Surgical exploration of 71 free flaps in crisis following head and neck reconstruction

The use of a skin paddle-containing vein graft for arteriovenous looping in two-stage free flap reconstruction of lower extremities

BACKGROUND

Arteriovenous (AV) looping prior to the lower extremity free flap reconstruction enables better venous drainage in flap circulation, leading to less flap complications and better survival. A two-staged reconstruction including free tissue transfer after AV looping ensures a robust venous drainage of the flap. Arterialization of the AV loop results in less venous problems after the free flap reconstruction. However, major problems of this staged operation include AV loop kinking, heavy compression and loop exposure, leading to AV graft failure and interruption of surgical planning. The purpose of this article is to summarize probable flaws we noticed in conventional two-stage lower limb reconstruction and overcome those problems using the skin paddle-containing vein graft.

METHOD

Eight patients with lower limb defects underwent lower limb reconstruction surgery using this technique at our institute. The mean age was 52 years old. Of the eight patients, three of them have the defect due to infection. Three of them was due to trauma and three of them was due to full-thickness burn. Five of the defects located at foot. The other three defects located at heel, knee, and pretibial region. All of them require AV looping because of unavailability of nearby recipient vessels. They all received a two-stage operation, including the first stage AV looping with a skin paddle-containing vein graft and the second stage definite free tissue transfer.

RESULTS

The mean defect size was 140 cm2 (72-225). The mean length of AV loops was 17.1 cm (8-25). The mean size of skin paddles for vein grafts was 19.4 cm2 (15-24). The mean size of free ALT flaps 154.4 cm2 (105-252). All eight patients experienced a smooth postoperative course with no major or minor complications. There were no graft thrombosis or graft rupture complications during the vascular maturation period. All eight AV loops survived during maturation. All eight patients progressed to the second stage surgery. Maturation time ranged from 5 to 7 days. Free ALT flap was employed during the second stage reconstruction. All flaps survived at the last follow-up visit. There was no partial flap loss and complications. The mean follow-up time was 12.25 months, ranging from 8 to 17 months.

CONCLUSION

The skin paddle-containing vein graft is an effective modification of the regular vein graft for AV looping procedure. The skin paddle prevents the underlying AV loop from compression, kinking and twisting during maturation. It also aids assessing patency of the AV loop and avoids the formation of adhesion between the AV loop and the surrounding tissue.

The Optimal Length-of-Stay After Microvascular Breast Reconstruction: A Cost-Utility Analysis

BACKGROUND

Length-of-stay (LOS) can have a large impact on overall surgical costs. Several studies have demonstrated that a shortened LOS is safe and effective after microvascular breast reconstruction (MBR). The optimal LOS from a cost-utility perspective is not known.

METHODS

The authors used a decision tree model to evaluate the cost-utility, from the perspective of the hospital, of a variety of LOS strategies. Health state probabilities were estimated from an institutional chart review. Expected costs and quality-adjusted life-years (QALY) were assess using Monte Carlo simulation and sensitivity analyses.

RESULTS

Over a ten-year period, our overall flap loss and take-back rates were 1.6% and 4.9%, respectively. After rollback, a 3-day LOS was identified as the most cost-effective strategy, with an expected cost of $41,680.19 and an expected health utility of 25.68 QALYs. Monte Carlo sensitivity analysis confirmed that discharge on POD3 was the most cost-effective strategy in the majority of simulations when the willingness-to-pay threshold varied from $50,000-$130,000/QALY gained.

CONCLUSION

This cost-utility analysis suggests that a 3-day LOS is the most cost-effective strategy after MBR.

Free Flap Transfer, a Safe and Efficient Method for Reconstruction of Composite Skull Base Defects After Salvage Resection of Advanced Intracranial and Extracranial Communicating Tumors

OBJECTIVE

Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution.

METHODS

The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed.

RESULTS

There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively.

CONCLUSIONS

Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.

Increased salvage rates with early reexploration: A retrospective analysis of 547 free flap cases

BACKGROUND

Free flap complications are generally rare, but not negligible since they may exert paramount impact on both patients and care providers. The aim of the study was to identify risk factors for reexploration and assess predictors associated with increased salvage rates.

