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Othman S, Robinson E, Kamdar D, Pereira L, Miles B, Kasabian A, Ricci JA, Knobel D. Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index. J Reconstr Microsurg 2024. [PMID: 39038462 DOI: 10.1055/s-0044-1788540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors. METHODS A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications. RESULTS A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003). CONCLUSION The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.
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Affiliation(s)
- Sammy Othman
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Emma Robinson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Uniondale, New York, New York
| | - Dev Kamdar
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Lucio Pereira
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Brett Miles
- Department of Otolaryngology, Northwell Health, New Hyde Park, New York, New York
| | - Armen Kasabian
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Joseph A Ricci
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
| | - Denis Knobel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwell Health, New Hyde Park, New York, New York
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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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Thiem DGE, Siegberg F, Vinayahalingam S, Blatt S, Krüger M, Lethaus B, Al-Nawas B, Zimmerer R, Kämmerer PW. The Perfect Timing-Immediate versus Delayed Microvascular Reconstruction of the Mandible. Cancers (Basel) 2024; 16:974. [PMID: 38473338 DOI: 10.3390/cancers16050974] [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: 01/18/2024] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
In this retrospective study, the clinical and economic implications of microvascular reconstruction of the mandible were assessed, comparing immediate versus delayed surgical approaches. Utilizing data from two German university departments for oral and maxillofacial surgery, the study included patients who underwent mandibular reconstruction following continuity resection. The data assessed included demographic information, reconstruction details, medical history, dental rehabilitation status, and flap survival rates. In total, 177 cases (131 male and 46 females; mean age: 59 years) of bony free flap reconstruction (72 immediate and 105 delayed) were included. Most patients received adjuvant treatment (81% with radiotherapy and 51% combined radiochemotherapy), primarily for tumor resection. Flap survival was not significantly influenced by the timing of reconstruction, radiotherapy status, or the mean interval (14.5 months) between resection and reconstruction. However, immediate reconstruction had consumed significantly fewer resources. The rate of implant-supported masticatory rehabilitation was only 18% overall. This study suggests that immediate jaw reconstruction is economically advantageous without impacting flap survival rates. It emphasizes patient welfare as paramount over financial aspects in clinical decisions. Furthermore, this study highlights the need for improved pathways for masticatory rehabilitation, as evidenced by only 18% of patients with implant-supported dentures, to enhance quality of life and social integration.
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Affiliation(s)
- Daniel G E Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Fabia Siegberg
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Shankeeth Vinayahalingam
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Sebastian Blatt
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Leipzig, Liebigstraße 12, 04103 Leipzig, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
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Topkan E, Somay E, Selek U. RE: Fibular free flap necrosis after mandibular reconstruction surgery with osteoradionecrosis: Establishment and verification of an early warning model. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 125:101745. [PMID: 38141824 DOI: 10.1016/j.jormas.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/25/2023]
Affiliation(s)
- Erkan Topkan
- Department of Radiation Oncology, Faculty of Medicine, Baskent University, Adana, Turkey
| | - Efsun Somay
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey; Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Kyrenia University, Girne, Cyprus.
| | - Ugur Selek
- Department of Radiation Oncology, Faculty of Medicine, Koc University, Istanbul, Turkey
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McIlwain W, Inman J, Namin A, Kazi A, Shumrick C, Ducic Y. Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy. Semin Plast Surg 2023; 37:39-45. [PMID: 36776801 PMCID: PMC9911226 DOI: 10.1055/s-0042-1759797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.
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Affiliation(s)
- Wesley McIlwain
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Jared Inman
- Otolaryngology/Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Arya Namin
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Aasif Kazi
- Otolaryngology/Head and Neck Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Christopher Shumrick
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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Moltaji S, El Khatib A, Rogers AD. Delayed axial flaps for coverage of a fourth degree scalp burn. J Surg Case Rep 2022; 2022:rjac468. [PMID: 36299910 PMCID: PMC9586711 DOI: 10.1093/jscr/rjac468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Although free tissue transfers may be required to cover wounds of the head and neck with bone involvement and exposure, options lower on the reconstructive ladder should still be considered during the planning process. We present a case of an elderly gentleman with a history of cardiovascular comorbidity and neck radiotherapy, who sustained a deep flame burn injury to his scalp. Two delayed axial flaps, based on the superficial temporal and supraorbital arteries respectively, were used to obtain durable coverage of this complex wound.
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Affiliation(s)
- S Moltaji
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - A El Khatib
- Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - A D Rogers
- Correspondence address. D718, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, M4N 3M5, Toronto, Canada. Tel: +4164806100 ext 3769; Fax: +4164804531; E-mail:
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Slijepcevic AA, Young G, Shinn J, Cannady SB, Hanasono M, Old M, Grewal JS, Ghanem T, Ducic Y, Curry JM, Wax MK. Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction. JAMA Otolaryngol Head Neck Surg 2022; 148:555-560. [PMID: 35476871 PMCID: PMC9047712 DOI: 10.1001/jamaoto.2022.0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Incidence of perioperative free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown. Objective To assess the outcomes of a second revascularization attempt for compromised free flaps. Design, Setting, and Participants This multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. Main Outcome and Measure Flaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts. Results A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage. Conclusions and Relevance In this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Gavin Young
- School of Medicine, Oregon Health & Science University, Portland
| | - Justin Shinn
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Matthew Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew Old
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The Ohio State University, Columbus
| | - Jeewanjot S Grewal
- Department of Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Tamer Ghanem
- Department of Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | | | - Joseph M Curry
- Department of Otolaryngology-Head & Neck Surgery, Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Oregon Health & Science University, Portland
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