The Value of the Nutritional Indicators in Predicting Free Flap Failure From a Multicentre Database

OBJECTIVE

Nutritional and inflammatory statuses have been associated with complications in microvascular-free flaps during head and neck surgeries. This study aimed to evaluate the potential of nutritional indicators in predicting postoperative free flap complications.

STUDY DESIGN

We conducted a 20-year retrospective, case-control study within a defined cohort.

SETTING

The study involved head and neck cancer patients from the Chang Gung Research Database who underwent simultaneous tumor ablation and free flap wound reconstruction between January 1, 2001, and December 31, 2019.

METHODS

We employed logistic regression and stratified analysis to assess the risk of free flap complications and the subsequent need for flap revision or redo in relation to nutritional indicators and other clinical variables.

RESULTS

Of the 8066 patients analyzed, 687 (8.5%) experienced free flap complications. Among these, 197 (2.4%) had free flap failures necessitating a redo of either a free flap or a pedicled flap. Beyond comorbidities such as chronic obstructive pulmonary disease, end-stage renal disease, and a history of prior radiotherapy, every 10-unit decrease in the preoperative prognostic nutritional index (PNI) was consistently associated with an increased risk of both free flap complications and failure. The covariate-adjusted odds ratios were 1.90 (95% confidence interval [CI]: 1.42-2.54) and 1.89 (95% CI: 1.13-3.17), respectively.

CONCLUSION

A lower preoperative PNI suggests a higher likelihood of microvascular free flap complications in head and neck surgeries. Further randomized controlled trial designs are required to establish causality.

The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer

BACKGROUND

Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients.

METHODS

A 20-year retrospective case-control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis.

RESULTS

Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12-5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders.

CONCLUSIONS

Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population.

LEVEL OF EVIDENCE: 3

The use of artificial intelligence in reconstructive surgery for head and neck cancer: a systematic review

OBJECTIVES

The popularity of artificial intelligence (AI) in head and neck cancer (HNC) management is increasing, but postoperative complications remain prevalent and are the main factor that impact prognosis after surgery. Hence, recent studies aim to assess new AI models to evaluate their ability to predict free flap complications more effectively than traditional algorithms. This systematic review aims to summarize current evidence on the utilization of AI models to predict complications following reconstructive surgery for HNC.

METHODS

A combination of MeSH terms and keywords was used to cover the following three subjects: "HNC," "artificial intelligence," and "free flap or reconstructive surgery." The electronic literature search was performed in three relevant databases: Medline (Ovid), Embase (Ovid), and Cochrane. Quality appraisal of the included study was conducted using the TRIPOD Statement.

RESULTS

The review included a total of 5 manuscripts (n = 5) for a total of 7524 patients. Across studies, the highest area under the receiver operating characteristic (AUROC) value achieved was 0.824 by the Auto-WEKA model. However, only 20% of reported AUROCs exceeded 0.70. One study concluded that most AI models were comparable or inferior in performance to conventional logistic regression. The highest predictors of complications were flap type, smoking status, tumour location, and age.

DISCUSSION

Some models showed promising results. Predictors identified across studies were different than those found in existing literature, showing the added value of AI models. However, the algorithms showed inconsistent results, underlying the need for better-powered studies with larger databases before clinical implementation.

Reconstructive flap surgery in head and neck cancer patients: an interdisciplinary view of the challenges encountered by radiation oncologists in postoperative radiotherapy

Background

Major advances have been made in reconstructive surgery in the last decades to reduce morbidity in head and neck cancer. Flaps are now present in 80% of patients with oral cavity cancer to cover anatomic, functional, and cosmetic needs. However, gaps in interdisciplinary innovation transfer from surgery to postoperative radiotherapy (poRT) remain challenging. We aimed to provide an interdisciplinary view of the challenges encountered by radiation oncologists in planning head and neck postoperative radiotherapy.

Methods

A systematic and critical review was conducted to address areas of optimization in surgery and radiology that may be relevant to poRT.

Results

Despite extensive surgical literature on flap techniques and salvage surgery, 13 retrospective series were identified, where flap outcomes were indirectly compared between surgery alone or poRT. These low-evidence studies suggest that radiotherapy accelerates flap atrophy, fibrosis, and osteoradionecrosis and deteriorates functional outcomes. Preliminary evidence suggests that tumor spread occurs at the flap-tissue junction rather than in the flaps. One prospective 15-patient study showed 31.3% vs. 39.2% flap volume reduction without or with poRT. In an international consensus, experts recognized the needs for optimized flap-sparing poRT against flap-related functional deterioration and bone damage. CT, MRI, and PET-CT modalities show potential for the delineation of the junction area between native tissues and flap for flap segmentation and to characterize flap-specific changes quantitatively and correlate them with patterns of relapse or complications.

Conclusion

Flap management in poRT is insufficiently documented, but poRT seems to damage flaps. Current gaps in knowledge underscore the need for prospective flap assessment and interdisciplinary trials investigating flap morbidity minimization by flap-sparing poRT planning.

Postoperative inpatient surgical complications following head and neck microvascular free tissue transfer

BACKGROUND

Complications following head and neck microvascular free tissue transfer (MFTT) are common. Less is known about when they occur.

METHOD

Retrospective study of patients with primary or recurrent head and neck cancer undergoing MFTT reconstruction at a tertiary care institution. MFTT reconstructions with inpatient postoperative complications were included. The Kruskal-Wallis test was used to compare median postoperative day (POD) onset of complication by flap type.

