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Enin K, Bellas A, Puram SV, Jackson RS, Doering M, Pipkorn P. Clinical applications of vascularized fascia lata in head and neck reconstruction: A systematic review. Am J Otolaryngol 2024; 45:104432. [PMID: 39151381 DOI: 10.1016/j.amjoto.2024.104432] [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: 09/16/2023] [Accepted: 07/21/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Given limitations in the current literature, the precise indications, techniques, and outcomes relevant to vascularized fascia lata free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature to evaluate indications, methods, and complications for vascularized fascia lata free flap reconstruction. METHODS A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the head and neck region using vascularized fascia lata. Articles were reviewed based on relevance, with the primary outcome being surgical complications and surgical indications. RESULTS A comprehensive search revealed 783 articles and 5 articles were ultimately found to be appropriate to this review- 55 patients undergoing free flap reconstruction were identified. Overall complication rates were 10.9 % for major complications and 18.1 % for minor complications. Follow-up spanned 1 to 95 months with a median of 48 months. CONCLUSIONS Microvascular reconstruction of the head and neck with vascularized fascia lata is achievable with high adaptability and reliability reported in the literature.
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Affiliation(s)
- Kwasi Enin
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Andrew Bellas
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Sidharth V Puram
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Ryan S Jackson
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Michelle Doering
- Washington University in St. Louis - Bernard Becker Medical Library, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Devarasetty VVNM, Vickery JW, Maslow JI. Outcomes of Pedicled Groin Flaps for Upper Extremity Injuries. Hand (N Y) 2024:15589447241265520. [PMID: 39051474 DOI: 10.1177/15589447241265520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
BACKGROUND Free flap reconstruction has become the more common treatment over pedicled groin flaps for reconstruction of upper extremity injuries in recent years. Groin flaps are still used for a variety of reasons, though limited literature is available to guide surgeons and patients regarding outcomes. This study aimed to investigate the epidemiology and outcomes of pedicled groin flaps for upper extremity pathology. METHODS The study was a single-institution retrospective case series at a level one trauma center including patients who underwent pedicled groin flaps for upper extremity soft tissue coverage between 1992 and 2022. The data collected included patient and injury characteristics, surgical management, and complication data. Ordinal logistic regression, univariate analysis, and bivariate analysis were performed to assess the relationship between the total number of groin flap surgeries and complications with patient and injury characteristics. RESULTS The analysis included 88 pedicled groin flaps performed for upper extremity injuries, with a median follow-up of 1.14 years after injury. Patients had a median age of 35 (interquartile range [IQR]: 22-49) years and underwent a median of 4 (IQR: 3-5.25) surgeries with stiffness (90.6%), partial flap loss (38%), and infection (32%) as the most common complications. High-energy injuries increased the risk of requiring more surgeries based on ordinal logistic regression. Univariate and bivariate analysis revealed no significant difference in wound complications based on patient or injury characteristics. CONCLUSIONS Patients undergoing pedicled groin flaps for upper extremity injuries can expect to undergo an average of 4 surgeries, and high-energy injuries predict the need for more surgeries.
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Affiliation(s)
| | - Justin W Vickery
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jed I Maslow
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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3
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Kagaya Y, Takanashi R, Arikawa M, Kageyama D, Higashino T, Akazawa S. The Ischemic Tolerance up to Four Hours of Free Jejunum Flap: A Retrospective Cohort Study. J Reconstr Microsurg 2024; 40:407-415. [PMID: 38272057 DOI: 10.1055/a-2253-8371] [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: 01/27/2024]
Abstract
BACKGROUND While free jejunum transfer (FJT) following total pharyngo-laryngo-esophagectomy (TPLE) is a reliable reconstruction technique, the jejunum flap is viewed as more susceptible to ischemia than a standard free flap. Animal studies have indicated that the jejunum can tolerate ischemia for as little as 2 to 3 hours. Clinical studies also reported increased complications after the FJT with more than 3 hours of ischemia. Traditionally, our institution has carried out FJT with an initial intestinal anastomosis, followed by a vascular anastomosis, which often results in extended jejunal ischemia time. In this study, we retrospectively examined the actual tolerance of the jejunum to ischemia, considering perioperative complications and postoperative dysphagia. METHODS We retrospectively studied 402 consecutive cases involving TPLE + FJT. Patients were divided into five groups based on jejunum ischemia time (∼119 minutes, 120∼149 minutes, 150∼179 minutes, 180∼209 minutes, 210 minutes∼), with each variable and result item compared between the groups. Univariate and multivariate analyses were conducted to identify independent factors influencing the four results: three perioperative complications (pedicle thrombosis, anastomotic leak, surgical site infection) and dysphagia at 6 months postoperatively. RESULTS The mean jejunal ischemia time was 164.6 ± 28.4 (90-259) minutes. When comparing groups divided by jejunal ischemia time, we found no significant differences in overall outcomes or complications. Our multivariate analyses indicated that jejunal ischemia time did not impact the three perioperative complications and postoperative dysphagia. CONCLUSION In TPLE + FJT, a jejunal ischemia time of up to 4 hours had no effect on perioperative complications or postoperative dysphagia. The TPLE + FJT technique, involving a jejunal anastomosis first followed by vascular anastomosis, benefits from an easier jejunal anastomosis but suffers from a longer jejunal ischemia time. However, we found that ischemia time does not pose significant problems, although we have not evaluated the effects of jejunal ischemia extending beyond 4 hours.
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Affiliation(s)
- Yu Kagaya
- Department of Plastic and Reconstructive Surgery, National Cancer Center, Tokyo, Japan
- Department of Plastic, Reconstructive and Aesthetic Surgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Ryo Takanashi
- Department of Plastic and Reconstructive Surgery, National Cancer Center, Tokyo, Japan
| | - Masaki Arikawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center, Tokyo, Japan
| | - Daisuke Kageyama
- Department of Plastic and Reconstructive Surgery, National Cancer Center, Tokyo, Japan
| | - Takuya Higashino
- Department of Plastic and Reconstructive Surgery, National Cancer Center East, Kashiwa, Japan
| | - Satoshi Akazawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center, Tokyo, Japan
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Kostares E, Kostares M, Kostare G, Tsakris A, Kantzanou M. Prevalence of free flap failure in mandibular osteoradionecrosis reconstruction: a systematic review and meta-analysis. Sci Rep 2024; 14:11087. [PMID: 38750124 PMCID: PMC11096303 DOI: 10.1038/s41598-024-61862-1] [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: 10/23/2023] [Accepted: 05/10/2024] [Indexed: 05/18/2024] Open
Abstract
Our study aimed to estimate the prevalence of total free flap failure following free flap reconstruction for mandibular osteoradionecrosis (mORN) and assess the impact of potential moderators on this outcome. A comprehensive systematic literature search was independently conducted by two reviewers using the Medline, Scopus, Web of Science and Cochrane Library databases. Quality assessment of the selected studies was performed, and prevalence estimates with 95% confidence intervals (CI) were calculated. Outlier and influential analyses were conducted, and meta-regression analyses was employed to investigate the effects of continuous variables on the estimated prevalence. Ultimately, forty-six eligible studies (involving 1292 participants and 1344 free flaps) were included in our meta-analysis. The findings of our study revealed a prevalence of 3.1% (95% CI 1.3-5.4%) for total free flap failure after reconstruction for mORN. No study was identified as critically influential, and meta-regression analysis did not pinpoint any potential sources of heterogeneity. These findings provide valuable insights for researchers and serve as a foundation for future investigations into the management of mandibular osteoradionecrosis and the prevention of free flap failure in this context.
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Affiliation(s)
- Evangelos Kostares
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece.
| | - Michael Kostares
- Department of Anatomy, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Georgia Kostare
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Maria Kantzanou
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
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Hamrouni N, Højvig JH, Knudsen UK, Skovgaard KK, Jensen LT, Bonde CT, Odgaard A. Microvascular free flap coverage of complex soft tissue defects after revision total knee arthroplasty: a cross-sectional observation study. Acta Orthop 2024; 95:186-191. [PMID: 38630868 PMCID: PMC11024721 DOI: 10.2340/17453674.2024.40183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 02/10/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND AND PURPOSE Soft tissue defects after total knee arthroplasties (TKA) represent a major orthopedic challenge with amputation as a feared outcome. Microvascular free flap coverage (FFC) can increase limb salvage rates, but complications related to the procedure are yet to be explored further. We aimed to review a single-center experience with FFC for soft tissue defects related to revision total knee arthroplasty. METHODS Through a retrospective chart review from 2006 to 2021, we identified all patients who had FFC of a knee with an existing TKA. Typically, patients underwent 2-stage revision arthroplasty. To identify areas of intervention, we divided the entire regimen into 2 phases divided by the free flap surgery (pre- and post-free flap). RESULTS We identified 18 patients with a median age at free flap surgery of 69 years (range 39-85), who were followed for a median of 5.1 years (range 2 months to 10.6 years). The median duration from primary TKA to their final operation was 17.5 months (range 19 days to 7 years). Patients underwent a mean of 7.6 surgical procedures on their knee with 3.6 orthopedic revisions prior to the FFC and 0.6 after. Soft tissue coverage was achieved in all patients and no patients underwent amputation. One-third of patients experienced early complications at recipient site after free flap surgery. There were no donor site complications. CONCLUSION Microvascular FFC of complex soft tissue defects after revision total knee arthroplasty proved achievable in all patients with successful limb salvage in all patients.
