Risk Factors of Free Flap Outcomes After Head and Neck Cancer Surgery: A Multivariable Analysis From a Single Center Experience

INTRODUCTION

Risk factors for unfavorable outcomes, such as surgical site infection (SSI) and flap loss, following free flap reconstruction in patients with head and neck cancer are repeatedly reported without a definitive conclusion. Institutional reviews and meta-analyses each have their advantages and limitations. Although this study is without a definitive answer to these questions, it contributes to the literature by identifying potential influencing factors.

METHODS

This single-center cohort study included 596 patients who underwent head and neck reconstruction between 2015 and 2017. Patients were initially divided into two groups based on the presence or absence of SSI, and a similar comparison was made for flap loss. Data were further analyzed using univariate and multivariate logistic regression.

RESULTS

The overall SSI rate was 18.29%, with the age of patients (65-74 years, adjusted OR 2.41, p < 0.001; > 74 years, adjusted OR 3.53, p < 0.001) and segmental mandibulectomy (adjusted OR 1.81, p = 0.035) as independent risk factors. The overall flap failure rate was 4.4%, with medial sural flap (adjusted OR 6.89; p = 0.025) and prolonged operative time per hour (adjusted OR 1.38; p < 0.001) identified as significant influencing factors.

CONCLUSION

Age should not be the sole determinant for excluding patients for free tissue transfer, though it may elevate the SSI rate. Special attention is potentially needed during postoperative care for patients who received segmental mandibulectomy, medial sural flap, or experienced prolonged operative time. Identifying these risk factors can assist surgeons in optimizing flap outcomes before head and neck reconstruction.

Assessing Donor Site Morbidity and Impact on Quality of Life in Free Flap Microsurgery: An Overview

Donor site morbidity remains a significant concern in free flap microsurgery, with implications that extend beyond immediate postoperative outcomes to affect patients' long-term quality of life. This review explores the multi-faceted impact of donor site morbidity on physical, psychological, social, and occupational well-being, synthesizing findings from the existing literature. Particular attention is given to the functional limitations, sensory deficits, aesthetic outcomes, and chronic pain associated with commonly utilized free flaps. Advancements in surgical techniques, including nerve-sparing and muscle-sparing methods, as well as innovations, like perforator flaps, have demonstrated the potential to mitigate these morbidities. Furthermore, the integration of regenerative medicine strategies, such as stem cell therapy and fat grafting, and technological innovations, including virtual reality rehabilitation and biofeedback devices, has shown promise in enhancing recovery and minimizing long-term complications. Despite these advances, challenges persist in standardizing QoL assessments and optimizing donor site management. This review emphasizes the need for a holistic, patient-centered approach in reconstructive microsurgery, advocating for further research to refine current strategies, improve long-term outcomes, and develop robust tools for QoL evaluation. By addressing these gaps, reconstructive surgeons can better align surgical objectives with the comprehensive well-being of their patients.

Medial sural artery perforator flap following orbital exenteration

An extended orbital exenteration defect in a male in his mid-80s was successfully reconstructed with a medial sural artery perforator flap. To our knowledge, this flap has not been described in the literature for such defects until now. While it may require meticulous intramuscular perforator dissection, it provides several advantages; it is thin, pliable, has a long pedicle of large calibre facilitating microanastomosis and provides adequate coverage where the amount of chimeric muscle can easily be tailored to the defect's surface area and volume. In addition, its robust vascular supply can withstand volume changes post radiation therapy. Two years after surgery, the patient has healed well with an excellent functional outcome.

Characterization of the MSAP Flap in Head and Neck Surgical Oncology: A 3D Cadaveric Study

OBJECTIVES

The medial sural artery (MSA) perforator flap is a versatile free flap. However, the cutaneous perforators are not well characterized. The objectives of this pilot anatomical study were to: (1) visualize in three-dimensions, as in-situ, the origin, course, and distribution of the cutaneous perforators, (2) characterize the number and frequency of the perforators, and (3) quantify mean pedicle length.

METHODS

Thirteen cadaveric specimens were dissected, digitized, and modeled in 3D. Three-dimensional models and dissection photographs were used to determine the origin, course, number, distribution, and pedicle length of MSA perforators.

RESULTS

The most common pattern consisted of three perforators (39% of specimens). The maximum number of perforators identified was four (23%). The majority of specimens (92%) had a cutaneous perforator originating from the lateral branch of the MSA and coursed most frequently in the second (43%) and third (37%) quartiles of the length of the tibia. Mean pedicle length was 19.1 ± 6.9 cm. Perforators originating from the medial branch of the MSA were significantly (p < 0.05) shorter than those from the lateral branch and were found to course only in the first quartile.

CONCLUSION

The 3D models constructed in this study provide a comprehensive overview of the location and course of the perforators, enabling measurement of parameters in 3D-space. Anatomical characterization of the MSA perforator flap using 3D analysis can assist reconstructive surgeons in understanding the relevant anatomy and optimizing the surgical technique for flap harvest.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:4298-4303, 2024.

Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction

The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium.

