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Risk factors associated with early and late free flap complications in head and neck osseous reconstruction. Eur Arch Otorhinolaryngol 2023; 280:811-817. [PMID: 36056974 DOI: 10.1007/s00405-022-07619-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/14/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE This study was designed to identify risk factors for post-operative complications in micro-anastomosed osteomyocutaneous free flaps (MOFF) and analyzed their consequences in long term. METHODS A retrospective review of 100 MOFF realized between May 2007 and October 2019 was performed. Demographic data, perioperative management and postoperative complications were enrolled and analyzed in a multivariate model. Patients were followed for ≥ 6 months. RESULTS Major surgical complication rate was 20% with 5% of overall free flap failure rate and 6% of anastomosis salvage surgery. Risk identified for major surgical complication was alcohol consumption (p = 0.0054). Minor surgical complications occurred in 26% of patients mostly due to infections (19%). No significant risk factor was associated to minor surgical complications. Major and minor medical complication rates were, respectively, 10% and 10%. Risk identified for major medical complication were age over 70 (p = 0.0253) and history of chemotherapy (p = 0.0277). Risk identified for minor medical complication were alcohol consumption p = 0.0232) and a history of radiotherapy (p = 0.0329). CONCLUSIONS Alcoholism is an independent risk factor for the surgical complication of MOFF that must be taken into account before surgery. Patients with a history of chemotherapy, radiotherapy or who are over 70 years of age are at greater risk of postoperative medical complications and require special attention.
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Mata Ribeiro L, Tsao CK, Hung YL, Chu CH, Lin LC, Lin MH, Peng C, Cheong DCF, Hung SY, Liao CT. Venous Size Discrepancy Is a Critical Factor When Using Superficial Temporal Vessels as Recipient Vessels for Free Flaps. J Reconstr Microsurg 2022; 38:654-663. [PMID: 35213928 DOI: 10.1055/s-0042-1743165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels. METHODS We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels. RESULTS A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates. CONCLUSION Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.
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Affiliation(s)
- Luís Mata Ribeiro
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital; Chang Gung University and Medical College, Taoyuan, Taiwan.,Department of Plastic and Reconstructive Surgery, São José Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Chung-Kan Tsao
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Liang Hung
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chun-Hui Chu
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Li-Ching Lin
- Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mo-Han Lin
- Center of Tissue Engineering, School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi Peng
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - David Chon-Fok Cheong
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Shao-Yu Hung
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Ta Liao
- Department of Otolaryngology, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
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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] [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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4
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Outcome of 1000 free flap head and neck reconstructions at a tertiary cancer care institute in India. EUROPEAN JOURNAL OF PLASTIC SURGERY 2020. [DOI: 10.1007/s00238-020-01693-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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5
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Marinone Lares SG, Clark S, Mathy JA, Chaplin J, McIvor N. Evaluation of a novel database for quality assurance at a head and neck service in New Zealand: an audit of free flap head and neck reconstruction. ANZ J Surg 2020; 90:1386-1390. [PMID: 32436238 DOI: 10.1111/ans.15974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/17/2020] [Accepted: 04/25/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Clinical audit is a critical quality improvement exercise, yet efficient audit tools are lacking. The main objective of this study was to evaluate a recently deployed database in facilitating the process of clinical audit, and the secondary objective was to evaluate the outcomes of free flap reconstruction of the head and neck at our centre. METHODS A head and neck cancer-specific database was customized to suit the needs of our head and neck multidisciplinary team. Data has been entered prospectively into this database since March of 2018. An audit of free flap reconstruction of the head and neck over a 12-month period was performed using the database and analysed as a case study to examine its efficacy as a clinical audit tool. Additionally, the outcomes of free flap reconstruction at our centre were compared to those reported in the international literature. RESULTS The database allows flexible and specific queries, analysis and export of data, and can provide immediate results. However, issues with data quality and completeness were identified. In this audit, the overall 30-day complication rate and 30-day mortality in patients undergoing free flap reconstruction of the head and neck were 58% and 3%, respectively. CONCLUSION The database is fit for its intended purpose as an audit tool. Outcomes of free flap reconstruction of the head and neck at our centre are comparable to those of institutions overseas.
