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Kota S, Khan NS, Bollig K, Bridgeman M, Bollig CA. Outcomes of Head and Neck Free Tissue Transfer Requiring Vein Grafting: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2024; 170:1280-1288. [PMID: 38415862 DOI: 10.1002/ohn.689] [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: 01/15/2024] [Accepted: 01/21/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE To systematically review the literature to determine the prevalence of free flap failure in head and neck free flaps requiring vein grafting. DATA SOURCES Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to August 2022. REVIEW METHODS The population of interest included adult and pediatric patients undergoing reconstruction of oncologic or traumatic head and neck defects with a free flap requiring a vein graft that presents the success/failure rate. The primary outcome was the flap failure rate, and the secondary outcome was the flap compromise/revision rate. Inclusion and exclusion criteria were designed to capture all study designs. Initially, 2778 articles were identified by the search strategy. Two reviewers independently performed the review, data extraction for analysis, and a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Meta-analysis was performed using a random effects model. RESULTS Eleven studies of 789 flaps were included for data extraction. Random effects meta-analysis resulted in an estimated prevalence of free flap failure of 12.30% (95% confidence interval: 6.39%-19.49%, I2 = 77.4%). CONCLUSION Taking into account that head and neck free tissue transfers that require a vein graft are typically associated with more challenging reconstructions and the lack of a suitable alternative, vein grafts appear to be a reliable method for bridging the gap between the flap and recipient vessels in head and neck free tissue transfer when indicated.
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Affiliation(s)
- Sharwani Kota
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Najm S Khan
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Kassie Bollig
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew Bridgeman
- Robert Wood Johnson Library of the Health Sciences, New Brunswick, New Jersey, USA
| | - Craig A Bollig
- Department of Otolaryngology-Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Dattilo LW, Russell TI, Warinner CB, Starmer H, Annino DJ, Goguen LA, Sethi RKV, Uppaluri R, Windon MJ, Bergmark RW, Rettig EM. Patient Experience of Head and Neck Surgery With Free Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2024; 150:311-317. [PMID: 38386356 PMCID: PMC10884946 DOI: 10.1001/jamaoto.2023.4750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/22/2023] [Indexed: 02/23/2024]
Abstract
Importance Major head and neck surgery with microvascular free tissue transfer reconstruction is complex, with considerable risk of morbidity. Little is known about patients' experiences, including decision-making prior to, and regret following, free flap surgery. Objective To characterize patient experiences and decision regret of patients undergoing head and neck reconstructive free flap surgery. Design, Setting, and Participants This mixed-methods cohort study comprising semistructured interviews was conducted June to August 2021 at a single tertiary academic cancer center. Participants underwent head and neck reconstructive surgery with microvascular free tissue transfer (flap) more than 3 months before recruitment (range, 3 months to 4 years). Interview transcripts were qualitatively analyzed for themes. Participants also completed a Decision Regret Scale questionnaire. Exposure Microvascular free flap surgery for head and neck reconstruction. Main Outcomes and Measures Thematic analysis of interviews, decision regret score. Results Seventeen participants were interviewed. Median (IQR) age was 61 (52-70) years. Overall, 7 participants were women (49%), and 10 of 17 were men (59%). The most common free flap was fibula (8/17, 47%). Three major themes with 9 subthemes were identified: theme 1 was the tremendous effect of preoperative counseling on surgical decision-making and satisfaction, with subthemes including (1) importance of clinical care team counseling on decision to have surgery; (2) emotional context colors preoperative understanding and retention of information; (3) expectation-setting affects satisfaction with preoperative counseling; and (4) desire for diversified delivery of preoperative information. Theme 2 was coexisting and often conflicting priorities, including (1) desire to survive above all else, and (2) desire for quality of life. Theme 3 was perception of surgery as momentous and distressing, including (1) surgery as a traumatic event; (2) centrality of mental health, emotional resolve, and gratitude to enduring surgery and recovery; and (3) sense of accomplishment in recovery. On the Decision Regret Scale, most participants had no regret (n = 8, 47%) or mild regret (n = 5, 29%); 4 had moderate-to-severe regret (24%). Conclusions and Relevance In this mixed-methods cohort study, patient experiences surrounding major head and neck reconstructive free flap surgery were described. Opportunities to improve support for this complex and vulnerable population, and to mitigate decision regret, were identified.
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Affiliation(s)
- Lillian W. Dattilo
- Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye & Ear, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Chloe B. Warinner
- Harvard Medical School, Boston, Massachusetts
- Department of Otolaryngology, Massachusetts Eye & Ear, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Heather Starmer
- Department of Otolaryngology–Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Donald J. Annino
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Laura A. Goguen
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rosh K. V. Sethi
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ravindra Uppaluri
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Melina J. Windon
- Department of Otolaryngology–Head and Neck Surgery, University of Kentucky, Lexington
| | - Regan W. Bergmark
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Eleni M. Rettig
- Harvard Medical School, Boston, Massachusetts
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
- Center for Head and Neck Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
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Elmer NA, Araya S, Panichella J, Egleston B, Deng M, Patel SA. Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction: What Are the Roles of Procedure Indication and Defect Etiology? Ann Plast Surg 2023; 90:229-236. [PMID: 36796044 PMCID: PMC10084812 DOI: 10.1097/sap.0000000000003429] [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] [Indexed: 02/18/2023]
Abstract
BACKGROUND Advancements in lower extremity (LE) microsurgery have allowed for the expansion of indications for LE reconstructions. This project aims to better understand the temporal pattern and risk factors associated with LE free flap failure based on the clinical indication. MATERIALS AND METHODS We analyzed all patients undergoing LE free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 prospectively collected data to determine rates and timing of reoperation. Free flaps were stratified by indication, type, and timing of reoperation. Weibull survival models were used to compare rates of takebacks among time intervals. Multivariable logistic regression was used to identify independent predictors for unplanned reoperation. RESULTS Four hundred seven of LE free flaps were analyzed. There was a 14.5% rate (59/407) of unplanned reoperation within the first 30 postoperative days (PODs) after surgery. When stratified by the indication necessitating reoperation, patients with an underlying vascular indication had the highest rate of reoperation (40.9%). The reoperation rates were significantly different between indications (P < 0.05) The mean daily proportion of patients experiencing reoperation was highest during POD 0 to 2 (1.47% reoperations per day), which dropped significantly during POD 3 to 10 (0.55% per day) and again during POD 11 to 30 (0.28% per day, P < 0.05). African American race as well as malignant, prosthetic/implant, and wound/infectious indications were significant independent predictors for unplanned reoperation. CONCLUSIONS Lower extremity reconstruction is an important reconstructive option for the coverage of a myriad of defects. Understanding the differences between postoperative reoperation timelines among indication subtypes is important for updated flap monitoring protocols, optimizing ERAS pathways, and beginning dangle protocols.
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Affiliation(s)
| | - Sthefano Araya
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Juliet Panichella
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
| | - Brian Egleston
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Mengying Deng
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA
| | - Sameer A. Patel
- Fox Chase Cancer Center/ Temple University Division of Plastic and Reconstructive Surgery
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