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Li Y, Li Z, Lv Q, Gu Y, Qi Y, Li J, Liu Y, Ma G. Prevalence and risk factors of postoperative delirium in tumor patients after free flap reconstruction: A systematic review and meta-analysis of case-control studies. Surgery 2024:S0039-6060(24)00306-4. [PMID: 38910046 DOI: 10.1016/j.surg.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/12/2024] [Accepted: 05/06/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND Postoperative delirium is a severe complication of flap transplantation surgery, adversely affecting surgical prognoses. The intricate pathophysiology of postoperative delirium renders the elucidation of its risk factors challenging. This research aims to delineate the prevalence and the specific risk factors of postoperative delirium in patients with cancer undergoing free flap reconstruction through a systematic review and meta-analysis to enlighten proactive prevention measures. METHODS The researchers systematically queried both the international and Chinese databases. Searches were performed for publications from inception until September 14, 2023, using the terms "free tissue flaps," "delirium," "neoplasms," and "risk factors." Data synthesis and statistical analysis were conducted using Stata SE (version 15.0) to calculate the combined effect size for identified risk factors. Reported outcomes included weighted mean differences or odds ratios with their respective 95% confidence intervals. RESULTS Twelve case-control studies were included (ntotal = 3,256). Among them, 515 patients developed postoperative delirium after free flap surgery, compared with 2,741 patients who did not. The outcomes suggest that the risk factors include but are not limited to age, male, late neoplasm staging, use of hypnotic or antipsychotic, history of background diseases, psychiatric review, tracheotomy, and impaired wound healing. In contrast, early neoplasm staging and others are the protective factors with statistical significance. Multivariate analysis further identified significant correlations between preoperative albumin, perioperative blood transfusion, sleep disturbance, postoperative visual analog scale, postoperative albumin, smoking, and the appearance of postoperative delirium. CONCLUSION The determined risk factors were grouped into preoperative, intraoperative, and postoperative categories substantiated by current data to present instructions for postoperative delirium prevention.
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Affiliation(s)
- Yifei Li
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhifeng Li
- First Department of Maxillofacial Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, People's Republic of China
| | - Qianwen Lv
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yunpeng Gu
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yue Qi
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Jiyang Li
- Department of Fat Grafting, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yicheng Liu
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Guie Ma
- Department of General Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
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2
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Aschen SZ, O'Connell GM, Kutler DI, Spector JA. Financial (dis)incentives to surgical management of head and neck cancer care. Head Neck 2024; 46:1362-1369. [PMID: 38265174 DOI: 10.1002/hed.27649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/27/2023] [Accepted: 01/14/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Patients with head and neck cancer (HNC) often require complex surgical reconstruction. This retrospective, cross-sectional study compares financial factors influencing HNC and breast cancer (BC) care to examine care disparities. METHODS Pricing data from 2012 to 2021 was abstracted from the CMS Physician Fee Schedule Look-Up Tool. Nonprofit and research support was quantified by searching the NIH, IRS, and GuideStar databases. New York State Department of Health data from 2015 to 2019 was analyzed to compare costs, charges, and payer mix. RESULTS HNC reconstructive procedures reimburse lower than comparable breast procedures (p < 0.05). Nonprofit and research support for HNC is disproportionately low relative to disease burden. Patients hospitalized for HNC surgical procedures generated higher costs and lower charges than patients with BC (p < 0.05). CONCLUSION Comparatively low procedure reimbursement, low nonprofit support, and high cost of care for patients with HNC relative to patients with BC may contribute to care disparities for patients with HNC.
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Affiliation(s)
- Seth Z Aschen
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - David I Kutler
- Department of Otolaryngology, Weill Cornell Medicine, New York, New York, USA
| | - Jason A Spector
- Division of Plastic and Reconstructive Surgery, Weill Cornell Medicine, New York, New York, USA
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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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4
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Wu RT, Lin JAJ, Su CCL, Wei FC. Sequential free fibula transfers: Quality of life and systematic review. Microsurgery 2024; 44:e31184. [PMID: 38747121 DOI: 10.1002/micr.31184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/04/2024] [Accepted: 04/26/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Successive osteoseptocutaneous fibula transfers for jaws reconstruction are rare but important options. This study contributes patient-reported and clinical outcomes, as well as systematically reviews all existing reports. METHODS All sequential fibula transfers performed by the senior author were reviewed from a prospectively managed database, including University of Washington quality of life (UWQoL). Systematic review was conducted in PubMed and Cochrane databases for similar publications. RESULTS Eighteen patients (average age 51.5 years) received sequential fibulas (mean 4.7 years between reconstructions). Secondary fibulas more often had benign indications (72.2% vs. 33.3%, p = .04), most commonly osteoradionecrosis (38.9%). At a mean follow-up of 30.5 months, the average interincisal distance increased from 21.8 to 27.6 mm, and 92.3% tolerated an oral diet following the second fibula. Eight patients completed the UW-QoL before and after the second fibula, and three prior to the first fibula. Composite physical function was significantly decreased from 96.7 prefibula reconstruction to 63.3 following the first (p < .001) and 64.2 after the second fibula (p < .001). There were no differences in other domains. The systematic review yielded six articles reporting 56 patients (mean 39 months between fibulas). Secondary fibulas were performed for repeat malignancy (45%) and osteoreadionecrosis (39%), resulting in elevated tube feeding from 20% following the first to 39% following the second, but overall high quality of life in two studies. CONCLUSIONS Sequential osteoseptocutaneous fibula reconstructions of jaws are often performed for benign indications such as osteoradionecrosis. Overall function and QoL are comparable with those following the first fibula transfer.
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Affiliation(s)
- Robin T Wu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan, Taiwan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Hospital, Stanford, California, USA
| | - Jennifer An-Jou Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Charlie Chun-Lin Su
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Fu-Chan Wei
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Department of Reconstructive Microsurgery, Medical College, Chang Gung University, Taoyuan, Taiwan
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5
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Üstün GG, Kaplan GO, Sert G, Uzun H. Flap loss in head and neck reconstruction: Is there a singular cause for failure? J Plast Reconstr Aesthet Surg 2024; 91:353-359. [PMID: 38442516 DOI: 10.1016/j.bjps.2024.02.050] [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: 11/06/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 03/07/2024]
Abstract
Despite the high success rates reported in head and neck reconstruction, free flap failures continue to persist. Understanding the factors associated with flap loss and improving overall success are paramount. This study aimed to comprehensively assess the factors influencing flap revision and free tissue transfer survival in head and neck reconstruction. The study included 70 patients with defects in the lower two-thirds of the head and neck region and underwent reconstruction using free flaps. Patient age, gender, smoking status, comorbidities and data on the location and aetiology of the defect, the specific type of flap employed, the recipient artery and vein chosen, instances of revision and the overall success of the flap were collected. The investigation aimed to establish correlations between these variables as well as flap success and revision rates. No statistically significant differences were observed in arterial and venous anastomosis revision rates, or flap survival, in relation to variables such as age, gender, flap type, smoking status, comorbidities, recipient artery or vein and the number of vein anastomoses. The malignant tumour group exhibited a lower requirement for arterial revision and a higher flap survival rate compared to the benign tumour group. This study underscores the comparable safety profiles of perforator-based and conventional flaps in head and neck reconstruction. Furthermore, it reveals that patient characteristics are not contraindications for free tissue transfer. Additionally, the quantity of the veins and choice of recipient vessels are flexible and do not significantly impact flap success. The higher rates of flap success in patients with malignant aetiology requires further investigation.