RESULTS

Of 1090 patients undergoing MFTT reconstruction, 126 (11.6%) patients experienced inpatient complications including fibula (n = 35), anterolateral thigh (n = 60), or radial forearm (n = 31) MFTTs. POD onset was shortest for surgical site hematoma (median = 1 [IQR 1-5]), and longest for donor site infection (median = 11.5 [IQR 8-15]). There was no significant difference between flap types and POD onset of complications (p > 0.05).

CONCLUSION

Hematoma formation and flap failure occur earliest during hospitalization, while dehiscence, infection, and fistula occur later. There is no difference in complication timing between flap types.

A Survey of Microvascular Technique Preferences Among American Head Neck Society Members

OBJECTIVE

To identify practices in microvascular techniques in routine and challenging scenarios.

STUDY DESIGN

Cross-sectional study.

METHODS

A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021.

RESULTS

The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029).

CONCLUSIONS

This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1265-1277, 2024.

The Perfect Timing-Immediate versus Delayed Microvascular Reconstruction of the Mandible

In this retrospective study, the clinical and economic implications of microvascular reconstruction of the mandible were assessed, comparing immediate versus delayed surgical approaches. Utilizing data from two German university departments for oral and maxillofacial surgery, the study included patients who underwent mandibular reconstruction following continuity resection. The data assessed included demographic information, reconstruction details, medical history, dental rehabilitation status, and flap survival rates. In total, 177 cases (131 male and 46 females; mean age: 59 years) of bony free flap reconstruction (72 immediate and 105 delayed) were included. Most patients received adjuvant treatment (81% with radiotherapy and 51% combined radiochemotherapy), primarily for tumor resection. Flap survival was not significantly influenced by the timing of reconstruction, radiotherapy status, or the mean interval (14.5 months) between resection and reconstruction. However, immediate reconstruction had consumed significantly fewer resources. The rate of implant-supported masticatory rehabilitation was only 18% overall. This study suggests that immediate jaw reconstruction is economically advantageous without impacting flap survival rates. It emphasizes patient welfare as paramount over financial aspects in clinical decisions. Furthermore, this study highlights the need for improved pathways for masticatory rehabilitation, as evidenced by only 18% of patients with implant-supported dentures, to enhance quality of life and social integration.

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis

BACKGROUND

 Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes.

METHODS

 A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status.

RESULTS

 Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts.

CONCLUSION

 Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.

Introduction and preliminary application report for a novel 3D printed perforator navigator for fibular flap surgery

The aim of this study was to introduce and report on a 3D-printed perforator navigator and its clinical application. Integrated imaging and 3D printing techniques were employed for the design and manufacture of a perforator navigator. Key techniques included establishing a digital image coordinate system, localizing perforator fascia piercing points, creating a reference plane for the perforator course, and projecting the perforator course onto the body surface. All cases of maxillofacial defect repaired with free fibular myocutaneous flaps, from January 2019 to January 2022, were reinvestigated. Patients treated using traditional perforator localization methods were assigned into group Ⅰ, while those who had a navigator used during treatment were allocated to group Ⅱ. Outcome measurements included perforator positioning accuracy, perforator preparation time (PT), and flap growth score. Capillary refilling time and degree of flap swelling were recorded on the 1st, 3rd, and 7th days after surgery. On the 10th day after surgery, the flap survival situation was graded. In total, 25 patients were included in the study. Perforator preparation time for group Ⅱ was significantly less (p ＝ 0.04) than for group Ⅰ (1038.6 ± 195.4 s versus 1271.4 ± 295.1 s. In group Ⅱ, the mean positioning deviation for the perforator navigator was 2.12 cm less than that for the high-frequency color Doppler (p ＝ 0.001). Group Ⅱ also had a higher score than group Ⅰ for overall flap growth evaluation (nonparametric rank sum test, p ＝ 0.04). Within the scale of the study, it seems that perforator localization and navigation using a 3D-printed navigator is technically feasible, and helps to improve the clinical outcome of free fibular flaps. The perforator navigator will play a useful role in displaying the perforator course, improving the accuracy of perforator localization, reducing surgical injury, and ultimately enhancing flap success rate.

Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study

Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.

Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19

INTRODUCTION

Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state.

METHODS

This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022.

RESULTS

Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period.

CONCLUSION

Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications.

LEVEL OF EVIDENCE

4 Laryngoscope, 2023.

Outcomes Associated with Multiple Free Tissue Transfers Performed in a Single Day

Background: Although microvascular free tissue transfer (MFTT) remains technically challenging, surgeons may need to perform >1 MFTT operations in a given day. Objective: To compare MFTT outcomes in cases where surgeons completed one versus two flaps per day by measuring flap viability and complication rates. Methods: A retrospective review was conducted of MFTT cases from January 2011 to February 2022 with >30-day follow-up. Outcomes, including flap survival and operating room takeback, were compared using multivariate logistic regression analysis. Results: Of 1096 patients meeting inclusion criteria (1105 flaps), there was a male predominance (n = 721, 66%). Mean age was 63.0 ± 14.4 years. Complications requiring takeback were identified in 108 flaps (9.8%) and were greatest for double flaps in the same patient (SP) (27.8%, p = 0.06). Flap failure occurred in 23 (2.1%) cases and was also greatest for double flaps in the SP (16.7%, p = 0.001). Takeback (p = 0.06) and failure (p = 0.70) rates were not different between days with one versus two unique patient flaps. Conclusions: Among patients undergoing MFTT, those treated on days in which surgeons perform two unique cases compared with single cases will demonstrate no difference in outcomes, as measured by flap survival and takeback, whereas patients with defects requiring multiple flaps will experience greater takeback and failure rates.