METHODS

A retrospective cohort study was conducted for free flaps performed between 2006 and 2015. Patient demographics, indications and flap types were analyzed together with complications and time to reexploration.

RESULTS

Among 547 consecutive free flaps, 11.5% required acute reexploration. Hematoma together with vascular compromise was the main cause (41.9%) for reexploration, followed by hematoma only (19.4%), venous (16.1%) and arterial (6.5%) thrombosis. Hematoma was associated with an increased risk for concomitant vascular complication (p < 0.02). The incidence of total and partial flap necrosis was 3.5% and 3.7% respectively. There was an overall 71.4% salvage rate. The median time from detection of a compromised flap to reexploration was 3.0 h. Significantly higher salvage rates were observed for cases reexplored within (82.4%) compared to after (57.1%) 3.0 h (OR 3.50 (95% CI 1.10 to 11.13, p = 0.034)).

CONCLUSIONS

The current study highlights the importance of early intervention, including evacuation of hematomas that may lead to vascular compromise. Adequate monitoring of venous outflow was found necessary to improve flap salvage rates, whereas arterial complications were mainly related to persistent arterial injury in traumatized extremities with reduced salvage rates. Free flap surgery requires trained staff and immediate access to operating facilities to ensure high flap survival rates.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.

METHODS

Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey.

RESULTS

Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.

CONCLUSION

The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay

BACKGROUND

The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments.

METHODS

A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold.

RESULTS

A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2.

CONCLUSION

The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.

Revisiting the sternocleidomastoid flap as a reconstructive option in head and neck surgery

Background

The sternocleidomastoid can be used as a pedicled flap in head and neck reconstruction. It has previously been associated with high complication rates, likely due in part to the variable nature of its blood supply.

Objective

To provide clinicians with an up-to-date review of clinical outcomes of sternocleidomastoid flap surgery in head and neck reconstruction, integrated with a review of vascular anatomical studies of the sternocleidomastoid.

Methods

A literature search of the Medline and Web of Science databases was conducted. Complications were analysed for each study. The trend in success rates was analysed by date of the study.

Results

Reported complication rates have improved over time. The preservation of two vascular pedicles rather than one may have contributed to improved outcomes.

Conclusion

The sternocleidomastoid flap is a versatile option for patients where prolonged free flap surgery is inappropriate. Modern vascular imaging techniques could optimise pre-operative planning.

Oromandibular reconstruction using microvascularized bone flap: report of 1038 cases from a single institution

This retrospective study was performed to review 1038 patients who underwent mandibular reconstruction with free vascularized bone flaps at a single institution between 2006 and 2017. Of these patients, 827 (79.67%) had fibula flaps, 197 (18.98%) had deep circumflex iliac artery perforator (DCIA) flaps, and 11 (1.06%) had scapula bone flaps. The most common pathological diagnosis was ameloblastoma (n=366, 35.26%), followed by squamous cell carcinoma (n=278, 26.78%) and osteoradionecrosis (n=152, 14.64%). Fifty-seven patients (5.49%) had major complications requiring surgical intervention and one patient died of a pulmonary embolism. Venous crisis was the most frequent major complication (n=20, 1.93%), followed by haematoma (n=17, 1.64%) and flap necrosis (n=14, 1.35%). One-stage mandibular reconstruction was preferred whenever possible, as this generally decreases the financial and hospitalization burden. The four-segment method of jaw reconstruction appeared to achieve good aesthetic appearance results in Asian patients and this was not associated with a higher risk of segment ischemia compared with the three-segment method.

Prediction of Flap Compromise by Preoperative Coagulation Parameters in Head and Neck Cancer Patients

PURPOSE

Studies on coagulation parameters (including activated partial thromboplastin time, prothrombin time, thrombin time, fibrinogen [FIB], platelet count, and D-dimer) in flap compromise are limited. The aim of the present study was to compare coagulation parameter variables in patients with and without flap compromise.

