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Yen YH, Luo SD, Chen WC, Li CY, Chiu TJ, Wang YM, Wu SC, Yang YH, Chen YH, Wu CN. The Value of the Nutritional Indicators in Predicting Free Flap Failure From a Multicentre Database. Otolaryngol Head Neck Surg 2024; 171:63-72. [PMID: 38501382 DOI: 10.1002/ohn.706] [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: 11/16/2023] [Revised: 01/26/2024] [Accepted: 02/05/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE Nutritional and inflammatory statuses have been associated with complications in microvascular-free flaps during head and neck surgeries. This study aimed to evaluate the potential of nutritional indicators in predicting postoperative free flap complications. STUDY DESIGN We conducted a 20-year retrospective, case-control study within a defined cohort. SETTING The study involved head and neck cancer patients from the Chang Gung Research Database who underwent simultaneous tumor ablation and free flap wound reconstruction between January 1, 2001, and December 31, 2019. METHODS We employed logistic regression and stratified analysis to assess the risk of free flap complications and the subsequent need for flap revision or redo in relation to nutritional indicators and other clinical variables. RESULTS Of the 8066 patients analyzed, 687 (8.5%) experienced free flap complications. Among these, 197 (2.4%) had free flap failures necessitating a redo of either a free flap or a pedicled flap. Beyond comorbidities such as chronic obstructive pulmonary disease, end-stage renal disease, and a history of prior radiotherapy, every 10-unit decrease in the preoperative prognostic nutritional index (PNI) was consistently associated with an increased risk of both free flap complications and failure. The covariate-adjusted odds ratios were 1.90 (95% confidence interval [CI]: 1.42-2.54) and 1.89 (95% CI: 1.13-3.17), respectively. CONCLUSION A lower preoperative PNI suggests a higher likelihood of microvascular free flap complications in head and neck surgeries. Further randomized controlled trial designs are required to establish causality.
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Affiliation(s)
- Yuan-Hao Yen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wei-Chih Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
- Department of Health care Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Tai-Jan Chiu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yung-Hsuan Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Nung Wu
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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2
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Diaddigo SE, Lavalley MN, Truong AY, Otterburn DM. Catastrophic complications following microvascular free tissue transfer: A 10-year review of NSQIP data. J Plast Reconstr Aesthet Surg 2024; 93:42-50. [PMID: 38640554 DOI: 10.1016/j.bjps.2024.02.058] [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: 10/03/2023] [Revised: 02/01/2024] [Accepted: 02/22/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION There is an absence of literature regarding the risks of catastrophic medical outcomes (CMOs) such as stroke, cardiac arrest, and pulmonary embolism in microvascular free tissue transfer. This study aims to determine the CMO and mortality rates, as well as risk factors, associated with microvascular reconstruction of the head and neck, extremity, and breast. METHODS This study uses data from the American College of Surgeons National Surgical Quality Improvement Program. Cases of microvascular free tissue transfer from 2012 to 2021 were analyzed to assess the 30-day rates of CMOs, including death, as well as associated risk factors. RESULTS Of the 22,839 included patients, 785 (3.44%) experienced 1043 CMOs, including 99 (0.43%) deaths. Pulmonary complications of prolonged respiratory failure and pulmonary embolism were the most common. Independent risk factors included age, male sex, underweight status, longer operation times, American Society of Anesthesiologists (ASA) class of III or above, wound classification other than clean, and underlying conditions such as diabetes, hypertension, chronic obstructive pulmonary disorder, dyspnea, metastatic cancer, and ventilator dependence. CMOs were associated with an average 10-day delay in hospital discharge. Multivariate regression analysis revealed that head and neck reconstructions were associated with increased risk of CMO (OR 4.96; p < 0.0001). CONCLUSION This is the largest study to examine CMOs following microvascular free tissue transfer. Compared to previous literature spanning the period between 2006 and 2011, we observed a decreased rate of CMOs but a slight increase in 30-day mortality. Our data provide updated and comprehensive criteria for risk stratification and patient counseling. The modifiable risk factors reported in our study should be considered in elective, non-urgent cases of microvascular reconstruction.
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Affiliation(s)
- Sarah E Diaddigo
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Myles N Lavalley
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - Albert Y Truong
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA
| | - David M Otterburn
- NewYork-Presbyterian Hospital, Columbia University/Weill Cornell Medicine, New York, NY, USA.
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3
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Ho CH, Luo SD, Chen WC, Chiu TJ, Wang YM, Wu SC, Yang YH, Li SH, Kuo SCH, Wu CN. The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08727-5. [PMID: 38758243 DOI: 10.1007/s00405-024-08727-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients. METHODS A 20-year retrospective case-control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis. RESULTS Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12-5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders. CONCLUSIONS Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Chun-Hsien Ho
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung, 83301, Taiwan
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung, 83301, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Wei-Chih Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung, 83301, Taiwan
| | - Tai-Jan Chiu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yao-Hsu Yang
- School of Traditional Chinese Medicine, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- Health Information and Epidemiology Laboratory, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Shau-Hsuan Li
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Spencer Chia-Hao Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Nung Wu
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, No. 123, Dapi Rd., Niaosong District, Kaohsiung, 83301, Taiwan.