Is Preoperative Serum Albumin Predictive of Adverse Outcomes in Head and Neck Cancer Surgery?

BACKGROUND

Patients with head and neck cancer are at increased risk of malnutrition due to tumor burden and surgical morbidity.

PURPOSE

The purpose of this study was to evaluate the association between preoperative serum albumin and 30-day adverse outcomes in patients undergoing head and neck cancer surgery.

STUDY DESIGN, SETTING, SAMPLE

This was a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. Patients undergoing an ablative head and neck cancer procedure were included. Patients who had an unclear tumor location based on coding or missing outcome data were excluded.

PREDICTOR VARIABLE

The primary predictor variable was preoperative albumin categorized as low (<3.4 g/dL), intermediate (3.4 to 3.9 g/dL), or high (>3.9 g/dL).

OUTCOME VARIABLE

The primary outcome variable was intensive care unit (ICU)-level complications scored using the Clavien-Dindo classification system. This is a tool used to grade surgical complications, with grade IV and V complications defined as requiring ICU-level care.

COVARIATES

Covariates were demographic (age, sex, body mass index), medical (smoking, functional status, weight loss), and perioperative (concurrent procedures, tumor location, reconstructive modality).

ANALYSES

Descriptive, bivariate, and multiple logistic regression with bootstrap resampling statistics were used to evaluate the association between albumin and adverse outcomes. A significance level of P ≤ .05 was significant.

RESULTS

A total of 4,491 subjects met inclusion criteria and had a documented albumin. There were 435 subjects with low albumin levels, 1,305 with intermediate levels, and 2,751 with high levels. In bivariate analysis, low albumin levels were associated with an increased risk of ICU-level complications, any complication, extended length of stay, and adverse discharge disposition (all P ≤ .001), while high levels were protective (all P ≤ .001). In bootstrapped multivariate analysis using intermediate albumin as the reference group and adjusting for demographics, tumor location, and reconstructive modality among others, low albumin levels were an independent predictor of ICU-level complications (P = .008, odds ratio, 1.64; 95% confidence interval, 1.14 to 2.40), while high levels were protective (P = .014, odds ratio, 0.689; 95% confidence interval, 0.521 to 0.923).

CONCLUSIONS

Preoperative serum albumin was an independent predictor of adverse outcomes following ablative head and neck cancer procedures.

Effect of 2 Teams and Operative Time on Complications After Oral Cavity Free Flap Reconstruction

OBJECTIVE

Evaluate the effects of operative time and 2 team approach on complications after soft tissue free flap reconstruction for oral tongue cancer.

METHODS

Patients with oncologic glossectomy with myocutaneous or fasciocutaneous free flap reconstruction were included from the 2015 to 2018 American College of Surgery National Surgical Quality Improvement Program. The primary predictive variables assessed were operative time and 2 team approach; control variables included age, sex, body mass index (BMI), 5-question-modified frailty index (mFI-5), American Society of Anesthesiologists (ASA) class, and total work relative value units (wRVU). Outcomes assessed included 30-day mortality, 30-day reoperation, hospital length of stay beyond 30 days, readmission, medical and surgical complications, and non-home discharge. Multivariable logistic/linear regression models were used to predict surgical outcomes.

RESULTS

Microvascular soft tissue free flap reconstruction of the oral cavity after glossectomy was performed on 839 patients. Operative time was independently associated with readmission, prolonged length of stay, surgical complications, medical complications, and non-home discharge. A 2-team approach was independently associated with prolonged length of stay and medical complications. The mean operative time of the 1-team and 2-team approach was 8.73 and 9.13 hours. The 1-team approach did not significantly increase operative time (P = .16).

CONCLUSIONS

In the largest study to date of operative time on post-surgical outcomes after glossectomy and soft tissue free flap reconstruction, we found longer operative times increased rates of postoperative complications and non-home discharge. The 1-team approach is non-inferior to the 2-team approach with respect to operating time and complications.

Current role of artificial intelligence in head and neck cancer surgery: a systematic review of literature

Aim

Artificial intelligence (AI) is a new field of science in which computers will provide decisions-supporting tools to help doctors make difficult clinical choices. Recent AI applications in otolaryngology include head and neck oncology, rhinology, neurotology, and laryngology. The aim of this systematic review is to describe the potential uses of AI in head and neck oncology with a special focus on the surgical field.

Methods

The authors performed a systematic review, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, in the main medical databases, including PubMed, Scopus, and Cochrane Library, considering all original studies published until February 2023 about the role of AI in head and neck cancer surgery. The search strategy included a combination of the following terms: "artificial intelligence" or "machine learning" and "head and neck cancer".

Results

Overall, 303 papers were identified and after duplicate removal (12 papers) and excluding papers not written in English (1 paper) and off-topic (4 papers), papers were assessed for eligibility; finally, only 12 papers were included. Three main fields of clinical interest were identified: the most widely investigated included the role of AI in surgical margins assessment (7 papers); the second most frequently evaluated topic was complications assessment (4 papers); finally, only one paper dealt with the indication of salvage laryngectomy after primary radiotherapy.

Conclusions

The authors report the first systematic review in the literature concerning the role of AI in head and neck cancer surgery. An increasing influx of AI applications to clinical problems in otolaryngology is expected, so specialists should be increasingly prepared to manage the constant changes. It will always remain critical for clinicians to use their skills and knowledge to critically evaluate the additional information provided by AI and make the final decisions on each patient.

