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Paladino JR, Zheng Y, Gasteratos K, Corvi JJ, Park KH, Akelina Y. Rat Microvascular Model is Tolerant to Technical Errors. J Reconstr Microsurg 2024; 40:245-252. [PMID: 37579784 DOI: 10.1055/a-2153-2467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
BACKGROUND Extensive studies have been conducted using the rat model to understand the potential technical errors that lead to anastomotic failure. However, current literature indicates that the rat model has excellent tolerance to diverse errors committed by microsurgeons. The error-investigating rat model is often created by one or two experienced surgeons, and only one isolated technical error is examined. These biases may potentially cause limitations of the results from previous studies. Meanwhile, venous anastomoses have rarely been investigated in previous literature. Therefore, it is important to elucidate this topic with a more comprehensive study design. METHODS Ninety-four arterial and 94 venous anastomoses on Sprague-Dawley rat femoral vessels that were performed by 47 microsurgeons who participated in the microsurgery course at the Columbia University and the University of Thessaloniki were evaluated. In total, 10 technical errors were examined: (1) disruption of suture line, (2) back-wall stitch, (3) oblique stitch, (4) wide bite, (5) partial thickness bite, (6) unequal suture distance, (7) tear in vessel wall, (8) excessively tight suture, (9) suture threads in lumen, and (10) large edge overlap. The frequency of each error committed, and the 30-minute postoperative patency was also recorded. The underlying causal relationship between these errors, potential interaction, and the short-term anastomosis patency was analyzed statistically. RESULTS Only the back-wall stitch was found to have a significant causal effect on arterial anastomosis failure (p < 0.001). Back-wall stitch, wide bite, and partial thickness bite significantly impact venous anastomosis patency (p < 0.001). No other statistically significant result was found. CONCLUSION Overall, the rat model is highly resilient to various technical errors despite these mistakes being often considered clinically unacceptable. Therefore, researchers need to consider the resilience of the rat model when designing and analyzing future studies. In addition, microsurgery instructors should focus on individual stitch quality rather than the final patency.
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Affiliation(s)
- Joseph R Paladino
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - YuanDian Zheng
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - John J Corvi
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Katherine H Park
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yelena Akelina
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York
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Kiuchi T, Ishii N, Uno T, Uoya Y, Sakai S, Matsuzaki K, Kishi K. Flap Monitoring Using Interstitial Fluid Glucose Measurements. Plast Surg (Oakv) 2024; 32:299-304. [PMID: 38681251 PMCID: PMC11046269 DOI: 10.1177/22925503221116284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Background: Various flap monitoring techniques have been used in the early detection of anastomotic thrombus; however, the use of automatic and continuous monitoring methods is presently uncommon. The purpose of this study was to investigate trends in interstitial fluid glucose concentration (IFG) in flap monitoring by measuring IFG automatically and continuously. Methods: Nine patients underwent unilateral breast reconstruction using a transverse rectus abdominis myocutaneous flap with vascular anastomosis. Two IFG measuring devices were attached to each patient. One device was attached to the flap (flap IFG) and the other to the healthy breast (control IFG). In each case, flap IFG, control IFG, and IFG ratio (flap IFG/control IFG) were recorded in the initial 72 h post-surgery (first half) and also in the subsequent 72 h (second half). In all of the cases, the mean values recorded in the first half and those in the second half were compared. Results: All flaps survived. The flap IFG didn't fall below 40 mg/dL in the first half. The minimum flap IFG and IFG ratio were 42 mg/dL and 0.55 in the first half. The flap IFG was significantly higher in the first half than in the second half in all cases, and the IFG ratio was similar in 8 cases. Furthermore, mean flap IFG and mean IFG ratio in all cases in the first half were significantly higher than in the second half. Conclusions: IFG measurements may complement conventional flap monitoring, particularly in the early postoperative period.
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Affiliation(s)
- Tomoki Kiuchi
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Japan
| | - Naohiro Ishii
- Department of Plastic and Reconstructive Surgery, International University of Health and Welfare Hospital, Nasushiobara City, Japan
| | - Takahiro Uno
- Department of Plastic and Reconstructive Surgery, Keio University Tokyo, Tokyo, Japan
| | - Yuichiro Uoya
- Department of Plastic and Reconstructive Surgery, Keio University Tokyo, Tokyo, Japan
| | - Shigeki Sakai
- Department of Plastic and Reconstructive Surgery, Keio University Tokyo, Tokyo, Japan
| | - Kyoichi Matsuzaki
- Department of Plastic and Reconstructive Surgery, School of Medicine, International University of Health and Welfare, Chiba, Japan
| | - Kazuo Kishi
- Department of Plastic and Reconstructive Surgery, Keio University Tokyo, Tokyo, Japan
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Matsuki T, Tsutsumi S, Miyamoto S, Kano K, Momiyama K, Asako Y, Yamashita T. Removal of a Giant Parapharyngeal Space Oncocytoma Without Osteotomy. Ear Nose Throat J 2024; 103:NP203-NP206. [PMID: 34632850 DOI: 10.1177/01455613211048973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oncocytoma arising from the parotid gland and extending into the parapharyngeal space (PPS) has not been previously reported. A 64-year-old woman presented with a large slowly growing mass extending from the parotid to the submandibular area, expanding medially to displace the pharynx across the midline. Core-needle biopsy revealed an oncocytoma in the PPS measuring 120 × 88 × 60 mm in size. Although the tumor was of an unprecedentedly large size and extended into multiple spaces, it could be removed via a cervical-parotid approach without osteotomy. The resected tumor was again diagnosed as oncocytoma. A postoperative complication was weakness of the ipsilateral facial nerve, which almost completely resolved in 6 months. No recurrence has been noted on 1 y follow-up. We were able to resect an extremely large oncocytoma arising from the parotid gland without osteotomy.
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Affiliation(s)
- Takashi Matsuki
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shohei Tsutsumi
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shunsuke Miyamoto
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Koichi Kano
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kaho Momiyama
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yukiko Asako
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
| | - Taku Yamashita
- Department of Otorhinolaryngology, Head and Neck Surgery, Kitasato University School of Medicine, Sagamihara, Japan
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Thiem DGE, Siegberg F, Vinayahalingam S, Blatt S, Krüger M, Lethaus B, Al-Nawas B, Zimmerer R, Kämmerer PW. The Perfect Timing-Immediate versus Delayed Microvascular Reconstruction of the Mandible. Cancers (Basel) 2024; 16:974. [PMID: 38473338 DOI: 10.3390/cancers16050974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/18/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Daniel G E Thiem
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Fabia Siegberg
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Shankeeth Vinayahalingam
- Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Sebastian Blatt
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Maximilian Krüger
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Bernd Lethaus
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
| | - Rüdiger Zimmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Tübingen, Osianderstr. 2-8, 72076 Tübingen, Germany
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Leipzig, Liebigstraße 12, 04103 Leipzig, Germany
| | - Peer W Kämmerer
- Department of Oral and Maxillofacial Surgery, Facial Plastic Surgery, University Medical Centre Mainz, Augustusplatz 2, 55131 Mainz, Germany
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Mohammadi S, Taghizadeh N, Abdollahi A, Mohammadi S. "Y" anastomosis, a solution in doubtful venous anastomosis: a case report and review of the literature. J Med Case Rep 2023; 17:498. [PMID: 38041206 PMCID: PMC10693078 DOI: 10.1186/s13256-023-04177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/12/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Lower lip squamous cell carcinoma is a significant subtype of head and neck cancer, constituting about 25-30% of cases. Traditional surgical methods, like primary closure, have limitations in managing large resections of lip tumors. Recent advancements in surgical techniques, particularly free flaps, have shown promising results in addressing these challenges. The Y-shaped anastomosis is an innovative approach aimed at enhancing the efficiency of microvascular free flap surgeries for improved lip cancer reconstruction outcomes. CASE PRESENTATION A 77-year-old Persian male with lower lip squamous cell carcinoma underwent tumor resection with a 2 cm safety margin, bilateral neck dissection, and lip reconstruction using the right radial forearm free flap. The surgery incorporated a Y-shaped anastomosis to improve venous pedicle outcomes. CONCLUSION In this case, it was decided not to open the first anastomosis but to add the second end to the side one to provide two vascular supports for the venous anastomosis. Y anastomosis makes the surgery easier and decreases complications resulting from vascular size mismatch.
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Affiliation(s)
- Soha Mohammadi
- ENT and Head & Neck Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Nima Taghizadeh
- ENT and Head & Neck Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Arash Abdollahi
- Student Research Committee, Iran University of Medical Sciences, Tehran, Iran
| | - Shabahang Mohammadi
- ENT and Head & Neck Research Center, The Five Senses Health Institute, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
- Department of Otolaryngology-Head and Neck Surgery, Firoozgar Hospital, Iran University of Medical Sciences, Valadi Street, Valiasr Sq, Tehran, Iran.