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Affiliation(s)
| | - Sita Clark
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Jon A Mathy
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand.,Auckland Regional Plastic Surgery Unit, Auckland, New Zealand
| | - John Chaplin
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Nick McIvor
- Department of Otolaryngology-Head and Neck Surgery, Auckland City Hospital, Auckland, New Zealand
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6
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Ischemic Preconditioning and Iloprost Reduces Ischemia-Reperfusion Injury in Jejunal Flaps. Plast Reconstr Surg 2019; 144:124-133. [DOI: 10.1097/prs.0000000000005708] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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7
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Primary surgical treatment versus salvage surgery: Results of free flap reconstruction performed in 100 patients with oropharyngeal cancer. Surg Oncol 2019; 28:174-179. [DOI: 10.1016/j.suronc.2018.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/26/2018] [Accepted: 12/31/2018] [Indexed: 11/16/2022]
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8
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Ratnagiri R, Jena S, Parvathi P, Srikanth R, Raju GSN. Reconstruction in head-and-neck cancers - analysis of the learning curve. Natl J Maxillofac Surg 2018; 9:191-195. [PMID: 30546234 PMCID: PMC6251285 DOI: 10.4103/njms.njms_66_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Oral cancers are some of the most common cancers in India. Most patients present with locally advanced disease requiring extensive resection resulting in large defects. Reconstruction of these defects plays a major role in restoring form and function to these patients, as well as enabling the delivery of adjuvant therapy on time. AIM OF THE STUDY The aim of this study was to analyze the learning curve involved in microvascular surgery. MATERIALS AND METHODS A retrospective analysis of the case records of all patients of oral cancers, who underwent resection and reconstruction between January 2008 and December 2012 at our institute, was done. Demographic, clinical, and pathological data were collected and analyzed. Statistical analysis was done using the SPSS software. RESULTS The operative time and the postoperative ventilation (7.8 h and 3.7 days, respectively) were significantly higher than those for pedicled flaps (3.6 h and 1.4 days, respectively). Both these variables reached statistical significance with P < 0.05 and < 0.04. The hospital stay was also statistically significantly longer for patients who underwent free-flap reconstruction (17.9 days vs. 7.9 days; P < 0.05). The number of reexplorations were higher in the free-flap group (31), when compared to the pedicled flap group (9). However, partial flap loss was higher in the pedicled flap subset when compared to the free-flap group. The complications significantly dropped after the performance of 30-40 free flaps. CONCLUSION There is a steep learning curve in microvascular surgery, but the cosmetic and functional outcomes outweigh the complications.
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Affiliation(s)
- Ranganath Ratnagiri
- Department of Surgical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Shubhranshu Jena
- Department of Surgical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - P. Parvathi
- Department of Plastic and Reconstructive Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - R. Srikanth
- Department of Plastic and Reconstructive Surgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G. S. N. Raju
- Department of Surgical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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9
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A novel technique for clinical examination of buried head and neck free flaps. EUROPEAN JOURNAL OF PLASTIC SURGERY 2018. [DOI: 10.1007/s00238-017-1369-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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10
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Wolff KD, Rau A, Kolk A. Perforator flaps from the lower leg for intraoral reconstruction: Experience of 131 flaps. J Craniomaxillofac Surg 2018; 46:338-345. [DOI: 10.1016/j.jcms.2017.11.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/11/2017] [Accepted: 11/17/2017] [Indexed: 11/29/2022] Open
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11
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Is Robot-Assisted Surgery Really Scarless Surgery? Immediate Reconstruction with a Jejunal Free Flap for Esophageal Rupture after Robot-Assisted Thyroidectomy. Arch Plast Surg 2017; 44:550-553. [PMID: 29069877 PMCID: PMC5801790 DOI: 10.5999/aps.2017.00941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/18/2017] [Accepted: 07/30/2017] [Indexed: 12/02/2022] Open
Abstract
Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.
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12
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Chang EI. Impact of venous outflow tract on survival of osteocutaneous free fibula flaps for mandibular reconstruction: A 14-year review. Head Neck 2017; 39:1454-1458. [DOI: 10.1002/hed.24796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 12/30/2016] [Accepted: 02/17/2017] [Indexed: 02/03/2023] Open
Affiliation(s)
- Eric I. Chang
- Division of Plastic and Reconstructive Surgery; Fox Chase Cancer Center; Philadelphia Pennsylvania
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13
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Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head and neck reconstruction: Complications, outcomes and strategies for management of flap failure: Analysis of 2019 flaps in single institute. Microsurgery 2013; 34:339-44. [DOI: 10.1002/micr.22212] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Revised: 11/22/2013] [Accepted: 11/27/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Cheng-Chun Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, College of Medicine; Kaohsiung Taiwan
| | - Pao-Yuan Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, College of Medicine; Kaohsiung Taiwan
| | - Khong-Yik Chew
- Department of Plastic; Reconstructive and Aesthetic Surgery, Kandang Kerbau Women's and Children's Hospital; Singapore
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University, College of Medicine; Kaohsiung Taiwan
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Geddes CR, Tang M, Yang D, Morris SF. An assessment of the anatomical basis of the thoracoacromial artery perforator flap. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2013; 11:23-7. [PMID: 24115845 DOI: 10.1177/229255030301100102] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap. METHODS A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels. RESULTS THE PERFORATORS THROUGH THE PM MUSCLE TO THE OVERLYING SKIN INCLUDED THREE REGIONAL GROUPS: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery. DISCUSSION The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.
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Affiliation(s)
- Christopher Robert Geddes
- Department of Anatomy, Neurobiology and Surgery, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
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15
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Fujioka M. Factors Predicting Total Free Flap Loss after Microsurgical Reconstruction Following the Radical Ablation of Head and Neck Cancers. ACTA ACUST UNITED AC 2013. [DOI: 10.5402/2013/952971] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background. With greater experience in microsurgical reconstruction, free tissue transfer has become common and reliable. However, total flap necrosis after microsurgical reconstruction is sometimes seen in patients who have undergone radical ablation of head and neck malignancies. We investigated factors predicting free flap loss in head and neck reconstruction. Methods. We reviewed the records of 111 free flap reconstructions carried out among 107 patients with head and neck cancer who required radical resection and microsurgical reconstruction in our unit from 2004 through 2010. Among these patients, 6 showed total flap necrosis postoperatively. We investigated the associations between primary or recurrent tumor, type of flaps, chemotherapy, and radiotherapy and flap loss. Results. Five of 20 (25.0%) patients who underwent radiotherapy developed flap necrosis: among the 91 patient who did not undergo radiotherapy, only one (1.1%) developed. Preoperative radiotherapy was statistically identified as the most important risk factor for postoperative flap failure. Conclusions. Patients receiving radiation treatment are more likely to develop total flap failure when they undergo reconstructive surgery with free flaps after tumor ablation, because the combination of endarteritis and chronic ischemia caused by radiation damaged endothelial membrane in the recipient vessels, consequently, thrombosis tends to develop.
