Head and Neck Reconstruction:

Fifty free flaps from the ear

BACKGROUND

Reconstruction of facial and intraoral defects is often challenging. Local pedicled flaps may not always be available and distant free flaps usually have suboptimal color match and texture for the facial area. The aim of this study was to assess whether auricular free flaps are a valid reconstructive option.

METHODS

Clinical data and outcomes of patients who underwent reconstruction with microsurgical flaps from the ear between 2011 and 2021 were analyzed. Patient demographic data, type of flaps, etiology, location and size of the defect, features of the pedicle and recipient vessels, complications, and additional surgeries were reviewed.

RESULTS

Overall, 48 patients with 50 microsurgical flaps were identified. Thirty-one patients (65%) were men and 17 were (35%) women. The median age was 62 years. Among the 50 flaps, 26 (52%) were helix flaps, 20 (40%) were temporal artery posterior auricular skin flaps, and 4 (8%) were extended helix flaps. The nose was the most frequently reconstructed region (n = 32, 64%), followed by the tongue (n = 6, 12%), floor of the mouth (n = 5%), lower eyelid (n = 2%), and in one (2%) patient each, restoration of the upper eyelid, ear, larynx, esophagus, lower lip, and palate. The median follow-up was 74 months. Three flaps (6%) were lost, and the overall rate of complications was 46%. Surgical intervention was required in 7 (14%) cases. All cases healed with acceptable cosmesis.

CONCLUSIONS

The ear is a valuable source of tissue for complex reconstructions of the face and intraoral regions. However, this technique is surgically demanding and should be reserved for selected cases.

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Polycaprolactone/β-Tricalcium Phosphate Composite Scaffolds with Advanced Pore Geometries Promote Human Mesenchymal Stromal Cells' Osteogenic Differentiation

Critical-sized mandibular bone defects, arising from, for example, resections after tumor surgeries, are currently treated with autogenous bone grafts. This treatment is considered very invasive and is associated with limitations such as morbidity and graft resorption. Tissue engineering approaches propose to use 3D scaffolds that combine structural features, biomaterial properties, cells, and biomolecules to create biomimetic constructs. However, mimicking the complex anatomy and composition of the mandible poses a challenge in scaffold design. In our study, we evaluated the dual effect of complex pore geometry and material composition on the osteogenic potential of 3D printed scaffolds. The scaffolds were made of polycaprolactone (PCL) alone (TCP0), or with a high concentration of β-tricalcium phosphate (β-TCP) up to 40% w/w (TCP40), with two complex pore geometries, namely a star- (S) and a diamond-like (D) shape. Scanning electron microscopy and microcomputed tomography images confirmed high fidelity during the printing process. The D-scaffolds displayed higher compressive moduli than the corresponding S-scaffolds. TCP40 scaffolds in simulated body fluid showed deposition of minerals on the surface after 28 days. Subsequently, we assessed the differentiation of seeded bone marrow-derived human mesenchymal stromal cells (hMSCs) over 28 days. The early expression of RUNX2 in the cell nuclei confirmed the commitment toward an osteogenic phenotype. Moreover, alkaline phosphatase (ALP) activity and collagen deposition displayed an increasing trend in the D-scaffolds. Collagen type I was mainly present in the deposited extracellular matrix (ECM), confirming deposition of bone matrix. Finally, Alizarin Red staining showed successful mineralization on all the TCP40 samples, with higher values for the S-shaped scaffolds. Taken together, our study demonstrated that the complex pore architectures of scaffolds comprised TCP40 stimulated osteogenic differentiation and mineralization of hMSCs in vitro. Future research will aim to validate these findings in vivo.

Regeneration of Critical-Sized Mandibular Defects Using 3D-Printed Composite Scaffolds: A Quantitative Evaluation of New Bone Formation in In Vivo Studies

Mandibular tissue engineering aims to develop synthetic substitutes for the regeneration of critical size defects (CSD) caused by a variety of events, including tumor surgery and post-traumatic resections. Currently, the gold standard clinical treatment of mandibular resections (i.e., autologous fibular flap) has many drawbacks, driving research efforts toward scaffold design and fabrication by additive manufacturing (AM) techniques. Once implanted, the scaffold acts as a support for native tissue and facilitates processes that contribute to its regeneration, such as cells infiltration, matrix deposition and angiogenesis. However, to fulfil these functions, scaffolds must provide bioactivity by mimicking natural properties of the mandible in terms of structure, composition and mechanical behavior. This review aims to present the state of the art of scaffolds made with AM techniques that are specifically employed in mandibular tissue engineering applications. Biomaterials chemical composition and scaffold structural properties are deeply discussed, along with strategies to promote osteogenesis (i.e., delivery of biomolecules, incorporation of stem cells, and approaches to induce vascularization in the constructs). Finally, a comparison of in vivo studies is made by taking into consideration the amount of new bone formation (NB), the CSD dimensions, and the animal model.