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Ooms M, Winnand P, Heitzer M, Katz MS, Peters F, Bickenbach J, Hölzle F, Modabber A. Does the Anastomosis Recipient Vessel Have an Influence on Free Flap Perfusion in Microvascular Head and Neck Reconstruction-A Retrospective Analysis of 338 Cases with Comparison of Flap Perfusion between Different Arterial and Venous Recipient Vessels in Radial Free Forearm Flaps, Anterolateral Thigh Flaps, and Fibula Free Flaps. J Clin Med 2024; 13:2763. [PMID: 38792305 PMCID: PMC11122445 DOI: 10.3390/jcm13102763] [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: 04/07/2024] [Revised: 04/29/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Flap perfusion is a prerequisite for microvascular free flap survival and a parameter routinely used for flap monitoring. The aim of this study was to investigate the influence of the anastomosis recipient vessel on flap perfusion. Methods: Flap perfusion was retrospectively analyzed in 338 patients who underwent head and neck reconstruction with microvascular free flaps between 2011 and 2020. The Oxygen-to-see tissue oxygen analysis system measurements for intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 8 and 2 mm tissue depths were compared between arterial anastomosis recipient vessels (external carotid artery [ECA], facial artery [FAA], lingual artery [LIA], and superior thyroid artery [STA]) and venous anastomosis recipient vessels (internal jugular vein [IJV], combination of IJV and IJV branches, IJV branches, and external jugular vein). Results: The postoperative hemoglobin concentration at 2 mm tissue depth differed significantly between arterial anastomosis recipient vessels (ECA, 41.0 arbitrary units [AU]; FAA, 59.0 AU; LIA, 51.5 AU; STA, 59.0 AU; p = 0.029). This difference did not persist in the multivariable testing (p = 0.342). No other differences in flap blood flow, hemoglobin concentration, or hemoglobin oxygen saturation were observed between the arterial and venous anastomosis recipient vessels (p > 0.05 for all). Conclusions: The arterial and venous recipient vessels used for anastomosis did not influence microvascular free flap perfusion. This underlines the capability of the studied recipient vessels to adequately perfuse free flaps, may explain the observed indifferent flap survival rates between commonly used anastomosis recipient vessels, and implies that the recipient vessel is not a confounding variable for flap monitoring with the Oxygen-to-see tissue oxygen analysis system. Further prospective studies are needed to confirm the findings.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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Philips R, Best KA, Agarwal A, Sagheer H, Selman Y, Sweeney L, Wax M, Krein H, Heffelfinger R, Luginbuhl A, Curry J. A Survey of Microvascular Technique Preferences Among American Head Neck Society Members. Laryngoscope 2024; 134:1265-1277. [PMID: 37610286 DOI: 10.1002/lary.30995] [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: 01/27/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To identify practices in microvascular techniques in routine and challenging scenarios. STUDY DESIGN Cross-sectional study. METHODS A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021. RESULTS The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029). CONCLUSIONS This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length. LEVEL OF EVIDENCE 5 Laryngoscope, 134:1265-1277, 2024.
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Affiliation(s)
- Ramez Philips
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Keisha A Best
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Aarti Agarwal
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Hamad Sagheer
- Department of Anesthesiology, University of Florida, Gainesville, Florida, U.S.A
| | - Yamil Selman
- Head and Neck Surgical Oncology, Memorial Healthcare System, Hollywood, Florida, U.S.A
| | - Larissa Sweeney
- Department of Otolaryngology-Head and Neck Surgery, University of Miami, Miami, Florida, U.S.A
| | - Mark Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
| | - Howard Krein
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Adam Luginbuhl
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
| | - Joseph Curry
- Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, U.S.A
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6
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Wei D, Zhu H, He J, Bao T, Bi L. Introduction and preliminary application report for a novel 3D printed perforator navigator for fibular flap surgery. J Craniomaxillofac Surg 2024; 52:23-29. [PMID: 38129182 DOI: 10.1016/j.jcms.2023.11.004] [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: 07/25/2023] [Revised: 10/02/2023] [Accepted: 11/23/2023] [Indexed: 12/23/2023] Open
Abstract
The aim of this study was to introduce and report on a 3D-printed perforator navigator and its clinical application. Integrated imaging and 3D printing techniques were employed for the design and manufacture of a perforator navigator. Key techniques included establishing a digital image coordinate system, localizing perforator fascia piercing points, creating a reference plane for the perforator course, and projecting the perforator course onto the body surface. All cases of maxillofacial defect repaired with free fibular myocutaneous flaps, from January 2019 to January 2022, were reinvestigated. Patients treated using traditional perforator localization methods were assigned into group Ⅰ, while those who had a navigator used during treatment were allocated to group Ⅱ. Outcome measurements included perforator positioning accuracy, perforator preparation time (PT), and flap growth score. Capillary refilling time and degree of flap swelling were recorded on the 1st, 3rd, and 7th days after surgery. On the 10th day after surgery, the flap survival situation was graded. In total, 25 patients were included in the study. Perforator preparation time for group Ⅱ was significantly less (p = 0.04) than for group Ⅰ (1038.6 ± 195.4 s versus 1271.4 ± 295.1 s. In group Ⅱ, the mean positioning deviation for the perforator navigator was 2.12 cm less than that for the high-frequency color Doppler (p = 0.001). Group Ⅱ also had a higher score than group Ⅰ for overall flap growth evaluation (nonparametric rank sum test, p = 0.04). Within the scale of the study, it seems that perforator localization and navigation using a 3D-printed navigator is technically feasible, and helps to improve the clinical outcome of free fibular flaps. The perforator navigator will play a useful role in displaying the perforator course, improving the accuracy of perforator localization, reducing surgical injury, and ultimately enhancing flap success rate.
