recurrent tumors or to improve quality of life by a secondary reconstruction. A salvage free flap transfer to replace a lost transplant exhibits good success rates. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Walia A, Lee JJ, Jackson RS, Hardi AC, Bollig CA, Graboyes EM, Zenga J, Puram SV, Pipkorn P. Management of Flap Failure After Head and Neck Reconstruction: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2021; 167:224-235. [PMID: 34491852 PMCID: PMC8972962 DOI: 10.1177/01945998211044683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically review management of flap loss in head and neck construction with free tissue transfer as compared with locoregional flap or conservative management. DATA SOURCES Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched up to October 2019. REVIEW METHODS Candidate articles were independently reviewed by 2 authors. Articles were considered eligible if they included adequate reporting of flap management after flap loss and outcomes for survival of reconstruction, length of hospitalization, and perioperative complications. RESULTS A total of 429 patients had acute flap failure in the perioperative period. The overall success with a secondary free flap was 93% (95% CI, 0.89-0.97; n = 26 studies, I2 = 12.8%). There was no difference in hospitalization length after secondary reconstruction between free tissue transfer and locoregional flaps or conservative management (relative risk of hospitalization ≥2 weeks, 96%; 95% CI, 0.80-1.14; n = 3 studies, I2 = 0). The pooled relative risk of perioperative complications following free tissue transfer was 0.60 when compared with locoregional flap or conservative management (95% CI, 0.40-0.92; n = 5 studies, I2 = 0). CONCLUSION Salvage reconstruction with free tissue transfer has a high success rate. Second free flaps following flap failure had a similar length of hospitalization and lower overall complication rate than locoregional reconstruction or conservative management. A second free tissue transfer, when feasible, is likely a more reliable and effective procedure for salvage reconstruction.
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Affiliation(s)
- Amit Walia
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Jake J Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Angela C Hardi
- Bernard Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.,Department of Genetics, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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Guo B, Fang X, Shan Y, Li J, Shen Y, Ma C. Salvage mandibular reconstruction: multi-institutional analysis of 17 patients. Int J Oral Maxillofac Surg 2021; 51:191-199. [PMID: 34384647 DOI: 10.1016/j.ijom.2021.07.014] [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: 10/26/2020] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
Unsuccessful mandibular reconstruction occasionally occurs, leaving the patient with undesirable function and contours. In such cases, second- or third-time corrective operations are challenging. However, published studies on the complicated retreatment of such patients are scarce. A retrospective analysis covering the years 2015-2019 was conducted in three centers. All 17 patients included had undergone prior failed mandibular reconstructions in other institutions. Salvage secondary or tertiary reconstructive surgeries were attempted and the results are presented. Major factors for these failed reconstructions included exposed non-vascularized bone grafts (n = 7, 41.2%), flap loss (n = 4, 23.5%), exposed artificial joint (n = 3, 17.6%), skewed occlusion with deformity (n = 1, 5.9%), non-union (n = 1, 5.9%), and recurrence (n = 1, 5.9%). Fibula flaps were transferred in 15 patients, while iliac flaps were used in two patients for mandibular re-do reconstructions. Virtual surgical designs were conducted in nine (52.9%) patients, with navigation-guided approaches performed in three cases. Postoperative functions were relatively favorable in these complicated mandibular re-do reconstruction cases. Mandibular symmetry (mandibular length and height; P = 0.002) and condylar position (P < 0.001) were regained after these re-do attempts. Secondary or tertiary mandibular re-do reconstruction can still achieve good functional outcomes with appropriate preoperative selection and well-conceived designs, especially with the aid of virtual surgery and navigation.
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Affiliation(s)
- B Guo
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - X Fang
- Department of Oral and Maxillofacial Surgery, Xiangya Stomatological Hospital, Central South University, Changsha, Hunan, China
| | - Y Shan
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - J Li
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Y Shen
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - C Ma
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.
