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Han SH, Ockerman K, Kirchmier M, Mardourian M, Bryan J, Cox E, Chim H, Spiguel L, Momeni A, Sorice-Virk S. Thrombotic Consequences of COVID-19 Infection on Microsurgical Reconstruction. Microsurgery 2024; 44:e31219. [PMID: 39207212 DOI: 10.1002/micr.31219] [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: 12/14/2023] [Revised: 06/12/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Evidence has shown increased morbidity and mortality for patients with COVID-19 infection within 7 weeks of surgery. However, no studies have specifically investigated the effects of COVID-19 in microsurgical outcomes. This study evaluated thrombotic and overall complications after free tissue transfer for a variety of indications in patients with and without previous COVID-19 infection. METHODS A retrospective cohort study was performed in adult patients with or without a history of COVID-19 infection who underwent microsurgical reconstruction between 2017 and 2022. Patients with a history of COVID-19 infection were matched to controls based on age, gender, race, body mass index, history of diabetes, coronary artery disease, hypertension, Caprini score, tobacco use, and flap indication. RESULTS From 2017 to 2022, 35 patients had a documented history of COVID-19. Matched case analysis determined a 4.8 times increased odds ratio of postoperative complications in the COVID-19 group compared with controls (p = 0.002). Significantly, more patients with COVID-19 experienced total or partial flap loss and anastomotic issues (COVID-19: 7/35, Control: 0/35; p < 0.001). There was no significant difference in incidence of VTE (COVID-19: 1/35, Control: 0/35; p = 0.493). Of note, 62.9% of the COVID-19 group were discharged on anticoagulants (versus 14.3% in the control group [p < 0.001]). CONCLUSION COVID-19 has dire, long-lasting effects on virtually every organ system, chief among them, the microcirculation. Further studies are needed to fully determine the extent and influence of COVID-19 on complex procedures such as free tissue transfer and how to optimize the screening, workup, and postoperative care to guard against the associated thrombotic consequences.
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Affiliation(s)
- Sabrina H Han
- Division of Plastic and Reconstructive Surgery, University of Chicago, Chicago, Illinois, USA
| | - Kyle Ockerman
- Division of Plastic and Reconstructive Surgery, University of Chicago, Chicago, Illinois, USA
| | - Matthew Kirchmier
- Division of Plastic and Reconstructive Surgery, University of Chicago, Chicago, Illinois, USA
| | - Markos Mardourian
- Division of Plastic and Reconstructive Surgery, University of Colorado, Aurora, Colorado, USA
| | - Jaimie Bryan
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Elizabeth Cox
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Harvey Chim
- Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Florida, USA
| | - Lisa Spiguel
- Division of Surgical Oncology, University of Florida, Gainesville, Florida, USA
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, California, USA
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Panettella T, Meroni M, Scaglioni MF. How to increase the success rate in microsurgical free and pedicled flap reconstructions with intraoperative multistep ICG imaging: A case series with 400 consecutive cases. J Plast Reconstr Aesthet Surg 2024; 97:147-155. [PMID: 39151286 DOI: 10.1016/j.bjps.2024.07.047] [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: 02/27/2024] [Revised: 06/08/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Over the last decade, microsurgical soft-tissue transfer became the gold standard for various reconstructions throughout the body. Continuous improvement of instruments and surgical techniques, such as intraoperative indocyanine green angiography (ICG-A), allowed for a very high success rate. This study aimed to assess and validate the role of a standard intraoperative ICG-A in free and pedicled flap surgery to improve overall outcomes. PATIENTS AND METHODS From April 2018 to April 2023, 400 consecutive patients who underwent reconstruction using free and pedicled flaps were enrolled. ICG-A was always performed in a free flap after flap elevation, after microsurgical anastomosis, immediately after the flap inset, and after wound closure. In the pedicled flap, the sequential procedure was performed after flap elevation, flap inset, and wound closure. RESULTS All 400 patients who underwent flap reconstruction using intraoperative ICG-A had an extremely low incidence of necrosis (0.75% partial necrosis among free and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications, such as hematoma, seroma, wound dehiscence, and wound infections, were managed with a second operation. No flaps were lost, and all patients were successfully treated. CONCLUSIONS This study showed how systematic multistep ICG-A for intraoperative assessment of free and pedicled flap perfusion can significantly reduce the complication rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner.
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Affiliation(s)
- Tania Panettella
- Department of Hand, and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Zentrum für Plastische Chirurgie, Pyramide Clinic, Zurich, Switzerland
| | - Mario F Scaglioni
- Department of Hand, and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland; Zentrum für Plastische Chirurgie, Pyramide Clinic, Zurich, Switzerland.
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Tsai CH, Chen YJ, Lin YC, Liu YC, Kao HK, Mao SH. New-Onset Atrial Fibrillation Is a Red Flag to Microvascular Free Tissue Transfer Failure in Head and Neck Cancer Patients. J Reconstr Microsurg 2024. [PMID: 38593991 DOI: 10.1055/a-2302-6992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND Postoperative new-onset atrial fibrillation (AF) has been shown to be associated with increased surgical morbidity and mortality following cancer ablation surgery. However, evidence of new-onset AF's impact on surgical outcomes in head and neck cancer patients undergoing tumor ablation and microvascular free tissue transfer remains scarce. This study aims to evaluate the association between AF and surgical outcomes in these patients. METHODS We enrolled head and neck cancer patients who underwent tumor ablation reconstructed with microvascular free tissue transfer from the National Health Insurance Research Database (NHIRD). Patients were grouped into the following: (1) without AF, (2) new-onset AF, and (3) preexisting AF. The groups were matched by propensity score based on age, gender, cancer stage, and comorbidities. The primary outcome was postoperative complications, whereas all-cause mortality was the secondary outcome. RESULTS In total, 26,817 patients were included in this study. After matching, we identified 2,176 (79.24%) patients without AF, 285 (10.37%) with preexisting AF, and 285 (10.37%) with new-onset AF. Our results demonstrated that the free flap failure rate was twofold escalated in patients with new-onset AF (9.8%) compared to those without AF (5.4%) or preexisting AF (5.3%; p = 0.01). However, we did not identify significant differences among other postoperative complications across groups. Additionally, we found that the risk of all-cause mortality was significantly elevated in patients with preexisting AF (p < 0.001) compared to those without AF or new-onset AF. CONCLUSION Our study demonstrated that new-onset AF is associated with an increased risk of flap failure and could serve as a predictor. On the other hand, all-cause mortality in patients with preexisting AF was significantly elevated. Close postoperative monitoring in patients with new-onset and preexisting AF is crucial to identify any potential adverse effects.