Crafting Contours: A Comprehensive Guide to Scrotal Reconstruction

This review delves into reconstructive methods for scrotal defects arising from conditions like Fournier's gangrene, cancer, trauma, or hidradenitis suppurativa. The unique anatomy of the scrotum, vital for thermoregulation and spermatogenic function, necessitates reconstruction with thin and pliable tissue. When the scrotal defect area is less than half the scrotal surface area, scrotal advancement flap can be performed. However, for larger defects, some type of transplantation surgery is required. Various options are explored, including testicular transposition, tissue expanders, split-thickness skin grafts, local flaps, and free flaps, each with merits and demerits based on factors like tissue availability, defect size, and patient specifics. Also, physicians should consider how testicular transposition, despite its simplicity, often yields unsatisfactory outcomes and impairs spermatogenesis. This review underscores the individuality of aesthetic standards for scrotal reconstruction, urging surgeons to tailor techniques to patient needs, health, and defect size. Detailed preoperative counseling is crucial to inform patients about outcomes and limitations. Ongoing research focuses on advancing techniques, not only anatomically but also in enhancing post-reconstruction quality of life, emphasizing the commitment to continuous improvement in scrotal reconstruction.

Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps

PURPOSE

It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications.

METHODS

All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively.

RESULTS

Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned.

CONCLUSIONS

CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high.

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p  = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p  = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

The Free Medial Sural Artery Perforator Flap (MSAPF): An Indispensable Tool for Head and Neck Reconstruction

Background

Modern head and neck surgery is characterized by its emphasis on three important objectives of reconstructive and rehabilitative procedures-cosmesis, function and coverage of vital structures. Reconstruction with free flaps is a necessity when the defects become too large for more simple reconstruction options such as skin grafting and local flaps. The medial sural artery perforator flap (MSAPF) is a thin flap with a long pedicle. It has tremendous potential for applications in small-to-moderate soft tissue defects. Furthermore, chimeric MSAPF includes a skin paddle and a separated piece of medial gastrocnemius muscle, allows more freedom for flap insetting especially in 3-D reconstruction.

Purpose

The aim was to study the assessment of feasibility of MSAPF for head and neck reconstruction.

Method

Prospective case study from January 2019 to December 2019 was carried out in oral cancer patients with squamous cell carcinoma of the tongue, buccal mucosa and floor of the mouth which was reconstructed using MSAPF after oncologic resection.

Results

We reconstructed 20 patients using MSAPF. It was designed according to the size and site of the defect. Donor site was primarily closed in all cases. Great results were obtained. Out of 20 MSAP, 19 flaps survived. Flap failed in one case due to venous thrombosis. The thickness of the flap ranged from 4-9 mm, pedicle length ranged from 8-13mm, number of perforators ranged from 1-2, arterial diameter ranged from 1.5-2 mm and venous diameter ranged from 1-3mm.

Conclusion

MSAPF is a good alternative for head and neck reconstruction with the advantages of thin and pliable skin, a long and reliable vascular pedicle, straightforward intramuscular dissection, the possibility of chimeric flap design and minimal donor site morbidity.

The profunda artery perforator flap for head and neck reconstruction

INTRODUCTION

The profunda artery perforator (PAP) fasciocutaneous flap is underutilized in head and neck reconstruction, with advantages including ease of harvest and minimal donor site morbidity.

METHODS

Cadaveric dissection of cutaneous perforators to origin at profunda femoris system to characterize vascular anatomy.

RESULTS

22 PAP flaps were studied. Each contained 1-6 cutaneous perforators originating from the profunda system, designated into A, B, or C vascular pedicle systems. Muscular perforators did not consistently extend to skin in systems A and C, but all dissections demonstrated myocutaneous perforator in system B. Average distance from groin crease to cutaneous perforators of A, B, and C respectively was 8 cm (range 3-15 cm), 11.4 cm (range 5-17 cm), and 17.5 cm (range 12.5-22 cm). Average pedicle length was 11.07 cm (range 7-16 cm), 11.78 cm (range 9-16 cm), and 11.23 cm (range 9-15 cm). Average vena comitans diameter at origin was 3.14 mm (range 1.27-4.46 mm). Average arterial diameter at origin was 2.07 mm (range 1.27-3.82 mm). Range of maximal primary closure was 6-11 cm.

CONCLUSION

PAP free flap demonstrates reliable vascular anatomy in cadavers, with adequate pedicle length and vessel diameter. All specimens contained adequate myocutaneous perforator to support free tissue transfer.

Comparison of outcomes between single- and multiple-perforator-based free perforator flaps: A systematic review and meta-analysis

BACKGROUND

Perforator-based free perforator flaps have become an important tool for the reconstruction of tissue defects. The effect of the number of perforators on the outcomes of perforator flaps has been widely debated. This study aimed to compare the outcomes of single- and multiple-perforator-based free perforator flaps in free-flap reconstruction.

METHODS

We searched PubMed, Web of Science, EMBASE, Chinese BioMedical Literature Database (CBM), Cochrane Library, and clinicaltrials.gov between January 2000 and June 2021 to identify studies that reported data on the outcomes of free perforator flaps. Two authors individually extracted data and performed quality assessment. Outcomes, including partial flap loss, total loss, fat necrosis, arterial insufficiency, venous insufficiency, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications, were evaluated.

