Outcomes of Head and Neck Free Tissue Transfer Requiring Vein Grafting: Systematic Review and Meta-analysis

OBJECTIVE

To systematically review the literature to determine the prevalence of free flap failure in head and neck free flaps requiring vein grafting.

DATA SOURCES

Search strategies created in collaboration with a medical librarian were implemented using PubMed, Cochrane, Scopus, Web of Science, and Google Scholar from inception to August 2022.

REVIEW METHODS

The population of interest included adult and pediatric patients undergoing reconstruction of oncologic or traumatic head and neck defects with a free flap requiring a vein graft that presents the success/failure rate. The primary outcome was the flap failure rate, and the secondary outcome was the flap compromise/revision rate. Inclusion and exclusion criteria were designed to capture all study designs. Initially, 2778 articles were identified by the search strategy. Two reviewers independently performed the review, data extraction for analysis, and a quality assessment. Primary Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. Meta-analysis was performed using a random effects model.

RESULTS

Eleven studies of 789 flaps were included for data extraction. Random effects meta-analysis resulted in an estimated prevalence of free flap failure of 12.30% (95% confidence interval: 6.39%-19.49%, I2 = 77.4%).

CONCLUSION

Taking into account that head and neck free tissue transfers that require a vein graft are typically associated with more challenging reconstructions and the lack of a suitable alternative, vein grafts appear to be a reliable method for bridging the gap between the flap and recipient vessels in head and neck free tissue transfer when indicated.

Bone reconstruction using CAD/CAM technology in head and neck surgical oncology. A narrative review of state of the art and aesthetic-functional outcomes

Bone defects following resections for head and neck tumours can cause significant functional and aesthetic defects. The choice of the optimal reconstructive method depends on several factors such as the size of the defect, location of the tumour, patient’s health and surgeon’s experience. The reconstructive gold standard is today represented by revascularised osteo-myocutaneous or osteomuscular flaps with osteosynthesis using titanium plates. Commonly used donor sites are the fibula, iliac crest, and lateral scapula/scapular angle. In recent years, computer-aided design (CAD)/computer assisted manufacturing (CAM) systems have revolutionised the reconstructive field, with the introduction of stereolithographic models, followed by virtual planning software and 3D printing of plates and prostheses. This technology has demonstrated excellent reliability in terms of accuracy, precision and predictability, leading to better operative outcomes, reduced surgical times and decreased complication rates. Among the disadvantages are high costs, implementation times and poor planning adaptability. These problems are finding a partial solution in the development of “in house” laboratories for planning and 3D printing. Strong indications for the use of CAD/CAM technologies today are the reconstruction of total or subtotal mandibular or maxillary defects and secondary bone reconstructions.

Free flap reconstruction at a rural-based tertiary medical college hospital: Barriers and outcomes

BACKGROUND AND OBJECTIVES

In a rural-based setting, providing optimal treatment is often difficult owing to the limited resources and financial constraints being rampant in cancer care delivery. Oncological resections often result in large, complex defects requiring free flap reconstruction to achieve cosmetic and/or functional goals. This article focuses on our experience of starting and promoting microvascular reconstruction in a rural tertiary medical college hospital.

METHODS

Retrospective observational study of patients undergoing free flap reconstruction for oncological indications was included. Standard oncological principles were followed for cancer extirpation. Free flap reconstruction was done using loupes of 4× magnification. Flap-related outcomes and barriers in doing free flap reconstruction were analysed.

RESULTS

A total of 56 patients were included. The most common free flap undertaken was free anterolateral thigh flap in 21 (37.5%) patients. The mean duration of reconstruction was 438 min. Re-exploration was undertaken in 17 patients (30.4%). Nonsalvageable flap loss was 19.64%. Adjuvant treatment was administered in all patients as per oncological indications, albeit with some delay in 12.5%. Barriers to reconstruction were noted in the pre-, intra- and postoperative periods.

CONCLUSION

Reconstruction with free flaps is feasible in a resource-constrained setup with careful planning and a multidisciplinary team approach to overcome the barriers.

Evidence-Based Approaches to Anticoagulation in Reconstructive Microsurgery-A Systematic Literature Review

This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The objective was to balance the prevention of thrombotic complications commonly leading to flap failure, with the risk of increased bleeding complications associated with anticoagulant use. A meticulous PubMed literature search following Evidence-Based-Practice principles yielded 79 relevant articles, including both clinical and animal studies. The full-texts were carefully reviewed and evaluated by the modified Coleman methodology score. Clinical studies revealed diverse perioperative regimens, primarily based on aspirin, heparin, and dextran. Meta-analyses demonstrated similar flap loss rates with heparin or aspirin. High doses of dalteparin or heparin, however, correlated with higher flap loss rates than low dose administration. Use of dextran is not recommended due to severe systemic complications. In animal studies, systemic heparin administration showed predominantly favorable results, while topical application and intraluminal irrigation consistently exhibited significant benefits in flap survival. The insights from this conducted systematic review serve as a foundational pillar towards the establishment of evidence-based guidelines for anticoagulation in microsurgery. An average Coleman score of 55 (maximum 103), indicating low overall study quality, however, emphasizes the need for large multi-institutional, randomized-clinical trials as the next vital step.

Thermal Imaging as a Method to Indirectly Assess Peripheral Vascular Integrity and Tissue Viability in Veterinary Medicine: Animal Models and Clinical Applications

Infrared thermography (IRT) is a technique that indirectly assesses peripheral blood circulation and its resulting amount of radiated heat. Due to these properties, thermal imaging is currently applied in human medicine to noninvasively evaluate peripheral vascular disorders such as thrombosis, thromboembolisms, and other ischemic processes. Moreover, tissular damage (e.g., burn injuries) also causes microvasculature compromise. Therefore, thermography can be applied to determine the degree of damage according to the viability of tissues and blood vessels, and it can also be used as a technique to monitor skin transplant procedures such as grafting and free flaps. The present review aims to summarize and analyze the application of IRT in veterinary medicine as a method to indirectly assess peripheral vascular integrity and its relation to the amount of radiated heat and as a diagnostic technique for tissue viability, degree of damage, and wound care.

