Microvascular free tissue transfer in organ transplantation patients: is it safe?

Outcomes of Head and Neck Microvascular Free Tissue Transfer for Advanced Cutaneous Squamous Cell Carcinoma: A Comparison of Solid Organ Transplant Recipients to Nontransplant Patients

BACKGROUND

Patients with solid organ transplant (SOT) are at increased risk of developing aggressive cutaneous malignancies due to their immunosuppression, particularly cutaneous squamous cell carcinoma (cSCC).

PURPOSE

There is limited data regarding SOT patients with locally advanced cSCC requiring radical surgery and microvascular free tissue transfer (MVFTT). Our objectives were to characterize outcomes in SOT patients and compare them with a non-SOT cohort.

STUDY DESIGN

This is a retrospective cohort study of patients undergoing MVFTT for advanced cSCC of the head and neck between January 2016 and May 2020 at a tertiary referral center. Patients who underwent MVFTT as part of curative intent surgery for advanced cSCC during the study were considered for inclusion. Exclusion criteria included distant metastasis, palliative intent treatment, age less than 18 years, and lip primaries.

PREDICTOR

The predictor variable was SOT status. A cohort of non-SOT patients was matched to the SOT cohort based on age, smoking status, tumor stage, and defect size.

MAIN OUTCOME VARIABLES

The primary reconstructive outcome was the major surgical complications and secondary outcome measures included major medical complications and minor surgical complications. The primary oncologic outcome was overall survival and the secondary outcome was disease-specific survival. The primary predictor was transplant status.

COVARIATES

Covariates included patient comorbidities, prior treatment, tumor stage, type of reconstruction, pathologic findings, and adjuvant therapy.

ANALYSIS

Continuous and categorical variables were compared using Student's T test and Fisher's exact test. Survival was calculated using the Kaplan-Meier method and differences in survival between groups were calculated using the log-rank test. Statistical significance was set a priori at P ≤ .05.

RESULTS

Fourteen SOT and 14 matched non-SOT patients met inclusion criteria. There was not a statistically significant difference in the rate of major surgical complications (7 vs 7%, P = .74) between the SOT and non-SOT cohorts. Rates of minor (21 vs 43%, P = .26) wound complications and medical complications (0 vs 14%, P = .24) were also similar between the SOT and non-SOT cohorts. Locoregional recurrences and distant metastasis were more common for SOT patients, though this was not statistically significant. Overall survival was significantly worse for SOT patients (21.7 vs 31.0 months, P = .04), though there was not a significant difference in disease-free survival (9.8 vs 31.0 months, P = .17).

CONCLUSIONS AND RELEVANCE

MVFTT in the management of SOT patients with locally advanced head and neck cSCC demonstrates similar complication rates with non-SOT patients. While survival and oncologic outcomes are worse in the SOT cohort, aggressive surgical intervention with MVFTT can be performed with comparable complication rates to patients without a history of SOT.

Perforator Free Flap Coverage of Chronic Lower Extremity Ulcers in Patients With Autoimmune Diseases Under Immunosuppression

Objectives. Lower extremity ulcers are quite common in patients with autoimmune diseases. Due to chronic use of immunosuppressants, these wounds may develop into deeper wounds resulting in exposure of bone or tendon, which in turn may require free tissue transfers for coverage. The author reviewed perforator free flap transfers performed in this group of patients and analyzed the results. Methods. A retrospective review was performed on all patients who underwent perforator free flap transfer for coverage of lower extremity ulcers without trauma, over a 10-year period. Patient demographics, administered immunosuppressants, and flap and donor site complications were analyzed. Results. Twenty-two perforator free flap transfers were performed in patients with autoimmune diseases, including 18 thoracodorsal perforator flaps, 2 anterolateral thigh flaps, and 2 deep inferior epigastric artery flaps. There was no total flap loss, but there was a high rate of partial flap necrosis (40.9%) and wound dehiscence (40.9%). Intake of corticosteroids was significantly associated with postoperative complications ( P < .05). Conclusion. As partial loss of flap and wound dehiscence is much more common in this group of patients, treatment may take longer, and a fully informed consent should be obtained preoperatively. Surgeons should not avoid performing perforator free flap transfers in patients with autoimmune diseases under immunosuppression; instead, much more preparation and caution are required.

Choice of Regional Flaps for Oral Cancer Defects: Relevance in Current Era

Introduction

Microvascular free flaps (MVFF) are the current standard of care for reconstruction of oral ablative defects; however, pedicled myocutaneous flaps (PMCF) are still used widely in India. The rationale behind the preference for selecting PMCF in the present era is not well understood. The associated complications and swallowing outcomes are variable.

Methods

We retrospectively analysed the records of patients who underwent reconstructive surgery for oral cancer ablative defects over a 3-year period.