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Affiliation(s)
- Galip Gencay Üstün
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey.
| | - Güven Ozan Kaplan
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey
| | - Gökhan Sert
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey
| | - Hakan Uzun
- Department of Plastic Reconstructive and Aesthetic Surgery, Hacettepe University Faculty of Medicine, Sıhhiye, Ankara 06100, Turkey
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6
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Lee ZH, Canzi A, Yu J, Chang EI. Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction. J Clin Med 2024; 13:1311. [PMID: 38592147 PMCID: PMC10932027 DOI: 10.3390/jcm13051311] [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: 12/26/2023] [Revised: 02/03/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium.
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Affiliation(s)
| | | | | | - Edward I. Chang
- Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX 77030, USA
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7
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Nakamura A, Aihara Y, Chiba K, Matsumine H, Sakurai H, Kawamata T. Efficacy of the pedicle trapezius muscle flap for the multisurgical removal of pediatric posterior fossa anaplastic ependymoma. Childs Nerv Syst 2023; 39:1635-1639. [PMID: 37016090 DOI: 10.1007/s00381-023-05941-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/23/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVE Exceedingly refractory, pediatric anaplastic ependymoma in many cases requires multisurgical removal. The high risk of poor wound healing and CSF leakage especially at the posterior fossa make this tumor difficult to treat. CASE A 9-year-old girl has had 4th ventricular anaplastic ependymoma since the age of 3. She experienced tumor removal 8 times including 4 posterior fossa craniotomies because tumors were disseminated not only to the posterior fossa but also to the cerebral hemispheres. She also underwent a dermal graft using a free flap. She experienced CSF leaks and meningitis frequently because the wound healing was poor. We performed a dermal flap closure using a pedicle trapezius muscle flap with a plastic surgeon when we performed the 5th tumor removal. RESULT We achieved complete wound closure in spite of broad deficiencies in subcutaneous and epidermal tissues. After that, recurrences of posterior fossa tumors presented within a short term, and tumor removal via an incision of a pedicle trapezius muscle flap was performed without recurrence of CSF leaks and meningitis. DISCUSSION AND CONCLUSION For the first time, we are able to report on the efficacy of using the pedicle trapezius muscle flap for multisurgical removal of pediatric posterior fossa anaplastic ependymoma. The muscle flap was found to be effective because of the multiple surgeries expected, and the pedicle trapezius muscle flap was found to be resilient to multiple surgical procedures. Although advantageous, the dorsal scapular artery which is required for flap creation is actually difficult to harvest. Compared to a flee flap, the pedicle trapezius muscle flap maintains vascular supply. Furthermore, this technique has the possibility of being applied to defective dura mater closure that cannot be watertight due to multiple surgeries. However, it is very important to inform the patient's family not only about the improved efficacy of surgery, but also to raise awareness on consequential cosmetic issues.
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Affiliation(s)
- Akikazu Nakamura
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Yasuo Aihara
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan.
| | - Kentaro Chiba
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Hajime Matsumine
- Department of Plastic Surgery, Tokyo Woman's Medical University, Tokyo, Japan
| | - Hiroyuki Sakurai
- Department of Plastic Surgery, Tokyo Woman's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
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8
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Chang K, Akakpo KE, Graboyes EM, Zenga J, Puram SV, Pipkorn P. Free tissue reconstruction in the "vessel-depleted" neck: A multi-institutional cohort study. Microsurgery 2023; 43:205-212. [PMID: 36285983 DOI: 10.1002/micr.30978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 08/16/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Much of the literature on free tissue reconstruction in the "vessel-depleted" neck is focused on identification of vessels outside the pretreated field and data on free flap outcomes when infield microvascular anastomosis is performed remain scarce. We aim to report on free flap outcomes and recipient vessel choice in a large cohort of patients with prior radiation and neck dissection (RTND) to the ipsilateral side of vessel anastomosis. METHODS A retrospective review was performed including patients who received head and neck free tissue transfer following prior RTND to the ipsilateral side of vessel anastomosis. Pretreatment data, free flap type, defect site, and recipient vessel choice were reported. Recipient vessel choice was stratified according to neck dissection level and prior free flap. Primary outcome was free flap survival (total failure, partial failure, success) within 30 days after surgery. RESULTS This study included 72 free flap cases in 68 patients. Free flap success was 94.4%; one case (1.4%) resulted in total flap loss and three cases (4%) had partial flap loss. The facial (35%), external carotid (ECA) (25%), and superior thyroid arteries (16%) were the most common recipient arteries. The external jugular (EJV) (38%), facial (30%), and internal jugular veins (IJV) (15%) were the most common recipient veins. The superior thyroid artery was used less frequently with a prior level 2-3/4 neck dissection compared to a prior level 1-3/4 neck dissection (6% vs. 17%, p = 0.83). The facial artery (7% vs. 67%, p < 0.01) and vein (13% vs. 46%, p = 0.04) were used less frequently when a prior free flap with ipsilateral anastomosis was performed. The superior thyroid, ECA, IJV, and EJV were more commonly used in this subgroup. CONCLUSION Free tissue transfer with infield microvascular anastomosis in a neck with prior RTND can be safely done with comparable outcomes to surgically naïve, non-irradiated necks.
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Affiliation(s)
- Katherine Chang
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA
| | - Kenneth E Akakpo
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, Wisconsin, 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, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA.,Department of Genetics, Washington University, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University, St. Louis, Missouri, USA
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Zhang D, Jin C, Han T, Chen J, Ali Raza M, Li B, Wang L, Yan H. Sinomenine promotes flap survival by upregulating eNOS and eNOS-mediated autophagy via PI3K/AKT pathway. Int Immunopharmacol 2023; 116:109752. [PMID: 36739833 DOI: 10.1016/j.intimp.2023.109752] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 02/05/2023]
Abstract
Large skin defects and surgical tissue reconstructions are frequently covered utilizing random flaps. The flap has the advantage of being designed according to the size and shape of a surgical wound. However, the necrosis of the distal part of the flap restricts the clinical application of flaps. Sinomenine (SIN) is the major active component of sinomenium acutum. SIN has been demonstrated to inhibit oxidative stress and stimulate autophagy in a cell, animal, and clinical studies. The protective and proliferative effects of sinomenium on HUVECs were evaluated by scratched test, CCK-8, and EDU assays. For the flap survival, we established a mouse random pattern flap model and observed the effects of SIN injected intraperitoneally. The survival area and blood flow intensity of the flap in sinomenium group were significantly increased compared to the control group. Our results demonstrate that SIN promotes flap survival. Sinomenium enhances eNOS expression in the flap and reduces the level of oxidative stress, promotes autophagy flux increase, reduces apoptosis, and promotes angiogenesis. Having a therapeutic benefit of SIN, Autophagy inhibitor 3-MA shows its critical role by reversing the beneficial effects of SIN, and the nitric oxide synthase inhibitor l-NAME both stimulated HUVECs that explore the relationship between autophagy flux and nitric oxide synthase. Furthermore, the mechanism in our study reveals the changes in the signal pathway of PI3K/AKT, the protective effect of SIN during antioxidant activity, the activation of eNOS through PI3K/AKT signaling pathway affects autophagy through the eNOS system, and promote the random flap survival.
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Affiliation(s)
- Dupiao Zhang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Chen Jin
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Tao Han
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Jianpeng Chen
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Mazhar Ali Raza
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Baolong Li
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Liang Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China; The Second Clinical Medical College of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Hede Yan
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China; Zhejiang Provincial Key Laboratory of Orthpaedics, Wenzhou, Zhejiang Province, China.