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Affiliation(s)
- Chia-Hsuan Tsai
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung & Chang Gung University College of Medicine, Keelung, Taiwan
| | - Yu-Jen Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkuo & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yu-Chih Lin
- Research Services Center for Health Information, Chang Gung University, Taoyuan City, Taiwan
| | - Yao-Chang Liu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Keelung & Chang Gung University College of Medicine, Keelung, Taiwan
| | - Huang-Kai Kao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkuo & Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Shih-Hsuan Mao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkuo & Chang Gung University College of Medicine, Taoyuan, Taiwan
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Ho CY, Roan TL, Hsieh CY, Yu YC, Chen YS. The use of a skin paddle-containing vein graft for arteriovenous looping in two-stage free flap reconstruction of lower extremities. Microsurgery 2024; 44:e31041. [PMID: 37009759 DOI: 10.1002/micr.31041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/01/2023] [Accepted: 03/20/2023] [Indexed: 04/04/2023]
Abstract
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.
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Affiliation(s)
- Chun-Yee Ho
- Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Tyng-Luen Roan
- Division of Plastic Surgery, Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Chi-Ying Hsieh
- Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Yen-Chen Yu
- Division of Plastic Surgery, Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Yo-Shen Chen
- Division of Plastic Surgery, Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan
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Mohamed AAS, Mai L, Rao G, Fan S, Mashrah MA, Holkom MAM, Pan C, Lin Z. Perioperative risk factors impact on intensive care unit length of stay (ICU length of stay) in oral squamous cell carcinoma. BMC Oral Health 2023; 23:624. [PMID: 37658335 PMCID: PMC10474623 DOI: 10.1186/s12903-023-03304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 08/11/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND The trend in postoperative care for free flap patients is to deescalate from routine ICU admission into a specialty recovery unit. This study aims to investigate the predictive parameters in a routine perioperative clinical assessment that are expected to be directly correlated with prolonged ICU length of stay in at-risk patients who received oral reconstructive surgery for squamous cell carcinoma (OSCC). METHODS All patients who underwent ablative surgery for OSCC with free flap reconstruction and were managed in the ICU were included in this study. The primary outcome was ICU-length of stay. Perioperative, operative and postoperative parameters were analyzed using single test ( t-test, ANOVA analysis, correlation coefficients, effect size) and multivariate regression test. The P-value was set as < 0.005 to be considered statically significant. RESULTS The study included 136 homogeneous patients, with a mean ICU length of stay of 4.5 (± 4.43 day). Patients with pre-operative positive renal dysfunction (P = 0.004), peripheral vascular disease (P < 0.001), postoperative complications (P = 0.028) or positive heart failure class III (P < 0.001 ) were recognized as at-risk patients for a significantly longer ICU length of stay. CONCLUSION Patients with perioperative severe renal dysfunction, peripheral vascular disease, postoperative complication or high NYHA class are prone to have a significantly longer ICU length of stay. Several factors were considered as confounders contributing to increased ICU management time in combination with other variables. Additionally, in highly risk patient, the presence of the highly trained medical support, including the appropriate nursing care, is more critical than those patients without these risk factors.
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Affiliation(s)
- Abdo Ahmed Saleh Mohamed
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ibb University, Ibb, Yemen
| | - Lianxi Mai
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Guangxin Rao
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Song Fan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China
| | - Mubarak Ahmed Mashrah
- Department of Oral Implant, Guangdong Engineering Research of Oral Restoration and reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Mohamed Ali Mahyoub Holkom
- Department of Oral & Maxillofacial Surgery- head & neck oncology, School of Stomatology, Wuhan University, Wuhan, Hubei, China
| | - Chaobin Pan
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
| | - Zhouyu Lin
- Department of Oral & Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang Road, Guangzhou, 510120, China.
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Soto E, Peacock PW, Clark AR, King TW, de la Torre JI, Patcha P, Fix RJ, Myers RP. A Systematic Review of Microsurgical Pedicle Lengthening in Free Tissue Transfer. Ann Plast Surg 2023; 90:S379-S386. [PMID: 37332209 DOI: 10.1097/sap.0000000000003450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Traumatic injuries that require free tissue flaps for reconstruction may require vascular pedicle extension between the flap and recipient vessels to form a clear anastomosis. Currently, a variety of techniques are used, each with their own potential benefits and harms. In addition, reports in the literature conflict on the reliability of pedicle extensions of vessels in free flap (FF) surgery. The objective of this study is to systematically assess the available literature about outcomes of pedicle extensions in FF reconstruction. METHODS A comprehensive search was performed for relevant studies published up to January 2020. Study quality was assessed using the Cochrane Collaboration risk of bias assessment tool and a set of predetermined parameters was extracted by 2 investigators independently for further analysis. The literature review yielded 49 studies investigating pedicled extension of FF. Studies meeting inclusion criteria underwent data extraction focusing on demographics, conduit type, microsurgical technique, and postoperative outcomes. RESULTS The search yielded 22 retrospective studies totaling 855 procedures from 2007 to 2018 in which 159 complications (17.1%) were reported in patients aged between 39 and 78 years. Overall heterogeneity of articles included in this study was high. Free flap failure and thrombosis were the 2 most prevalent major complications noted: vein graft extension technique had the highest rate of flap failure (11%) in comparison with the arterial graft (9%) and arteriovenous loops (8%). Arteriovenous loops had a rate of thrombosis of 5% versus 6% in arterial grafts and 8% in venous grafts. Bone flaps maintained the highest overall complication rates per tissue type at 21%. The overall success rate of pedicle extensions in FFs was 91%. Arteriovenous loop extension resulted in a 63% decrease in the odds of vascular thrombosis and a 27% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). Arterial graft extension resulted in a 25% decrease in the odds of venous thrombosis and a 19% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). CONCLUSIONS This systematic review strongly suggests that pedicle extensions of the FF in a high-risk complex setting are a practical and effective option. There may be a benefit to using arterial versus venous conduits, although further examination is warranted given the small number of reconstructions reported in the literature.
