Microvascular Free Flaps: a Major Advance in Head and Neck Reconstruction

Characterization of the MSAP Flap in Head and Neck Surgical Oncology: A 3D Cadaveric Study

OBJECTIVES

The medial sural artery (MSA) perforator flap is a versatile free flap. However, the cutaneous perforators are not well characterized. The objectives of this pilot anatomical study were to: (1) visualize in three-dimensions, as in-situ, the origin, course, and distribution of the cutaneous perforators, (2) characterize the number and frequency of the perforators, and (3) quantify mean pedicle length.

METHODS

Thirteen cadaveric specimens were dissected, digitized, and modeled in 3D. Three-dimensional models and dissection photographs were used to determine the origin, course, number, distribution, and pedicle length of MSA perforators.

RESULTS

The most common pattern consisted of three perforators (39% of specimens). The maximum number of perforators identified was four (23%). The majority of specimens (92%) had a cutaneous perforator originating from the lateral branch of the MSA and coursed most frequently in the second (43%) and third (37%) quartiles of the length of the tibia. Mean pedicle length was 19.1 ± 6.9 cm. Perforators originating from the medial branch of the MSA were significantly (p < 0.05) shorter than those from the lateral branch and were found to course only in the first quartile.

CONCLUSION

The 3D models constructed in this study provide a comprehensive overview of the location and course of the perforators, enabling measurement of parameters in 3D-space. Anatomical characterization of the MSA perforator flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for flap harvest.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:4298-4303, 2024.

Retrospective three-dimensional analysis of bone resorption volumes of free microvascular scapular and fibular grafts

Defects in head and neck regions are standardly treated with microvascular grafts, such as free scapular (SFF) and fibular flaps (FFF), which are subject to a certain amount of bone resorption over time. The aim of this study was the 3-dimensional evaluation of bone resorption volume in both grafts. Over a period of 10 years, computed tomograms (CT) of patients with mandibular reconstructions with SFFs and FFFs were examined. The respective grafts were segmented as well as 3-dimensionally measured. Furthermore, factors such as gender, age, nicotine abuse, previous disease with type 2 diabetes, and adjuvant therapies, were examined for their influence. A total of 211 CT scans from 67 patients (40 SFFs and 27 FFFs) were included in the study. SFFs showed slightly higher median bone volumes (87.60% at 730 days and 86.55% at 1500 days) than FFFs (84.40% at 730 days and 82.10% at 1500 days). When final volumes were considered, FFFs had higher mean volume values (88.22%) than SFFs (83.82%), with significant correlation between resorption volume and time progression (r = 0.357, p = 0.024). All previously mentioned factors had no significant effect on bone resorption. Bone volumes of FFFs showed postoperative volume reductions similar to those of SFFs, with isolated SFFs having markedly lower volume values. The choice of a microvascular graft for reconstruction in the mandible proves difficult regarding bone resorption. The presented results may support decisions about future transplantations.

Survival of vascularized osseous flaps in mandibular reconstruction: A network meta-analysis

Objective

An evidence regarding which bony flap for reconstruction of mandibular defects following tumour resection is associated with the highest survival rate is still lacking. This network meta-analysis (NMA) aimed to guide surgeons selecting which vascularized osseous flap is associated with the highest survival rate for mandibular reconstruction.

Methods

From inception to March 2021, PubMed, Embase, Scopus, and Cochrane library were searched to identify the eligible studies. The outcome variable was the flap survival rate. The Bayesian NMA accompanied by a random effect model and 95% credible intervals (CrI) was calculated.