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Affiliation(s)
- Nizar Hamrouni
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen.
| | - Jens H Højvig
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Ulrik K Knudsen
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Kurt K Skovgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Lisa T Jensen
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Christian T Bonde
- Department of Plastic Surgery and Burns Treatment, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen
| | - Anders Odgaard
- Department of Orthopedic Surgery, Center of Head, Neck and Orthopedics, University Hospital of Copenhagen, Rigshospitalet, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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6
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Cheng L, Tan Y, Cui L, Zheng Y, Qin C, Tian L. The sucker-like end-to-side arterial anastomosis for free flap in extremities reconstruction: a retrospective study of 78 cases. J Orthop Surg Res 2024; 19:119. [PMID: 38311748 PMCID: PMC10838452 DOI: 10.1186/s13018-024-04597-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/28/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND The application of end-to-side (ETS) anastomosis for flap transfer poses challenges, particularly in cases of significant size discrepancy between the donor and flap arteries. Herein, a novel ETS anastomosis technique, termed "sucker-like ETS anastomosis", is developed to mitigate and rectify such vessel discrepancies. This study aims to evaluate the efficacy of this technique in tissue defect reconstruction through free flap transfer. METHODS Between September 2018 and March 2023, the medical records and follow-up data of 78 patients who underwent free flap transfer using sucker-like ETS anastomosis for significant artery size discrepancies were collected and retrospectively analyzed. RESULTS Among the 78 cases that received free flap transfer, the range of artery size discrepancy (flap artery vs donor artery) was 1:1.6-1:4 (mean: 1:2.5). Following anastomosis with the sucker-like ETS technique, 75 cases achieved flap survival without requiring additional surgical intervention, yielding a one-stage success rate of 96.2%. Three cases experienced post-operative venous crises, with two cases surviving after vein exploration and one case undergoing flap necrosis, necessitating a secondary skin graft. Seven cases faced delayed wound healing but eventually achieved complete healing following dressing changes. No arterial crisis was observed during hospitalization. With an average follow-up of 13 months, the surviving flaps exhibited excellent vitality without flap necrosis or pigment deposition. Overall, the application of sucker-like ETS arterial anastomosis for flap transfer resulted in a high overall surgical success rate of 98.7% (77/78). CONCLUSION The application of sucker-like ETS anastomosis for free flap transfer is highly effective, particularly in cases with significant size discrepancy between the recipient and donor arteries.
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Affiliation(s)
- Liangkun Cheng
- Department of Hand Microsurgery, Chongqing Great Wall Orthopaedic Hospital, Chongqing, 400016, China
| | - Yuzhong Tan
- Department of Hand Microsurgery, Chongqing Great Wall Orthopaedic Hospital, Chongqing, 400016, China
| | - Liuchao Cui
- Department of Hand Microsurgery, Chongqing Great Wall Orthopaedic Hospital, Chongqing, 400016, China
| | - Yun Zheng
- Department of Hand Microsurgery, Chongqing Great Wall Orthopaedic Hospital, Chongqing, 400016, China
| | - Chenghe Qin
- Department of Orthopedics - Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China.
| | - Lin Tian
- Department of Hand Microsurgery, Chongqing Great Wall Orthopaedic Hospital, Chongqing, 400016, China.
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Burke CE, Mundy LR, Gupta J, Wong AL, Enobun B, O'Hara NN, Bangura A, O'Connor KC, Jauregui JJ, Miller NF, O'Toole RV, Pensy RA. Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter? J Reconstr Microsurg 2024; 40:59-69. [PMID: 37186096 DOI: 10.1055/s-0043-1768219] [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: 05/17/2023]
Abstract
BACKGROUND Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. METHODS A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. RESULTS We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. CONCLUSION Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.
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Affiliation(s)
- Cynthia E Burke
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lily R Mundy
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jayesh Gupta
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Alison L Wong
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Blessing Enobun
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan N O'Hara
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Abdulai Bangura
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Katherine C O'Connor
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Julio J Jauregui
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan F Miller
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Robert V O'Toole
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Raymond A Pensy
- Department of Orthopaedics, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
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Nööjd M, Wyckman A, Steinvall I, Elmasry M. Flap Survival after Reconstructive Surgery for Pressure Ulcers: A Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5451. [PMID: 38098948 PMCID: PMC10721125 DOI: 10.1097/gox.0000000000005451] [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: 08/02/2023] [Accepted: 10/10/2023] [Indexed: 12/17/2023]
Abstract
Background Pressure ulcers are troublesome for patients and require considerable resources to resolve. Previous studies have focused on recurrence, whereas there are few studies on flap survival. The aim was to describe the group and to analyze possible factors for flap survival. Method A descriptive retrospective analysis of all operations between 2008 and 2020 was carried out. Flap survival at 40 days was assessed. A flap was classified as a failure if a reoperation with removal or replacement was planned before, or in connection with, the first return visit. Variables of patient demographics, details of the pressure ulcers, and surgical treatment and care were analyzed with multivariable logistic regression for their effect on flap survival. Results A total of 111 flaps were included [78 (70%) with random blood supply and 33 (30%) with axial or perforator-based blood supply]; 54 (49%) of the flaps were fasciocutaneous. Body mass index was 25 (IQR 22-28). Flap survival rate was 90%. Variables associated with flap failure were higher body mass index, congenital spinal cord injury, type of blood supply to the flap, and the use of methylene blue to guide debridement of the wound. Conclusions The findings show factors that can be modified to improve future results, including a normalized body mass index and use of methylene blue in surgery to outline wound edges and depth, as this has been shown to protect against flap failure. Our data suggest that random flaps, such as V-Y, are preferable to axial flaps in the studied group.
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Affiliation(s)
- Mari Nööjd
- From the Department of Hand Surgery, Plastic Surgery and Burns and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Alexander Wyckman
- From the Department of Hand Surgery, Plastic Surgery and Burns and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ingrid Steinvall
- From the Department of Hand Surgery, Plastic Surgery and Burns and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Moustafa Elmasry
- From the Department of Hand Surgery, Plastic Surgery and Burns and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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9
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Guzzini M, Ciclamini D, Arioli L, Titolo P, Carrozzo A, Latini F, Battiston B, Ferretti A. Correlation between Risk Factors and Healing Times in Long Bone Nonunions Treated with Corticoperiosteal Flap from the Medial Femoral Condyle. J Reconstr Microsurg 2023; 39:502-507. [PMID: 36577498 DOI: 10.1055/a-2004-2364] [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: 12/29/2022]
Abstract
BACKGROUND The rate of fracture nonunion varies depending on the anatomical site. Numerous procedures have been proposed to treat recalcitrant nonunions. The vascularized medial femoral condyle corticoperiosteal free flap (MFCCFF) is increasingly used in nonunions with small bone loss.The percentage of success of the MFCCFF is high but the factors involved in delayed bone healing or failure of this technique or the contraindications are not described in the literature.This multicentric study aims to identify and report the different factors involved in determining the time of bone healing in the treatment of atrophic nonunion of long bones with the vascularized medial MFCCFF. METHODS All patients who underwent vascularized medial MFCCFF from January 2011 to December 2020 for the treatment of recalcitrant atrophic nonunions of long bones. Patients were reviewed at 2 and 6 weeks, and 3, 6, and 12 months postoperatively and evaluated by physical and radiographic examinations and patient-reported outcome measures. RESULTS The final study population comprised 59 patients with a mean follow-up of 26.2 ± 7.6 months, a rate of bone healing of 94.9% with a mean radiographic bone healing time of 4.1 ± 1.3 months, and low morbidity of the donor site. Diabetes mellitus, a body mass index (BMI) ≥30 kg/m2, and ≥2 previous surgeries on the fracture site were factors predicting timing for bone healing at the multivariate analysis. CONCLUSION This study demonstrates the MFCCFF as an effective and safe procedure for the treatment of the recalcitrant atrophic nonunion of long bones. An association was found between the lengthening of bone healing time and a high BMI, presence of ≥2 previous surgical interventions, and diabetes mellitus, indicating these comorbidities as risk factors (not absolute contraindications) for this microsurgical treatment. So, to our knowledge, the MFCCFF could be the first-choice treatment for atrophic nonunion of long bones.