From bench to bedside - current clinical and translational challenges in fibula free flap reconstruction

Fibula free flaps (FFF) represent a working horse for different reconstructive scenarios in facial surgery. While FFF were initially established for mandible reconstruction, advancements in planning for microsurgical techniques have paved the way toward a broader spectrum of indications, including maxillary defects. Essential factors to improve patient outcomes following FFF include minimal donor site morbidity, adequate bone length, and dual blood supply. Yet, persisting clinical and translational challenges hamper the effectiveness of FFF. In the preoperative phase, virtual surgical planning and artificial intelligence tools carry untapped potential, while the intraoperative role of individualized surgical templates and bioprinted prostheses remains to be summarized. Further, the integration of novel flap monitoring technologies into postoperative patient management has been subject to translational and clinical research efforts. Overall, there is a paucity of studies condensing the body of knowledge on emerging technologies and techniques in FFF surgery. Herein, we aim to review current challenges and solution possibilities in FFF. This line of research may serve as a pocket guide on cutting-edge developments and facilitate future targeted research in FFF.

Intraoperative Enteral Nutrition Feeding in Free-Flap Healing after Reconstruction Surgery for Head and Neck Cancers

OBJECTIVE

To investigate the beneficial outcomes of intraoperative enteral feeding in free-flap regeneration after extended head and neck cancer resection and flap reconstruction surgery.

STUDY DESIGN

A pilot randomized, double-blind, placebo-controlled clinical trial.

SETTING

Single tertiary care center.

METHODS

Patients with advanced head and neck cancers requiring radical tumor resections and free-flap reconstruction were randomly assigned to receive intraoperative enteral nutrition feeding (100 kcal/100 mL at 10-20 mL/h) via a nasogastric tube during free-flap reconstruction (n = 28) or continue fasting (n = 28). The primary outcome was impaired free-flap regeneration that required surgical reintervention within 90 days after the operation. Participants were enrolled between April 2020 and January 2022; the 90-day follow-up ended in April 2022.

RESULTS

The incidence of total or partial flap failure was similar between the 2 groups (14.2% or n = 4 in each group), but the rate of wound dehiscence or edge necrosis was significantly reduced in the feeding group (n = 6 vs 0 for fasting vs feeding; absolute risk reduction, 25.0% [95% confidence interval, 6.9-43.0]%; p = 0.022). Hospital stay length was shorter (p = 0.042) and hand grip strength was better preserved (p = 0.025) in the feeding group. Plasma concentrations of interleukin (IL)-6 and IL-8 after the operation increased significantly more in the fasting group. Perioperative adverse events did not differ between the 2 groups.

CONCLUSION

Perioperative enteral feeding is a simple, safe, and effective approach to improve perioperative systemic catabolism and proinflammatory reactions, thereby enhancing early wound regeneration after major operations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role of Lactate Measurement in Flap Monitoring: An Useful Adjunct

Background  Detection of vascular compromise in flap is often a challenging task for reconstructive surgeons. A timely salvage procedure depends on objectivity and reliability of postoperative flap monitoring. This study determined if flap capillary lactate helps in prediction of flap viability in first 48 postoperative hours of surgery. Methods  We conducted this study on all flaps with accessible skin paddle where capillary lactate values were assessed along with clinical observation to check viability of flap at 0, 1, 6, 12, 24 and 48 hours of surgery. The data was statistically analyzed for significance and area under the receiver operating characteristic curve was used for calculating cutoff value for lactate. Results  Out of a total of 30 patients included in this study, 25 were males and the mean age was 45.03 years. Fifteen patients underwent free flap and rest pedicled. Highly significant association of role of clinical observation in the outcome of flap was found. The average of lactate values for survived and distally ischemic flap was 5.32 ± 1.91 and 8.38 ± 1.81, respectively, which was highly significant. The cutoff value of lactate below which all flaps survived was found to be 6.09 mmol/L. Conclusion  Flap capillary lactate measurement is an easy, quick, cost-effective, and objective tool for checking viability of flaps.

Determination of Flap Survival Isolated From Wound Bed Vasculature Using a Murine Axial Flap Model

Background: Axial pattern flaps are a common reconstructive option following resection of soft tissue malignancies. We determine the early dependence of an axial flap on wound bed vasculature by isolating the underlying wound bed and depriving contact with the overlying flap. Materials and Methods: Mice were divided into 5 groups: No silicone (n = 7), silicone in the proximal 50% of the wound bed (n = 8), silicone in the distal 50% of the wound bed (n = 5), silicone over the full length of the wound bed with pedicle preservation (n = 5), and silicone over the full length of the wound bed with pedicle sacrifice (n = 5). The pedicle was the lateral thoracic artery. Daily photographs were taken, and the percent of viable flap was determined using ImageJ© software (public domain JAVA image processing program, National Institute of Health, Bethesda, MA). Percent flap viability for each group was compared to the no silicone group, which acted as the reference. Results: Mean differences in percent flap necrotic area (with 95% confidence interval) compared to the no silicone group were -0.15% (-15.09 to 14.09), 2.07% (-5.26 to 9.39), 2.98% (-10.98 to 16.94), and 14.21% (0.48 to 27.94) for the full-length silicone with preserved pedicle, proximal silicone, distal silicone, and full-length silicone with sacrificed pedicle groups, respectively. The full-length silicone with sacrificed pedicle group had a significant difference in flap viability (P = .045) compared to the no silicone group. Conclusion: We investigate the role of the wound bed vasculature in a murine axial flap model and demonstrate that the wound bed vasculature is not essential for early distal flap survival.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience

BACKGROUND

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors.

METHODS

A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022.

RESULTS

The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04).