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Affiliation(s)
- Masaki Fujioka
- Division of Functional Reconstructive Surgery, Department of Surgical Therapeutics, National Hospital Organization Nagasaki Medical Center, Nagasaki 856-8562, Japan
- Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki 856-8562, Japan
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16
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Checcoli E, Bianchini C, Ciorba A, Candiani M, Riberti C, Pelucchi S, Pastore A. Reconstructive Head and Neck Surgery: Oncological and Functional Results. TUMORI JOURNAL 2013; 99:493-9. [DOI: 10.1177/030089161309900409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims The aim of this retrospective study is to review the experience in performing head and neck reconstruction surgery between 1989 and 2009 at the ENT Department of the University Hospital of Ferrara, Italy, considering the oncological as well as the functional and psychological outcome. Methods and study design Thirty-three consecutive patients were enrolled. Patients underwent flap reconstruction following primary or salvage surgery for squamous cell carcinoma of the oral cavity or oropharynx. Oncological results in terms of survival rate and disease-free interval, as well as functional and psychological results were evaluated. Results The oncological results, i.e. survival rate related to cancer stage and disease-free interval, were in agreement with those of the literature. Functional assessment, swallowing function and speech intelligibility were statistically poorer in patients affected by oropharyngeal malignancies than in patients affected by oral cancer. Quality of life was compromised in terms of reduced relationships and onset of depression or irritability. Conclusions Reconstructive surgery can be considered a relatively standard procedure in the treatment of head and neck cancer. The main drawback is still related to the major impact on patients' quality of life and functional status.
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Affiliation(s)
| | | | - Andrea Ciorba
- ENT Department, University Hospital of Ferrara, Ferrara, Italy
| | - Marco Candiani
- Plastic Surgery Unit, University Hospital of Ferrara, Ferrara, Italy
| | - Carlo Riberti
- Plastic Surgery Unit, University Hospital of Ferrara, Ferrara, Italy
| | | | - Antonio Pastore
- ENT Department, University Hospital of Ferrara, Ferrara, Italy
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17
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Head and neck reconstruction using microsurgery: a 9-year retrospective study. Eur Arch Otorhinolaryngol 2013; 270:2737-43. [DOI: 10.1007/s00405-013-2390-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 01/29/2013] [Indexed: 01/24/2023]
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19
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Foley BD, Thayer WP, Honeybrook A, McKenna S, Press S. Mandibular Reconstruction Using Computer-Aided Design and Computer-Aided Manufacturing: An Analysis of Surgical Results. J Oral Maxillofac Surg 2013; 71:e111-9. [DOI: 10.1016/j.joms.2012.08.022] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 08/24/2012] [Accepted: 08/24/2012] [Indexed: 11/30/2022]
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20
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Hsieh TY, Chang KP, Lee SS, Chang CH, Lai CH, Wu YC, Huang SH, Lai CS, Lin SD. Free flap reconstruction in patients with advanced oral squamous cell carcinoma: analysis of patient survival and cancer recurrence. Microsurgery 2012; 32:598-604. [PMID: 22903315 DOI: 10.1002/micr.22009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 05/02/2012] [Accepted: 05/08/2012] [Indexed: 01/01/2023]
Abstract
BACKGROUND The purpose of this study was to compare the initial conditions and treatment outcomes of patients with advanced stage IV oral squamous cell carcinoma (OSCC) treated with or without free flap reconstruction following ablative tumor resection. METHODS Two hundred forty-two pathological stage IV OSCC patients (without distant metastasis) treated by tumor ablation with free flap reconstruction (Group 1; n = 93) or without free flap reconstruction (Group 2; n = 149 treated with split-thickness skin grafts, primary closure of defects, secondary granulation of defects, and local or regional flaps) were recruited. We compared patient survival and cancer recurrence rates between these two groups. RESULTS Group 1 had significantly more advanced tumor stage than group 2. Despite the unfavorably expected prognosis in group 1, both positive margin rate (17.2% in Group 1 versus 23.5% in Group 2, P = 0.213) and cancer recurrence rate (36.6% in Group 1 versus 38.3% in Group 2; P = 0.792) were not significantly different between the two groups. The 5-year disease-specific survival were also the same (51.4% in Group 1 versus 52.6% in Group 2; P = 0.493). CONCLUSIONS Although cancer stages were more advanced in patients requiring free flap reconstruction, patient survival, and cancer recurrence in the patients with free flap reconstruction were maintained as patients without free flap.