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Burns HR, Skochdopole AJ, Alfaro Zeledon R, Pederson WC. Pediatric Microsurgery and Free-Tissue Transfer. Semin Plast Surg 2023; 37:231-239. [PMID: 38098684 PMCID: PMC10718656 DOI: 10.1055/s-0043-1776698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
Advancements in microsurgery, along with increased microsurgical experience in pediatric patients, have made free-tissue transfer a reliable modality for pediatric bone and soft tissue reconstruction today. Free-tissue transfer is most commonly used in children for the coverage of large or complex defects resulting from traumatic, oncologic, or congenital etiologies. While flap success and complication rates between pediatric and adult populations are similar, special considerations must be taken into account within the pediatric population. In this article, we will describe common indications, technical nuances, and clinical considerations for the management of the pediatric free-tissue transfer patient.
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Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Anna J. Skochdopole
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Richardo Alfaro Zeledon
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - William C. Pederson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
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Kisser U, Koepernik S. Microvascular anastomotic coupler for venous end-to-side anastomoses in head and neck reconstructive surgery. Eur Arch Otorhinolaryngol 2023; 280:4709-4712. [PMID: 37528315 PMCID: PMC10477101 DOI: 10.1007/s00405-023-08136-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The use of coupler devices has become mainstream in microsurgical end-to-end venous anastomoses (EEA) for free flaps in head and neck reconstruction. Reports about end-to-side venous anastomoses (ESA) using a coupler are scarce, though. METHODS The surgical technique of end-to-side anastomosis using a coupler device is described. End-to-side anastomoses and end-to-end anastomoses with a vascular coupler are compared with respect to postoperative vascular complications. RESULTS 124 patients were included, 76 with EEA, 48 with ESA. Postoperative venous complications occurred in 5.3% and 2.1%, respectively. CONCLUSIONS ESA is a valuable alternative to EEA when using a coupler device providing more flexibility to the surgeon.
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Affiliation(s)
- Ulrich Kisser
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany.
| | - Sophie Koepernik
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
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8
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Zheng L, Lv XM, Shi Y, Huang MW, Zhang J, Liu SM. Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region. Int J Oral Maxillofac Surg 2023; 52:423-429. [PMID: 35987710 DOI: 10.1016/j.ijom.2022.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/04/2022] [Accepted: 04/20/2022] [Indexed: 10/15/2022]
Abstract
Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.
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Affiliation(s)
- L Zheng
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China.
| | - X-M Lv
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - Y Shi
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - M-W Huang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - J Zhang
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
| | - S-M Liu
- Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology, Beijing, PR China
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Swanson MS, Gantz O, Zhou S, Fisher L, Kezirian E, Tan MH, Zhang Y, Chambers TN, Sinha UK, Kokot N. Comparison of Free Flap Outcomes at a University Hospital versus County Hospital Setting for Head and Neck Reconstruction. Int Arch Otorhinolaryngol 2023; 27:e183-e190. [PMID: 37125366 PMCID: PMC10147463 DOI: 10.1055/s-0043-1768204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 10/25/2020] [Indexed: 05/02/2023] Open
Abstract
Introduction Patients at public county hospitals often have poorer access to healthcare with advanced disease on presentation. These factors, along with limited resources at county hospitals, may have an impact on outcomes for patients requiring complex head and neck reconstruction. Objective To delineate differences in the frequency of complications in two different care settings, a public county hospital and a private university hospital. Methods Retrospective review of otolaryngology patients at a university hospital compared with a publicly-funded county hospital. The main outcome measure was major complications including total flap loss or unplanned reoperation in 30 days. Secondary outcome measures included medical complications, partial flap loss, and unplanned hospital readmission in 30 days. Results In the county hospital sample ( n = 58) free flap failure or reoperation occurred in 20.7% of the patients, and minor complications, in 36.2% of the patients. In the university hospital sample ( n = 65) flap failure or reoperation occurred in 9.2% of the patients, and minor complications, in 12.3% of the patients. Patients at the private hospital who had surgery in the oropharynx were least likely to have minor complications. Conclusion Patients at the county hospital had a higher but not statistically significant difference in flap failure and reoperation than those at a university hospital, although the county hospital experienced more minor postoperative complications. This is likely multifactorial, and may be related to poorer access to primary care preoperatively, malnutrition, poorly controlled or undiagnosed medical comorbidities, and differences in hospital resources.
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Affiliation(s)
- Mark S. Swanson
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
| | - Oliver Gantz
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
- Address for correspondence Oliver Gantz, MD USC Tina and Rick Caruso Department of Otolaryngology – Head and Neck Surgery1540 Alcazar Street, Suite 204Q, Los Angeles, CA 90033United States
| | - Sheng Zhou
- Keck School of Medicine, University of Southern California (USC), Los Angeles, California, United States
| | - Laurel Fisher
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
| | - Eric Kezirian
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
| | - Michael H. Tan
- Keck School of Medicine, University of Southern California (USC), Los Angeles, California, United States
| | - Yanchen Zhang
- Keck School of Medicine, University of Southern California (USC), Los Angeles, California, United States
| | - Tamara N. Chambers
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
| | - Uttam K. Sinha
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
| | - Niels Kokot
- Tina and Rick Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California (USC), Los Angeles, California, United States
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Uehara M, Habu M, Sasaguri M, Tominaga K. Post-reconstruction Free Flap Complications After Oral Cancer Ablation. J Maxillofac Oral Surg 2023; 22:20-27. [PMID: 37041939 PMCID: PMC10082861 DOI: 10.1007/s12663-023-01854-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/14/2023] [Indexed: 01/27/2023] Open
Abstract
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.
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Affiliation(s)
- Masataka Uehara
- Unit of Oral and Maxillofacial Surgery, Shimonoseki City Hospital, 1-13-1 Koyocho, Shimonoseki City, Yamaguchi 750-8520 Japan
| | - Manabu Habu
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Masaaki Sasaguri
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
| | - Kazuhiro Tominaga
- Division of Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Fukuoka Japan
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Slijepcevic AA, Yang S, Petrisor D, Chandra SR, Wax MK. Management of the Failing Flap. Semin Plast Surg 2023; 37:19-25. [PMID: 36776810 PMCID: PMC9911216 DOI: 10.1055/s-0042-1759563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Free tissue transfer has become the reconstructive modality of choice for replacing composite tissue defects. While the success rate in high-volume centers is reported to be greater than 95%, up to 10% of patients will require revision of their vascular anastomosis secondary to thrombosis or compromise to flow. In the intraoperative setting, immediate revision is successful in the majority of cases. Rarely, the flap cannot be revascularized and a secondary option must be used. In the perioperative setting revision is successful if the patient can be brought back to the operating room in a timely fashion. Revision rates up to 70% are reported. A small number of these patients may then suffer a second episode of compromise where revision is less successful at 30%. In these cases, consideration should be given to secondary reconstruction rather than attempting salvage. Finally, there are a small number of patients whose flaps will fail following discharge from the hospital. These patients can rarely be salvaged and secondary reconstructive options should be explored.
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Affiliation(s)
| | - Sara Yang
- Department of Otolaryngology - HNS, Oregon Health Sciences University, Portland, Oregon
| | - Daniel Petrisor
- Department of Oral Maxillofacial Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Srinivasa R. Chandra
- Department of Oral Maxillofacial Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Mark K. Wax
- Department of Otolaryngology - HNS, Oregon Health Sciences University, Portland, Oregon
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12
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Chiesa-Estomba CM, González-García JA, Genden EM, Piazza C, Guntinas-Lichius O, Vander-Poorten V, Kowalski LP, López F, Quer M, Rodrigo JP, Sanabria Á, Fernández-Álvarez V, Suárez C, Cohen O, de Bree R, Shaha AR, Mäkitie AA, Ferlito A. Complications related to the Cook-Swartz implantable Doppler probe use in head and neck microvascular reconstruction: a systematic review. Eur Arch Otorhinolaryngol 2023; 280:23-37. [PMID: 35941283 DOI: 10.1007/s00405-022-07577-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/26/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Vascular perfusion research has been dedicated to identify inexpensive, effective, and easy to use methods to assess free flap perfusion for both buried and non-buried flaps. METHODS Systematic review of complications in patients underwent Head and Neck microsurgical reconstruction and vascular implantable Doppler monitoring. RESULTS Sixteen articles were included for qualitative analysis. 2535 (92.2%) patients received IDP monitorization. Venous thrombosis was the most common vascular complication effecting 28 (1.1%). Regarding complications potentially related to the use of the IDP, just one study described the presence of granuloma formation along the suture line in 2 (0.07%) patients. CONCLUSIONS Our findings indicated that Cook-Swartz IDP will represents a safe and effective device for FF monitoring in HN reconstructive micro-surgery. A detailed prospective registration of the results and complications related to the use of IDP remains mandatory to precisely estimate results, cost, and complications.