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Affiliation(s)
| | | | | | - Timothy W King
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jorge I de la Torre
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Prasanth Patcha
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - R Jobe Fix
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Uehara M, Habu M, Sasaguri M, Tominaga K. Post-reconstruction Free Flap Complications After Oral Cancer Ablation. J Maxillofac Oral Surg 2023; 22:20-27. [PMID: 37041939 PMCID: PMC10082861 DOI: 10.1007/s12663-023-01854-2] [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: 06/11/2021] [Accepted: 01/14/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Microvascular free flap transfer is considered a standard reconstruction after the ablation of oral cancer. Although the success rate is high, flap complications occasionally occur. This study investigated the reasons for and local factors involved in complications of free flap transfer and explored how to salvage the flaps. Patients and Methods The cases of 53 patients who underwent a free flap transfer [radial forearm flaps (n = 36), abdominis musculocutaneous flaps (n = 6), scapular osteocutaneous flaps (n = 10), and fibular osteocutaneous flap (n = 1)] were analyzed: flap complications were observed in five of the cases. Results In the all five cases, a salvage operation was performed under general anesthesia. The flap complications occurred within 33 h after anastomosis. In the salvage operation, thrombotic occlusion in veins of flap feeders was observed in three of the five cases. The possible reasons for flap complications were a twisting of the anastomosed vein where two veins were united, pressure to the feeder due to subcutaneous hematoma, and edema of adjacent tissue and/or drain tube; the reason was not clear in one case. The flaps were successfully salvaged in four cases by thrombectomy in veins, release of pressure at the veins, and/or interposition of the vein graft. Conclusion Surgeons should pay close attention to the pressure and/or twisting in the feeder as well as the hemostasis in the surgical field, and a salvage operation should be carried out immediately when a flap complication is identified.
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Affiliation(s)
- Masataka Uehara
- Unit of Oral and Maxillofacial Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho, Shimonoseki City, Yamaguchi 750-8520 Japan
| | - Manabu Habu
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Masaaki Sasaguri
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Kazuhiro Tominaga
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
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Mashrah MA, Aldhohrah T, Abdelrehem A, Sabri B, Ahmed H, Al-Rawi NH, Yu T, Zhao S, Wang L, Ge L. Postoperative care in ICU versus non-ICU after head and neck free-flap surgery: a systematic review and meta-analysis. BMJ Open 2022; 12:e053667. [PMID: 34992114 PMCID: PMC8739421 DOI: 10.1136/bmjopen-2021-053667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE Admission to the intensive care unit (ICU) has long been considered as routine by most head and neck surgeons after microvascular free-flap transfer. This study aimed to answer the question 'Is there a difference in the flap survival and postoperative complications rates between admission to intensive care unit (ICU) versus Non-ICU following microvascular head and neck reconstructive surgery?'. DESIGN Systematic review, and meta-analysis. METHODS The PubMed, Embase, Scopus and Cochrane Library electronic databases were systematically searched (till April 2021) to identify the relevant studies. Studies that compared postoperative nursing of patients who underwent microvascular head and neck reconstructive surgery in ICU and non-ICU were included. The outcome variables were flap failure and length of hospital stay (LOS) and other complications. Weighted OR or mean differences with 95% CIs were calculated. RESULTS Eight studies involving a total of 2349 patients were included. No statistically significant differences were observed between ICU and non-ICU admitted patients regarding flap survival reported (fixed, risk ratio, 1.46; 95% CI 0.80 to 2.69, p=0.231, I2=0%), reoperation, readmission, respiratory failure, delirium and mortality (p>0.05). A significant increase in the postoperative pneumonia (p=0.018) and sepsis (p=0.033) was observed in patients admitted to ICU compared with non-ICU setting. CONCLUSION This meta-analysis showed that an immediate postoperative nursing in the ICU after head and neck microvascular reconstructive surgery did not reduce the incidence of flap failure or complications rate. Limiting the routine ICU admission to the carefully selected patients may result in a reduction in the incidence of postoperative pneumonia, sepsis, LOS and total hospital charge.
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Affiliation(s)
- Mubarak Ahmed Mashrah
- Department of Dental Implantology, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | | | - Ahmed Abdelrehem
- Department of Craniomaxillofacial and Plastic Surgery, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Bahia Sabri
- Guanghua Stomatology Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hyat Ahmed
- Dalian Medical University, Dalian, Liaoning, China
| | - Natheer H Al-Rawi
- Department Oral & Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, UAE
| | - Tian Yu
- Zhishan Stomatology Center, Guangzhou, Guangdong, China
| | - Shiyong Zhao
- Department of Dental Implantology, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Liping Wang
- Department of Dental Implantology, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
| | - Linhu Ge
- Department of Dental Implantology, Affiliated Stomatology Hospital of Guangzhou Medical University, Guangdong Engineering Research Center of Oral Restoration and Reconstruction, Guangzhou Key Laboratory of Basic and Applied Research of Oral Regenerative Medicine, Guangzhou, Guangdong, China
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Kao KK, Nishikawa SM, Faringer PD. Surgical and Patient Reported Outcomes After DIEP Breast Reconstruction at a Low-Volume Community Hospital Without Microvascular Fellowship Training. EPLASTY 2021; 21:e9. [PMID: 35603019 PMCID: PMC9128728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Microsurgical breast reconstruction is typically performed at large, academic centers by fellowship-trained surgeons. This study examines surgical and patient-reported outcomes (PROs) after deep inferior epigastric perforator (DIEP) flap breast reconstruction at a community hospital by surgeons without fellowship training. METHODS A prospective clinical database and BREAST-Q results were obtained from 33 patients after 45 DIEP flaps performed between 2016 and 2020. PROs and complications were compared to normative data and multi-institutional series. Regression analysis of patient and surgical factors with BREAST-Q scores was performed. RESULTS Thirty-one patients completed BREAST-Q (response rate = 94%). Overall flap survival was 97.8%. Complications were not statistically different from larger published series (P > 0.05). Patients reported excellent outcomes after breast reconstruction: satisfaction with breasts (80.6 ± 4.3), satisfaction with outcome (88.3 ±17.7), psychosocial well-being (80.74 ± 17.4), sexual well-being (68.2 ± 24.1), physical well-being - chest (73.8 ± 16.1), and physical well-being - abdomen (73.3 ± 17.4). PROs were not statistically different from published multicenter data with the exception of superior scores in sexual well-being (P < 0.05) and breast satisfaction (P < 0.0001). Satisfaction with outcome varied by patient age and was 20.7 points higher for patients over 55 compared to patients 46 to 55 years of age (P < 0.05). Satisfaction with breasts was 29 points lower after total flap loss (P < 0.005). Psychosocial well-being scores were 26.98 points lower after a takeback (P < 0.05). Sexual well-being and physical well-being - chest scores were negatively related to increasing body mass index (BMI) (P < 0.05). CONCLUSION DIEP flap breast reconstruction can be performed with high quality and excellent PROs at a community hospital by surgeons without microvascular fellowship training.
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Affiliation(s)
- Kenneth K. Kao
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
| | - Scott M. Nishikawa
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
| | - Paul D. Faringer
- Department of Plastic Surgery, Kaiser Permanente Moanalua Medical Center; Honolulu, HI
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10
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Lewcun J, Massand S, Trangucci J, Shen C, Johnson TS. Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting. J Reconstr Microsurg 2021; 38:466-471. [PMID: 34583394 DOI: 10.1055/s-0041-1735835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. METHODS A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. RESULTS Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). CONCLUSION Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.