Results

Ninety-seven pedicled myocutaneous flaps [89 pectoralis major myocutaneous (PMMC) flaps, eight lower trapezius island myocutaneous (TMC) flaps] and 113 MVFFs were performed. The reasons for selecting PMCF were financial constraints 38.7%, MVFF salvage 22.5%, medically compromised 10.7%, vessel-depleted neck 6.4%, old age with PS2 + 5.3%, early recurrence 5.3%, borderline resectable 4.3%, palliative resection 2.1%. Overall complication rate was 20.4%. Of patients, 50.7% and 34.7% were on regular and semisolid diet, respectively; 66.6% had acceptable swallowing-related social well-being.

Conclusion

PMCFs have an important role in developing countries with patients having financial constraints. The other potential reasons driven by patient factors were discussed. The swallowing outcomes are good, with majority of the people having socially acceptable swallowing function.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction

BACKGROUND

Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures.

METHODS

The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis.

RESULTS

Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279).

CONCLUSION

Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.

Postoperative Complications of Plastic and Reconstructive Surgery in Solid Organ Transplant Recipients

INTRODUCTION

As the number of organ transplants and the survival rate increase, solid organ transplant patients will need more plastic and reconstructive surgery. However, such patients take immunosuppressants, including prednisone, which makes wound healing slower and plastic surgeons more hesitate to operate. In this study, we examined postoperative complications of organ transplant patients who have undergone plastic and reconstructive surgery.

MATERIALS & METHODS

Between 2002 and 2018, the total number of patients who visited our clinic after receiving organ transplants was 77. Retrospective reviews were performed on 35 patients, excluding those who received conservative treatment. Demographics, underlying diseases, causes of organ transplantation, immunosuppressive regimen, types of procedures, and postoperative complications were analyzed.

RESULTS

A total of 35 patients received 42 procedures. Eleven patients had undergone kidney transplantation, and 24 had undergone liver transplantation. The type of procedures were local flap (23.8%), primary closure (23.8%), skin graft (11.9%), and free flap (2.4%). There were 2 cases of aesthetic surgery. Among all the cases, complications occurred in 8 procedures (19%). Hematoma was the most common complication, followed by skin necrosis. All except 3 patients were completely healed within 6 weeks.

DISCUSSION

This study showed that hematoma was the most frequently occurring complication. In a few cases, wound healing was delayed. So, bleeding control was very important to prevent the development of hematoma. And organ transplants may not be a problem for plastic and reconstructive surgery.

Is Aesthetic Surgery Safe in the Solid Organ Transplant Patient? An International Survey and Review

BACKGROUND

Improved immunosuppression and lifespans have afforded solid organ transplant (SOT) recipients the opportunity to seek aesthetic surgery.

OBJECTIVES

To determine current trends in the provision of aesthetic in the SOT patient population, we polled the international plastic surgery community. We specifically sought to evaluate their experiences with this patient population, as well as to perform a review of the literature to provide updated guidelines for practitioners who may consider performing surgery in the SOT patient population.

METHODS

A web-based survey was sent to national and international colleagues to query the experiences and complication rates of performing aesthetic surgery in this patient population.

RESULTS

Thirty percent of the 1308 respondents performed surgery in SOT patients. Three hundred and forty practitioners performed 552 procedures with a 4.3% complication rate. Over 68% of all procedures were performed on kidney transplant recipients.

CONCLUSIONS

SOT patients can safely undergo elective aesthetic procedures. We recommend working closely with the medical team to assure the best outcomes.

Reconstructive surgery in immunocompromised patients: evaluation and therapy

Background: An increasing number of patients undergoing reconstructive surgery are immunocompromised due to different reasons and different medical treatments. Some of the used immunosuppressive drugs may affect the process of wound healing and thereby, impair the long-term success of surgical treatment. Therefore, this retrospective analysis aimed at the evaluation of the perioperative treatment and surgical outcome of immunocompromised patients undergoing different reconstructive procedures.

Methods: A retrospective review was performed of 8 immunocompromised patients with different primary diseases who needed reconstructive surgery: 2 patients with non-Hodgkin lymphoma, 1 patient with an acute myeloid leukemia, 1 patient with colitis ulcerosa, 1 patient with liver cirrhosis, 1 patient with chronic polyarthritis, and 2 patients with malignant melanoma.

Results: In 7 of our 8 presented cases, multiple operations with wound debridements have been necessary to optimize the granulation of the wound bed before reconstructive surgery. 3 out of these 7 patients required further operations due to wound dehiscence or necrosis, with 2 of them as a result of increased immunosuppressive therapy. 5 out of 8 patients needed no further surgical treatment.

Conclusions: Both the perioperative drug therapy and the reconstructive surgery concept need to be determined carefully in each individual case of the immunocompromised patients. Thus, the appropriate point in time of operation to achieve the best possible wound healing as well as the complexity of the procedure will require the consideration of a ‘less is more’ strategy in selected cases.