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Chang BA, Asarkar AA, Horwich PM, Nathan CAO, Hayden RE. Regional pedicled flap salvage options for large head and neck defects: The old, the new, and the forgotten. Laryngoscope Investig Otolaryngol 2022; 8:63-75. [PMID: 36846409 PMCID: PMC9948595 DOI: 10.1002/lio2.983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/06/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives The objective of this article is to review options for regional pedicled reconstruction for large head and neck defects in a salvage setting. Methods Relevant regional pedicled flaps were identified and reviewed. Expert opinion and supporting literature were used to summarize and describe the available options. Results Specific regional pedicled flap options are presented including the pectoralis major flap, deltopectoral flap, supraclavicular flap, submental flap, latissimus flap, and trapezius flap. Conclusions Regional pedicled flaps are useful options in a salvage setting even for large defects and should be in the armamentarium of any reconstructive head and neck surgeon. Each flap option carries specific characteristics and considerations.
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Affiliation(s)
- Brent A. Chang
- Department of Otolaryngology – Head & Neck SurgeryMayo Clinic ArizonaPhoenixArizonaUSA
| | - Ameya A. Asarkar
- Department of Otolaryngology/Head and Neck SurgeryLouisiana State University Health Sciences Center & Feist‐Weiller Cancer CenterShreveportLouisianaUSA,Department of SurgeryOverton Brooks Veterans Affairs Medical Center (OBVAMC)ShreveportLouisianaUSA
| | - Peter M. Horwich
- Head and Neck Specialists, HCA South Atlantic, Sarah Cannon Cancer InstituteCharlestonSouth CarolinaUSA
| | - Cherie Ann O. Nathan
- Department of Otolaryngology/Head and Neck SurgeryLouisiana State University Health Sciences Center & Feist‐Weiller Cancer CenterShreveportLouisianaUSA,Department of SurgeryOverton Brooks Veterans Affairs Medical Center (OBVAMC)ShreveportLouisianaUSA
| | - Richard E. Hayden
- Department of Otolaryngology – Head & Neck SurgeryMayo Clinic ArizonaPhoenixArizonaUSA
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Noori O, Pereira J, Stamou D, Ch'ng S, Varey A. Vasopressors Improve Outcomes in Autologous Free Tissue Transfer: A Systematic Review and Meta-analysis. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.08.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/02/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
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Becker P, Blatt S, Pabst A, Heimes D, Al-Nawas B, Kämmerer PW, Thiem DGE. Comparison of Hyperspectral Imaging and Microvascular Doppler for Perfusion Monitoring of Free Flaps in an In Vivo Rodent Model. J Clin Med 2022; 11:jcm11144134. [PMID: 35887901 PMCID: PMC9321983 DOI: 10.3390/jcm11144134] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/12/2022] [Accepted: 07/14/2022] [Indexed: 01/27/2023] Open
Abstract
To reduce microvascular free flap failure (MFF), monitoring is crucial for the early detection of malperfusion and allows timely salvage. Therefore, the aim of this study was to evaluate hyperspectral imaging (HSI) in comparison to micro-Doppler sonography (MDS) to monitor MFF perfusion in an in vivo rodent model. Bilateral groin flaps were raised on 20 Sprague−Dawley rats. The femoral artery was transected on the trial side and re-anastomosed. Flaps and anastomoses were assessed before, during, and after the period of ischemia every ten minutes for overall 60 min using HSI and MDS. The contralateral sides’ flaps served as controls. Tissue-oxygenation saturation (StO2), near-infrared perfusion index (NPI), hemoglobin (THI), and water distribution (TWI) were assessed by HSI, while blood flow was assessed by MDS. HSI correlates with the MDS signal in the case of sufficient and completely interrupted perfusion. HSI was able to validly and reproducibly detect tissue perfusion status using StO2 and NPI. After 40 min, flap perfusion decreased due to the general aggravation of hemodynamic circulatory situation, which resulted in a significant drop of StO2 (p < 0.005) and NPI (p < 0.005), whereas the Doppler signal remained unchanged. In accordance, HSI might be suitable to detect MFF general complications in an early stage and further decrease MFF failure rates, whereas MDS may only be used for direct complications at the anastomose site.
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Affiliation(s)
- Philipp Becker
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstr. 170, 56072 Koblenz, Germany;
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
- Correspondence:
| | - Sebastian Blatt
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Andreas Pabst
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstr. 170, 56072 Koblenz, Germany;
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Diana Heimes
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Bilal Al-Nawas
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Peer W. Kämmerer
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
| | - Daniel G. E. Thiem
- Department of Oral and Maxillofacial Surgery, University Medical Centre Mainz, 55131 Mainz, Germany; (S.B.); (D.H.); (B.A.-N.); (P.W.K.); (D.G.E.T.)
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Min SH, Choe SH, Kim WS, Ahn SH, Cho YJ. Effects of ischemic conditioning on head and neck free flap oxygenation: a randomized controlled trial. Sci Rep 2022; 12:8130. [PMID: 35581399 PMCID: PMC9114019 DOI: 10.1038/s41598-022-12374-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 05/09/2022] [Indexed: 11/09/2022] Open
Abstract
Flap failure after microvascular reconstructive surgery is a rare but devastating complication caused by reperfusion injury and tissue hypoperfusion. Remote ischemic conditioning (RIC) provides protection against ischemia/reperfusion injury and reduces tissue infarction. We hypothesized that RIC would enhance flap oxygenation and exert organ-protective effects during head and neck free flap reconstructive surgery. Adult patients undergoing free flap transfer surgery for head and neck cancer were randomized to receive either RIC or sham-RIC during surgery. RIC consisted of four cycles of 5-min ischemia and 5-min reperfusion applied to the upper or lower extremity. The primary endpoint, tissue oxygen saturation of the flap, was measured by near-infrared spectroscopy on the first postoperative day. Organ-protective effects of RIC were evaluated with infarct size of rat hearts perfused with plasma dialysate from patients received RIC or sham-RIC. Between April 2018 and July 2019, 50 patients were randomized (each n = 25) and 46 were analyzed in the RIC (n = 23) or sham-RIC (n = 23) groups. Tissue oxygen saturation of the flap was similar between the groups (85 ± 12% vs 83 ± 9% in the RIC vs sham-RIC groups; P = 0.471). Myocardial infarct size after treatment of plasma dialysate was significantly reduced in the RIC group (44 ± 7% to 26 ± 6%; P = 0.018) compared to the sham-RIC group (42 ± 6% to 37 ± 7%; P = 0.388). RIC did not improve tissue oxygenation of the transferred free flap in head and neck cancer reconstructive surgery. However, there was evidence of organ-protective effects of RIC in experimental models. Trial registration: Registry number of ClinicalTrials.gov: NCT03474952.
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Affiliation(s)
- Se-Hee Min
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 102 Heukseok-ro, Heukseok-dong, Dongjak-gu, Seoul, 06973, South Korea
| | - Suk Hyung Choe
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Won Shik Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Jeil ENT Clinic, 23, Nonhyeon-ro 131-gil, Gangnam-gu, Seoul, 06045, South Korea
| | - Soon-Hyun Ahn
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
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Kaleem A, Patel N, Tursun R. Minimally Invasive Cervical Access in Head and Neck Microvascular Surgery. J Oral Maxillofac Surg 2022; 80:1127-1133. [DOI: 10.1016/j.joms.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
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18
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Hummelink SL, Paulus VA, Wentink EC, Ulrich DJ. Development and Evaluation of a Remote Patient Monitoring System in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4008. [PMID: 35186614 PMCID: PMC8849395 DOI: 10.1097/gox.0000000000004008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/28/2021] [Indexed: 11/26/2022]
Abstract
Flap monitoring after a deep inferior epigastric perforator flap breast reconstruction is crucial to detect complications in time. A novel and innovative wireless device has been developed and tested in a feasibility study. This study describes our experience with remote patient monitoring via this device in postoperative monitoring of deep inferior epigastric perforator flaps.
