Prediction of outcomes in 150 patients having microvascular free tissue transfers to the head and neck

Application of Free Flaps in Reconstruction of Head and Neck Soft Tissue Defects With Bone Exposure

BACKGROUND

Reconstruction of head and neck soft tissue defects with bone exposure is both challenging and technically demanding for plastic surgeon. Objectives in head and neck soft tissue defects with bone exposure reconstruction are consistent restoration of functionality while also improving appearance. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 4 years.

METHODS

A retrospective analysis was conducted from June 2019 to June 2023 on 12 patients treated at our hospital for head and neck soft tissue defects with bone exposure due to various causes. These included 4 cases of trauma from car accidents, 1 burn case, and 7 postoperative malignant tumor removals. The defect sizes ranged from 4 × 6 to 15 × 45 cm. Different free flaps were used for repair based on the defect, including 6 anterolateral thigh flaps, 3 forearm flaps, 2 latissimus dorsi flaps, and 1 dorsalis pedis flap. Flaps were designed and harvested to match the defect size and transplanted via anastomosed vessels.

RESULTS

All 12 flaps survived successfully. One patient required flap thinning surgery postoperatively. All patients were followed up for over 3 months, showing good color and texture of the transplanted flaps, satisfactory healing, and significant aesthetic improvement. Donor sites showed significant scarring without functional impairment.

CONCLUSION

Free flap repair for head and neck soft tissue defects with bone exposure is feasible and yields good results.

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.

Tissue Transfer After Tongue Resection: Micro-Vascular Reconstruction Using Radial Artery Free Flap versus Reconstruction by Split Thickness Skin Graft in T2 Lesions of Tongue Carcinoma

To compare postoperative complications, functional rehabilitation, surgical outcomes of the radial artery forearm free flap (RAFFF) and split thickness skin graft (STSG) reconstruction of postsurgical defect in T2 lesions of cancer oral cavity. Observational Prospective comparative study. Academic tertiary referral centre. In our study of forty four patients, after tumour resection, half underwent reconstruction using RAFFF (Group I) and another half by STSG (Group II). All of the patients were followed postoperatively to determine and compare their functional outcomes related to donor site and recipient site complications, speech, deglutition and mouth opening. The speech intelligibility and deglutition were each assessed using Articulation Handicap Index and Vedio-fluoroscopy using the Functional oral intake scale. Operative time for STSG reconstruction was shorter at 2.2 ± 0.97 SD hours compared to 5.9 ± 1.24 SD hours for RAFFF reconstruction. Hospital stay was 8.3 ± 1.19 SD days for STSG patients and 12.6 ± 1.7 SD days for RAFFF patients. The functional outcomes of speech quality and swallowing were near comparable in both groups but the donor site complications were significant in the RAFFF group. Operative time, hospital stay and donor site complications are both significantly reduced with the STSG as opposed to RAFF. Functional and oncologic results of both methods are near comparable. To conclude, STSG can be used for reconstruction of the post-surgical defects in T2 lesions of the tongue.

Perforating patterns of cutaneous perforator vessels in anterolateral thigh flaps for head and neck reconstruction and clinical outcomes

Background

Anterolateral thigh (ALT) flaps are versatile soft tissue flaps that have become the standard soft-tissue flaps used for head and neck reconstruction. They provide a long vascular pedicle, constant vessel diameter, abundant soft tissue coverage, and minimal donor site morbidity. The ALT flap was initially designed on the basis of a septocutaneous (SC) perforator. However, more recent research has shown that a substantial number of ALT flaps are now based on musculocutaneous (MC) perforators, and the ratio between MC and SC perforators varies among studies. In this study, we analyzed the perforating pattern of ALT flaps along with their clinical outcomes during head and neck reconstruction in the Korean population.

Methods

From October 2016 to July 2020, 68 patients who had undergone an ALT flap procedure for head and neck reconstruction were enrolled retrospectively. The perforating pattern of the cutaneous perforator vessel (MC perforator/SC perforator/oblique branch), pedicle length, and flap size were analyzed intraoperatively. Patient demographics and flap necrosis rates were also calculated.

Results

The highest number of cutaneous perforator vessels supplying the ALT flap were the MC perforators (87%). The proportion of MC perforators was significantly higher than that of the SC perforators and oblique branches. Flap necrosis occurred in seven cases (11.86%); sex, hypertension, diabetes mellitus, coronary artery disease, perforator course, and history of radiotherapy did not significantly affect flap necrosis.