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Affiliation(s)
- Matteo Guzzini
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Davide Ciclamini
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Leopoldo Arioli
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Paolo Titolo
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Alessandro Carrozzo
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Francesca Latini
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
| | - Bruno Battiston
- Hand Surgery and Reconstructive Microsurgery Department, CTO Hospital, A.O.U. Città della Salute e della Scienza, Turin, Italy
| | - Andrea Ferretti
- Orthopaedic and Trauma Surgery Unit, A.O.U. Sant'Andrea, La Sapienza University of Rome, Rome, Italy
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10
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Tarle M, Čvrljević I, Raguž M, Lukšić I. Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps. J Clin Med 2023; 12:5314. [PMID: 37629355 PMCID: PMC10455496 DOI: 10.3390/jcm12165314] [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] [Received: 07/23/2023] [Revised: 08/10/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.
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Affiliation(s)
- Marko Tarle
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
- School of Dental Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Igor Čvrljević
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
| | - Marina Raguž
- Department of Neurosurgery, Dubrava University Hospital, 10000 Zagreb, Croatia;
- School of Medicine, Catholic University of Croatia, 10000 Zagreb, Croatia
| | - Ivica Lukšić
- Department of Maxillofacial Surgery, Dubrava University Hospital, 10000 Zagreb, Croatia; (M.T.); (I.Č.)
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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11
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Irawati N, Every J, Dawson R, Leinkram D, Elliott M, Ch'ng S, Low H, Palme CE, Clark J, Wykes J. Effect of operative time on complications associated with free flap reconstruction of the head and neck. Clin Otolaryngol 2023; 48:175-181. [PMID: 36321439 DOI: 10.1111/coa.14000] [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: 02/20/2022] [Revised: 09/15/2022] [Accepted: 10/23/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate whether prolonged operative time is negatively associated with post-operative complications and length of stay in patients undergoing microvascular free flap reconstruction for complex head and neck defects. METHODS 342 consecutive patients undergoing microvascular reconstruction for head and neck defects between 2017-2019 at a single institution were evaluated. Operative outcomes and operative time were compared whilst controlling for patient and treatment related factors. RESULTS Mean operative time was 551 min and length of stay was 16.2 days. An 11% increase in the risk of a post-operative complication was observed for every additional hour of operative time (OR 1.11, 95% CI 1.03-1.21, p = 0.011) after adjusting for patient and treatment factors. A cut-off of 9 h yielded a 92% increase in complications on either side of this (OR 1.92, 95% CI 1.18-3.13, p = 0.009). Increased operative time was also associated with increased length of stay and return to theatres, but not medical complications. CONCLUSION Prolonged operative time is significantly associated with increased surgical complications, length of stay and return to theatres when performing microvascular reconstructive surgery for head and neck defects.
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Affiliation(s)
- Nina Irawati
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - James Every
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Rebecca Dawson
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - David Leinkram
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia
| | - Michael Elliott
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Sydney Ch'ng
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Hubert Low
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Carsten E Palme
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - Jonathan Clark
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health District, Sydney, New South Wales, Australia
| | - James Wykes
- Department of Head and Neck Surgery, Sydney Head and Neck Cancer Institute, Chris O'Brien Lifehouse, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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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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An Analysis of Volume, Length and Segmentation of Free Fibula Flap in Reconstruction of the Jaws: Investigation of Their Role on Flap Failure. REPORTS 2023. [DOI: 10.3390/reports6010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Reconstruction of defects of the jaws is mainly performed via free fibula flap. An incidence of 2–21% of overall flap failure is still described. We investigated the roles of volume, length and number of fibula flap segments on flap survival using novel three-dimensional segmentation tools. We also analyzed the role of other possible risk factors. Seventy-one consecutive patients with a follow up of at least three months and who underwent free fibula flap reconstruction in a single center between 2002 and 2022 have been evaluated. A total of 166 fibula segments were analyzed. Malignancies were the main reason of resection (45.1%). In 69% of the cases a reconstruction of the mandible was performed. The flaps were mainly divided in two segments (39%) (range 1–4), with a mean length of 2.52 cm and a mean volume was 3.37 cm3. Total flap failure (TFF) occurred in 12 cases, (16.9%), while partial flap failure (PFF) appeared in 3 patients (4.2%). Volume, length and number of fibula flap segments did not seem to influence flap failure incidence in uni- and multivariate analysis. Reconstruction of the maxilla and use of a recipient vessel different from the facial artery seemed to significantly impact on flap failure. Smoking and previous surgeries showed a higher trend to flap failure, but they did not reach statistical significance. Prospective and multicentric analysis on a wider population should be assessed.
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14
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Mortada H, Alwadai A, Bamakhrama B, Alsinan T, Hanawi MD, Alfaryan SM, Obeid FM, Arab K. The Impact of Diabetes Mellitus on Breast Reconstruction Outcomes and Complications: A Systematic Literature Review and Meta-analysis. Aesthetic Plast Surg 2023; 47:570-583. [PMID: 36688982 DOI: 10.1007/s00266-023-03258-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 01/01/2023] [Indexed: 01/24/2023]
Abstract
INTRODUCTION As the incidence of breast cancer and diabetes rises, so does the number of patients with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at a higher risk for post-operative complications. The current study examined the effects of diabetes on BR wound outcomes and overall complications post-operatively. METHODS This study followed the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. We conducted a systematic search and meta-analysis for published articles on the effects of DM on BR in January 2022 using the PubMed, MEDLINE, and Cochrane databases. Diabetes, breast reconstruction, and complications were used as keywords. RESULTS Forty-three studies were included in the qualitative synthesis, and five provided data to be included in the meta-analysis published between 2006 and 2020. A total of 19,731 patients (9.07%) had diabetes, whereas 197,812 patients had no diabetes. The results of the pooled outcomes revealed no differences in the risk of total flap loss (p = 0.892) and wound infection (p = 0.579,). Nevertheless, the risk of wound dehiscence was significantly higher among patients with diabetes than their non-diabetic counterparts (p < 0.0001). CONCLUSION Diabetic patients undergoing BR have a significantly higher risk of wound dehiscence. As a result of the adverse effects of diabetes status on BR outcomes, patients need to be counseled about optimizing their diabetes management before surgery. Because of the heterogeneity in our results, prospective randomized studies are needed to shed light on the consequences of diabetes mellitus in BR surgeries. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Hatan Mortada
- Division of Plastic Surgery, Department of Surgery, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia. .,Department of Plastic Surgery & Burn Unit, King Saud Medical City, Riyadh, Saudi Arabia.
| | - Abdulelah Alwadai
- Department of Plastic Surgery & Burn Unit, Aseer central hospital, Abha, Saudi Arabia
| | - Basma Bamakhrama
- Division of Plastic and Reconstructive Surgery, Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tuqa Alsinan
- Department of Pediatric Surgery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.,College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Maha Darwish Hanawi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Saud Mansour Alfaryan
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Faisal M Obeid
- Department of Surgery, College of medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Khalid Arab
- Division of Plastic Surgery, Department of Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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15
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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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16
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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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17
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Liu Q, Aggarwal A, Wu M, Darwish OA, Baldino K, Haug V, Agha RA, Orgill DP, Panayi AC. Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:1793-1804. [PMID: 35351394 DOI: 10.1016/j.bjps.2022.02.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/14/2022] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND As rates of breast cancer and type II diabetes increase, so does the number of women with diabetes undergoing breast reconstruction (BR). Patients with diabetes are at increased risk of postoperative complications. This meta-analysis seeks to evaluate the post-operative outcomes of women with diabetes who underwent BR following mastectomy. METHOD This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The EMBASE, PUBMED, and MEDLINE electronic databases were searched from inception to November 1, 2020 for studies published in English. Outcomes evaluated were overall complications, surgical complications, and longer hospital stay. Subgroup analysis investigated outcomes, such as implant/flap failure, infection, and necrosis. RESULTS Sixty-five studies met our inclusion criteria and 38 provided data to be included in the meta-analysis. A total of 151,585 patients were included, of which 9299 had diabetes. Women with diabetes were more likely to experience overall complications (11.6% vs 5.6%; p<0.0001) and surgical complications (7.7% vs 3.3%; p<0.0001), and were more likely to have a prolonged hospital stay (p = 0.04) than women without diabetes. Subgroup analysis showed that implant loss (2.5% vs 1.6%; p = 0.0003), infection (6.8% vs 2.5%; p<0.0001) and necrosis (23.8% vs 6.5; p = 0.001) were significantly higher in women with diabetes. CONCLUSIONS This study provides evidence that diabetes mellitus increases the risk of complications in patients with breast cancer undergoing BR after mastectomy. Prospective studies are required to establish whether diabetes that is well-controlled prior to reconstruction, including diabetes that is paired with adjuvant radiation therapy, reduces the perioperative risks.