Clinical analysis of factors affecting the failure of free flaps used in head and neck reconstruction

BACKGROUND

Free tissue transfer is the preferred method of reconstructing head and neck defects, with a success rate of approximately 95%. Although flap failure is uncommon, it has a major impact on patient morbidity and diminishes quality of life, making it is important to investigate the causes of flap failure.

METHODS

This retrospective chart review analyzed patients who underwent free tissue transfer during head and neck reconstruction at a single institution between 2016 and 2021.

RESULTS

During the study period, 58 patients underwent 60 free flap procedures. Revision surgery was needed in 14 patients. Subsequent free flap surgery was performed in one patient, and three free flaps (5%) could not be salvaged. Cardiovascular disease was significantly associated with flap failure, and venous congestion (thrombosis) was the most common reason for revision surgery.

CONCLUSION

Cardiovascular disease clearly emerged as a factor related to the failure of free flap surgery, and this issue warrants particular attention in patients for whom free tissue transfer is planned.

Risk factors associated with postoperative complications following free flap reconstruction of head and neck defects

BACKGROUND

Free flap reconstruction of head and neck defects is routinely performed with a high success rate nowadays. However, postoperative complications are still commonly observed. The aim of this study is to investigate risk factors correlated with postoperative complications following free flap reconstruction of head and neck defects.

METHODS

A retrospective study of all patients undergoing free flap reconstruction of head and neck defects between January 2018 and January 2020 at Sun Yat-sen Memorial Hospita, Guangzhou, China was performed. Preoperative, intraoperative, and postoperative data were collected retrospectively. The primary outcome variables were postoperative complications, which were divided into medical and surgical complications. All patients were grouped by either complications or no complications. Univariate and multivariate logistic regression models were used to identify risk factors predicting complications.

RESULTS

850 patients underwent free flap reconstruction of head and neck defects during the study period (Male: 65.29%; Mean [SD] age: 54.90 [13.78] years). Postoperative complications developed in 125 (14.71%) patients, among which, 101 (11.88%) patients developed surgical complications, 29 (3.41%) patients developed medical complications and 5 (0.59%) patients developed both surgical and medical complications. Total flap necrosis was observed in 11 (1.29%) patients. After multivariate analysis, several risk factors incluing postoperative ICU admission, coronary heart disease, post radiotherapy surgery and flap types were identified correlated with postoperative complications.

CONCLUSIONS

Our study identified related variables for a higher risk of postoperative complications development following free flap reconstruction of head and neck defects. Early detection of these risk factors will improve prognosis.

Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation

Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.

The role of computer aided design/computer assisted manufacturing (CAD/CAM) and 3- dimensional printing in head and neck oncologic surgery: A review and future directions

Microvascular free flap reconstruction has remained the standard of care in reconstruction of large tissue defects following ablative head and neck oncologic surgery, especially for bony structures. Computer aided design/computer assisted manufacturing (CAD/CAM) and 3-dimensionally (3D) printed models and devices offer novel solutions for reconstruction of bony defects. Conventional free hand techniques have been enhanced using 3D printed anatomic models for reference and pre-bending of titanium reconstructive plates, which has dramatically improved intraoperative and microvascular ischemia times. Improvements led to current state of the art uses which include full virtual planning (VP), 3D printed osteotomy guides, and patient specific reconstructive plates, with advanced options incorporating dental rehabilitation and titanium bone replacements into the primary surgical plan through use of these tools. Limitations such as high costs and delays in device manufacturing may be mitigated with in house software and workflows. Future innovations still in development include printing custom prosthetics, 'bioprinting' of tissue engineered scaffolds, integration of therapeutic implants, and other possibilities as this technology continues to rapidly advance. This review summarizes the literature and serves as a summary guide to the historic, current, advanced, and future possibilities of 3D printing within head and neck oncologic surgery and bony reconstruction. This review serves as a summary guide to the historic, current, advanced, and future roles of CAD/CAM and 3D printing within the field of head and neck oncologic surgery and bony reconstruction.

Prediction of Wound Failure in Patients with Head and Neck Cancer Treated with Free Flap Reconstruction: Utility of CT Perfusion and MR Perfusion in the Early Postoperative Period

BACKGROUND AND PURPOSE

Free flap reconstruction in patients with head and neck cancer carries a risk of postoperative complications, and radiologic predictive factors have been limited. The aim of this study was to assess the factors that predict free flap reconstruction failure using CT and MR perfusion.

MATERIALS AND METHODS

This single-center prospective study included 24 patients (mean age, 62.7 [SD, 9.0] years; 16 men) who had free flap reconstruction from January 2016 to May 2018. CT perfusion and dynamic contrast-enhanced MR imaging with conventional CT and MR imaging were performed between 2 and 4 days after the free flap surgery, and the wound assessments within 14 days after the surgery were conducted by the surgical team. The parameters of CT perfusion and dynamic contrast-enhanced MR imaging with conventional imaging findings and patient demographics were compared between the patients with successful free flap reconstruction and those with wound failure as appropriate. P < .05 was considered significant.