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10
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Tharakan T, Marfowaa G, Akakpo K, Jackson R, Zenga J, Puram SV, Pipkorn P. Multiple simultaneous free flaps for head and neck reconstruction: A multi-institutional cohort. Oral Oncol 2023; 136:106269. [PMID: 36462329 PMCID: PMC10559876 DOI: 10.1016/j.oraloncology.2022.106269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 11/05/2022] [Accepted: 11/24/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVES To describe the experience of two tertiary academic centers with multiple, simultaneous free flaps for complex head and neck defect reconstruction. METHODS Patients undergoing multiple, simultaneous free flaps from 2017 to 2022 were retrospectively reviewed. RESULTS Seventy-one patients (64.8% male, median age 61 years) were identified and underwent 143 free flaps. The leading surgical indication was squamous cell carcinoma (n = 48, 67.6%). Defect sites included oral cavity, maxilla, pharynx, parotid, skull base, and scalp. The most common free flap combinations were fibula (FFF) with anterolateral thigh flap (n = 33, 46.5%), radial forearm (RFFF) with scapula (n = 11, 15.5%), and RFFF with FFF (n = 10, 14.1%). Median operative time was 12 h. Median length of hospitalization was 10 days. At last follow-up (median 6 months), 141 flaps (98.6%) survived without partial nor complete flap failure. CONCLUSION Multiple, simultaneous free flaps are a rare, yet reliable option for head and neck reconstruction in select patients with defects involving several tissue types, multiple functional areas, or large volumes.
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Affiliation(s)
- Theresa Tharakan
- Department of Otolaryngology- Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Gifty Marfowaa
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, MO, United States
| | - Kenneth Akakpo
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, MO, United States
| | - Ryan Jackson
- Department of Otolaryngology- Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, MO, United States
| | - Sidharth V Puram
- Department of Otolaryngology- Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States; Department of Genetics, Washington University in St Louis School of Medicine, St Louis, MO, United States
| | - Patrik Pipkorn
- Department of Otolaryngology- Head and Neck Surgery, Washington University in St Louis School of Medicine, St Louis, MO, United States.
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11
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Shankhdhar VK, Mantri MR, Wagh S, Thiagarajan S, Chaukar D, Jaiswal D, Mathews S. Microvascular Flap Reconstruction for Head and Neck Cancers in Previously Operated and/or Radiated Neck: Is It Safe? Ann Plast Surg 2022; 88:63-67. [PMID: 34225312 DOI: 10.1097/sap.0000000000002951] [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: 11/26/2022]
Abstract
BACKGROUND Microvascular reconstruction after oncologic resection with curative intent in recurrent or second primary cancer cases is challenging not only because of the complexity of the defect but also due to difficulty in finding suitable donor vessels in the neck that has already been subjected to surgery and subsequent adjuvant treatment. In our present study, we evaluated the success of free flaps, reexplorations, and factors associated with reexploration and with flap failures in previously operated and/or radiated neck. METHODS In this retrospective study, we analyzed patients who underwent microvascular reconstruction from January 2016 to December 2018 in patients with previous surgery and/or radiation, considered as "already treated neck" (ATN). These cases were reviewed to analyze variables that included age, sex, indication for surgery (recurrence, second primary, osteoradionecrosis, and secondary reconstruction), duration since previous surgery or radiation, free flap done, donor vessels used, the need to go to the contralateral neck or outside the neck, need for vein grafts, flap reexploration rate, flap survival rate, and hospital stay of the patients. We also tried to identify factors that predisposed for a reexploration after performing reconstruction with a free flap in ATN. RESULTS Of 1522 free flaps done, 371 patients were included in the study. Flap success rate was 90.8% in ATN, which was comparable to naive neck (94%; P = 0.108). The reexploration rate in ATN (16.2%) was significantly higher (P = 0.0003) than in naive neck (9.8%). The previous treatment (neck dissection) received [P = 0.001; odds ratio, 13.7 (1.87-101.6)] was the most significant predisposing factor, and patients undergoing osteocutaneous flaps were more prone to undergo reexplorations (P = 0.05). Side of anastomosis, vessel used for anastomosis, comorbidities, and time since previous treatment did not affect the reexploration rate significantly. CONCLUSIONS Microvascular reconstruction can be safely performed in ATN with good success rates, and it should not be a deterrent in whom free flap is required to achieve best functional outcome. However, it may be associated with increase in reexploration rates in the postoperative period. Patients having undergone a previous neck dissection are at more risk of undergoing this reexploration in comparison with radiotherapy (RT)/chemotherapy and radiotherapy (CTRT) alone.
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12
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Hyodo I, Nakamura R, Okumura S, Kamei Y, Yasuda H, Suzuki H. Feasibility and Safety of Microvascular Anastomoses Within Previously-Dissected Neck Regions. J UOEH 2022; 44:331-339. [PMID: 36464307 DOI: 10.7888/juoeh.44.331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The selection of appropriate recipient vessels is important for the success of head and neck reconstruction. Vessels located outside of previously-dissected neck regions tend to be more frequently selected due to relative ease of preparation. However, some advantages are offered regarding dead space filling and formation by using vascular anastomoses within regions previously dissected, or reusing former free flap pedicle due to their proximity to the defect. We analyzed microsurgical anastomoses in patients requiring oral reconstruction who had previously undergone neck dissection. Contralateral vascular anastomoses were preoperatively planned in 10 cases of which 9 could be successfully performed (achievement rate, 90%). Ipsilateral side anastomoses were planned in 28 cases, with 26 anastomosed as planned (achievement rate, 92.9%). There was no statistically significant difference between the two groups. Vascular anastomosis within the scar region can be performed safely, based on preoperative planning and intraoperative judgment.
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Affiliation(s)
- Ikuo Hyodo
- Department of Plastic and Reconstructive Surgery, University Hospital of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8556, Japan
- Department of Plastic and Reconstructive Surgery, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya 464-8681, Japan
| | - Ryota Nakamura
- Department of Plastic and Reconstructive Surgery, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya 464-8681, Japan
| | - Seiko Okumura
- Department of Plastic and Reconstructive Surgery, Aichi Cancer Center Hospital, Chikusa-ku, Nagoya 464-8681, Japan
| | - Yuzuru Kamei
- Department of Plastic and Reconstructive Surgery, Nagoya University Graduate School of Medicine, Showa-ku, Nagoya 466-8560, Japan
| | - Hiroshi Yasuda
- Department of Plastic and Reconstructive Surgery, University Hospital of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8556, Japan
| | - Hideaki Suzuki
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Occupational and Environmental Health, Japan. Yahatanishi-ku, Kitakyushu 807-8556, Japan
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13
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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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14
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Lai CS, Shen CH, Chang YT, Liu SA, Lu CT, Tsai YC, Chen IC, Feng CH, Wu CY. Recipient vessel selection for multiple free flap transfers in head and neck reconstruction at different periods. Microsurgery 2021; 41:438-447. [PMID: 33988860 DOI: 10.1002/micr.30752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Treatment decisions can be challenging in patients undergoing multiple oropharyngeal microsurgical reconstructions at different periods by various causes. We, retrospectively, reviewed patients with at least three consecutive free flap reconstructions to determine the optimal strategy for selecting recipient vessels. METHODS Then, 36 patients (33 men and 3 women) who underwent at least 3 microsurgical reconstructions with a total of 51 free flap transfers for head and neck defects were included in this report. The most common reason for multiple microsurgical reconstructions was recurrent disease. For reconstructions, recipient vessel candidates on the same side of the head and neck were prioritized; if ipsilateral vessels were unavailable, contralateral recipient vessels, which might necessitate vein grafts, were used. RESULTS The most common reconstructions were anterolateral thigh flaps (19 cases). The most commonly used contralateral recipient vessels were the superior thyroid artery, facial artery, and external jugular vein. All vessel anastomoses were performed using the end-to-end method. Postoperative complications occurred at the sites of 26 free flap reconstructions. The overall flap reconstruction success rate in patients with at least three surgeries was 90.2%. The median follow-up duration was 25.8 months. During follow-up, 26 patients survived until the end of follow-up. CONCLUSIONS In patients undergoing multiple free flap reconstructions, recipient vessels on the ipsilateral side that have not been subjected to radiation should be selected first. Recipient vessels contralateral to the reconstruction side can then be selected; however, they may require vein grafts. Finally, distant healthy recipient vessels can be selected through vein grafting.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Shih-An Liu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China.,Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chin-Hsing Feng
- Division of Plastic and Reconstructive Surgery Laboratory, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
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15
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Lin CH, Kudva A. Simultaneous Reconstruction of Mandibular and Maxillary Defects Using the Single Free Fibular Osseocutaneous Flap: Case Series and Review of the Literature. Ann Plast Surg 2021; 86:428-433. [PMID: 33587455 DOI: 10.1097/sap.0000000000002436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The facial profile requires adequate maxillary and mandibular projection. Although oral cancer tumor ablation might create ipsilateral maxillary and mandibular defect, fibular flap is popular in mandibular defect reconstruction. However, the maxillary defect results in sunken cheek or oral contracture. A single fibular flap can provide several struts to rebuild 2 jaws with adequate 3-dimensional spatial placement. MATERIALS AND METHODS In total, 7 cases of secondary oral contracture and 2 cases of primary oncologic tumor ablation underwent single fibular flap for 2 jaws. Using multiple osteotomies, the distal fibular struts were used for the upper jaw, the second struts were discarded (3-4 cm), and proximal struts were used for mandible defect reconstruction. There were 5 accompanying free flaps for facial lining (2) and contralateral oral contracture release (3). RESULTS All flaps survived without distal strut avascular necrosis, but 2 patients died from tumor metastasis. These patients presented adequate middle and lower facial profile. One patient underwent mandibular fibula strut distraction osteogenesis followed by integrated teeth on both jaws. CONCLUSIONS Single fibular transfer can accomplish 2 jaw bony defects and facial profile reconstruction. It can release oral contracture functionally and correct sunken cheek aesthetically. The reconstructed fibula can allow secondary teeth implantation rehabilitation.