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Mishu MD, Zolper EG, Dekker PK, Fleury CM, Bekeny JC, Fan KL, Attinger CE, Evans KK. Should Antiplatelet Therapy Be Withheld Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population. Plast Reconstr Surg 2022; 149:95e-103e. [PMID: 34936629 DOI: 10.1097/PRS.0000000000008666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antiplatelet agents are typically withheld perioperatively because of bleeding concerns. Dual antiplatelet therapy, such as aspirin and clopidogrel, has significant morbidity and mortality benefits in patients with ischemic heart disease or peripheral vascular disease. This study aims to evaluate the impact of perioperative dual antiplatelet therapy in the lower extremity free tissue transfer population. METHODS Lower extremity free tissue transfers performed by the senior author (K.K.E.) from 2011 to 2019 were retrospectively reviewed. Demographics, comorbidities, perioperative dual antiplatelet therapy, and free tissue transfer characteristics were recorded. Outcomes of interest included flap success, hematoma formation, blood transfusion requirements, and cardiac event occurrence. RESULTS One hundred ninety-five free tissue transfers were included. Median age at the time of free tissue transfer was 56.5 years. Median Charlson Comorbidity Index was 3. Thirty-four patients were on clopidogrel, which was either withheld (n = 20) or continued (n = 14) on the day of free tissue transfer. Incidence of blood transfusion was significantly higher in both the withheld and continued versus nonclopidogrel groups. Flap success was statistically equivalent between groups (withheld, 90.0 percent; continued, 92.9 percent; nonclopidogrel, 95.0 percent; p = 0.346). Cardiac events occurred most often in the continued group (21.4 percent) compared to the withheld (5.0 percent) and nonclopidogrel (0.6 percent) groups. On multivariate analysis, holding clopidogrel remained significant for increased odds of postoperative transfusion. The clopidogrel group was no longer significant for intraoperative transfusion. CONCLUSIONS Despite increases in volume of blood products transfused, free tissue transfer can be performed safely with perioperative dual antiplatelet therapy. Withholding dual antiplatelet therapy on the day of free tissue transfer was not associated with decreased intraoperative transfusion; thus, dual antiplatelet therapy can safely be continued throughout the operative course to minimize cardiovascular risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Abstract
INTRODUCTION Some free flaps develop postoperative vessel thrombosis, which influences the flap survival rate. Early discovery and identification of vascular crisis are critical to the success rate of flap salvage. The primary aims of this study were to determine the features of postoperative blood supply changes in fibular flaps with normal and abnormal blood flow, using near-infrared spectroscopy (NIRS), to monitor oxygenation and blood flow, and to characterize the probable risk factors for vascular crisis. METHODS Sixty-three consecutive patients undergoing reconstruction of unilateral mandibular defects with free fibular flaps at the Peking University School of Stomatology were included. Patients were divided into 2 groups, A (n = 38) and B (n = 25); fibular flaps in group A underwent continuous NIRS monitoring from immediately postoperatively until 7 days postoperatively (approximately 150 hours), whereas fibular flaps and opposite mandibles in group B underwent intermittent monitoring: once every 4 hours during the first 24 hours postoperatively and once every 12 hours from 24 to 168 hours postoperatively. RESULTS Six fibular flaps developed vascular thromboses: 4 were venous thromboses and 2 were arterial thromboses; 5 were rescued after exploration. Of 6 regional oxygen saturation (rSO2) values in the continuous monitoring group, 4 showed no significant differences at any time point compared with the intermittent monitoring group (P > 0.05). The rSO2 of the fibular flap was significantly different from that in the opposite mandible in the first 36 hours postoperatively (P < 0.05). This difference decreased over time. During the initial period of venous thrombosis, rSO2, deoxyhemoglobin, and oxygenated hemoglobin all rose slightly, then showed simultaneous rapid reduction. However, the magnitude of reduction was smaller for deoxyhemoglobin than for oxygenated hemoglobin. CONCLUSIONS Near-infrared spectroscopy can be used for noninvasive and reliable assessment of oxygenation and blood flow in free flaps through continuous, real-time monitoring. It is also portable, inexpensive, and simple to operate. In addition, the detection depth of NIRS is up to 2.0 cm, so it can be used to monitor buried flaps with depths <2.0 cm.
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Affiliation(s)
- Si-Yuan Ouyang
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Zhi-Gang Cai
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Xiao Feng Shan
- From the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology and National Clinical Research Center for Oral Diseases and National Engineering Laboratory for Digital and Material Technology of Stomatology and Beijing Key Laboratory of Digital Stomatolog, HaiDian District, Beijing, China
| | - Yue Li
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, P.R. China
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Torres Fuentes CE, Rodríguez Mantilla IE, Cáceres DNG, Camargo Gonzalez DF. Red Blood Cell Transfusion and its Relationship with Pedicle Thrombosis in Microvascular Free Flaps. J Reconstr Microsurg 2021; 38:402-408. [PMID: 34474496 DOI: 10.1055/s-0041-1733994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Carlos Eduardo Torres Fuentes
- Hand Surgery and Microsurgery Division, Department of Plastic and Reconstructive Surgery, Hospital de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Iván Enrique Rodríguez Mantilla
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Diego Nicolás Guerrero Cáceres
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Diego Felipe Camargo Gonzalez
- Department of plastic and reconstructive surgery, Hospital de San José. Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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Ong AA, Ducic Y, Pipkorn P, Wax MK. Implantable Doppler Removal After Free Flap Monitoring Among Head and Neck Microvascular Surgeons. Laryngoscope 2021; 132:554-559. [PMID: 34363218 DOI: 10.1002/lary.29810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/26/2021] [Accepted: 07/31/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Investigate current practice patterns of head and neck microvascular reconstructive surgeons when removing an implantable Doppler after free flap surgery. STUDY DESIGN Cross-sectional survey study. METHODS Survey distributed to head and neck microvascular reconstructive surgeons. Data regarding years performing free tissue transfer, case numbers, management of implantable Doppler wire, and complications were collected. RESULTS Eighty-five responses were analyzed (38,000 cases). Sixty-six responders (77.6%) use an implantable Doppler for postoperative monitoring, with 97% using the Cook-Swartz Doppler Flow Monitoring System. Among this group, 65.2% pull the wire after monitoring was complete, 3% cut the wire, and 31.8% have both cut and pulled the wire. Of those who have cut and pulled the wire, 48% report cutting and pulling the wire with equal frequency, 43% formerly pulled the wire and now cut the wire, and 9% previously cut the wire but now pull the wire. Of those who pull the wire, there were two injuries to the pedicle requiring return to the operating for flap salvage, and one acute venous congestion. Of the nine who previously pulled the wire, six (67%) cited concerns with major bleeding/flap compromise as the reason for cutting the wire. CONCLUSION In this study, most surgeons use an implantable Doppler for monitoring of free flaps postoperatively. In extremely rare instances, pulling the implantable Doppler wire has resulted in flap compromise necessitating revision of the vascular anastomosis. Cutting the wire and leaving the proximal portion in the surgical site has been adopted as a management option. LEVEL OF EVIDENCE 4 Laryngoscope, 2021.
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Affiliation(s)
- Adrian A Ong
- Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, Buffalo, New York, U.S.A
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas, U.S.A
| | - Patrik Pipkorn
- Department of Otolaryngology-Head and Neck Surgery, Washington University, St. Louis, Missouri, U.S.A
| | - Mark K Wax
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, U.S.A
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Kwasnicki RM, Noakes AJ, Banhidy N, Hettiaratchy S. Quantifying the Limitations of Clinical and Technology-based Flap Monitoring Strategies using a Systematic Thematic Analysis. Plast Reconstr Surg Glob Open 2021; 9:e3663. [PMID: 34262835 DOI: 10.1097/GOX.0000000000003663] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/05/2021] [Indexed: 11/26/2022]
Abstract
Background Multiple techniques exist to monitor free flap viability postoperatively, varying with practical and personal preference, yet the limitations of each technique remain unquantified. This systematic review aims to identify the most commonly reported limitations of these techniques in clinical practice. Methods A systematic review was conducted according to PRISMA guidelines using MEDLINE, EMBASE, and Web of Science with search criteria for postoperative free flap monitoring techniques. Search results were independently screened using defined criteria by two authors and a senior clinician. Limitations of the techniques found in the discussion section of eligible articles were recorded and categorized using thematic analysis. Results A total of 4699 records were identified. In total, 2210 articles met the eligibility criteria and were subsequently reviewed, with 195 papers included in the final analysis. The most frequently reported limitations of clinical monitoring were interpretation requiring expertise (25% of related papers), unsuitability for buried flaps (21%), and lack of quantitative/objective values (19%). For noninvasive technologies, the limitations were lack of quantitative/objective values (21%), cost (16%), and interpretation requiring expertise (13%). For invasive technologies, the limitations were application requiring expertise (25%), equipment design and malfunction (13%), and cost (13%). Conclusions This is the first systematic review to quantify the limitations of different flap monitoring techniques, as reported in the literature. This information may enhance the choice in monitoring strategy for a reconstructive service, and inform the development and refinement of new flap monitoring technologies.
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Lindell JS, Blaschke BL, Only AJ, Parikh HR, Gorman TL, Vang SX, Mahajan AY, Cunningham BP. The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model. Journal of Reconstructive Microsurgery Open 2021. [DOI: 10.1055/s-0041-1729639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Abstract
Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers.
Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care.
Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019.
Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.