Conclusion

The ALT free flap procedure remains popular for reconstruction of the head and neck. In this study, we observed that the majority of cutaneous vessels supplying the flaps were MC perforators (87%). When using the MC perforator during flap elevation, careful dissection of the perforator is required to achieve successful ALT flaps because intramuscular dissection is difficult. Perforator pattern and history of radiotherapy did not affect flap necrosis.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap

Background

The radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF.

Methods

1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis.

Results

Thirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05).

Conclusion

The FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity.

Graphical Abstract

Multidisciplinary reconstructive management of residual recalcitrant empyema cavity: A retrospective observational cohort study

BACKGROUND

Patients with stage III empyema require chest wall fenestration to enable lung re-expansion and continuous drainage of the persisting empyema cavity. This chronic wound negatively affects patients' exercise tolerance, ability to carry out activities of daily living, and quality of life.

METHODS

Eight consecutive patients underwent chest wall reconstruction following fenestration and were followed up over a minimum of 12 months. This study included adult patients (over 18 years of age). There were no exclusion criteria. Data were collected retrospectively.

RESULTS

Eight patients (six male and two female), with a mean age of 56 years (range, 22-76), were included. All of them had comorbidities including history of neoplasia (n = 6), atrial fibrillation (n = 3), and hypertension (n = 2). Aetiology of empyema included lung cancer resection complicated by bronchopleural fistula (n = 4), pneumonia (n = 2), and pleural effusion (n = 2). Five patients had a low metabolic reserve evident by a low BMI (range, 16-22), and a median malnutrition universal screen tool (MUST) score of 2 (range, 1-4). Following intensive infection control and nutritional support, patients underwent reconstruction 11 months (median; range 5-51) after fenestration. Seven patients were followed up and had no recurrence of empyema and bronchopleural fistula. They all reported significant improvements in their quality of life, and their Eastern Cooperative Oncology Group (ECOG) performance status improved from three to one. One patient died 56 days post-reconstruction from cardiorespiratory failure, which required readmission to hospital.

CONCLUSION

We demonstrate that free tissue reconstruction including multidisciplinary input and optimisation at all stages of care successfully closes residual recalcitrant empyema cavity without recurrence and leads to significant improvements in the quality of life.

Risk factors for surgical site infection in free-flap reconstructive surgery for head and neck cancer: Retrospective Australian cohort study

BACKGROUND

Surgical site infections (SSI) are common complications of free-flap reconstruction for head and neck cancer defects. This study aimed to identify risk factors for SSI following a significant change in local antibiotic prophylaxis practice.

METHODS

A retrospective cohort study was conducted of 325 patients receiving free-flap reconstruction for head and neck cancer defects at a tertiary hospital in Melbourne, Australia between 2013 and 2019. Charts were queried for recipient SSI (primary outcome), donor SSI, other infections, antibiotic use, hospital length of stay, and mortality.

RESULTS

Risk factors for SSI included female sex, T-classification, hardware insertion, clindamycin prophylaxis, and operative duration. There was a trend toward increased SSI with shorter ≤24 h prophylaxis (OR: 0.43).

CONCLUSION

Antibiotic duration and type were associated with SSI. Complexity of surgery, T-classification, hardware use, and operative duration were also independently associated with SSI. A prospective trial is indicated to elicit optimal prophylactic antibiotic duration.

Head and neck reconstruction using free flaps: a 30-year medical record review

Background

The free flap surgical method is useful for the reconstruction of head and neck defects. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 30 years.

Methods

Between 1989 and 2018, a total of 866 free flap procedures were performed on 859 patients with head and neck defects, including 7 double free flaps. The causes of vascular crisis and salvage rate were analyzed, and the total flap survival rate calculated among these patients. Additionally, the survival and complication rates for each flap type were compared.

Results

The 866 cases included 557 radial forearm flaps, 200 anterolateral thigh flaps, 39 fibular osteocutaneous flaps, and 70 of various other flaps. The incidence of the vascular crisis was 5.1%; its most common cause was venous thrombosis (52.3%). Salvage surgery was successful in 52.3% of patients, and the total flap survival rate was 97.6%. The success rate of the radial forearm flap was higher than of the anterolateral flap (p<0.01), and the primary sites of malignancy were the tongue, tonsils, and hypopharynx, respectively.