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Affiliation(s)
- Dong Wei
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, PR China
| | - Huiyong Zhu
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, PR China
| | - Jianfeng He
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, PR China
| | - Tingwei Bao
- Department of Oral and Maxillofacial Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, PR China
| | - Ling Bi
- Department of Stomatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Zhejiang Province, PR China.
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7
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Domack A, Sandelski MM, Ali S, Blackwell KE, Buchakjian M, Bur AM, Cannady SB, Castellanos CX, Ducic Y, Ghanem TA, Huang AT, Jackson RS, Kokot N, Li S, Pipkorn P, Puram SV, Rezaee R, Rajasekaran K, Shnayder Y, Sinha UK, Sukato D, Suresh N, Tamaki A, Thomas CM, Thorpe EJ, Wax MK, Yang S, Ziegler A, Pittman AL. Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19. Laryngoscope 2023. [PMID: 37937733 DOI: 10.1002/lary.31159] [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: 05/08/2023] [Revised: 08/03/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. METHODS This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. RESULTS Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. CONCLUSION Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. LEVEL OF EVIDENCE 4 Laryngoscope, 2023.
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Affiliation(s)
- Aaron Domack
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Morgan M Sandelski
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Syed Ali
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Keith E Blackwell
- Department of Otolaryngology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Marisa Buchakjian
- Department of Otolaryngology, University of Iowa Health Care, Iowa City, Iowa, USA
| | - Andrés M Bur
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Steven B Cannady
- Department of Otolaryngology, University of Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Carlos X Castellanos
- Caruso Department of Otolaryngology, University of Southern California, Los Angeles, California, USA
| | - Yadranko Ducic
- Dallas/Fort Worth, Head & Neck Cancer Center of Texas, Texas, USA
| | - Tamer A Ghanem
- Department of Otolaryngology, Henry Ford Health, Detroit, Michigan, USA
| | - Andrew T Huang
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Ryan S Jackson
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Niels Kokot
- Caruso Department of Otolaryngology, University of Southern California, Los Angeles, California, USA
| | - Shawn Li
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Patrik Pipkorn
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sidharth V Puram
- Department of Otolaryngology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rod Rezaee
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Karthik Rajasekaran
- Department of Otolaryngology, University of Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Yelizaveta Shnayder
- Department of Otolaryngology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Uttam K Sinha
- Caruso Department of Otolaryngology, University of Southern California, Los Angeles, California, USA
| | - Daniel Sukato
- Department of Otolaryngology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Neeraj Suresh
- Department of Otolaryngology, University of Pennsylvania Medicine, Philadelphia, Pennsylvania, USA
| | - Akina Tamaki
- Department of Otolaryngology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Carissa M Thomas
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eric J Thorpe
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mark K Wax
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sara Yang
- Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Ziegler
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
| | - Amy L Pittman
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
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8
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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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Ooms M, Winnand P, Heitzer M, Peters F, Bock A, Katz MS, Hölzle F, Modabber A. Attached compared with unattached surface probes for monitoring flap perfusion in microvascular head and neck reconstruction: a feasibility study. Sci Rep 2023; 13:15939. [PMID: 37743387 PMCID: PMC10518317 DOI: 10.1038/s41598-023-43151-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023] Open
Abstract
Unattached surface probes are commonly used with the O2C analysis system (LEA Medizintechnik, Germany) to monitor microvascular free flap perfusion. This study compared attached and unattached surface probes for extraoral free flaps. The study included 34 patients who underwent extraoral microvascular head and neck reconstruction between 2020 and 2022. Flap perfusion was monitored postoperatively using the O2C analysis system at 0, 12, 24, 36, and 48 h, with an attached surface probe at 3 mm tissue depth and an unattached surface probe at 2 mm and 8 mm tissue depths. Clinical complications, technical errors, and perfusion measurement values were compared. No clinical complications (attachment suture infections) or technical errors (probe detachment) occurred. Flap blood flow values of the probes were partially different (3 mm vs. 2 and 8 mm: p < 0.001; p = 0.308) and moderately correlated (3 mm with 2 and 8 mm: r = 0.670, p < 0.001; r = 0.638, p < 0.001). Hemoglobin concentration and oxygen saturation values were generally different (3 mm vs. 2 and 8 mm: all p < 0.001) and variably correlated (3 mm with 2 and 8 mm: r = 0.756, r = 0.645; r = 0.633, r = 0.307; all p < 0.001). Both probes are comparable in terms of technical feasibility and patient safety, with flap perfusion values dependent on tissue measurement depth.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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10