RESULTS

There were 19 patients with successful free flap reconstruction and no wound complications (mean age, 63.9 [SD, 9.5] years; 14 men), while 5 patients had wound failure (mean age, 58.0 [SD, 5.7] years; 2 men). Blood flow, blood volume, MTT, and time maximum intensity projection (P = .007, .007, .015, and .004, respectively) in CT perfusion, and fractional plasma volume, volume transfer constant, peak enhancement, and time to maximum enhancement (P = .006, .039, .004, and .04, respectively) in dynamic contrast-enhanced MR imaging were significantly different between the 2 groups.

CONCLUSIONS

CT perfusion and dynamic contrast-enhanced MR imaging are both promising imaging techniques to predict wound complications after head and neck free flap reconstruction.

Porcine small intestine graft for reconstruction of oral defects

OBJECTIVE

To evaluate the feasibility and outcomes of porcine submucosal allograft (Biodesign Sinonasal Repair Graft [Cook Medical, Bloomington, IN]) in oral cavity and oropharynx reconstruction after ablative surgery.

METHODS

We conducted a prospective and retrospective review of patients who underwent Biodesign Sinonasal Repair Graft reconstruction for oral and oropharyngeal surgical defects at a single institution between 2018 and 2020. A total of 11 patients were included in the study. Data points included their perioperative medical and demographic data, immediate postoperative course, and follow-up visits at 10 days and at 2 months. The clinicopathologic characteristics of their disease, postoperative esthetic, and functional outcomes were recorded and analyzed.

RESULTS

Eleven procedures have been performed, and all patients received Biodesign reconstruction either immediately after ablation or after they failed a previous reconstruction. None of the patients had bone exposure. The subsites included oral tongue (n = 6), floor of the mouth (n = 3), buccal mucosa (n = 1), and soft palate (n = 1). In all cases, the operations and the postoperative course were uneventful. The mean defect size was 22 cm2. The median start of oral intake was at 2 days postoperatively. The Biodesign graft healed well in all patients with no total graft loss. There was one complication that required revision surgery due to obstruction of Wharton's duct by the Biodesign material.

CONCLUSIONS

Biodesign can be a viable option for small and medium-sized oral and oropharyngeal defects in patients who are medically unfit or do not want to undergo a free flap surgery.

LEVEL OF EVIDENCE

4.

Extending the Reach of Craniofacial Free Flaps Using the Descending Branch of the Lateral Circumflex Femoral Vessels

SUMMARY

Craniofacial free tissue transfer is sometimes complicated by insufficient pedicle length and/or paucity of recipient vessels. A saphenous vein graft can be used to reach the high-flow, large-caliber vessels of the neck, but because of the vein's taper and thick wall, there is often a mismatch. Following the principle of like-for-like, the authors prefer the descending branch of the lateral circumflex femoral vessels to achieve a more anatomical pedicle extension for free tissue transfer in complex craniofacial reconstruction. The authors' experience using the descending branch of the lateral circumflex femoral pedicle extender from 2010 to 2019 was reviewed. Indications, patient characteristics, reconstruction site, flap type, pedicle length, recipient vessels, and vascular complications were noted. The authors reviewed two strategies for implementation of the pedicle extender: in some cases, the flap was first transferred and allowed to perfuse on the descending branch of the lateral circumflex femoral vessels in the thigh, and then transferred to the recipient vessels (double-ischemia transfer); and in other cases, the flap and pedicle extender were transferred such that the flap underwent a single period of ischemia (single-ischemia transfer). The descending branch of the lateral circumflex femoral pedicle extender was used in 17 craniofacial cases. Indications included tumor, trauma, osteoradionecrosis, and congenital. Double-ischemia transfer was used in eight cases and single-ischemia transfer in nine. The longest pedicle extender in the series was 15 cm. Arterial thrombosis occurred in one case. This case series demonstrates that the descending branch of the lateral circumflex femoral pedicle extender is a viable option for complex craniofacial free tissue transfer cases. It provides ample length and excellent vessel match, following the like-for-like principle.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Risk of Free Flap Failure in Head and Neck Reconstruction: Analysis of 21,548 Cases From A Nationwide Database

BACKGROUND

Head and neck reconstruction is complicated and is made even more challenging by free flap failure. We identified risk factors associated with free flap failure in records extracted from a nationwide database of a 23 million populations.