CONCLUSION

Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Larynx Cancer: Reconstructive Options

Reconstruction for laryngeal cancer will depend on the defect left by surgical resection and patient-related factors such as medical comorbidities and history of previous radiation treatment. The goals of reconstruction are to preserve and/or restore the primary functions of the larynx (breathing, swallowing, voicing). Options include primary closure, locoregional flaps, and microvascular free tissue each with their advantages and disadvantages, which should be considered when planning reconstruction.

Impacts of vascular comorbidities on free flap perfusion in microvascular head and neck reconstruction

PURPOSE

Arterial hypertension (AHTN), type 2 diabetes mellitus (DM), and atherosclerotic vascular disease (ASVD) are common vascular comorbidities in patients undergoing reconstruction of the head and neck region with a microvascular free flap. These conditions may affect flap perfusion (microvascular blood flow and tissue oxygenation), which is a prerequisite for flap survival and thus reconstruction success. This study aimed to investigate the impacts of AHTN, DM, and ASVD on flap perfusion.

METHODS

Data from 308 patients who underwent successful reconstruction of the head and neck region with radial free forearm flaps, anterolateral thigh flaps, or fibula free flaps between 2011 and 2020 were retrospectively analyzed. Flap perfusion was measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system. Flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation were compared between patients with and without AHTN, DM, and ASVD.

RESULTS

Intraoperative hemoglobin oxygen saturation and postoperative blood flow were lower in patients with ASVD than in patients without ASVD (63.3% vs. 69.5%, p = 0.046; 67.5 arbitrary units [AU] vs. 85.0 AU, p = 0.036; respectively). These differences did not persist in the multivariable analysis (all p > 0.05). No difference was found in intraoperative or postoperative blood flow or hemoglobin oxygen saturation between patients with and without AHTN or DM (all p > 0.05).

CONCLUSION

Perfusion of microvascular free flaps used for head and neck reconstruction is not impaired in patients with AHTN, DM, or ASVD. Unrestricted flap perfusion may contribute to the observed successful use of microvascular free flaps in patients with these comorbidities.

Effect of operative time on complications associated with free flap reconstruction of the head and neck

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.

Post-reconstruction Free Flap Complications After Oral Cancer Ablation

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.

The effects of psychosocial determinants on post-operative complications of head and neck free flap patients

PURPOSE

Not much is known about how pre-operative psychosocial factors affect head and neck free flap outcomes. Hence, the objective of the study is to determine if a patient's pre-operative self-perception and quality of life affect post-operative complications and hospital length of stay after free flap surgery.

MATERIALS AND METHODS

This was a prospective cohort study. Patients who underwent a free flap surgery at an academic tertiary care center between January 2021 and March 2022 were asked to fill out the Rosenberg Self Esteem Scale and the Short Form 36 Health Questionnaire before surgery. A chart review of their medical records was then performed. Analysis of the data was performed using Spearman Correlation, Fisher exact test, Mann-Whitney and Multivariate Logistic Regression on STATA 15.

RESULTS

Sixty-one patients (73.8 % male; mean [SD; range] age: 60.9 [14.0, 23.1-86.8]) who underwent free flap surgery agreed to participate in the study. Most of the participants were not Caucasian (59 %). The most common indication for surgery was malignancy (93 %). The post-operative complication rate was 34.4 % and included 3 hematoma (4.9 %), 3 free flap failure (4.9 %), 9 wound dehiscence (14.8 %), 10 salivary fistulas (16.4 %), and 3 aspiration pneumonia or chyle leak (4.9 %). There were no mortalities. The mean role limitations due to physical health subscore [SD; range], social functioning subscore, pain subscore, and general health subscore of the SF-36 were 61.9 [39.2, 0-100], 70.7 [27.5, 0-100], 62.1 [25.7, 0-100], and 67.8 [20.3, 20-100], respectively. On univariate analysis, decreased physical limitations, better social functioning, less pain and better general health were associated with fewer overall post-operative complications, but was not correlated with length of stay. This held true for social functioning and general health even in multivariate analysis accounting for age and smoking history. The mean Rosenberg Self Esteem Scale score was 24.3 [4.1, 13-30].

CONCLUSIONS

In this study, patients with more limited social function and worse general health had more overall post-operative complications. It is important to continue to explore how pre-operative quality of life and other psychosocial factors can affect surgical outcomes.

Preoperative Predictors of Free Flap Failure

OBJECTIVE

Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure.

STUDY DESIGN

Retrospective cohort study of 1070 patients.

SETTING

Head and neck surgical oncology service at a tertiary care center from 2005 to 2019.

METHODS

Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery).

RESULTS

In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure.

CONCLUSION

Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.

Risk factors associated with early and late free flap complications in head and neck osseous reconstruction

PURPOSE

This study was designed to identify risk factors for post-operative complications in micro-anastomosed osteomyocutaneous free flaps (MOFF) and analyzed their consequences in long term.

METHODS

A retrospective review of 100 MOFF realized between May 2007 and October 2019 was performed. Demographic data, perioperative management and postoperative complications were enrolled and analyzed in a multivariate model. Patients were followed for ≥ 6 months.

RESULTS

Major surgical complication rate was 20% with 5% of overall free flap failure rate and 6% of anastomosis salvage surgery. Risk identified for major surgical complication was alcohol consumption (p = 0.0054). Minor surgical complications occurred in 26% of patients mostly due to infections (19%). No significant risk factor was associated to minor surgical complications. Major and minor medical complication rates were, respectively, 10% and 10%. Risk identified for major medical complication were age over 70 (p = 0.0253) and history of chemotherapy (p = 0.0277). Risk identified for minor medical complication were alcohol consumption p = 0.0232) and a history of radiotherapy (p = 0.0329).