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Ooms M, Winnand P, Heitzer M, Peters F, Bock A, Katz M, Hölzle F, Modabber A. Flap perfusion monitoring with an attached surface probe in microvascular reconstruction of the oral cavity. Clin Oral Investig 2023; 27:5577-5585. [PMID: 37522990 PMCID: PMC10492739 DOI: 10.1007/s00784-023-05177-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/17/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Postoperative flap monitoring is essential in oral microvascular reconstruction for timely detection of vascular compromise. This study investigated the use of attached surface probes for the oxygen-2-see (O2C) analysis system (LEA Medizintechnik, Germany) for intraoral flap perfusion monitoring. MATERIALS AND METHODS The study included 30 patients who underwent oral reconstruction with a microvascular radial-free forearm flap (RFFF) or anterolateral thigh flap (ALTF) between 2020 and 2022. Flap perfusion was measured with attached (3-mm measurement depth) and unattached surface probes (2- and 8-mm measurement depths) for the O2C analysis system at 0, 12, 24, 36, and 48 h postoperatively. Flap perfusion monitoring with attached surface probes was evaluated for cut-off values for flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation indicative of vascular compromise and for accuracy and concordance with unattached surface probes. RESULTS Three RFFFs were successfully revised, and one ALTF was unsuccessfully revised. The cut-off values indicative of vascular compromise for flap perfusion monitoring with attached surface probes were for RFFF and ALTF: blood flow < 60 arbitrary units (AU) and < 40AU, hemoglobin concentration > 100AU and > 80AU (both > 10% increase), and hemoglobin oxygen saturation < 40% and < 30%. Flap perfusion monitoring with attached surface probes yielded a 97.1% accuracy and a Cohen's kappa of 0.653 (p < 0.001). CONCLUSIONS Flap perfusion monitoring with attached surface probes for the O2C analysis system detected vascular compromise accurately and concordantly with unattached surface probes. CLINICAL RELEVANCE Attached surface probes for the O2C analysis system are a feasible option for intraoral flap perfusion monitoring.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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11
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Lim BJ, Shin JY, Roh SG, Lee NH, Chung YK. Clinical analysis of factors affecting the failure of free flaps used in head and neck reconstruction. Arch Craniofac Surg 2023; 24:159-166. [PMID: 37654235 PMCID: PMC10475704 DOI: 10.7181/acfs.2023.00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/25/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Free tissue transfer is the preferred method of reconstructing head and neck defects, with a success rate of approximately 95%. Although flap failure is uncommon, it has a major impact on patient morbidity and diminishes quality of life, making it is important to investigate the causes of flap failure. METHODS This retrospective chart review analyzed patients who underwent free tissue transfer during head and neck reconstruction at a single institution between 2016 and 2021. RESULTS During the study period, 58 patients underwent 60 free flap procedures. Revision surgery was needed in 14 patients. Subsequent free flap surgery was performed in one patient, and three free flaps (5%) could not be salvaged. Cardiovascular disease was significantly associated with flap failure, and venous congestion (thrombosis) was the most common reason for revision surgery. CONCLUSION Cardiovascular disease clearly emerged as a factor related to the failure of free flap surgery, and this issue warrants particular attention in patients for whom free tissue transfer is planned.
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Affiliation(s)
- Beom Jin Lim
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Jin Yong Shin
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Si-Gyun Roh
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Nae-Ho Lee
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
| | - Yoon Kyu Chung
- Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea
- Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
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12
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Uehara M, Habu M, Sasaguri M, Tominaga K. Post-reconstruction Free Flap Complications After Oral Cancer Ablation. J Maxillofac Oral Surg 2023; 22:20-27. [PMID: 37041939 PMCID: PMC10082861 DOI: 10.1007/s12663-023-01854-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/14/2023] [Indexed: 01/27/2023] Open
Abstract
Introduction Microvascular free flap transfer is considered a standard reconstruction after the ablation of oral cancer. Although the success rate is high, flap complications occasionally occur. This study investigated the reasons for and local factors involved in complications of free flap transfer and explored how to salvage the flaps. Patients and Methods The cases of 53 patients who underwent a free flap transfer [radial forearm flaps (n = 36), abdominis musculocutaneous flaps (n = 6), scapular osteocutaneous flaps (n = 10), and fibular osteocutaneous flap (n = 1)] were analyzed: flap complications were observed in five of the cases. Results In the all five cases, a salvage operation was performed under general anesthesia. The flap complications occurred within 33 h after anastomosis. In the salvage operation, thrombotic occlusion in veins of flap feeders was observed in three of the five cases. The possible reasons for flap complications were a twisting of the anastomosed vein where two veins were united, pressure to the feeder due to subcutaneous hematoma, and edema of adjacent tissue and/or drain tube; the reason was not clear in one case. The flaps were successfully salvaged in four cases by thrombectomy in veins, release of pressure at the veins, and/or interposition of the vein graft. Conclusion Surgeons should pay close attention to the pressure and/or twisting in the feeder as well as the hemostasis in the surgical field, and a salvage operation should be carried out immediately when a flap complication is identified.