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Khoo MJW, Ooi ASH. Management of postreconstructive head and neck salivary fistulae: A review of current practices. J Plast Reconstr Aesthet Surg 2021; 74:2120-2132. [PMID: 33551359 DOI: 10.1016/j.bjps.2020.12.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 12/11/2020] [Accepted: 12/22/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Salivary fistulas are common complications after reconstructive head and neck surgery with significant morbidity. Yet, there are no established guidelines for their management. METHOD A comprehensive search of PubMed was performed from 01/01/2000 to 06/31/2019 to evaluate all treatment options in postreconstructive head and neck fistulas. RESULTS Nineteen articles with 132 patients were included. Thirty-nine of 132(30%) patients were treated with conventional wound care. All fistulas closed after 51.6±54.0 days with no refistulations. Thirty-eight of 132(29%) patients were treated with negative pressure wound therapy (NPWT). Thirty-eight of 40(95%) fistula closed after 14.7±12.0 days with no refistulations. The reduced healing time was statistically significant as compared to patients on conventional wound care (p < 0.001). Fifty-three of 132(40%) patients received surgical management. Forty-four of 53(83%) patients had complete fistula closure without postoperative complications. A pedicled flap was used in 60% of cases (n = 32). CONCLUSION Most salivary fistulas close with conservative management. NPWT potentially shortens fistula healing time while it achieves similar closure rates as conventional wound care. In the absence of contraindications, NPWT should be trialed on all salivary fistulas. Surgical management should be reserved for large, chronic, high-risk fistulas or those not responding to a trial of conservative treatment. Secondary reconstruction should be kept as simple as possible.
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Affiliation(s)
- Mark Junn Wei Khoo
- Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Adrian Seng Huan Ooi
- Polaris Plastic & Reconstructive Surgery, 3 Mount Elizabeth, #08-05 Mount Elizabeth Medical Centre, Singapore 288510, Singapore.
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10
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Outcome of 1000 free flap head and neck reconstructions at a tertiary cancer care institute in India. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01693-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Chiu WK, Chou CY, Chen SG, Chen C, Wang HJ, Yang TF. Is sequential free flap safe in oral cancer reconstruction in the same patient? An outcome and complication analysis. Jpn J Clin Oncol 2020; 50:152-158. [PMID: 31670807 DOI: 10.1093/jjco/hyz142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/20/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sequential free flap reconstruction in patient with head and neck cancer can provide reliable and effective wound coverage. Only a few studies have reported on the outcome and complications analysis but without consensus on the recipient vessels and flap chosen. Herein, we presented the outcome and analysed the risk factors for complications in sequential free flap reconstruction. PATIENTS AND METHODS Patients who had sequential free tissue transfers due to cancer recurrence, second primary cancer, or secondary correction of the soft tissue contractures and volume deficits were all included. Variables extracted included demographics, comorbidities, free flap characteristics, infection, dehiscence and flap necrosis rates. RESULTS In total, 40 patients with 92 free flaps were analyzed; 42 initial and 50 sequential free flaps. The most common recipient vessels for sequential flap were contralateral superficial thyroid vessels (68%). The most common flap for both initial and sequential free flap was anterolateral thigh flap (64.3 and 62%). The success rate of sequential free flap was 92.0 compared to 92.9% for initial free flap, which showed no significant difference. Female was independently associated with delayed wound healing with an odds ratio of 90.91 (95% confidence interval 0.001-0.17, P = 0.001), as well as diabetes with an odds ratio of 31.14 (95% confidence interval 2.60-373.19, P = 0.007). Sequential free flap was not a risk factor for any complication. CONCLUSIONS Sequential free flap is a reliable method for head and neck surgery without more complication rate comparing to initial free flap reconstruction. More attentions should be paid on patients with preferential risk for certain complications.