RESULTS

Thirty-two studies with 2498 flaps were included in our analysis. No significant difference was found in the rates of partial loss and arterial insufficiency of flaps, hemorrhage and hematoma, wound dehiscence at recipient sites and donor site complications. However, the multiple-perforator group showed significantly lower rates of total loss (relative risk [RR] = 1.08, 95% confidence interval [CI]: 0.78-1.79, p = .754), fat necrosis (RR = 1.79, 95% [CI]: 1.36-2.36, p = .000) and venous insufficiency (RR = 1.72, 95% CI: 1.07-2.79, p = .026) than the single-perforator group.

CONCLUSION

The rates of total loss, fat necrosis and venous insufficiency in the multiple-perforator group were lower than those in the single-perforator group. Hence, we recommend that multiple perforators be included in the free perforator flap when appropriate, to yield better clinical outcomes in reconstruction.

Simultaneous Paramedian Pedicle Forehead and Free Medial Sural Artery Perforator Flap Reconstruction of a Composite Nasal Defect: A Case Report

BACKGROUND

Extensive nasal defects after resection of a malignancy are a challenge for all plastic surgeons. Nasal composite tissue defects have to be reconstructed with multiple staging surgeries. A paramedian pedicled forehead flap and free tissue transfer can be used for lining and skin replacement at different stages. In general, free tissue transfer is used for nasal lining and nasal floor reconstruction at the preliminary stage. Several weeks or months later, a paramedian pedicled forehead flap is used to replace the skin. Intermediate stages will also be necessary, and therefore the total therapeutic course is very long.

AIM AND OBJECTIVES

The aim of this study was to report the simultaneous use of a paramedian pedicle forehead flap and a free medial sural artery perforator (MSAP) flap to reconstruct a composite nasal defect after wide excision of squamous cell carcinoma.

PATIENT

In 2015, a 57-year-old woman with squamous cell carcinoma of the nose underwent tumor wide excision, which caused a composite defect involving multiple nasal subunits (partial tip, dorsum, right sidewall, right ala subunits). She received both a pedicled paramedian forehead flap to replace the skin and an MSAP flap to reconstruct the lining during the same procedure. At the intermediate stage 4 weeks later, the pedicled forehead flap was elevated and tailored. Then, a further 4 weeks later, flap division was performed.

RESULTS

The patient received a total of 3 surgical procedures to reconstruct the composite defects of multiple nasal subunits. Nasal reconstruction was done within 2 months. The patient was satisfied with the aesthetic appearance and functional outcome.

CONCLUSIONS

Simultaneous paramedian pedicle forehead and free flap reconstruction can provide an effective solution for composite nasal defects. Satisfactory functional and aesthetic results can be achieved.

[Research progress of clinical application of medial sural artery perforator flap]

Objective

To review the research progress of the clinical application of the medial sural artery perforator flap (MSAPF).

Methods

The relevant domestic and abroad literature on the clinical application of MSAPF was extensively consulted, and the research progress were summarized and analyzed in aspect of its definition, anatomical characteristics, clinical application, surgical resection and improvement, and advantages and disadvantages of flaps, etc.

Results

MSAPF has the advantages of relatively constant anatomical position, thin flap texture, long vascular pedicle, large vessel diameter, no sacrifice of main blood vessels, concealed donor site, no hair, and fewer complications; it can carry nerves, tendons, and muscles to construct chimeric flaps to repair three-dimensional wounds; and can also repair wounds with high aesthetic and functional requirements such as hand, foot and ankle, head and neck, etc.

Conclusion

The MSAPF is a versatile, various forms, functional diversification, and three-dimensional flap donor site with various application forms and ideal repair effectiveness.

The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements

BACKGROUND

The medial sural artery perforator free flap (MSAP) has gained increasing popularity in head and neck reconstruction. Its slightly bulkier nature than the radial forearm flap, combined with negligible donor site morbidity, makes it an ideal candidate for the reconstruction of partial glossectomy defects. The ability to harvest the MSAP as a chimeric flap with a portion of the medial gastrocnemius muscle gives it greater flexibility in soft tissue reconstruction.

METHODS

A retrospective study of patients with partial glossectomy defects reconstructed using the MSAP by a single surgeon was performed. Perioperative data, donor and recipient site characteristics, complications, and outcomes were analyzed. A video is included to show technical points for the harvest of the flap.

RESULTS

A total of 10 patients were included. The average age was 59.1 years, with a mean of 43.5% of the tongue resected. All flaps survived, with no major complications. At follow-up, the patients had regained an average of 86.5% of original speech, with none requiring NG feeding. The average MSAP skin flap thickness was 7.8 mm, with 6 flaps being harvested as chimeric fasciocutaneous muscle flaps. Five flaps incorporated 2 perforators. Two case examples are presented.

CONCLUSION

The chimeric MSAP perforator allows for more robust partial glossectomy reconstruction with improved postoperative functional outcomes. It should be considered as the workhorse flap for partial tongue reconstruction.