Mayo Clinic Experience with Unfavorable Results After Free Tissue Transfer to Head and Neck

The Buccal Fat Pad as a Primary Flap for the Reconstruction of Intraoral Defect After Resection of Oral Cavity Malignant Tumors: A Retrospective Study

BACKGROUND

Among the various local and regional flaps used for the reconstruction of intraoral defects after oral cavity cancer surgery, the pedicled buccal fat pad (BFP) flap is considered a reliable alternative. Reconstruction with a BFP flap is particularly feasible in oral cavity areas, such as the posterior maxilla, buccal mucosa, retromolar trigone, and gingivobuccal sulcus. The purpose of this study was to analyze the outcomes of pedicled BFP as a primary reconstruction flap for small to medium intraoral posterior oral cavity postresection defects operated in our institute.

METHODS

This study was designed as a retrospective study. Thirty-seven patients with oral cavity cancer underwent wide local excision with adequate margins, followed by reconstruction of the defect with a pedicled BFP flap. Defect size, postoperative healing of the surgical site, mouth opening at 6 months, and any associated complications were assessed.

RESULTS

The mean age of the patients was 47.38±9.95 years with a male-to-female ratio of 3.6:1. Mean defect size at the greatest dimension was 5.01±1.39 cm. The mean preoperative mouth opening of patients was 35±6.4 mm, whereas the mean postoperative mouth opening after 6 months of follow-up was 27.8±9.2 cm.

CONCLUSION

The BFP flap is a convenient, reliable, and feasible reconstruction modality after oncological resection of posterior oral cavity cancers. Harvesting a BFP flap is minimally invasive with fewer complications, shorter recovery time, no donor site morbidity, and allows early initiation of adjuvant therapy postoperatively.

Efficacy of ultrasound guided superior laryngeal nerve block on sedation for delayed extubation in maxillofacial surgery with free flap reconstruction

OBJECTIVE

Superior laryngeal nerve block (SLNB) is a regional anesthesia technique for addressing airway response. However, SLNB on the efficacy of sedation in patients with delayed extubation is unknown, particularly for maxillofacial surgery (MS). The aim of the study was to assess whether ultrasound guided (UG) SLNB reduces the incidence of moderate to severe cough for delayed extubation in MS with free flap reconstruction.

METHODS

60 patients were randomly assigned to the GEA group (control group) and the SLNB group (UG-SLNB postoperatively, study group). During the initial two postoperative hours, the incidence of moderate and severe cough, agitation, and the number of patients requiring rescue propofol and flurbiprofen were recorded. Additionally, the time spent under the target level of sedation, postoperative hemodynamics, and the total does of propofol during the postoperative 24 h were recorded.

RESULTS

The data showed the SLNB group had a significantly lower incidence of moderate to severe cough and agitation (p < 0.05), and a longer sedation time (p < 0.05). The number of patients required rescue propofol and flurbiprofen, as well as the hemodynamic changes, were significantly different between the two groups (p < 0.05).

CONCLUSION

The use of UG-SLNB is associated with reduced incidence of postoperative cough. Moreover, SLNB can enhance the efficacy of postoperative sedation with need of fewer agents postoperatively.

CLINICAL TRIAL REGISTRATION

ChiCTR2000039982.

Salvage mandibular reconstruction: multi-institutional analysis of 17 patients

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.

Unfavorable outcomes in microsurgery: possibilities for improvement

The main aim of the present report is to describe our learning curve in microsurgery and how we solved the problems that frequently occur during the first phases of this learning curve. We analyzed the medical records of 69 patients that underwent head and neck reconstruction with free flaps in our department. The patients were divided into two groups. Group 1 included the patients reconstructed between January 2011 and June 2017, whilst Group 2 included those reconstructed between July 2017 and August 2018. A χ² test was used to compare the differences between the two groups in terms of flap failure (failure and partial failure) and eventual clinical errors. The p value was set at 0.05. Flap failure and clinical errors were most frequently observed in Group 1 (p < 0.05). Greater awareness of the need for proper functioning of the anastomosis during surgery, along with more exhaustive postoperative monitoring might explain the lower number of failures and signs of vascular compromise observed in Group 2. A number of variables may influence flap survival. Postoperative care, head position, kinking, body temperature, blood pressure and the ability to recognize the sign of vascular compromise all play a fundamental role following surgery. However, microsurgery is not just a routine type of surgery, and a properly trained team with several types of professionals must be adequately prepared to obtain acceptable results.

Soft Tissue Reconstruction for Head and Neck Ablative Defects

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.

Combined Use of Liposuction and Arthroscopic Shaving for Delayed Debulking of Free Flaps in Head and Neck Reconstruction

BACKGROUND

Bulky appearance after free flap reconstruction in patients with head and neck cancer is common and requires revision to achieve improved final outcomes. Although different delayed debulking methods have been reported, the procedure can be technically difficult in patients with severe scaring after adjuvant radiotherapy. The present study proposes a combined method of liposuction and arthroscopic shaving for delayed contouring of free flaps in head and neck reconstruction.

METHODS

In this study, 12 patients with head and neck cancer who had bulky flaps after cancer ablation surgery and immediate free anterolateral thigh flap reconstruction were included. These patients underwent delayed debulking through the combined arthroscopic shaving and liposuction method at least 3 months after the initial reconstruction or the completion of adjuvant radiotherapy (if required). Age, sex, cancer stages, the presence or absence of adjuvant radiotherapy, the interval between the initial free flap reconstruction and the debulking procedure, complications, and subjective satisfaction ratings were recorded 1 and 6 months after the revision surgery.

RESULTS

All patients were men, with an average age of 56.3 years (43-69 years), and 9 (75%) patients underwent adjuvant radiotherapy. Partial flap loss was not observed in the study patients, and subjective satisfaction ratings improved after the debulking procedure.

CONCLUSIONS

The combined liposuction and arthroscopic shaving method can facilitate the debulking and contouring procedures in patients with head and neck cancer after free flap reconstruction. With appropriate timing, the combined procedure can be simple and safe, even in patients with severe scaring after adjuvant radiotherapy.