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Affiliation(s)
- Wen-Kuan Chiu
- Division of Plastic Surgery, Department of Surgery, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
| | - Chang-Yi Chou
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shyi-Gen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chiehfeng Chen
- Division of Plastic Surgery, Department of Surgery, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cochrane, Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Hsian-Jenn Wang
- Division of Plastic Surgery, Department of Surgery, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ten-Fang Yang
- Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan.,Graduate Institute of Medical Informatics and Cardiology, Taipei Medical University and Hospital, Taipei, Taiwan
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Girkar F, Thiagarajan S, Malik A, Sawhney S, Deshmukh A, Chaukar D, D'Cruz A. Factors predisposing to the development of orocutaneous fistula following surgery for oral cancer: Experience from a tertiary cancer center. Head Neck 2019; 41:4121-4127. [PMID: 31497921 DOI: 10.1002/hed.25951] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/24/2019] [Accepted: 08/26/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Orocutaneous fistula (OCF) is one of the frequently encountered postoperative complications following surgery for oral cancer, leading to prolonged hospital stay and delay in the initiation of adjuvant therapy. METHODS We included all patients with oral cancer operated between January 2016 to December 2017 and at risk to develop an OCF. We assessed the incidence of OCF, its management, and factors predisposing to its development. RESULTS Of 587 eligible patients, 9% developed OCF. On univariate and multivariate analysis, patients undergoing bilateral neck dissection or with surgical site infection (SSI) (P < .001) were at maximum risk. On univariate analysis, the incidence was higher following resections for tongue-floor of mouth sub site (P = .002), irrespective of the type of flap used for reconstruction. Majority (57%) required surgical intervention for management. CONCLUSION The presence of SSI and performing bilateral neck dissection posed the maximum risk for developing OCF in patients undergoing surgery for oral cancer.
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Affiliation(s)
- Farhana Girkar
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | | | - Akshat Malik
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | - Shikhar Sawhney
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anuja Deshmukh
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | - Devendra Chaukar
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
| | - Anil D'Cruz
- Department of Head & Neck Oncology, Tata Memorial Hospital, Mumbai, India
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Kubota A, Murai Y, Umezawa H, Ishisaka E, Tsukiyama A, Nakagawa S, Matano F, Ogawa R, Morita A. Second Free Flap Surgery for Skull Base Tumors: Case Report and Literature Review. J NIPPON MED SCH 2019; 86:248-253. [PMID: 31484881 DOI: 10.1272/jnms.jnms.2019_86-406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Tumors of the skull base, such as meningiomas, tend to recur. With progress in free vascularized flap surgery, an increasing number of studies are investigating skull base reconstruction with free flaps after tumor removal. In this report, we discuss the results of second free flap surgery after skull base reconstructive surgery. We retrospectively analyzed data from patients treated at our center during the period from 2013 through 2017. All four patients identified had skull base anaplastic meningioma and had undergone radiotherapy. In all cases, the flap and donor blood vessel were sourced from sites that differed from those used in the previous surgeries. No complications developed, such as cerebrospinal fluid leakage, meningitis, wound infection, wound hemorrhage, or flap necrosis. Because the first flap was found to be unviable, it was difficult to preserve and was removed. Essential points in preventing complications are anchoring at the appropriate site, pinprick testing of the created flap, and use of multilayered countermeasures to prevent cerebrospinal fluid leakage.
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Affiliation(s)
- Asami Kubota
- Department of Neurological Surgery, Nippon Medical School
| | - Yasuo Murai
- Department of Neurological Surgery, Nippon Medical School
| | - Hiroki Umezawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| | | | | | | | | | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
| | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
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14
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Abstract
Microvascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.