Conclusion

The free flap technique is the most reliable method for head and neck reconstruction; however, the radial forearm free flap showed the highest success rate (98.9%). In patients with malignancy, flap failure was more common in the anterolateral thigh (5.5%) and fibular (5.1%) flaps.

Factors impacting successful salvage of the failing free flap

BACKGROUND

Understanding factors impacting successful salvage of a compromised free flap.

METHODS

Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764).

RESULTS

Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04).

CONCLUSIONS

There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision.

Predicting length of stay in head and neck patients who undergo free flap reconstruction

OBJECTIVE

Understanding factors that affect postoperative length of stay (LOS) may improve patient recovery, hasten postoperative discharge, and minimize institutional costs. This study sought to (a) describe LOS among head and neck patients undergoing free flap reconstruction and (b) identify factors that predict increased LOS.

METHODS

A retrospective cohort was performed of 282 head and neck patients with free flap reconstruction for oncologic resection between 2011 and 2013 at a tertiary academic medical center. Patient demographics, tumor characteristics, and surgical and infectious complications were characterized. Multivariable regression identified predictors of increased LOS.

RESULTS

A total of 282 patients were included. Mean age was 64.7 years (SD = 12.2) and 40% were female. Most tumors were located in the oral cavity (53.9% of patients), and most patients underwent radial forearm free flap (RFFF) reconstruction (RFFF-73.8%, anterolateral thigh flap-11.3%, and fibula free flap-14.9%). Intraoperative complications were rare. The most common postoperative complications included nonwound infection (pneumonia [PNA] or urinary tract infection [UTI]) (15.6%) and wound breakdown/fistula (15.2%). Mean and median LOS were 13 days (SD = 7.7) and 10 days (interquartile range = 7), respectively. Statistically significant predictors of increased LOS included flap take back (Beta coefficient [C] = +4.26, P < .0001), in-hospital PNA or UTI (C = +2.52, P = .037), wound breakdown or fistula (C = +5.0, P < .0001), surgical site infection (C = +3.54, P = .017), and prior radiation therapy (C = +2.59, P = .004).

CONCLUSION

Several perioperative factors are associated with increased LOS. These findings may help with perioperative planning, including the need for vigilant wound care, optimization of antibiotics prophylaxis, and institution-level protocols for postoperative care and disposition of free flap patients.

LEVEL OF EVIDENCE

2b; retrospective cohort.

Analysis of the impact of chronic corticosteroid use on free flap reconstruction

BACKGROUND

Systemic corticosteroids negatively impact wound healing, potentially increasing postoperative wound complication rates. In this study, the authors utilize the American College of Surgeons (ACS) National Surgical Quality Improvement (NSQIP) database to investigate the impact of chronic steroid usage on postoperative complications following microvascular free tissue transfer procedures.

METHODS

The ACS NSQIP database was queried for all free flap procedures performed between 2005 and 2016. Patients with a history of chronic steroid use (n = 159) were compared to patients with no history of chronic steroid use (n = 3,405). The two cohorts were compared by univariate analysis, followed by multivariate binary logistic regression for all complications noted to be statistically significant on univariate analysis.

RESULTS

Patients treated with systemic corticosteroids were more likely to be smokers, have a history of diabetes, hypertension, bleeding disorders, hypoalbuminemia, anemia, and have a wound infection at time of surgery. There were increased rates of bleeding requiring transfusion (37.7 vs. 27.5% p = .005), overall surgical complications (48.4 vs. 36.7%, p = .003) and overall complication rates (56.0 vs. 42.3%, p = .001) in these patients. On multivariate analysis, chronic steroid use was not associated with increased risk of surgical complications (OR = 2.540, p = .056, 95% CI 0.975-6.622), overall complications (OR = 2.303, p = .086, 95% CI 0.888-5.973), or wound complications. However, chronic steroid usage conferred nearly a four times increased risk for major bleeding complications (OR = 3.995, p = .009, 95% CI 1.415-11.279).

CONCLUSION

Chronic corticosteroid use does not increase rates of wound complications, reoperation, or readmission. However, this population may be at increased risk for major bleeding requiring blood transfusion following free flap reconstruction.

Multivariate analysis as an advantageous approach for prediction of the adverse outcome in head and neck microvascular reconstructive surgery

BACKGROUND

The use of a free flap has become a mainstay of reconstruction following the ablative surgery in head and neck. The success rates are about 90%, however, several factors have been described to have an adverse effect on free flap survival.

