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Stevens MN, Prasad K, Sharma RK, Gallant JN, Habib DRS, Langerman A, Mannion K, Rosenthal E, Topf MC, Rohde SL. Comparative Outcomes for Microvascular Free Flap Monitoring Outside the Intensive Care Unit. Otolaryngol Head Neck Surg 2024; 171:381-386. [PMID: 38667749 DOI: 10.1002/ohn.780] [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: 11/10/2023] [Revised: 03/01/2024] [Accepted: 03/19/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE There is a trend towards nonintensive care unit (ICU) or specialty ward management of select patients. Here, we examine postoperative outcomes for patients transferred to a general ward following microvascular free flap (FF) reconstruction of the head and neck. STUDY DESIGN Retrospective quality control study. SETTING Single tertiary care center. METHODS Consecutive patients who underwent FF of the head and neck before and after a change in protocol from immediate postoperative monitoring in the ICU ("Pre-protocol") to the general ward setting ("Post-protocol"). Outcomes included overall length of stay (LOS), ICU LOS, FF compromise, and postoperative complications. RESULTS A total of 150 patients were included, 70 in the pre-protocol group and 80 in the post-protocol group. There were no significant differences in age, sex, comorbidities, tumor stage, or type of FF. Mean LOS decreased from 8.18 to 7.68 days (P = .4), and mean ICU LOS decreased significantly from 5.2 to 1.7 days (P < .01). There were no significant differences in postoperative or airway-related complications (P = .6) or FF failure rate (2.9% vs 2.6%, P > .9). There was a non-significant increase in ancillary consults in the post-protocol group (45% vs 33%, P = .13) and a significant increase in rapid response team calls, a nurse-driven safety net for abnormal vitals or mental status (19% vs 3%, P = .003). CONCLUSION We show the successful implementation of a protocol shifting care of FF patients from the ICU to a general ward postoperatively, suggesting management on the floor with less frequent flap monitoring is safe and conserves ICU beds. Additional teaching and familiarity with these patients may over time reduce the rapid response calls.
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Affiliation(s)
- Madelyn N Stevens
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kavita Prasad
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rahul K Sharma
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | - Kyle Mannion
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eben Rosenthal
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael C Topf
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sarah L Rohde
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Hernandez Alvarez A, Lee D, Kim EJ, Schuster K, Taritsa I, Foppiani J, Valentine L, Weidman AA, Comer C, Lee BT, Lin SJ. An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures. J Reconstr Microsurg 2024. [PMID: 38889744 DOI: 10.1055/s-0044-1787776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
BACKGROUND Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage. METHODS A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed. RESULTS From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique. CONCLUSION Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.
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Affiliation(s)
| | - Daniela Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin J Kim
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Kirsten Schuster
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Iulianna Taritsa
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jose Foppiani
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Lauren Valentine
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Allan A Weidman
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carly Comer
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bernard T Lee
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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3
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Fakurnejad S, Gulati A, Stanford-Moore GB, Park AM, Heaton CM, Seth R, Knott PD. The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck. Facial Plast Surg Aesthet Med 2024; 26:148-151. [PMID: 37166789 DOI: 10.1089/fpsam.2022.0395] [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: 05/12/2023] Open
Abstract
Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.
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Affiliation(s)
- Shayan Fakurnejad
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Arushi Gulati
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
- UC San Francisco School of Medicine, San Francisco, California, USA
| | - Gaelen B Stanford-Moore
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrea M Park
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Chase M Heaton
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rahul Seth
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
| | - P Daniel Knott
- Department of Otolaryngology Head & Neck Surgery, University of California San Francisco, San Francisco, California, USA
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4
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Ma Y, Li S, Shan X, Zhang L, Cai Z. Continuous Monitoring of Buried Free Bone Flap Microcirculation Using a Near-Infrared Spectroscopy System. Plast Reconstr Surg 2024; 153:626e-631e. [PMID: 37166029 DOI: 10.1097/prs.0000000000010610] [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: 05/12/2023]
Abstract
SUMMARY Postoperative evaluation of free flaps remains a challenging task. The current accepted standard for diagnosis of vascular compromise remains clinical observation. In recent years, near-infrared spectroscopy (NIRS) has been widely used as a noninvasive objective monitoring tool for postoperative evaluation of soft-tissue flaps. However, methods for monitoring bone flaps remain inadequate. In this study, NIRS was applied for the first time to monitor free buried bone flaps that were used for mandibular reconstruction. The penetrating property of NIRS was used to measure the tissue oxygenation index (TOI) of deep tissues, which reflected the microcirculatory status of the tissues. Changes in TOI values were monitored continuously in 59 cases of free bone flaps up to 72 hours after surgery. Five cases of vascular compromise were noted by clinical observation. Two fibula flaps were total failures, one of which showed a sharp decrease in TOI value to 45% in a short period of time; the other showed a continual gradual decrease to 55%. The observed sudden (<50%) and continuous (>10%) decreases in TOI values suggest that more attention should be paid to revision surgical procedures. The authors conclude that NIRS holds promise as an objective and valid method for clinical evaluation of buried bone flaps.
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Affiliation(s)
- Yixin Ma
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Engineering Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital Stomatology; and National Clinical Research Center for Oral Diseases
| | - Shijun Li
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Engineering Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital Stomatology; and National Clinical Research Center for Oral Diseases
| | - Xiaofeng Shan
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Engineering Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital Stomatology; and National Clinical Research Center for Oral Diseases
| | - Lei Zhang
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Engineering Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital Stomatology; and National Clinical Research Center for Oral Diseases
| | - Zhigang Cai
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology; National Engineering Laboratory for Digital and Material Technology of Stomatology; Beijing Key Laboratory of Digital Stomatology; and National Clinical Research Center for Oral Diseases
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Aksamitiene E, Heffelfinger RN, Hoek JB, Pribitkin ED. Standardized Pre-clinical Surgical Animal Model Protocol to Investigate the Cellular and Molecular Mechanisms of Ischemic Flap Healing. Biol Proced Online 2024; 26:2. [PMID: 38229030 DOI: 10.1186/s12575-023-00227-w] [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: 06/13/2023] [Accepted: 12/14/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Some of the most complex surgical interventions to treat trauma and cancer include the use of locoregional pedicled and free autologous tissue transfer flaps. While the techniques used for these reconstructive surgery procedures have improved over time, flap complications and even failure remain a significant clinical challenge. Animal models are useful in studying the pathophysiology of ischemic flaps, but when repeatability is a primary focus of a study, conventional in-vivo designs, where one randomized subset of animals serves as a treatment group while a second subset serves as a control, are at a disadvantage instigated by greater subject-to-subject variability. Our goal was to provide a step-by-step methodological protocol for creating an alternative standardized, more economical, and transferable pre-clinical animal research model of excisional full-thickness wound healing following a simulated autologous tissue transfer which includes the primary ischemia, reperfusion, and secondary ischemia events with the latter mimicking flap salvage procedure. RESULTS Unlike in the most frequently used classical unilateral McFarlane's caudally based dorsal random pattern skin flap model, in the herein described bilateral epigastric fasciocutaneous advancement flap (BEFAF) model, one flap heals under normal and a contralateral flap-under perturbed conditions or both flaps heal under conditions that vary by one within-subjects factor. We discuss the advantages and limitations of the proposed experimental approach and, as a part of model validation, provide the examples of its use in laboratory rat (Rattus norvegicus) axial pattern flap healing studies. CONCLUSIONS This technically challenging but feasible reconstructive surgery model eliminates inter-subject variability, while concomitantly minimizing the number of animals needed to achieve adequate statistical power. BEFAFs may be used to investigate the spatiotemporal cellular and molecular responses to complex tissue injury, interventions simulating clinically relevant flap complications (e.g., vascular thrombosis) as well as prophylactic, therapeutic or surgical treatment (e.g., flap delay) strategies in the presence or absence of confounding risk factors (e.g., substance abuse, irradiation, diabetes) or favorable wound-healing promoting activities (e.g., exercise). Detailed visual instructions in BEFAF protocol may serve as an aid for teaching medical or academic researchers basic vascular microsurgery techniques that focus on precision, tremor management and magnification.