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Affiliation(s)
- Qinxin Liu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ayushi Aggarwal
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; University of Maryland School of Medicine, Baltimore, MD 21201, United States of America
| | - Mengfan Wu
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America; Department of Plastic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong 518036, China
| | - Oliver A Darwish
- California Northstate University College of Medicine, Elk Grove, CA 95757, United States of America
| | - Kodi Baldino
- The University of Connecticut School of Medicine, Farmington, CT 06030, United States of America
| | - Valentin Haug
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Riaz A Agha
- Department of Plastic Surgery, Barts Health NHS Trust, London, United Kingdom
| | - Dennis P Orgill
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America
| | - Adriana C Panayi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, United States of America.
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18
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Ota Y, Moore AG, Spector ME, Casper K, Stucken C, Malloy K, Lobo R, Baba A, Srinivasan A. Prediction of Wound Failure in Patients with Head and Neck Cancer Treated with Free Flap Reconstruction: Utility of CT Perfusion and MR Perfusion in the Early Postoperative Period. AJNR Am J Neuroradiol 2022; 43:585-591. [PMID: 35361578 PMCID: PMC8993192 DOI: 10.3174/ajnr.a7458] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/08/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Free flap reconstruction in patients with head and neck cancer carries a risk of postoperative complications, and radiologic predictive factors have been limited. The aim of this study was to assess the factors that predict free flap reconstruction failure using CT and MR perfusion. MATERIALS AND METHODS This single-center prospective study included 24 patients (mean age, 62.7 [SD, 9.0] years; 16 men) who had free flap reconstruction from January 2016 to May 2018. CT perfusion and dynamic contrast-enhanced MR imaging with conventional CT and MR imaging were performed between 2 and 4 days after the free flap surgery, and the wound assessments within 14 days after the surgery were conducted by the surgical team. The parameters of CT perfusion and dynamic contrast-enhanced MR imaging with conventional imaging findings and patient demographics were compared between the patients with successful free flap reconstruction and those with wound failure as appropriate. P < .05 was considered significant. RESULTS There were 19 patients with successful free flap reconstruction and no wound complications (mean age, 63.9 [SD, 9.5] years; 14 men), while 5 patients had wound failure (mean age, 58.0 [SD, 5.7] years; 2 men). Blood flow, blood volume, MTT, and time maximum intensity projection (P = .007, .007, .015, and .004, respectively) in CT perfusion, and fractional plasma volume, volume transfer constant, peak enhancement, and time to maximum enhancement (P = .006, .039, .004, and .04, respectively) in dynamic contrast-enhanced MR imaging were significantly different between the 2 groups. CONCLUSIONS CT perfusion and dynamic contrast-enhanced MR imaging are both promising imaging techniques to predict wound complications after head and neck free flap reconstruction.
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Affiliation(s)
- Y Ota
- From the Division of Neuroradiology (Y.O., R.L., A.B., A.S.)
| | - A G Moore
- Department of Radiology (A.G.M.), Western Michigan University, Kalamazoo, Michigan
| | - M E Spector
- Department of Radiology, and Department of Otolaryngology (M.E.S., K.C., C.S., K.M.), University of Michigan, Ann Arbor, Michigan
| | - K Casper
- Department of Radiology, and Department of Otolaryngology (M.E.S., K.C., C.S., K.M.), University of Michigan, Ann Arbor, Michigan
| | - C Stucken
- Department of Radiology, and Department of Otolaryngology (M.E.S., K.C., C.S., K.M.), University of Michigan, Ann Arbor, Michigan
| | - K Malloy
- Department of Radiology, and Department of Otolaryngology (M.E.S., K.C., C.S., K.M.), University of Michigan, Ann Arbor, Michigan
| | - R Lobo
- From the Division of Neuroradiology (Y.O., R.L., A.B., A.S.)
| | - A Baba
- From the Division of Neuroradiology (Y.O., R.L., A.B., A.S.)
| | - A Srinivasan
- From the Division of Neuroradiology (Y.O., R.L., A.B., A.S.)
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19
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Arakelyan S, Aydogan E, Spindler N, Langer S, Bota O. A retrospective evaluation of 182 free flaps in extremity reconstruction and review of the literature. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2022; 11:Doc01. [PMID: 35111561 PMCID: PMC8779818 DOI: 10.3205/iprs000162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Introduction: During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure. Patients and methods: In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications. Results: In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion: Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery.
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Affiliation(s)
- Sergey Arakelyan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany,*To whom correspondence should be addressed: Sergey Arakelyan, Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Liebigstrasse 20, 04103 Leipzig, Germany, E-mail:
| | - Emrah Aydogan
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Nick Spindler
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Stefan Langer
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Germany
| | - Olimpiu Bota
- University Center of Orthopaedic, Trauma and Plastic Surgery University Hospital Carl Gustav Carus, TU Dresden, Germany
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20
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Shires CB, Sebelik M. The submental flap: Be wary. Clin Case Rep 2022; 10:e05260. [PMID: 35028149 PMCID: PMC8741872 DOI: 10.1002/ccr3.5260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/07/2021] [Accepted: 10/12/2021] [Indexed: 11/17/2022] Open
Abstract
The submental island flap (SIF) is as an alternative to free flaps in head and neck reconstruction. 10 patients underwent submental flaps. All ten patients suffered failure of SIF as the definitive reconstructive procedure. Despite comparing favorably to free tissue transfer in published reports, our SIF had high failure rate.
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21
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Utility of Dermal Wound Matrices Compared with Local-Tissue Rearrangement and Free Flap Reconstruction for Oncologic Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis. Plast Reconstr Surg 2021; 149:469-480. [PMID: 34905752 DOI: 10.1097/prs.0000000000008774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Local tissue rearrangement, free flap reconstruction, and Bilayer Wound Matrix represent reconstructive modalities for coverage of scalp defects; however, preferred indications are less clear. The authors aimed to evaluate the efficacy of these interventions. METHODS A retrospective review (2008 to 2019) was performed of subjects requiring soft-tissue reconstruction of oncologic scalp wounds. Subjects were dual matched into two comparative cohorts based on age and wound size/wound age: (1) local tissue rearrangement versus Bilayer Wound Matrix, and (2) free flap reconstruction versus Bilayer Wound Matrix. Ninety-day wound coverage, reoperation rates, hospital length of stay, operative time, and wound complications were compared. RESULTS In total, 361 subjects were included. Following matching, 126 subjects constituted the local tissue rearrangement versus Bilayer Wound Matrix cohort, and 56 constituted the free flap reconstruction versus Bilayer Wound Matrix cohort. Local tissue rearrangement/Bilayer Wound Matrix median defect size was 35 ± 42.5 cm2. Local tissue rearrangement provided significantly better wound coverage at 90 days (95.2 percent) compared to Bilayer Wound Matrix (84.1 percent) (p < 0.040), although reoperation rates (7.9 percent versus 15.9 percent) did not differ (p < 0.271). Median defect size in the free flap reconstruction/Bilayer Wound Matrix cohort was 100 ± 101.1 cm2. Ninety-day success (free flap reconstruction, 92.9 percent; Bilayer Wound Matrix, 96.4 percent; p < 1.00) and reoperation rates (14.3 percent versus 3.6 percent; p < 0.352) were similar between groups. Free flap reconstruction had significantly greater operative time (418 minutes versus 100 minutes; p < 0.001) and length of stay (3 days versus 0.5 days; p < 0.001). CONCLUSIONS Local tissue rearrangement may be more reliable for smaller wounds (<100 cm2) when compared to Bilayer Wound Matrix. Bilayer Wound Matrix may have comparable efficacy to free flap reconstruction for larger defects (150 to 250 cm2), and may be more cost-effective, given greater operative time and length of stay associated with free flap reconstruction. Free flap reconstruction is preferentially used in complicated large defects in the setting of radiation therapy, and for large defects that have failed Bilayer Wound Matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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22
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Pai K, Baaklini C, Cabrera CI, Tamaki A, Fowler N, Maronian N. The Utility of Comorbidity Indices in Assessing Head and Neck Surgery Outcomes: A Systematic Review. Laryngoscope 2021; 132:1388-1402. [PMID: 34661923 DOI: 10.1002/lary.29905] [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: 04/19/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the utility of comorbidity index (CI) scores in predicting outcomes in head and neck surgery (HNS). The CIs evaluated were the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), Kaplan-Feinstein Index (KFI), American Society of Anesthesiologists Physical Status (ASA-PS), Adult Comorbidity Evaluation-27 (ACE-27), National Cancer Institute Comorbidity Index (NCI-CI), and the Washington University Head and Neck Comorbidity Index (WUHNCI). METHODS We report a systematic review according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases (PubMed, Cochrane, and Embase) and manual search of bibliographies identified manuscripts addressing how CI scores related to HNS outcomes. RESULTS A total of 116 studies associated CI scores with HNS outcomes. CIs were represented in the literature as follows: ASA-PS (70/116), CCI (39/116), ACE-27 (24/116), KFI (7/116), NCI-CI (3/116), ECI (2/116), and WUHNCI (1/116). The most frequently cited justification for calculating each CI (if provided) was: CCI for its validation in other studies, ACE-27 for its utility in cancer patients, and ECI for its comprehensive design. In general, the CCI and ACE-27 were predictive of mortality in HNS. The ECI was most consistent in predicting >1-year mortality. The ACE-27 and KFI were most consistent in predicting medical complications. CONCLUSION Despite inconsistencies in the literature, CIs provide insights into the impact of comorbidities on outcomes in HNS. These scores should be employed as an adjunct in the preoperative assessment of HNS patients. Comparative studies are needed to identify indices that are most reliable in predicting HNS outcomes. LEVEL OF EVIDENCE NA Laryngoscope, 2021.