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Affiliation(s)
- Chih-Hung Lin
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital and University, Taoyuan, Taiwan
| | - Adarsh Kudva
- Deparrtment of Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, India
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16
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Kushida-Contreras BH, Manrique OJ, Gaxiola-García MA. Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature. Ann Surg Oncol 2021; 28:2882-2895. [PMID: 33550502 DOI: 10.1245/s10434-021-09590-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures. METHODS A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications. RESULTS The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases. CONCLUSIONS Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.
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Affiliation(s)
| | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York, NY, USA
| | - Miguel Angel Gaxiola-García
- Plastic and Reconstructive Surgery Department, Mexico's Children Hospital (Hospital Infantil de México "Federico Gómez"), Mexico City, Mexico.
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17
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A Sequential Thoracoacromial Artery Perforator Flap for Reconstructing the Donor Site of Sternocleidomastoid Myocutaneous Flaps. Ann Plast Surg 2020; 84:657-664. [DOI: 10.1097/sap.0000000000002042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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18
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Marchi F, Al Deek NF. Double free flaps for oromandibular defects: It is much more than bone length and surface area. Oral Oncol 2020; 109:104730. [PMID: 32416970 DOI: 10.1016/j.oraloncology.2020.104730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/15/2020] [Accepted: 04/17/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Filippo Marchi
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan
| | - Nidal F Al Deek
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
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19
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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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20
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Zeiderman MR, Pu LLQ. Contemporary reconstruction after complex facial trauma. BURNS & TRAUMA 2020; 8:tkaa003. [PMID: 32341916 PMCID: PMC7175762 DOI: 10.1093/burnst/tkaa003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/07/2020] [Indexed: 11/12/2022]
Abstract
Complex facial trauma requires complex repair and solutions. This process is challenging for the surgeon who seeks to manage the expectations of the patient and family while achieving the best possible result. Historically, the use of pedicled flaps, and then free tissue transfer, were the primary techniques utilized. Advancements in soft-tissue reconstruction, such as perforator flaps and pre-expanded and prefabricated flaps, allow refinement of the soft-tissue reconstruction process to create the best initial soft-tissue coverage. The advent of contemporary technologies, such as virtual surgical planning, stereolithography and customized implants and plates, facilitates a tailored approach to the patient’s reconstructive needs for precise bony reconstruction. When surgical and technological techniques are combined in complementary multistage reconstructions, better reconstructive and aesthetic outcomes are achievable than ever before. In this review, the authors present a summary of the management of complex facial trauma based on the senior author’s broad experience. Initial management and contemporary reconstructive techniques and technology to provide optimal outcomes are reviewed. A case series of complex facial traumas and their reconstructive process is also presented to demonstrate how complementary staged procedures can yield an optimal result. We believe the reconstructive surgeon managing complex facial trauma should strive to incorporate contemporary technologies and techniques into their armamentarium to provide the best patient care.
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Affiliation(s)
- Matthew R Zeiderman
- Division of Plastic Surgery, Department of Surgery, University of California, Davis, 2335 Stockton Boulevard, Room 6008 Sacramento, CA 95817, USA
| | - Lee L Q Pu
- Division of Plastic Surgery, Department of Surgery, University of California, Davis, 2335 Stockton Boulevard, Room 6008 Sacramento, CA 95817, USA
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21
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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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22
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Sharif KF, Sims JR, Yue LE, Baik FM, Kiplagat KJ, Buchbinder D, Okay DJ, Chai RL, Urken ML. Reconstructive and prosthodontic outcomes after multiple palatomaxillary reconstructions. Laryngoscope 2019; 130:2349-2353. [PMID: 31886884 DOI: 10.1002/lary.28481] [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: 10/30/2019] [Accepted: 11/25/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A subset of patients who undergo major palatomaxillary reconstruction do not initially achieve their intended oncologic and/or reconstructive goals and require additional surgery. We aim to detail the unique management considerations in this patient population. METHODS We performed a retrospective review of patients who underwent palatomaxillary reconstruction by the senior author (m.l.u.) between 1998 and 2016. RESULTS Twenty-one patients required multiple reconstructions. The median time to second reconstruction was 17 months. The most common reason for a second reconstruction was for recurrent disease (10 of 21), followed by functional/aesthetic reasons (7 of 21) and osteoradionecrosis (4 of 21). Four patients went on to have a third reconstruction, and two underwent a fourth. A total of 27 reconstructions were performed, consisting of 20 soft tissue free flaps, four vascularized bone free flaps, and three locoregional flaps. CONCLUSION This patient cohort represents unique oncologic and reconstructive challenges. With long-term follow-up, multiple reconstructions may be required to optimize oncologic and functional/aesthetic outcomes. This is the first series of its kind that details the reasons for, as well as the outcomes of, patients who required multiple reconstructive procedures following initial palatomaxillary reconstruction. LEVEL OF EVIDENCE 2B Laryngoscope, 130:2349-2353, 2020.
