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Thariat J, Carsuzaa F, Beddok A, Deneuve S, Marcy PY, Merlotti A, Dejean C, Devauchelle B. Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy. Front Oncol 2024; 14:1379861. [PMID: 38665951 PMCID: PMC11043495 DOI: 10.3389/fonc.2024.1379861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Background Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy. Methods A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT. Results Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications. Conclusion Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.
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Affiliation(s)
- Juliette Thariat
- Department of Radiotherapy, Centre François-Baclesse, Caen, France
- Corpuscular Physics Laboratory, IN2P3, Ensicaen, CNRS UMR 6534, Caen, France
- Faculté de Médecine de Caen, Université de Normandie, Caen, France
| | - Florent Carsuzaa
- Department of Otorhinolaryngology - Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
| | - Arnaud Beddok
- Institut Curie, PSL Research University, University Paris Saclay, Inserm LITO, Orsay, France
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Sophie Deneuve
- Surgical Oncology Department, Centre Léon Bérard, UNICANCER, Lyon, France
- Inserm, U1296 Unit, “Radiation: Defense, Health and Environment”, Centre Léon Bérard, Lyon, France
| | - Pierre-Yves Marcy
- Polyclinics ELSAN Group, Department of Radiodiagnostics and Interventional Imaging, PolyClinics Les Fleurs, Ollioules, France
| | - Anna Merlotti
- Radiotherapy Department, S. Croce & Carle Teaching Hospital, Cuneo, Italy
| | | | - Bernard Devauchelle
- Departement of Maxillofacial Surgery, University Hospital of Amiens Picardy, Research Unit, UR7516 CHIMERE, University of Picardy Jules Verne, Institut Faire Faces, Amiens, France
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Owen S. Commentary on: "Buccal Fat Advancement Transposition Flap for Reconstruction of Midface Volume Defects" by Seth J. Davis et al. Facial Plast Surg Aesthet Med 2024. [PMID: 38597715 DOI: 10.1089/fpsam.2024.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Scott Owen
- Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Head and Neck Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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Free flap volume changes: can we predict ideal flap size and future volume loss? Curr Opin Otolaryngol Head Neck Surg 2022; 30:375-379. [PMID: 36036533 DOI: 10.1097/moo.0000000000000832] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Under anticipating free flap volume may lead to deficits in functional and aesthetic outcomes. Alternatively, over anticipating may compromise airway patency, lead to prolonged tracheostomy dependence or poor oral intake, and cause poor cosmetic outcomes. Surgeons face a fine balance in creating a functional reconstruction that accounts adequately for volume changes in the future. RECENT FINDINGS Recent studies are elucidating the complex and multifactorial volume changes of free flaps that are dependent on postoperative radiation, flap composition, weight fluctuations, and site of reconstruction. Radial forearm free flaps typically lose about 40% of their volume, regardless of patient-dependent variables. Muscle flaps exhibit significant fluctuations with patient-dependent variables. Adipose-prevalent flaps are likely more resistant to radiation effects but are more dependent on postoperative weight changes in the patient. SUMMARY Free flap volume over anticipation recommendations range from 1.1 to 1.4 times the final volume to account for future atrophy but patient characteristics including postoperative radiation, anticipated weight loss, and flap composition should be incorporated into intraoperative decisions for final flap volume.
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Carsuzaa F, Verillaud B, Marcy PY, Herman P, Dufour X, Favier V, Thariat J. Interdisciplinary challenges and aims of flap or graft reconstruction surgery of sinonasal cancers: What radiologists and radiation oncologists need to know. Front Oncol 2022; 12:1013801. [PMID: 36203460 PMCID: PMC9530815 DOI: 10.3389/fonc.2022.1013801] [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: 08/07/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
In sinonasal cancer surgery, a fundamental challenge is to understand the postoperative imaging changes after reconstruction. Misinterpretation of post-operative imaging may lead to a misdiagnosis of tumor recurrence. Because radiotherapy planning is based on imaging, there are many gaps in knowledge to be filled in the interpretation of postoperative imaging to properly define radiotherapy tumor volumes in the presence of flaps. On the other hand, radiotherapy may be responsible for tissue fibrosis or atrophy, the anatomy of the reconstructed region and the functional outcomes may change after radiotherapy compared to surgery alone. This narrative review illustrates the interdisciplinary aims and challenges of sinonasal reconstructive surgery using flaps or grafts. It is particularly relevant to radiologists and radiation oncologists, at a time when intensity modulated radiotherapy and proton therapy have the potential to further contribute to reduction of morbidity.