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Affiliation(s)
- Joseph Lewcun
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Sameer Massand
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - John Trangucci
- Department of Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, Pennsylvania
| | - Chan Shen
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Timothy S Johnson
- Division of Plastic Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, Pennsylvania
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11
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Utility of Viscoelastic Tests to Predict Flap Thrombosis: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3769. [PMID: 34408964 PMCID: PMC8360463 DOI: 10.1097/gox.0000000000003769] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/21/2021] [Indexed: 12/02/2022]
Abstract
Background: Flap thrombosis is a rare but devastating complication in microsurgery. Preoperative identification of patients at increased risk for microvascular thrombosis remains challenging. Viscoelastic testing (VET) provides a comprehensive evaluation of the clotting process and can effectively identify hypercoagulability. However, the utility of VET in microvascular reconstruction remains unclear. Methods: A systematic review of the association between VET and pedicle thrombosis and free flap loss was performed in accordance with Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Identified studies were reviewed independently by two authors for pertinent data. Results: Six studies met inclusion criteria. Heterogenous study design and outcome reporting complicated direct comparisons and precluded a formal meta-analysis. Four studies found a statistically significant relationship between VET results and flap thrombosis or flap loss. The maximum clot strength and the fibrinogen-to-platelet ratio (FPR) were key viscoelastic parameters in these studies, both representing a measure of maximal clot strength. Specifically, an elevated FPR (>42%) generated a sensitivity and specificity for flap loss ranging from 57% to 75% and 60% to 82%, respectively. Notably, the negative predictive value for flap failure with a normal preoperative FPR was greater than 90% in all studies reporting a correlation. The remaining two studies reported no predictive value for VET with respect to flap failure or pedicle thrombosis. Conclusion: The results of this review suggest that VET, particularly parameters relating to clot strength, may help clinicians identify patients at risk for flap thrombosis. However, uncontrolled and heterogenous reporting limit definitive conclusions, and high-quality diagnostic studies are needed to better determine the clinical utility of viscoelastic testing for free flap patients.
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12
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Wallner J, Schwaiger M, Edmondson SJ, Mischak I, Egger J, Feichtinger M, Zemann W, Pau M. Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery. Cancers (Basel) 2021; 13:cancers13163937. [PMID: 34439092 PMCID: PMC8394988 DOI: 10.3390/cancers13163937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/27/2021] [Accepted: 08/02/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. MATERIAL AND METHODS Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18-90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. RESULTS This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. CONCLUSIONS At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.
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Affiliation(s)
- Juergen Wallner
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
- Department of Cranio-Maxillofacial Surgery, AZ Monica and the University Hospital Antwerp, 2018 Antwerp, Belgium
| | - Michael Schwaiger
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
- Correspondence: ; Tel.: +43-(0)316-385-80722
| | - Sarah-Jayne Edmondson
- Department of Plastic and Reconstructive Surgery, Guy’s and St. Thomas’ Hospital, London SE1 7EH, UK;
| | - Irene Mischak
- University Clinic of Dental Medicine and Oral Health, Medical University of Graz, 8036 Graz, Austria;
| | - Jan Egger
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
- Institute for Computer Graphics and Vision, Graz University of Technology, 8036 Graz, Austria
| | - Matthias Feichtinger
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
| | - Wolfgang Zemann
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
| | - Mauro Pau
- Department of Oral & Maxillofacial Surgery, Medical University of Graz, 8036 Graz, Austria; (J.W.); (J.E.); (M.F.); (W.Z.); (M.P.)
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13
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Meaike JD, Moran SL. Response to the Letter to the Editor Regarding Article "Is Rural Plastic Surgery Feasible and Important?: A Survey and Review of the Literature. Ann Plast Surg 2021; 87:230. [PMID: 34253704 DOI: 10.1097/sap.0000000000002551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Yoshimatsu H, Karakawa R, Scaglioni MF, Fuse Y, Tanakura K, Yano T. Application of intraoperative indocyanine green angiography for detecting flap congestion in the use of free deep inferior epigastric perforator flaps for breast reconstruction. Microsurgery 2021; 41:522-526. [PMID: 33764594 DOI: 10.1002/micr.30734] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND The use of intraoperative indocyanine green (ICG) angiography has been well documented for confirmation of arterial perfusion in transferred free flaps. However, no previous report has yet focused on whether ICG angiography can be used to detect congestion in free flaps. The present report investigates the feasibility of ICG angiography for detecting flap congestion intraoperatively through illustrative cases. METHODS From September 2019 to September 2020, 65 consecutive female patients who underwent breast reconstructions using a free deep inferior epigastric perforator (DIEP) flap were enrolled in this study. Forty-eight patients with 52 DIEP flaps were eligible for the study after application of the exclusion criteria. ICG angiography was performed after elevation of the flap, after completion of the anastomoses, and after inset of the flap. RESULTS In five cases (9.6%), an inadequate highlight was demonstrated with ICG angiography performed after flap elevation. All such cases were deemed congestive since robust bleeding was observed with the prick test. ICG angiography demonstrated sufficient highlight of the flap after removal of the clamp on the superficial inferior epigastric vein. In two cases (4.2%), kinking of the pedicle vein of the DIEP flap was found with ICG angiography performed after inset of the flap. In both cases, the pedicle and the flap were reinset. All flaps survived completely postoperatively. CONCLUSION ICG angiography can detect flap congestion, and the proposed 3-step protocol is useful for the prevention of postoperative complications.
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Affiliation(s)
- Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Mario F Scaglioni
- Department of Plastic and Reconstructive Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenta Tanakura
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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15
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Feng AL, Nasser HB, Rosko AJ, Casper KA, Malloy KM, Stucken CL, Prince ME, Chinn SB, Spector ME. Revisiting pedicled latissimus dorsi flaps in head and neck reconstruction: contrasting shoulder morbidities across mysofascial flaps. ACTA ACUST UNITED AC 2021; 8. [PMID: 34337111 PMCID: PMC8323836 DOI: 10.20517/2347-9264.2021.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.