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Affiliation(s)
- Kavya Pai
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio, U.S.A
| | - Carla Baaklini
- Northeast Ohio Medical University, Rootstown, Ohio, U.S.A
| | - Claudia I Cabrera
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Akina Tamaki
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Fowler
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
| | - Nicole Maronian
- Department of Otolaryngology-Head and Neck Surgery, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.,Case Western Reserve University School of Medicine, Cleveland, Ohio, U.S.A
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Gardner JR, Gau V, Page P, Dunlap Q, King D, Crabtree D, Sunde J, Vural E, Moreno MA. Association of Continuous Intraoperative Vasopressor Use With Reoperation Rates in Head and Neck Free-Flap Reconstruction. JAMA Otolaryngol Head Neck Surg 2021; 147:1059-1064. [PMID: 34591083 DOI: 10.1001/jamaoto.2021.1841] [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 Continuous vasopressor use in free-flap reconstruction is a point of contention among microvascular surgeons despite data demonstrating safety. Objective To investigate the association between continuous vasopressor use and the incidence of reoperation in the early postoperative period. Design, Setting, and Participants In this cohort study, a retrospective medical record review was conducted of patients who underwent head and neck free-flap reconstructions between May 1, 2014, and October 31, 2019, in an academic tertiary care center. All patients undergoing free-flap reconstruction for head and neck defects were included. Exposures Continuous intraoperative vasopressors. Main Outcomes and Measures Patient medical records were queried for demographic variables; intraoperative use of vasopressors; vasopressor type, duration, and infusion rate; reoperation within the first 5 postoperative days; and reason for reoperation. Results Four hundred forty-nine consecutive free-flap reconstructions were performed on 426 patients. The mean age was 62 years (IQR, 55.7-71.1); 293 patients were men (65.3%), 380 were White (84.6%), 55 were Black (12.2%), and 14 were of other race or ethnicity (3.1%). A total of 174 patients received a continuous vasopressor during their reconstruction. Twenty-three reoperations occurred within 5 days postoperatively, 8 of which included vasopressors during initial intervention. Vasopressor type had no association with reoperation (4.5% vs 5.5% [8/174 vs 15/275, respectively] for patients who received vasopressors vs those who did not) (dobutamine odds ratio [OR], 1.02 [95% CI, 0.21-2.91]; dopamine OR, 1.48 [95% CI, 0.33-4.26]). No difference was seen in the duration (dobutamine OR, 1.50 [95% CI, 0.78-2.90]; dopamine OR, 0.87 [95% CI, 0.59-1.28]) or infusion rate (dobutamine OR, 1.50 [95% CI, 0.99-1.02]; dopamine OR, 1.00 [95% CI, 0.99-1.01]) of vasopressors between patients who underwent reoperation and those who did not. Analysis after the exclusion of reasons for reoperation that did not represent possible microvascular anastomosis failure (eg, Doppler malfunction, donor site complications) showed no increased propensity for reoperation (OR, 1.18; 95% CI, 0.27-3.9). Conclusions and Relevance In this cohort study, use of vasopressors for extensive periods intraoperatively during free-tissue transfer appeared to have no association with the rate of reoperation within 5 days of intervention, regardless of agent used, simultaneous use of agents, type of free-flap operation performed, or reason for reoperation. This study adds to the body of literature supporting the judicious use of vasopressors in patients requiring intraoperative pharmacological pressure support during free-flap reconstruction.
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Affiliation(s)
- James Reed Gardner
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Victoria Gau
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Patrick Page
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Quinn Dunlap
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Deanne King
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Donald Crabtree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock
| | - Jumin Sunde
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Emre Vural
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Mauricio Alejandro Moreno
- Division of Head and Neck Oncology and Surgery, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
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Schoenbrunner A, Hackenberger PN, DeSanto M, Chetta M. Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction. Plast Reconstr Surg 2021; 148:185e-189e. [PMID: 34133372 DOI: 10.1097/prs.0000000000008154] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone. METHODS A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.). RESULTS Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases. CONCLUSION Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.
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Affiliation(s)
- Anna Schoenbrunner
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Paige N Hackenberger
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Marisa DeSanto
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
| | - Matthew Chetta
- From the Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center; The Ohio State University College of Medicine; and the Ohio University Heritage College of Osteopathic Medicine
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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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Moellhoff N, Broer PN, Heidekrueger PI, Ninkovic M, Ehrl D. Impact of patients' gender on microvascular lower extremity reconstruction. J Plast Surg Hand Surg 2021; 56:47-52. [PMID: 34292803 DOI: 10.1080/2000656x.2021.1914638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.
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Affiliation(s)
- Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Paul I Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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Distal Arterialized Venous Supercharging Improves Perfusion and Survival in an Extended Dorsal Three-Perforasome Perforator Flap Rat Model. Plast Reconstr Surg 2021; 147:957e-966e. [PMID: 34019505 DOI: 10.1097/prs.0000000000007990] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perforator flaps are commonly applied for a variety of skin defects. Many strategies (e.g., hyperbaric oxygen and preconditioning) have been investigated to improve flap survival, but a postoperative 2.03 to 18.2 percent flap necrosis frequency remains a major complication. The authors hypothesized that a distal arterialized venous supercharged (DAVS) flap procedure might improve perfusion and survival in an extended three-perforasome perforator flap rat model and rescue flap ischemia intraoperatively. METHODS One hundred twenty male Sprague-Dawley rats (200 to 300 g) were divided into the thoracodorsal artery (TDA) flap group and the DAVS flap group (n = 60 per group). An approximately 11 × 2.5-cm2 flap based on the TDA perforasome was designed in the TDA flap. A DAVS flap was designed based on the TDA flap and supercharged by anastomosing the rat caudal artery with the deep circumflex iliac vein. At postoperative times 1, 3, 6, and 12 hours and 1, 3, 5, and 7 days, perfusion and angiography were compared. On day 7, flap viability and angiogenesis were assessed using histology and Western blotting. RESULTS The DAVS flap showed a higher survival rate compared with the TDA flap (100 percent versus 81.93 ± 5.38 percent; p < 0.001). All blood flow ratios of deep circumflex iliac artery to TDA perforasome and of choke zone II to choke zone I were higher in the DAVS flap (all p < 0.05). Angiography qualitatively revealed that choke vessels in choke zone II dilated earlier and extensively in the DAVS flap group. CD34+ vessels (68.66 ± 12.53/mm2 versus 36.82 ± 8.99/mm2; p < 0.001) and vascular endothelial growth factor protein level (0.22 ± 0.03 versus 0.11 ± 0.03; p < 0.001) were significantly increased in the DAVS flap group. CONCLUSIONS The DAVS procedure improves three-perforasome perforator flap survival and can be used for rescuing flap ischemia intraoperatively. Further study is needed before possible clinical adoption for reconstructive operations.