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Affiliation(s)
- Jackson S. Lindell
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Breanna L. Blaschke
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
- Department of Orthopaedic Surgery, TRIA Orthopaedic Center, Bloomington, Minnesota
| | - Arthur J. Only
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, Minnesota
| | - Harsh R. Parikh
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Tiffany L. Gorman
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Sandy X. Vang
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ashish Y. Mahajan
- Department of Orthopaedic Surgery, Regions Hospital, St. Paul, Minnesota
| | - Brian P. Cunningham
- Department of Orthopaedic Surgery, Methodist Hospital, St. Louis Park, Minnesota
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Kohler LH, Köhler H, Kohler S, Langer S, Nuwayhid R, Gockel I, Spindler N, Osterhoff G. Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study. BMC Surg 2021; 21:222. [PMID: 33931056 PMCID: PMC8086299 DOI: 10.1186/s12893-021-01232-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Free flap surgery is an essential procedure in soft tissue reconstruction. Complications due to vascular compromise often require revision surgery or flap removal. We present hyperspectral imaging (HSI) as a new tool in flap monitoring to improve sensitivity compared to established monitoring tools. METHODS We performed a prospective observational cohort study including 22 patients. Flap perfusion was assessed by standard clinical parameters, Doppler ultrasound, and HSI on t0 (0 h), t1 (16-28 h postoperatively), and t2 (39-77 h postoperatively). HSI records light spectra from 500 to 1000 nm and provides information on tissue morphology, composition, and physiology. These parameters contain tissue oxygenation (StO2), near-infrared perfusion- (NIR PI), tissue hemoglobin- (THI), and tissue water index (TWI). RESULTS Total flap loss was seen in n = 4 and partial loss in n = 2 cases. Every patient with StO2 or NIR PI below 40 at t1 had to be revised. No single patient with StO2 or NIR PI above 40 at t1 had to be revised. Significant differences between feasable (StO2 = 49; NIR PI = 45; THI = 16; TWI = 56) and flaps with revision surgery [StO2 = 28 (p < 0.001); NIR PI = 26 (p = 0.002); THI = 56 (p = 0.002); TWI = 47 (p = 0.045)] were present in all HSI parameters at t1 and even more significant at t2 (p < 0.0001). CONCLUSION HSI provides valuable data in free flap monitoring. The technique seems to be superior to the gold standard of flap monitoring. StO2 and NIR PI deliver the most valuable data and 40 could be used as a future threshold in surgical decision making. Clinical Trial Register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00020926.
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Affiliation(s)
- Lukas H Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany.
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Saxony, Germany
| | - Simon Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Stefan Langer
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Rima Nuwayhid
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Saxony, Germany
| | - Nick Spindler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Georg Osterhoff
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
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Dekerle L, Cortese S, Salleron J, Rauch P, Mastronicola R, Beulque E, Chatard M, Hamitouche S, Alao O, Dolivet G. Long-term survival after head and neck cancer surgery with immediate free flap reconstruction. ANN CHIR PLAST ESTH 2021; 66:357-363. [PMID: 33824027 DOI: 10.1016/j.anplas.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/04/2021] [Accepted: 02/23/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Head and neck cancer is one of the most frequent cancers worldwide. A combination treatment including surgery is known to have a better survival rate than exclusive radiotherapy-chemotherapy. In extreme cases of non-metastatic patients who have voluminous tumor, or complex location, surgery with immediate reconstruction by free flap could be an option to improve long term survival. PURPOSE To share experience of long-term survival of patients with head and neck cancer who underwent oncologic surgery with immediate free flap reconstruction, and to analyze influencing factors. METHODS All consecutive patients treated with free flaps for reconstruction of extensive defects after resection of head and neck cancer in our center (Nancy, France) were retrieved from the hospital database. Data was recorded in a systematic way. Bivariate and multivariate Cox proportional hazards models were used for statistical analysis. RESULTS Between 1997 and December 2007, 70 patients underwent surgical resection of head and neck tumor with free flap reconstruction. 11 patients were excluded because of missing data. Follow-up time was 7.4 years, IQR from 4.3 to 11.3. Overall survival was 53.8%, 95% CI [39.9%; 65.8%] at 5 years and 38.6% [24.8%; 52.3%] at 10 years. Age>60 years at the surgery HR 2,373 (1,143; 4,927) and TNM score 3-4 HR 2,524 (1,093; 5,828) were statistically associated to a lesser survival rate. CONCLUSION The ability to successfully and safely perform free flaps increases treatment options for patients with advanced head and neck cancer in a selected population. it seems worthwhile to perform these microvascular reconstructions.
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Affiliation(s)
- L Dekerle
- Department of Plastic and Reconstructive Surgery, Nancy University Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France.
| | - S Cortese
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
| | - J Salleron
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
| | - P Rauch
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
| | - R Mastronicola
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
| | - E Beulque
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
| | - M Chatard
- Department of Plastic and Reconstructive Surgery, Nancy University Hospital, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - S Hamitouche
- Department of Head and neck surgery, Nancy University Hospital, Nancy, France
| | - O Alao
- Department of Digestive Surgery, Grenoble Alpes University Hospital, Grenoble, France
| | - G Dolivet
- Department of Oncologic Surgery "Institut de Cancérologie de Lorraine", Nancy, France
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Wang YJ, Wang XL, Jin S, Zhang R, Gao YQ. Meta-analysis of arterial anastomosis techniques in head and neck free tissue transfer. PLoS One 2021; 16:e0249418. [PMID: 33793654 PMCID: PMC8016284 DOI: 10.1371/journal.pone.0249418] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/17/2021] [Indexed: 12/03/2022] Open
Abstract
The present meta-analysis aimed to investigate the differences in the incidence of thrombosis and vascular compromise in arterial anastomosis between microvascular anastomotic devices and hand-sewn techniques during free tissue transfer in the head and neck. We searched for articles in PubMed/Medline, CNKI, WANFANG DATA, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Web of Science, from January 1, 1962 till April 1, 2020 that reported data of microvascular anastomosis during free tissue transfer in the head and neck. The incidence of arterial thrombosis or vascular compromise, or both was the primary outcome. The secondary outcome was anastomotic time. We also assessed the sensitivity and the risk of bias. This meta-analysis included 583 arterial anastomoses from six studies. The group using microvascular anastomotic devices tended to have an increased incidence of arterial thrombosis and vascular compromise (risk ratio (RR), 3.42; P = 0.38; 95% confidence interval (CI), 0.91–12.77). The hand-sewn technique took significantly longer to perform the anastomosis compared with that of the microvascular anastomotic devices (weighted mean difference, 15.26 min; P<0.01; 95% CI, 14.65–15.87). Microvascular anastomotic devices might increase the risk of arterial thrombosis and vascular compromise compared with the hand-sewn technique; however, further randomized controlled trials are needed to provide a more accurate estimate. The application of microvascular anastomotic devices will help to reduce anastomotic surgery time and achieve acceptable vessel opening, benefiting from the developments of arterial couplers and microsurgical techniques.
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Affiliation(s)
- Yu-Jing Wang
- Department of Nursing, School and Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province, China
| | - Xiu-Ling Wang
- Department of Cardiology, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Shan Jin
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province, China
| | - Ran Zhang
- Department of Oral and Maxillofacial Surgery, School and Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province, China
| | - Yu-Qin Gao
- Department of Nursing, School and Hospital of Stomatology, China Medical University, Shenyang, Liaoning Province, China
- * E-mail:
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Molitor M, Mestak O, Pink R, Foltan R, Sukop A, Lucchina S. The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 165:113-130. [PMID: 33821844 DOI: 10.5507/bp.2021.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/26/2021] [Indexed: 11/23/2022] Open
Abstract
Micro-vascular flaps have been used for the repair of challenging defects for over 45 years. The risk of failure is reported to be around 5-10% which despite medical and technical advances in recent years remains essentially unchanged. Precise, continuous, sensitive and specific monitoring together with prompt notification of vascular compromise is crucial for the success of the procedure. In this review, we provide a classification and brief description of the reported methods for monitoring the micro-vascular flap and a summary of the benefits over direct visual monitoring. Over 40 different monitoring techniques have been reported but their comparative merits are not always obvious. One looks for early detection of a flap's compromise, improved flap salvage rate and a minimal false-positive or false-negative rate. The cost-effectiveness of any method should also be considered. Direct visualisation of the flap is the method most generally used and still seems to be the simplest, cheapest and most reliable method for flap monitoring. Considering the alternatives, only implantable Doppler ultrasound probes, near infrared spectroscopy and laser Doppler flowmetry have shown any evidence of improved flap salvage rates over direct visual monitoring.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Ondrej Mestak
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Richard Pink
- Department of Maxillofacial Surgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Rene Foltan
- Department of Maxillofacial Surgery, General University Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, University Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stefano Lucchina
- Hand Unit, General Surgery Department, Locarno's Regional Hospital, Via Ospedale 1, 6600 Locarno, Switzerland
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Zhang S, Xiong T, Li S, Liu X, Yang Y, Zhao Z. Double Thread Suspension: A Novel Technique to Facilitate End-to-Side Venous Anastomosis With a Microvascular Coupling Device in Head and Neck Reconstruction. J Oral Maxillofac Surg 2021; 79:1954-1962. [PMID: 33901452 DOI: 10.1016/j.joms.2021.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Microvascular free tissue transfer has become a mainstay for head and neck reconstruction, and vascular anastomosis is 1 of the most challenging aspects. This study aimed to explore a safe, convenient, and efficient technique for end-to-side venous anastomosis using the coupling device. MATERIALS AND METHODS We evaluated a novel surgical strategy, double thread suspension (DTS), by reviewing data collected in a consecutive series of 60 patients who underwent free tissue grafting after surgical resection of head and neck tumors. Patients who underwent end-to-side microvascular anastomosis using the microvascular coupler device were randomly divided into the DTS group (n = 30) and the traditional procedure group (TRA, n = 30), the demographic data, coupler size, anastomosis time, microvascular complications, and flap survival were determined. RESULTS The optional size range of coupler devices in the DTS group is better than that of the conventional group, ranging from 1.5 to 4.0 mm compared with 2.0 to 4.0 mm. The average anastomosis time was 4.68 ± 0.43 minutes in the DTS group which was significantly lower than the conventional group that was 9.24 ± 1.46 minutes (P < .0001) . There was no statistically significant difference between the 2 groups in coupler related complications or flap survival. CONCLUSION The novel DTS technique provides the advantages of lowering procedure complexity, reducing operative time, and preventing tearing of vessel wall, therefore making DTS-guided end-to-side anastomosis a safe, relatively straightforward, and reliable technique.