CONCLUSIONS

Alcoholism is an independent risk factor for the surgical complication of MOFF that must be taken into account before surgery. Patients with a history of chemotherapy, radiotherapy or who are over 70 years of age are at greater risk of postoperative medical complications and require special attention.

Postoperative analysis of osseous midface reconstructions: The value of imaging and a novel scoring system for complexity and operative success

BACKGROUND

Few standardized methods exist for evaluating the postoperative outcomes of osteocutaneous free flaps. We propose an anatomic-based scoring system for midface free flap reconstruction.

METHODS

One hundred and twelve patients across four institutions underwent osteocutaneous reconstruction of the midface. Postoperative scans were scored based on the number of independent osseous subunits reconstructed (Subunit Score), the number of different bony appositions with bony contact (Contact Score), and the number of osseous segments in anatomic position (Position Score). These were added together to create a Total Score.

RESULTS

Osteocutaneous radial forearm flaps had the lowest Subunit Score (p = 0.001). Fibula flaps had the highest Contact Score (p = 0.0008) and Position Score (p = 0.001). Virtual surgical planning was associated with an increased Subunit Score (p = 0.02) and Total Score (p = 0.04).

CONCLUSIONS

We propose a novel scoring system for osseous midface reconstruction based on postoperative imaging scans. This can help guide management decisions and create a common language to compare outcomes.

Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: a systematic review and meta-analysis

The commonest cause of microvascular free flap failure is thrombosis at the anastomosis. Pharmacological antithrombotic therapies have been used to mitigate this risk, but they carry the risk of bleeding and haematoma formation. To justify any intervention, it is necessary to evaluate the benefits and balance of risks. This meta-analysis aims to quantify the value of systemic anticoagulation during head and neck free tissue reconstruction. We performed a systematic review on the impact of additional prophylactic antithrombotic therapy on head and neck (H&N) free tissue transfer (on top and above the use of low molecular weight heparin to prevent deep vein thrombosis). We carried a PRISMA-guided literature review, following registration with PROSPERO. All studies analysing the possible impact of prophylactic anticoagulants on free flap surgery in the head and neck were eligible. The primary outcome was perioperative free flap complications (perioperative thrombosis, partial or total free flap failure, thrombo-embolic events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation or bleeding complications requiring further intervention. We identified eight eligible studies out of 454. These included 3531 free flaps for H&N reconstruction. None of the assessed interventions demonstrated a statistically significant improvement in free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated an increased relative risk of free flap complications [RR 1.54 (0.73-3.23)] compared to control albeit not statistically significant (p = 0.25). Pooled analysis from the included studies showed that the prophylactic use of therapeutic doses of anticoagulants significantly (p = 0.003) increased the risk of haematoma and bleeding requiring intervention [RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure. Additional anticoagulation does not reduce the incidence of free flap thrombosis and failure. Unfractionated heparin (UFH) consistently increased the risk of free flap complications. The use of additional anticoagulation as 'prophylaxis' in the perioperative setting, increases the risk of haematoma and bleeding.

Aspirin, heparin and ischemia time in microvascular free flap surgery - their influence and an optimal anticoagulation protocol

BACKGROUND

Microvascular surgery has become a standardized technique for reconstruction of large tissue defects in Head and Neck Reconstructive Surgery. However, the main dreaded complications are thrombosis of blood vessels or major bleeding after surgery. Several different anticoagulation protocols have been established in the last decades to overcome these problems with varying degrees of success.

METHODS

Over a period of six years, a standardized anticoagulation protocol including acetylsalicylic acid (ASA) and unfractionated heparin (UFH) for direct intraoperative and postoperative administration was established, optimized and compared to a previously used non-standardized protocol. A total of 178 flap surgeries were included in the development and optimization process of the protocol.

RESULTS

ASA significantly increased the risk of complications when used for longer than 72 h (OR = 2.52; p = 0.002; 95% CI 1.39-4.59). Administration of UFH reduced flap loss (bolus: OR 0.68; p = 0.47; 95% CI 0.24-1.93; continuous UFH administration: OR = 0.61; p = 0.33; 95% CI 0.22-1.66), however doses greater than 500 IU/ h of UFH as continuous infusion increased the risk of complications. Reduction in ischemia time had no effect on the occurrence of complications.

CONCLUSION

Anticoagulation regimes in microvascular surgery can influence the postoperative complication rate. The optimal protocol should consist of a combination of ASA and UFH for the intraoperative and direct postoperative phase. Prolonged administration of ASA as well as doses &gt;500 IU/ h of UFH are to be avoided due to the increased complication rate.

Maxillo-mandibular Defect Reconstruction with Bilateral Free Fibula Flaps with Dental Implant Placement and Immediate Loading: A Case Report of the Three-team Approach

Patients with advanced malignant tumors, including both jaws, is a challenging task for a head and neck surgeon. Current treatment landscape demonstrates good functional, anatomical, and aesthetic results in patients who could previously receive only palliative care. The extensive tissue defects resulting from oncological resections in the head and neck region require immediate reconstruction due to the exposure of vital structures and their contact with the external environment. A patient was operated using a three-team multidisciplinary approach involving simultaneous work of three specialized teams of maxillofacial and reconstructive microsurgeons, as well as an implantologist and a prosthodontist. This approach allowed simultaneous tumor resection with subsequent reconstruction of the intraoperative defect involving bilateral harvesting of two revascularized free fibular osteomusculocutaneous flaps with dental implantation and simultaneous rehabilitation of dentition with crowns.