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Affiliation(s)
- Florent Carsuzaa
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
- *Correspondence: Florent Carsuzaa,
| | - Benjamin Verillaud
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Pierre-Yves Marcy
- Department of Radiology, Clinique du Cap d’Or, La Seyne-sur-mer, France
| | - Philippe Herman
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Lariboisière, Paris, France
| | - Xavier Dufour
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, University Hospital of Poitiers, Poitiers, France
- Laboratoire Inflammation, Tissus Epithéliaux et Cytokines (LITEC), University of Poitiers, Poitiers, France
| | - Valentin Favier
- Department of Oto-Rhino-Laryngology-Head and Neck Surgery, Hôpital Gui de Chauliac, University Hospital of Montpellier, Montpellier, France
| | - Juliette Thariat
- Department of Radiation Oncology, Centre François Baclesse, Caen, France
- Laboratoire de Physique Corpusculaire UMR6534 IN2P3 ENSICAEN CNRS, Normandy University, Caen, France
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Stanford-Moore GB, Thompson EC, Gulati A, Carpenter P, Park A, Seth R, Knott PD. Outcomes of Vascularized Versus Nonvascularized Adipofascial Grafts for Parotidectomy Reconstruction. Facial Plast Surg Aesthet Med 2022; 25:232-237. [PMID: 35856681 DOI: 10.1089/fpsam.2022.0048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives: Parotidectomy defects can leave patients with considerable functional and cosmetic deformities. We aim to compare the success rates and complications associated with vascularized versus nonvascularized adipofascial grafts for reconstruction, including flap failure, return to surgery, infection, and delay to adjuvant treatment. Methods: Retrospective case series of patients undergoing either adipofascial anterolateral thigh (AFALT) free tissue transfer or free fat transfer (FFT) after parotidectomy from January 2010 to January 2020. Group comparisons and logistic regression were used to determine predictors of outcome measures. Results: Seventy-six patients underwent AFALT reconstruction, and 73 patients underwent FFT reconstruction. Patients treated with AFALT reconstruction had more aggressive tumor characteristics and underwent more complex resections, most commonly radical parotidectomy (n = 55, 72.4%). Postoperative complications at both the donor and recipient sites were more common in the FFT group (N = 20, 27.4% in FFT vs. N = 11, 14.5% in AFALT, odds ratio = 0.45, 95% confidence interval = 0.20-1.02, p = 0.052). Conclusions: Although used in more advanced disease and in a more heavily treated wound bed, the AFALT free flap was safe and associated with fewer infectious complications than that offered by FFT.
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Affiliation(s)
- Gaelen B. Stanford-Moore
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | | | - Arushi Gulati
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
- UC San Francisco School of Medicine, San Francisco, California, USA
| | - Patrick Carpenter
- Department of Otolaryngology Head and Neck Surgery, Virginia Tech University, Blacksburg, Virginia, USA
- Carilion Clinic, Roanoake, Virginia
| | - Andrea Park
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - P. Daniel Knott
- Department of Otolaryngology Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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David AP, Zebolsky AL, Park AM, Heaton CM, Knott PD, Seth R. Effect of microporous polysaccharide hemospheres on anterolateral thigh free flap donor site complications. Laryngoscope Investig Otolaryngol 2022; 7:380-387. [PMID: 35434322 PMCID: PMC9008183 DOI: 10.1002/lio2.770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/31/2022] [Indexed: 12/21/2022] Open
Abstract
Background Postoperative seroma is the most common donor site complication following anterolateral thigh (ALT) free flap harvest for head and neck reconstruction. The utility of novel microporous polysaccharide hemospheres (MPH) has not been studied as a hemostatic agent in this setting. Methods Prospective, single‐blind, randomized controlled trial of patients undergoing fasciocutaneous ALT harvest for head and neck reconstruction at a tertiary academic medical center between April 2018 and February 2020. The intervention (MPH) group received 3 g of topical MPH to the ALT donor site prior to closure whereas the control group did not receive application of MPH. Outcomes included total drain output (ml), drain output during postoperative days (POD) 1–3 alone, drain duration (days), and incidence of donor site hematoma, seroma, or infection. Results Twenty‐nine patients were randomized to the MPH group and 26 to the control group. For MPH and control groups, mean total drain output was 284.7 ± 153.0 ml versus 317.9 ± 177.6 ml (p = .527), mean POD 1–3 drain output alone was 169.3 ± 88.8 ml versus 157.9 ± 78.7 ml (p = .749), and drain duration was 5.9 ± 1.5 days versus 6.5 ± 1.6 days (p = .144), respectively. There was no significant difference in seroma (p = .733), hematoma (p = .492), or infection (p = 1.000). Drain output was not significantly influenced by gender, age, body weight, or smoking habits. Conclusion MPH administration to ALT free flap donor sites did not significantly improve drain output, hematoma formation, or seroma formation. Level of Evidence 2
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Affiliation(s)
- Abel P. David
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
| | - Aaron L. Zebolsky
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
| | - Andrea M. Park
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
| | - Chase M. Heaton
- Division of Head and Neck Oncologic Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
| | - P. Daniel Knott