METHODS

We have performed a retrospective analysis of the treatment outcome of 93 microvascular flaps and evaluated the factors influencing the risk of flap loss including patients' age, body mass index, smoking, general medical history and previous oncological treatment.

RESULTS

Out of 93 flaps the total necrosis have been observed in 15 flaps with gradual improvement in the consecutive years. In individual analysis the patients age, BMI, and comorbidities did not reveal any significant relation. The history of any previous oncological treatment represented a significant adverse factor of success rate (p=0.035), and was even more significant when patients experienced all treatment modalities prior to the reconstructive procedure (p=0.009). Multivariate logistic regression model indicated that only surgery (p=0.0008), chemotherapy (p=0.02), cardiovascular diseases (p=0.05) and patient's age (p=0.02) represented significant factors impairing the success rate.

CONCLUSION

Incorporating multivariate analysis represents important statistical approach for better prediction of free flaps survival in head and neck reconstructive surgery. Incorporation of additional collective information could provide more precise approach in the risk of the flap loss assessment.

Blood loss and duration of surgery are independent risk factors for complications after breast reconstruction

BACKGROUND

Complications after breast reconstructive surgery are common, and they can be caused by a wide range of factors. The aim of the present study was to identify independent perioperative risk factors for postoperative complications after breast reconstruction.

METHODS

A retrospective study was performed of 623 consecutive breast cancer patients who had undergone deep inferior epigastric perforator (DIEP) flap, latissimus dorsi (LD) flap, lateral thoracodorsal flap (LTDF), or tissue expander with secondary implant (EXP). Data on demography, perioperative parameters, and complications were collected. Logistic regression models adjusted to the reconstruction method and to confounding demographic factors were used for statistical analysis.

RESULTS

Increased blood loss for each 10-ml step increased the risk for overall early complications (p = 0.017), early seroma (p = 0.037), early resurgery (p = 0.010), late local overall complications (p = 0.024), and late fat necrosis (p = 0.031). Longer duration of surgery for each 10-minute step increased the risk of overall early complications (p = 0.019), but, in the univariate model, there was an increased risk for nine different types of complications (p = 0.004-0.029). There was no association between the experience of the surgeon performing the procedure and the frequency of complications.

CONCLUSIONS

Duration of surgery and blood loss during surgery are independent risk factors for postoperative complications, and should be minimised. Further research is needed to establish the association between the experience of the surgeon and the occurrence of complications.

Preoperative radiation therapy and its effects on outcomes in microsurgical head and neck reconstruction

OBJECTIVE: Preoperative radiation therapy is considered a significant factor in head and neck reconstruction.

STUDY AND DESIGN AND SETTING: In our consecutive series of 114 patients, 44 patients had prior head and neck irradiation. The 2 groups were compared on the basis of age, ischemic time, and flap size and were found not to be statistically different. The average ischemic time for the irradiated group was 94.1 minutes, and the average was 102.8 minutes for the nonirradiated group. The average flap size for the irradiated group was 69.5 cm 2 , and was 72.0 cm 2 , for the nonirradiated group.

RESULTS: Using a single-factor analysis of variance, the 2 groups did not differ statistically. The overall major flap complication rate for both irradiated and nonirradiated groups was approximately 10%.

CONCLUSION: Microvascular reconstruction was accomplished in both irradiated and nonirradiated head and neck patients, with a 99% total flap survival rate and a 10% major flap complication rate.

The importance of in-hospital mortality for patients requiring free tissue transfer for head and neck oncology

Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n=42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n=26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.

Predictors of complications of free flap reconstruction in head and neck surgery: Analysis of 304 free flap reconstruction procedures

OBJECTIVES

The objectives of this study were to classify and analyze perioperative complications following free flap reconstruction in the head and neck and investigate potential predictors of these complications.

METHODS

A retrospective chart analysis of 304 consecutive free flap reconstructions for defects in the head and neck were examined. Patient and operative characteristics as well as complications were recorded prospectively and analyzed using ordinal logistic regression.

RESULTS

The overall complication rate was 32.6% with a perioperative mortality rate of 0.3%. The flap loss rate was 2.0% and the partial flap necrosis rate was 1.0%. Multivariate analysis demonstrated a significant correlation between perioperative complication and tumor stage as well as reconstruction site.