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Affiliation(s)
- Tung-Ying Hsieh
- Division of Plastic and Reconstructive Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, Republic of China
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21
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Arce K, Bell R, Potter J, Buehler M, Potter B, Dierks E. Vascularized free tissue transfer for reconstruction of ablative defects in oral and oropharyngeal cancer patients undergoing salvage surgery following concomitant chemoradiation. Int J Oral Maxillofac Surg 2012; 41:733-8. [DOI: 10.1016/j.ijom.2012.03.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 01/10/2012] [Accepted: 03/02/2012] [Indexed: 12/01/2022]
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Abstract
BACKGROUND The Wellington Regional Plastic, Maxillofacial & Burns Unit based at Hutt Hospital provides comprehensive reconstructive services to central New Zealand with a population of 1.1 million. Free tissue transfer procedures in the Unit were audited to determine the indications and rate of usage in our population, our success and complication rates, and how these compare with published series. METHODS Prospectively collected data on all free tissue transfer procedures between January 2006 and September 2010 were analysed. RESULTS Two hundred and seven free flaps including 17 flap types being performed on 186 consecutive patients including 199 primary and 8 salvage flaps. Eighty-three percent were elective and 17% were acute cases. The majority of the flaps were used for head and neck (48%) and breast (31.5%) reconstruction. Ulnar forearm flap was the most commonly used fasciocutaneous flap. 18.8% of patients had major complications requiring return to theatre. Microsurgical revision was performed in nine (4.3%) flaps of which six were successfully salvaged. Overall, 13 flaps (6.3%) failed completely, giving an overall success rate of 93.7%. Haematoma requiring formal drainage occurred in 12 (5.8%) cases. DISCUSSION The wide variety of flaps used reflects the very broad range of defects requiring free flap reconstruction. We show a free flap success rate of 93.7% in our medium-sized regional unit. Our microsurgical revision rate of 4.3% is lower than the revision rate of 10% in reported series with high overall success rates. More consistent early detection of failing flaps is likely to further improve our overall success rate.
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Affiliation(s)
- Jonathan P S Heather
- Wellington Regional Plastic, Maxillofacial & Burns Unit, Hutt Hospital, High Street, Lower Hutt, New Zealand
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David S, Dassonville O, Poissonnet G, Chamorey E, Vallicioni J, Demard F, Médard de Chardon V, Santini J, Bozec A. Les échecs de la chirurgie reconstructrice cervicofaciale par lambeaux libres : facteurs favorisants et prise en charge. ANN CHIR PLAST ESTH 2011; 56:308-14. [DOI: 10.1016/j.anplas.2010.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2009] [Accepted: 07/01/2010] [Indexed: 11/28/2022]
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Chang KP, Lai CH, Liang WL, Lai CS, Lin SD. Alternative reconstruction of donor defect of free radial forearm flap in head and neck cancer. J Plast Surg Hand Surg 2010; 44:31-6. [DOI: 10.3109/02844310903351251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Transaxillary-subclavian transfer of pedicled latissimus dorsi musculocutaneous flap to head and neck region. J Craniofac Surg 2010; 21:771-5. [PMID: 20485045 DOI: 10.1097/scs.0b013e3181d7a3cc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Free-tissue transfer is the reconstruction of choice for most head and neck defects. However, pedicled flaps are also used, especially in high-risk patients and after failure of a free flap. The aim of this study was to compare transaxillary-subclavian pedicled latissimus dorsi musculocutaneous (PLDMC) flap, pectoralis major musculocutaneous flap, and free-tissue transfer for head and neck reconstruction in American Society of Anesthesiologists grades II and III patients. During the last 4 years, PLDMC flap with a modified transaxillary-subclavian route for transfer to the neck was used in 8 patients, pectoralis major musculocutaneous flap was used in 7 patients, and free flaps were used in 12 patients for head and neck reconstructions. These 3 methods were compared regarding the flap dimensions, complications, flap outcome scores, hospitalization time, and cost of the treatment. Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regarding the operation time, flap complications, outcomes, and cost of total treatment, although statistically not significant, PLDMC group offered the fastest reconstruction with highest flap outcome scores and minimum cost. Free-tissue transfer is the procedure of choice especially for functional reconstruction of head and neck region. Occasionally, there exist cases in whom a pedicled flap could offer a safer option. The PLDMC flap transferred via the transaxillary-subclavian route may be preferred than, with advantages including increased arc of rotation, safer pedicle location, shorter duration of the procedure, and reduced complication rates and costs.
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Bell RB, Gregoire C. Reconstruction of Mandibular Continuity Defects Using Recombinant Human Bone Morphogenetic Protein 2: A Note of Caution in an Atmosphere of Exuberance. J Oral Maxillofac Surg 2009; 67:2673-8. [DOI: 10.1016/j.joms.2009.07.085] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 07/27/2009] [Indexed: 11/28/2022]
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Sarukawa S, Asato H, Okazaki M, Nakatsuka T, Takushima A, Harii K. Clinical evaluation and morbidity of 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984–2003. ACTA ACUST UNITED AC 2009; 40:148-52. [PMID: 16687334 DOI: 10.1080/02844310600652894] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We evaluated 192 patients who had 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984-2003. The main postoperative complications were thrombosis, leaks, and stenosis. In this series, the rate of thrombosis was 7/201 (3.5%), that of leaks was 17/201 (8.5%), and that of stenosis was 25/201 (13.0%). When we assessed the relation between pre-existing conditions, surgical techniques, and these complications, we found only one significant difference: a history of alcohol misuse was associated with a reduction in the incidence of thrombosis. The surgical techniques did not affect the development of leaks or stenosis, which means that a complicated surgical technique is unnecessary.
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Affiliation(s)
- Shunji Sarukawa
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo.