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Affiliation(s)
- Sheng Zhang
- Professor, Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Tengteng Xiong
- Oral and Maxillofacial Surgery Resident-In-Training, Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Sainan Li
- Oral and Maxillofacial Surgery Resident-In-Training, Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Xinyu Liu
- Oral and Maxillofacial Surgery Resident-In-Training, Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
| | - Yan Yang
- Attending Doctor, Xiangya Stomatological Hospital, Xiangya School of Stomatology, Central South University, Changsha, Hunan, P.R. China
| | - Zhili Zhao
- Attending Doctor,Department of Oral and Maxillofacial Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China.
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Burkhard JP, Pfister J, Giger R, Huber M, Lädrach C, Waser M, Olariu R, Engel D, Löffel LM, Schaller B, Wuethrich PY. Perioperative predictors of early surgical revision and flap-related complications after microvascular free tissue transfer in head and neck reconstructions: a retrospective observational series. Clin Oral Investig 2021; 25:5541-5550. [PMID: 33686470 PMCID: PMC8370926 DOI: 10.1007/s00784-021-03864-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/25/2021] [Indexed: 11/15/2022]
Abstract
Objectives The aim of this study was to determine the influence of perioperative fluid management and administration of vasopressors on early surgical revision and flap-related complications in free tissue transfer. Materials and methods Intraoperative amount of fluid and of vasopressors, relevant perioperative parameters, and comorbidities were recorded in 131 patients undergoing head and neck microvascular reconstruction and compared with early surgical complications, defined as interventions requiring surgery after a flap-related complication, and/or other surgical problems in the operating room within 30 days after initial surgery. The relationship between perioperative variables for each revision category was determined using an optimized multiple logistic regression. Results The administration of diuretics (p=0.001) as a treatment for perioperative fluid overload and the type of flap (p=0.019) was associated with a higher risk of early surgical revisions. Perioperative fluid overload (p=0.039) is significantly related to flap-related complications. We found no effect of intraoperative administration of vasopressors on early surgical revisions (p=0.8) or on flap-related complications (norepinephrine p=0.6, dobutamine p=0.5). Conclusion Perioperative fluid overload is associated with higher risks of early surgical revision and flap-related complications. In contrast, the administration of vasopressors seemed to have no effect on either surgical revision rate or flap-related complications. Clinical relevance In patients receiving microvascular reconstructions, a balanced fluid administration perioperatively and a targeted use of vasopressors should be the necessary strategy to reduce the complication rates in head and neck surgery.
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Affiliation(s)
- John-Patrik Burkhard
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Jelena Pfister
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Roland Giger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Claudia Lädrach
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Manuel Waser
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Benoît Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
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Suh JM, Chung CH, Chang YJ. Head and neck reconstruction using free flaps: a 30-year medical record review. Arch Craniofac Surg 2021; 22:38-44. [PMID: 33714251 PMCID: PMC7968978 DOI: 10.7181/acfs.2020.00745] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Joong Min Suh
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Chul Hoon Chung
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Yong Joon Chang
- Department of Plastic and Reconstructive Surgery, Kangdong Sacred Heart Hospital, Seoul, Korea
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Frohwitter G, Nobis CP, Weber M, Oetter N, Rau A, Kesting MR, Lutz R. Thermal Imaging in a Clinically Non-assessable Free Flap Reconstruction of the Face. Plast Reconstr Surg Glob Open 2021; 9:e3440. [PMID: 33680684 DOI: 10.1097/GOX.0000000000003440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/29/2020] [Indexed: 01/19/2023]
Abstract
Free flap monitoring and early detection of malperfusion are a central aspect in reconstructive surgery. Warm ischemia, measured as the time a certain tissue is able to survive without any additional medical or thermal treatment, ranges from hours in muscle and nerval tissue up to days in bony tissue. Hence, meticulous flap monitoring is essential to discover early signs of malperfusion and decide upon timely re-intervention. Besides clinical examination techniques and Doppler sonography, a multitude of mostly experimental procedures are available to evaluate free flap perfusion. Particularly in older patients, the assessment of the skin island in microvascular grafts is a demanding task because the natural loss of elasticity, the reduction of subcutaneous tissue, and the decrease in water content limit the visibility of capillary filling and favor hematomas. We report a case of a 90-year-old woman with an extensive cutaneous squamous cell carcinoma of the right zygomatic and lateral orbital region without any locoregional or distant metastasis. Due to the resilient health status, we decided for a surgical approach with consecutive microvascular radial forearm flap reconstruction. On account of the difficult assessment of elderly skin after microvascular transplantation, we decided on additional flap monitoring by thermal heat imaging during the operation and aftercare. This case report discusses the successful application of thermal heat imaging in a clinical non-assessable free flap and discusses the application of dynamic infrared thermography as a monitoring tool in microvascular free flap surgery.
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Smith JR, Teven CM, Choudry U, Gottlieb LJ. Ultradelayed Arterial Thrombosis: Critical Flap Ischemia After Phalloplasty. Ann Plast Surg 2021; 86:182-187. [PMID: 32826439 DOI: 10.1097/sap.0000000000002508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Delayed arterial thrombus causing loss of a cutaneous free flap at or beyond 6 months is a rare phenomenon. The purpose of this report is to describe 2 cases of arterial compromise requiring medical and surgical intervention at or beyond 6 months after radial forearm free flap (RFFF) phalloplasty and to define the phenomenon of ultradelayed arterial thrombosis. METHODS Patient 1 is a 44-year-old transmale who presented with pulselessness, pallor, and hypersensitivity of his neophallus 10 years status post-RFFF phalloplasty using a saphenous vein interposition graft (SVIG) between the superficial femoral artery (SFA) and radial artery (RA). Patient 2 is a 35-year-old transmale who presented with similar complaints 6 months status post-RFFF phalloplasty with the same vascular connections as above. RESULTS Patient 1 was found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator, resulting in partial loss limited to the distal three fourths of the shaft. Patient 2 was also found to have an arterial thrombus distal to the SFA-SVIG anastomosis requiring catheter-directed thrombolysis with tissue plasminogen activator and common femoral artery CFA-RA bypass, resulting in partial loss limited to the neoglans. CONCLUSIONS Ultradelayed arterial thrombosis is a rare phenomenon requiring urgent intervention. The exact causes of this phenomenon, whether mechanical or physiological or both, have yet to be fully elucidated but it is hypothesized that the original anastomosis may continue to serve as the critical blood supply to its flap as far as 10 years after surgery.
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Affiliation(s)
- Jesse R Smith
- From the Section of Plastic Surgery and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL
| | - Chad M Teven
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Phoenix, AZ
| | - Umar Choudry
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN
| | - Lawrence J Gottlieb
- From the Section of Plastic Surgery and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL
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Scaglioni MF, Meroni M, Fritsche E, Rajan G. Internal mammary artery perforators as recipient vessels for free tissue transfer in head and neck reconstruction: A case report and literature review. Microsurgery 2020; 41:355-360. [PMID: 33159486 DOI: 10.1002/micr.30680] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 10/23/2020] [Indexed: 11/12/2022]
Abstract
Head and neck defect reconstruction is a common challenge for plastic surgeons. Microsurgical free tissue transfer is a frequently used solution but its success strictly depends on the quality of recipient vessels. A particularly demanding situation occurs when there are no nearby available vessels because of previous extensive neck dissection and radiotherapy. In similar cases, it is necessary to resort to other and farther vessels. Common alternatives might be the thoraco-acromial vessels, the transverse cervical vessels, and the internal mammary vessel. Recently, the perforator vessels of the internal mammary artery and vein were shown to be safe alternatives as recipient vessels for autologous breast reconstruction, causing less morbidity and allowing adequate perfusion of rather large flaps. Here we present a floor of the mouth reconstruction after cancer relapse resection. In this case, we employed a chimeric anterolateral thigh (ALT) free flap anastomosed to the internal mammary perforator vessels in end-to-end fashion. A 46-years-old male patient presented a defect in the floor of the mouth and base of the tongue after cancer removal. No nearby vessels were available because of extensive fibrosis and damages due to previous surgeries and radiotherapy. Therefore, on the basis of our experience in autologous breast reconstruction, we chose the internal mammary perforator vessels in the recipient side and we harvested a chimeric ALT-based skin island then split into two parts for mouth reconstruction and monitoring. We performed the anastomosis resorting to internal mammary perforator vessels and we obtained a satisfactory result from both the functional and aesthetic point of view. Postoperative course was uneventful and at 6 months follow up the reconstructive result was good with no functional issue. We believe that this might be a valid and modern evolution of the use of internal mammary vessels as recipient vessels and that it is a worthy addition in the field of perforator-anastomosed flaps, extending its application also to head and neck reconstructions. Moreover, a brief literature review about alternative recipient vessels for depleted neck is also provided.