CONCLUSIONS

The rate and grade of complications with free flap reconstruction in the head and neck were found to be low. Higher tumor stage and pharyngoesophageal reconstruction were found to be associated with increased complication grades, whereas preoperative radiation alone and chemoradiation were not. Smoking and alcohol use, age, diabetes mellitus, peripheral vascular disease, and preoperative myocardial infarction as well as preoperative cerebrovascular accident were not found to be associated with increased complications. No statistically significant difference in complication grades was found with different flap types or indications for reconstruction.

Health-related quality of life, surgical and aesthetic outcomes following microvascular free flap reconstructions: an 8-year institutional review

INTRODUCTION

Microvascular free flap reconstruction has revolutionised the reconstruction of complex defects of traumatic, oncological, congenital and infectious aetiologies. Complications of microvascular free flap procedures impact negatively on patient post-operative course and outcome.

METHODS

We performed a retrospective analysis of 102 consecutive patients undergoing 108 free flap procedures at a tertiary referral centre over an 8-year period. Logistic regression analysis was used to identify factors predictive of free flap complications. Health-related quality of life (HRQoL) and aesthetic outcomes were assessed using the Short Form 36 questionnaire and a satisfaction visual analogue scale respectively.

RESULTS

In total, 108 free tissue transfers were performed; 23% were fasciocutaneous free flaps, 69% musculocutaneous and 8% osteoseptocutaneous. The overall flap success rate was 92.6%. Over a third of patients (34.3%) had flap-related complications ranging from minor wound dehiscence to total flap loss. ASA (American Society of Anesthesiologists) grade ≥2 (OR: 16.9, 95% CI: 15.3-18.1, p<0.009), history of smoking (OR: 6.1, 95% CI: 5.5-7.2, p<0.049), body mass index ≥25 kg/m(2) (OR: 21.3, 95% CI: 20.8-22.1, p<0.003), low albumin (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2-3.9, p<0.003) and peripheral vascular disease (OR: 6.9, 95% CI: 5.9-7.5, p<0.036) were identified as factors independently predictive of free flap complications.

CONCLUSIONS

Patients undergoing uncomplicated free flap surgery and those reporting superior post-operative flap aesthesis have higher HRQoL scores. Microvascular free tissue transfer has revolutionised our approach to the reconstruction of complex defects, providing a safe, reliable procedure to restore functionality and quality of life for patients.

Postoperative complications in 202 cases of microvascular head and neck reconstruction

INTRODUCTION

This retrospective study was intended to determine the incidence and causes of postoperative complications in patients following head and neck reconstruction using microvascular free flaps.

PATIENTS AND METHODS

A total of 202 consecutive microvascular free flaps were performed for reconstruction of the head and neck by the same surgeon, 85% of the defects arose following the treatment of malignancies. Flap donor sites included latissimus-dorsi flap (n=83), radial forearm (n=35), fibula (n=31), iliac crest (n=36), TRAM flap (n=3), groin flap (n=l), jejunal flap (n=13). The incidence of postoperative complications and patient-related characteristics (age, sex, diagnosis, comorbidity level, operation duration, defect site, history of radiotherapy/chemotherapy) were retrospectively analyzed.

RESULTS

Free flaps proved to be extremely reliable, with a 2.9% incidence of free flap failure. Postoperative medical complications occurred in 11.4% of cases, with cardiac, pulmonary and infectious complications predominating.

CONCLUSION

The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of postoperative complications is related to the preoperative comorbidity.

Head and neck reconstruction with free flaps: a report on 213 cases

The aim of this retrospective study is to review the experience of our institution in performing microvascular head and neck reconstruction between 2000 and 2004. During this period, 213 free flaps, including 146 radial forearm free flaps, 60 fibular flaps and 7 scapular flaps, were performed. Free flap success rate and complications were reported. The pre-treatment factors influencing these results were subsequently analyzed. Functional and aesthetic outcomes were evaluated by the same clinician. There were 14 free flap failures, giving an overall free flap success rate of 93.4%. Salvage surgery for recurrent cancer was the only factor correlated with a higher risk of free flap failure (P = 0.0004). The local complication rate was 20.9%. High level of comorbidity (P = 0.009), salvage surgery for recurrent cancer (P = 0.03) and hypopharyngeal surgery (P = 0.002) were associated with a higher risk of local complications. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results.

