Free flap complications: when is enough, enough?

Head and neck reconstruction with pedicled flaps in the free flap era

Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

Morphomic analysis as an aid for preoperative risk stratification in patients undergoing major head and neck cancer surgery

BACKGROUND

Patients undergoing major head and neck cancer surgery (MHNCS) may develop significant postoperative complications. To minimize the risk of complications, clinicians often assess multiple measures of preoperative health in terms of medical comorbidities. One emerging method to decrease surgical complications is preoperative assessment of patient frailty measured by specific tissue characteristics. We hypothesize that morphomic characteristics of the temporalis region serve as predictive markers for the development of complications after MHNCS.

METHODS

We performed a retrospective review of 69 patients with available computed tomography (CT) imaging who underwent MHNCS from 2006-2012. To measure temporalis region characteristics, we used morphomic analysis of available preoperative CT scans to map out the region. All available CT scans had been performed as part of the patient's routine work-up and were not ordered for morphomic analysis. We describe the correlation among temporalis fat pad volume (TFPV), mean zygomatic arch thickness, and incidence of postoperative complications.

RESULTS

We noted significant difference in the zygomatic bone thickness and TFPV between patients who had medical complications, surgical complications, or total major complications and those who did not. Furthermore, by use of binary logistic regression, our data suggest decreased TFPV and zygomatic arch thickness are stronger predictors of developing postoperative complications than previously studies preoperative characteristics.

CONCLUSIONS

We describe morphomic analysis of the temporalis region in patients undergoing MHNCS to identify patients at risk for complications. Regional anatomic morphology may serve as a marker to objectively determine a patient's overall health. Use of the temporalis region is appropriate in patients undergoing MHNCS because of the availability of preoperative scans as part of routine work up for head and/or neck cancer.

Free tissue transfer for head and neck reconstruction in solid organ transplant patients

BACKGROUND

Patients with head and neck malignancies who have had solid organ transplant and require free tissue transfer are a unique population. This study was performed to evaluate the effect of immunosuppression on the rate of perioperative complications and the success of free tissue transfer in the head and neck.

METHODS

Complications in solid organ transplant patients undergoing free tissue transfer for reconstruction of head and neck malignancies from 1998 to 2010 were evaluated.

RESULTS

A total of 22 flaps in 17 patients were performed. Eight patients (11 of 22 flaps) had complications. The median hospital stay was 6 days (range, 4-26 days). The median length of follow-up was 13.5 months (range, 3.5-49.9 months).

CONCLUSIONS

Solid organ transplant patients are at an increased risk of de novo malignancies due to chronic immunosuppression. This study demonstrates that free tissue transfer is a viable option in transplant patients with morbidity similar to nontransplant patients.

Effect of neoadjuvant chemoradiation and postoperative radiotherapy on expression of heat shock protein 70 (HSP70) in head and neck vessels

Background

Preoperative radiotherapy and chemotherapy in patients with head and neck cancer result in changes to the vessels that are used to construct microsurgical anastomoses. The aim of the study was to investigate quantitative changes and HSP70 expression of irradiated neck recipient vessels and transplant vessels used for microsurgical anastomoses.

Methods

Of 20 patients included in this study five patients received neoadjuvant chemoradiation, another five received conventional radiotherapy and 10 patients where treated without previous radiotherapy. During surgical procedure, vessel specimens where obtained by the surgeon. Immunhistochemical staining of HSP70 was performed and quantitative measurement and evaluation of HSP70 was carried out.

Results

Conventional radiation and neoadjuvant chemoradiation revealed in a thickening of the intima layer of recipient vessels. A increased expression of HSP70 could be detected in the media layer of the recipient veins as well as in the transplant veins of patients treated with neoadjuvant chemoradiation. Radiation and chemoradiation decreased the HSP70 expression of the intima layer in recipient arteries. Conventional radiation led to a decrease of HSP70 expression in the media layer of recipient arteries.

Conclusion

Our results showed that anticancer drugs can lead to a thickening of the intima layer of transplant and recipient veins and also increase the HSP70 expression in the media layer of the recipient vessels. In contrast, conventional radiation decreased the HSP70 expression in the intima layer of arteries and the media layer of recipient arteries and veins. Comparing these results with wall thickness, it was concluded, that high levels of HSP70 may prevent the intima layer of arteries and the media layer of vein from thickening.

Dental implants after reconstruction with free tissue transfer

The transfer of composite tissue flaps by microvascular techniques has become the standard for reconstructing complex defects of the oral and maxillofacial regions. Despite advances in these techniques, sites reconstructed by free tissue transfer (free flaps) are often compromised by scarring, bulky tissue, and altered architecture. Dental rehabilitation is often impossible without endosseous implants to aid in stabilization and retention of prostheses. The most commonly used free flaps, however, have significant shortcomings with regard to implant placement, prosthetics, and maintenance. This article describes some site development and prosthetic techniques that can be applied to improve outcomes when dental implants are used in conjunction with free flap reconstruction.

Predictors of morbidity following free flap reconstruction for cancer of the head and neck

BACKGROUND

Free flap reconstruction of head and neck cancer defects is complex with many factors that influence perioperative complications. The aim was to determine if there was an association between perioperative variables and postoperative outcome.

METHODS

We evaluated 185 patients undergoing free flap reconstruction following ablation of head and neck cancer between 1999 and 2001. Demographic, laboratory, surgical and anesthetic variables were analyzed using univariate and multivariable techniques.