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Affiliation(s)
- Mario F Scaglioni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Matteo Meroni
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Elmar Fritsche
- Department of Hand- and Plastic Surgery, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Gunesh Rajan
- Department of Otolaryngology, Head & Neck Surgery, Luzerner Kantonsspital, Lucerne, Switzerland.,Otolaryngology, Head & Neck Surgery, Medical School, University of Western Australia, Perth, Australia
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35
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Wang S, Zhang W, Yu Y, Wang T, Yang H, Peng X. Factors Affecting Volume Change of Anterolateral Thigh Flap in Head and Neck Defect Reconstruction. J Oral Maxillofac Surg 2020; 78:2090-8. [DOI: 10.1016/j.joms.2020.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/22/2022]
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Lese I, Biedermann R, Constantinescu M, Grobbelaar AO, Olariu R. Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers. J Plast Reconstr Aesthet Surg 2020; 74:512-522. [PMID: 33039304 DOI: 10.1016/j.bjps.2020.08.126] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. METHODS Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. RESULTS A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001). CONCLUSION If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.
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Affiliation(s)
- Ioana Lese
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland.
| | - Raphael Biedermann
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Mihai Constantinescu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Adriaan O Grobbelaar
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
| | - Radu Olariu
- Department of Plastic and Hand Surgery, Inselspital, Bern University Hospital, Freiburgstrasse 4, 3010 Bern, Switzerland
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Buitrago G, Caballero F, Montealegre GE. Reconstruction with Free Flaps of Head and Neck Cancer Defects: A National Cohort Study. Plast Reconstr Surg Glob Open 2020; 8:e3018. [PMID: 32983776 DOI: 10.1097/GOX.0000000000003018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/08/2020] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to determine the perioperative mortality rate, reintervention rate, and total healthcare costs for head and neck cancer patients who underwent free tissue transfer (FTT) in Colombia. The prognostic factors associated with those results were estimated.
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Sievert M, Koch M, Goncalves M, Richter D, Tamse R, Mueller SK, Gostian AO, Traxdorf M, Harréus U, Iro H. [Thrombosis of sewn vs. coupled anastomoses in microvascular head and neck reconstructions]. Laryngorhinootologie 2020; 100:453-459. [PMID: 32927485 DOI: 10.1055/a-1253-8392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Anastomotic Coupling Device for microvascular anastomoses has become widely used in free tissue transplantation. This study compares the thrombosis rate and flap failure as a function of the anastomosis technique at a large head and neck cancer center. MATERIAL AND METHODS Retrospective analysis of all patients receiving free flap reconstructions in the period 2001-2019. Reconstruction type, recipient vessels, number of venous anastomoses, coupler size, and operation time were investigated. We compared the rates of venous thrombosis between hand sewn and coupled anastomoses, as well as the rate of flap failure. RESULTS A total of 403 free flap reconstructions were performed for over 17 years. The venous anastomosis was sewn in 113 flaps in single suture technique, and in 290 cases, coupler device was used. The rate of venous thrombosis requiring immediate surgical revision was 6.2 % (7/113) in the sewn group compared to 7.6 % in the coupled group (22/290; p = 0.627). With an overall success rate of 95.0 % (383/403), the rate of flap failure was 3.6 % (4/113) and 5.5 % (16/290; p = 0.421), respectively. Surgical time is comparable with 680 ± 144 minutes in the hand-sewn group and 688 ± 167 minutes in the coupled group (p = 0.678). CONCLUSIONS With similar success rates, the coupler device is an effective alternative to venous anastomosis in single suture technique. Due to the generally low rate of pedicle thrombosis in both groups, we cannot separate the influence of the anastomosis technique from possible interfering variables.
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Affiliation(s)
- Matti Sievert
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Michael Koch
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Miguel Goncalves
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Daniel Richter
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Rosalie Tamse
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Sarina K Mueller
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Antoniu-Oreste Gostian
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Maximilian Traxdorf
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
| | - Uli Harréus
- Hals-Nasen-Ohrenheilkunde, Kopf-Hals-Gesichtschirurgie, Asklepios-Stadtklinik Bad Tölz, Deutschland
| | - Heinrich Iro
- Hals-Nasen-Ohrenklinik, Kopf- und Halschirurgie, Universitätskliniken Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Deutschland
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Sweeny L, Curry J, Crawley M, Cave T, Stewart M, Luginbuhl A, Heffelfinger R, Krein H, Petrisor D, Bender-Heine A, Wax MK. Factors impacting successful salvage of the failing free flap. Head Neck 2020; 42:3568-3579. [PMID: 32844522 DOI: 10.1002/hed.26427] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/25/2020] [Accepted: 07/28/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Larissa Sweeny
- Department of Otolaryngology - Head and Neck Surgery, Louisiana State University Health Science Center - New Orleans, New Orleans, Louisiana, USA
| | - Joseph Curry
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Meghan Crawley
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Taylor Cave
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - Matthew Stewart
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam Luginbuhl
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ryan Heffelfinger
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Howard Krein
- Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Petrisor
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Adam Bender-Heine
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Mark K Wax
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA.,Department of Otolaryngology - Head and Neck Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Sievert M, Goncalves M, Tamse R, Mueller SK, Koch M, Gostian AO, Iro H, Scherl C. Postoperative management of antithrombotic medication in microvascular head and neck reconstruction: a comparative analysis of unfractionated and low-molecular-weight heparin. Eur Arch Otorhinolaryngol 2020; 278:1567-1575. [PMID: 32710177 PMCID: PMC8057982 DOI: 10.1007/s00405-020-06219-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/15/2020] [Indexed: 11/29/2022]
Abstract
Purpose Free flap reconstruction is a valuable technique to preserve function in oncological head and neck surgery. Postoperative graft thrombosis is a dreaded risk. This study aims to compare low-dose unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) in perioperative thrombosis prophylaxis. Methods This is a retrospective analysis of 266 free flaps performed at our academic center. A comparison was made between 2 patient groups, based on their respective postoperative prophylaxis protocols either with UFH (n = 87) or LMWH (n = 179). Primary endpoints were the frequency of transplant thrombosis and the number of flap failures. Secondary endpoints were the occurrence of peri- and postoperative complications. Results The flap survival rate was 96.6% and 93.3% for the groups UFH and LMWH, respectively (P = 0.280). The rate of postoperative bleeding requiring revision was 4.6% and 6.7% for each group, respectively (P = 0.498). We found a hematoma formation in 4.6% and 3.9% (P = 0.792). Conclusion The free-flap survival rate using low-dose UFH seems to be equivalent to LMWH regimens without compromising the postoperative outcome. Consequently, for risk-adapted thrombosis prophylaxis, either LMWH or UFH can be administrated.
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Affiliation(s)
- Matti Sievert
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany.
| | - Miguel Goncalves
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Rosalie Tamse
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Sarina K Mueller
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Michael Koch
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Heinrich Iro
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
| | - Claudia Scherl
- Department of Otorhinolaryngology, Head and Neck Surgery, Friedrich Alexander University of Erlangen-Nuremberg, Waldstrasse 1, 91054, Erlangen, Germany
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El Baba B, Watfa W, Youssef L, Di Summa PG, Bou Khalil P, Jurjus AR, Loyens DB, Sertel S, Jurjus RA. Review and update on the use of the microanastomotic coupler device for arterial anastomosis in free tissue transfer. Br J Oral Maxillofac Surg 2021; 59:16-20. [PMID: 32620301 DOI: 10.1016/j.bjoms.2020.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 06/12/2020] [Indexed: 11/21/2022]
Abstract
While a simple interrupted sutured anastomosis remains the gold standard in microsurgery, the introduction of the microanastomotic coupler device (MACD) has decreased procedure time and thrombosis risk, and improved the patency of venous anastomoses. The aim of this review is to update the evidence-based advantages of the MACD on arteries, based on clinical and experimental data, and to compare them to the hand-sewn approach in free flap transfer. All relevant articles that appeared in the PubMed and Medline/Ovid databases during the past three decades were reviewed. After exclusions, 11 studies were retained and discussed. The MACD had a generally shorter arterial anastomosis time, with improved flap survival and reduced ischaemia compared with the hand-sewn approach. The use of the MACD in arterial anastomosis is an efficient and less time-consuming alternative to the hand-sewn technique, provided that the selection of vessels is appropriate and the vessel diameter is large enough to do the anastomosis.