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Affiliation(s)
- Edita Aksamitiene
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA
- Present address: Beckman Institute for Advanced Science and Technology, University of Illinois Urbana-Champaign, 405 N. Mathews Ave | M/C 251, Room 4357, Urbana, IL, 61801, USA
| | - Ryan N Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA
| | - Jan B Hoek
- Department of Pathology, Anatomy and Cell Biology, Thomas Jefferson University, 1020 Locust St, Room 527, Philadelphia, PA, 19107, USA
| | - Edmund deAzevedo Pribitkin
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut St., 6Th floor, Philadelphia, PA, 19107, USA.
- Sidney Kimmel Medical College, 31st Floor, 1101 Market Street, Philadelphia, PA, 19107, USA.
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Huang RW, Tsai TY, Hsieh YH, Hsu CC, Chen SH, Lee CH, Lin YT, Kao HK, Lin CH. Reliability of Postoperative Free Flap Monitoring with a Novel Prediction Model Based on Supervised Machine Learning. Plast Reconstr Surg 2023; 152:943e-952e. [PMID: 36790782 DOI: 10.1097/prs.0000000000010307] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Postoperative free flap monitoring is a critical part of reconstructive microsurgery. Postoperative clinical assessments rely heavily on specialty-trained staff. Therefore, in regions with limited specialist availability, the feasibility of performing microsurgery is restricted. This study aimed to apply artificial intelligence in postoperative free flap monitoring and validate the ability of machine learning in predicting and differentiating types of postoperative free flap circulation. METHODS Postoperative data from 176 patients who received free flap surgery were prospectively collected, including free flap photographs and clinical evaluation measures. Flap circulation outcome variables included normal, arterial insufficiency, and venous insufficiency. The Synthetic Minority Oversampling Technique plus Tomek Links (SMOTE-Tomek) was applied for data balance. Data were divided into 80%:20% for model training and validation. Shapley Additive Explanations were used for prediction interpretations of the model. RESULTS Of 805 total included flaps, 555 (69%) were normal, 97 (12%) had arterial insufficiency, and 153 (19%) had venous insufficiency. The most effective prediction model was developed based on random forest, with an accuracy of 98.4%. Temperature and color differences between the flap and the surrounding skin were the most significant contributing factors to predict a vascular compromised flap. CONCLUSIONS This study demonstrated the reliability of a machine-learning model in differentiating various types of postoperative flap circulation. This novel technique may reduce the burden of free flap monitoring and encourage the broader use of reconstructive microsurgery in regions with a limited number of staff specialists.
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Affiliation(s)
- Ren-Wen Huang
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Tzong-Yueh Tsai
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Yun-Huan Hsieh
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Chung-Chen Hsu
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Shih-Heng Chen
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Che-Hsiung Lee
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Yu-Te Lin
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Huang-Kai Kao
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
| | - Cheng-Hung Lin
- From the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University
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7
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Bigdeli AK, Strübing F, Troia R, Thomas B, Gazyakan E, Kneser U, Hirche C. A Retrospective Matched-Pair Analysis of Long-term Outcomes after Successful Lower Extremity Free Flap Salvage. J Reconstr Microsurg 2023; 39:633-639. [PMID: 37023767 DOI: 10.1055/s-0043-1764488] [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: 04/08/2023]
Abstract
BACKGROUND Pedicle occlusion with total free flap loss after microvascular lower extremity reconstruction is a considerably rare yet devastating complication. Fortunately, in the majority of cases, emergency salvage takebacks of compromised free flaps are initiated in a timely manner. In this report, we present our analysis of long-term outcomes following transient vascular compromise mitigated through successful free flap salvage in the lower extremity. METHODS We performed a single-center retrospective matched-pair analysis of 46 patients with lower extremity free flap reconstructions. Cases underwent successful revisions of microvascular compromise (n = 23), whereas controls had uneventful postoperative courses (n = 23). Patient-reported outcome questionnaires and physical evaluations were used to assess general quality of life, functional outcomes, and cosmesis (Lower Extremity Functional Scale [LEFS], Lower Limb Outcomes Questionnaire [LLOQ], Short Form 36 (SF-36), Vancouver Scar Scale [VSS]). The mean follow-up time was 4.4 years. RESULTS The health-related quality of life assessed by the SF-36 did not differ significantly between both groups in any of the subscales (p ≥ 0.15 for all subscales). Functional outcomes did not show significant differences between both groups according to the LEFS (p = 0.78) and LLOQ (p = 0.45). The overall scar appearance assessed by the VSS showed significantly poorer cosmesis in the re-exploration group (p = 0.014). CONCLUSION Salvage of compromised free flaps in the lower extremity yields similar long-term outcomes compared to noncompromised free flaps with regard to function and quality of life. However, free flap revisions may lead to impaired scar formation. This study provides further evidence that the opportunity for urgent re-exploration is indispensable.
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Affiliation(s)
- Amir K Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Felix Strübing
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Roman Troia
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Otolaryngology, University Medical Centre Mannheim, Mannheim, Germany
| | - Benjamin Thomas
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
- Department of Plastic, Hand- and Reconstructive Microsurgery, Handtrauma- and Replantation Center, BG Unfallklinik Frankfurt am Main gGmbH, Affiliated Hospital of Goethe University Frankfurt, Frankfurt, Germany
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Hwang TZ, Wang YM, Jeng SF, Lee YC, Chen TS, Su SY, Huang CC, Lam CF. Intraoperative Enteral Nutrition Feeding in Free-Flap Healing after Reconstruction Surgery for Head and Neck Cancers. Otolaryngol Head Neck Surg 2023; 169:843-851. [PMID: 36960779 DOI: 10.1002/ohn.335] [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: 10/24/2022] [Revised: 01/31/2023] [Accepted: 02/26/2023] [Indexed: 03/25/2023]
Abstract
OBJECTIVE To investigate the beneficial outcomes of intraoperative enteral feeding in free-flap regeneration after extended head and neck cancer resection and flap reconstruction surgery. STUDY DESIGN A pilot randomized, double-blind, placebo-controlled clinical trial. SETTING Single tertiary care center. METHODS Patients with advanced head and neck cancers requiring radical tumor resections and free-flap reconstruction were randomly assigned to receive intraoperative enteral nutrition feeding (100 kcal/100 mL at 10-20 mL/h) via a nasogastric tube during free-flap reconstruction (n = 28) or continue fasting (n = 28). The primary outcome was impaired free-flap regeneration that required surgical reintervention within 90 days after the operation. Participants were enrolled between April 2020 and January 2022; the 90-day follow-up ended in April 2022. RESULTS The incidence of total or partial flap failure was similar between the 2 groups (14.2% or n = 4 in each group), but the rate of wound dehiscence or edge necrosis was significantly reduced in the feeding group (n = 6 vs 0 for fasting vs feeding; absolute risk reduction, 25.0% [95% confidence interval, 6.9-43.0]%; p = 0.022). Hospital stay length was shorter (p = 0.042) and hand grip strength was better preserved (p = 0.025) in the feeding group. Plasma concentrations of interleukin (IL)-6 and IL-8 after the operation increased significantly more in the fasting group. Perioperative adverse events did not differ between the 2 groups. CONCLUSION Perioperative enteral feeding is a simple, safe, and effective approach to improve perioperative systemic catabolism and proinflammatory reactions, thereby enhancing early wound regeneration after major operations.