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Affiliation(s)
- Kayvon F Sharif
- THANC (Thyroid, Head and Neck Cancer) Foundation, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - John R Sims
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Lauren E Yue
- THANC (Thyroid, Head and Neck Cancer) Foundation, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Fred M Baik
- Department of Otolaryngology-Head and Neck Surgery, Stanford University Medical Center, Stanford, California
| | - Kimberly J Kiplagat
- THANC (Thyroid, Head and Neck Cancer) Foundation, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Daniel Buchbinder
- Division of Oral and Maxillofacial Surgery, Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Devin J Okay
- Division of Prosthodontics and Maxillofacial Prosthetics, Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Raymond L Chai
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
| | - Mark L Urken
- THANC (Thyroid, Head and Neck Cancer) Foundation, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York.,Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York
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23
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Sequential reconstruction for recurrent head and neck cancer: A 10-year experience. Arch Plast Surg 2019; 46:449-454. [PMID: 31550750 PMCID: PMC6759442 DOI: 10.5999/aps.2019.00157] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Most patients with head and neck cancer successfully undergo oncologic resection followed by free or local flap reconstruction, depending on the tumor’s size and location. Despite effective curative resection and reconstruction, head and neck cancer patients still face a high risk of recurrence and the possibility of a second primary cancer. Moreover, surgeons hesitate to perform sequential reconstruction following curative resection for several reasons. Few large-scale studies on this subject are available. Therefore, we retrospectively evaluated the outcome of sequential head and neck reconstruction to determine the possible risks. Methods In total, 467 patients underwent head and neck reconstruction following cancer resection at our center from 2008 to 2017. Of these cases, we retrospectively reviewed the demographic and clinical features of 58 who had sequential head and neck reconstruction following resection of recurrent cancer. Results Our study included 43 males (74.1%) and 15 females (25.9%). The mean age at the initial operation was 55.4±15.3 years, while the mean age at the most recent operation was 59.0±14.3 years. The interval between the first and second operations was 49.2±62.4 months. Twelve patients (20.7%) underwent surgery on the tongue, and 12 (20.7%) had procedures on the oropharynx. Thirty-four patients (58.6%) received a sequential free flap reconstruction, and 24 patients (41.4%) were treated using locoregional flaps. No cases of flap failure occurred. Conclusions Our findings suggest that patients who need additional operations with recurrent head and neck cancer could optimally benefit from sequential curative resections and reconstructions.
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24
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Three Simultaneous Free Flaps to Reconstruct a Complex Frozen Neck and a Large Hypopharyngeal Fistula. J Craniofac Surg 2019; 30:e203-e205. [PMID: 30608378 DOI: 10.1097/scs.0000000000005093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Frozen neck and hypopharyngeal fistula are sometimes present after tumor ablation of the larynx, multiple local surgeries with scar tissue, and radiotherapy and chemotherapy. This multiorgan involvement requires 1 or even 2 flaps. We present a 63-year-old heavy smoker with frozen neck tissue and simultaneous large hypopharyngeal fistula and neck defect. After careful preoperative planning, he was successfully treated with 3 simultaneous free flaps: 2 anterolateral thigh flap (ALT) and 1 lateral arm flap (LAF). One ALT was used as a patch to restore the hypopharynx continuity. A second ALT was used to cover the anterior neck defect and the LAF flap was used to reconstruct the submandibular area. The flaps survived and the patient had a 5 mm proximal fistula which was sutured, and he was able to eat per mouth. By combining multiple free flaps, we were able to restore the function of the hypopharynx and to cover the esthetic units of the neck by avoiding the "turkey neck" appearance.
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25
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Free Flap Outcomes of Microvascular Reconstruction after Repeated Segmental Mandibulectomy in Head and Neck Cancer Patients. Sci Rep 2019; 9:7951. [PMID: 31138880 PMCID: PMC6538601 DOI: 10.1038/s41598-019-44467-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 05/17/2019] [Indexed: 11/25/2022] Open
Abstract
This is the first study to investigate the impact of a second fibula flap or a soft tissue flap combined with bridging plate for a repeated segmental mandibulectomy reconstruction on flap outcomes in head and neck cancer patients. A retrospective comparative analysis (2007–2016) of 61 patients who underwent a second segmental mandibulectomy was performed. 20 patients underwent a fibula flap reconstruction whereas 41 had a soft tissue flap and plate reconstruction. No significant difference was seen in the operative time, total hospital stay, flap loss, re-exploration rates, plate exposure rate, or recipient site infection rate. On multivariate analysis, patients reconstructed with a soft tissue flap and bridging plate (odds ratio (OR) 3.997; 95% confidence interval (CI), 1.046–15.280, p = 0.043) and complications developed in previous surgery (OR 4.792; 95% CI, 1.120–20.493, p = 0.035) were shown to be independent predictors of a prolonged nasogastric tube dependence. The utilization of a soft tissue flap with plate is associated with comparative results of acute complication rate within 1 week, recipient site infection rate, and plate exposure rate to free fibula flaps alone. Free fibula flaps may result in a decreased risk for prolonged tube dependence compared to free soft tissue flap reconstructions.
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26
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Ercin BS, Bicer A, Yigitturk G, Cinar C, Cavusoglu T, Uyanikgil Y, Gurler T. Who needs extra time? Amniotic membrane wrapped pauci-suture model for rapid anastomoses . J Plast Surg Hand Surg 2019; 53:89-96. [PMID: 30654665 DOI: 10.1080/2000656x.2018.1550419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
An ideal anastomosis method will obtain the highest post-anastomotic vessel patency and will repair the vessel anatomically with minimal thrombosis in an easier, faster and cheaper fashion. To achieve these goals an anastomosis model using an amniotic membrane is introduced. The study was performed on the femoral arteries of 22 Wistar Albino rats (11 control group, 11 experimental group). In the experiment group, the microvascular anastomosis was completed with three sutures and a patch of amniotic membrane which was wrapped around the anastomotic site. The conventional anastomosis technique with eight sutures was performed in the control group. The effects of the model on the patency and histological structure of the vessels were evaluated. As a result, normal patency was determined radiologically and macroscopically in all of the anastomoses. No thrombosis or aneurysm was detected in any of the anastomoses. In the angiographic study, vessel patency was detected in both the control and experimental groups. The average time to complete the arterial anastomosis was 18.14 (±2.84) and 10.39 (±2.45) minutes in the control and the experiment groups respectively. In the histological studies, anti-eNOS staining revealed that endothelin levels were significantly higher in the experimental group. This method describes a new anastomosis model in microvascular surgery with promising results that call for additional experimental studies and further clinical implementations. We believe that this experimental technique can be put into clinical practice as an alternative to the conventional microvascular anastomosis technique.
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Affiliation(s)
- Burak Sercan Ercin
- a Department of Plastic, Reconstructive and Aesthetic Surgery , Turkish Ministry of Health, Siirt Urban Hospital , Siirt , Turkey
| | - Ahmet Bicer
- b Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery , Ege University , Izmir , Turkey
| | - Gurkan Yigitturk
- c Faculty of Medicine, Department of Histology and Embryology , Mugla Sitki Kocman University , Mugla , Turkey
| | - Celal Cinar
- d Faculty of Medicine, Department of Radiology, Division of Interventional Radiology , Ege University , Izmir , Turkey
| | - Turker Cavusoglu
- e Faculty of Medicine, Department of Histology and Embryology , Ege University , Izmir , Turkey.,f Cord Blood, Cell And Tissue Research And Application Centre, Ege University , Izmir , Turkey
| | - Yigit Uyanikgil
- e Faculty of Medicine, Department of Histology and Embryology , Ege University , Izmir , Turkey.,f Cord Blood, Cell And Tissue Research And Application Centre, Ege University , Izmir , Turkey
| | - Tahir Gurler
- b Faculty of Medicine, Department of Plastic, Reconstructive and Aesthetic Surgery , Ege University , Izmir , Turkey
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Nokovitch L, Davrou J, Bidault F, Devauchelle B, Dakpé S, Vacher C. Vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction. Surg Radiol Anat 2018; 41:447-454. [PMID: 30552489 DOI: 10.1007/s00276-018-2166-2] [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: 05/01/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Initially described by Baudet in 1982, the fibula flap including the lateral head of the soleus muscle allows a one-stage reconstruction for large maxillo-mandibular defects. The aim of this study was to evaluate the number of muscular branches destined to the soleus muscle and their distance from the origin of the fibular artery, to assess the vascular anatomy of the free fibula flap including the lateral head of the soleus muscle applied to maxillo-mandibular reconstruction. METHODS We performed a cadaveric anatomic study on ten lower limbs, and a CT angiography anatomic study on 38 legs. The number of soleus branches originating from the fibular artery, and the distance between the origin of the fibular artery and each of the identified branches were measured. RESULTS The number of soleus branches destined to the lateral head of the soleus muscle is variable, with in our study 1-3 branches found. Soleus branches destined to the lateral head of the soleus muscle emerged at a distance ranging between 0 and 2.9 cm (mean value = 1.82 cm) from the origin of the fibular artery in 40% of cases, between 3 and 5.9 cm (mean value = 4.27 cm) from the origin of the fibular artery in 37% of cases, and was at a distance of 6 cm or more (mean value = 6.93 cm) from the origin of the fibular artery in 20% of cases. CONCLUSIONS An origin of the soleus vessels in close proximity to the origin of the fibular artery represents the main limitation of this flap, the length of the remaining fibular pedicle making it difficult to achieve secure anastomosis in the cervical area. The vascular distribution of the proximal part of the lateral head of the soleus muscle being segmental, it is possible to lengthen the flap pedicle ligating the most proximal soleus branches originating from the fibular artery.