METHODS

We used International Classification of Diseases, Ninth Version, codes 140 to 149 and 161 to identify patients in Taiwan's National Health Insurance Research Database with head and neck cancer between 2000 and 2013. Patient's age, sex, neoadjuvant treatment, comorbidities, and anticoagulation use were also retrieved. Free flap reconstruction twice, or free flap and pedicle flap reconstructions during the same hospitalization were recorded as free flap failure. Logistic regression was used to identify factors that increased risk of free flap failure.

RESULTS

A total of 21,548 patients with head and neck cancer were identified; 883 (4.1%) experienced free flap failure. Use of aspirin, clopidogrel, urokinase, prostaglandin (PGE1), low-molecular-weight heparin, and operation time were associated with free flap failure. However, some potential confounders could not be identified from the database.

CONCLUSIONS

Several statistically significant findings were prone to influence by potential confounders. The clinically applicable result was that longer operation time and preoperative chemotherapy could increase the likelihood of free flap failure. On the other hand, several factors were proved to be irrelevant to free flap failure.

Comparison of the surgical outcomes of free flap reconstruction for primary and recurrent head and neck cancers: a case-controlled propensity score-matched study of 1,791 free flap reconstructions

This study was designed to compare the outcome and analyze the operation-related risk factors in free flap reconstruction for patients with primary and recurrent head and neck cancers. A 1:1 propensity score-matched analysis of the microsurgery registry database of the hospital. The primary outcome of the free flap reconstruction had a higher failure rate in the recurrent group than the primary group (5.1% vs. 3.1%, p = 0.037). Among the 345 pairs in the matched study population, there were no significant differences between the primary and recurrent groups regarding the rate of total flap loss (3.5% vs. 5.5%, p = 0.27) and secondary outcomes. This study revealed that free flap reconstruction had a higher failure rate in the recurrent group than the primary group, but such a difference may be attributed by the different patient characteristics.

Shape Accuracy and Surface Quality of Additively Manufactured, Optimized, Patient-Specific Bone Plates

Powder-based additive manufacturing technologies such as powder bed fusion (PBF) using a laser beam (PBF-LB) and PBF using an electron beam (PBF-EB) allow the manufacturing of complex, patient-specific implants from titanium alloys at appropriate manufacturing expenses and thus production cost. To meet medical quality requirements, mechanical post-treatment (e.g., grinding and polishing) is often required. However, different medical applications require specific quality characteristics. It is therefore necessary to assess the fulfillment of the requirements for each case individually with regard to the manufacturing technologies. This study investigated the potential of the two mentioned additive manufacturing technologies for manufacturing patient-specific, topology-optimized bone plates that are used for osteosynthesis (the joining of bone segments) in the reconstruction of the mandible (lower jaw). Identical individualized implants were manufactured and subsequently treated with established industrial processes and examined according to medical quality requirements. Crucial quality requirements for this medical application are the shape accuracy (for exact bone positioning and even load transmission) as well as the surface quality (to enhance fatigue strength and prevent bone ingrowth in view of the subsequent easy removal of the plates). The machining of the implants is shown in comparison to distinguish the two manufacturing processes from established procedures.

Microvascular reconstruction for maxillofacial defects: a retrospective analysis of outcomes and complications in 121 consecutive cases

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.

Objective Selection Criteria between ALT and Radial Forearm Flap in Oral Soft Tissues Reconstruction

Different locoregional and free flaps were described for oral soft tissues reconstruction after oncological resections; however, free flaps remain the first choice. Among free flaps, the radial forearm flap (RFF) and the anterolateral thigh perforator flap (ALT) are preferred the most. The lack of standardization of the flap choice leaves the selection to the surgeon's experience. The purpose of our observational study is to provide an algorithm to support the flap choice for the reconstruction of oral soft tissues. Sixty patients with squamous cell carcinoma of oral soft tissues were enrolled in our study. All the patients underwent preoperative magnetic resonance imaging (MRI) to measure the three-dimensional size of the tumor. During the follow-up, the patients were evaluated by using the University of Washington-Quality of Life Questionnaire. The questionnaire score was better for small tumors and worse for large tumors in both functional and relational fields. We observed that most of the overlapping results were obtained for small defects and the choice of RFF, as well as for large defects and the use of ALT. We observed that in the preoperative time, it is possible to select which flap between radial forearm and ALT is more appropriate for oral soft tissues defects reconstruction, according to the size of the tumor evaluated by MRI. We propose a decisional algorithm that suggests the type of flap to use between ALT and RFF.

Transillumination method for intraoperative mapping subfascial plexus of free-style radial forearm flap

BACKGROUND

Without well recognizing the vascular territories of the perforator, it might damage the pedicle and diminish the survival of the flap. This study described a transillumination method for intraoperative mapping of subfascial plexus of the perforator in radial forearm flap and also compared the perioperative outcomes and complications of the method with the standard folded, bipaddled forearm flap in head and neck reconstruction.