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Affiliation(s)
- Aurora Vincent
- Otolaryngology, Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Raja Sawhney
- Facial Plastic and Reconstructive Surgery, Otolaryngology Head and Neck Surgery, University of Florida, Gainesville, Florida
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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15
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Copelli C, Tewfik K, Cassano L, Pederneschi N, Catanzaro S, Manfuso A, Cocchi R. Management of free flap failure in head and neck surgery. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:387-392. [PMID: 29165433 PMCID: PMC5720866 DOI: 10.14639/0392-100x-1376] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/11/2017] [Indexed: 11/23/2022]
Abstract
Free flap surgery is overall considered the gold standard in head and neck reconstruction, with a success rate of 95%. The management of a total flap necrosis and which solution, between a pedicled or a second free flap, is safer for a salvage procedure is still controversial. Object of this study is to describe the authors' management of total free flap loss in head and neck reconstruction and compare the choices and results to those reported in the literature. From January 2012 to January 2016, 149 consecutive free flaps were performed at the Maxillo- Facial Operative Unit of the Hospital Casa Sollievo della Sofferenza in San Giovanni Rotondo (Italy) for reconstruction of head and neck defects. Of these, 6 flaps were lost due to a total necrosis. In 5 cases it was decided to harvest a second free flap, and in the remaining patient a temporalis muscle flap was used. All the free salvage flaps were successful, without complications and with a good aesthetic and functional recovery. Analysing the data obtained, and comparing them with those reported in the literature, it can be concluded that a second subsequent free flap can be considered an ideal and safe procedure in salvage surgery.
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Affiliation(s)
- C Copelli
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - K Tewfik
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - L Cassano
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - N Pederneschi
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - S Catanzaro
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - A Manfuso
- Operative Unit of Maxillo-Facial Surgery, Federico II University, Naples, Italy
| | - R Cocchi
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
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16
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Multiple Free Flap Reconstructions of Head and Neck Defects Due to Oral Cancer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1337. [PMID: 28740764 PMCID: PMC5505825 DOI: 10.1097/gox.0000000000001337] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 03/27/2017] [Indexed: 11/26/2022]
Abstract
Objective: We studied complications following multiple free flap reconstructions in the head and neck. Methods: In this cohort, 26 patients (14 men and 12 women) who underwent multiple microvascular free flap reconstructions were included in the study. The reasons for secondary reconstruction were recurrence of tumor (12 cases), necrosis of transferred skin and/or bone (6 cases), reconstruction plate fracture or exposure (4 cases), and others (4 cases). A third reconstruction in 4 cases and a fourth reconstruction in 1 case were performed. Results: No flap necrosis occurred. Postsurgical infections occurred at only secondary reconstructions in 7 patients. Although 4 cases with a history of external radiation therapy were anastomosed at contralateral side, those 4 cases suffered from severe pre-and postsurgical infection of the ipsilateral side. Postsurgical infection occurred in 2 cases with anastomoses at the ipsilateral side of the neck and required drainage after secondary surgery. Conclusions: A history of external radiation therapy and the existence of severe preoperative infection affected complications after multiple reconstructions.
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17
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AL Deek NF, Wei FC, Tsao CK. Fistulae After Successful Free Tissue Transfer to Head and Neck. Clin Plast Surg 2016; 43:739-45. [DOI: 10.1016/j.cps.2016.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Kuuskeri M, O’Neill AC, Hofer SO. Unfavorable Results After Free Tissue Transfer to Head and Neck. Clin Plast Surg 2016; 43:639-51. [DOI: 10.1016/j.cps.2016.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Cannady SB, Hatten K, Wax MK. Postoperative Controversies in the Management of Free Flap Surgery in the Head and Neck. Facial Plast Surg Clin North Am 2016; 24:309-14. [PMID: 27400844 DOI: 10.1016/j.fsc.2016.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Free tissue transfer is the gold standard for reconstructing head and neck defects. Free flap success approaches 95% in centers with experience, affording unparalleled ability to restore form and function in cancer, trauma, or other major composite tissue loss. It is critical to manage the perioperative variables that predict success; several areas of controversy have not yet reached consensus. This review focuses on postoperative anticoagulation, fluid management, and flap monitoring methods. These areas of controversy potentially influence flap survival. We review published practices considered within the standard of care, why controversy remains, and future directions to reach standardization.