Results

Twenty-two studies with a total of 1513 patients, comparing four osseous flaps namely fibula free flap (FFF), deep circumferential iliac artery flap (DCIA), scapula flap, and osteocutaneous radial forearm flap (ORFF) were included. The respective survival rates of FFF, DCIA, Scapula, and ORFF were 94.50%, 93.12%, 97%, and 95.95%. The NMA failed to show a statistically significant difference between all comparators (FFF versus DCIA (Odd ratio, 1.8; CrI, 0.58,5.0); FFF versus ORFF (Odd ratio, 0.57; CrI, 0.077; 2.9); FFF versus scapula flap (Odd ratio, 0.25; CrI, 0.026; 1.5); DCIA versus ORFF (Odd ratio, 0.32; CrI, 0.037; 2.1); DCIA versus scapula flap (Odd ratio, 0.14; CrI, 0.015; 1.1) and ORFF versus scapula flap (Odd ratio, 2.3; CrI, 0.16; 34)).

Conclusion

Within the limitations of the current NMA, FFF, DCIA, Scapula, and ORFF showed a comparable survival rate for mandibular reconstruction. Although the scapula flap reported the highest survival rate compared to other osseous flaps for mandibular reconstruction; however, the decision making when choosing an osseous flap should be based on many factors rather than simply flap survival rate.

A novel loop neurorrhaphy technique to preserve lower lip sensate in mandibular reconstruction using an innervated vascularized iliac bone flap

BACKGROUND

This study aimed to introduce a novel loop neurorrhaphy technique using an innervated vascularized iliac bone flap (VIBF) with vascularized ilioinguinal nerve (IIN) to reconstruct the inferior alveolar nerve (IAN) and preserve lower lip sensation simultaneously with mandibular reconstruction.

METHODS

This study prospectively included patients who underwent mandibular reconstruction using VIBF from May 2018 to April 2020. Subjects were allocated into two groups: (1) Group I; innervated VIBF with loop neurorrhaphy (IIN doubly anastomosed with IAN and mental nerve), (2) Group II (control); conventional VIBF. Evaluation was done with operative time, intraoperative indocyanine green (ICG), lower lip sensory assessment (two-point discrimination [TPD] test and current perception threshold [CPT]), and drooling.

RESULTS

Twelve patients were included; 6 in each group, (7 males and 5 females), age ranging from 18 to 57 years (average: 36.75 years). In all cases, intraoperative perfusion of IIN was confirmed by ICG. Group I showed a statistically significant more flap harvesting time compared with group II (mean difference, 5.67 min; P = 0.0091). There was a significant difference in sensory recovery favoring group I (P < 0.05). The TPD results in group I showed an average of 9.8 ± 6.9 mm and 6.2 ± 5.7 mm on operated and non-operated sides, while Group II showed a poor sensory recovery, and the TPD showed an average of 24.6 ± 6.7 mm and 8.4 ± 2.3 mm on operated and non-operated sides. The CPT results showed a significant difference between both groups. In Group I, the extent of drooling was 3.16 ± 0.75, while in Group II, the score was 1.6 ± 0.81, revealing a significant difference favoring Group I.

CONCLUSIONS

Concurrent mandibular reconstruction using VIBF and loop neurorrhaphy with vascularized IIN to reconstruct IAN successfully restore lower jaw form and preserve lip sensation.

Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism

OBJECTIVE

To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care center.

METHODS

All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses.

RESULTS

Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission.

CONCLUSION

Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

Functional Outcomes of the Medial Sural Artery Perforator Flap in Oral Cavity Reconstruction

BACKGROUND

The medial sural artery perforator (MSAP) flap is an ideal option for reconstruction of oral cavity defects owing to its thin and pliable nature and favorable donor site. Our study presents an assessment of functional outcomes including speech and swallowing in patients with oral cavity tumors reconstructed with MSAP flaps.

METHODS

Patients undergoing MSAP reconstruction for oral cavity tumors between January 2014 and January 2018 were identified from our prospective head and neck cancer database. Functional outcomes were assessed in conjunction with the Speech and Language Team with a minimum follow-up of 6 months. Function (speech and swallowing) was recorded as a performance status scale set up by the assessing health care professional.