METHODS

Between January 2011 and December 2017, we applied the transillumination method in 12 patients who underwent head and neck reconstruction with forearm flaps immediately after surgical resection of oral cancer (case group). For comparison, we identified 12 age- and gender-matched patients who received head and neck reconstruction with folded, bipaddled radial forearm flaps (control group). Demographic factors, diagnosis, flap size, perioperative data, and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference in harvesting time, operative time, or blood loss between the case and control groups. No patient experienced donor-site complication. There was no significant difference in recipient-site complication between the case and control groups.

CONCLUSION

The transillumination method can allow plastic surgeons to easily identify the perforator vascular plexus of the radial forearm flap, which facilitates intraoperative flap design in head and neck reconstruction without increasing harvesting time and risk of postoperative complications.

Association between blood pressure and postoperative hematomas in the patients undergoing head and neck cancer reconstruction

BACKGROUND

Postoperative hematoma is one of the most common complications of free flap reconstruction and compromises the perfusion of pedicles and perforators. Therefore, we reviewed our patients to analyze the associated risk factors.

METHOD

This study involved a retrospective chart review from 2014 to 2016. We identified the patients undergoing free flap reconstructions for head and neck cancer. Patients with postoperative hematoma requiring surgical intervention were included.

RESULT

We enlisted 289 patients undergoing head and neck reconstructions. Eighteen patients (6.2%) had postoperative hematomas of which 12 hematomas occurred within the first 3 days and 9 in the first 24 hours. Elevated systolic blood pressure increased the risk of hematoma formation, but hematoma was not associated with higher failure rate. Tachycardia was observed in the patients with hematoma.

CONCLUSIONS

Transient elevated blood pressure increased the risk of hematoma. We suggest controlling systolic blood pressure below 150 mm Hg for prevention of hematoma.

Blood Loss and Transfusion Rates in Microsurgical Head and Neck Reconstruction

Background:

Free flap reconstruction cases of the head and neck are often complex, long and have a multitude of risks. One of the greatest risks is intraoperative blood loss and need for transfusion. The purpose of this study was to examine basic patient and procedure characteristics in head and neck free flap reconstruction pre- and postoperatively that may help to predict severity of blood loss.

Methods:

A retrospective chart analysis of 67 free flap reconstructions for head and neck defects was performed. Patient characteristics, surgical variables, length of stay, and postoperative complications were reviewed and compared between the transfused and nontransfused patients. Characteristics between transfused and nontransfused patients were analyzed using two-tailed t tests and Fisher’s exact tests.

Results:

Of the 67 procedures, 19 reconstructions (28.4%) required a transfusion. Transfused patients were found to have a lower preoperative hemoglobin and elevated coagulation labs. The average length of stay was also statistically longer for transfused patients. There was no statistical difference in patient characteristics, length of surgery, type of free flap, or complication rate in the transfused versus nontransfused patients.

Conclusions:

Our study demonstrates that head and neck microsurgical resection and reconstruction presents patients with a transfusion risk of over 28%. We found that patients with a lower preoperative hemoglobin and abnormal coagulation levels are at a higher risk for receiving a transfusion. We also have demonstrated that patients who received a transfusion had a statistically significant longer length of stay.

Microsurgical head and neck reconstruction in patients with coronary artery disease: A perioperative assessment algorithm

BACKGROUND

With the rising number of patients in advanced age receiving microsurgical procedures, coronary artery disease (CAD) and its challenging management is of increasing importance. Evidence based data concerning morbidity and mortality are rare. We present our experiences with this highly selected patient population and propose a preoperative assessment algorithm.

PATIENTS AND METHODS

Between January 2006 and May 2016, a total of 57 patients with CAD received 58 free flaps. Median age of our patients was 64 years (interquartile range 57.5-70.0). Squamous cell carcinoma was the reason for reconstruction in all cases. Defect of the buccal, gum, tongue, lip, trigone, palatal, and hypopharyngeal regions were reconstructed. Patient characteristics and comorbidities were recorded. We especially focused on the preoperative cardiac assessment and treatment of patients who were scheduled for microsurgical free tissue transfer such as medical history, cardiac risk assessment, and further cardiac testing such as Doppler-echocardiography and myocardial perfusion assessment. Intraoperative course as well as postoperative morbidity and mortality was described.

RESULTS

About 54.4% of the selected cohort received cardiac catheterization due to a clinical preoperative cardiac assessment performed individually by the cardiologist on duty. In total, 52 fasciocutaneous anterolateral thigh flaps, four osteocutaneous fibula flaps, and two radial forearm flaps were performed. The flap survival rate was 96.6%. The overall surgical complication rate was 28.1% (16 patients), mostly due to wound infections (seven cases) and partial flap necrosis (four cases). Three patients died, resulting in a mortality rate of 5.2%.