The Impact of Transfer-Related Ischemia on Free Flap Metabolism and Electrolyte Homeostasis-A New In Vivo Experimental Approach in Pigs

Free flap tissue transfer represents the gold standard for extensive defect reconstruction, although malperfusion due to thrombosis remains the leading risk factor for flap failure. Recent studies indicate an increased immune response and platelet activation in connection with pathologic coagulation. The underlying cellular and molecular mechanisms remain poorly understood, however. The presented study, therefore, aims to investigate if transfer-related ischemia alters intra-flap metabolism and electrolyte concentrations compared to central venous blood after free flap transfer in pigs to establish a novel experimental model. Free transfer of a myocutaneous gracilis flap to the axillary region was conducted in five juvenile male pigs. The flap artery was anastomosed to the axillary artery, and intra-flap venous blood was drained and transfused using a rubber-elastic fixed intravenous catheter. Blood gas analysis was performed to assess the effect of transfer time-induced ischemia on intra-flap electrolyte levels, acid-base balance, and hemoglobin concentrations compared to central venous blood. Time to flap reperfusion was 52 ± 10 min on average, resulting in a continuous pH drop (acidosis) in the flaps' venous blood compared to the central venous system (p = 0.037). Potassium (p = 0.016), sodium (p = 0.003), and chloride (p = 0.007) concentrations were significantly increased, whereas bicarbonate (p = 0.016) and calcium (p = 0.008) significantly decreased within the flap. These observations demonstrate the induction of anaerobic glycolysis and electrolyte displacement resulting in acidosis and hence significant tissue damage already after a short ischemic period, thereby validating the novel animal model for investigating intra-flap metabolism and offering opportunities for exploring various (immuno-) thrombo-hemostatic issues in transplantation surgery.

Effect of Perioperative Antithrombotics on Postoperative Transfusion and Hematoma in Head and Neck Free Flaps

Objective

To explore if antiplatelet or anticoagulant therapy increases the risk of transfusion requirement or postoperative hematoma formation in patients undergoing microvascular reconstruction for head and neck defects.

Study Design

Retrospective cohort study.

Setting

Departments of Otolaryngology-Head and Neck Surgery at the University of Alabama at Birmingham, the University of Colorado, and the University of California Irvine.

Methods

A multi-institutional, retrospective review on microvascular reconstruction of the head and neck between August 2013 to July 2021. Perioperative antithrombotic data were collected to examine predictors of postoperative transfusion and hematoma.

Results

A total of 843 free flaps were performed. Preoperative hemoglobin, hematocrit, operative time, and flap type were positive predictors of postoperative transfusion in both bivariate (P < .0001) and multivariate analyses (P < .0001). However, neither anticoagulation nor antiplatelet therapy were predictive of postoperative transfusion rates and hematoma formation.

Conclusion

Antithrombotic regimens do not increase the risk of postoperative transfusion or hematoma in head and neck microvascular reconstruction. Based on this limited data, perioperative antithrombotic regimens can be considered in patients who may otherwise be at risk for these postoperative complications.

Reconstruction in Salvage Surgery for Head and Neck Cancers

Introduction

Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers.

Study Design

This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017.

Methods

The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported.

Results

Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor.

Conclusions

Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

Role of Lactate Measurement in Flap Monitoring: An Useful Adjunct

Background  Detection of vascular compromise in flap is often a challenging task for reconstructive surgeons. A timely salvage procedure depends on objectivity and reliability of postoperative flap monitoring. This study determined if flap capillary lactate helps in prediction of flap viability in first 48 postoperative hours of surgery. Methods  We conducted this study on all flaps with accessible skin paddle where capillary lactate values were assessed along with clinical observation to check viability of flap at 0, 1, 6, 12, 24 and 48 hours of surgery. The data was statistically analyzed for significance and area under the receiver operating characteristic curve was used for calculating cutoff value for lactate. Results  Out of a total of 30 patients included in this study, 25 were males and the mean age was 45.03 years. Fifteen patients underwent free flap and rest pedicled. Highly significant association of role of clinical observation in the outcome of flap was found. The average of lactate values for survived and distally ischemic flap was 5.32 ± 1.91 and 8.38 ± 1.81, respectively, which was highly significant. The cutoff value of lactate below which all flaps survived was found to be 6.09 mmol/L. Conclusion  Flap capillary lactate measurement is an easy, quick, cost-effective, and objective tool for checking viability of flaps.

Free Tissue Transfer in Head and Neck Reconstruction: A Multidisciplinary 15-Year Experience

BACKGROUND

Free tissue transfer is considered the gold standard in reconstruction of extensive defects in head and neck surgery. The aim of this 15-year retrospective study is to analyze the outcomes of free tissue transfers in the head and neck area in a tertiary referral university hospital.

MATERIALS AND METHODS

A retrospective, single-center study of all patients undergoing free tissue transfers for head and neck reconstruction between 2006 and 2020 was performed. Patient demographics, comorbidities, flap characteristics, outcomes and complications were assessed.

RESULTS

A total of 353 free flaps were performed. The most common defect etiology was synchronous oncologic resection (74.2%). The majority of patients had at least one comorbidity (70.3%), with smoking recorded in 46.2% of the cases and alcohol consumption in 31.7%. The anterolateral thigh flap was the most commonly used flap (37.7%), followed by the osteoseptocutaneous fibula flap (26.9%). Our overall flap success rate was 97.7%, while the overall complication rate was 45.9%.

CONCLUSIONS

Free tissue transfer in head and neck reconstruction is reliable. However, complication rates remain high due to the complexity of such cases and frequent presence of comorbidities. Nonetheless, when effectively managed within a multidisciplinary team, complications rarely jeopardize the overall reconstruction outcome.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Background  One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods  Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results  Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion  MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision

OBJECTIVE

To determine if antithrombotic therapy improves head and neck microvascular free flap survival following anastomotic revision.

STUDY DESIGN

A retrospective review of all patients with microvascular free tissue transfer to the head and neck between August 2013 and July 2021.

SETTING

Otolaryngology-Head and Neck Surgery Departments at University of Alabama at Birmingham, University of Colorado, and University of California Irvine.