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Affiliation(s)
- Lara Nokovitch
- Anatomy Laboratory of the University of Medicine Paris V René Descartes, AP-HP Surgical School, Paris, France.,Department of Maxillo-Facial Surgery, University Hospital of Amiens, Picardie Jules Verne University, Amiens, France
| | - Julien Davrou
- Department of Maxillo-Facial Surgery, University Hospital of Amiens, Picardie Jules Verne University, Amiens, France
| | - François Bidault
- Radiology Department, Gustave Roussy Institute, Villejuif, France
| | - Bernard Devauchelle
- Department of Maxillo-Facial Surgery, University Hospital of Amiens, Picardie Jules Verne University, Amiens, France
| | - Stéphanie Dakpé
- Department of Maxillo-Facial Surgery, University Hospital of Amiens, Picardie Jules Verne University, Amiens, France
| | - Christian Vacher
- Department of Maxillo-Facial Surgery, Beaujon Hospital, AP-HP, 100 boulevard du Général Leclerc, 92110, Clichy, France. .,University of Medicine Paris-Diderot, EA 2496, Paris, France.
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Face Transplant: Status of Current Supporting Technology to Plan and Perform the Operation and Monitor the Graft in the Postoperative Period. J Craniofac Surg 2018; 29:820-822. [PMID: 29750725 DOI: 10.1097/scs.0000000000004605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Face transplant has rapidly advanced since the first operation in 2005, and to date, 40 partial or full-face transplants have been performed. The safety and efficacy of this operation are aided at all phases by supporting technologies. These include advanced imaging techniques to plan the operation, devices to monitor the flap in the immediate perioperative period, and noninvasive imaging and serum markers to monitor for acute and chronic rejection. Some of the technologies, such as those used in the immediate perioperative period, have extensive evidence supporting their use, whereas those to detect acute or chronic rejection remain investigational. The technologies of today will continue to evolve and make the operation safer with improved outcomes; however, the most significant barrier for face transplant continues to be immunologic rejection.
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Löfstrand J, Chang KP, Lin JAJ, Loh CYY, Chou HY, Kao HK. Third Repeat Microvascular Reconstruction in Head and Neck Cancer Patients Aged 65 Years and Older: A Longitudinal and Sequential Analysis. Sci Rep 2017; 7:15740. [PMID: 29146958 PMCID: PMC5691199 DOI: 10.1038/s41598-017-15948-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/06/2017] [Indexed: 11/12/2022] Open
Abstract
Performing a sequential third free flap for reconstruction of a head and neck defect after cancer resection can be challenging, and the problem is further compounded in elderly patients. The outcomes in this clinical scenario are currently unknown and this study aims to compare the results in elderly patients with younger patients in a high-volume microsurgical unit. A retrospective review of 126 consecutive patients who had undergone three sequential free flap reconstructions after head and neck cancer was performed. The patients were divided into two groups – older or younger than 65 years old (n = 105 and n = 21, respectively). Patient demographics, intraoperative and postoperative outcomes were noted and analyzed. The overall flap success in this patient cohort was 94.4% (7 flap losses in 126 patients). Cardiovascular complications were significantly more common in the older group (19% vs. 1.9%, p = 0.001). Delirium occurred more frequently in the older group compared with the younger group (23.8% vs. 6.7%, p = 0.023). There were no significant differences regarding surgical complications. With adequate planning, a sequential third free flap can be performed safely and successfully in patients who are more than 65 years of age. Particular attention to the perioperative morbidity in elderly patients is crucial for successful outcomes.
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Affiliation(s)
- Jonas Löfstrand
- Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Gothenburg, Sweden.,Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Kai-Ping Chang
- Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Jennifer An-Jou Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Charles Yuen Yung Loh
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsuan-Yu Chou
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Chen CL, Zenga J, Roland LT, Pipkorn P. Complications of double free flap and free flap combined with locoregional flap in head and neck reconstruction: A systematic review. Head Neck 2017; 40:632-646. [DOI: 10.1002/hed.25005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 09/15/2017] [Accepted: 09/26/2017] [Indexed: 11/11/2022] Open
Affiliation(s)
- Collin L. Chen
- Department of Otolaryngology - Head and Neck Surgery; Washington University in St Louis School of Medicine; St Louis Missouri
| | - Joseph Zenga
- Department of Otolaryngology - Head and Neck Surgery; Washington University in St Louis School of Medicine; St Louis Missouri
| | - Lauren T. Roland
- Department of Otolaryngology - Head and Neck Surgery; Washington University in St Louis School of Medicine; St Louis Missouri
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery; Washington University in St Louis School of Medicine; St Louis Missouri
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Oxygen-Sensing Paint-On Bandage: Calibration of a Novel Approach in Tissue Perfusion Assessment. Plast Reconstr Surg 2017; 140:89-96. [PMID: 28654595 DOI: 10.1097/prs.0000000000003421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Knowledge of tissue oxygenation status is fundamental in the prevention of postoperative flap failure. Recently, the authors introduced a novel oxygen-sensing paint-on bandage that incorporated an oxygen-sensing porphyrin with a commercially available liquid bandage matrix. In this study, the authors extend validation of their oxygen-sensing bandage by comparing it to the use of near-infrared tissue oximetry in addition to Clark electrode measurements. METHODS The oxygen-sensing paint-on bandage was applied to the left hind limb in a rodent model. Simultaneously, a near-infrared imaging device and Clark electrode were attached to the right and left hind limbs, respectively. Tissue oxygenation was measured under normal, ischemic (aortic ligation), and reperfused conditions. RESULTS On average, the oxygen-sensing paint-on bandage measured a decrease in transdermal oxygenation from 85.2 mmHg to 64.1 mmHg upon aortic ligation. The oxygen-sensing dye restored at 81.2 mmHg after unclamping. Responses in both control groups demonstrated a similar trend. Physiologic changes from normal to ischemic and reperfused conditions were statistically significantly different in all three techniques (p < 0.001). CONCLUSIONS The authors' newly developed oxygen-sensing paint-on bandage exhibits a comparable trend in oxygenation recordings in a rat model similar to conventional oxygenation assessment techniques. This technique could potentially prove to be a valuable tool in the routine clinical management of flaps following free tissue transfer. Incorporating oxygen-sensing capabilities into a simple wound dressing material has the added benefit of providing both wound protection and constant wound oxygenation assessment.