CONCLUSION

CAD patients receiving head and neck microsurgical reconstructions are still at high risk for adverse consequences due to surgery. The microsurgical community is requested to share the experience of those cases in order to develop reliable and evidence based statements of the perioperative risks and prognosis for these patients. We additionally introduce a standardized perioperative cardiac assessment and treatment algorithm for head and neck surgery patients with CAD.

Designing a Fibular Flow-Through Flap with a Proximal Peroneal Perforator-Free Flap for Maxillary Reconstruction

Reconstruction of a composite maxillary defect is frequently performed with a fibular osteocutaneous free flap to address both the bony and mucosal defect. If during the harvest of the fibula a distal skin perforator is not present due to vascular variations, reconstruction can potentially be done using the soleus muscle for filling of the palatal mucosal defect. An additional challenge arises when the accompanying skin paddle that has been harvested is not perfused, but the fibula remains viable. This case report describes salvage following loss of the skin paddle in an osteocutaneous fibular free flap by designing a fibular flow-through flap using a proximal peroneal perforator free flap. The use of this second free flap allows a skin paddle to be positioned on the distal fibular segment, provides a surgical backup, and limits the donor sites to the same extremity.

Free tissue flaps in head and neck reconstruction: clinical application and analysis of 93 patients of a single institution

Introduction

Reconstruction with a free flap is routine in head and neck surgery because of better functional outcomes, improved esthetics, and generally higher success rates.

Objective

To evaluate the clinical outcomes in patients undergoing different microvascular free flap reconstructions.

Methods

This was a retrospective study of 93 patients undergoing reconstructions with free flaps from 2007 to 2015. Four types of free flap were performed: anterolateral thigh (76.3%), radial forearm (16.1%), fibula (4.3%) and jejunum (3.3%). Patients’ demographic data were collected, and the outcomes measured included flap survival and complications. Postoperative functional and oncological outcome were also analyzed.

Results

The patients included 73 men and 20 women, with a mean age of 56.1 years. The most common tumor location was the tongue. Squamous cell carcinoma represented the vast majority of the diagnosed tumors (89.2%). The most common recipient vessels were the superior thyroid artery (77.4%) and the internal jugular vein (91.4%). Nine patients required emergency surgical re-exploration and the overall flap success rate was 90.3%. Venous thrombosis was the most common cause for re-exploration. Other complications included wound infection (5.4%), wound dehiscence (1.1%), partial flap necrosis (9.7%), fistula formation (10.8%), and 1 bleeding (1.1%). The majority of patients had satisfactory cosmetic and functional results of both donor site and recipient site after 46.7 months of mean follow-up.

Conclusion

Microsurgical free flap is shown to be a valuable and reliable method in head and neck surgery. It can be used safely and effectively with minimal morbidity in selected patients. The reconstruction can be performed by appropriately skilled surgeons with acceptable outcomes. Success rate appears to increase as clinical experience is gained.

Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery

BACKGROUND

The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival.

METHODS

We have performed a retrospective analysis of the treatment outcome of 93 microvascular flaps and evaluated the factors influencing the risk of flap loss including patients' age, body mass index, smoking, general medical history and previous oncological treatment.

RESULTS

Out of 93 flaps the total necrosis have been observed in 15 flaps with gradual improvement in the consecutive years. In individual analysis the patients age, BMI, and comorbidities did not reveal any significant relation. The history of any previous oncological treatment represented a significant adverse factor of success rate (p=0.035), and was even more significant when patients experienced all treatment modalities prior to the reconstructive procedure (p=0.009). Multivariate logistic regression model indicated that only surgery (p=0.0008), chemotherapy (p=0.02), cardiovascular diseases (p=0.05) and patient's age (p=0.02) represented significant factors impairing the success rate.

CONCLUSION

Incorporating multivariate analysis represents important statistical approach for better prediction of free flaps survival in head and neck reconstructive surgery. Incorporation of additional collective information could provide more precise approach in the risk of the flap loss assessment.

Free anterolateral thigh flap and masseter nerve transfer for reconstruction of extensive periauricular defects: Surgical technique and clinical outcomes

BACKGROUND

Radical tumor ablation in the periauricular area often results in extensive soft tissue defects, including facial nerve sacrifice, bone and/or dura defects. Reconstruction of these defects should aim at restoring facial reanimation, wound closure, and facial and neck contours. We present our experience using free anterolateral thigh flap (ALT) in combination with masseter nerve to facial nerve transfer in managing complex defects in the periauricular area.

METHODS

Between 2011 and 2015 six patients underwent a combined procedure of ALT flap reconstruction and masseter nerve transfer, to reconstruct extensive, post tumor resection, periauricular defects. The ALT flap was customized according to the defect. For smile restoration, the masseter nerve was transferred to the buccal branch of the facial nerve. If the facial nerve stump was preserved, interposition of nerve grafts to the zygomatic and frontal branches was performed to provide separate eye closure. The outcomes were analyzed by assessing wound closure, contour deformity, symmetry of the face, and facial nerve function.