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Affiliation(s)
- Tzer-Zen Hwang
- Department of Otolaryngology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Ming Wang
- Department of Critical Care Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Seng-Feng Jeng
- Department of Plastic Surgery, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Yi-Chen Lee
- Department of Nutrition Therapy, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
- Department of Nutrition, I-Shou University, Kaohsiung, Taiwan
| | - Tzu-Shan Chen
- Department of Medical Research, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Shin-Ying Su
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Chien-Chi Huang
- Department of Medical Research, E-Da Hospital and E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- Department of Anesthesiology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chia-Yi, Taiwan
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9
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Luo L, Wu B, Jie Z, Hu Y. Editorial: Advances of innovative therapeutic strategies in age-related diseases. Front Bioeng Biotechnol 2023; 11:1288352. [PMID: 37829566 PMCID: PMC10565498 DOI: 10.3389/fbioe.2023.1288352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- Ling Luo
- Clinical Pharmacology Institute, Pharmaceutical School, Nanchang University, Nanchang, China
| | - Bin Wu
- State Key Laboratory of Materials Processing and Die & Mould Technology, School of Materials Science and Engineering, Huazhong University of Science and Technology, Wuhan, China
| | - Zhiwei Jie
- Department of Orthopaedic Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiqiang Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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10
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Hagiga A, Gultiaeva M, Harry LE. Thrombophilia and Preoperative Deep Venous Thrombosis and Their Effect on Free Flap Survival: A Scoping Review. Plast Surg (Oakv) 2023; 31:183-191. [PMID: 37188128 PMCID: PMC10170632 DOI: 10.1177/22925503211024871] [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: 10/16/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
Background: A proper preoperative planning is essential to prevent flap failure. However, venous workup for flaps has not been commonly performed or utilized as a preoperative screening tool. A scoping review was conducted to explore preoperative venous system screening, including deep vein thrombosis diagnosis, and its effect on flap survival rate. This review identified existing gaps of knowledge and emphasized potential research areas for future studies. Methods: Two independent reviewers searched 3 electronic databases from inception to September 2020. Retrieved appropriate articles were selected systematically by title, abstract, and full review of the article. Studies were included if they enrolled patients who had thrombophilia or deep venous thrombosis (DVT) preoperatively and had undergone a free flap reconstruction. For eligible studies, the following information was extracted: basic demographics (sex, age, comorbidities), preoperative scans type, free flap type, clotting mode (causes), wound type, and flap survival. Results: Seventeen articles were found eligible for this review. Traumatic aetiology was found in 63 (33.6%) patients, while 124 (66.3%) patients had a non-traumatic aetiology. Preoperative screening for patients with non-traumatic aetiology was reported in 119 patients. In these patients, the flap survived in 107 (89.91%) patients. Four studies investigating patients with traumatic DVT aetiology, 60 patients (out of 63) had a preoperative computed tomography angiography or duplex. Those patients had 100% flap survival rates. Conclusion: Further investigations are required to identify venous thrombosis incidence in patients with non-traumatic thrombosis aetiology as this cohort of patients is at high risk of flap failure. Finally, the prognostic validity of available preoperative screening tools to identify high-risk patients should be assessed, such as imaging techniques, which would include venous duplex scanning, may prevent failure in free flap surgery.
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Affiliation(s)
- Ahmed Hagiga
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
| | - Mariia Gultiaeva
- Brighton and Sussex University Hospitals NHS Trust, Royal Sussex University Hospital, Brighton, United Kingdom
| | - Lorraine E. Harry
- Queen Victoria Hospital NHS Foundation Trust, East Grinstead, United Kingdom
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11
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Jarnalo M, Machado P, Baptista D, Brito ÍM. Phlebitis of the draining vein of an ALT free flap for forearm reconstruction. Microsurgery 2023; 43:418-419. [PMID: 36916497 DOI: 10.1002/micr.31039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/15/2023] [Accepted: 03/03/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Mariana Jarnalo
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Oporto, Oporto, Portugal
| | - Pedro Machado
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Oporto, Oporto, Portugal
| | - Diana Baptista
- Department of Anatomical Pathology, Centro Hospitalar e Universitário de São João, Oporto, Portugal
| | - Íris M Brito
- Department of Plastic, Reconstructive and Aesthetic Surgery and Burn Unit, Centro Hospitalar e Universitário de São João, Oporto, Portugal.,Department of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Oporto, Oporto, Portugal
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12
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Knoedler S, Hoch CC, Huelsboemer L, Knoedler L, Stögner VA, Pomahac B, Kauke-Navarro M, Colen D. Postoperative free flap monitoring in reconstructive surgery-man or machine? Front Surg 2023; 10:1130566. [PMID: 36911625 PMCID: PMC9992807 DOI: 10.3389/fsurg.2023.1130566] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Free tissue transfer is widely used for the reconstruction of complex tissue defects. The survival of free flaps depends on the patency and integrity of the microvascular anastomosis. Accordingly, the early detection of vascular comprise and prompt intervention are indispensable to increase flap survival rates. Such monitoring strategies are commonly integrated into the perioperative algorithm, with clinical examination still being considered the gold standard for routine free flap monitoring. Despite its widespread acceptance as state of the art, the clinical examination also has its pitfalls, such as the limited applicability in buried flaps and the risk of poor interrater agreement due to inconsistent flap (failure) appearances. To compensate for these shortcomings, a plethora of alternative monitoring tools have been proposed in recent years, each of them with inherent strengths and limitations. Given the ongoing demographic change, the number of older patients requiring free flap reconstruction, e.g., after cancer resection, is rising. Yet, age-related morphologic changes may complicate the free flap evaluation in elderly patients and delay the prompt detection of clinical signs of flap compromise. In this review, we provide an overview of currently available and employed methods for free flap monitoring, with a special focus on elderly patients and how senescence may impact standard free flap monitoring strategies.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - Cosima C. Hoch
- Department of Otolaryngology, Head and Neck Surgery, Rechts der Isar Hospital, Technical University Munich, Munich, Germany
| | - Lioba Huelsboemer
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Viola A. Stögner
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - David Colen
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
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13
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Odorico SK, Reuter Muñoz K, J Nicksic P, Gunderson KA, Wood K, H Nkana Z, Bond E, Poore SO. Surgical and demographic predictors of free flap salvage after takeback: A systematic review. Microsurgery 2023; 43:78-88. [PMID: 35611652 PMCID: PMC10084419 DOI: 10.1002/micr.30921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 03/21/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage. METHODS A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis. RESULTS The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure. CONCLUSIONS Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.
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Affiliation(s)
- Scott K Odorico
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Katie Reuter Muñoz
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter J Nicksic
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kirsten A Gunderson
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Kasey Wood
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Zeeda H Nkana
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Evalina Bond
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Samuel O Poore
- Division of Plastic Surgery, Department of Surgery, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wisconsin, USA
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14
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Hathorn T, Nickel C, Sharma A, Shabani S, Padhya T, Mifsud M. How do i salvage that flap?; An evidence-based primer on salvage techniques for head & neck microvascular free flaps. Oral Oncol 2023; 136:106246. [PMID: 36402054 DOI: 10.1016/j.oraloncology.2022.106246] [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: 10/23/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an "other" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.