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Affiliation(s)
- Allen L Feng
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Hassan B Nasser
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Andrew J Rosko
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Keith A Casper
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Kelly M Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Chaz L Stucken
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Mark E Prince
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, MI 48109, USA
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16
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Kim S, Lee DH, Ahn KM. Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases. Maxillofac Plast Reconstr Surg 2020; 42:29. [PMID: 32884927 PMCID: PMC7447709 DOI: 10.1186/s40902-020-00273-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 12/15/2022] Open
Abstract
Background Microvascular reconstruction is the treatment of choice after oral cancer ablation surgery. There are few published studies of free flap survival among Korean populations. This study aimed to determine the survival rate after 121 consecutive cases of maxillofacial microvascular reconstruction and to analyze the complications associated with microsurgery. Methods This study included consecutive patients who underwent microsurgical reconstruction with free flaps, from January 2006 through September 2019, performed by a single surgeon at the oral and maxillofacial surgery department of a tertiary medical center. A total of 121 cases were reviewed retrospectively. The flap survival rate, flap type, radiotherapy history, complications, and treatment results were analyzed. Results Four different flap types were used for microvascular reconstruction: radial forearm (n = 65), fibula (n = 34), latissimus dorsi (n = 21), and serratus anterior muscle with rib bone free flap (n = 1). Total necrosis of the flap was found in four cases (two latissimus dorsi flaps and two fibular flaps). The free flap survival rate was 97.5%. Nineteen patients received radiotherapy before surgery, and none of them experienced flap failure. The mean operation time was 334 ± 83.1 min, and the mean ischemic time was 48.9 ± 12.7 min. Conclusions The success rate was reliable and comparable with previous studies. The success rate was not affected by radiation therapy. Free flaps can be safely used even after radiation treatment.
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Affiliation(s)
- SeongRyoung Kim
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Dong-Hun Lee
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
| | - Kang-Min Ahn
- Department of Oral and Maxillofacial Surgery, College of Medicine, University of Ulsan, Asan Medical Center, 88 Olympic-ro, 43-gil, Songpa-gu, Seoul, 05505 Korea
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17
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Tewfik K, Manfuso A, Cassano L, Pederneschi N, Copelli C. Designing a Masterclass in free flap surgery for head and neck surgeons: Our experience. Microsurgery 2020; 40:929. [PMID: 32767678 DOI: 10.1002/micr.30638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/17/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Karim Tewfik
- IRCCS Ospedale Casa Sollievo della Sofferenza, Maxillo-Facial Department, San Giovanni Rotondo, Puglia, IT, Italy
| | - Alfonso Manfuso
- IRCCS Ospedale Casa Sollievo della Sofferenza, Maxillo-Facial Department, San Giovanni Rotondo, Puglia, IT, Italy
| | - Lazzaro Cassano
- IRCCS Ospedale Casa Sollievo della Sofferenza, Maxillo-Facial Department, San Giovanni Rotondo, Puglia, IT, Italy
| | - Nicola Pederneschi
- IRCCS Ospedale Casa Sollievo della Sofferenza, Maxillo-Facial Department, San Giovanni Rotondo, Puglia, IT, Italy
| | - Chiara Copelli
- IRCCS Ospedale Casa Sollievo della Sofferenza, Maxillo-Facial Department, San Giovanni Rotondo, Puglia, IT, Italy
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18
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Bender-Heine A, Sweeny L, Curry JM, Petrisor D, Young G, Hyzer J, Cave T, Li R, Cannady S, Miles B, Wax MK. Management of the Acute Loss of a Free Flap to the Head and Neck-A Multi-institutional Review. Laryngoscope 2020; 131:518-524. [PMID: 32716574 DOI: 10.1002/lary.28886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/20/2020] [Accepted: 06/08/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES/HYPOTHESIS To review the management of failed free tissue transfers among four large institutions over a 13-year period to provide data and analysis for a logical, algorithmic, experience-based approach to the management of failed free flaps. STUDY DESIGN Retrospective case series. METHODS A multi-institutional retrospective chart review of free tissue transfers to the head and neck region between 2006 and 2019 was performed. Patients with a failed free flap during their hospitalization after surgery to the head and neck were identified and reviewed. Patient age, co-morbidities, risk factors, flap characteristics, tumor specifics, and length of hospital stay were reviewed, collected, and analyzed. RESULTS One hundred eighteen flap failures met criteria. The most common failed flap in this review was the osteocutaneous flap 52/118 (44%). The recipient site of the initial free flap (P < .001) was the only statistically significant parameter strongly correlated with management. Osteocutaneous flap failures, fasciocutaneous, bowel, and muscle-only flaps tended to be managed most commonly with a second free flap. Myocutaneous flap failures were managed equally with either a second free flap or a regional flap. CONCLUSIONS The most important factor in management of a failed free flap is the recipient site. A second free flap is often the preferred treatment, but in the acute setting, local or regional flaps may be viable options depending on the recipient site, circumstances of flap loss, and patient- specific comorbidities. An algorithm for management of the acute flap loss is presented in this review. LEVEL OF EVIDENCE 4 Laryngoscope, 131:518-524, 2021.
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Affiliation(s)
- Adam Bender-Heine
- Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, USA
| | - Larissa Sweeny
- Department of Otolaryngology-Head and Neck Surgery, Louisiana State University Health Science Center-New Orleans, New Orleans, Louisiana, USA
| | - Joseph M Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Petrisor
- Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Gavin Young
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Jeffrey Hyzer
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Taylor Cave
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Ryan Li
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Steven Cannady
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brett Miles
- Department of Otolaryngology-Head and Neck Surgery, Mount Sinai School of Medicine, New York, New York, U.S.A
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health and Science University, Portland, Oregon, USA
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19
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Zaid W, Schlieve T. The Early Effects of Coronavirus Disease-2019 on Head and Neck Oncology and Microvascular Reconstruction Practice: A National Survey of Oral and Maxillofacial Surgeons Enrolled in the Head and Neck Special Interest Group. J Oral Maxillofac Surg 2020; 78:1859-1868. [PMID: 32745533 PMCID: PMC7366104 DOI: 10.1016/j.joms.2020.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 01/02/2023]
Abstract
PURPOSE The coronavirus disease-2019 (COVID-19) pandemic has affected healthcare systems across the nation. The purpose of this study is to gauge the early effects of the COVID-19 pandemic on head and neck oncology and reconstructive surgery (HNORS) practice and evaluate their practice patterns especially ones that might be impacted by COVID-19 and compare them to the current literature. METHODS This study is a cross-sectional study that surveyed fellowship-trained oral and maxillofacial surgeons in HNORS. This cohort of surgeons was contacted via a generated email list of surgeons enrolled in the American Association of Oral and Maxillofacial Surgeons pathology special interest group. An electronic survey contained 16 questions to assess the COVID-19 effect on HNORS practice and capture their practice patterns from mid-March to mid-April 2020. Statistical analysis was performed to analyze counts, percentages, and response rates. RESULTS We had a 60% response rate (39 of 64); 72% of our responders worked at academic institutions, 18% marked themselves as hybrid academic/private practice, and only 10% were considered hospital-based surgeons. Only 8% of the survey respondents were requested to pause head and neck cancer surgery, whereas 24% were requested to pause free flap surgery during the pandemic. Fifty-five percent agreed that the head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks was a reasonable delay for head and neck cancer cases, whereas 29% thought they should not be delayed for any amount of time. Regarding practice patterns, microvascular reconstruction was the favored method (100%). Respondents generally admitted patients to an intensive care unit postoperatively (92%) and were kept on a ventilator (53%). CONCLUSION The COVID-19 pandemic had a small impact on the surgical treatment of patients with head and neck oncology. Most HNORS surgeons are practicing in accordance with recently published literature.