METHODS

Perioperative use of anticoagulation, antiplatelets, intraoperative heparin bolus, tissue plasminogen activator (tPA) and vasopressor use, and leech therapy were collected plus microvascular free flap outcomes. The primary endpoint was free flap failure. Analyses of free flaps that underwent anastomotic revision with or without thrombectomy were performed.

RESULTS

A total of 843 microvascular free flaps were included. The overall rate of flap failure was 4.0% (n = 34). The overall rate of pedicle anastomosis revision (artery, vein, or both) was 5.0% (n = 42) with a failure rate of 47.6% (n = 20) after revision. Anastomotic revision significantly increased the risk of flap failure (odds ratio [OR] 52.68, 95% confidence interval [CI] [23.90, 121.1], p < .0001) especially when both the artery and vein were revised (OR 9.425, 95% CI [2.117, 52.33], p = .005). Free flap failure after the anastomotic revision was not affected by postoperative antiplatelet therapy, postoperative prophylactic anticoagulation, intraoperative heparin bolus, tPA, and therapeutic anticoagulation regardless of which vessels were revised and if a thrombus was identified.

CONCLUSION

In cases of microvascular free tissue transfer pedicle anastomotic revision, the use of antithrombotic therapy does not appear to significantly change free flap survival outcomes.

The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction

Background and Objective

The deep inferior epigastric artery perforator (DIEP) flap was first described by Koshima and Soeda in 1989 and is now well-established as the gold standard in breast reconstruction. Lately, this issue has been explored in the context of head and neck reconstruction, highlighting growing interest in the use of the DIEP flap beyond breast reconstruction, but its usage in other anatomical regions appears elusive. Nevertheless, DIEP flap reconstruction may be a viable choice for complex, three-dimensional head and neck deformities while upholding the criteria of minimal donor site morbidity, according to a recent review. To determine whether the DIEP flap may be used successfully in other types of reconstruction, we conducted a review on the use, applications, and outcomes of the DIEP flap in non-breast reconstruction. This is, as far as we are aware, the first comprehensive analysis of all applications of the DIEP flap other than for breast reconstruction.

Methods

A literature review was performed using PubMed to include all relevant articles in English or French published up to February 2022. Keywords included "DIEP flap" and "deep inferior epigastric perforator flap".

Key Contents and Findings

A total of 1,299 articles were identified with 105 on the use of the DIEP flap in non-breast reconstruction. This suggests increasing recognition of the DIEP flap as a feasible option for reconstruction of most anatomical regions, especially in lower limb and head and neck reconstruction, followed by gynecological reconstruction. The DIEP flap was also utilized in the reconstruction of upper limb, thigh and hip defects. Less commonly, it has been used for penoscrotal, groin, sternal, buttock and abdomen reconstruction.

Conclusions

The scientific body of evidence showed the robustness and versatility of the DIEP flap in non-breast reconstruction, with its relative pros and cons at different anatomical regions.

The Reversed Flow Hemisoleus Propeller Muscle Flap

BACKGROUND

Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet.

OBEJECTIVES

The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap.

PATIENTS AND METHODS

A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects.

RESULTS

All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity.

CONCLUSIONS

The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.

Spontaneous Lymph Flow Restoration in Free Flaps: A Pilot Study

BACKGROUND

Oncologic excision and trauma can be responsible for major defects and lymphedema. Free flaps are commonly used for reconstruction. We aimed to determine if lymphatic flow between flap and recipient site can be restored without lymphatic surgery.

METHODS

15 free flaps were performed in different patients in our center. Infrared-based lymphography was used to plan surgery. Indocyanine green (ICG) was injected in the flap's subdermal tissue and also at the edges of the skin defect. Circumferential lymphatic channels were marked 5 min after the ICG injection. Fluorescent images were recorded with an infrared camera system. The flap inset was obtained by putting side to side the flap markings and the recipient site markings. Infrared-based lymphography was performed on every patient one year after surgery. Spontaneous lymph flow restoration was judged positive if lymphatic connections were observed between the flap and the recipient site.

RESULTS

seven free ALT and eight DIEP flaps were performed. All ALT flaps were designed following the limb axis which is the lymphatic axiality. Spontaneous lymph flow restoration was observed for the seven ALT flaps. Eight DIEP flaps were designed upside down and one was designed following the lymph axiality. Spontaneous lymph flow restoration was only observed for the one designed following the lymph axiality.

CONCLUSIONS

designing reconstructive free flap regarding lymph axiality seems to improve spontaneous lymph flow restoration between flap and recipient site without any specific lymphatic surgery.

Easy and Simple Techniques to Reconstruct Natural Nailfold with the Wrap-around Flap for Finger Reconstruction

The wrap-around flap (WAF) has become a popular approach to thumb reconstruction because the results are functionally and cosmetically excellent. By modifying to a partial toenail transfer, the WAF can also be used for finger reconstruction. However, performing cosmetically superior finger reconstruction is a significant challenge because it is difficult to reconstruct the natural nailfold by partial nail transplantation, although partial nail transplantation is required to reconstruct a narrow fingernail. One side of the reconstructed lateral nailfold tends to be a missing nail margin, and one side of the proximal nailfold angle tends to be retracted. Based on the rationale that loss of the lateral nailfold volume due to the postoperative tension of the volar flap would result in a missing nail margin, the volume of the lateral nailfold was maintained with a single thread that was passed from the nail to the volar flap. Additionally, half of the proximal nailfold from the nail plate was elevated to advance it forward. The results indicated that a cosmetically natural nailfold was achieved with the WAF approach to finger reconstruction. These easy and simple techniques enable reconstruction of a cosmetically natural nailfold using WAF for finger reconstruction.