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Affiliation(s)
- Masataka Uehara
- Unit of Oral and Maxillofacial Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho, Shimonoseki City, Yamaguchi 750-8520 Japan
| | - Manabu Habu
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Masaaki Sasaguri
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Kazuhiro Tominaga
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
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13
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Pabst A, Zeller AN, Raguse JD, Hoffmann J, Goetze E. Microvascular reconstructions in oral and maxillofacial surgery - Results of a survey among oral and maxillofacial surgeons in Germany, Austria, and Switzerland. J Craniomaxillofac Surg 2023; 51:71-78. [PMID: 36858829 DOI: 10.1016/j.jcms.2023.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 01/29/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
This study aimed to evaluate the use of microvascular free flaps (MFF) in oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland. A dynamic online questionnaire, using 42-46 questions, was sent to OMF surgeons based in hospitals in Germany, Austria, and Switzerland. The questionnaire was evaluated internally and externally. Aside from general information, data were collected on organizational aspects, approaches, MFF types and frequency, presurgical planning, intraoperative procedures, perioperative medications, flap monitoring, and patient management. Participants mostly performed 30-40 MFF each year (11/53). Most stated that the COVID-19 pandemic did influence MFF frequency (25/53) to varying extents. Radial forearm flap was most frequently used (37/53), followed by ALT (5/53), and fibula flap (5/53). Primary reconstruction was performed by most participants (35/48). Irradiated bony transplants were mostly used for implant placement after 12 months (23/48). Most participants (38/48) used reconstruction plates, followed by miniplates (36/48), PSI reconstruction (31/48), and PSI miniplates (10/48). Regarding the postoperative use of anticoagulants, low-molecular-weight (37/48) and unfractioned heparins (15/48) were widely used, most often for 3-7 days (26/48). Clinical evaluation was mostly preferred for flap monitoring (47/48), usually every 2 h (34/48), for at least 48 h (19/48). Strong heterogeneity in MFF reconstructions in OMFS was found, especially regarding the timepoints of reconstruction, types of osteosynthesis, and postoperative MFF management. These findings provide the chance to further compare the different treatment algorithms regarding relevant MFF aspects, such as postoperative management. This could create evidence-based treatment algorithms that will further improve the clinical outcomes in MFF reconstructions.
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Affiliation(s)
- Andreas Pabst
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstr. 170, 56072, Koblenz, Germany.
| | - Alexander-N Zeller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jan Dirk Raguse
- Department of Oral and Maxillofacial Surgery, Specialist Clinic Hornheide, Dorbaumstr. 300, 48157, Münster, Germany
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Elisabeth Goetze
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstr. 11, 91054, Erlangen, Germany
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14
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Tu CH, Hong SF. Preoperative anemia: Predictor of free flap reconstruction complications in head and neck cancer. CHINESE J PHYSIOL 2023; 66:21-27. [PMID: 36814153 DOI: 10.4103/cjop.cjop-d-22-00115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Free flap reconstruction has been the mainstay among reconstruction surgeries for head and neck cancer. Intraoperative and postoperative hemoglobin (Hb) levels were both possible risk factors of flap failure and had been discussed widely. However, few investigations of preoperative Hb were seen in the previous study with its effect to flap condition remain uncertain and no conclusions in the literature. Patients who underwent free flap reconstruction after head and neck surgery in our institution between May 2014 and May 2019 were enrolled. The postoperative flap condition was observed carefully, and re-exploration was performed if necessary. We then retrospectively collected patient data with several intraoperative and postoperative indices. A total of 598 patients were enrolled in our study. The total major flap complication rate was 10.6%, with an overall success rate of 89.4%. They were predominantly male (95%), and most of them underwent free flap reconstruction for the first time (91%). A total of 81 (13%) patients received radiotherapy before reconstruction. Among all factors, the preoperative Hb level and free flap type showed significance in univariate and multivariate analyses. A previous history of radiotherapy, body mass index, nutrition status, or poorly controlled diabetes mellitus showed no significant results in either univariate or multivariate analysis. Our study showed that a lower preoperative Hb level affects free flap survival. Meanwhile, preoperative radiotherapy history has no significant influence in either univariate or multivariate analysis.