RESULTS

Ninety-eight patients (53%) developed complications, of which 74 were considered major, giving a major morbidity rate of 40%. Predictors of major complications were increasing patient age, ASA class, and smoking. Predictors of medical complications were ASA class, smoking, age and crystalloid replacement. Predictors of surgical complications were tracheostomy, preoperative hemoglobin, and preoperative radiotherapy.

CONCLUSION

Patient age, comorbidity, smoking, preoperative hemoglobin, and perioperative fluid management are potential predictors of postoperative complications following free flap reconstruction for cancer of the head and neck.

Color doppler ultrasonography is a reliable predictor of free tissue transfer outcomes in head and neck reconstruction

OBJECTIVE

The purpose of our investigation was to report our experience with a color flow doppler (CFD) ultrasonography for postoperative monitoring of free tissue transfers.

METHODS

A retrospective analysis of head and neck free tissue transfers at a single institution between 2000 and 2005 (n = 84; 80 successful, 4 failures). CFD measured blood flow velocity (cm/sec) and resistance to flow in the pedicle vein and artery on postoperative days 1, 3, and 7.

RESULTS

Analysis of artery/vein ratio revealed vascular congestion by postoperative day 3 which later resolved. In flap failures, there was a significant reduction (P < 0.05) in venous blood flow by postoperative day 3. Waveform morphology representing vascular resistance and origin of donor flap did not correlate with flap outcome (r(2) = 0.23 and 0.44 respectively).

CONCLUSION

Postoperative monitoring of free tissue transfers may allow for detection of poor perfusion. CFD is an objective method of studying blood flow postoperatively.

EBM RATING

C-4.

Reconstruction of defects in the head and neck with free flaps: 20 years experience

Between March 1982 and December 2002 we did a total of 534 reconstructions with free flaps from various donor sites for 529 patients. The jejunum was the donor site in 181 reconstructions (34%), followed by the radial forearm flap in 173 reconstructions (32%); 86% of the reconstructions were immediately after excisions. Surgical re-exploration was necessary in 37 patients (7%); the failure rate from necrosis of the flap was 5%. Factors associated with complications were American Society of Anesthesiology (ASA) class and age.

Factors affecting cancer recurrence after microvascular flap reconstruction of the head and neck

OBJECTIVE

Our objective was to determine which factors are associated with cancer recurrence after microvascular reconstruction of the head and neck for squamous cell carcinoma (SCC).

STUDY DESIGN

A cohort of patients who fit the inclusion/exclusion criteria were identified retrospectively.

METHODS

A group of 184 patients who underwent successful surgical resection and simultaneous microvascular reconstruction of the head and neck for treatment of SCC were identified. The mean age was 60 (range 23-90) years, there were 115 males and 69 females, and mean follow-up was 26.2 (range 1-99) months. Various factors were analyzed to determine whether they were associated with cancer recurrence, including those pertaining to 1) recipient vessel choice, 2) prior cancer treatment, and 3) cancer staging criteria. Statistical analysis was performed using SPSS statistical software.

RESULTS

Overall cancer stage (P = .005), T stage (P = .0001), history of previous cancer treatment (P = .004), and history of previous chemotherapy (P = .044) were found to be statistically significant predictors of cancer recurrence on univariate analysis. However, on multivariate analysis, only T stage (P = .005) and history of previous cancer treatment (P = .008) remained as statistically significant predictors of cancer recurrence. Recipient vessel selection was not statistically associated with cancer recurrence.

CONCLUSIONS

In our study, only T stage and a history of previous cancer treatment were associated with increased cancer recurrence. Neither the recipient vessel chosen nor its location impacted cancer recurrence. This suggests that recipient vessel selection and preparation for microvascular reconstruction do not jeopardize the adequacy of oncologic resection and are therefore oncologically sound.

Complications of free flap transfers for head and neck reconstruction following cancer resection

The reported success rate of microvascular free flap reconstruction ranges between 95% and 97%. However when complications occur, they must be identified early and managed efficiently because there is a narrow window of opportunity to salvage potential flap failure. While technical advances in instrumentation and magnification have improved overall success rates, the rare complication may prove devastating for the patient, his/her hospital stay, and the optimum rehabilitation. Complications of microvascular free tissue transfer may occur at the recipient site or at the donor site. Complications occurring at the recipient site are largely a result of vessel thrombosis while complications occurring at the donor site may result from many causes, ranging from infection to those related to the harvesting of the flap. Irrespective of the site of the complication, it is essential that complications be recognized and addressed early in their course to prevent or minimize devastating consequences.

Postoperative monitoring of free flaps in UK plastic surgery units

Monitoring free-tissue transfers in the postoperative period is valuable for detection of failing flaps. As well as conventional methods, a myriad of sophisticated techniques have been reported in the literature. Using a postal questionnaire, a survey was conducted to delineate current protocols employed in UK plastic surgery units. Data were received from 148 plastic surgeons in 51 units. All surgeons used clinical assessment, although there was significant disparity in the duration and frequency of postoperative monitoring. Adjuvant techniques such as laser Doppler flowmetry were routinely used by less than 20% of surgeons. We conclude that there is considerable variation in postoperative monitoring of free flaps, with significant clinical and resource implications. A protocol based on robust evidence is thus recommended.