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Mericli AF, Friedstat JS, Chang EI, Hanasono MM. Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula: A case report. Microsurgery 2017; 37:243-247. [PMID: 28295569 DOI: 10.1002/micr.30129] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 10/11/2016] [Accepted: 10/27/2016] [Indexed: 11/06/2022]
Abstract
Simultaneous maxillary and mandibular reconstruction is exceedingly rare. These are complicated cases, requiring consideration of multiple variables: defect components, donor site morbidity, recipient vessels, and so forth. We describe a unique case of secondary maxillary/mandibular reconstruction in a 59-year-old male. The original defect was created after removal of a buccal squamous cell carcinoma, involving the external cheek skin, buccal mucosa, right mandibular body, and right inferior maxilla; a free vertical rectus abdominis musculocutaneous flap was used for the initial reconstruction. At the time of presentation to our clinic, the patient was tube-feed-dependent, unable to speak, and distressed regarding his appearance. We revised his reconstruction, rebuilding his maxilla and hemimandible using two free fibula flaps from a single fibula. The fibulae were vascularized via vein grafts and an ALT flap was used for external cheek resurfacing. All flaps survived and there were no complications at seven months since his surgery (when this report was written). The patient had intelligible speech and maintained adequate nutrition with a soft diet. Simultaneous vascularized bony reconstruction of the maxilla and mandible using a single fibula flap may be performed safely and with good outcomes.
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Affiliation(s)
- Alexander F Mericli
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Jonathan S Friedstat
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Edward I Chang
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Saunders S, Reese S, Lam J, Wulu J, Jalisi S, Ezzat W. Extended use of perioperative antibiotics in head and neck microvascular reconstruction. Am J Otolaryngol 2017; 38:204-207. [PMID: 28139320 DOI: 10.1016/j.amjoto.2017.01.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 01/17/2017] [Indexed: 11/17/2022]
Abstract
PURPOSE Many head and neck surgical procedures are considered clean-contaminated wounds and antibiotic prophylaxis is recommended. Despite prophylaxis, the incidence of surgical site infections remains significant - especially in the setting of free tissue transfer. The antibiotic course is often of a longer duration after free tissue transfer than the recommended 24hour post-operatively. Currently, there is no consensus on appropriate antibiotic regimen or duration at this time. This study investigates the outcomes of a 7-day perioperative antibiotic regimen after microvascular reconstruction of the head and neck at our institution. MATERIALS AND METHODS A retrospective review was performed of 72 patients undergoing microvascular free tissue at our institution between 09/2011 and 03/2014. The antibiotic regimen, post-operative surgical (including surgical site infections) and medical complications were noted. Our rates of complications and adverse events were compared to all surgical patients, as well as all inpatients hospital-wide with use of the University Health System Consortium database. RESULTS Seventy-two subjects met inclusion criteria for this study. The majority of subjects received cefazolin/metronidazole (69.4%). Subjects with beta-lactam allergy received clindamycin (12.5%). The remainder received an alternative regimen (18.1%). All received at least 7days of antibiotics. The rate of hospital acquired C. difficile diarrhea was 0.57% hospital-wide, 1.13% in Otolaryngology patients, and 1.4% in this study. There were no instances of a multi-drug resistant infection or any adverse reactions to the administration of antibiotics. When compared with other antibiotic regimens, clindamycin was associated with a significantly increased rate of either medical or surgical infections (OR 14.38, p=0.02) and longer hospital stay (average=18days, p<0.05). CONCLUSION The use of a 7-day prophylactic antibiotic regimen is not associated with an increased risk of antibiotic-associated infections, multi-drug resistant infections, or antibiotic-associated complications. The use of clindamycin is associated with increased risk of medical and surgical infections post-operatively and should be avoided in the prophylactic perioperative phase after free tissue transfer of the head and neck.
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Affiliation(s)
- Stefanie Saunders
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Stephen Reese
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jimmy Lam
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Jacqueline Wulu
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Scharkuh Jalisi
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Waleed Ezzat
- Department of Otolaryngology - Head and Neck Surgery, Boston University School of Medicine, Boston, MA, USA.
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Yang B, Qu Y, Su M, Li J, Li H, Xing R, Han Z. Characteristics and surgical management of flap compromise caused by thrombosis of the internal jugular vein. J Craniomaxillofac Surg 2017; 45:347-351. [DOI: 10.1016/j.jcms.2016.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 10/16/2016] [Accepted: 12/08/2016] [Indexed: 11/16/2022] Open
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Wei FC, AL Deek NF, Cheng MH, Lin CH. The Triangle of Unfavorable Outcomes After Microsurgical Head and Neck Reconstruction. Clin Plast Surg 2016; 43:615-20. [DOI: 10.1016/j.cps.2016.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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36
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Chang EI, Hanasono MM, Butler CE. Management of Unfavorable Outcomes in Head and Neck Free Flap Reconstruction. Clin Plast Surg 2016; 43:653-67. [DOI: 10.1016/j.cps.2016.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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37
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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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38
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Trismus Secondary Release Surgery and Microsurgical Free Flap Reconstruction After Surgical Treatment of Head and Neck Cancer. Clin Plast Surg 2016; 43:747-52. [DOI: 10.1016/j.cps.2016.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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39
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Santamaria E, de la Concha E. Lessons Learned from Delayed Versus Immediate Microsurgical Reconstruction of Complex Maxillectomy and Midfacial Defects. Clin Plast Surg 2016; 43:719-27. [DOI: 10.1016/j.cps.2016.05.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tsao CK, Loh CYY, Barrera JM. Free tissue transfer as a vascular source for the vessel-depleted neck. Head Neck 2016; 38:E2515-E2518. [PMID: 27442917 DOI: 10.1002/hed.24539] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 05/17/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Reconstructing head and neck defects postoncologic resection can be challenging. This problem is further amplified when tackling the vessel-depleted or hostile neck. Free flaps still provide the gold standard of reconstructing such defects. However, with increasing reconstructions, recipient vessel options rapidly diminish. This article provides a technique and strategy in managing such difficult cases using previous free flap pedicles. It also highlights the importance of flap selection in paving the way for future successful reconstructions. METHODS We present a fifth sequential free flap reconstruction postoncologic buccal resection and mention the key steps taken to ensure the safe and successful reuse of previous free flap pedicles. RESULTS Intraoperative and postoperative photographs are clearly presented with a particular focus on the management of the recipient pedicle. CONCLUSION Adequate planning and strategic selection of free flaps with long pedicles can provide the necessary vascular sources needed for future successful free flap head and neck reconstructions. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2515-E2518, 2016.
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Affiliation(s)
- Chung-Kan Tsao
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taiwan, Peoples Republic of China.
| | - Charles Yuen Yung Loh
- Center for Vascularized Composite Allotransplantation, Department of Plastic Surgery, Chang Gung Memorial Hospital, Department of Reconstructive Microsurgery, College of Medicine, Chang Gung University, Taiwan
| | - Joaquim Megias Barrera
- Department of Plastic Surgery, Chang Gung Memorial Hospital, Taiwan, Peoples Republic of China
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Offodile AC, Chang KP, Chen HH, Loesch E, Hung SY, Kao HK. Feasibility and Outcomes of the Third or More Episodes of Sequential Microvascular Reconstruction for Recurrent or Second Primary Oral Cancer. Ann Surg Oncol 2016; 23:3765-3772. [PMID: 27207095 DOI: 10.1245/s10434-016-5283-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study was a robust examination of the clinical outcomes and technical feasibility of sequential microvascular reconstruction for recurrent or second primary oral cancer. METHODS A retrospective, cross-sectional analysis of adult patients undergoing microvascular reconstruction of head and neck oncologic defects was performed at Chang Gung Memorial Hospital, spanning 10 years. The patients were divided into three groups as follows: first episode, second episode, and third or more episodes of reconstruction. Demographics, operative details, and clinical outcomes were compared. RESULTS The study cohort included 3186, 319, and 62 patients who respectively received first, second, and third or more episodes of reconstruction. The most common tumor sites were the tongue (36.9 %) and the buccal region (36.8 %), with squamous cell carcinoma as the prevalent histology. The anterior lateral thigh was the most popular donor site used (76.1 %). The third or more episodes of microvascular reconstruction were associated with an increased incidence of flap failure (8.1 %) relative to the first (1.9 %; p = 0.003) and the second (1.6 %; p = 0.01) episodes. Re-exploration of venous occlusion (9.7 vs. 3.2 %), neck wound infections (53.2 vs. 35.5 %), fistula (17.7 vs. 8.1 %), and hospital stay (28.9 ± 14.6 vs. 25.3 ± 10.1) also showed significantly higher values for the third or more episodes group than for the first episode group. CONCLUSIONS Sequential microvascular reconstruction for recurrent or second primary oral cancer is associated with an increased incidence of postoperative complications. However, in appropriate candidates for repeat ablation, microvascular reconstruction remains the gold standard for attaining functional and cosmetic outcomes.
