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Ouyang SB, Wu ZH, Zhang YP, Lu XL. Comprehensive analysis of risk factors for flap necrosis in free flap reconstruction of postoperative tissue defects in oral and maxillofacial tumors. Sci Rep 2024; 14:18676. [PMID: 39134569 PMCID: PMC11319768 DOI: 10.1038/s41598-024-69159-z] [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: 05/15/2024] [Accepted: 08/01/2024] [Indexed: 08/15/2024] Open
Abstract
Free flap reconstruction for postoperative tissue defects in oral and maxillofacial tumors is a critical component of reconstructive surgery. Identifying risk factors for flap necrosis is essential for improving surgical outcomes and patient quality of life. A retrospective study was conducted on patients who underwent free flap reconstruction between January 2020 and December 2023. Patients were included if they had comprehensive medical records and at least a six-month follow-up. We excluded those with a history of flap necrosis, uncontrolled systemic diseases, non-adherence to postoperative care, or concurrent malignancy treatments. Data on demographics, comorbidities, flap characteristics, and operative details were collected and analyzed using univariate analysis and logistic regression tests. Univariate analysis did not find a significant correlation between flap necrosis and factors such as hyperlipidemia, lymph node metastasis, or flap type. However, diabetes mellitus, oral infections, and albumin levels below 35 g/L were significantly associated with flap necrosis. Multivariate logistic regression showed diabetes mellitus increased the odds of flap necrosis by approximately ninefold, and oral infection increased it by over tenfold. Diabetes mellitus, oral infection, and low albumin levels are significant risk factors for flap necrosis in free flap reconstruction after oral and maxillofacial surgery. Prompt identification and management of these factors are crucial to mitigate the risk of flap necrosis.
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Affiliation(s)
- Shao-Bo Ouyang
- Jiangxi Province Clinical Research Center for Oral Diseases, Jiangxi Province Key Laboratory of Oral Biomedicine, The Affiliated Stomatological Hospital, Jiangxi Medical College, Nanchang University, 49 Fuzhou Road, Donghu District, Nanchang, 330006, Jiangxi Province, China
| | - Zhi-Hong Wu
- Affiliated Stomatological Hospital of Jiujiang University, 69 Xunyang East Road, Xunyang District, Jiujiang, 332099, Jiangxi Province, China
| | - Yan-Ping Zhang
- Nanchang Dental Disease Prevention and Treatment Center, 190 Shengli Road, Nanchang, 330008, Jiangxi Province, China
| | - Xiao-Li Lu
- Jiangxi Province Clinical Research Center for Oral Diseases, Jiangxi Province Key Laboratory of Oral Biomedicine, The Affiliated Stomatological Hospital, Jiangxi Medical College, Nanchang University, 49 Fuzhou Road, Donghu District, Nanchang, 330006, Jiangxi Province, China.
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Yen YH, Luo SD, Chen WC, Li CY, Chiu TJ, Wang YM, Wu SC, Yang YH, Chen YH, Wu CN. The Value of the Nutritional Indicators in Predicting Free Flap Failure From a Multicentre Database. Otolaryngol Head Neck Surg 2024; 171:63-72. [PMID: 38501382 DOI: 10.1002/ohn.706] [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: 11/16/2023] [Revised: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Nutritional and inflammatory statuses have been associated with complications in microvascular-free flaps during head and neck surgeries. This study aimed to evaluate the potential of nutritional indicators in predicting postoperative free flap complications. STUDY DESIGN We conducted a 20-year retrospective, case-control study within a defined cohort. SETTING The study involved head and neck cancer patients from the Chang Gung Research Database who underwent simultaneous tumor ablation and free flap wound reconstruction between January 1, 2001, and December 31, 2019. METHODS We employed logistic regression and stratified analysis to assess the risk of free flap complications and the subsequent need for flap revision or redo in relation to nutritional indicators and other clinical variables. RESULTS Of the 8066 patients analyzed, 687 (8.5%) experienced free flap complications. Among these, 197 (2.4%) had free flap failures necessitating a redo of either a free flap or a pedicled flap. Beyond comorbidities such as chronic obstructive pulmonary disease, end-stage renal disease, and a history of prior radiotherapy, every 10-unit decrease in the preoperative prognostic nutritional index (PNI) was consistently associated with an increased risk of both free flap complications and failure. The covariate-adjusted odds ratios were 1.90 (95% confidence interval [CI]: 1.42-2.54) and 1.89 (95% CI: 1.13-3.17), respectively. CONCLUSION A lower preoperative PNI suggests a higher likelihood of microvascular free flap complications in head and neck surgeries. Further randomized controlled trial designs are required to establish causality.