Retrograde Free Venous Flaps for Extremity Reconstruction: A Roadmap

Background and Objectives: Retrograde free venous flaps represent a separate entity among free venous flaps: their physiology is still unclear, but they provide an immediate visible refill after reconnection, with a similar behaviour to conventional flaps. Therefore, the dimensions and the indications of these flaps can be extended beyond what was previously believed, and they can be easily customized, including with respect to tendons and nerves. Nevertheless, they are still debated and regarded as unsafe. Materials and Methods: From 2012 to 2019, we performed 31 retrograde free venous flaps on 31 patients to reconstruct hands, digits, and in one case the heel. All the flaps were arterialized in a retrograde manner; the donor site was the forearm in 28 cases, the foot in 2 cases, and the calf in 1 case. We recorded the size, vein architecture, donor site, donor artery, donor morbidity, function for composite and non-composite flaps, immediate complications, late complications, survival rate, and the number of revisions. We recorded the hand function when appropriate. A total of 10 flaps were also intraoperatively studied with indocyanine green to monitor their hemodynamical behaviour. Results: All the patients were followed for an average of 8 months (6−15). The flap dimensions ranged from 6 cm2 to 136 cm2. All the flaps, except two that had complete necrosis, survived. Two flaps had partial necrosis. There was no correlation between necrosis and the size of the flap, with one case of necrosis and one of partial necrosis in the small flaps (<10 cm2). None of the cases with partial necrosis needed a new flap. Two flaps developed a late arterio-venous shunt that was ligated. Conclusions: The retrograde free venous flaps proved to be a useful tool for complex reconstructions of the hand and extremities. They can provide a large island of pliable skin and composite tissue with tendons and nerves, but surgeons must be aware of some caveats.

Results of contralateral anastomosis of microvascular free flaps in head and neck reconstruction

OBJECTIVES

Despite various solutions to the issue of ipsilateral vessel-depleted neck in microvascular head and neck reconstruction, concrete data on its safety and implementation are scarce. This paper focuses on the feasibility and success rates of contralateral anastomosis in free flap reconstruction in the head and neck region.

METHODS

This single-center retrospective study at a tertiary referral center includes all patients who underwent free flap reconstruction of the head and neck with contralateral anastomosis between January 1st, 2007 and February 28th, 2021. Primary objectives were frequency, success, and flap-associated complication rates. Secondary objectives were recipient vessels and flap type.

RESULTS

Of 318 patients who underwent microvascular reconstruction, anastomosis was performed on the contralateral side of the neck in 32 patients (10.0%). Recipient vessels involved mainly the superior thyroid artery (74.2%; n = 23) and the facial vein (51.1%; n = 23). Thirty patients (93.8%) received a radial forearm free flap. Flap-associated complications occurred in 12.5% of included cases (n = 4): one partial flap necrosis (3.1%), one anastomotic insufficiency (3.1%), one venous thrombosis of the microvascular pedicle (3.1%), and one wound dehiscence (3.1%). All of these complications were resolved without complete flap loss.

CONCLUSION

This study demonstrates that contralateral anastomosis is a successful and safe option in microvascular head and neck reconstruction, especially using a radial forearm free flap. Thus, anastomosing to the contralateral side of the neck can be advocated as a valuable option in the ipsilateral vessel-depleted neck.

Intra- and Extrathoracic Malignant Tracheoesophageal Fistula-A Differentiated Reconstructive Algorithm

BACKGROUND

Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients.

PATIENTS AND METHODS

18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, n = 1), jejunum (n = 3) or combined ALT-jejunum flaps (n = 2).

RESULTS

Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF.

CONCLUSION

TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.

Mechanical Anastomotic Coupling Device versus Hand-sewn Venous Anastomosis in Head and Neck Reconstruction-An Analysis of 1694 Venous Anastomoses

Background  There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established.

Material and Method  We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured.

Result  A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group ( p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes ( p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss ( p = 0.001).

Conclusion  MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Microvascular nose reconstruction after extended tumor resection

&lt;b&gt;Introduction:&lt;/b&gt; The nose is the central and probably the most important organ of the face. In view of the three-dimensional shape and variety of tissues, reconstructive surgery after tumor resection in this anatomical region requires the surgeon's knowledge of anatomy. &lt;br&gt;&lt;b&gt;Materials and Method:&lt;/b&gt; In the years 2010-2019, 48 patients were treated in the Oncological and Reconstructive Surgery Clinic for extended nasal tumors, which required the use of free microvascular flaps after resection for functional and aesthetic supply of anatomical structures of the nose. &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; In 48 patients, a total of 92 free microvascular flaps were used for nasal reconstruction including: radial forearm free flap in 24 patients, radial forearm free flap with radial bone in 14 patients, auricular free flap in 16 patients, radial forearm free flap in combination with auricle free flap in 7 patients, double auricular free flap in 6 patients, radial forearm free flap in combination with double auricular free flap in 4 patients. Total necrosis of the free flap was noted in 4 cases, partial in 6 patients. &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The presented surgical techniques using microvascular free flaps constitute a recognized method of treatment and should be used in everyday surgeon practice. The results demonstrated in this article allow to obtain optimal functional and aesthetic effects.

Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism

OBJECTIVE

To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE).

STUDY DESIGN

Retrospective cohort study.

SETTING

Single tertiary care center.

METHODS

All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses.

RESULTS

Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission.

CONCLUSION

Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

Full-Thickness Tumor Resection of Oral Cancer Involving the Facial Skin-Microsurgical Reconstruction of Extensive Defects after Radical Treatment of Advanced Squamous Cell Carcinoma

Simple Summary

Advanced malignant tumors of the oral cavity are challenging because they impose serious oncological and functional requirements on the treatment specialist. Depending on the localization and the extent of the primary tumor, a full-thickness resection affecting the facial skin may be necessary to achieve a complete tumor resection. The resulting defects need adequate reconstruction in order to restore the aesthetics and functionality of the orofacial system. In this retrospective analysis, the authors aimed to evaluate treatment techniques for these tumors and analyze the clinical outcome of the related procedures. Full-thickness tumor resection with free flap reconstruction due to advanced cancer was performed in 33 patients.