RESULTS

A total of 38 patients underwent reconstruction with the MSAP flap over the study period. The patient cohort included 10 female patients and 28 male patients. The age range was from 30 to 78 years, with a mean age of 56.8 years. Complications included 1 flap loss and 1 donor site wound dehiscence.Most patients (84.2%) had intelligible speech at 6-month follow-up and further improvement at 1 year (92.1%). All patients resumed feeding on postoperative day 4, and only 7.8% (n = 3) of the patients required assistance with feeding at 1-year follow-up.

CONCLUSIONS

The MSAP flap provides adequate small-volume replacement for oral cavity reconstructions. Our results indicate that most patients achieve a full diet with no restrictions by 1 year after reconstruction. Most of our patients demonstrated excellent speech with little or no need for repetition in conversation. Over the past few years, this has become the flap of choice for oral cavity reconstruction in our unit.

Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction

OBJECTIVE

Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction.

STUDY DESIGN

Retrospective multi-institutional review of prospectively collected databases at tertiary care centers.

METHODS

Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history.

RESULTS

Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002).

CONCLUSION

This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:347-353, 2020.

More Harm Than Benefit of Perioperative Dexamethasone on Recovery Following Reconstructive Head and Neck Cancer Surgery: A Prospective Double-Blind Randomized Trial

PURPOSE

Prospective studies on the effect of dexamethasone after microvascular reconstructive head and neck surgery are sparse despite the widespread use of dexamethasone in this setting. The aim of this study was to clarify whether perioperative use of dexamethasone would improve the quality and speed of recovery. The authors hypothesized that dexamethasone would enhance recovery and diminish pain and nausea.

MATERIALS AND METHODS

Ninety-three patients with oropharyngeal cancer and microvascular reconstruction were included in this prospective double-blinded randomized controlled trial. Patients in the study group (n = 51) received dexamethasone 60 mg over 3 perioperative days; 42 patients did not receive dexamethasone and served as controls. Patient rehabilitation, postoperative opioid and insulin consumption, postoperative nausea and vomiting (PONV), and C-reactive protein (CRP), leukocyte, and lactate levels were recorded.

RESULTS

There was significantly less pain in the study group (P = .030) and the total oxycodone dose for 5 days postoperatively was lower (P = .040). Dexamethasone did not significantly lessen PONV for 5 days postoperatively (P > .05). There were no differences between groups in intensive care unit or hospital stay or in other clinical measures of recovery. Patients receiving dexamethasone required significantly more insulin compared with patients in the control group (P < .001). Lactate and leukocyte levels were significantly higher (P < .001) and CRP levels were significantly lower in the study group.

CONCLUSION

The only benefit of perioperative dexamethasone use was lower total oxycodone dose; however, the disadvantages were greater. Because dexamethasone can have adverse effects on the postoperative course, routine use of dexamethasone as a pain or nausea medication during reconstructive head and neck cancer surgery is not recommended.

Secondary free-flap reconstruction following ablation for acute invasive fungal sinusitis

OBJECTIVE

Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis.

STUDY DESIGN

Retrospective case series.

METHODS

Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed.

RESULTS

Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive.

CONCLUSION

Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:815-819, 2017.

Modified free latissimus dorsi musculocutaneous flap in the reconstruction of extensive postoncologic defects in the head and neck region

Oncological resection of advanced carcinoma in the head and neck region results in vast defects. The free latissimus dorsi musculocutaneous flap (FLDMF) is one of the most commonly used flaps for the repair of complex head and neck defects. We tried to modify FLDMF to multiple segments or combine it with acellular dermis to fit through-and-through defects in the oral-facial region during the last decade. A retrospective review of patients with FLDMF reconstruction between 2004 and 2012 was undertaken. Demographics, histology, surgical management, disease control and overall survival, complications, radiotherapy, aesthetic outcome, as well as economic results were analyzed. The majority of the patients (66.7%) had recurrent tumors, and the rest of the patients had primary tumor with stage IV. Fourteen patients (38.9%) had a history of prior radiation therapy, whereas 27.8% of the patients had postoperative radiation therapy. The areas of the defects vary from 52 cm to 180 cm (mean, 86.4 cm). The flap failed in 1 of the 37 patients. The complications at the recipient site include hematoma (n = 6, 16.7%), venous insufficiency (n = 4, 11.1%), infection (n = 3, 8.3), and partial flap necrosis (n = 2, 5.5%). The donor-site complications include delayed healing, necrosis of skin graft, and limited shoulder function. The 5-year overall survival rate was 39.1%, and the 5-year disease-free survival rate was 22.1%. In conclusion, the FLDMF could be modified to fit vast defects where voluminous tissue is needed to be transferred in the head and neck region.