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Affiliation(s)
- Waleed Zaid
- Associate Professor, Department of Oral and Maxillofacial Surgery, Site Director of Oral and Maxillofacial Surgery - Baton Rouge, Louisiana State University Health Sciences Center - New Orleans, New Orleans, LA.
| | - Thomas Schlieve
- Assistant Professor of Surgery, Division of Oral and Maxillofacial Surgery, Dallas, TXl, Residency Program Director, Division of Oral and Maxillofacial Surgery, Dallas, TX, Director of Oral and Maxillofacial Surgery, Parkland Memorial Hospital, Dallas, TX, Director of Oral and Maxillofacial Surgery, Texas Health Presbyterian- Dallas, Dallas, TX
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20
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Beudeker N, Smits I, Spierings R, Rijntalder T, Verduijn PS, de Wit T, Mureau MA, Rakhorst HA. Starting an autologous breast reconstruction program after plastic surgical training. Is it as good as it gets? J Plast Reconstr Aesthet Surg 2020; 73:286-294. [DOI: 10.1016/j.bjps.2019.07.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/11/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
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21
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Gabrick K, Alperovich M, Chouari F, Mets EJ, Reinhart M, Dinis J, Avraham T. Breast reconstruction patterns and outcomes in academic and community practices within a single institution. Breast J 2019; 26:924-930. [PMID: 31788914 DOI: 10.1111/tbj.13693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 11/28/2022]
Abstract
Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale-New Haven Hospital (YNHH), both academic (AP) and community-based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple-sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community-based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.
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Affiliation(s)
- Kyle Gabrick
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Michael Alperovich
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Fouad Chouari
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Elbert J Mets
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Manuel Reinhart
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Jacob Dinis
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
| | - Tomer Avraham
- Department of Surgery, Yale School of Medicine, Section of Plastic and Reconstructive Surgery, New Haven, CT, USA
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22
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Cervenka B, Olinde L, Gould E, Farwell D, Moore M, Kaufman M, Bewley A. Use of a non-ICU specialty ward for immediate post-operative management of head and neck free flaps; a randomized controlled trial. Oral Oncol 2019; 99:104464. [DOI: 10.1016/j.oraloncology.2019.104464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/01/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
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23
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Copelli C, Tewfik K, Cassano L, Pederneschi N, Catanzaro S, Manfuso A, Cocchi R. Management of free flap failure in head and neck surgery. ACTA OTORHINOLARYNGOLOGICA ITALICA 2018; 37:387-392. [PMID: 29165433 PMCID: PMC5720866 DOI: 10.14639/0392-100x-1376] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/11/2017] [Indexed: 11/23/2022]
Abstract
Free flap surgery is overall considered the gold standard in head and neck reconstruction, with a success rate of 95%. The management of a total flap necrosis and which solution, between a pedicled or a second free flap, is safer for a salvage procedure is still controversial. Object of this study is to describe the authors' management of total free flap loss in head and neck reconstruction and compare the choices and results to those reported in the literature. From January 2012 to January 2016, 149 consecutive free flaps were performed at the Maxillo- Facial Operative Unit of the Hospital Casa Sollievo della Sofferenza in San Giovanni Rotondo (Italy) for reconstruction of head and neck defects. Of these, 6 flaps were lost due to a total necrosis. In 5 cases it was decided to harvest a second free flap, and in the remaining patient a temporalis muscle flap was used. All the free salvage flaps were successful, without complications and with a good aesthetic and functional recovery. Analysing the data obtained, and comparing them with those reported in the literature, it can be concluded that a second subsequent free flap can be considered an ideal and safe procedure in salvage surgery.
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Affiliation(s)
- C Copelli
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - K Tewfik
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - L Cassano
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - N Pederneschi
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - S Catanzaro
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - A Manfuso
- Operative Unit of Maxillo-Facial Surgery, Federico II University, Naples, Italy
| | - R Cocchi
- Operative Unit of Maxillo-Facial Surgery, Otolaryngology and Dentistry, Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
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Petrovics L, Nagy T, Hardi P, Bognar L, Pavlovics G, Tizedes G, Takacs I, Jancso G. The effect of trimetazidine in reducing the ischemia-reperfusion injury in rat epigastric skin flaps. Clin Hemorheol Microcirc 2018; 69:405-415. [DOI: 10.3233/ch-170335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Laura Petrovics
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Tibor Nagy
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Peter Hardi
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Laura Bognar
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | | | | | - Ildiko Takacs
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
| | - Gabor Jancso
- Department of Surgical Research and Techniques, Medical School, University of Pécs, Hungary
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Utility and Versatility of the Supraclavicular Artery Island Flap in Head and Neck Reconstruction. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018. [DOI: 10.1016/j.otoeng.2017.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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26
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Santaliz-Ruiz LE, Rivera-Morales MD, Giudiceandrea I, Franceschi F, Domenech-Fagundo E, Pérez-Mitchell C, Avilés D, Pérez-Nieves R. Fibula osteomyocutaneous free flap in mandibular reconstruction: clinical experience in a community-based hospital. EUROPEAN JOURNAL OF PLASTIC SURGERY 2017. [DOI: 10.1007/s00238-017-1377-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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González-García JA, Chiesa-Estomba CM, Sistiaga JA, Larruscain E, Álvarez L, Altuna X. Utility and versatility of the supraclavicular artery island flap in head and neck reconstruction. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2017; 69:8-17. [PMID: 28506450 DOI: 10.1016/j.otorri.2017.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/22/2017] [Accepted: 03/12/2017] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The supraclavicular island flap is a rotational pedicled flap and may have some advantages in head and neck reconstruction compared with free-tissue transfer when this kind of reconstruction is not affordable or recommended. MATERIAL AND METHODS We present our experience during the year 2016 in the application of the supraclavicular island flap in five cases as an alternative to microvascular reconstruction in several defects after resection of head and neck tumours. In two patients, the flap was used to close the surgical pharyngostoma after total laryngectomy with partial pharyngectomy. In one patient, it was used in lateral facial reconstruction after partial resection of the temporal bone. In one case, it was used to close a skin defect after total laryngectomy with prelaryngeal tissue extension. And in the last case to close a neck skin defect after primary closure of a pharyngo-cutaneous fistula. There were no flap complications, and the result was satisfactory in all cases. RESULTS The supraclavicular artery island flap is useful and versatile in head and neck reconstruction. Operating room time in aged patients or those with comorbidities will be reduced compared to free flaps. The surgical technique is relatively easy and can be used for skin and mucosal coverage. CONCLUSION The supraclavicular island flap could be a recommended option in head and neck reconstruction, its use seems to be increasing and provides a safe and time-saving option to free flaps in selected patients.