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Affiliation(s)
- Cheng Hung Tu
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - San Fu Hong
- Department of ENT Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan
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15
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Bollig CA, Walia A, Pipkorn P, Jackson R, Puram SV, Rich JT, Paniello RC, Zevallos JP, Stevens MN, Wood CB, Rohde SL, Sykes KJ, Kakarala K, Bur A, Wieser ME, Galloway TLI, Tassone P, Llerena P, Bollig KJ, Mattingly TR, Pluchino T, Jorgensen JB. Perioperative Outcomes in Patients Who Underwent Fibula, Osteocutaneous Radial Forearm, and Scapula Free Flaps: A Multicenter Study. JAMA Otolaryngol Head Neck Surg 2022; 148:965-972. [PMID: 36074455 PMCID: PMC9459906 DOI: 10.1001/jamaoto.2022.2440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/30/2022] [Indexed: 11/14/2022]
Abstract
Importance Studies comparing perioperative outcomes of fibula free flaps (FFFs), osteocutaneous radial forearm free flaps (OCRFFFs), and scapula free flaps (SFFs) have been limited by insufficient sample size. Objective To compare the perioperative outcomes of patients who underwent FFFs, OCRFFFs, and SFFs. Design, Setting, and Participants This cohort study assessed the outcomes of 1022 patients who underwent FFFs, OCRFFFs, or SFFs for head and neck reconstruction performed at 1 of 6 academic medical centers between January 2005 and December 2019. Data were analyzed from September 17, 2021, to June 9, 2022. Main Outcomes and Measures Patients were stratified based on the flap performed. Evaluated perioperative outcomes included complications (overall acute wound complications, acute surgical site infection [SSI], fistula, hematoma, and flap failure), 30-day readmissions, operative time, and prolonged hospital length of stay (75th percentile, >13 days). Patients were excluded if data on flap type or clinical demographic characteristics were missing. Associations between flap type and perioperative outcomes were analyzed using logistic regression, after controlling for other clinically relevant variables. Adjusted odds ratios (aORs) with 95% CIs were generated. Results Perioperative outcomes of 1022 patients (mean [SD] age, 60.7 [14.5] years; 676 [66.1%] men) who underwent major osseous head and neck reconstruction were analyzed; 510 FFFs (49.9%), 376 OCRFFFs (36.8%), and 136 SFFs (13.3%) were performed. Median (IQR) operative time differed among flap types (OCRFFF, 527 [467-591] minutes; FFF, 592 [507-714] minutes; SFF, 691 [610-816] minutes). When controlling for SSI, FFFs (aOR, 2.47; 95% CI, 1.36-4.51) and SFFs (aOR, 2.95; 95% CI, 1.37-6.34) were associated with a higher risk of flap loss than OCRFFFs. Compared with OCRFFFs, FFFs (aOR, 1.77; 95% CI, 1.07-2.91) were associated with a greater risk of fistula after controlling for the number of bone segments and SSI. Both FFFs (aOR, 1.77; 95% CI, 1.27-2.46) and SFFs (aOR, 1.68; 95% CI, 1.05-2.69) were associated with an increased risk of 30-day readmission compared with OCRFFFs after controlling for Charlson-Deyo comorbidity score and acute wound complications. Compared with OCRFFFs, FFFs (aOR, 1.78; 95% CI, 1.25-2.54) and SFFs (aOR, 1.96; 95% CI, 1.22-3.13) were associated with a higher risk of prolonged hospital length of stay after controlling for age and flap loss. Conclusions and Relevance Findings of this cohort study suggest that perioperative outcomes associated with OCRFFFs compare favorably with those of FFFs and SFFs, with shorter operative times and lower rates of flap loss, 30-day readmissions, and prolonged hospital length of stay. However, patients undergoing SFFs represented a more medically and surgically complex population than those undergoing OCRFFFs or FFFs.