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Affiliation(s)
- Yuan-Hao Yen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chih Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Health care Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Tai-Jan Chiu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yung-Hsuan Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Nung Wu
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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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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Jagtiani K, Bhatia P, Jain R, Singh GP, Gurav S. Prosthetic Management of Flap-Related Complications Following Glossectomy in Locally Advanced Tongue Cancer. Indian J Plast Surg 2023; 56:382-385. [PMID: 37705811 PMCID: PMC10497335 DOI: 10.1055/s-0043-1772455] [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: 09/15/2023] Open
Abstract
Total glossectomy defects resulting from postoncologic resection are commonly reconstructed with locoregional or free flaps. However, effectively managing complications that may arise after reconstruction can be a significant challenge. We present a unique case series describing prosthetic management of flap-related complications following glossectomy in patients treated for locally advanced tongue cancer. Three patients underwent total glossectomy, neck dissection, reconstruction using free flap, and tracheostomy. Two patients developed an intraoral fistula located in the anterior region of the floor of the mouth. The third patient developed a flap failure requiring a second procedure using a pectoralis major myocutaneous flap for correction of the orocutaneous fistula that ultimately did not heal. Mandibular obturator prostheses lined with a soft liner were fabricated for all the patients, which helped reduce salivary incontinence and improve swallowing and speech. This case series highlights that a collaborative interdisciplinary team approach is crucial for optimizing postoperative function and outcomes when managing complications from reconstructive procedures.
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Affiliation(s)
- Kiran Jagtiani
- Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Parel, Mumbai, India
| | - Prachi Bhatia
- Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Parel, Mumbai, India
| | - Radhika Jain
- Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Parel, Mumbai, India
| | - Gurkaran Preet Singh
- Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Parel, Mumbai, India
| | - Sandeep Gurav
- Department of Dental and Prosthetic Surgery, Tata Memorial Hospital, Parel, Mumbai, India
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Hathorn T, Nickel C, Sharma A, Shabani S, Padhya T, Mifsud M. How do i salvage that flap?; An evidence-based primer on salvage techniques for head & neck microvascular free flaps. Oral Oncol 2023; 136:106246. [PMID: 36402054 DOI: 10.1016/j.oraloncology.2022.106246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an "other" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.
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Affiliation(s)
- Travis Hathorn
- USF Health Morsani College of Medicine, 560, Channelside Dr, Tampa, FL 33602, United States
| | - Christopher Nickel
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Abhay Sharma
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Sepehr Shabani
- The University of Texas Medical Branch, Department of Otolaryngology - Head & Neck Surgery, 301 University Blvd., Galveston, TX 77555, United States
| | - Tapan Padhya
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Matthew Mifsud
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States.