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Sanchez-Porro Gil L, Leon Vintro X, Lopez Fernandez S, Vega Garcia C, Pons Playa G, Fernandez Garrido M, Masia Ayala J. The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses. J Clin Med 2021; 10:jcm10061333. [PMID: 33807085 PMCID: PMC8004983 DOI: 10.3390/jcm10061333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/12/2021] [Accepted: 03/19/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. Methods: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. Results: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. Conclusions: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.
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Affiliation(s)
- Lidia Sanchez-Porro Gil
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
- Correspondence: or
| | - Xavier Leon Vintro
- Department of Otolaryngology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain;
| | - Susana Lopez Fernandez
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Carmen Vega Garcia
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Gemma Pons Playa
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Manuel Fernandez Garrido
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
| | - Jaume Masia Ayala
- Department of Plastic and Reconstructive Surgery, Hospital Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain; (S.L.F.); (C.V.G.); (G.P.P.); (M.F.G.); (J.M.A.)
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Zheng Y, Li Z, Yin M, Gong X. Heme oxygenase‑1 improves the survival of ischemic skin flaps (Review). Mol Med Rep 2021; 23:235. [PMID: 33537805 PMCID: PMC7893698 DOI: 10.3892/mmr.2021.11874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/12/2021] [Indexed: 01/17/2023] Open
Abstract
Heat shock protein 32 (Hsp32), also known as heme oxygenase‑1 (HO‑1), is an enzyme that exists in microsomes. HO‑1 can be induced by a variety of stimuli, including heavy metals, heat shock, inflammatory stimuli, heme and its derivatives, stress, hypoxia, and biological hormones. HO‑1 is the rate‑limiting enzyme of heme catabolism, which splits heme into biliverdin, carbon monoxide (CO) and iron. The metabolites of HO‑1 have anti‑inflammatory and anti‑oxidant effects, and provide protection to the cardiovascular system and transplanted organs. This review summarizes the biological characteristics of HO‑1 and the functional significance of its products, and specifically elaborates on its protective effect on skin flaps. HO‑1 improves the survival rate of ischemic skin flaps through anti‑inflammatory, anti‑oxidant and vasodilatory effects of enzymatic reaction products. In particular, this review focuses on the role of carbon monoxide (CO), one of the primary metabolites of HO‑1, in flap survival and discusses the feasibility and existing challenges of HO‑1 in flap surgery.
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Affiliation(s)
- Yinhua Zheng
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Zhenlan Li
- Department of Rehabilitation Medicine, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Min Yin
- Department of Nephrology, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Xu Gong
- Department of Hand and Foot Surgery, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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Postoperative Management After Total Pharyngolaryngectomy Using the Free Ileocolon Flap: A 5-Year Surgical Intensive Care Unit Experience. Ann Plast Surg 2021; 84:68-72. [PMID: 31246671 DOI: 10.1097/sap.0000000000001953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Management after total pharyngolaryngectomy with free ileocolon flaps can be challenging. Adequate postoperative surgical guidelines are essential to avoid complications. Factors, such as agitation, hypotension, or prolonged mechanical ventilation, might compromise final outcomes. Herein, we describe our experience in the early postoperative care of patients after total pharyngolaryngectomy with immediate reconstruction using the free ileocolon flap. METHODS This is a retrospective review of all patients who underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. Demographics, etiology of resection, neoadjuvant therapy, surgical time, method of sedation, postoperative use of vasopressors, length of intensive care unit (ICU) stay, time of discontinuation of mechanical ventilation, and complications were recorded and analyzed. RESULTS Between 2010 and 2015, a total of 34 patients underwent total pharyngolaryngectomy and immediate reconstruction using the free Ileocolon flap. The most common cause of total pharyngolaryngectomy was cancer. Twenty-eight patients had neoadjuvant therapy (radiation). The average surgical time was 11.5 hours (range, 8-14.5 hours), average length of ICU stay was 3 days (range, 2-15 days) with an average time for mechanical ventilation cessation of 3 days (range, 1-20 days). Midazolam and dexmedetomidine were the most common sedatives used during surgery and in the ICU period. Three patients required vasopressors due to hypotension, 2 had unplanned self-extubation from the tracheostomy site, 2 experienced postoperative bleeding, 1 had pneumonia, 4 required unplanned return to the operating room, 2 had partial flap loss, and 1 had complete flap loss. CONCLUSIONS Overall, a majority of patients recovered well postoperatively with minimal complications and low rate of reoperation. Our research provides a foundation to develop a risk-stratified approach to determine the need for an ICU admission or early transfer to floor care.
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Nnamani Silva ON, Nguyen AB, Hoffman WY. Craniectomy with microvascular flap reconstruction in a patient taking infliximab for vasculitis. BMJ Case Rep 2020; 13:13/12/e238614. [PMID: 33298502 DOI: 10.1136/bcr-2020-238614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
For patients whose vasculitis is managed with biologic medications, no reports or evidence-based guidance exists regarding the perioperative management of microvascular flaps. We present a case of a 78-year-old patient with Takayasu's arteritis (TA) and diabetes mellitus who was taking infliximab and underwent wide local excision of squamous cell carcinoma, craniectomy and reconstruction with a latissimus dorsi flap. TA, an immune-mediated large cell vasculitis characterised by granuloma formation, tends to affect larger vessels and aortic branches. The typical localisation of this condition raises concerns about potentially compromised pedicle and recipient vessels (ie, superficial temporal arteries), which could hinder postoperative flap success. Discontinuation of infliximab 4 weeks before surgery and resumption 6 weeks after led to favourable results. This case addresses the gap in the literature concerning stopping and restarting biologic drugs in the perioperative setting and documents a successful course of a microvascular procedure in a patient with vasculitis.
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Affiliation(s)
- Ogonna N Nnamani Silva
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Audrey B Nguyen
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
| | - William Y Hoffman
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California San Francisco, San Francisco, California, USA
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Zapata-Ospina A, Chen J, Tee R, Jeng SF, Karki B, Shih HS. Harvesting the anterolateral thigh flap with non-sizable perforators. J Plast Reconstr Aesthet Surg 2020; 74:1022-1030. [PMID: 33551361 DOI: 10.1016/j.bjps.2020.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present. METHODS A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival. SURGICAL TECHNIQUE Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle. RESULTS A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites. CONCLUSIONS It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.
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Affiliation(s)
- Alejandro Zapata-Ospina
- Plastic, Reconstructive and Microsurgery Department, Pablo Tobón Uribe Hospital, Cl. 78b #69-240, Medellín, Antioquia, Colombia
| | - Jill Chen
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Richard Tee
- Auckland Regional Plastic Reconstructive and Hand Surgery Service, Middlemore Hospital, 100 Hospital Road, Auckland, New Zealand
| | - Seng-Feng Jeng
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C
| | - Bishal Karki
- Department of Burns, Plastic & Reconstructive Surgery, Kirtipur Hospital, Swet Binayak Marg, Thapathali-11, Kathmandu, Nepal
| | - Hsiang-Shun Shih
- Department of Plastic and Reconstructive Surgery, E-Da Hospital, No.1 Yida Road, Jiaosu Village, Yanchao District, Kaohsiung City 82445, Taiwan, R.O.C..
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Reconstruction of Full-thickness Soft Tissue Defects with Integra: Risk Factors and Treatment Algorithm. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3099. [PMID: 33133950 PMCID: PMC7544316 DOI: 10.1097/gox.0000000000003099] [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: 11/22/2019] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
Background: Despite the fact that dermal substitutes are widely used in reconstructive surgery, there have been no studies focused on predictors of complications or delayed matrix take. We propose an algorithm for management of soft tissue reconstruction with Integra dermal matrix, based on our 5-year-long clinical experience. Methods: An estimated 111 patients who underwent Integra reconstruction of full-thickness soft tissue defects of different anatomical sites and etiology were enrolled, and dichotomized in two groups according to complications. Participants were further studied according to the wound healing strategy: healing by secondary intention, skin graft (STSG), and flap surgery. A regression analysis was conducted in the whole sample to identify possible predictors of complications. Results: No significant differences according to complications were observed. The between-group statistical analysis showed significant differences in age, comorbidities, defect area, diagnosis, and defect site. The regression analysis revealed that the timing of split-thickness skin graft (STSG) was not influenced by age, comorbidities, body mass index (BMI), defect area, site, wound etiology, and risk factors in the subjects who underwent a two-step reconstruction. Healing by secondary intention is recommended for small post-oncological defects of the head, especially in elderly and multimorbid patients. Variables that may interfere with dermal substitutes’ incorporation are independent of the timing of STSG placement; therefore, no predictors of complications or delayed matrix take were identified. Conclusions: Our findings showed that Integra can be used in a wide range of patients regardless of their general features, thus acting as a useful alternative to conventional reconstructive techniques in selected cases.