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Shinomiya R, Sunagawa T, Nakashima Y, Kodama A, Hayashi Y, Tokumoto M, Adachi N. Monitoring Vascular Compromise Using Ultrasound After Free Tissue Transfer. J Ultrasound Med 2020; 39:1213-1222. [PMID: 31880342 DOI: 10.1002/jum.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the clinical utility of high-resolution ultrasound (US) for monitoring vascular compromise after free tissue transfer. METHODS Fifty-two tissue transfers in the extremities were included in this study. Blood flow around the anastomotic pedicle and subcutaneous tissue of the grafted flap was monitored with pulsed color and power Doppler US whenever the conventional monitoring method, comprising the bedside assessment of the temperature, capillary refill, and flap color, showed abnormalities until 1 week after reconstruction. RESULTS All flaps were indicated for US monitoring, with 44 flaps showing Doppler signals in each position, even though conventional flap monitoring showed an abnormality. Forty of the 44 flaps showed no flap failure, whereas the remaining 4 flaps developed partial necrosis. Abnormal US findings were noted in 8 of the 52 flaps. Ultrasound revealed interruption of venous blood flow around the anastomotic pedicle in 6 of 8 flaps. Emergent exploration revealed venous occlusion at the anastomotic pedicle, similar to the US finding. In 2 of the 8 flaps, US showed no blood flow to either the anastomotic pedicle or subcutaneous tissue. Emergent exploration revealed arterial occlusion at the anastomotic pedicle. Seven of the 8 reexplored flaps were salvaged after revision surgery with complete flap survival. Partial flap survival was noted in 1 case, but complete flap failure was avoided. CONCLUSIONS Ultrasound is a useful adjunct that enables a direct assessment of perfusion in grafted tissues, which may reduce unnecessary exploration when conventional flap monitoring shows an abnormality.
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Affiliation(s)
- Rikuo Shinomiya
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Sunagawa
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nakashima
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akira Kodama
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuta Hayashi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Maya Tokumoto
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Tapia B, Garrido E, Cebrian JL, Castillo JLD, Alsina E, Gilsanz F. New techniques and recommendations in the management of free flap surgery for head and neck defects in cancer patients. Minerva Anestesiol 2020; 86:861-871. [PMID: 32486605 DOI: 10.23736/s0375-9393.20.13997-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Free flap surgery is the gold standard surgical treatment for head and neck defects in cancer patients. Outcomes have improved considerably, probably due to recent advances in surgical techniques. In this article, we review improvements in the parameters traditionally used to optimize hematocrit levels and body temperature and to prevent vasoconstriction, and describe the use of cardiac output-guided fluid management, a technique that has proved useful in other procedures. Finally, we review other parameters used in free flap surgery, such as clotting/platelet management and nutritional optimization.
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Affiliation(s)
- Blanca Tapia
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain -
| | - Elena Garrido
- Department of Anesthesia an Intensive Care, Wexner Medical Center, Columbus, OH, USA
| | - Jose L Cebrian
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Jose L Del Castillo
- Department of Oral and Maxillofacial Surgery, La Paz University Hospital, Madrid, Spain
| | - Estibaliz Alsina
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
| | - Fernando Gilsanz
- Department of Anesthesia and Intensive Care, La Paz University Hospital, Madrid, Spain
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Chakrabarti S, Gupta DK, Gupta M, Daga D, Mishra A, Sharma SS, Chugh R, Singh SK. Versatility and Reliability of Islanded Pedicled Nasolabial Flap in Head and Neck Cancer Reconstruction. Laryngoscope 2020; 130:1967-1972. [PMID: 32267549 DOI: 10.1002/lary.28662] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Reconstruction of head and neck cancer ablative defects is challenging. A modification of the nasolabial flap (islanded pedicled nasolabial flap [ipNLF]) is an easy and reliable option for reconstruction of small- to medium-sized defects of the head and neck, especially in resource-constrained and high-volume centers. STUDY DESIGN AND METHODS We present the retrospective analysis of 27 consecutive patients reconstructed with ipNLF at two high-volume cancer centers, Homi Bhabha Cancer Hospital, Varanasi, India; and Army Hospital Research and Referral, New Delhi, India. The functional outcomes measured were duration of weaning of feeding and tracheotomy tubes and speech assessment (speech intelligible rating score [SIR]) postsurgery. Complications assessed were flap loss, orocutaneous fistula, donor site wound dehiscence, oral incompetence, and angle of mouth deviation. RESULTS The most common ablative defect was of the oral cavity (22 patients), followed by the oropharynx (4 patients) and hypopharynx (1 patient). The mean operating time for flap harvesting and insetting was 57.7 minutes. The mean durations for postoperative feeding tube and tracheotomy removal were 10 and 5 days, respectively. Twenty-four subjects had SIR scores of I or II. None of the subjects had flap loss, orocutaneous fistula, or donor site wound dehiscence. Twenty-five subjects had no oral incompetence, and 26 subjects had no or minimal angle of mouth deviation. CONCLUSION This is the largest series of ipNLF to date and emphasizes the versatility, reliability, reproducibility and excellent functional and acceptable cosmetic outcomes of this flap for the reconstruction of judiciously chosen head and neck ablative defects. LEVEL OF EVIDENCE 2C Laryngoscope, 130: 1967-1972, 2020.
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Affiliation(s)
| | | | - Monika Gupta
- Department of Head and Neck Oncology, Homi Bhabha Cancer Hospital, Varanasi
| | - Dipti Daga
- Department of Head and Neck Oncology, Homi Bhabha Cancer Hospital, Varanasi
| | - Aseem Mishra
- Department of Head and Neck Oncology, Homi Bhabha Cancer Hospital, Varanasi
| | | | - Rajeev Chugh
- Dept of ENT-HNS, Army Hospital Research and Referral, New Delhi
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Kozak GM, Katzel EB, Rose JF, Nathan SL, Wu LC. An Analysis of Specialty-Specific Microsurgical Head and Neck Reconstruction: A Look at a Single Institution and National Trends Over a Decade. Ann Plast Surg 2020; 84:413-7. [DOI: 10.1097/sap.0000000000002082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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46
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Mannelli G, Gazzini L, Comini LV, Parrinello G, Nocini R, Marchioni D, Molteni G. Double free flaps in oral cavity and oropharynx reconstruction: Systematic review, indications and limits. Oral Oncol 2020; 104:104637. [PMID: 32217459 DOI: 10.1016/j.oraloncology.2020.104637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/02/2020] [Accepted: 03/07/2020] [Indexed: 11/17/2022]
Abstract
The simultaneous use of two different free flaps, harvested from distinct donor sites, has demonstrated a reasonable degree of safety and success rates in head and neck composite defects reconstruction. Unfortunately, their relatively low frequent use, together with the lack of proper statistics on their management strategies, make their indications weak of robust conclusions to better define their role in common practice. The aim of the present study was to review the literature of the last 15 years regarding simultaneous free flap transposition, presenting advantages, disadvantages, and results of this technique, with the final purpose to propose an up-to-date panorama for the use of double free flap for complex head and neck defects reconstruction. Depending on which factors are present, surgeons may choose to select an approach that is theoretically safer, but yields less-than-ideal functional outcomes, such as local flap. Two free flaps may be necessary when the defect contains both a large, complex bony defect, large soft tissue needs, and proper surgical planning and meticulous monitoring continues to be the cornerstone of success.
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Affiliation(s)
- Giuditta Mannelli
- Head and Neck Oncology and Robotic Surgery, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Luca Gazzini
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Lara Valentina Comini
- Otorhinolaryngology Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Riccardo Nocini
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Daniele Marchioni
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
| | - Gabriele Molteni
- Otorhinolaryngology Unit, University Hospital AOUI Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy
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Kramer A, Metanes I, Amir A, Franco E, Doweck I, Bryzgalin L, Eyal N, Segal-trabelsi M, Lavi I, Bitterman A, Har-shai Y. The establishment of a microvascular free flap service in a medium-sized hospital (500 beds)—an eight-year experience. Eur J Plast Surg 2020; 43:37-42. [DOI: 10.1007/s00238-019-01548-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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González Moreno I, Torres del Río S, Vázquez Olmos C. Seguimiento del cáncer de cabeza y cuello tratado. Lo que el radiólogo debe conocer. Radiología 2020; 62:13-27. [DOI: 10.1016/j.rx.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/27/2019] [Accepted: 07/29/2019] [Indexed: 11/25/2022]
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49
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González-moreno I, Torres del Río S, Vázquez Olmos C. Follow-up in head and neck cancer. What the radiologist must know. Radiología (English Edition) 2020; 62:13-27. [DOI: 10.1016/j.rxeng.2019.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Young AMH, Bache S, Segaren N, Murphy S, Maraka J, Durrani AJ. Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy. Front Surg 2019; 6:53. [PMID: 31921882 PMCID: PMC6932995 DOI: 10.3389/fsurg.2019.00053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 08/27/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap. Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded. Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025). Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.
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Affiliation(s)
- Adam M H Young
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Sarah Bache
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nicolas Segaren
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Suzane Murphy
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Jane Maraka
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Amer J Durrani
- Department of Plastic Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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