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Affiliation(s)
- José A González-García
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España.
| | - Carlos M Chiesa-Estomba
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España
| | - Jon A Sistiaga
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España
| | - Ekhiñe Larruscain
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España
| | - Leire Álvarez
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España
| | - Xabier Altuna
- Servicio de Otorrinolaringología y Cirugía de Cabeza y Cuello, Hospital Universitario Donostia-Donostia Unibersitate Ospitalea, Donostia-San Sebastián, Gipuzkoa, España
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Dat AD, Loh IW, Bruscino-Raiola F. Free-flap salvage: muscle only versus skin paddle - an Australian experience. ANZ J Surg 2016; 87:1040-1043. [PMID: 26991473 DOI: 10.1111/ans.13522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/30/2016] [Accepted: 02/08/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Free-tissue transfer flaps are an effective reconstructive option for complex wounds; however, flap failure is a dreaded complication requiring timely re-exploration and salvage. The aim of this study was to determine whether salvage rates were higher in skin flaps, as opposed to muscle flaps, due to the durability of the overlying skin paddle allowing for better visual post-operative monitoring and more timely recognition of the threatened flap. METHODS We conducted a retrospective analysis of all patients who underwent a free flap at an Australian tertiary centre between 2004 and 2014. Data were collected on patient demographics, indication, flap type, time of recognition of the threatened flap and re-exploration outcome. Data were analysed using Stata version 13 (StataCorp, College Station, TX, USA). Student's t-test, analysis of variance and Pearson's chi-squared test were used to compare groups. RESULTS There were 560 patients who underwent 573 free flaps. The most common indication was trauma. There were 58 re-explorations with a successful salvage rate of 79.3% (46/58). Overall complete flap loss rate was 2.1% (12/573). In flaps requiring re-exploration, there was a higher complete flap loss rate for muscle only flaps versus those with a skin paddle (P-value = 0.041). CONCLUSION While timely recognition and re-exploration of the compromised free flap in the early postoperative setting is important in determining the flap salvage success, it is demonstrated that salvage rates are poorer for muscle only flaps compared with flaps with a skin paddle.
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Affiliation(s)
- Anthony D Dat
- Plastic, Hand and Faciomaxillary Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Ian W Loh
- Plastic, Hand and Faciomaxillary Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Frank Bruscino-Raiola
- Plastic, Hand and Faciomaxillary Surgery Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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Ligh CA, Nelson JA, Wink JD, Gerety PA, Fischer JP, Wu LC, Kanchwala SK. An analysis of early oncologic head and neck free flap reoperations from the 2005-2012 ACS-NSQIP dataset. J Plast Surg Hand Surg 2015; 50:85-92. [PMID: 26571114 DOI: 10.3109/2000656x.2015.1106407] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There are limited population-based studies that examine perioperative factors that influence postoperative surgical take-backs to the OR following free flap (FF) reconstruction for head/neck cancer extirpation. The purpose of this study was to critically analyse head/neck free flaps (HNFF) captured in the ACS-NSQIP dataset with a specific focus on postoperative complications and the incidence of factors associated with re-operation. METHODS The 2005-2012 ACS-NSQIP datasets were accessed to identify patients undergoing FF reconstruction after a diagnosis of head/neck cancer. Patient demographics, comorbidities, and perioperative risk factors were examined as covariates, and the primary outcome was return to OR within 30 days of surgery. A multivariate regression was performed to determine independent preoperative factors associated with this complication. RESULTS In total, 855 patients underwent FF for head/neck reconstruction most commonly for the Tongue (24.7%) and Mouth/Floor/cavity (25.0%). Of these, 153 patients (17.9%) returned to the OR within 30 days of surgery. Patients in this cohort had higher rates of wound infections and dehiscence (p < 0.01). Medical complications were significantly higher and included pneumonia (12.4% vs 5.0%, p < 0.01), prolonged ventilation (16.3% vs 4.8%, p < 0.01), myocardial infarction (2.6% vs 0.6%, p = 0.017), and sepsis (7.2% vs 3.4%, p = 0.033). Regression analysis demonstrated that visceral flaps (OR = 9.7, p = 0.012) and hypoalbuminemia (OR = 2.4, p = 0.009) were significant predictors of a return to the OR. CONCLUSION Based on data from the nationwide NSQIP dataset, up to 17% of HNFF return to the OR within 30 days. Although this data-set has some significant limitations, these results can cautiously help to improve preoperative patient optimisation and surgical decision-making.
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Affiliation(s)
- Cassandra A Ligh
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Jonas A Nelson
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Jason D Wink
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Patrick A Gerety
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - John P Fischer
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Liza C Wu
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
| | - Suhail K Kanchwala
- a Division of Plastic Surgery , Hospital of the University of Pennsylvania , Philadelphia , PA , USA
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Colletti G, Tewfik K, Bardazzi A, Allevi F, Chiapasco M, Mandalà M, Rabbiosi D. Regional Flaps in Head and Neck Reconstruction: A Reappraisal. J Oral Maxillofac Surg 2015; 73:571.e1-571.e10. [DOI: 10.1016/j.joms.2014.10.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/07/2014] [Accepted: 10/21/2014] [Indexed: 10/24/2022]
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31
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Reexamining Free Flap Breast Reconstruction in the Community and University Setting. Ann Plast Surg 2014; 73 Suppl 2:S171-4. [DOI: 10.1097/sap.0000000000000204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Peters TTA, Post SF, van Dijk BAC, Roodenburg JLN, van der Laan BFAM, Werker PMN, Halmos GB. Free flap reconstruction for head and neck cancer can be safely performed in both young and elderly patients after careful patient selection. Eur Arch Otorhinolaryngol 2014; 272:2999-3005. [PMID: 25217081 DOI: 10.1007/s00405-014-3268-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 08/29/2014] [Indexed: 01/05/2023]
Abstract
Surgical treatment of head and neck cancer often results in complex defects requiring reconstruction with microvascular free tissue transfer. However, in elderly patients, curative treatment with radical surgery and free flap reconstruction is often withheld. The objective of this study is to assess the outcomes of free flap surgery in elderly patients, using a standard surgical complication classification system. A retrospective review was conducted of patients who underwent primary free flap reconstruction following major surgery for head and neck cancer between 1995 and 2010. Complications were assessed using the Clavien Dindo classification system, and grades III-V were classified as major complications. Comorbidity was classified according to the adult comorbidity evaluation index 27. A comparison was done between patients <70 and ≥70 years. Two hundred-two patients were included in this study. Multivariate analysis showed that only disease stage was a significant predictor of recipient site complications, and comorbidity was the only significant predictor of medical complications. Age was not a predictor of complications. There were no significant differences in disease specific or overall survival between young and elderly patients. Optimal patient selection for free flap surgery is essential. This requires thorough pre-operative assessment, including analysis of comorbidity in both young and elderly patients. Patients' biological age, and not chronological age, should be individually determined to assess feasibility of major surgery. Patients should not be denied surgery based on age alone.
