Current concepts in microvascular reconstruction

Reconstructive procedures in maxillofacial oncosurgery

OBJECTIVE

Oropharyngeal cancers are a biologically heterogenous group of tumors with diverse risk factors including tobacco, alcohol, HPV, inherited disorders, the acquired immunodeficiency of Karposi's Sarcoma and non Hodgkin's lymphoma. In the Czech Republic, oropharyngeal cancers represent around 2% of all cancers. The treatment of these tumors is long and complex. Reconstructive procedures in maxillofacial oncosurgery demand good interdisciplinary collaboration and great professional preparedness of the surgical and nursing team. Patient age and stage of disease, including the presence of metastases are of key importance. A prerequisite for the success of surgical treatment is removal of the tumor with a sufficient safety margin. Reconstructive procedures then follow.

AIM

To highlight the importance of radical tumor resection and describe reconstruction of the defect in a group of our patients.

METHODS AND RESULTS

From 2008 to 2013, 23 patients with oropharyngeal carcinoma underwent radical surgical removal of tumor, followed by reconstruction of postoperative defects using distant and free flaps. The histopathology showed predominantly squamous cell carcinomas and one of Merkel cell carcinoma. 16 patients had malignant disease detected in III-IV. In only 7 cases was treatment initiated in the first and second stages of the disease. In these patients, the tumors were removed with a safety margin of healthy tissue and in none, did the basic cancer recur . The postoperative course in terms of flap engraftment and overall condition of the patient was uneventful. All of these patients still enjoy a good life quality with a current mean survival in range 5 - 76 months. Radical surgical removal of a malignant tumor in the early stages of the disease is associated with fewer postoperative complications and longer survival.

CONCLUSION

To avoid the risk of local and/or systemic postoperative complications, appropriate patient selection is important. Overall, the traditional, classic reconstructive procedures with the use of prostheses, in many cases is still the best option in our experience.

Negative pressure wound therapy in head and neck surgery

IMPORTANCE Negative pressure wound therapy has been shown to accelerate healing. There is a paucity of literature reporting its use as a tool to promote wound healing in head and neck reconstruction. OBJECTIVE To review 1 institution's experience with negative pressure dressings to further describe the indications, safety, and efficacy of this technique in the head and neck. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series at a tertiary care academic hospital. One hundred fifteen patients had negative pressure dressings applied between April 2005 and December 2011. Data were gathered, including indications, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, bone exposure, great vessel exposure, in the field of previous microvascular free tissue transfer, or in the case of peristomal application in laryngectomy). EXPOSURE Negative pressure wound therapy utilized after head and neck reconstruction. MAIN OUTCOMES AND MEASURES Indications for therapy, length and number of dressing applications, identification of wound healing risk factors, classification of wound complexity, wound healing results, and adverse events related to the use of the device. RESULTS Negative pressure wound therapy was used primarily for wounds of the neck (94 of 115 patients [81.7%]) in addition to other head and neck locations (14 of 115 patients [12.2%]), and free tissue transfer donor sites (7 of 115 patients [6.1%]). The mean (SD) wound size was 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2), with an application length of 3.7 (1.4) days. Potential risk factors for compromised wound healing were present in 82 of 115 patients (71.3%). Ninety-one of 115 patients (79.1%) had complex wounds. Negative pressure dressings were used in wounds with salivary contamination (n = 64), bone exposure (n = 40), great vessel exposure (n = 25), previous free tissue transfer (n = 55), and peristomal application after laryngectomy (n = 32). Adverse events occurred in 4 of 115 patients (3.5%). CONCLUSIONS AND RELEVANCE Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal. LEVEL OF EVIDENCE 4.

Closure of laryngectomy defects in the age of chemoradiation therapy

The use of chemoradiation therapy in laryngeal cancer has resulted in significant reconstructive challenges. Although reconstruction of salvage laryngectomy defects remains controversial, current literature supports aggressive management of these defects with vascularized tissue, even when there is sufficient pharyngeal tissue present for primary closure. Significant advancement in reconstructive techniques has permitted improved outcomes in patients with advanced disease who require total laryngopharyngectomy or total laryngoglossectomy. Use of enteric and fasciocutaneous flaps result in good patient outcomes. Finally, wound complication rates after salvage surgery approach 60% depending on comorbid conditions such as cardiac insufficiency, hypothyroidism, or extent of previous treatment. Neck dehiscence, great vessel exposure, fistula formation, or cervical skin necrosis results in complex wounds that can often be treated initially with negative pressure dressings followed by definitive reconstruction. The timing of repair and approach to the vessel-depleted neck also present challenges in this patient population. Currently, there is significant institutional bias in the management of the patient with postchemoradiation salvage laryngectomy. Future prospective multi-institutional studies are certainly needed to more clearly define optimal treatment of these difficult patients.

Free flap transfer in cranio-maxillofacial surgery: a review of the current data

BACKGROUND

The advances of cranio-maxillofacilal surgery are considerably driven by the evolution of microsurgical techniques. At present, these methods continue to provide new therapeutic options to the field. Especially, free flap transfer has evolved to become an integral part of current treatment protocols for head and neck malignancies. It ensures uneventful wound healing even after previous radiotherapy and can often preserve form and function. For many patients, this may lead to a significant improvement in their quality of life.

OBJECTIVES

This review summarizes aspects of tumor therapy, the impact of radiation, and discusses different techniques of microvascular tissue transfer.

DISCUSSION

Specific advantages in different anatomical sites of the head and neck region are highlighted in contrast to existing alternatives. Selected cases exemplify the use of popular transplants.

SUMMARY

While planning reconstructions, it is important to consider both the functional and aesthetic aspects. The best individual outcome is based on a thoughtful match of available methods to a given defect and the patient's condition.