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Yamashiro M, Hasegawa K, Uzawa N, Michi Y, Ishii J, Yoshitake H, Kobayashi J, Yagihara K, Okabe S, Amagasa T. Complications and Outcome of Free Flap Transfers for Oral and Maxillofacial Reconstruction: Analysis of 213 Cases. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1348-8643(09)80013-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Iseli TA, Yelverton JC, Iseli CE, Carroll WR, Magnuson JS, Rosenthal EL. Functional outcomes following secondary free flap reconstruction of the head and neck. Laryngoscope 2009; 119:856-60. [DOI: 10.1002/lary.20200] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Analysis of Microvascular Free Flaps for Reconstruction of Advanced Mandibular Osteoradionecrosis: A Retrospective Cohort Study. J Oral Maxillofac Surg 2008; 66:2545-56. [DOI: 10.1016/j.joms.2007.08.041] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Revised: 06/06/2007] [Accepted: 08/21/2007] [Indexed: 11/23/2022]
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Pohlenz P, Blessmann M, Heiland M, Blake F, Schmelzle R, Li L. Postoperative complications in 202 cases of microvascular head and neck reconstruction. J Craniomaxillofac Surg 2007; 35:311-5. [PMID: 17855103 DOI: 10.1016/j.jcms.2007.05.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Accepted: 05/04/2007] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION This retrospective study was intended to determine the incidence and causes of postoperative complications in patients following head and neck reconstruction using microvascular free flaps. PATIENTS AND METHODS A total of 202 consecutive microvascular free flaps were performed for reconstruction of the head and neck by the same surgeon, 85% of the defects arose following the treatment of malignancies. Flap donor sites included latissimus-dorsi flap (n=83), radial forearm (n=35), fibula (n=31), iliac crest (n=36), TRAM flap (n=3), groin flap (n=l), jejunal flap (n=13). The incidence of postoperative complications and patient-related characteristics (age, sex, diagnosis, comorbidity level, operation duration, defect site, history of radiotherapy/chemotherapy) were retrospectively analyzed. RESULTS Free flaps proved to be extremely reliable, with a 2.9% incidence of free flap failure. Postoperative medical complications occurred in 11.4% of cases, with cardiac, pulmonary and infectious complications predominating. CONCLUSION The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of postoperative complications is related to the preoperative comorbidity.
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Affiliation(s)
- Philipp Pohlenz
- Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Dassonville O, Poissonnet G, Chamorey E, Vallicioni J, Demard F, Santini J, Lecoq M, Converset S, Mahdyoun P, Bozec A. Head and neck reconstruction with free flaps: a report on 213 cases. Eur Arch Otorhinolaryngol 2007; 265:85-95. [PMID: 17690895 DOI: 10.1007/s00405-007-0410-1] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 07/17/2007] [Indexed: 10/23/2022]
Abstract
The aim of this retrospective study is to review the experience of our institution in performing microvascular head and neck reconstruction between 2000 and 2004. During this period, 213 free flaps, including 146 radial forearm free flaps, 60 fibular flaps and 7 scapular flaps, were performed. Free flap success rate and complications were reported. The pre-treatment factors influencing these results were subsequently analyzed. Functional and aesthetic outcomes were evaluated by the same clinician. There were 14 free flap failures, giving an overall free flap success rate of 93.4%. Salvage surgery for recurrent cancer was the only factor correlated with a higher risk of free flap failure (P = 0.0004). The local complication rate was 20.9%. High level of comorbidity (P = 0.009), salvage surgery for recurrent cancer (P = 0.03) and hypopharyngeal surgery (P = 0.002) were associated with a higher risk of local complications. An unrestricted oral diet and an intelligible speech were recovered by respectively 76 and 88% of the patients. Microvascular free flaps represent an essential and reliable technique for head neck reconstruction and allow satisfactory functional results.
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Affiliation(s)
- Olivier Dassonville
- Département d'Oto-Rhino-Laryngologie et de chirurgie de la Face et du Cou, Centre Antoine Lacassagne, 33 Avenue de Valombrose, 06189, Nice Cedex, France.
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Bozec A, Poissonnet G, Converset S, Lattes L, Chamorey E, Vallicioni J, Demard F, Dassonville O. La reconstruction mandibulaire par lambeaux libres osseux: résultats fonctionnels. ACTA ACUST UNITED AC 2007; 124:16-24. [PMID: 17336917 DOI: 10.1016/j.aorl.2006.08.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2006] [Accepted: 08/28/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this retrospective study is to evaluate functional results of oromandibular reconstruction with osseous free flaps. MATERIAL AND METHODS A total of 67 patients who underwent oromandibular reconstruction with fibula (n=60) or scapular (n=7) free flap between 2000 and 2004 were included in this study. We analysed functional results (alimentation, elocution, mouth opening and cosmetic appearance) and researched the potentially predictive factors of these results (age, comorbidity, preoperative irradiation, type of defect...; Chi(2) test). RESULTS The rate of free flap success was 89.6%. A functional result considered as normal or subnormal was obtained by more than 50% of patients. Oral alimentation (without tube feeding) and intelligible speech were recovered by 92.5% of patients. Through and through defects and free flap failures were determinant predictive factors of worse functional outcomes. CONCLUSION Fibula free flap is considered as the flap of choice for oromandibular reconstruction and allows excellent functional results.