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Affiliation(s)
- Travis Hathorn
- USF Health Morsani College of Medicine, 560, Channelside Dr, Tampa, FL 33602, United States
| | - Christopher Nickel
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Abhay Sharma
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Sepehr Shabani
- The University of Texas Medical Branch, Department of Otolaryngology - Head & Neck Surgery, 301 University Blvd., Galveston, TX 77555, United States
| | - Tapan Padhya
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Matthew Mifsud
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States.
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15
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Heitzer M, Ooms M, Katz MS, Peters F, Kilic K, Tolba R, Jockenhoevel S, Hermanns-Sachweh B, Hölzle F, Modabber A. Evaluation of the long-term results of vascular anastomosis using polyurethane adhesive and shape-memory stent in the rat carotid artery model. Microsurgery 2022; 42:480-489. [PMID: 35670105 DOI: 10.1002/micr.30926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/04/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In free flaps, 5%-10% of complications are related to failure of sutured vascular anastomoses. Adhesive-based microvascular anastomoses are potential alternatives but are associated with failure rates of 70% in research studies. VIVO is a new adhesive with slow biodegradation within 6 months that has shown a 100% patency rate in research studies over 2 h observation time but long-term patency has not been evaluated. The authors hypothesize that VIVO will enable a reliable microvascular procedure comparable to sutured anastomoses over a 28-day period. MATERIALS AND METHODS The right common carotid artery of 60 male Sprague Dawley rats, ~450 g, were used for microvascular end-to-end anastomosis. VIVO was applied with reduced sutures with a temporary catheter in one group and in the other with a custom-shaped memory stent. Anastomoses with eight interrupted sutures served as control. All groups were n = 20. Anastomosis time and bleeding were recorded for each procedure. Doppler flowmetry was performed 20 min, 1, 10, and 28 days postoperatively. Postmortem toluidine staining was used for semi-quantitative analysis of stenosis, thrombosis, necrosis, and aneurysm formation by histologic evaluation. RESULTS No occlusion was detected 20 min and 1 day postoperative, and after 28 days of observation in all anastomoses. The anastomosis time of the VIVO with catheter group was about 32% significantly faster than the VIVO with stent group. In the VIVO group with stent, the bleeding time was ~80% shorter than in the control group with 2.1 ± 0.3 and VIVO with catheter 2.0 ± 0.5 (p ≤ .001 each). Minor and nonsignificant stent-associated thrombus formation and stent-typical intraluminal stenosis were detected exclusively in the VIVO with stent group. CONCLUSION Within the limitations of a rat study, the use of VIVO in anastomosis showed promising results. VIVO with catheter was found to be advantageous.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Konrad Kilic
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - René Tolba
- Institute of Laboratory Animal Science and Experimental Surgery of RWTH-Aachen, Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid and Medical Textiles (BioTex), AME-Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | | | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
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16
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Slijepcevic AA, Young G, Shinn J, Cannady SB, Hanasono M, Old M, Grewal JS, Ghanem T, Ducic Y, Curry JM, Wax MK. Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction. JAMA Otolaryngol Head Neck Surg 2022; 148:555-560. [PMID: 35476871 PMCID: PMC9047712 DOI: 10.1001/jamaoto.2022.0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Incidence of perioperative free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown. Objective To assess the outcomes of a second revascularization attempt for compromised free flaps. Design, Setting, and Participants This multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. Main Outcome and Measure Flaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts. Results A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage. Conclusions and Relevance In this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Oregon Health & Science University, Portland
| | - Gavin Young
- School of Medicine, Oregon Health & Science University, Portland
| | - Justin Shinn
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia
| | - Matthew Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston
| | - Matthew Old
- Department of Otolaryngology-Head & Neck Surgery, College of Medicine, The Ohio State University, Columbus
| | - Jeewanjot S Grewal
- Department of Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Tamer Ghanem
- Department of Otolaryngology-Head & Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | | | - Joseph M Curry
- Department of Otolaryngology-Head & Neck Surgery, Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Mark K Wax
- Department of Otolaryngology-Head & Neck Surgery, School of Medicine, Oregon Health & Science University, Portland
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17
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Mata Ribeiro L, Tsao CK, Hung YL, Chu CH, Lin LC, Lin MH, Peng C, Cheong DCF, Hung SY, Liao CT. Venous Size Discrepancy Is a Critical Factor When Using Superficial Temporal Vessels as Recipient Vessels for Free Flaps. J Reconstr Microsurg 2022; 38:654-663. [PMID: 35213928 DOI: 10.1055/s-0042-1743165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels. METHODS We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels. RESULTS A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates. CONCLUSION Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.
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Affiliation(s)
- Luís Mata Ribeiro
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; Chang Gung University and Medical College, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, São José Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Chung-Kan Tsao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Liang Hung
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Hui Chu
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Li-Ching Lin
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mo-Han Lin
- Center of Tissue Engineering, School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi Peng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - David Chon-Fok Cheong
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Ta Liao
- Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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18
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Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases. Plast Reconstr Surg Glob Open 2021; 9:e3961. [PMID: 34881134 PMCID: PMC8647881 DOI: 10.1097/gox.0000000000003961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/04/2021] [Indexed: 12/02/2022]
Abstract
Background: Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment. Methods: Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma. Results: Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001). Conclusions: Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.
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19
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Organ preservation surgery for pyriform sinus carcinoma with vocal cord fixation: functional and oncological outcomes. Eur Arch Otorhinolaryngol 2021; 279:3611-3617. [PMID: 34825265 DOI: 10.1007/s00405-021-07182-w] [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: 08/02/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Pyriform sinus carcinoma with vocal cord fixation is stratified as stage T3 and above, and non-surgical treatment is generally preferred according to the guidelines, aiming to preserve laryngeal function. However, long-term survival is often compromised by deep infiltration of the tumor. Vertical hemipharyngolaryngectomy (VHPL) was previously reported to be a feasible surgical approach for organ preservation. The aim of this study was to evaluate the functional and oncological outcomes of VHPL in patients. METHODS Patients who underwent VHPL type II (total VHPL, which includes the removal of a vertical section of the thyroid cartilage through the anterior commissure to the upper border of the cricoid cartilage) for pyriform sinus cancer with vocal cord fixation at the authors' institute between 1999 and 2015 were retrospectively analyzed. Functional outcomes concerning swallowing and decannulation were evaluated. Successful functional preservation was defined as laryngeal preservation as well as oral realimentation and decannulation within 6 months after surgery. The oncological outcomes were measured by overall survival (OS) and disease-free survival (DFS) with Kaplan-Meier curves and comparisons were performed between the VHPL-treated patients and patients who underwent non-surgical treatment within the same period. RESULTS A total of 23 patients (stage T3, 17 patients; stage T4, 6 patients) whose initial treatment was VHPL type II were studied, and a cohort of 123 patients was selected as the control group. Pedicle and free flap reconstructions were performed on 12 and 11 patients, respectively. Postoperative radiation and chemoradiation was performed on 14 and 3 patients, respectively. Flap failure and pharyngeal fistula were detected in 2 and 5 patients, respectively. Oral realimentation and decannulation within 6 months were achieved in 82.6% (19 patients) and 87.0% (20 patients) of patients, respectively, and the total functional preservation rate of the study cohort at 6 months was similar to that of the control cohort. (78.3% vs. 82.9%, p = 0.28). After a median follow-up period of 49 months, 9 recurrences and 8 deaths had occurred in the study cohort. According to the Kaplan-Meier analysis, the study cohort had superior DFS (5-year DFS 60.3% vs. 44.6%, p = 0.04) and similar OS (5-year OS 63.8% vs 57.0% p = 0.28) compared with those in the control group. CONCLUSION VHPL yielded favorable oncological and functional outcomes in patients with unilateral pyriform sinus carcinoma and vocal cord fixation.