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Affiliation(s)
- Craig Allen Bollig
- Department of Otolaryngology–Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Amit Walia
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Patrik Pipkorn
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ryan Jackson
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Sidharth V. Puram
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Jason T. Rich
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Randy C. Paniello
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Jose P. Zevallos
- Department of Otolaryngology–Head and Neck Surgery, Washington University in St Louis, St Louis, Missouri
| | - Madelyn N. Stevens
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. Burton Wood
- Department of Otolaryngology–Head and Neck Surgery, University of Tennessee Health Science Center, Memphis
| | - Sarah L. Rohde
- Department of Otolaryngology–Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin J. Sykes
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Kiran Kakarala
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Andres Bur
- Department of Otolaryngology, Head and Neck Surgery, University of Kansas Medical Center, Kansas City
| | - Margaret E. Wieser
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Tabitha L. I. Galloway
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Patrick Tassone
- Department of Otolaryngology–Head and Neck Surgery, University of Missouri School of Medicine, Columbia
| | - Pablo Llerena
- Department of Otolaryngology–Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kassie J. Bollig
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
| | - Tyler R. Mattingly
- Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, University of Louisville, Louisville, Kentucky
| | - Tyler Pluchino
- Department of Otolaryngology Head and Neck Surgery and Communicative Disorders, University of Louisville, Louisville, Kentucky
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16
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Rothweiler R, Gerlach V, Voss P, Poxleitner P, Ermer M, Gross C, Schwer C, Vach K, Kalbhenn J, Metzger M. Aspirin, heparin and ischemia time in microvascular free flap surgery - their influence and an optimal anticoagulation protocol. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 123:e556-e562. [PMID: 35272089 DOI: 10.1016/j.jormas.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Microvascular surgery has become a standardized technique for reconstruction of large tissue defects in Head and Neck Reconstructive Surgery. However, the main dreaded complications are thrombosis of blood vessels or major bleeding after surgery. Several different anticoagulation protocols have been established in the last decades to overcome these problems with varying degrees of success. METHODS Over a period of six years, a standardized anticoagulation protocol including acetylsalicylic acid (ASA) and unfractionated heparin (UFH) for direct intraoperative and postoperative administration was established, optimized and compared to a previously used non-standardized protocol. A total of 178 flap surgeries were included in the development and optimization process of the protocol. RESULTS ASA significantly increased the risk of complications when used for longer than 72 h (OR = 2.52; p = 0.002; 95% CI 1.39-4.59). Administration of UFH reduced flap loss (bolus: OR 0.68; p = 0.47; 95% CI 0.24-1.93; continuous UFH administration: OR = 0.61; p = 0.33; 95% CI 0.22-1.66), however doses greater than 500 IU/ h of UFH as continuous infusion increased the risk of complications. Reduction in ischemia time had no effect on the occurrence of complications. CONCLUSION Anticoagulation regimes in microvascular surgery can influence the postoperative complication rate. The optimal protocol should consist of a combination of ASA and UFH for the intraoperative and direct postoperative phase. Prolonged administration of ASA as well as doses >500 IU/ h of UFH are to be avoided due to the increased complication rate.
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Affiliation(s)
- René Rothweiler
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Vanessa Gerlach
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pit Voss
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philipp Poxleitner
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Ermer
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Gross
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Schwer
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kirstin Vach
- Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marc Metzger
- Department of Oral and Maxillofacial Surgery, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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17
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Ooms M, Puladi B, Houschyar KS, Heitzer M, Rashad A, Bickenbach J, Hölzle F, Modabber A. Smoking and microvascular free flap perfusion in head and neck reconstruction: radial free forearm flaps and anterolateral thigh flaps. Sci Rep 2022; 12:13902. [PMID: 35974131 PMCID: PMC9381556 DOI: 10.1038/s41598-022-18216-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 11/09/2022] Open
Abstract
Head and neck reconstruction with microvascular free flaps is frequently performed in smokers. Smoking causes various alterations in the cardiovascular system. The aim of this study was to investigate the effects of smoking on flap perfusion as a critical factor for flap survival. A total of 370 patients reconstructed with a radial free forearm flap (RFFF) or anterolateral thigh flap (ALTF) in the head and neck region between 2011 and 2020 were retrospectively analyzed. Flap perfusion measurements with the O2C tissue oxygen analysis system were compared between nonsmokers, light smokers (< 20 pack-years), and heavy smokers (≥ 20 pack-years). The blood flow was intraoperatively equal in RFFFs (84.5 AU vs. 84.5 AU; p = 0.900) and increased in ALTFs (80.5 AU vs. 56.5 AU; p = 0.001) and postoperatively increased in RFFFs (114.0 AU vs. 86.0 AU; p = 0.035) and similar in ALTFs (70.5 AU vs. 71.0 AU; p = 0.856) in heavy smokers compared to nonsmokers. The flap survival rate was similar in nonsmokers, light smokers, and heavy smokers (97.3%, 98.4%, and 100.0%). Smoking partially increases rather than decreases microvascular free flap perfusion, which may contribute to similar flap survival rates in smokers and nonsmokers.