Outcome and complications of 540 microvascular free flaps: the Hamburg experience

The aim of this study was to retrospectively analyze surgical outcome and complications of 540 free flap procedures performed at the Department of Oral and Maxillofacial Surgery of the University Medical Center Hamburg-Eppendorf during 1987-2005. A total of 532 patients were reconstructed with 540 flaps: 32% were latissimus dorsi flaps, 23% were radial forearm flaps, 21% were iliac crest flaps, 10% were fibula flaps, 6% were jejunal flaps, and 8% were other flaps. Thrombosis of one of the vessels and hematoma were the most frequent causes of failure in microvascular free tissue transfer. A total free flap failure occurred in 34 (6.2%) and a partial flap failure in 42 (7.7%) patients. The most reliable flap in regard to survival was the radial forearm flap. The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck.

Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm

We present our 14-year experience of free tissue transfer following surgery for head and neck neoplasm. We evaluated 346 patients mean age 57 years, 65% had squamous cell carcinoma; the most frequent sites were oral cavity and mandible (168) craniomaxillo facial region (94) pharynx +/- cervical oesophagus and oropharyngostomes (84). In 327 (95%) cases the reconstruction was a success. Flap revision was necessary in 29 (8.4% of total) and recovery was successful in 10/29. Nine patients (2.6%) died perioperatively. Poor preoperative condition, previous treatment, and requirement for vein graft were significantly associated with increased risk of major complications after surgery. Cosmetic and functional outcomes were assessed on 1-10 scales: 69 and 77% of patients, respectively, had cosmetic and functional results in the 7-10 range, indicating successful outcome. Overall survival probabilities, estimated on 338 patients with malignant disease, were 53% at 2 years and 32% at 5 years. Most patients, but not all, had advanced disease stage, and 188 (54%) had recurrent disease. Hence, overall survival rates are acceptable and justify the use of complex reconstruction procedures in such patients.

Quality of life after free-flap reconstruction in patients with oral and pharyngeal cancer

BACKGROUND

Our aim was to investigate quality of life and outcome after microvascular free-flap reconstruction after oncologic surgery.

METHODS

Forty-four patients with a large carcinoma in the oral cavity, oral pharynx, or hypopharynx underwent free-flap surgery with or without radiotherapy. Patients completed the University of Washington Quality-of-Life Questionnaire preoperatively and four times during the 12 postoperative months. Survival rates and complications were analyzed.

RESULTS

Postoperative composite quality-of-life scores were significantly lower than before treatment with no significant overall improvement during the follow-up. The scores for disfigurement, chewing, speech, and shoulder function remained significantly below the preoperative level throughout the follow-up. Sociodemographic factors predicted quality of life. Heavy drinking and unemployment caused a 2.4-fold and a 4.4-fold increase in risk of death, respectively. The rates for overall survival, tumor recurrence, flap success, and surgical complications were consistent with previous literature.

CONCLUSION

Sociodemographic variables affect quality of life and patient survival in patients with oral cancer treated with microvascular free-flap reconstruction.

Towards performance measurement in reconstructive surgery: A multicentre pilot study of free and pedicled flap procedures

OBJECTIVES

To pilot the acceptability and feasibility of clinical audit in free and pedicled flap reconstruction. To establish a baseline flap failure rate in participating units, so that a sample size calculation could be performed for future national audit.

METHODS

A proforma was piloted over a 3-month period in four participating units, during which time data on 93 reconstructive procedures involving free and pedicled flaps was collected. The patients included those where large transfers of tissue were required such as for coverage of grade IIIb compound tibial fractures and breast reconstruction after mastectomy, and also smaller flap transfers such as after skin cancer excision.

RESULTS

The proforma was found to be acceptable to clinicians and the feasibility of the data collection process was established. Overall there was a total flap survival of 89% and secondary operations to the donor or recipient sites were required in 11% of patients.

CONCLUSIONS

This study demonstrates the feasibility of comparative audit for free and pedicled flap procedures using the methods proposed. Based on the incidence of flap failure observed in this pilot study, at least 18 months of prospective data collection on consecutive patients is required to fulfil the statistical requirements of comparative audit. The establishment of a routinely collected minimum dataset is proposed as one means of meeting these requirements.