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Affiliation(s)
- Anaeze C Offodile
- Department of Plastic Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Kai-Ping Chang
- Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Hsin-Hung Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Eric Loesch
- Tufts University School of Medicine, Boston, MA, USA
| | - Shao-Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taoyuan, Taiwan.
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Geiger EJ, Basques BA, Chang CC, Son Y, Sasaki CT, McGregor A, Ariyan S, Narayan D. Pedicle versus free flap reconstruction in patients receiving intraoperative brachytherapy. J Plast Surg Hand Surg 2016; 50:227-32. [DOI: 10.3109/2000656x.2016.1152974] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Sandulache VC, Vandelaar LJ, Skinner HD, Cata J, Hutcheson K, Fuller CD, Phan J, Siddiqui Z, Lai SY, Weber RS, Zafereo ME. Salvage total laryngectomy after external-beam radiotherapy: A 20-year experience. Head Neck 2016; 38 Suppl 1:E1962-8. [PMID: 26879395 DOI: 10.1002/hed.24355] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2015] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The purpose of this study was to present our evaluation of the clinical and functional outcomes after salvage total laryngectomy (STL). METHODS We conducted a retrospective review of 218 patients who underwent STL between 1994 and 2014. RESULTS Seventy percent of patients originally had T1 or T2, N0 tumors and 73% had definitive external-beam radiotherapy (EBRT) alone. A majority utilized tracheoesophageal prosthesis (77%) and were gastrostomy free (80%) at last follow-up. The 5-year disease control and overall survival (OS) rates were 65% and 57%, respectively. Patients with a disease-free interval after initial treatment <2 years were more likely to develop a recurrence (p = .001) and die of disease (p = .032) after STL. The disease-free interval after EBRT impacted disease control (p < .001), with 5-year disease control of 92% for >5-year disease-free interval and 60% for <2-year disease-free interval. CONCLUSION Most patients remain disease-free after STL, achieve intelligible tracheoesophageal speech, and maintain an oral diet. Delayed recurrence after initial treatment portends better survival and may indicate a distinct biological profile. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1962-E1968, 2016.
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Affiliation(s)
- Vlad C Sandulache
- Bobby R. Alford Department of Otolaryngology Head and Neck Surgery, Baylor College of Medicine, Houston, Texas
| | | | - Heath D Skinner
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Juan Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Katherine Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jack Phan
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zuhair Siddiqui
- The University of Texas Medical School at Houston, Houston, Texas
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Randal S Weber
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark E Zafereo
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Pool C, Kass J, Spivack J, Nahumi N, Khan M, Babus L, Teng MS, Genden EM, Miles BA. Increased Surgical Site Infection Rates following Clindamycin Use in Head and Neck Free Tissue Transfer. Otolaryngol Head Neck Surg 2015; 154:272-8. [DOI: 10.1177/0194599815617129] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/23/2015] [Indexed: 11/15/2022]
Abstract
Objective The development of surgical site infections (SSIs) can put the viability of free tissue transfer reconstructions at risk, often resulting in considerable postoperative morbidity and prolonged hospitalization. Current antibiotic prophylactic guidelines suggest a first- or second-generation cephalosporin with metronidazole for clean-contaminated cases and recommend clindamycin as an alternative choice in penicillin-allergic patients. This study was designed to examine the rates of postoperative infection associated with prophylactic antibiotic regimens, including patients receiving clindamycin as an alternative due to penicillin allergy. Study Design Case series with chart review. Setting Tertiary academic medical center. Subjects Patients undergoing major ablative head and neck resection involving the pharynx and oral cavity reconstructed via free tissue transfer. Methods The sample included patients (n = 266) who underwent free tissue transfer involving the oral cavity and pharynx from 2009 to 2014. Data included demographic data, medical comorbidities, anatomic tumor subsite and surgical procedure, and prophylactic antibiotic regimen. SSI data were examined up to 30 days after the initial surgical procedure. Multivariate logistic regression analysis was performed to determine the overall risk for SSI. Culture data were also reviewed. Results The data indicated that clindamycin was associated with an approximate 4-fold increased risk for SSI (odds ratio, 3.784; 95% confidence interval: 1.367-10.470 [ P = .010]) after controlling for possible confounding factors. Conclusion For patients with a true penicillin allergy, we recommend broader gram-negative coverage with alternative antibiotics, such as cefuroxime, when undergoing free tissue transfer in the head and neck.
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Affiliation(s)
- Christopher Pool
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason Kass
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Spivack
- Department of Population Health Science and Policy, Icahn Medical Institute, New York, New York, USA
| | - Nadav Nahumi
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mohemmed Khan
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lenard Babus
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marita S. Teng
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric M. Genden
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brett A. Miles
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Han HH, Lim YM, Park SW, Lee SJ, Rhie JW, Lee JH. Improved skin flap survival in venous ischemia-reperfusion injury with the use of adipose-derived stem cells. Microsurgery 2015; 35:645-52. [PMID: 26510716 DOI: 10.1002/micr.22522] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/03/2015] [Accepted: 09/14/2015] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The purpose of this study was to investigate the efficacy of stem cell therapy as an adjuvant treatment for congested skin flap. METHOD Sprague-Dawley rats (n = 21) were randomized into three groups. In group I, the flap was sutured without venous ischemia. In group II, the vein was selectively clamped for 4 hours, and complete medium was administered upon clamp removal. In group III, ADSCs were administered upon removing the clamp. On postoperative day 7, the survival areas and the histopathologic findings were assessed. In addition, the expression of heme oxygenase (HO)-1 and nuclear factor (NF)-κB was assessed using immunofluorescent staining and western blot analyses. RESULTS Compared with group II, group III showed significantly increased flap survival (31.2% ± 11.9% vs. 51.6% ± 13.6%, P < 0.05). The degree of histological abnormalities was significantly lower in group III than in group II (9.38% ± 1.39 vs. 6.46% ± 2.57, P < 0.05). In addition, in group III, the expression of NF-κB was significantly lower (0.51 ± 0.21 vs. 0.34 ± 0.21, P < 0.05), whereas that of HO-1 was significantly higher (0.25 ± 0.11 vs. 0.43 ± 0.18, P < 0.01). Immunofluorescent staining also showed more HO-1-positive cells in group III than in group II (10.9% ± 1.6% vs. 16.0% ± 1.7%, P < 0.01). CONCLUSION Our study demonstrated that treatment with ADSCs significantly increased flap survival in venous ischemia-reperfusion conditions. Further investigation of these protective effects and optimization of the treatment protocol could make cell therapy a viable treatment.
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Affiliation(s)
- Hyun Ho Han
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
| | - Young Min Lim
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
| | - Sang Wook Park
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
| | - Su Jin Lee
- Department of Molecular Biomedicine, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
| | - Jong Won Rhie
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
| | - Jung Ho Lee
- Department of Plastic and Reconstructive Surgery, College of Medicine, The Catholic University of Korea, Seoul, 137-701, Republic of Korea
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