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20
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Kudpaje A, Thankappan K, Rajan RP, Vidhyadharan S, Balasubramanian D, Wakure A, Mathew J, Sharma M, Iyer S. Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction. Indian J Surg Oncol 2021; 12:530-537. [PMID: 34658581 DOI: 10.1007/s13193-021-01368-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 06/03/2021] [Indexed: 11/28/2022] Open
Abstract
This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.
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Affiliation(s)
- Akshay Kudpaje
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Krishnakumar Thankappan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India.,Department of Head and Neck Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, AIMS Ponekkara PO, Kochi, Kerala India
| | - Rajisha Paruthappara Rajan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Sivakumar Vidhyadharan
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Deepak Balasubramanian
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Abhijeet Wakure
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Jimmy Mathew
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Mohit Sharma
- Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
| | - Subramania Iyer
- Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala India
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21
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Abstract
PURPOSE OF REVIEW To highlight three clinical arenas in which head and neck free-flap compromise is encountered and acted upon: nonoperative, operative and postoperative realms. RECENT FINDINGS Time to identification and intervention is paramount to successful free-flap salvage. Surgical microvascular revision remains chief amongst strategies to revert vascular compromise of a free-flap. Adjuncts, such as thrombolytics and systemic anticoagulation have an important role in the complex work of microvascular free tissue care. Venous congestion of free flaps holds favorable for salvage when compared with arterial insufficiency. SUMMARY Vascular compromise of head and neck free flaps is a rare and feared event for microvascular surgeons, with successful transfers rates approaching above 95%. Success in salvage is dependent on prompt identification of tissue compromise and timely, directed interventions to re-establish tissue perfusion.
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22
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Primary thrombolysis for free flap surgery in head and neck reconstruction: a case report and review. Arch Plast Surg 2021; 48:511-517. [PMID: 34583436 PMCID: PMC8490121 DOI: 10.5999/aps.2021.00171] [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] [Received: 01/16/2021] [Accepted: 05/27/2021] [Indexed: 11/20/2022] Open
Abstract
The use of free flaps is an essential and reliable method of reconstruction in complex head and neck defects. Flap failure remains the most feared complication, the most common cause being pedicle thrombosis. Among other measures, thrombolysis is useful when manual thrombectomy has failed to restore flap perfusion, in the setting of late or established thrombosis, or in arterial thrombosis with distal clot propagation. We report a case of pedicle arterial thrombosis with distal clot propagation which occurred during reconstruction of a maxillectomy defect, and was successfully treated with thrombolysis using recombinant tissue plasminogen activator. We also review the literature regarding the use of thrombolysis in free flap surgery, and propose an algorithm for the salvage of free flaps in head and neck reconstruction.
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23
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Walia A, Lee JJ, Jackson RS, Hardi AC, Bollig CA, Graboyes EM, Zenga J, Puram SV, Pipkorn P. Management of Flap Failure After Head and Neck Reconstruction: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2021; 167:224-235. [PMID: 34491852 PMCID: PMC8972962 DOI: 10.1177/01945998211044683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To systematically review management of flap loss in head and neck construction with free tissue transfer as compared with locoregional flap or conservative management. DATA SOURCES Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched up to October 2019. REVIEW METHODS Candidate articles were independently reviewed by 2 authors. Articles were considered eligible if they included adequate reporting of flap management after flap loss and outcomes for survival of reconstruction, length of hospitalization, and perioperative complications. RESULTS A total of 429 patients had acute flap failure in the perioperative period. The overall success with a secondary free flap was 93% (95% CI, 0.89-0.97; n = 26 studies, I2 = 12.8%). There was no difference in hospitalization length after secondary reconstruction between free tissue transfer and locoregional flaps or conservative management (relative risk of hospitalization ≥2 weeks, 96%; 95% CI, 0.80-1.14; n = 3 studies, I2 = 0). The pooled relative risk of perioperative complications following free tissue transfer was 0.60 when compared with locoregional flap or conservative management (95% CI, 0.40-0.92; n = 5 studies, I2 = 0). CONCLUSION Salvage reconstruction with free tissue transfer has a high success rate. Second free flaps following flap failure had a similar length of hospitalization and lower overall complication rate than locoregional reconstruction or conservative management. A second free tissue transfer, when feasible, is likely a more reliable and effective procedure for salvage reconstruction.
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Affiliation(s)
- Amit Walia
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Jake J Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Angela C Hardi
- Bernard Becker Medical Library, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Evan M Graboyes
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Joseph Zenga
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.,Department of Genetics, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
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The Effect of Smoking on the Postoperative Course After Head and Neck Reconstruction With a Vascularized Free Flap: A Retrospective Study. J Craniofac Surg 2021; 32:1810-1812. [PMID: 34319682 DOI: 10.1097/scs.0000000000007526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The objective of the present study is to determine the impact of smoking on hospital and intensive care unit stay, need for surgical reintervention, Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, and surgical complications after head and neck reconstructions. METHODS All 153 patients who underwent head and neck reconstructions with free tissue transfer at the department of oral and maxillofacial surgery at the University Hospitals of Leuven between January 1, 2015 and December 31, 2018 were enrolled in this retrospective cohort study. Data from medical charts were extracted. Univariate and multiple regression analyses were performed. A level of significance of P < 0.05 (α = 0.05) was used. RESULTS Smoking was not associated with Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity, hospital or ICU stay, the incidence of postoperative complications in both flap and donor site, or surgical reintervention. CONCLUSIONS Regarding the outcomes included in this study, smoking status should not be considered as a critical factor in patient selection for head and neck reconstructions with a vascularized free flap.
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Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3663. [PMID: 34262835 PMCID: PMC8274739 DOI: 10.1097/gox.0000000000003663] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/05/2021] [Indexed: 11/26/2022]
Abstract
Background Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. Methods A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. Results A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). Conclusions This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.
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26
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Mady LJ, Poonia SK, Baddour K, Snyder V, Kurukulasuriya C, Frost AS, Cannady SB, Chinn SB, Fancy T, Futran N, Hanasono MM, Lewis CM, Miles BA, Patel U, Richmon JD, Wax MK, Yu P, Solari MG, Sridharan S. Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction. Head Neck 2021; 43:3032-3041. [PMID: 34145676 DOI: 10.1002/hed.26789] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/10/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND We aim to define a set of terms for common free flap complications with evidence-based descriptions. METHODS Clinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of "good" or "fair") were eliminated. RESULTS Five out of nineteen terms scored K < 0.74. Eliminated terms included "vascular compromise"; "cellulitis"; "surgical site abscess"; "malocclusion"; and "non- or mal-union." Terms that achieved consensus were "total/partial free flap failure"; "free flap takeback"; "arterial thrombosis"; "venous thrombosis"; "revision of microvascular anastomosis"; "fistula"; "wound dehiscence"; "hematoma"; "seroma"; "partial skin graft failure"; "total skin graft failure"; "exposed hardware or bone"; and "hardware failure." CONCLUSION Standardized reporting would encourage multi-institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk-adjusted benchmarks, and enhance education and communication.
