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Natasha, Dixit PK, Katrolia D, Karmakar S, Rai R, Kala PC, Kothari N, Singla P, Singh AP, Humnekar A. Beyond the Scalpel: Physiological factors influencing free flap outcomes in head and neck reconstruction - A prospective study. J Plast Reconstr Aesthet Surg 2024; 95:121-123. [PMID: 38901079 DOI: 10.1016/j.bjps.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/31/2024] [Accepted: 06/06/2024] [Indexed: 06/22/2024]
Affiliation(s)
- Natasha
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Pawan Kumar Dixit
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Deepti Katrolia
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Shilpi Karmakar
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Rohit Rai
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Prakash Chandra Kala
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Nikhil Kothari
- Department of Anaesthesiology and Critical Care, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Priyanka Singla
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Apoorva Pratap Singh
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Jodhpur, India.
| | - Akhilesh Humnekar
- Department of Burns and Plastic Surgery, All Indian Institute of Medical Sciences, Kalyani, India.
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Herzog I, Panchal D, Sikder S, Park JB, Mendiratta D, Mansukhani PA, Lee ES. Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes. Ann Plast Surg 2024; 92:S251-S254. [PMID: 38556683 DOI: 10.1097/sap.0000000000003868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
INTRODUCTION Malnutrition is associated with increased mortality in patients with head and neck (H&N) cancer. Because albumin levels are used as a surrogate for nutritional status, the purpose of this study is to assess whether malnutrition is associated with adverse postoperative outcomes in H&N free flap reconstruction. MATERIALS AND METHODS The 2006-2018 National Surgical Quality Improvement Program Database was queried for patients undergoing flap procedures of the H&N based on Current Procedure Terminology codes. Patients were included if they were operated on by an otolaryngologist or when the primary surgical site was H&N. Nutritional status was categorized as malnourished (preoperative albumin level <3.5 g/dL) or normal (preoperative albumin level ≥3.5 g/dL). Major complications included pulmonary complications, cardiac complications, deep vein thrombosis/pulmonary embolism, and sepsis/septic shock. Minor complications included surgical infection, urinary tract infection, bleeding, and dehiscence. Data were analyzed via univariate chi-square and multivariate regression analyses. RESULTS Of the patients, 2532 (83.3%) had normal albumin and 506 (16.7%) had hypoalbuminemia. Patients with hypoalbuminemia were more likely to have smoking history (P = 0.008), pulmonary comorbidity (P < 0.001), renal comorbidity (P = 0.018), disseminated cancer (P < 0.001), steroid use (P < 0.001), recent weight loss (P < 0.001), bleeding disorder (P = 0.023), and preoperative transfusion (P < 0.001). After adjustment for preoperative variance, malnourished patients were more likely to experience death (P < 0.001), return to operating room (P < 0.001), free flap failure (P = 0.008), pulmonary complication (P < 0.001), deep vein thrombosis/pulmonary embolism (P = 0.019), wound disruption (P = 0.042), intraoperative transfusion (P < 0.001), minor complication (P < 0.001), major complication (P < 0.001), and extended length of stay (P < 0.001). Of the patients with normal albumin, 2.1% experienced flap failure compared with 6.3% of patients with hypoalbuminemia. It should be noted that malnourished patients were 3.370 times more likely to experience flap failure (95% confidence interval, 1.383-8.212; P = 0.008) and 3.975 times more likely to experience death (95% confidence interval, 1.700-9.626; P = 0.001) than those with normal albumin. CONCLUSION Malnutrition is associated with death, flap failure, minor complications, and other major complications following H&N free flap surgery, even after controlling for preoperative variance. Optimizing preoperative nutrition status before free flap procedures may ameliorate morbidity and mortality in H&N patients.