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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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Karamanos E, Shah AR, Kim JN, Wang HT. Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching. J Reconstr Microsurg 2020; 37:315-321. [PMID: 32892332 DOI: 10.1055/s-0040-1716388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis. METHODS The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications. RESULTS A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications. CONCLUSION Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.
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Affiliation(s)
- Efstathios Karamanos
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Amita R Shah
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Julie N Kim
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
| | - Howard T Wang
- Department of Surgery, Division of Plastic and Reconstructive Surgery, UT Health San Antonio, San Antonio, Texas
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Giovacchini F, Bensi C, Paradiso D, Docimo R, Tullio A. Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2020; 278:2171-2185. [PMID: 32870364 DOI: 10.1007/s00405-020-06286-z] [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: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery. METHODS The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale. RESULTS A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81). CONCLUSIONS The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.
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Affiliation(s)
- Francesco Giovacchini
- Maxillo-Facial Surgery Unit, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Caterina Bensi
- Paediatric Dentistry Post-Graduate School, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy.
| | - Daniele Paradiso
- S.S.D. of Oral Surgery and Ambulatory, Santa Maria Della Misericordia Hospital, Piazza Menghini 1, San Sisto, Perugia, Italy
| | - Raffaella Docimo
- Paediatric Dentistry, Department of Surgical Sciences, University of Rome "Tor Vergata", Via Montpellier 1, Rome, Italy
| | - Antonio Tullio
- Maxillo-Facial Surgery, University of Perugia, Perugia, Italy
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Garip M, Van Dessel J, Grosjean L, Politis C, Bila M. The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis. Br J Oral Maxillofac Surg 2020; 59:e79-e98. [PMID: 33546845 DOI: 10.1016/j.bjoms.2020.07.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 07/17/2020] [Indexed: 12/15/2022]
Abstract
Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75-33.49; p<0.01), and of 4.57% for overall surgical complications (95% CI: 1.97-7.15; p<0.01). No significant difference in risk was found for flap failure (95% CI: -4.33-9.90; p=0.44), surgical site infection (95% CI: -0.88-2.60; p=0.33) and fistula formation (95% CI: -3.81-3.71; p=0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I2=63.02%; p=0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.
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Affiliation(s)
- M Garip
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium.
| | - J Van Dessel
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - L Grosjean
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - C Politis
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
| | - M Bila
- Department of Oral and Maxillofacial Surgery, University Hospitals Leuven, Campus Sint-Rafaël, Kapucijnenvoer 33, 3000 Leuven, Belgium; OMFS-IMPATH Research Group, Department of Imaging and Pathology, Faculty of Medicine, University of Leuven, Kapucijnenvoer 33, 3000 Leuven, Belgium
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Yu J, Hong JP, Suh HP, Park JY, Kim DH, Ha S, Lee J, Hwang JH, Kim YK. Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction. Nutrients 2020; 12:nu12020562. [PMID: 32098138 PMCID: PMC7071524 DOI: 10.3390/nu12020562] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3), with a PNI <40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p <0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 ± 55.5 days vs. 28.3 ± 24.4 days, p <0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.
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Affiliation(s)
- Jihion Yu
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.P.H.); (H.P.S.)
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.P.H.); (H.P.S.)
| | - Jun-Young Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Seungsoo Ha
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Joonho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Jai-Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
| | - Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea; (J.Y.); (J.-Y.P.); (D.-H.K.); (S.H.); (J.L.); (J.-H.H.)
- Correspondence: ; Tel.: +82-2-3010-5976
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Matošević M, Pegan A, Sambunjak D, Solter D, Vagić D, Rašić I, Košec A. Significance of Anthropometric and Nutritive Factors in Oral and Oropharyngeal Cancer Patients Undergoing Free Flap Reconstruction. J Oral Maxillofac Surg 2019; 78:644-650. [PMID: 31838094 DOI: 10.1016/j.joms.2019.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/12/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE This study analyzed associations between preoperative nutritional status and the incidence of early postoperative complications as a primary outcome in patients with oral and oropharyngeal cancer undergoing free flap reconstruction. We hypothesized that preoperative nutritional status may be linked with specific complications, allowing for better preoperative risk assessment. PATIENTS AND METHODS This longitudinal, retrospective cohort study encompassed 113 patients, all treated surgically for oral and oropharyngeal cancer in the period from March 2013 up to March 2018 in a tertiary referral center. Variables considered were preoperative and postoperative serum albumin and protein values; body mass index; waist-to-hip ratio; circumference of the neck, waist, hip, and thigh; number of cigarettes smoked per day during the 10-year period before surgery; average alcohol consumption; operative time; and postoperative albumin administration. RESULTS Our study identified preoperative protein serum concentration (≤62 g/L), postoperative albumin administration (≥200 mL), number of cigarettes smoked per day (>20), and prolonged operative time (≥450 minutes) to be associated with postoperative complications. CONCLUSIONS This is the first study reporting cutoff values of clinical significance in assessing patient preoperative nutritional status in light of reducing postoperative complications after free flap reconstruction.
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Affiliation(s)
- Marijana Matošević
- Student, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Alan Pegan
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Dario Sambunjak
- Assistant Professor, Department of Sociology, Catholic University of Croatia, Zagreb, Croatia
| | - Darko Solter
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Davor Vagić
- Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ivan Rašić
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Andro Košec
- Assistant Professor, Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Centre Sestre Milosrdnice, University of Zagreb School of Medicine, Zagreb, Croatia.
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Retrospective evaluation of diagnostic accuracy of free flap monitoring with the Cook-Swartz-Doppler probe in head and neck reconstruction. J Craniomaxillofac Surg 2019; 47:1973-1979. [PMID: 31810844 DOI: 10.1016/j.jcms.2019.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/13/2019] [Accepted: 11/15/2019] [Indexed: 11/21/2022] Open
Abstract
The Cook-Swartz-Doppler probe is an easy to handle and reliable tool for free flap monitoring. In the head and neck region different confounders can affect the read out. We therefore analyzed the use of the Doppler probe regarding these potential difficulties and to compare the diagnostic accuracy in arterial or venous monitoring of free flaps in the head and neck region. A retrospective study was performed in which all patients were included who underwent free flap surgery in the head and neck region in the Department of Plastic Surgery and the Department of Maxillofacial Surgery of our institution between 2010 and 2018 and were monitored with an implanted Doppler probe. 147 free tissue transfers were included. No significance was found for arterial and venous placement of the Doppler probe for sensitivity (artery 83.3%; vein 84.6%; p = 0.87), specificity (artery 89.2%; vein 96.1%; p = 0.17) and negative predictive value (artery 96.7%; vein 94.2%; p = 0.55). A better positive predictive value for placing the Doppler probe around the artery (82.7%) than the vein (61.1%) was found in our study (p = 0.056). The better positive predictive value in arterial monitoring suggests that this is the more reliable measuring method to assess flap perfusion in the head and neck region.
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Miyamoto S, Arikawa M, Kagaya Y, Kageyama D, Fukunaga Y. Large-to-Small End-to-Side Venous Anastomosis in Free Flap Transfer. J Surg Res 2019; 245:377-382. [PMID: 31425879 DOI: 10.1016/j.jss.2019.07.084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 06/03/2019] [Accepted: 07/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Vessel size discrepancy is one of the major risk factors for anastomotic failure in free flap transfer. The situation becomes challenging for reconstructive microsurgeons when the recipient vein is much smaller than the flap vein. We investigated the feasibility of large-to-small end-to-side venous anastomosis for such cases. MATERIALS AND METHODS The subjects were 16 consecutive patients who underwent a free flap transfer for oncologic defects with a large-to-small end-to-side venous anastomosis. The larger flap vein was anastomosed to the side slit of the smaller recipient vein under an operating microscope. Surgical details and postoperative outcome were investigated retrospectively. RESULTS An anterolateral thigh flap was used in five patients, a superficial inferior epigastric artery flap in four, a thoracodorsal artery perforator flap in three, and a latissimus dorsi musculocutaneous flap and a fibular osteocutaneous flap in two patients each. The internal mammary vein and the anterior tibial vein were most frequently used as a recipient vein (four patients each), followed by the deep inferior epigastric vein (three patients). The extent of vessel size discrepancy ranged from 1.3- to 3.3-fold, and the mean discrepancy was 1.9-fold. No anastomotic failure occurred postoperatively, and the flap survived in all patients. CONCLUSIONS Large-to-small end-to-side venous anastomosis can be a versatile option when only a small vein is available as a recipient vein. Internal mammary, deep inferior epigastric, and anterior tibial veins are good candidates for this technique.