Vascular surgeries in West Africa: challenges and prospects

BACKGROUND

The field of vascular surgery is evolving in sub-Saharan Africa but the practice is bedeviled by lack of expertise and infrastructure challenges. The consequences are a low volume of operations and a dearth of data. Available data are not representative of the wider picture, therefore, this study was undertaken to evaluate the practice of vascular surgery in a tertiary institution, in the light of the prevailing challenges.

METHODS

Data from all patients with vascular-related pathologies managed in our surgical outpatient clinic and accident and emergency wards were obtained from the clinic and in-patient records from January 2008 to December 2012. Age, sex, diagnosis, treatment, and complications were noted. There were 73 patients comprising 45 (61.6%) males and 28 (38.4%) females. The age range was 1-90 years (mean 43.5 years).

RESULTS

The pathologies managed included end-stage renal disease (n = 36, 49.3%), nontraumatic and posttraumatic aneurysms (n = 13, 17.8%), vascular trauma (n = 12, 16.4%), peripheral vascular disease (n = 5, 6.9%), congenital vascular malformations (n = 4, 5.5%), and thrombotic diseases (n = 3, 4.1%). Fifty-four (74.0%) surgeries were performed, with a complication rate of 5.5% and 2.7% mortality.

CONCLUSIONS

The practice of vascular surgery in Zaria, Nigeria, is fraught with challenges. The gap created by the dearth of skilled vascular surgeons is filled by competent cardiothoracic surgeons. Infrastructure decay and lack of prostheses limit the number and variety of operable cases. These challenges result in preventable morbidity and mortality.

Free tissue transfer for head and neck reconstruction in solid organ transplant patients

BACKGROUND

Patients with head and neck malignancies who have had solid organ transplant and require free tissue transfer are a unique population. This study was performed to evaluate the effect of immunosuppression on the rate of perioperative complications and the success of free tissue transfer in the head and neck.

METHODS

Complications in solid organ transplant patients undergoing free tissue transfer for reconstruction of head and neck malignancies from 1998 to 2010 were evaluated.

RESULTS

A total of 22 flaps in 17 patients were performed. Eight patients (11 of 22 flaps) had complications. The median hospital stay was 6 days (range, 4-26 days). The median length of follow-up was 13.5 months (range, 3.5-49.9 months).

CONCLUSIONS

Solid organ transplant patients are at an increased risk of de novo malignancies due to chronic immunosuppression. This study demonstrates that free tissue transfer is a viable option in transplant patients with morbidity similar to nontransplant patients.

The new face of transplant surgery: a survey on cosmetic surgery in transplant recipients

BACKGROUND

Transplant surgery has undergone tremendous advances within the last decade. Improvements in surgical techniques, availability of potent immunosuppressive medications, and utilization of more sophisticated post-transplant immunosuppression protocols have revolutionized the field. These developments have resulted in increased allograft survival, prolonged longevity, and improved quality of life in transplant organ recipients. Elimination of steroids in many postoperative immunosuppressive regimens has tremendously impacted the quality of life and physical appearance of these patients. They are living longer and more normal lives than previously considered possible. As a testament to the success of transplantation surgery, many transplant patients are now seeking aesthetic surgery.

METHODS

A survey was sent to ASPS members asking about their experience with transplant patients undergoing aesthetic procedures.

RESULTS

Of the 789 (18%) plastic surgeons who responded, 201 (25%) have performed aesthetic surgery on transplant recipients. A total of 278 patients underwent 292 surgical aesthetic procedures and 64 patients underwent 94 nonsurgical aesthetic procedures. The incidence of reported perioperative complications was 3.4%. There were very few additional precautions taken with these patients relative to the general population. With the exception of obtaining medical clearance, these additional precautions were inconsistent among plastic surgeons.

CONCLUSION

Cosmetic surgery in transplant recipients is being successfully practiced in the USA. Surgical and nonsurgical aesthetic procedures are being performed safely in organ transplant recipients without a significant increase in the incidence or degree of complications. If certain precautions are undertaken, these patients may expect a degree of success comparable to that of the rest of the population.

[Organ transplantation, composite tissue allotransplantation, and plastic surgery]

Transplantations play an increasing role for plastic reconstructive surgeons. The increasing number of solid organ transplantations and the improved long-term survival rates lead to increased numbers of these patients also undergoing plastic and reconstructive procedures. Free flap transfer in solid organ transplant patients is feasible with no higher risk to both transplant function and postoperative complications than for nontransplant patients, even during immune suppression. Composite tissue allotransplantation (CTA) is an evolving field in plastic reconstructive surgery with hands, arms, partial faces, abdominal walls, and knee joints being transferred in clinical settings. However only an interdisciplinary approach using all available resources in highly selected patients after exhausting all other plastic reconstructive procedures is able to achieve reasonable results. The potential complications of long-term immune suppression and patient compliance have to be balanced with the expected and achieved functional result of CTA, whose procedures must be discussed as a potential tissue or organ transplantation, given the legal and logistic implications. The interdisciplinary cooperation of transplant surgeons, microsurgeons, psychologists, and ergo- and physiotherapists is mandatory to achieve successful CTA results.