Abstract

Advanced tumors of the head and neck are challenging for the treatment specialist due to the need to synergize oncological and functional requirements. Free flap reconstruction has been established as the standard of care for defects following tumor resection. However, depending on the affected anatomic subsite, advanced tumors may impose specific difficulties regarding reconstruction, especially when full-thickness resection is required. This study aimed to evaluate reconstructive strategies and oncological outcomes in patients with full-thickness resection of the oral cavity. A total of 33 patients with extensive defects due to squamous cell carcinoma of the oral cavity were identified. Indications, reconstructive procedures, and clinical outcome were evaluated. Thirty-two patients (97%) presented locally advanced tumors (T3/T4). Complete tumor resection was achieved in 26 patients (78.8%). The anterolateral thigh flap was the most frequently used flap (47.1%), and the primary flap success rate was 84.8%. The cohort demonstrated a good local control rate and moderate overall and progression-free survival rates. Most patients regained full competence regarding oral alimentation and speech. Full-thickness tumor resections of the head and neck area may be necessary due to advanced tumors in critical anatomic areas. In many cases, radical surgical treatment leads to good oncological results. Free flap reconstruction has been shown to be a suitable option for extensive defects in aesthetically challenging regions.

Removal of patient-specific reconstruction plates after mandible reconstruction with a fibula free flap: is the plate the problem?

Computer-aided microvascular mandible reconstruction is an increasingly common procedure in oral and maxillofacial surgery. The aim of this retrospective single-centre study was to evaluate the rate and specifics of hardware removal after fibula free flap (FFF) fixation with a patient-specific reconstruction plate. The study included patients who underwent hardware removal between April 2017 and October 2019. Statistical analyses were performed regarding the different indications for plate removal (dental implantation versus complication) and the surgical approach (intraoral versus extraoral). Plate removal was performed in 29 of 98 patients (29.6%) after FFF fixation with a patient-specific reconstruction plate. Plate removal was done prior to dental implantation in 58.6% of cases and due to complications in 41.4%. Complications seen between reconstructive surgery and plate removal were less frequent in the dental rehabilitation group (8/17 vs 12/12; P=0.002). Within this group, 35.3% of plates were removed intraorally, and the majority of partial plate removals were performed in the patients with plate removal for dental rehabilitation (72.7% vs 27.3%). Hospitalization was shorter with an intraoral approach (1.7 days vs 4.0 days, P=0.052). The removal of patient-specific reconstruction plates prior to dental implantation is often partial and can be performed intraorally. The use of patient-specific miniplates for fixation of FFF might facilitate later dental rehabilitation.

The Impact of Healthcare-Associated Infections in Patients Undergoing Oncological Microvascular Head and Neck Reconstruction: A Prospective Multicentre Study

Simple Summary

Healthcare-associated infections (HAIs) result in an increased morbidity and a delay in adjuvant therapy—thus increasing the cancer recurrence rates—in patients undergoing oncological microvascular head and neck reconstruction. HAIs also result in a cost increase for the Health System. We prospectively analysed the incidence, clinical characteristics, risk factors and impacts of these infections in 65 patients undergoing head and neck free-flap reconstruction in three third-level university hospitals in Madrid (Spain). The three of them implemented the same antibiotic prophylactic regimen for surgical interventions. The rate of HAIs was 61.54%. The following complications were significantly more frequent in patients with HAIs: need to reoperate (p = 0.009), duration of hospital admission (p < 0.001) and delay in starting radiotherapy (p = 0.009). This manuscript aims to point out the importance of preventing HAIs in head and neck cancer patients, as they have shown a higher risk of postoperative complications.

Abstract

(1) Background: Healthcare-associated infections (HAIs) after head and neck free-flap reconstruction are a common postoperative complication. Risk factors for HAIs in this context and their consequences have not been adequately described. (2) Methods: Ongoing prospective multicentre study between 02/2019 and 12/2020. Demographic characteristics and outcomes were analysed, focusing on infections. (3) Results: Forty out of 65 patients (61.54%) suffered HAIs (surgical site infection: 52.18%, nosocomial pneumonia: 23.20%, bloodstream infection: 13% and urinary tract infection: 5.80%). Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were the most frequently implicated. The significant risk factors for infection were: previous radiotherapy (Odds ratio (OR): 5.42; 95% confidence interval (CI), 1.39–21.10), anaemia (OR: 8.00; 95% CI, 0.96–66.95), salvage surgery (eight out of eight patients), tracheostomy (OR: 2.86; 95% CI, 1.01–8.14), surgery duration (OR: 1.01; 95% CI, 1.00–1.02), microvascular reoperation <72 h (eight/eight) and flap loss (eight/eight). The major surgical complications were: a need to reoperate (OR: 6.89; 95% CI, 1.42–33.51), prolonged hospital admission (OR: 1.16; 95% CI, 1.06–1.27) and delay in the initiation of postoperative radiotherapy (OR: 9.07; 95% CI, 1.72–47.67). The sixth month mortality rate in patients with HAIs was 7.69% vs. 0% in patients without HAIs (p = 0.50). (4) Conclusions: HAIs were common after this type of surgery, many of them caused by resistant microorganisms. Some modifiable risk factors were identified. Infections played a role in cancer prognosis by delaying adjuvant therapy.

Systematic Review of Free Tissue Transfer Used in Pediatric Lower Extremity Injuries

Aims: To analyze the recent literature regarding the different types of free tissue transfer used in pediatric lower-limb trauma, trends, flap success rates, and the anatomical location of reconstruction. Method: A search was conducted involving the MEDLINE database using the key words "Paediatric," "Pediatric," "Children," "Lower limb," "Lower extremity," "Leg," "Ankle," "Foot," "Free flap," "Flap," "Microsurgery," and "Free tissue transfer" in a 3-component search applying the Boolean operators "OR" and "AND." The search was condensed to articles published in the last 5 years. Results: In total, 240 studies were retrieved. Thirty-nine titles were selected and after reviewing the abstracts, 10 articles fit the inclusion and exclusion criteria. A total of 220 free flaps were used to reconstruct defects. Age range was between 2 and 17 years. Complete flap failure rate was 4.5% (n = 10). The anterolateral thigh perforator flap was the commonest flap used (n = 59), and the latissimus dorsi flap was the commonest muscle flap used (n = 51). Sixty-five percent of flaps were fasciocutaneous/perforator, while muscle flaps accounted for only 33% of flaps. The foot and ankle region accounted for 72% of defects. Conclusion: With evidence of improved success rates, free tissue transfer has become a popular choice in reconstruction of pediatric lower-limb trauma injuries. This study shows that perforator/fasciocutaneous flaps have recently become a more popular choice over muscle flaps. Overall, the success rate of free flaps in pediatric lower-limb trauma is high (95.5%) and comparable with the adult population.