Microvascular anastomotic coupler assessment in head and neck reconstruction

OBJECTIVE

To assess the advantages of using mechanical anastomotic systems in head and neck free tissue transfer.

STUDY DESIGN

Case series with chart review.

SETTING

A university-based tertiary care center.

SUBJECTS AND METHODS

A retrospective review of mechanical venous coupler devices in head and neck reconstruction performed between October 2004 and December 2006. A total of 261 venous anastomoses were performed in 234 consecutive patients. Five types of flaps were performed: radial forearm (66%), anterior lateral thigh (12%), fibula (9%), rectus abdominis (8%), and latissimus dorsi (2%). Demographic data were collected, and the outcomes measured were flap survival and microvascular complications.

RESULTS

The size of the venous anastomosis ranged from 1.5 to 4.0 mm, with most being 3.0 mm (56%) followed by 3.5 mm (23%). The most common recipient vein used was a stump off the internal jugular vein (76%) followed by the external jugular vein (17%). Microvascular complications occurred in <5% (n = 11) of patients, with >50% of those being arterial insufficiency (n = 7). Total failures occurred in 3% (n = 7) of patients: 1.5% (n = 4) acute failures (<5 days) and 1.5% (n = 3) late failures. Of the acute failures, causes included venous congestion (n = 1) and arterial insufficiencies (n = 3). The venous coupler used in the failures was 3.0 mm in diameter. Free flap failures resulting from arterial insufficiency involved coupling to the external jugular vein, while the remaining free flap failures (n = 4) used the internal jugular vein.

CONCLUSION

With an early venous failure rate of 0.38%, mechanical anastomosis is an adequate alternative to hand-sewn techniques.

Parascapular free flaps in skin malignancies

This study was a retrospective review of a case series of nine patients, aged 40 to 83 years, presenting to the head and neck cancer department at Wake Forest Baptist Medical Center, with a diagnosis of head and neck cutaneous squamous cell carcinoma (SCC), requiring reconstruction after surgical resection. In this group of patients, parascapular fasciocutaneous free flaps proved to be a safe, reliable, and cosmetically effective choice for reconstruction of head and neck skin cancer defects. Choosing donor tissue from a relatively non-sun exposed area can prevent potential development of new malignancies that may arise from donor sites using sun-exposed skin. We discuss the benefits and versatility of the parascapular fasciocutaneous free flap and our experience in using this flap to reconstruct complex surgical defects.

A novel Split-Thickness Skin Graft Donor Site

OBJECTIVE: To eliminate morbidity of the thigh split-thickness skin graft (STSG) donor site in forearm flaps, the feasibility of harvesting from an alternate site was assessed.

STUDY DESIGN: Case series with planned data collection.

SETTING: A tertiary care academic setting.

SUBJECTS AND METHODS: Data were collected from patients undergoing forearm flap reconstruction over 13 months. The forearm flap harvesting procedure was modified to incorporate STSG harvest directly from the flap skin paddle.

RESULTS: There were 66 patients in this cohort, with mean age of 62.6 years. There were 58 fasciocutaneous radial forearm free flaps (RFFFs), three osteocutaneous RFFF, three ulnar flaps, and two reverse-flow RFFFs. The majority of flaps were used for mucosal coverage (n = 54), but 12 flaps were used for external skin coverage. The mean forearm defect was 36.5 cm2 (12–77 cm2). Harvesting from the forearm skin paddle was successful in 64 patients (97%). Two patients required a thigh STSG; both patients were octogenarians with frail skin.