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Affiliation(s)
- Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Behrus Puladi
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Khosrow Siamak Houschyar
- Department of Dermatology and Allergology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ashkan Rashad
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
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18
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Influence of biological sex on intra- and postoperative course of microvascular free flap reconstructive surgery in the head and neck region: A retrospective analysis involving 215 patients. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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19
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Suyama Y, Yagi S, Fukuoka K, Morita M, Kinjo A, Fukuhara T, Fujiwara K, Kodani I, Osaki Y. Risk Factors of Free Flap Complications in Reconstruction for Head and Neck Cancer. Yonago Acta Med 2022; 65:215-225. [DOI: 10.33160/yam.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Yoshiko Suyama
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Shunjiro Yagi
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Kohei Fukuoka
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Maki Morita
- Department of Plastic and Reconstructive Surgery, Tottori University Hospital, Yonago 683-8504, Japan
| | - Aya Kinjo
- Department of Social Medicine, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan
| | - Takahiro Fukuhara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Kazunori Fujiwara
- Division of Otolaryngology, Head and Neck Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan and
| | - Isamu Kodani
- Division of Oral and Maxillofacial Surgery, Department of Sensory and Motor Organs, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8504, Japan
| | - Yoneatsu Osaki
- Department of Social Medicine, School of Medicine, Faculty of Medicine, Tottori University, Yonago 683-8503, Japan
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Wu K, Gong Z, Wu H, Mao Y, Zhang S. Evaluating the role of low molecular heparin to prevent anterolateral thigh flap compromise in 2460 head and neck defect cases. J Oral Maxillofac Surg 2022; 80:944-948. [DOI: 10.1016/j.joms.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/18/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
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21
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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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22
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Wang KY, Liu WC, Chen CF, Chen LW, Chen HC, Yang KC. Osteomyocutaneous Free Fibula Flap Prevents Osteoradionecrosis and Osteomyelitis in Head and Neck Cancer Reconstruction. J Reconstr Microsurg 2021; 37:524-529. [PMID: 33517570 DOI: 10.1055/s-0040-1722647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Osteoradionecrosis (ORN) is one of the most severe complications of free fibula reconstruction after radiotherapy. The gold standard treatment of osteomyelitis involves extensive debridement, antibiotics, and sufficiently vascularized muscle flap coverage for better circulation. Therefore, we hypothesized that free fibula flap with muscle could decrease the risk of ORN. METHODS This study consisted of 85 patients who underwent reconstruction with free fibula flap in head and neck cancer by a single reconstructive surgeon at Kaohsiung Veterans General Hospital over a period of 19 years (1998-2016). Patients with postoperative adjuvant radiotherapy were included in the study and were grouped by either free fibula osteocutaneous flap or free fibula osteomyocutaneous flap (with flexor hallucis longus muscle), and the incidence of ORN was compared. RESULTS Of the 85 patients, 15 were reconstructed with osteocutaneous fibula flap and 70 were with osteomyocutaneous fibula flap. The rate of ORN or osteomyelitis was significantly lower in the muscle group (18.6%, n = 13/70 vs. 46.7%, n = 7/15, p = 0.020, Chi-square test). CONCLUSION Vascularized muscle transfer increases perfusion of surrounding tissues and the bone flap, thereby decreasing the incidence of osteomyelitis or osteonecrosis.
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Affiliation(s)
- Kuan-Ying Wang
- Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,Division of Plastic Surgery and Reconstructive Surgery, Chuanghua Christian Hospital, Chuanghua, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Wen-Chung Liu
- Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China.,School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chun-Feng Chen
- Department of Oromaxillofacial Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,Dental Laboratory Technology, Shu Zen College of Medicine and Management, Kaohsiung, Taiwan, Republic of China
| | - Lee-Wei Chen
- Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Hung-Chi Chen
- International Medical Service Center of China Medical University Hospital, Taichung City, Taiwan, Republic of China.,Department of Plastic Surgery, China Medical University, Taichung City, Taiwan, Republic of China
| | - Kuo-Chung Yang
- Division of Plastic and Reconstructive Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of China.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China.,School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
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23
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Hahn HM, Lee DH, Lee IJ. Influence of time interval between endovascular intervention and free flap transfer on flap outcomes in critical limb-threatening ischemia: A retrospective analysis of 64 consecutive cases. J Plast Reconstr Aesthet Surg 2020; 74:1544-1552. [PMID: 33454224 DOI: 10.1016/j.bjps.2020.12.051] [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: 07/28/2020] [Revised: 11/18/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Arterial revascularization and free flap reconstruction is safe and effective for limb salvage in patients with critical limb-threatening ischemia (CLTI). This study aimed to determine whether reconstruction outcomes were affected by the time interval between endovascular treatment and free flap transfer in lower extremity reconstruction for critical limb ischemia. METHODS Patients who underwent endovascular intervention and subsequent free flap reconstruction with >6 months of follow-up were reviewed. Those with wounds with oncological and traumatic etiologies were excluded. Patients' demographics, risk factors, details of microsurgical procedures, details of endovascular intervention, and flap outcomes were collected. RESULTS Overall, 64 consecutive patients (M:F = 50:14 and mean age, 57.3 [range, 29-82] years) were evaluated between November 2011 and October 2019. Angioplasty failed in three patients. For soft-tissue reconstruction, anterolateral free flaps were used most frequently (n = 54 and 84.4%). Flap-related complications developed in 12 cases, of which five cases included total flap necrosis. The interval between endovascular intervention and free flap transfer was not associated with flap loss in multivariate regression analysis. Patients with kidney transplants and higher serum creatinine were associated with total flap necrosis. Advanced age, failed angioplasty, and perfusion status of the pedal arch were associated with major flap complications. CONCLUSION The time interval between endovascular treatment and free flap reconstruction was not associated with flap complications. Free flap reconstruction of chronic wounds caused by CLTI can be safely planned regardless of the time duration from preoperative angioplasty.
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Affiliation(s)
- Hyung Min Hahn
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Dong Hwan Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea
| | - Il Jae Lee
- Department of Plastic and Reconstructive Surgery, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon-si, Gyeonggi-do 16499, Republic of Korea.
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