Head and neck surgery global outreach: Ethics, planning, and impact

Background

Head and neck surgical oncology and reconstruction are uniquely suited to address burdens of disease in underserved areas. Since these efforts are not well known in our specialty, we sought to understand global outreach throughout our society of surgeons.

Methods

Survey distributed to members of the American Head and Neck Surgery involved in international humanitarian head and neck surgical outreach trips.

Results

Thirty surgeons reported an average of seven trips to over 70 destinations. Identification of candidates, finances, on‐site patient care, complications, long‐term post‐surgical care, ethics, and educational goals are reported. We report a success rate of 90% on 125 free flaps performed in these settings.

Conclusions

The effort to answer the call for alleviating the global burden of surgical disease is strong within our specialty. There is a shared focus on humanitarian effort and teaching. Ethics of high resource surgeries such as free flap reconstruction remains controversial.

Resection and Reconstructive Options in the Management of Dermatofibrosarcoma Protuberans of the Head and Neck

Objective To discuss resection and various reconstructive options in patients with dermatofibrosarcoma protuberans (DFSP). Methods This study was conducted at Shifa International Hospital, Islamabad, Pakistan, from May 2018 to December 2019. All patients aged 20 years or above of either gender who were diagnosed to have DFSP over this period were included in the study. All the patients underwent wide local excision of the tumor under general anesthesia. A peroperative frozen section was conducted in all the cases to confirm complete excision. Immediate reconstruction was performed following the tumor excision. The choice of reconstruction, i.e. free, regional, or local flap was based on the size of the resultant defect. Results The mean age of the patients was 37.11 ±10.91 years. There were 12 (66.7%) males and six (33.3%) females. The mean duration of the disease was 11.22 ±2.94 months. The affected anatomical site showed that the face was involved in the majority, nine (50%) patients, followed by the scalp in four (22.2%), nape of the neck in three (16.7%), and supraclavicular region in two (11.1%) patients. In most of the cases, the free flap was observed, i.e. (n=9, 50%), followed by a regional flap in seven (38.9%), and the local flap in two (10.1%) patients. Conclusion Wide local excision of the disease, confirmed on frozen section, offers improved survival. Among DFSP of the head and neck, the face was found to be the affected anatomical site in half the cases. Also, reconstruction following tumor excision with a free flap is the most favorable option among patients with DFSP.

Compartmental Surgery With Microvascular Free Flap Reconstruction in Patients With T1-T4 Squamous Cell Carcinoma of the Tongue: Analysis of Risk Factors, and Prognostic Value of the 8th Edition AJCC TNM Staging System

Compartmental surgery and primary reconstruction with microvascular free flaps represent the gold-standard in the treatment of oral tongue squamous cell carcinoma (OTSCC). However, there are still unclear clinical features that negatively affect the outcomes. This retrospective study included 80 consecutive patients with OTSCC who underwent compartmental surgery and primary reconstruction by free flap. The oncologic outcomes, the reliability of the 8th edition American Joint Committee on Cancer (AJCC) staging system and the prognostic factors were evaluated. Fifty-nine males and 21 females (mean age 57.8 years, range 27-81 years) were treated between November 2010 and March 2018 (one patient had two metachronous primaries). Seventy-one patients (88.75%, 52 males, 19 females, mean age of 57.9 years, range of 27-81 years) had no clinical history of previous head and neck radiotherapy and were considered as naive. Histology showed radical surgery on 80/81 lesions (98.8%), with excision margins >0.5 cm, while in 1 case (1.2%), a close posterior margin was found. According to the 8th AJCC classification, 37 patients (45.7%) were upstaged shifting from the clinical to the pathological stage, and 39 (48.1%) showed an upstaging while shifting from the 7th to the 8th AJCC staging system (no tumors were downstaged). Nodal involvement was confirmed in 33 patients (40.7%). Perineural and lymphovascular invasion were present in 9 (11.1%) and 11 (13.6%) cases, respectively. Twenty-two patients (27.1%) underwent adjuvant therapy. The 5-years disease-specific, overall, overall relapse-free, locoregional relapse-free and distant metastasis-free survival rates were 73.2, 66.8, 62.6, 67.4, and 86%, respectively. Patients with a lymph node ratio >0.09 experienced significantly worse outcomes. Univariate analysis showed that patients with previous radiotherapy, stage IV disease, nodal involvement, and lymphovascular invasion had significantly worse outcomes. Multivariate analysis focused naive patients and showed that lymphovascular invasion, advanced stage of disease, and node involvement resulted reliable prognostic factors, and patients with the same tumor stage and histological risk factors who did not undergo adjuvant therapy experienced significantly worse outcomes. In our series, surgery played a major role in the treatment of local extension; adjuvant therapy resulted strictly indicated in patients with advanced-stage disease associated with risk factors.

Use of Cephalic Vein for Venous Anastomosis in Head and Neck Reconstruction: A Case Series

Purpose: To describe the use of the cephalic vein as a recipient vessel for venous outflow in head and neck reconstruction. The cephalic vein is used as a vessel in cases where there is a paucity of veins in the neck. This may be due to previous surgery, previous radiation therapy, or advanced cancer. The cephalic vein may also be used to salvage a failing free flap. Methods: It is a retrospective review of 230 free flaps that had been used in head and neck reconstruction performed from July 2014 to July 2018 by a single surgeon. Results: There were 6 patients in whom the cephalic vein was used as a recipient vessel. The cephalic vein was used in 2 cases where a tumor was involved with the internal jugular vein, in 1 case where a previous neck dissection had been done, in 1 case where internal jugular vein had iatrogenic damage, and in 2 cases a salvage procedure was done. In all cases, the cephalic vein was rotated above the clavicle. The cephalic vein easily reached the free flap vein and had a good caliber. There were no failures in any of the patients. Conclusion: The cephalic vein is a good option for venous anastomoses in patients in whom there is a paucity of recipient vessels in the neck.