CONCLUSION: A thigh STSG donor site, with its associated morbidities, can be eliminated in 97 percent of patients undergoing forearm flaps. Older patients with frail skin may require a thigh donor site.

Microvascular free tissue transfer for gene delivery: in vivo evaluation of different routes of plasmid and adenoviral delivery

Transfer of healthy autologous tissue as a microvascular free flap facilitates reconstruction during ablative cancer surgery. In addition to filling surgical defects, free flaps might concentrate viral vectors at the tumour bed and mediate local therapeutic effects. We evaluated the magnitude, topography and duration of luciferase gene expression after plasmid and adenoviral delivery in rat superficial inferior epigastric (SIE) flaps. For plasmid delivery, luciferase expression was significantly increased by all transduction routes (topical, intraflap injection, intravascular) (P<0.01) at day 1, but not at day 7. The spread of luciferase expression was significantly different between the 4 groups at 1 day (P=0.026) and was greatest for flaps transduced by intravascular injection. For adenoviral transduction, total radiance was significantly different between the transduced groups at 1, 14 and 28 days (P<0.05 for all comparisons). The highest levels of radiance were seen in the intravascular group. There was a statistically significant difference in the spread of light emission between the 3 groups at 1 (P=0.009) and 14 (P=0.013) days, but this was no longer evident at 28 days. Intravascular adenoviral delivery yields high-level, diffuse and durable gene expression in rat SIE flaps and is suitable for examination in therapeutic models.

Survival and function in patients with tumours of the head and neck operated on and reconstructed with free flaps

From 1983 to 2003, 131 patients were operated on in the head and neck region with 139 free flaps. They were operated on using a team approach of ear, nose, and throat surgeons and plastic surgeons, and sometimes maxillofacial surgeons. The tumours were squamous cell carcinoma (SCC) 104 (80%), salivary gland cancer 13 (10%), sarcoma 5 (4%), basal cell carcinoma 4 (3%), and others 4 (3%). The staging of the primary intraoral SCC tumours (n=79) was 42% in stage II, 28% in stage III, and 30% in stage IV. The survival of patients with primary oral SCC was compared with a previously treated previous series that gave an increase in tumour-related five-year survival from 48% to 58%. Most flaps were radial forearm flaps (73%). Fifteen percent were vascularised bone transfers. A questionnaire was sent to patients who had had oral/oropharyngeal tumours to measure function and satisfaction, to which 47/49 responded. The results including ability to chew and swallow; speech was good, with a median score of 0.78 (range 1-0).

Modern reconstruction techniques for oral and pharyngeal defects after tumor resection

Several techniques have been developed to reconstruct oral and pharyngeal defects following surgery, in order to restore function and cosmesis. These are primary closure, skin grafts, local transposition of skin, mucosa and/or muscle, regional flaps and free vascularized flaps. Because of the 'bulky', pedicled nature and problems with the donor area of locoregional flaps, and consequently frequently unsatisfactory functional results, free vascularized flaps have gained popularity during the last decade. The authors review the current options available to give physicians, who are not experienced in the field of reconstruction in the head and neck, an impression of the range of techniques available for reconstruction of oral and pharyngeal defects following tumor resection. For reconstruction of oral cavity and pharyngeal defects, fasciocutaneous (e.g. radial forearm and anterolateral thigh flaps) and myocutaneous free flaps (e.g. rectus abdominis and latissimus dorsi) have proven to be very reliable. Free vascularized osteocutaneous flaps (e.g. fibula and iliac crest) permit reconstructive options for bony defects of the mandible or maxilla that can be adapted to a variety of defects. Depending on the site, size and involved tissues of the surgical defect and patient factors, a variety of reconstructive options are available. For both soft tissue and bony defects of the upper aerodigestive tract, microvascular free flaps provide good functional outcomes.