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Affiliation(s)
- Leila J Mady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Seerat K Poonia
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Khalil Baddour
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vusala Snyder
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Ariel S Frost
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Cannady
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B Chinn
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Tanya Fancy
- Department of Otolaryngology-Head and Neck Surgery, West Virginia University, Morgantown, West Virginia, USA
| | - Neal Futran
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carol M Lewis
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Brett A Miles
- Department of Otolaryngology, Northwell Health, New York, New York, USA
| | - Urjeet Patel
- Department of Otolaryngology-Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois, USA
| | - Jeremy D Richmon
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mario G Solari
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shaum Sridharan
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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27
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Knitschke M, Sonnabend S, Bäcker C, Schmermund D, Böttger S, Howaldt HP, Attia S. Partial and Total Flap Failure after Fibula Free Flap in Head and Neck Reconstructive Surgery: Retrospective Analysis of 180 Flaps over 19 Years. Cancers (Basel) 2021; 13:cancers13040865. [PMID: 33670721 PMCID: PMC7922890 DOI: 10.3390/cancers13040865] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/10/2021] [Accepted: 02/16/2021] [Indexed: 11/16/2022] Open
Abstract
Fibula free flap (FFF) is widely used in head and neck reconstructive surgery and is considered as a standard and therapy of choice after ablative cancer surgery. The aim of this retrospective monocenter study was to determine the success rates of fibula free flaps for jaw reconstruction after ablative tumor surgery. The disease course of patients who underwent jaw reconstructive surgery with FFF from January 2002 to June 2020 was evaluated regarding the flap success rate. Flap failure was analyzed in detail and categorized into two groups: partial flap failure (PFF) and total flap failure (TFF). A total of 180 free fibular flaps were performed over the last 19 years and a total of 36 flap failures were recorded. TFF occurred in n = 20 (56.6%) and PFF in n = 16 cases (44.4%) cases. No statistically significant differences were found concerning patients' age at flap transfer, sex, BMI, ASA-Score, preoperative non-virtual or virtual surgical planning (non-VSP vs. VSP), and time of reconstruction (immediately vs. delayed). Duration of hospitalization shows statistically significant differences between both groups (p = 0.038), but no differences concerning operating time and duration on Intensive Care Unit (ICU). Partial flap failure appears to be underreported in literature. Sub- and complete failure of the skin paddle leads to clinical complaints like uncovered bone segments and plate exposure. Partial or complete FFF failure lead to infections on the recipient site and prolonged wound healing and therefore may cause a delay of the beginning of adjuvant radiation therapy (RT). PFF of hard tissue can be induced by RT.
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28
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Gazyakan E, Xiong L, Sun J, Kneser U, Hirche C. Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures. J Reconstr Microsurg 2021; 37:608-616. [PMID: 33592633 DOI: 10.1055/s-0041-1723823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. METHODS A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. RESULTS A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). CONCLUSION In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.
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Affiliation(s)
- Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaming Sun
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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29
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Schulz T, Leuschner S, Siemers F, Marotz J, Houschyar K, Corterier CC. Assessing flap perfusion after free tissue transfer using hyperspectral imaging (HSI). EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01784-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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30
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Phillips CJ, Barron MR, Kuckelman J, Derickson M, Sohn VY, Paige KT, Beshlian K. Mobile Smartphone Thermal Imaging Characterization and Identification of Microvascular Flow Insufficiencies in Deep Inferior Epigastric Artery Perforator Free Flaps. J Surg Res 2021; 261:394-399. [PMID: 33493892 DOI: 10.1016/j.jss.2020.12.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 10/24/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Mobile smartphone thermal imaging (MTI) devices correlate with blood flow, which makes them appealing adjuncts during reconstructive surgery. MTI was assessed in the setting of deep inferior epigastric artery perforator (DIEAP) free flaps. We hypothesized that MTI can be a surrogate for blood flow to identify microvascular flow insufficiencies. METHODS Nineteen patients underwent 30 DIEAP flaps for breast reconstruction. Images were obtained preoperatively, intraoperatively, and at instances of concern for flap viability. Three groups were evaluated: normal DIEAP flaps (NDFs), flaps with arterial insufficiency (AI), and flaps with venous congestion (VC). RESULTS All flaps were successful. There were significant temperature increases from max ischemia (24.5 ± 2.1°C) to 1 min after anastomosis (27.2 ± 1.6°C, P < 0.001). NDFs continued to warm until the final MTI was taken when leaving the operating room. There were no differences between MTI flap temperatures before transfer to the chest and after completion of microanastomosis. With questionable flap viability, VC and AI temperatures were found to be significantly colder than the NDF group (28.3 ± 1.9°C versus 32.2 ± 1.8°C, P = 0.003) in the VC group and (27.2 ± 0.7°C versus 32.2 ± 1.8°C, P = 0.001) in the AI group. After correction of the identified flow insufficiency, VC and AI rewarmed and temperatures were no different compared with NDF. CONCLUSIONS MTI recognizes microanastomotic failure and is a practical adjunct in the evaluation of free flap perfusion.
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Affiliation(s)
- Cody J Phillips
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington.
| | - Morgan R Barron
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | - John Kuckelman
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | | | - Vance Y Sohn
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington
| | - Keith T Paige
- Section of Plastic Surgery, The Polyclinic, Seattle, Washington; Swedish Cancer Institute, Swedish Medical Center, Seattle, Washington
| | - Kevin Beshlian
- Section of Plastic Surgery, The Polyclinic, Seattle, Washington
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31
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Han M, Ochoa E, Zhu B, Park AM, Heaton CM, Seth R, Knott PD. Risk Factors for and Cost Implications of Free Flap Take-backs: A Single Institution Review. Laryngoscope 2021; 131:E1821-E1829. [PMID: 33438765 DOI: 10.1002/lary.29382] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 01/03/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE/HYPOTHESIS For patients undergoing microvascular free tissue transfer (MFTT), we evaluated risk factors and financial implications of operating room (OR) take-back procedures. STUDY DESIGN Retrospective review at a tertiary care center. METHODS Patients who underwent MFTT for head and neck reconstruction from 2011 to 2018 were identified. We compared hospital length of stay and overall costs associated with OR take-back procedures. Multivariable regression analysis evaluated factors associated with OR take-backs during the same hospitalization. RESULTS A total of 727 free flaps were reviewed, and 70 OR take-backs (9.6%) were identified. Mean total length of stay (LOS) in the ICU was 3.4 days versus 6.7 days for non-take-back and take-back flaps, respectively (P < .001). Mean total LOS on the regular floor was 6.3 days versus 13.1 days, respectively (P < .001). This resulted in a cost differential of $33,507 (94.3% increase relative to non-take-back flaps). The total cost associated with an OR take-back was $39,786. Hematomas were the most common cause of take-backs and wound dehiscence was associated with the highest costs. On multivariable analysis, higher ASA class (OR, 2.06; 95% CI, 1.11-3.99; P = .026) and shorter ischemia times (OR, 0.52; 95% CI, 0.29-0.95; P = .030) were independently associated with increased risk of take-backs. CONCLUSIONS OR take-backs infrequently occur but are associated with a significant increase in financial burden when compared to free flap cases not requiring OR take-back. The large majority of the cost differential lies in a substantial increase of ICU and floor LOS for take-back flaps when compared to non-take-back flaps. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1821-E1829, 2021.
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Affiliation(s)
- Mary Han
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Edgar Ochoa
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Bovey Zhu
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Andrea M Park
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Chase M Heaton
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Rahul Seth
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - P Daniel Knott
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
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32
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Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review. J Reconstr Microsurg 2021; 37:300-308. [PMID: 33395711 DOI: 10.1055/s-0040-1722182] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. METHODS A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. RESULTS A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). CONCLUSION Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.