Bilateral Simultaneous Breast Reconstruction with DIEP- and TMG Flaps: Head to Head Comparison, Risk and Complication Analysis

Background: A two center retrospective cohort study of simultaneous bilateral breast reconstructions using double deep inferior epigastric perforator (DIEP) flaps and double transverse myocutaneous/upper gracilis (TMG) flaps was conducted. The aim of this study was to compare surgical procedures, complications, and overall outcome. Patients and Methods: Two study groups, either receiving a simultaneous bilateral breast reconstruction, with double DIEP flaps (n = 152) in group 1, or double TMG flaps (n = 86) in group 2, were compared. A detailed risk and complication analysis was performed. Patient characteristics, operative time and the need for further operations were evaluated. Results: Double DIEP patients had donor site complications in 23.7% and double TMG patients in 16.3% (p = 0.9075, RR 1.45). Flap loss rates of 3.5% (double TMG) and 2.6% (double DIEP) were recorded (p = 0.7071, RR 1.33). The need for postoperative lipofilling was significantly higher in double TMG patients (65.1% vs. 38.2 %, p = 0.0047, RR 1.71). Conclusion: Complication analysis favors the double DIEP procedure. Donor site morbidity was lower and less severe in the double TMG group. Later fat grafting was more frequently needed after double TMG reconstructions. Further studies, preferably of prospective nature, are needed to evaluate the benefit of bilateral simultaneous breast reconstructions.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Introduction:

Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment.

Material and Methods:

Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.

Results:

Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor.

Conclusion:

“Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

[Coverage in the management of loss of skin substances on the lower third of the leg: about 9 cases]

La couverture des pertes de substances cutanées du tiers inférieur de la jambe est compliquée, et ce dû à la pauvreté des tissus mous adjacents, la précarité de la vascularisation locale et l'exposition osseuse. Nous avons mené une étude rétrospective d'une série de 9 cas de couvertures cutanées du tiers distal de la jambe traitée au CHU Hassan 2 de Fès de l'année 2016 à 2018. L'objectif de notre étude est de relever la particularité des pertes de substances cutanées du tiers inférieur de la jambe, tout en soulignant la difficulté de couverture.

Free Flaps for Advanced Oral Cancer in the "Older Old" and "Oldest Old": A Retrospective Multi-Institutional Study

Introduction: Surgery followed by adjuvant therapy represents the most adequate treatment for advanced oral squamous cell carcinoma (OSCC). Free flaps are considered the best reconstructive option after major oral surgery. In the last decades, OSCC has increased in the elderly due to an augmented life span. The aim of this work is to evaluate the feasibility of microvascular surgery in patients older than 75 years, focusing on clinical and surgical prognosticators.

Methods: “Older old” (aged ≥ 75) and “oldest old” (>85) patients who underwent microvascular reconstruction for OSCC from 2002 to 2018 were retrospectively evaluated in three referral Head and Neck Departments. Demographic, clinical, and surgical data were collected and analyzed. Pre-operative assessment was performed by ASA and ACE-27 scores. Complications were grouped as medical or surgical, and major or minor according to the Clavien-Dindo scale.

Results: Eighty-four patients (72 “older old” and 12 “oldest old”) were treated with a free flap success rate of 94.1%. Thirty-seven (44.7%) and nine (10.7%) patients had minor and major medical complications, respectively; 18 (21.4%) and 17 (20.2%) had minor and major surgical complications, respectively. Twenty-one (25%) patients had both medical and surgical complications (with a statistically significant association, p = 0.018). Overall, 52 (61.9%) patients had at least one complication: ASA score, diabetes mellitus, and duration of general anesthesia (DGA) significantly impacted the complication rate at multivariate analysis.

Conclusion: Our data confirm the feasibility of free flaps for OSCC reconstruction in appropriately selected elderly patients. Pre-operative assessment and aggressive management of glycemia in patients with diabetes is mandatory. DGA should be reduced as much as possible to prevent post-surgical complications. Comprehensive geriatric assessment is of paramount importance in this subset of patients.

American Society of Anesthesiologists Class as Predictor for Perioperative Morbidity in Head and Neck Free Flaps

OBJECTIVE

To evaluate outcomes of free flaps in low- versus high-risk American Society of Anesthesiologists (ASA) classes utilizing a standardized perioperative clinical pathway.

STUDY DESIGN

Case series with chart review.

SETTING

Single tertiary care academic institution.

SUBJECTS AND METHODS

Data were collected from 301 patients who underwent 305 free flap reconstructions for head and neck defects from January 2012 to March 2016 by a single surgeon (M.M.). A standardized perioperative clinical pathway was utilized for all patients, aimed at abbreviating hospital stay and minimizing intensive care unit stay. Data included ASA classification, comorbidities, length of hospitalization, intensive care unit stay, 30-day mortality/readmission, discharge disposition, flap survival, and postoperative complications. Low-risk ASA classes were defined as 1 and 2 (n = 53) and high risk as 3 and 4 (n = 248).

RESULTS

Total medical complication rates (P = .012) were mildly increased in the high-risk group, as a result of increased minor-not major-medical complication rates (P = .007). Discharge to a nursing or rehabilitation facility was found to be more common in the high-risk group (P = .024). All other outcomes were not statistically different between the cohorts.

CONCLUSION

The ASA classification system is a validated tool in determining perioperative risk. We found that minor medical complications and discharge to a rehabilitation/nursing facility were increased in the high-risk ASA classes; otherwise, there were no statistical differences between the groups. These findings suggest that the ASA classification may be helpful for preoperative discharge planning and counseling but should not be used for patient selection or to assess candidacy for the procedure.

Pharyngeal Reconstruction with Microvascular Free Tissue Transfer

Reconstruction of pharyngoesophageal defects after total laryngectomies and extirpation of hypopharyngeal and upper esophageal carcinomas presents a challenging task. Goals of reconstruction include adequate voice rehabilitation and restoration of normal swallowing. The reconstructive armamentarium contains many options for reconstruction and creation of a new upper digestive tract. This review article focuses on the most commonly used free tissue transfer options for the reconstruction of these defects, with an assessment of their advantages and disadvantages.