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Affiliation(s)
- Shimpei Miyamoto
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan.
| | - Masaki Arikawa
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yu Kagaya
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Kageyama
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Fukunaga
- Department of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Lin Y, He JF, Zhang X, Wang HM. Intraoperative factors associated with free flap failure in the head and neck region: a four-year retrospective study of 216 patients and review of the literature. Int J Oral Maxillofac Surg 2019; 48:447-451. [DOI: 10.1016/j.ijom.2018.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 12/15/2022]
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Augustine HFM, Hu J, Najarali Z, McRae M. Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research. Plast Surg (Oakv) 2019; 27:54-65. [PMID: 30854363 DOI: 10.1177/2292550318800499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research. Methods A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication. Results A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery. Conclusion This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.
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Affiliation(s)
- Haley F M Augustine
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Jiayi Hu
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Zainab Najarali
- Department of Family Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Matthew McRae
- Department of Plastic Surgery, McMaster University, Hamilton, Ontario, Canada
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Is the Medial Sural Artery Perforator Flap a New Workhorse Flap? A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2019; 143:393e-403e. [DOI: 10.1097/prs.0000000000005204] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Targosinski S, Reichert B. Formation of a sensate forearm stump through neurovascular tissue transplantation. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-018-1433-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Multiple specialties have demonstrated increased risk of certain postoperative complications in patients with an increased body mass index (BMI). The goal of this study was to understand the outcomes of patients undergoing parotidectomy with an increased BMI and to identify any other patient risk factors for postoperative complications. This study was a retrospective chart review of 432 patients. Patient variables collected included BMI, age, gender, history of diabetes mellitus, type of parotidectomy, and pathology. Outcomes reviewed included facial nerve weakness, hematoma or seroma formation, and wound infection. The results showed that BMI had no statistically significant effect on complications. However, patients undergoing a total parotidectomy, malignant pathology, and patients with a history of diabetes mellitus had significantly more postoperative facial weakness. In conclusion, BMI does not influence postoperative complications in patients undergoing parotidectomy. Patients with diabetes, those undergoing total parotidectomies, and patients with malignant pathology have significantly more facial weakness and should be counseled accordingly.
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Kantar RS, Rifkin WJ, David JA, Cammarata MJ, Diaz-Siso JR, Levine JP, Golas AR, Ceradini DJ. Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database. Microsurgery 2018; 39:14-23. [PMID: 29719063 DOI: 10.1002/micr.30332] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/07/2018] [Accepted: 04/06/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders. RESULTS We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (β = .62; P < .001). CONCLUSIONS Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.
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Affiliation(s)
- Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Joshua A David
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Michael J Cammarata
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Alyssa R Golas
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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48
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Kearns MC, Baker J, Myers S, Ghanem A. Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018; 41:379-386. [PMID: 30100675 PMCID: PMC6061500 DOI: 10.1007/s00238-018-1417-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/28/2018] [Indexed: 12/02/2022]
Abstract
BACKGROUND Despite significant improvements in survival rates, free flap failures still occur even in experienced hands and are most commonly due to arterial or venous thrombosis. In the absence of an evidence-based guideline on the prevention of thrombosis, we reviewed the literature to assess the evidence base for commonly used interventions aimed at its prevention. METHODS A comprehensive literature search was performed using the following keywords "free flap" and microsurgery with "pre-operative screening," "prevention of thrombosis," "ketorolac," "heparin," "low molecular weight heparin," "aspirin," "dextran," and "statins." RESULTS Thirteen clinical studies were included in this review. No high-level evidence is available to support any perioperative or postoperative interventions aimed at reducing the risk of flap thrombosis. CONCLUSIONS Higher level studies are needed to investigate the clinical use of antithrombotic medications in microsurgery; however, given the small failure rates in modern practice, these will need to be large multicenter trials in order to reach sufficient power.Level of Evidence: Level III, risk/prognostic study.
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Affiliation(s)
- Marie C. Kearns
- Academic Plastic Surgery, Barts and the London School of Medicine and Dentistry, London, UK
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Jill Baker
- Academic Plastic Surgery, Barts and the London School of Medicine and Dentistry, London, UK
- Department of Plastic Surgery, St John’s Hospital, Livingston, West Lothian UK
| | - Simon Myers
- Academic Plastic Surgery, Barts and the London School of Medicine and Dentistry, London, UK
| | - Ali Ghanem
- Academic Plastic Surgery, Barts and the London School of Medicine and Dentistry, London, UK
- Centre for Cutaneous Research, Blizard Institute - Barts and The London School of Medicine, 4 Newark St, London, E1 2AT UK
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49
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Eskander A, Kang SY, Tweel B, Sitapara J, Old M, Ozer E, Agrawal A, Carrau R, Rocco J, Teknos TN. Quality Indicators: Measurement and Predictors in Head and Neck Cancer Free Flap Patients. Otolaryngol Head Neck Surg 2018; 158:265-272. [DOI: 10.1177/0194599817742373] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective To determine the predictors of length of stay (LOS), readmission within 30 days, and unplanned return to the operating room (OR) within 30 days in head and neck free flap patients. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (OSU, 2006-2012) were assessed. Multivariable logistic regression to assess the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results In total, 515 patients were identified, of whom 66% had oral cavity cancers, 33% had recurrent tumors, and 28% underwent primary radiotherapy. Of the patients, 31.5% had a LOS greater than 9 days, predicted by longer operative time, oral cavity and pharyngeal tumor sites, blood transfusion, diabetes mellitus, and any complication. A total of 12.6% of patients were readmitted within 30 days predicted by absent OSU preoperative assessment clinic attendance and any complication, and 14.8% of patients had an unplanned OR return predicted by advanced age. Conclusions When assessing quality metrics, adjustment for the complexity involved in managing patients with head and neck cancer with a high comorbidity index, clean contaminated wounds, and a high degree of primary radiotherapy is important. Patients seen in a preoperative assessment clinic had a lower risk of readmission postoperatively, and this should be recommended for all head and neck free flap patients. Quality improvement projects should focus on predictors and prevention of complications as this was the number one predictor of both increased length of stay and readmission.
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Affiliation(s)
- Antoine Eskander
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, University of Toronto, Sunnybrook Health Sciences Centre and Michael Garron Hospital, Toronto, Ontario, Canada
| | - Stephen Y. Kang
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Benjamin Tweel
- Department of Otolaryngology–Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jigar Sitapara
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Matthew Old
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Enver Ozer
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Amit Agrawal
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Ricardo Carrau
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - James Rocco
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
| | - Theodoros N. Teknos
- Department of Otolaryngology–Head & Neck Surgery, Division of Head & Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, Ohio, USA
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50
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Bouveau V, Potage D, Dubory A, Chevallier R, Meningaud JP, Niddam J, Flouzat-Lachaniette CH. A Distally Based Sartorius Muscle Flap for a Gustilo Grade-III Open Fracture of the Lateral Femoral Condyle and the Head of the Fibula with a Complex Soft-Tissue Defect: A Case Report and Review of the Literature. JBJS Case Connect 2017; 7:e93. [PMID: 29244658 DOI: 10.2106/jbjs.cc.17.00071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We present a case of lower-limb trauma associated with an extensive soft-tissue defect around the knee joint, which led to the exposure of bone and the metalwork that was used for the management of the associated fractures. Coverage was performed with a distally based sartorius muscle flap in a single-stage procedure, allowing good recovery with a nice aesthetic and functional outcome at the 1-year follow-up. Additionally, we discuss alternative options for the coverage of severe soft-tissue defects based on the clinical context. CONCLUSION A distally based sartorius muscle flap may be a suitable alternative for coverage of complex soft-tissue defects around the knee joint.
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Affiliation(s)
- Victoire Bouveau
- Departments of Orthopaedic Surgery (V.B., D.P., A.D., R.C., and C.-H.F.-L) and Plastic Surgery (J.-P.M and J.N.), Hôpital Henri Mondor (Assistance Publique-Hôpitaux de Paris), Université Paris Est Créteil (UPEC), Créteil Cedex, France
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