RESULTS

There were no partial or total flap losses. Stable wound closure and adequate volume replacement in the neck was achieved in all cases, as well as good facial tonus and symmetry. The mean follow-up time of clinical outcomes was 16.8 months. Smile restoration was graded as good or excellent in four cases, moderate in one and fair in one.

CONCLUSION

Extensive periauricular defects following oncologic resection could be adequately reconstructed in a combined procedure of free ALT flap and masseter nerve transfer to the facial nerve for smile restoration.

Relationship between BMI and Postoperative Complications with Free Flap in Anterolateral Craniofacial Reconstruction

Background:

Although we have seen tremendous advancement in microsurgery over the last 2 decades and free tissue transfer has become standard for head and neck reconstruction, surgeons still struggle to prevent postoperative complications. We examined the relationship between body mass index (BMI) and postoperative complications in patients undergoing rectus abdominis free flap transfer after anterolateral craniofacial resection.

Methods:

This was a retrospective review of reconstructive surgery using rectus abdominis musculocutaneous free flap in patients with locally advanced maxillary sinus carcinoma from 2003 to 2014 (n = 35, 27 men and 8 women; average age, 60.9 ± 7.8 years). All patients underwent craniofacial reconstruction after anterior and middle cranial fossa skull base resection and maxillectomy (class IV, subtype a) with palatal resection. Patients were categorized based on sex, BMI, and other parameters.

Results:

Recipient-site infection occurred in 11 patients (31.4%), cerebrospinal fluid leakage in 6 (17.1%), partial flap necrosis in 2 (5.7%), total flap necrosis in 1 (2.9%), and facial fistula in 4 (11.4%). Women showed partial flap necrosis significantly more frequently (P = 0.047), probably owing to poor vascular supply of the subcutaneous fat layer. Patients with low BMI (<20 kg/m²) showed recipient-site infection (P = 0.02) and facial fistula (P = 0.01) significantly more frequently owing to insufficient tissue volume and poor vascular supply.

Conclusion:

Postoperative recipient-site infection and facial fistula occurred mainly in low-BMI patients. Surgeons should take care to achieve sufficient donor tissue on low-BMI patients. Using a prosthetic obturator in low-BMI patients for craniofacial reconstruction can be a good alternative option to reduce postoperative complications due to insufficient donor tissue volume.

A new option with the pedicle thoracoacromial artery perforator flap for hypopharyngeal reconstructions

OBJECTIVES/HYPOTHESIS

The reconstruction of hypopharyngeal defects should focus on minimizing morbidity in a high-risk population while achieving adequate functional results with regard to the restoration of speech, swallowing, and airway control. We introduce the clinical application of the thoracoacromial artery perforator (TAAP) flap as a new reconstructive option for hypopharyngeal defects.

METHODS

This method was used to restore oncologic hypopharyngeal defects in nine patients: three who had previous irradiation and surgery, one who had previous surgery only, and another who had previous radiotherapy only.

RESULTS

All of the TAAP flaps of our series were transferred successfully and survived entirely. The donor sites were closed primarily in all cases. No fistulas, stenosis/strictures, dehiscence, or swelling occurred. Pectoralis major muscle function was completely preserved in all patients.

CONCLUSIONS

The use of TAAP flap to reconstruct hypopharyngeal defect is a simple and effective method that does not require microsurgical skills. The flap is thin and pliable, with a reliable blood supply.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1315-1320, 2016.

Sandwich flaps as a feasible solution for the management of huge mandibular composite tissue defects

In the current therapy of head and neck defects, surgical reconstruction with the aid of pedicle or free flaps is common practice. Suitable single flaps are available to solve most reconstructive challenges. However, reconstruction can become a problem in extensive mandibular defects, as they are often caused by large primary tumors or osteoradionecrosis. These composite defects often lead to large intraoral or extraoral fistulas due to the involvement of mucosa, skin, mandible and soft tissue. These issues call for a double flap approach in order to achieve adequate reconstruction. Therefore, we developed a surgical sandwich technique as presented in this study. The procedure features the acquisition and use of two vascular flaps which can be freely combined according to their desired features (for example being of high tissue volume or osteomyocutaneous). In our study we included 11 patients (ten male, one female) with a mean age of 57 years. Seven of the patients had defects due to osteoradionecrosis and four due to tumor resection. A sandwich technique was performed in a single operation in eight patients, whereas for three patients several operations were necessary. The flaps used included: fibula free flap (FFF); anterolateral thigh (ALT); radial forearm flap (RFF); deltopectoral flap (DPF) and tensor fascia lata (TFL). The following combinations were used: FFF and ALT (three cases), FFF and RFF (two), FFF and DPF (three), ALT and TFL (two), and two ALT flaps (one). The sandwich technique proved suitable for complex reconstructions and led to desirable esthetic and functional results. The flexibility in combining different free or pedicle flaps made it possible to address various defect situations and consequently offer satisfactory surgical reconstruction for complex cases.