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Klarendić A, Dovšak T. Femur Fracture Following Medial Femoral Condyle Flap Harvest: A Case Report. OPEN ACCESS SURGERY 2021. [DOI: 10.2147/oas.s333899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Guo B, Fang X, Shan Y, Li J, Shen Y, Ma C. Salvage mandibular reconstruction: multi-institutional analysis of 17 patients. Int J Oral Maxillofac Surg 2021; 51:191-199. [PMID: 34384647 DOI: 10.1016/j.ijom.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 10/20/2022]
Abstract
Unsuccessful mandibular reconstruction occasionally occurs, leaving the patient with undesirable function and contours. In such cases, second- or third-time corrective operations are challenging. However, published studies on the complicated retreatment of such patients are scarce. A retrospective analysis covering the years 2015-2019 was conducted in three centers. All 17 patients included had undergone prior failed mandibular reconstructions in other institutions. Salvage secondary or tertiary reconstructive surgeries were attempted and the results are presented. Major factors for these failed reconstructions included exposed non-vascularized bone grafts (n = 7, 41.2%), flap loss (n = 4, 23.5%), exposed artificial joint (n = 3, 17.6%), skewed occlusion with deformity (n = 1, 5.9%), non-union (n = 1, 5.9%), and recurrence (n = 1, 5.9%). Fibula flaps were transferred in 15 patients, while iliac flaps were used in two patients for mandibular re-do reconstructions. Virtual surgical designs were conducted in nine (52.9%) patients, with navigation-guided approaches performed in three cases. Postoperative functions were relatively favorable in these complicated mandibular re-do reconstruction cases. Mandibular symmetry (mandibular length and height; P = 0.002) and condylar position (P < 0.001) were regained after these re-do attempts. Secondary or tertiary mandibular re-do reconstruction can still achieve good functional outcomes with appropriate preoperative selection and well-conceived designs, especially with the aid of virtual surgery and navigation.
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Affiliation(s)
- B Guo
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - X Fang
- Department of Oral and Maxillofacial Surgery, Xiangya Stomatological Hospital, Central South University, Changsha, Hunan, China
| | - Y Shan
- Department of Oral and Maxillofacial Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - J Li
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - Y Shen
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China
| | - C Ma
- Department of Oral and Maxillofacial - Head and Neck Oncology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, China.
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Pier MM, Pasick LJ, Benito DA, Saini P, Patel S, Joshi AS, Goodman JF, Thakkar P. Adverse Events Associated with Implantable Dopplers during Microvascular Surgery. J Reconstr Microsurg 2020; 37:365-371. [PMID: 32942309 DOI: 10.1055/s-0040-1716858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Implantable Dopplers (IDs) are widely used for postoperative free flap vascular monitoring. However, IDs may contribute to free flap complications or failure and better understanding of device malfunctions is needed. METHODS The U.S. Food and Drug Administration's Manufacturer and User Facility Device Experience database was queried for all reports of ID adverse events from two leading manufacturers (Cook Vascular and Synovis Life Technologies) in free flap surgery from January 2010 to March 2020. Reports were reviewed and categorized. A comparison of reoperations within select categories was performed using Chi-square analysis. RESULTS Of 209 included reports, the most common device malfunctions were venous anastomotic coupler misalignment (35.4%) and coupler ring detachment (24.4%). Synovis devices were used in 100% of reports of vessel compression and Cook Vascular devices were used in 77.7% of reports of probe detachment. Of 74 patient-related adverse events, the most common were reoperation (47.3%) and vessel occlusion (28.4%). Of five reported events of flap failure, two were associated with loss of ID signal. The proportion of Doppler signal loss events leading to reoperation was significantly greater than the proportion of any other Doppler-related event leading to reoperation. Intraoperative coupler replacement was the most commonly reported intervention (n = 86), and venous anastomosis with hand-suturing occurred in 30 device malfunctions. CONCLUSION This study demonstrates a variety of ID-related malfunctions. One-third of device malfunctions were associated with patient complications, and false-positive Doppler signal loss contributed substantially to the requirement of surgical re-exploration. These are important considerations for surgical teams utilizing IDs in free tissue transfer procedures.
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Affiliation(s)
- Matthew M Pier
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Luke J Pasick
- Department of Otolaryngology-Head and Neck Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Daniel A Benito
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Prashant Saini
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Sahil Patel
- Department of Otolaryngology-Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Arjun S Joshi
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Joseph F Goodman
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Punam Thakkar
- Division of Otolaryngology-Head and Neck Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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Patel SY, Meram AT, Kim DD. Soft Tissue Reconstruction for Head and Neck Ablative Defects. Oral Maxillofac Surg Clin North Am 2019; 31:39-68. [PMID: 30449526 DOI: 10.1016/j.coms.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.
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Affiliation(s)
- Stavan Y Patel
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Andrew T Meram
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
| | - Dongsoo D Kim
- Department of Oral and Maxillofacial Surgery/Head and Neck Surgery, Louisiana State University Health Science Center, 1501 Kings Highway, Shreveport, LA 71103, USA
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