Factors affecting cancer recurrence after microvascular flap reconstruction of the head and neck

OBJECTIVE

Our objective was to determine which factors are associated with cancer recurrence after microvascular reconstruction of the head and neck for squamous cell carcinoma (SCC).

STUDY DESIGN

A cohort of patients who fit the inclusion/exclusion criteria were identified retrospectively.

METHODS

A group of 184 patients who underwent successful surgical resection and simultaneous microvascular reconstruction of the head and neck for treatment of SCC were identified. The mean age was 60 (range 23-90) years, there were 115 males and 69 females, and mean follow-up was 26.2 (range 1-99) months. Various factors were analyzed to determine whether they were associated with cancer recurrence, including those pertaining to 1) recipient vessel choice, 2) prior cancer treatment, and 3) cancer staging criteria. Statistical analysis was performed using SPSS statistical software.

RESULTS

Overall cancer stage (P = .005), T stage (P = .0001), history of previous cancer treatment (P = .004), and history of previous chemotherapy (P = .044) were found to be statistically significant predictors of cancer recurrence on univariate analysis. However, on multivariate analysis, only T stage (P = .005) and history of previous cancer treatment (P = .008) remained as statistically significant predictors of cancer recurrence. Recipient vessel selection was not statistically associated with cancer recurrence.

CONCLUSIONS

In our study, only T stage and a history of previous cancer treatment were associated with increased cancer recurrence. Neither the recipient vessel chosen nor its location impacted cancer recurrence. This suggests that recipient vessel selection and preparation for microvascular reconstruction do not jeopardize the adequacy of oncologic resection and are therefore oncologically sound.

Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases

BACKGROUND

Microvascular free tissue transfer has become a significant factor in the reconstruction of head and neck cancer patients. Various donor sites are available to enable anatomical and functional repair of a defect.

METHODS

All free vascularized tissue transfers performed during the period from March 1982 to September 2000 were retrieved from this hospital's database and analysed with regard to the surgical defect, chosen donor site and complications.

RESULTS

During the 18-year period a total of 1,164 patients with head and neck cancer were treated in this institution. A total of 500 free-flap reconstructions were performed for 479 patients. In the majority of patients (n = 451) reconstruction was indicated following ablative tumour surgery. With regard to donor site selection, the first choice of free jejunum was used in 181 patients, followed by the radial forearm flap in 140 patients. Among the 500 free-flap reconstructions, a total flap loss rate of 6% was observed. Patient age (p = 0.004) and tobacco use (p = 0.043) were significant risk factors for complications overall, whereas patient age (p = 0.021) and operating time (p = 0.043) were significantly correlated with local complications.

CONCLUSION

Immediate repair of head and neck defects using free tissue transfer is a successful and reliable method and is becoming the gold standard at many institutions. The complication rate is low once experience with these techniques has been acquired.

Olfactory neuroblastoma: past, present, and future?

OBJECTIVE

To consider the long-term survival and outcomes in patients with olfactory neuroblastoma undergoing craniofacial resection.

STUDY DESIGN

A single-center prospective cohort study.

METHODS

All patients with olfactory neuroblastoma treated in a 23-year period with craniofacial resection (with or without radiotherapy) were analyzed; a multivariate analysis was included.

RESULTS

Forty-two patients aged 12 to 70 years were assessed, 83% of whom had received no preceding treatment. Craniofacial resection was used in all cases, combined with radiotherapy in 24 patients (57%). Duration of follow-up ranged from 2 to 206 months (mean follow-up period, 57 mo). The disease-free actuarial survival and overall survival were 77% and 61% at 5 years and 53% and 42% at 10 years, respectively. A Cox regression analysis identified intracranial extension and orbital involvement as independent factors affecting outcome.

CONCLUSION

Craniofacial resection combined with radiotherapy offers the gold standard of care against which other approaches such as endoscopic resection must be judged.