MATERIALS AND METHODS

In this retrospective cohort study, patients were recruited from the Department of Oral and Maxillofacial Surgery at the Second Xiangya Hospital (Changsha, Hunan, China) from July 2016 through July 2017. The primary predictor variable was a set of coagulation parameters. The primary outcome variable was flap compromise. The other variables were age, gender, tumor stage, smoking, and prior radiotherapy. Descriptive, bivariate, receiver operating characteristic (ROC) curves and regression statistics were computed. Statistical significance was set at less than .05 with 95% reliability.

RESULTS

A total of 503 patients with 42 compromised flaps were identified in this study. Venous thrombosis, arterial thrombosis, or no confirmed reason for compromise was observed in 28, 5, or 9 compromised flaps, respectively. Only FIB was associated with flap compromise or venous thrombosis at adjusted analyses, although the predictive values were low at ROC analysis. For patients with D-dimer lower than 0.4 μg/mL, the likelihood of venous thrombosis was greater than that for patients with D-dimer of at least 0.4 μg/mL (P = .0414). For patients with FIB lower than 3.5 g/L, the likelihood of venous thrombosis was greater than that for patients with FIB of at least 3.5 g/L (P = .0336).

CONCLUSION

Decreased FIB was associated with a higher rate of flap compromise. In patients with D-dimer lower than 0.4 μg/mL or FIB lower than 3.5 g/L, the risk of venous thrombosis was higher.

Effect of local application of transcutaneous carbon dioxide on survival of random-pattern skin flaps

INTRODUCTION

Skin flap procedures are widely used to reconstruct skin and soft tissue defects. Skin flap necrosis is a serious postoperative complication. Many researchers have introduced pharmacological agents to improve flap ischemia in experimental studies. However, outcomes of these studies remain controversial. We previously demonstrated that transcutaneous CO₂ application improves hypoxia in fracture repair. In this study, we hypothesized that improving hypoxia by transcutaneous CO₂ application can improve the blood flow in skin flaps and increase angiogenesis. We investigated whether transcutaneous CO₂ application can increase the survival of random-pattern skin flaps.

MATERIALS AND METHODS

Six-week-old male Sprague-Dawley rats were divided into two equal groups: the control group (n = 6) and CO₂ group (n = 6). A random-pattern skin flap was constructed in these rats. Topical CO₂ was applied using a hydrogel every day for 5 days in the CO₂ group. The flap survival area was measured on postoperative days 1, 3, and 5. The vessel density and expression of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), and hypoxia-inducible factor-1α (HIF-1α) were evaluated on postoperative day 5.

RESULTS

A statistically significant difference was found in the percentage of the flap survival area between the two groups on postoperative days 3 and 5 (p < 0.05). Furthermore, the expression of VEGF and bFGF was significantly higher and that of HIF-1α was significantly lower in the CO₂ than in the control group (p < 0.05).

CONCLUSIONS

Transcutaneous CO₂ application can improve the blood flow in skin flaps and increase angiogenesis, thus increasing the survival of random-pattern skin flaps.

Characteristics and Management of Free Flap Compromise Following Internal Jugular Venous Thrombosis

PURPOSE

Free flap compromise after internal jugular venous thrombosis (IJVT) occurs fairly infrequently in oral and maxillofacial rehabilitation and reconstruction but could seriously affect the patient's postoperative recovery. The aim of this study was to analyze and discuss the characteristics and management of such flap compromise.

PATIENTS AND METHODS

The authors performed a retrospective case series of 13 patients who underwent reconstruction of oral and maxillofacial defects with anterolateral thigh flaps and developed flap compromise from IJVT from July 2014 through December 2016 at the Second Xiangya Hospital of Central South University (Changsha, China). The clinical features of flap compromise are described, and the precautions and improvement measures are reported.

RESULTS

All 13 patients were men with an average age of 50.3 years. Flap compromise caused by IJVT occurred on postoperative days 3 to 7, of which 2 flaps were salvaged (15.4%) and 11 flaps failed completely after immediate urgent re-exploration. Four patients presented with orocutaneous fistula after salvage surgery that healed well after a period of wound dressing.

CONCLUSIONS

Because of the late occurrence and low salvage rate of flap compromise caused by IJVT, intensive flap monitoring after reconstruction surgery is necessary for patients with free flap transfer.