Reconstruction Using Locoregional Flaps for Large Skull Base Defects

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano's algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano's classification extends horizontally from the cribriform plate to the orbital roof. According to Yano's algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.

Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction

BACKGROUND

Risk factors and techniques for free flap salvage in head and neck reconstruction are poorly described.

METHODS

We conducted a retrospective review of all head and neck free flaps performed from 2000 to 2010.

RESULTS

Overall, 151 of 2296 flaps (6.6%) underwent salvage for microvascular complications. Age, comorbidities, surgeon experience (p = .88), vein grafts, and supercharging (p = .45) did not affect flap salvage. Muscle-only flaps (p = .002) were associated with significantly worse outcomes. Coupled venous anastomoses were superior to handsewn anastomoses (p = .03). Arteriovenous thrombosis had worse outcomes than a venous or arterial thrombosis alone (p < .0001). Anticoagulation, thrombolytics, and thrombectomy did not improve survival. Multiple takebacks (p = .003) and late takebacks (>3 days) had significantly worse outcomes (p = .003). Flap salvage was 60.3% successful with 60 total flap losses (2.6%).

CONCLUSION

Although flap salvage should be attempted, multiple attempts are not recommended, especially for muscle-only flaps. Combined arteriovenous and late thrombosis has a dismal prognosis regardless of different salvage techniques. © 2015 Wiley Periodicals, Inc. Head Neck 38: E771-E775, 2016.

The fusion of craniofacial reconstruction and microsurgery: a functional and aesthetic approach

BACKGROUND

Reconstruction of large, composite defects in the craniofacial region has evolved significantly over the past half century. During this time, there have been significant advances in craniofacial and microsurgical surgery. These contributions have often been in parallel; however, over the past 10 years, these two disciplines have begun to overlap more frequently, and the techniques of one have been used to advance the other. In the current review, the authors aim to describe the available options for free tissue reconstruction in craniofacial surgery.

METHODS

A review of microsurgical reconstructive options of aesthetic units within the craniofacial region was undertaken with attention directed toward surgeon flap preference.

RESULTS

Anatomical areas analyzed included scalp, calvaria, forehead, frontal sinus, nose, maxilla and midface, periorbita, mandible, lip, and tongue. Although certain flaps such as the ulnar forearm flap and lateral circumflex femoral artery-based flaps were used in multiple reconstructive sites, each anatomical location possesses a unique array of flaps to maximize outcomes.

CONCLUSIONS

Craniofacial surgery, like plastic surgery, has made tremendous advancements in the past 40 years. With innovations in technology, flap design, and training, microsurgery has become safer, faster, and more commonplace than at any time in history. Reconstructive microsurgery allows the surgeon to be creative in this approach, and free tissue transfer has become a mainstay of modern craniofacial reconstruction.

Autologous Ilium Grafts: Long-Term Results on Immediate or Staged Functional Rehabilitation of Mandibular Segmental Defects Using Dental Implants after Tumor Resection

BACKGROUND

It is a challenge for clinicians to restore oral function in patients with segmental defects of the mandible because of tumor extirpation. Dental implant therapy following vascularized autologous ilium grafts is an effective method to restore oral function in patients with mandibular segmental defects.

PURPOSE

The aim of this retrospective study was to investigate the long-term clinical outcomes of ilium grafts combined with immediate or staged mandibular dental implant therapy to restore craniofacial defects resulting from tumor resection.

MATERIALS AND METHODS

Over a 5-year period (2000-2004), 32 patients who underwent mandibular segmental resection for tumors were treated with vascularized ilium grafts to augment bone volume. Seventeen patients received phase I therapy (immediate placement of implants), and 15 patients underwent phase II therapy (delayed placement of implants). A total of 110 dental implants were placed in these patients for mandibular restoration of the defective areas. Information regarding implant success and survival rates, marginal bone loss, soft tissue inflammation, complications of prosthesis, and patient satisfaction for the 8 to 12 years following oral reconstruction was obtained from patient records.

RESULTS

Although there was mild evidence of bone graft resorption, the vascularized autogenous ilium bone grafts were successful in all patients. The cumulative patient survival and success rate of the implants were 96.4% and 91.8%, respectively. The mean peri-implant bone resorption ranged from 1.0 to 1.2 mm over the 8- to 12-year follow-up period. The annual mean number of complications/repairs was from 0.11 to 0.07 per patient during the 8- to 12-year follow-up. Over 80% of the patients were fully satisfied with their restoration of oral function.

CONCLUSIONS

This study demonstrates that reconstruction of mandibular segmental defects because of resection of mandibular tumors using dental implants therapy combined with vascularized autogenous ilium grafts is an effective method to restore oral function.