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Affiliation(s)
- Steven B Cannady
- Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania, 800 Walnut Street, 18th Floor, Philadelphia, PA 19107, USA.
| | - Kyle Hatten
- Head and Neck Surgery, Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania, West 34th Street, Philadelphia, PA 19107, USA
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health Sciences University, Portland, OR 97239, USA
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20
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Glass GE, Mosahebi A, Shakib K. Cross-specialty developments: a summary of the mutually relevant recent literature from the journal of plastic, reconstructive and aesthetic surgery. Br J Oral Maxillofac Surg 2015; 54:13-21. [PMID: 26628201 DOI: 10.1016/j.bjoms.2015.08.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 08/26/2015] [Indexed: 12/18/2022]
Abstract
Keeping abreast of current developments is increasingly challenging when the volume of specialty articles being published is rising exponentially, and it is most acute when surgical specialties overlap, as in the case of head, neck, and facial reconstructive surgery. Here, the potential for missing key developments presents a compelling case for a summary article that highlights articles likely to be of mutual relevance. We evaluated 129 original studies and 6 reviews published in the Journal of Plastic, Reconstructive, and Aesthetic Surgery between September 2012 and August 2014, and summarised the main papers of interest and merit under the subheadings of head and neck reconstruction, cleft lip and palate, craniomaxillofacial surgery, facial palsy, facial trauma, and aesthetic surgery. Most of the evidence presented (86%) is level 4.
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Affiliation(s)
- Graeme E Glass
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Kennedy Institute of Rheumatology, Roosevelt Drive, Oxford, OX 3 7FY.
| | - Ash Mosahebi
- Royal Free Hospital NHS Foundation trust, Pond Street, Hampstead, London, NW3 2QG
| | - Kaveh Shakib
- Royal Free Hospital NHS Foundation trust, Pond Street, Hampstead, London, NW3 2QG
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21
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Invasive basal cell carcinoma in a xeroderma pigmentosum patient: facing secondary and tertiary aggressive recurrences. J Craniofac Surg 2015; 25:e336-8. [PMID: 24978686 DOI: 10.1097/scs.0000000000000596] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Xeroderma pigmentosum (XP) is characterized by photohypersensitivity of sun-exposed tissues and several thousand-fold increased risk of developing malignant neoplasms of the skin and eyes. Inherited molecular defects in nucleotide excision repair genes cause the autosomal recessive condition XP. A 56-year-old woman with XP presented with an extensive multirecurrence basal cell carcinoma in the left naso-orbital region. At the time of the first visit, the patient had already received several interventions with local reconstructive techniques, a full course of radiotherapy, and bilateral neck dissection. A large tumor resection and free flap reconstruction were performed. Three years 9 months afterward, an aggressive recurrence occurred, and a second resection was needed. A new free flap was transferred, and microvascular anastomoses were done to the pedicle of the previously transferred flap. Nine months later, the patient returned with frontal bone tumoral lesions, and third microsurgical intervention was done. At that time, the reconstruction was practiced by a composite chimeric flap with a rib portion. Its pedicle was anastomosed to the one of the second free flaps. The objective of this article was to report the authors' experience concerning a unique case of XP requiring a complex reconstruction of the anterior skull base. Xeroderma pigmentosum patients need an early diagnosis and removal of cutaneous tumor lesions as some of them behave aggressively, especially those affecting the face. Free flaps are good solutions for reconstruction and should proceed from non-sun-exposed areas of the body. If reconstructed areas are highly radiated and/or skin tumors affect deep anatomical areas, complications are frequent.
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22
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Success of sequential free flaps in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2014; 67:1186-93. [DOI: 10.1016/j.bjps.2014.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/11/2014] [Indexed: 11/18/2022]
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23
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Avery C. A perspective on the role of the pectoralis major flap in oral and maxillofacial oncology surgery. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/ors.12080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- C. Avery
- University Hospitals of Leicester; Leicester UK
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