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Affiliation(s)
- Thomas T A Peters
- Department of Otorhinolaryngology/Head and Neck Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands,
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Incidence of Surgical-Site Infection Is Not Affected by Method of Immediate Breast Reconstruction. Plast Reconstr Surg 2013; 132:20e-29e. [DOI: 10.1097/prs.0b013e318290f87e] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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de Wildt RP, Enajat M, Sawor JH, Fresow RNGM, Nanhekhan LV, van der Hulst RRWJ. The unilateral deep inferior epigastric perforator flap: Comparing university to community hospital. J Plast Surg Hand Surg 2012; 46:159-62. [DOI: 10.3109/2000656x.2012.686915] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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35
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Sorg H, Harder Y, Krueger C, Reimers K, Vogt PM. The nonhematopoietic effects of erythropoietin in skin regeneration and repair: from basic research to clinical use. Med Res Rev 2012; 33:637-64. [PMID: 22430919 DOI: 10.1002/med.21259] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Erythropoietin (EPO) is the main regulator of red blood cell production but there exists also a variety of nonhematopoietic properties. More recent data show that EPO is also associated with the protection of tissues suffering from ischemia and reperfusion injury as well as with improved regeneration in various organ systems, in particular the skin. This review highlights the mechanisms of EPO in the different stages of wound healing and the reparative processes in the skin emphasizing pathophysiological mechanisms and potential clinical applications. There is clear evidence that EPO effectively influences all wound-healing phases in a dose-dependent manner. This includes inflammation, tissue, and blood vessel formation as well as the remodeling of the wound. The molecular mechanism is predominantly based on an increased expression of the endothelial and inducible nitric oxide (NO) synthase with a consecutive rapid supply of NO as well as an increased content of vascular endothelial growth factor (VEGF) in the wound. The improved understanding of the functions and regulatory mechanisms of EPO in the context of wound-healing problems and ischemia/reperfusion injury, especially during flap surgery, may lead to new considerations of this growth hormone for its regular clinical application in patients.
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Affiliation(s)
- Heiko Sorg
- Department of Plastic, Hand- and Reconstructive Surgery, Hannover Medical School, 30625, Hannover, Germany.
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36
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Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. HEAD & NECK ONCOLOGY 2009; 1:33. [PMID: 19698095 PMCID: PMC2749848 DOI: 10.1186/1758-3284-1-33] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Accepted: 08/21/2009] [Indexed: 11/25/2022]
Abstract
Free flap success rates are in excess of 95%. Vascular occlusion (thrombosis) remains the primary reason for flap loss, with venous thrombosis being more common than arterial occlusion. The majority of flap failures occur within the first 48 hours. With early recognition and intervention of flap compromise salvage is possible. Successful salvage rates range from 28% to over 90%. Rapid re-exploration in this clinical setting is crucial to maximise the chances of flap salvage. If salvage is not feasible or unsuccessful then non-surgical methods of salvage may be employed with some possibility of success. The purpose of this article is to review the causes of free flap failure and to highlight the available options for salvage.
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Affiliation(s)
- Daniel Novakovic
- Department of Otolaryngology-Head and Neck Surgery, Princess Margaret Hospital, and University of Toronto, Toronto, Canada.
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37
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Bakri K, Moran SL. Monitoring for upper-extremity free flaps and replantations. J Hand Surg Am 2008; 33:1905-8. [PMID: 19084200 DOI: 10.1016/j.jhsa.2008.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 09/09/2008] [Indexed: 02/02/2023]
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38
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Vogel TR, Symons RG, Flum DR. A Population-Level Analysis: The Influence of Hospital Type on Trends in Use and Outcomes of Lower Extremity Angioplasty. Vasc Endovascular Surg 2008; 42:12-8. [DOI: 10.1177/1538574407308203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective The use of infrainguinal percutaneous transluminal angioplasty (PTA) has increased, but patterns of use have not been well studied. Academic institutions (AIs) and nonacademic institutions (NAIs) may have developed different practice patterns and may have different associated outcomes. Methods A retrospective statewide population-based administrative database was evaluated for patients undergoing PTA (1997-2004). Results A total of 1718 patients underwent PTA for claudication (51.9%), rest pain (12.1%), and ulceration or gangrene (23.1%). The use of infrainguinal stents (62.4% vs 60.8%), elective procedures (76.3% vs 79.8%), in-hospital death (1.6% vs 2.2%), 30-day mortality (2.1% vs 3.3%), readmission rates (17.1% vs 15.9%), and reintervention rates after readmission (38.5% vs 42.9%) were similar between groups. Increased use of PTA was noted in AIs versus NAIs (239.5% vs 53.9%). AIs were significantly less likely to perform PTA for rest pain (7.5% vs 14.4%, P < .05). Conclusion AIs had a more recent increase in the use of PTA, but less often used PTA for patients with rest pain compared with NAIs. Both center types had higher than expected 30-day readmission and reintervention rates. Further understanding of the implementation and associated outcomes of PTA is required.
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Affiliation(s)
- Todd R. Vogel
- Robert Wood Johnson Medical School, Division of Vascular Surgery, New Brunswick, New Jersey,
| | - Rebbecca G. Symons
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
| | - Dave R. Flum
- Surgical Outcomes Research Center, Department of Surgery, University of Washington, Seattle, Washington
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Abstract
Complex trauma to the forearm often involves significant damage to or loss of bone, muscle, skin, tendons, and neurovascular structures. Treatment focuses on regaining long-term hand function, which is best achieved by combining plastic and orthopedic surgical expertise in a team that includes experienced upper arm rehabilitation therapists. The reconstruction goal is to restore a level of hand function that allows the patient to incorporate the injured hand back into daily activities. We define complex defects as those involving significant segmental loss of one or more tissue types. This article provides a framework by which these often formidable and overwhelming injuries can be approached, and discusses some of the surgical options used to reconstruct complex defects of the forearm.
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Affiliation(s)
- Karim Bakri
- Mayo Clinic, Division of Plastic Surgery, 200 First Street SW, West 12 Mayo, Rochester, MN 55905, USA
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