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

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

Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction

OBJECTIVES

This study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction.

METHODS

A retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis.

RESULTS

For single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05).

CONCLUSIONS

Risk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.

Impact of intraoperative ischemia time on acute complications of head and neck microvascular free tissue transfer: A systematic review and meta-analysis

BACKGROUND

To evaluate the relationship between intraoperative ischemia time with acute microvascular free tissue transfer (MFTT) complications in head and neck reconstruction.

METHODS

A systematic review using PRISMA guidelines was performed. Inclusion encompassed all available studies published and indexed using PubMed, Medline, and Embase. Meta-analyses were performed using the Cochrane Review Manager tool. Methodological Index for Non-Randomized Studies (MINORS), the Revised Cochrane risk-of-bias tool for randomized trials, and the NIH Study Quality Assessment Tool for non-randomized prospective studies.

RESULTS

A total of 430 citations were reviewed. 25 were included in our overall qualitative analysis, and 14 for meta-analysis. When comparing ischemia times for flaps with and without complications, no significant difference was observed (p = 0.98). Additionally, in a separate cohort, no significant effect was realized when correlating ischemia time to overall rates and total complications.

CONCLUSION

Ischemia time was not significantly different between those with and without acute flap complications.

Using the DASH Questionnaire to Evaluate Donor Site Morbidity of the Serratus Anterior Free Flap in Head and Neck Reconstruction: A Multicenter Study

Objective: To evaluate donor site morbidity of the serratus anterior free flap (SAFF) in head and neck reconstruction. Methods: The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire (0 no disability to 100 most severe disability) was applied to 20 patients (M: 16; F: 4) who underwent ablative surgery and reconstruction of the head and neck using a SAFF. Applications, as well as the donor site, recipient site and flap-related complications, were evaluated. Results: SAFF was mainly used for tongue (n = 11; 55.0%) and pharyngeal reconstruction after a laryngopharyngectomy (n = 4; 20.0%). The majority of patients presented with stage IV disease (n = 12; 60%) and had undergone previous radiotherapy (n = 14; 70%). Our free flap survival rate was 88.9% and the pectoralis major muscle flap (PMMF) was used in 5 patients as a salvage option to reconstruct pharyngeal defects. The mean/median DASH score was 21.6/19.9 (healthy norm 10.1), indicating only mild to moderate disability. However, free flap failure and the additional harvest of PMMF multiplies donor site morbidity since it was associated with a 3- and 2.6-times higher DASH score (46.0 vs. 15.5; p = 0.039 and 39.9 vs. 15.47; p = 0.081). Conclusions: The SAFF represents a versatile flap for head and neck reconstruction with low donor site morbidity.

Free Flap Outcome in Irradiated Recipient Sites: A Systematic Review and Meta-analysis

The impact of previous radiotherapy on free flap outcome is still a subject of debate. Clinical investigations have come to divergent conclusions and the true effect of radiotherapy (XRT) on flap survival is not definitely known. Most studies investigating the factor often have their methodological limitations such as lack of statistical power as a consequence of the overall low failure rates together with few irradiated cases. This study will attempt to address the question whether previous radiotherapy is associated with a significantly higher incidence of flap failure or not.

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Background:

Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment.

Methods:

Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma.

Results:

Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001).

Conclusions:

Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery

BACKGROUND

Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery.

METHODS

Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database.

RESULTS

Hypertensive patients (n = 1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p = 0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR = 1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR = 1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR = 1.17 [95% CI 1.00, 1.37], p = 0.047). However, no difference in 30-day readmission was found (p > 0.05).

CONCLUSIONS

Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.

Bedside Neck Exploration for Venous Flow Coupler Signal Loss in Postoperative Free Tissue Transfer Monitoring

OBJECTIVE

To describe the role and efficacy of bedside neck exploration following free tissue transfer.

STUDY DESIGN

Retrospective case series.

SETTING

Single tertiary care institution.

METHODS

A retrospective chart review was conducted of 353 patients who underwent free tissue transfer between January 2017 and April 2021. Bedside exploration was performed under mild sedation in patients who had loss of venous Doppler signal with equivocal clinical signs of venous insufficiency.

RESULTS

A total of 11 patients underwent bedside assessment of the microvascular pedicle. In 6 cases, a return to the operating room was avoided. Five of these patients had coupler malfunction, and in 1 patient a venous kink was discovered and remedied at the bedside. Five patients required return to the operating room. Venous thrombosis requiring thrombectomy and revision of the venous anastomosis was discovered in 3 patients. One patient had a developing hematoma necessitating evacuation in the operating room, and 1 returned to the operating room due to sternocleidomastoid muscular compression of the venous pedicle. There were no flap failures within the study group. In all cases, broad-spectrum intravenous antibiotic coverage was prophylactically used, and no instances of wound infection were observed. Avoidance of returning to the operating room prevented an estimated $9222 of hospital charges per event.

CONCLUSION

Bedside neck exploration can be incorporated as a safe and cost-effective intermediary for definitive determination of need for return to the operating room.

Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis

BACKGROUND

There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis.

METHODS

We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated.

RESULTS

53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al.

STUDY

CONCLUSION

Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.

The pedicled lateral forehead flap in reconstructing oral floor defect - The last resort; case report

INTRODUCTION AND IMPORTANCE

Locoregional flaps, particularly the pedicled lateral forehead flap, are not usually used in reconstructing oral floor defects following oncologic resection. Rather, microscopic free flaps have evolved to be the standard of care in head and neck reconstruction. However, the pedicled lateral forehead flap could be valuable in floor of the mouth reconstruction in the absence of resources or other options.