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Affiliation(s)
- Amanda Y Shen
- Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
| | - Sarah Lonie
- Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
| | - Kaiyang Lim
- Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia
| | - Hannah Farthing
- Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia
| | - David J Hunter-Smith
- Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia.,Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
| | - Warren M Rozen
- Department of Plastics and Reconstructive Surgery, Eastern Health, Victoria, Australia.,Department of Plastics and Reconstructive Surgery, Peninsula Health, Victoria, Australia.,Department of Surgery, Faculty of Medicine, Monash University, Clayton, Victoria, Australia
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33
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Vieira L, Isacson D, Dimovska EOF, Rodriguez-Lorenzo A. Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3329. [PMID: 33564573 PMCID: PMC7858199 DOI: 10.1097/gox.0000000000003329] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/28/2020] [Indexed: 12/29/2022]
Abstract
Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients. METHODS Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey. RESULTS Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest. CONCLUSION The authors reflect on the causes and propose preventative strategies in each peri-operative stage.
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Affiliation(s)
- Luís Vieira
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel Isacson
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Eleonora O. F. Dimovska
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andres Rodriguez-Lorenzo
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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34
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Modified Clavien-Dindo Classification and Outcome Prediction in Free Flap Reconstruction among Patients with Head and Neck Cancer. J Clin Med 2020; 9:jcm9113770. [PMID: 33266480 PMCID: PMC7700532 DOI: 10.3390/jcm9113770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/16/2020] [Accepted: 11/19/2020] [Indexed: 12/04/2022] Open
Abstract
Because of limitations caused by unique complications of free flap reconstruction, the Clavien–Dindo classification was modified to include grade “IIIc” for “partial or total free flap failure.” From 2013 to 2018, 116 patients who had undergone free flap reconstruction for head and neck cancer with grade III or higher postoperative complications were grouped using the “Modified” Clavien–Dindo classification. Alcoholism displayed significant predictive effects between grade IIIb and IIIc (72.7% vs. 50%, p = 0.028). Significant differences were observed between grade IIIb and IIIc in the duration of hospital stay (23.1 ± 10.1 vs. 28.6 ± 11.9 days, p = 0.015), duration of intensive care unit stay (6.0 ± 3.4 vs. 8.7 ± 4.3 days, p = 0.001), reoperation times during the current hospitalization (1.4 ± 0.8 vs. 2.0 ± 1.0 times, p < 0.001), and wound infection rate (29.9% vs. 62.5%, p = 0.002). The severity levels were significantly positively correlated with reoperation times during the current hospitalization (p < 0.001), ICU stay (p = 0.001), and hospital stay (p < 0.001). The modified Clavien–Dindo classification with grade IIIc describes the perioperative complications of head and neck free flap reconstruction to predict clinical outcomes based on severity.
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Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2020; 74:512-522. [PMID: 33039304 DOI: 10.1016/j.bjps.2020.08.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. METHODS Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. RESULTS A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001). CONCLUSION If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland.
| | - Raphael Biedermann
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
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Chu CK, Fang L, Kaplan J, Liu J, Hanasono MM, Yu P. The chicken or the egg? Relationship between venous congestion and hematoma in free flaps. J Plast Reconstr Aesthet Surg 2020; 73:1442-1447. [PMID: 32209324 DOI: 10.1016/j.bjps.2020.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 02/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative hematoma and venous congestion after free tissue transfer may occur independently or concurrently. We aimed to explore the association between these two events. METHODS All free flap reconstructions for head and neck (HN) and breast from a single institution between 2004 and 2014 were retrospectively reviewed for reoperation for venous congestion and/or hematoma. RESULTS There were 2985 free flap cases for HN reconstruction and 2345 cases for breast reconstruction. In HN, 100 patients developed a hematoma (3.4%) and 84 patients developed venous congestion (2.8%). The prevalence of hematoma was 17.8% and 2.9% in the presence and absence of congestion, respectively (p<0.001). Among the 15 patients who had both hematoma and venous congestion were separate events that occurred from 1 to 9 days apart in 8 patients. Hematoma caused the compression of the pedicle vein in 4 patients, while venous congestion possibly caused hematoma in 3 patients. In breast, 56 patients developed a hematoma (2.4%) and 64 patients developed venous congestion (2.7%). The prevalence of hematoma was 12.5% and 2.1% in the presence and absence of congestion, respectively (p<0.001). In the 8 patients who developed both, hematoma and congestion were separate events in 4 patients. Venous congestion caused hematoma in 3 patients, and hematoma caused venous congestion in 1 patient. CONCLUSIONS Although postoperative hematoma and venous congestion often present concurrently, most events are not causally associated. When related, however, venous congestion leading to hematoma is more common in breast reconstruction, while hematoma preceding venous congestion is more common in HN reconstruction.
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Affiliation(s)
- Carrie K Chu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
| | - Lin Fang
- The Plastic Surgery Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jordan Kaplan
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Matthew M Hanasono
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Peirong Yu
- Department of Plastic Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Remote Ischemic Preconditioning in Microsurgical Head and Neck Reconstruction: A Randomized Controlled Trial. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2591. [PMID: 32095401 PMCID: PMC7015612 DOI: 10.1097/gox.0000000000002591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/28/2019] [Indexed: 01/19/2023]
Abstract
Background: The free flap failure rate is 5% in head and neck microsurgical reconstruction, and ischemia–reperfusion injury is an important mechanism behind this failure rate. Remote ischemic preconditioning (RIPC) is a recent intervention targeting ischemia–reperfusion injury. The aim of the present study was to investigate if RIPC improved clinical outcomes in microsurgical reconstruction. Methods: Head and neck cancer patients undergoing tumor resection and microsurgical reconstruction were included in a randomized controlled trial. Patients were randomized (1:1) to RIPC or sham intervention administered intraoperatively just before transfer of the free flap. RIPC was administered by four 5-minute periods of upper extremity occlusion and reperfusion. Clinical data were prospectively collected in the perioperative period and at follow-up on postoperative days 30 and 90. Intention-to-treat analysis was performed. Results: Sixty patients were randomized to RIPC (n = 30) or sham intervention (n = 30). All patients received allocated intervention. No patients were lost to follow up. At 30-day follow-up, flap failure occurred in 7% of RIPC patients (n = 2) and 3% of sham patients (n = 1) with the relative risk and 95% confidence interval 2.0 [0.2;20.9], P = 1.0. The rate of pedicle thrombosis was 10% (n = 3) in both groups with relative risk 1.0 [0.2;4.6], P = 1.0. The flap failure rate did not change at 90-day follow-up. Conclusions: RIPC is safe and feasible but does not affect clinical outcomes in head and neck cancer patients undergoing microsurgical reconstruction.