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Affiliation(s)
- Isabel Herzog
- From the Division of Plastic Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ
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Biermann N, Chak JC, Wiesmeier A, Klein SM, Ruewe M, Spoerl S, Kruppa P, Prantl L, Anker AM. Evidence-Based Approaches to Anticoagulation in Reconstructive Microsurgery-A Systematic Literature Review. Life (Basel) 2024; 14:82. [PMID: 38255697 PMCID: PMC10817551 DOI: 10.3390/life14010082] [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: 11/23/2023] [Revised: 12/18/2023] [Accepted: 12/30/2023] [Indexed: 01/24/2024] Open
Abstract
This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The objective was to balance the prevention of thrombotic complications commonly leading to flap failure, with the risk of increased bleeding complications associated with anticoagulant use. A meticulous PubMed literature search following Evidence-Based-Practice principles yielded 79 relevant articles, including both clinical and animal studies. The full-texts were carefully reviewed and evaluated by the modified Coleman methodology score. Clinical studies revealed diverse perioperative regimens, primarily based on aspirin, heparin, and dextran. Meta-analyses demonstrated similar flap loss rates with heparin or aspirin. High doses of dalteparin or heparin, however, correlated with higher flap loss rates than low dose administration. Use of dextran is not recommended due to severe systemic complications. In animal studies, systemic heparin administration showed predominantly favorable results, while topical application and intraluminal irrigation consistently exhibited significant benefits in flap survival. The insights from this conducted systematic review serve as a foundational pillar towards the establishment of evidence-based guidelines for anticoagulation in microsurgery. An average Coleman score of 55 (maximum 103), indicating low overall study quality, however, emphasizes the need for large multi-institutional, randomized-clinical trials as the next vital step.
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Affiliation(s)
- Niklas Biermann
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Juy Chi Chak
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Anna Wiesmeier
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Silvan M. Klein
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Marc Ruewe
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Steffen Spoerl
- Clinic and Polyclinic for Oral and Maxillofacial Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany;
| | - Philipp Kruppa
- Department of Plastic, Hand- and Reconstructive Surgery, Ernst von Bergmann Klinikum Potsdam, Charlottenstraße 72, D-14467 Potsdam, Germany;
| | - Lukas Prantl
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
| | - Alexandra M. Anker
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, D-93053 Regensburg, Germany; (N.B.); (J.C.C.); (A.W.); (S.M.K.); (L.P.)
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Okerosi S, Nkya A, Fagan J, Xu MJ. Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa. Curr Opin Otolaryngol Head Neck Surg 2023; 31:438-440. [PMID: 37820268 DOI: 10.1097/moo.0000000000000932] [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: 10/13/2023]
Abstract
PURPOSE OF REVIEW With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option. RECENT FINDINGS Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints. SUMMARY With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.
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Affiliation(s)
- Samuel Okerosi
- ENT Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Aslam Nkya
- Department of Otorhinolaryngology, Muhimibili National Hospital, Dar es Salaam, Tanzania
| | - Johan Fagan
- Division of Otolaryngology, University of Cape Town, Cape Town, South Africa
| | - Mary Jue Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Mihovilovic A, Martinovic D, Martinic J, Markovic D, Tarle M, Jerkovic D, Vuk S, Dediol E. Dynamometric outcomes of the donor site leg after vastus lateralis free flap harvest. J Craniomaxillofac Surg 2023; 51:755-759. [PMID: 37704506 DOI: 10.1016/j.jcms.2023.09.006] [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: 02/11/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
The vastus lateralis muscle is one of the four muscles that make up the quadriceps femoris muscle, and it is also the largest of them. Some studies have shown that patients experience lower quality of life and muscle weakness after surgical treatment of thigh muscles in order to perform reconstructive surgery of the head and neck. The aim of our study was to assess the quantitative and qualitative function of the lower extremities using an isokinetic dynamometer and a validated questionnaire on subjective difficulties in patients who underwent reconstructive surgery with the vastus lateralis free flap. Fourteen participants aged 20-70 years who suffered from malignant tumor in the head and neck region. The free vastus lateralis flap was used for reconstruction. All patients underwent isokinetic dynamometric measurement with the isokinetic dynamometer to test the isokinetic functions of the thigh muscles after surgery. In addition, subjective assessment of the lower extremities was performed using the validated questionnaire Lower Extremity Functional Scale. All isometric dynamometer measurements of the donor leg were compared with those of the unoperated leg. Peak torque and average power were significantly lower in the operated leg compared with the unoperated leg after 60°/s extension (p = 0.018 for peak torque, p = 0.021 for average power) and 180°/s extension (p = 0.019 for peak torque, p = 0.015 for average power). On the other hand, there was no statistically significant difference in dynamometer measurements after 60°/s flexion (p = 0.700 for peak torque, p = 0.854 for average power, and 180°/s flexion (p = 0.634 for peak torque, p = 0.571 for average power). The median value for the LEFS was 65.5 (40.00-71.25). The results of this study showed that there is a significant deterioration regarding the biophysical properties of the operated leg after harvesting vastus lateralis free flap.