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Affiliation(s)
- A Bozec
- Département d'otorhinolaryngologie et de chirurgie carcinologique de la face et du cou, centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice cedex, France.
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Brown JS, Magennis P, Rogers SN, Cawood JI, Howell R, Vaughan ED. Trends in head and neck microvascular reconstructive surgery in Liverpool (1992–2001). Br J Oral Maxillofac Surg 2006; 44:364-70. [PMID: 16169640 DOI: 10.1016/j.bjoms.2005.07.018] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2004] [Accepted: 07/30/2005] [Indexed: 11/16/2022]
Abstract
Microvascular reconstructive techniques in head and neck surgery are well established, but we are now entering an era of modification exemplified by perforator and free style free flaps. We present a review of the database introduced into the unit in 1992 over a 10-year period, during which time 977 patients with malignant disease were operated on and 620 defects were reconstructed with free flaps. There were 358 radial forearm flaps, 78 composite radial forearm flaps, 84 iliac crest flaps, 43 fibular flaps, 24 from the scapula, 26 from the latissimus dorsi, 4 from the rectus abdominis, and 3 from the lateral arm. The main changes over this time have been the use of more bulky flaps for larger resections of the tongue and the preference for iliac crest flaps over those from the fibula and forearm for composite reconstructions. Improving reliability of tissue transfer remains an important aim, and further development of reliable objective methods of monitoring of flaps is required.
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Affiliation(s)
- J S Brown
- Regional Maxillofacial Unit, University Hospital Aintree, Lower Lane, Liverpool, UK.
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Podrecca S, Salvatori P, Squadrelli Saraceno M, Fallahdar D, Calabrese L, Cantù G, Molinari R. Review of 346 patients with free-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstr Aesthet Surg 2006; 59:122-9. [PMID: 16703855 DOI: 10.1016/j.bjps.2005.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present our 14-year experience of free tissue transfer following surgery for head and neck neoplasm. We evaluated 346 patients mean age 57 years, 65% had squamous cell carcinoma; the most frequent sites were oral cavity and mandible (168) craniomaxillo facial region (94) pharynx +/- cervical oesophagus and oropharyngostomes (84). In 327 (95%) cases the reconstruction was a success. Flap revision was necessary in 29 (8.4% of total) and recovery was successful in 10/29. Nine patients (2.6%) died perioperatively. Poor preoperative condition, previous treatment, and requirement for vein graft were significantly associated with increased risk of major complications after surgery. Cosmetic and functional outcomes were assessed on 1-10 scales: 69 and 77% of patients, respectively, had cosmetic and functional results in the 7-10 range, indicating successful outcome. Overall survival probabilities, estimated on 338 patients with malignant disease, were 53% at 2 years and 32% at 5 years. Most patients, but not all, had advanced disease stage, and 188 (54%) had recurrent disease. Hence, overall survival rates are acceptable and justify the use of complex reconstruction procedures in such patients.
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Affiliation(s)
- S Podrecca
- Otorhinolaryngology Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori, Via Venezian, 1, 20133 Milano, Italy.
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Eckardt A, Meyer A, Laas U, Hausamen JE. Reconstruction of defects in the head and neck with free flaps: 20 years experience. Br J Oral Maxillofac Surg 2006; 45:11-5. [PMID: 16464523 DOI: 10.1016/j.bjoms.2005.12.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 12/14/2005] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- A Eckardt
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, OE7720, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany.
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Knoetgen J, Choudry U, Finical SJ, Johnson CH. Head and neck reconstruction with a second free flap following resection of a recurrent malignancy. Ann Plast Surg 2006; 55:378-83. [PMID: 16186703 DOI: 10.1097/01.sap.0000178812.87583.7a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A retrospective analysis of 12 patients with a head and neck tumor recurrence within a previous free flap treated with extirpation and a second free flap is reported. A 15-year experience at Mayo Clinic, Rochester, from 1988 to 2003 of 12 patients (5 men, 7 women) who underwent 25 free flaps is reviewed. The overall flap survival rate was 92%, with a 100% survival rate in the first free-tissue transfer and 85% survival rate in the second free-tissue transfer. There was 1 minor complication (8%) and there were 2 major complications (15%) among the second free flaps. Overall, 10 of 13 (77%) second free flaps were anastomosed to ipsilateral neck vessels. Moreover, in 5 of 13 cases (38%) the same artery and in 7 of 13 cases (54%) the same vein were used for both the first and second free flaps. Reconstruction of the head and neck with a second free flap in patients with a recurrent tumor is safe and effective. The original recipient vessels can often be used for the second reconstruction.
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Affiliation(s)
- James Knoetgen
- Division of Plastic Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Makimoto Y, Yamamoto S, Takano H, Motoori K, Ueda T, Kaneoya K, Shimofusa R, Uno T, Ito H, Okamoto Y. Lymphadenopathy in the Mesenteric Pedicle of the Free Jejunal Flap. J Comput Assist Tomogr 2006; 30:65-7. [PMID: 16365575 DOI: 10.1097/01.rct.0000177606.90817.cb] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Reconstructive surgery using the free jejunal flap is sometimes performed to close surgical defects in patients undergoing pharyngolaryngectomy for laryngeal or hypopharyngeal cancer. The clinical significance of lymph nodes in the flap was retrospectively examined. METHODS Fifteen patients had undergone a laryngectomy with free jejunal flap reconstruction between March 1996 and October 1999. The appearance and size of lymph nodes of the flap were examined by 3 radiologists. RESULTS Lymph nodes were observed in 10 patients. Size increases were noted within 1 year after surgery but not beyond 1 year. The pathologic diagnosis of the excised nodes was reactive lymphadenopathy. CONCLUSIONS Lymph nodes may occasionally become apparent in the free jejunal flap. There was no suggestion of metastatic lymph nodes when examined retrospectively. We speculate that this reaction was the result of environmental changes attributable to surgery.