CASE PRESENTATION

A-56 years old lady with multiple comorbidities who underwent near total glossectomy, bilateral supraomohyoid neck dissection, and right lateral mandibulotomy due to a locally advanced lingual squamous carcinoma. The last resort was the pedicled lateral forehead flap after many unsuccessful reconstructive attempts utilizing the free anterolateral flap, free radial forearm flap, and pedicled pectoralis major flap.

CLINICAL DISCUSSION

Decreased donor site morbidity and reliable anatomy are among many of the advantages that made free flaps favorable over locoregional pedicled flaps, especially in oral cavity defects coverage. Of the latter, the pedicled forehead flap, rich in vascularity and neighboring the oropharyngeal defects, could be used with different techniques and modifications. Close monitoring and patient condition optimization is required.

CONCLUSION

Choosing a particular reconstructive option should be done considering the available resources and expertise and the patient's condition. The pedicled forehead flap remains valuable when other options are inappropriate or have failed.

Head and neck free-flap salvage

PURPOSE OF REVIEW

To highlight three clinical arenas in which head and neck free-flap compromise is encountered and acted upon: nonoperative, operative and postoperative realms.

RECENT FINDINGS

Time to identification and intervention is paramount to successful free-flap salvage. Surgical microvascular revision remains chief amongst strategies to revert vascular compromise of a free-flap. Adjuncts, such as thrombolytics and systemic anticoagulation have an important role in the complex work of microvascular free tissue care. Venous congestion of free flaps holds favorable for salvage when compared with arterial insufficiency.

SUMMARY

Vascular compromise of head and neck free flaps is a rare and feared event for microvascular surgeons, with successful transfers rates approaching above 95%. Success in salvage is dependent on prompt identification of tissue compromise and timely, directed interventions to re-establish tissue perfusion.

Red Blood Cell Transfusion and its Relationship with Pedicle Thrombosis in Microvascular Free Flaps

BACKGROUND

 Free flaps have become a highly valuable tool for complex reconstructive surgeries. The requirement of red blood cell transfusion (RBCT) during the perioperative period is common and its effect on the free flap survival is debatable. The aim of this study was to determine the relationship between perioperative RBCT and vascular pedicle thrombosis (VPT).

METHODS

 For this study 302 free flaps performed between January 2006 and December 2019 were retrospectively analyzed. It included their characteristics from before, during, and after the surgical procedure. The incidence of VPT and flap survival were calculated based on Kaplan Meier's method and the relationship between VPT and perioperative variables were analyzed by Cox regression models.

RESULTS

 The transfusion group was represented by 62 flaps (20.5%) and no transfusion by 240 flaps. The overall transfusion requirement was 20.5% and the cumulative incidence of VPT was 9.11%. A statistically significant relationship was not demonstrated between flap survival and transfusion status (HR = 1.73 IC 95%: 0.5 to 3.96; p = 0.192) (p = 0.192) independently from the number of units transfused, the preoperative diagnosis of anemia, and the type of flap used and did not establish an increased risk of VPT.

CONCLUSIONS

 This study did not demonstrate an association between RBCT during preoperative period and the risk for VPT or microvascular free flap survival rate on postoperative follow up.

Clinical consequences of head and neck free-flap reconstructions in the DM population

Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.

Secondary tracheoesophageal puncture with the blind technique: 10 years' experience

PROPOSE

The aim of the present article is to propose an alternative technique to the traditional secondary tracheoesophageal puncture (TEP) for voice rehabilitation after total laryngectomy, describing the procedure step-by-step, analyzing the complications and long-term results.

METHODS

A retrospective study was conducted on patients who underwent secondary TEP with the blind technique using a rigid hysterometer. The main steps in this technique are described and illustrated. Patient demographics and surgical outcomes were assessed.

RESULTS

Thirty-two patients were enrolled in this study. In all but one case, risk factors that could hinder rigid esophagoscopy were identified (37.5% neopharyngeal/esophageal post-surgical issues, 81.3% prior radiotherapy, 21.9% cervical arthrosis, and 12.5% prior coloplasty or gastric transposition). No intra- or postoperative surgical complications were noted.

CONCLUSION

The blind technique offers an alternative method to perform a secondary TEP safely and efficiently in patients with unfavorable anatomical or clinical conditions, lowering the risk of procedure-related complications.

Multicentre evaluation of the interest in planned surgery for mandibular reconstruction with fibula free flap: a retrospective cohort study

PURPOSE

The aim of this study was to determine the impact and cost-effectiveness of virtual surgical planning during fibula free flap mandibular reconstruction on peri- and postoperative data.

METHODS

We conducted a retrospective cohort study from January 2012 to December 2016 in four French university centres.

RESULTS

Three hundred fibula free flaps for mandibular reconstruction were performed in 294 patients. Surgeries were planned in 29.7% of cases (n = 89). There was no significant difference in the rate of negative-margins excision, median length of hospital stay, operative time, and early complications between planned and non-planned surgeries. Morphological analysis revealed a higher rate of centred occlusion in planned patients (satisfactory alignment of interincisal points: Planned 65.5% vs Non-Planned 33.3%, p = 0.006).

CONCLUSION

In mandibular reconstruction by fibula free flap, the additional cost generated by virtual surgical planning does not seem to be balanced by savings resulting from a shorter operative course, a reduced hospital stay, or a reduction in postoperative complications. However, virtual surgical planning may provide a higher rate of centred occlusion. Long-term benefits should be assessed by further studies.