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Affiliation(s)
- Ante Mihovilovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000, Split, Croatia; Department of Maxillofacial Surgery, University of Split School of Medicine, 21000, Split, Croatia.
| | - Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000, Split, Croatia; Department of Maxillofacial Surgery, University of Split School of Medicine, 21000, Split, Croatia
| | - Jure Martinic
- Department of Oral Surgery, University of Split School of Medicine, 21000, Split, Croatia
| | - Domagoj Markovic
- Department of Cardiovascular Diseases, University Hospital of Split, 21000, Split, Croatia
| | - Marko Tarle
- Department of Maxillofacial Surgery, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Daniel Jerkovic
- Department of Oral Surgery, University of Split School of Medicine, 21000, Split, Croatia; Department of Oral Surgery, University Hospital of Split, 21000, Split, Croatia
| | - Sasa Vuk
- Department of Kinesiology of Sport, University of Zagreb Faculty of Kinesiology, 10000, Zagreb, Croatia
| | - Emil Dediol
- Department of Maxillofacial Surgery, University Hospital Dubrava, 10000, Zagreb, Croatia; Department of Maxillofacial Surgery, University of Zagreb School of Medicine, 10000, Zagreb, Croatia
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Wilson AD, Ernst Z, Wise A, Flores H, Garrett M, Torgerson T, Hamilton T, Vassar M. Harms Reporting in Systematic Reviews of the Microvascular Free Flap in Head and Neck Reconstruction. Otolaryngol Head Neck Surg 2023; 169:755-764. [PMID: 36924192 DOI: 10.1002/ohn.321] [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: 08/03/2022] [Revised: 01/23/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVE To evaluate harms reporting in systematic reviews (SRs) of microvascular free flap (MFF) in head and neck reconstruction. DATA SOURCES This cross-sectional analysis included searches from the following major databases from 2012 to June 1, 2022: MEDLINE (Pubmed and Ovid), Embase, Epistemonikos, and the Cochrane Database of Systematic Reviews. REVIEW METHODS In a masked duplicate manner, screening was performed using Rayyan, and data were extracted using a pilot-tested Google form. A MeaSurement Tool to Assess systematic Reviews-2 (AMSTAR-2) was used to appraise the methodological quality of reviews and the corrected covered area was calculated to detect primary study overlap across all reviews. Reviews were then grouped in pairs of 2, called dyads, and the corrected covered area was calculated again for each individual dyad. Dyads with high overlap (≥50%) were further investigated for the accuracy of harms reporting. RESULTS Our initial search yielded 268 records, with 50 SRs meeting the inclusion criteria. A total of 46 (92%) of the included reviews demonstrated 50% or more adherence to the items assessed in our harms checklist. Our corrected covered area tool revealed 0.6% primary study overlap across all reviews, and 1 dyad with high overlap (≥50%). No statistically significant relationship was observed between the completeness of harms reporting and reviews listing harms as a primary outcome, reviews reporting adherence to Preferred Reporting Items of Systematic Reviews and Meta-Analyses, or a review's AMSTAR rating. CONCLUSION This study identifies how harms reporting in SRs of MFF reconstruction of the head and neck can be improved and provides suggestions with the potential to mitigate the paucity in current literature.
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Affiliation(s)
- Andrew D Wilson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Zachary Ernst
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Audrey Wise
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Holly Flores
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Morgan Garrett
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Trevor Torgerson
- Department of Head and Neck Surgery and Communication Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Tom Hamilton
- Department of Otolaryngology-Head and Neck Surgery, Oklahoma State University Medical Center, Tulsa, Oklahoma, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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