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Affiliation(s)
- Yumi Makimoto
- Department of Radiology, Chiba University Hospital, Chiba, Japan
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Klug C, Berzaczy D, Voracek M, Enislidis G, Rath T, Millesi W, Ewers R. Experience with microvascular free flaps in preoperatively irradiated tissue of the oral cavity and oropharynx in 303 patients. Oral Oncol 2005; 41:738-46. [PMID: 15978858 DOI: 10.1016/j.oraloncology.2005.03.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2005] [Accepted: 03/29/2005] [Indexed: 11/18/2022]
Abstract
This study examined free flap reconstruction of surgical defects of the oral cavity and oropharynx after preoperative radiochemotherapy. Included in this analysis are 303 prospectively followed patients who underwent a multimodal treatment regime for advanced oral and oropharyngeal carcinoma. All patients received preoperative radiochemotherapy (Mitomycin C, 5-FU, 50 Gy), ablative surgery, and primary free flap reconstruction. Patient characteristics, surgical parameters like duration of surgery and ischaemia, size of defect, type of transplant, and clinical outcome parameters like duration of intensive care and hospitalization, type of complications, necessity and type of revision surgery were statistically evaluated. Overall flap success rate was 93.1%. Sixty seven patients required revision and 21 flaps (6.9%) were lost. Overall complication rate was 22.1%. Mean duration of intensive care (DOIC) and duration of overall postoperative hospitalization (DOH) were 11.0+/-9.6 days and 35.9+/-26.3 days, respectively. Flap success and flap related complications after 50 Gy focal radiation dosage were found in a comparable range as in published series of reconstructions in uncompromised tissue.
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Affiliation(s)
- Clemens Klug
- Hospital of Cranio-Maxillofacial and Oral Surgery, Medical University of Vienna, AKH, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Küntscher MV, Erdmann D, Boltze WH, Germann G. Use of a free jejunal graft for oesophageal reconstruction following perforation after cervical spine surgery: case report and review of the literature. Spinal Cord 2003; 41:543-8. [PMID: 14504610 DOI: 10.1038/sj.sc.3101439] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN : Single-subject (male, 16 years of age) case. OBJECTIVES To demonstrate a suitable method for oesophageal repair after perforation as a complication of anterior spinal fusion in an individual with quadriplegia, and to review the literature on oesophageal perforation and repair. SETTING University hospital, large trauma centre with departments for spinal injuries and reconstructive surgery in Germany. METHODS A free jejunal graft used for oesophageal reconstruction in a post-traumatic situation after a complicated treatment course in a C6 quadriplegic patient. RESULTS A protuberant loose screw of the titanium plate after anterior spinal fusion perforated the oesophagus. Imbricating sutures and a fascia lata patch were insufficient to repair the oesophageal leakage. An 8 cm long segment of the cervical oesophagus including a fistula had to be excised, and a free microsurgical jejunal flap was used for restitution of continuity. The jejunal vessels were connected to the superior thyroid artery and external jugular vein. At 1 week after the oesophageal repair, an enteral contrast study showed a small amount of contrast medium leaking at the oesophago-pharyngeal anastomosis. A percutaneous gastric tube was inserted, and oral feeding was limited to tea and still water for 4 weeks. The further course was uneventful. CONCLUSIONS Oesophageal perforation is a rare but recognized complication after cervical spine surgery, which can mostly be managed using secondary suture techniques. The free jejunal flap is a reliable and innovative tool in the particularly complex situation of a segmental oesophageal loss. It should be considered in similar cases to reconstruct oesophageal continuity or to treat stricture and fistula formations.
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Affiliation(s)
- M V Küntscher
- Department of Plastic, Reconstructive and Hand Surgery, Burn Center, BG, Trauma Center, Plastic and Hand Surgery, The University of Heidelberg, Ludwigshafen, Germany
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Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg 2003; 31:197-201. [PMID: 12914703 DOI: 10.1016/s1010-5182(03)00039-8] [Citation(s) in RCA: 139] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microvascular free tissue transfer has become a significant factor in the reconstruction of head and neck cancer patients. Various donor sites are available to enable anatomical and functional repair of a defect. METHODS All free vascularized tissue transfers performed during the period from March 1982 to September 2000 were retrieved from this hospital's database and analysed with regard to the surgical defect, chosen donor site and complications. RESULTS During the 18-year period a total of 1,164 patients with head and neck cancer were treated in this institution. A total of 500 free-flap reconstructions were performed for 479 patients. In the majority of patients (n = 451) reconstruction was indicated following ablative tumour surgery. With regard to donor site selection, the first choice of free jejunum was used in 181 patients, followed by the radial forearm flap in 140 patients. Among the 500 free-flap reconstructions, a total flap loss rate of 6% was observed. Patient age (p = 0.004) and tobacco use (p = 0.043) were significant risk factors for complications overall, whereas patient age (p = 0.021) and operating time (p = 0.043) were significantly correlated with local complications. CONCLUSION Immediate repair of head and neck defects using free tissue transfer is a successful and reliable method and is becoming the gold standard at many institutions. The complication rate is low once experience with these techniques has been acquired.