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Dadras M, Wallner C, Wagner JM, Huber J, Harati K, Lehnhardt M, Behr B. Negative pressure-induced hyperemia, a new modality in the monitoring of skin paddle containing free flaps. J Plast Reconstr Aesthet Surg 2019; 72:1963-1970. [PMID: 31611076 DOI: 10.1016/j.bjps.2019.09.008] [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: 01/25/2019] [Revised: 07/08/2019] [Accepted: 09/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND In free tissue transfer, monitoring is paramount to timely detect vascular complications. Although various technical methods have been introduced, clinical flap monitoring and, particularly, capillary refill test (CRT) remain the gold standard. In pale flaps, CRT is challenging as it relies on the color difference between blanched and perfused skin. We proposed a new method of negative pressure-induced hyperemia (NPIH) using handheld electrical negative pressure devices to improve flap monitoring. METHODS Forty consecutive patients who received 42 free flaps in our institution were included in the study. Postoperatively, digital photographs were taken during CRT and NPIH, and the color difference (ΔE) was calculated based on the images. Additionally, three surgeons and three nurses evaluated the ease of assessment of capillary refill and NPIH on each flap using five grades. RESULTS NPIH yielded a significantly higher color difference than CRT with a mean ΔE of 10.3 ± 3.3 versus 6.8 ± 4.2. Although for CRT, ΔE of 14 flaps was <5 and of seven flaps <3, all flaps had a ΔE of >5 for NPIH. Subjectively, both surgeons and nurses found NPIH in all flaps to be easier to assess with a mean score of 1.1 ± 0.3 versus 1.8 ± 1.1 for CRT. However, some flaps were found to be challenging or not assessable by CRT. CONCLUSION NPIH represents a safe, easily applicable, and cheap addition to the established clinical and technical examination methods and may offer advantages over conventional CRT in detecting arterial complications in pale flaps.
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Affiliation(s)
- Mehran Dadras
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Christoph Wallner
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Johannes Maximilian Wagner
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Julika Huber
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Kamran Harati
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Marcus Lehnhardt
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany
| | - Björn Behr
- BG University Hospital Bergmannsheil, Department of Plastic Surgery, Bürkle de la Camp-Platz 1, 44789 Bochum, Germany.
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Ballestín A, Casado JG, Abellán E, Vela FJ, Álvarez V, Usón A, López E, Marinaro F, Blázquez R, Sánchez-Margallo FM. Ischemia-reperfusion injury in a rat microvascular skin free flap model: A histological, genetic, and blood flow study. PLoS One 2018; 13:e0209624. [PMID: 30589864 PMCID: PMC6307726 DOI: 10.1371/journal.pone.0209624] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/07/2018] [Indexed: 12/29/2022] Open
Abstract
Ischemia reperfusion injury is associated with tissue damage and inflammation, and is one of the main factors causing flap failure in reconstructive microsurgery. Although ischemia-reperfusion (I/R) injury is a well-studied aspect of flap survival, its biological mechanisms remain to be elucidated. To better understand the biological processes of ischemia reperfusion injury, and to develop further therapeutic strategies, the main objective of this study was to identify the gene expression pattern and histological changes in an I/R injury animal model. Fourteen rats (n = 7/group) were randomly divided into control or ischemia-reperfusion group (8 hours of ischemia). Microsurgical anastomoses were objectively assessed using transit-time-ultrasound technology. Seven days after surgery, flap survival was evaluated and tissue samples were harvested for anatomopathological and gene-expression analyses.The I/R injury reduced the survival of free flaps and histological analyses revealed a subcutaneous edema together with an inflammatory infiltrate. Interestingly, the Arginase 1 expression level as well as the ratio of Arginase 1/Nitric oxide synthase 2 showed a significant increase in the I/R group. In summary, here we describe a well-characterized I/R animal model that may serve to evaluate therapeutic agents under reproducible and controlled conditions. Moreover, this model could be especially useful for the evaluation of arginase inhibitors and different compounds of potential interest in reconstructive microsurgery.
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Affiliation(s)
- Alberto Ballestín
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
- * E-mail:
| | - Javier G. Casado
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Elena Abellán
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - F. Javier Vela
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Verónica Álvarez
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Alejandra Usón
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Esther López
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Federica Marinaro
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Rebeca Blázquez
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
| | - Francisco Miguel Sánchez-Margallo
- Department of Microsurgery, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
- Stem Cell Therapy Unit, Jesús Usón Minimally Invasive Surgery Centre, Cáceres, Spain
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Verhelst PJ, Dons F, Van Bever PJ, Schoenaers J, Nanhekhan L, Politis C. Fibula Free Flap in Head and Neck Reconstruction: Identifying Risk Factors for Flap Failure and Analysis of Postoperative Complications in a Low Volume Setting. Craniomaxillofac Trauma Reconstr 2018; 12:183-192. [PMID: 31428242 DOI: 10.1055/s-0038-1651515] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/05/2018] [Indexed: 10/14/2022] Open
Abstract
The fibula free flap (FFF) has been a workhorse in maxillofacial reconstruction. High success rates of this technique are reported. However, identifying risk factors for flap failure and analyzing complications can open the way to better patient care. A retrospective analysis was conducted of all FFFs performed over a 20-year period at a low-volume single tertiary center to identify risk factors and postoperative complications. A total of 129 FFFs were included (122 mandible, 7 maxilla). Complete flap failure occurred in 12.4% and partial flap failure in 7.8% of patients. A significant relation was found between younger age and flap failure, and most failures were associated with venous thrombosis. In-hospital surgical complications occurred in 60.5%, in-hospital medical complications in 49.6%, and out-of-hospital complications in 77.5% of patients. The in-hospital reintervention rate was 27.1%, and including salvaged flaps, flap survival rate was 87.6%. Osteomyocutaneous FFF failure (complete 12.4%; partial 7.8%) is an important clinical reality in a low-volume head and neck reconstruction center resulting in an in-hospital reintervention rate of 27.1%. Postoperative complications are frequent, both surgical and out-hospital complications. These results provide a better understanding of the limitations of the FFF in a low-volume center and can be used to optimize care in this kind of setting.
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Affiliation(s)
- Pieter-Jan Verhelst
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Flore Dons
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Pieter-Jan Van Bever
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Joseph Schoenaers
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lloyd Nanhekhan
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Xu YM, Liu J, Qiu XW, Liu C, Wu HJ, Gong ZJ. Characteristics and Management of Free Flap Compromise Following Internal Jugular Venous Thrombosis. J Oral Maxillofac Surg 2018; 76:2437-2442. [PMID: 29859951 DOI: 10.1016/j.joms.2018.05.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Free flap compromise after internal jugular venous thrombosis (IJVT) occurs fairly infrequently in oral and maxillofacial rehabilitation and reconstruction but could seriously affect the patient's postoperative recovery. The aim of this study was to analyze and discuss the characteristics and management of such flap compromise. PATIENTS AND METHODS The authors performed a retrospective case series of 13 patients who underwent reconstruction of oral and maxillofacial defects with anterolateral thigh flaps and developed flap compromise from IJVT from July 2014 through December 2016 at the Second Xiangya Hospital of Central South University (Changsha, China). The clinical features of flap compromise are described, and the precautions and improvement measures are reported. RESULTS All 13 patients were men with an average age of 50.3 years. Flap compromise caused by IJVT occurred on postoperative days 3 to 7, of which 2 flaps were salvaged (15.4%) and 11 flaps failed completely after immediate urgent re-exploration. Four patients presented with orocutaneous fistula after salvage surgery that healed well after a period of wound dressing. CONCLUSIONS Because of the late occurrence and low salvage rate of flap compromise caused by IJVT, intensive flap monitoring after reconstruction surgery is necessary for patients with free flap transfer.
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Affiliation(s)
- Yu-Ming Xu
- Resident, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jiang Liu
- Resident, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiao-Wen Qiu
- Visiting Physician, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Chang Liu
- Resident, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Han-Jiang Wu
- Professor, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Zhao-Jian Gong
- Associate Professor, Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Video Tutorial for Clinical Flap-Monitoring in Plastic Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1478. [PMID: 29184725 PMCID: PMC5682161 DOI: 10.1097/gox.0000000000001478] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 07/12/2017] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text.
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