Effects of Aspirin and Low-Dose Heparin in Head and Neck Reconstruction using Microvascular Free Flaps

OBJECTIVE

The success of microvascular free-tissue transfer to the head and neck has been greatly increased secondary to increased experience, yet postoperative anticoagulation continues to be routinely used to prevent pedicle thrombosis. However, there is currently no consensus as to what the ideal regimen, if any, is recommended for postoperative anticoagulation. This study reviews the outcome and incidence of perioperative complications in patients undergoing free flaps for head and neck reconstruction, using a simple postoperative anticoagulation regimen of aspirin and subcutaneous heparin (SQH).

DESIGN

Retrospective chart review.

METHODS

With institutional review board approval, the charts of 261 patients undergoing free flap reconstruction from January 2000 to January 2004 were retrospectively reviewed. Patients who received a standard postoperative anticoagulation regimen of SQH (5000 U SC bid) and aspirin (325 mg PO qd) were included in the study (216 patients). Charts were reviewed for postoperative complications, specifically for free flap failure, vascular compromise (arterial insufficiency/venous congestion), and hematoma.

RESULTS

There were six flap failures (2.8%), resulting in an overall free flap survival rate of 97.2%. There were six patients with venous congestion of the flap that required neck exploration (2.8%), and 12 patients with postoperative hematoma (5.6%), requiring surgical intervention.

CONCLUSION

The free flap survival rate in patients undergoing head and neck reconstruction using this simple anticoagulation regimen of aspirin and SQH appears to be equivalent to the free flap survival rate in patients using other anticoagulation agents. In addition, aspirin and SQH do not increase the incidence of postoperative hematoma when compared with the other anticoagulation agents. Therefore, aspirin and SQH appear to be reliable postoperative anticoagulation agents for patients undergoing head and neck reconstruction using free flaps.

Comparing a Mechanical Device with Medicinal Leeches for Treating Venous Congestion

OBJECTIVE: To compare mechanical device therapy to medicinal leech therapy for treating venous congestion.

STUDY DESIGN: Fasciocutaneous flaps of 9 × 7-cm (porcine model, n = 11) were elevated and the associated veins clamped for 15 hours. Device-treated flaps (n = 6) were treated with up to 3 devices/flap. Leech-treated flaps (n = 5) were treated with 75 leeches/flap (5 leeches/hour). Treatment evaluation parameters included: blood volume removed, skin color, surface perfusion, tissue oxygen tension, and endpoint histology.

RESULTS: No significant differences were seen in blood volume removed, surface perfusion, and oxygen tension. However, significant differences were seen in skin color change over time. Histological assessment showed mild congestion in 5/5 leech-treated flaps and 2/6 device-treated flaps.

CONCLUSION: Device therapy was comparable to leech therapy for decongesting a 9 × 7-cm flap over a 15-hour period. However, digital images and significant differences in skin color change over time demonstrate that device therapy promotes more global decongestion versus leech therapy.

Comorbid condition as a prognostic factor for complications in major surgery of the oral cavity and oropharynx with microvascular soft tissue reconstruction

BACKGROUND

Identification of factors, especially comorbidity, that affect the incidence and severity of complications in head and neck cancer patients.

METHODS

One hundred patients with an oral/oropharynx carcinoma undergoing composite resection and microvascular soft tissue transfer were analyzed. Patient data and tumor and treatment factors were recorded. Comorbidity was graded by an Adult Comorbidity Evaluation 27 (ACE-27) test. Postoperative complications were scored according to their severity.

RESULTS

Comorbidity score ACE-27 grade 2 or higher was present in 47% of patients, whereas 33% had a clinically important complication develop. A comorbidity score of ACE-27 grade > or =2 was a strong predictor for complications (p <.001). There were no other predictors for postoperative complications.

CONCLUSIONS

Comorbidity is of great importance for prediction of postoperative complications in head and neck cancer patients, especially an ACE-27 grade > or =2. It may be concluded from these results that prevention of complications should focus on comorbidities.

Free flap complications: when is enough, enough?

The reconstruction of head and neck defects, be they traumatic, oncologic, or iatrogenic, has been revolutionized in the last two decades by the development and refinement of microvascular soft tissue transfer. What was once an onerous and often unpredictable procedure has become standardized and safe. The result is that free tissue transfer is becoming the standard of care for more and more patients, to the point that the profession must now readdress the role of more traditional techniques of reconstruction. This article reviews the recent literature on free flap-related complications to assess the appropriateness of widespread free flap reconstruction and discusses the changing indications and benefits of free tissue transfer and nonmicrovascular reconstruction.