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
| | - Rahul Seth
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology‐Head & Neck Surgery University of California San Francisco California USA
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Benjamin T, David AP, Zebolsky AL, Shuman EA, Park AM, Heaton CM, Knott PD, Seth R. Utility of Microporous Polysaccharide Hemosphere on Anterolateral Thigh Free Flap Donor Site Complications. Facial Plast Surg Aesthet Med 2021; 24:295-299. [PMID: 34516931 DOI: 10.1089/fpsam.2021.0141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Anterolateral thigh (ALT) microvascular free tissue transfer is an integral part of head and neck reconstructive surgery, but it can be complicated by postoperative donor site fluid collections. Objective: To measure the rate of hematoma and seroma formation in the ALT donor site in those treated with microporous polysaccharide hemosphere (MPH) and those without. Methods: This was a retrospective cohort study examining patients undergoing ALT free tissue transfer for head and neck reconstruction at a single academic center between 2014 and 2017. Primary outcomes were interventional hematomas and seromas and drain duration. Results: In total, 118 patients underwent ALT free flap reconstruction for head and neck defects. Of these, 57 patients received MPH at the donor site and 61 did not. Eleven patients had a clinically significant seroma in the non-MPH group compared with three in the MPH group (p = 0.045). Drain duration for the MPH group compared with that for the non-MPH group was 6.9 versus 8.2 days (p = 0.020), and drains were removed when output was <60 mL over 24 h. Conclusion: This study supports the use of MPH in ALT free flap donor sites for reduction of clinically significant postoperative seromas. Further investigation with larger prospective randomized clinical trials is warranted.
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Affiliation(s)
- Tania Benjamin
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.,Divisions of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Abel P David
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.,Divisions of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron L Zebolsky
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.,Divisions of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth A Shuman
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA.,Divisions of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Divisions of Head and Neck Oncologic Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Divisions of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
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Lee JJ, Wood CB, Puram SV, Zenga J, Bollig CA, Pipkorn P. Free vascularized parascapular fat flap for parotidectomy reconstruction. Am J Otolaryngol 2021; 42:103028. [PMID: 33848769 DOI: 10.1016/j.amjoto.2021.103028] [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: 02/24/2021] [Accepted: 03/29/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The contour defect resulting after parotidectomy can be cosmetically unappealing. Multiple reconstructive efforts have been reported to mitigate this problem. We describe a novel technique of vascularized parascapular fat reconstruction based on the circumflex scapular vessels and evaluate its outcomes. METHODS Consecutive patients who underwent parotidectomy with or without additional resections and vascularized parascapular fat flap reconstruction in 2020 were included. Demographic, morphologic, intraoperative, and postoperative data were assessed. RESULTS Eight patients (3 female) were included. Median cut-to-close time was 247 (range 209-298) minutes, including tumor ablation. None of the patients had any wound complications, and all except one was discharged on postoperative day 1. Flap monitoring was not performed. None reported any significant donor site morbidity except scar formation. At last follow up, all patients reported satisfactory facial contour. CONCLUSION Vascularized parascapular fat flap reconstruction of parotidectomy contour defects has satisfactory cosmetic outcomes with minimal morbidity and short hospitalization courses.
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David AP, Seth R, Knott PD. Facial Reanimation and Reconstruction of the Radical Parotidectomy. Facial Plast Surg Clin North Am 2021; 29:405-414. [PMID: 34217443 DOI: 10.1016/j.fsc.2021.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Radical parotidectomy may result from treating advanced parotid malignancies invading the facial nerve. Survival is often enhanced with multimodality treatment protocols, including postoperative radiation therapy. In addition to the reconstructive challenge of restoring facial nerve function, patients may be left with a significant cervicofacial concavity and inadequate skin coverage. This should be addressed with stable vascularized tissue that is resistant to radiation-induced atrophy. This article describes a comprehensive strategy, includes the use of the anterolateral thigh free flap, the temporalis regional muscle transfer, motor nerve to vastus lateralis grafts, nerve to masseter transfer, and fascia lata grafts for static suspension.
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Affiliation(s)
- Abel P David
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco, 2233 Post Street 3rd Floor, San Francisco, CA 94115, USA
| | - Rahul Seth
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco, 2233 Post Street 3rd Floor, San Francisco, CA 94115, USA
| | - Philip Daniel Knott
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of California, San Francisco, 2233 Post Street 3rd Floor, San Francisco, CA 94115, USA.
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