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Affiliation(s)
- André Eckardt
- Department of Oral and Maxillofacial Surgery, Hannover Medical University, Carl-Neuberg-Strasse 1, Hannover 30625, Germany.
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Abstract
Intensivists frequently collaborate with plastic and reconstructive surgeons in treating patients with major wounds, following significant reconstructive procedures, and following free-tissue transfers. Pressure ulcers are a significant source of morbidity and mortality in the intensive care unit; prevention, early recognition, and multidisciplinary treatment are critical components for successful management. Necrotizing fasciitis is an aggressive, soft-tissue infection that requires rapid diagnosis, early surgical intervention frequent operative debridements, and soft-tissue reconstruction Catastrophic abdominal injuries and infections can be treated with an open abdominal approach and require the expertise of a plastic surgeon to reconstruct the abdominal wall. The success of free-tissue transfers and complex reconstructive procedures requires a thorough understanding of the factors that improve flap survival.
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Affiliation(s)
- Gerard J Fulda
- Department of Surgery, Christiana Care Health Services, 4755 Ogletown-Stanton Road, Newark, DE 19718, USA.
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Zeebregts C, Acosta R, Bölander L, van Schilfgaarde R, Jakobsson O. Clinical experience with non-penetrating vascular clips in free-flap reconstructions. BRITISH JOURNAL OF PLASTIC SURGERY 2002; 55:105-10. [PMID: 11987941 DOI: 10.1054/bjps.2001.3762] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To date, the gold standard for performing a microvascular anastomosis has been the penetrating suture with attached needle. During the last two decades, non-penetrating techniques have been introduced, including the Unilink system for end-to-end anastomoses, and the VCS clip-applier system for both end-to-end and end-to-side anastomoses. The aim of this study was to compare the results of different techniques used to create microvascular anastomoses in free-flap reconstructions. Between January 1995 and October 1999, we performed 474 microvascular anastomoses in 216 consecutive free-tissue transfers. The anastomosis techniques included manual sutures (42%), Unilink rings (34%) and VCS clips (24%). Seven combined sutured-clipped anastomoses were excluded from further analysis. The mean anastomotic time when rings were applied was significantly shorter than when using clips (P 0.0001) or sutures (P 0.0001). Venous anastomoses using clips took less time than those using sutures (P 0.05). There were 19 anastomotic failures, all of which lead to early flap failure. Ten flaps were salvaged by early reoperation; nine flaps were lost. Three more flaps were lost as a result of other causes, bringing the flap survival rate down to 94.4%. Early flap failure was caused by failure of the arterial anastomosis in eight cases; all of them were sutured (these represented 5% of all arterial anastomoses with sutures). None of the clipped arterial anastomoses failed. Early flap failure was caused by failure of the venous anastomosis in 11 patients. Three of these anastomoses were sutured (representing 6% of all venous anastomoses with sutures), seven were anastomosed with rings (representing 5% of all venous anastomoses with rings) and one was clipped (representing 2% of all venous anastomoses with clips). Both the VCS clip-applier system and the Unilink system are easy to handle and allow fast microvascular anastomoses without intraluminal penetration. The patency rate of clipped vessels is at least as good as the patency rates of vessels anastomosed using sutures or rings.
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Affiliation(s)
- C Zeebregts
- Department of Surgery, University Hospital Groningen, Groningen, The Netherlands
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Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer. Head Neck 2001; 23:475-8. [PMID: 11360309 DOI: 10.1002/hed.1062] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Microvascular free flaps are becoming the reconstructive option of choice for many head and neck defects. Many previous studies have examined factors predicting free flap survival. No study has compared differences in free flap survival when anastomosed to the internal or external jugular systems. METHODS Retrospective review of all free flaps performed at an academic medical center by a single head and neck microvascular surgeon during the period July 1995 to December 1999. Flaps were closely monitored postoperatively and taken back to the operating room urgently for arterial insufficiency or venous congestion. RESULTS On hundred fifty-six free flaps were performed during this time period. Sixty-five free flaps were anastomosed to the external jugular (EJ) vein and 86 to the IJ system (62 to the proximal common facial vein, 17 end-side on the IJ, and 7 to other branches). Five had either two venous anastomoses or were anastomosed to other veins and were excluded from statistical analysis. Six (4%) vascular thromboses occurred; 5 were venous and 1 arterial. Success by group was 99% for IJ anastomosis (1 arterial thrombosis) and 92% for EJ anastomosis (5 venous thromboses, p =.03). Urgent anastomotic revision and reperfusion salvaged 5 of the 6 flaps (overall success 99%). CONCLUSIONS Although the overall success rate (96% success with 99% success with salvage) is comparable to other large series, microvascular free flaps anastomosed to the external jugular vein failed at a significantly higher rate than those anastomosed to the IJ system. This suggests that the IJ system should be used as a recipient vessel when feasible.
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Affiliation(s)
- A A Chalian
- University of Pennsylvania Medical Center, Department of Otorhinolaryngology-Head and Neck Surgery, 5th Floor Silverstein Building, 34th and Spruce Streets, Philadelphia, Pennsylvania 19104, USA.
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