Free Flap Reconstruction of the Maxilla

Tumors of the maxilla and midface are some of the most difficult to manage, not only in terms of treatment but also in terms of achieving acceptable orofacial reconstruction. Today, free flaps dominate the reconstructive field. Many patients can achieve successful reconstruction after free flap transfer with a return of intelligible speech, a regular diet, and acceptable cosmesis. Herein, the authors review free flap reconstruction of the maxilla, with a focus on the classifications of defects, when obturators are appropriate, types and sources of free flaps, and complications for which to beware.

Free-Flap Reconstruction of the Mandible

Mandible reconstruction has evolved over the years with advances in surgical options and three-dimensional technology. Although nonvascularized bone grafting is still used, vascularized flaps show advantages with immediate reconstruction, the possibility of immediate dental implants, and the ability to reconstruct composite defects of both soft tissue and bone. This article discusses current vascularized techniques for mandible reconstruction. While each reconstructive method has advantages and disadvantages, a defect-based reconstruction focused on full rehabilitation allows surgeons to plan and counsel the patient for the best available reconstruction.

Free Tissue Transfer in Pediatric Lower Limb Trauma

Free tissue transfer has become the standard in wound coverage and further refinements have given us newer flap donor sites or modifications of existing flaps to decrease morbidity; smaller vessels are being anastomosed, a direct spin-off following successful distal replantations. Younger children are presenting with traumatic defects similar to adults. Although there were apprehensions of free tissue transfer in children occasioned by smaller vessels, duration of procedure and concerns of growth following flap harvest, reports of small and large series have appeared in the literature with similar success. Pediatric-free tissue transfer is now an established entity. This article seeks to arrive at a consensus based on a review of the existing literature on free flaps for skin and soft-tissue coverage of lower limb trauma in children.

Higher Complication Rates in Self-Inflicted Gunshot Wounds After Microvascular Free Tissue Transfer

OBJECTIVES/HYPOTHESIS

Microvascular free tissue transfer is often employed to reconstruct significant facial defects from ballistic injuries. Herein, we present our comparison of complications between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer.

STUDY DESIGN

Retrospective case review.

METHODS

Approval was obtained from the JPS institutional review board. We performed a retrospective review of cases of ballistic facial injuries between October 1997 and September 2017 that underwent vascularized free tissue transfer for reconstruction. Comparisons were made between self-inflicted and non-self-inflicted gunshot wounds after microvascular free tissue transfer. The χ² test was used for all comparisons. P value and 95% confidence interval (CI) were reported.

RESULTS

There were 73 patients requiring free flap reconstruction after gunshot wounds to the face during the study period. There was a statistically significant difference in the rates of nonunion between self-inflicted and non-self-inflicted wounds (P = .02, 95% CI: 0.9 to 35.8) There were also no significant differences in flap failure (P = .10, 95% CI: -2.8 to 24.2), plate exposure (P = .28, 95% CI: -6.7 to 33.0), wound infection (P = .40, 95% CI: -8.9 to 31.2), scar contracture (P = .60, 95% CI: -8.1 to 25.1), and fistula formation (P = .13, 95% CI: -2.8 to 28.8) between patients with self-inflicted and those with non-self-inflicted wounds. Overall, complication rates were significantly higher in the self-inflicted group compared to the non-self-inflicted group (P < .0001, 95% CI: 32.6 to 68.6).

CONCLUSIONS

Patients with self-inflicted injuries had more complications postoperatively than those with non-self-inflicted injuries. This is likely helpful in surgical planning and patient counseling.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:837-840, 2019.

Intramuscular Lipoma within a Free Myocutaneous Flap: Systematic Review and Management

Lipomas are a common finding often of little clinical significance, but they can pose a challenge to the microsurgeon if discovered during flap harvesting, especially if found within the muscle along the pedicle or perforators. Here the authors report a case in which a well-circumscribed intramuscular lipoma was discovered within the muscle of a free myocutaneous right anterolateral thigh (ALT) vastus lateralis free flap. To the authors' knowledge, the management of lipoma during flap harvesting has not been previously discussed in the literature. A systematic review was performed, and an approach for the management of myocutaneous flaps containing a lipoma was described. Underappreciated considerations including lipoma location, growth pattern, and proximity to pedicle and perforators must be taken into account when evaluating a lipoma during flap harvest.

Antibiotic prophylaxis in clean-contaminated head and neck cases with microvascular free flap reconstruction: A systematic review and meta-analysis

BACKGROUND

Optimal antibiotic prophylaxis duration in head and neck clean-contaminated free-flap cases is unknown.

METHODS

A systematic review/meta-analysis was conducted using PubMed/MEDLINE, Cochrane Library, Web-of-Science, and Scopus databases.

RESULTS

Of the 3755 searched articles, 5 articles were included for a total of 861 patients. The recipient surgical site infection risk was significantly higher in patients receiving prophylactic antibiotics for ≤24 hours compared to >24 hours (relative risk [RR] 1.56; 95% confidence interval [CI] 1.13-2.14). In the post hoc multivariate analysis based on available individual-level data on 697 patients from 3 studies, the risk of surgical site infection for ≤24 hours versus >24 hours was not significant after adjusting for antibiotic type (RR 1.09; 95% CI 0.78-1.55). When compared to ampicillin-sulbactam, patients who received clindamycin prophylaxis had an increased likelihood of recipient surgical site infection (RR 2.85; 95% CI 1.95-4.17).

CONCLUSION

Less than or equal to 24 hours of antibiotic prophylaxis in head and neck clean-contaminated free-flap is likely sufficient but a strong conclusion remains elusive. Clindamycin prophylaxis increases the risk of recipient surgical site infection. Further prospective trials are necessary to clarify.

Free Bone Grafts for Mandibular Reconstruction in Patients Who Have Not Received Radiotherapy: The 6-cm Rule-Myth or Reality?

Bony reconstruction of the mandible after surgical resection results in improved rehabilitation and aesthetics. Composite tissue transfer has transformed reconstruction, particularly in patients who have received radiotherapy. However, there is morbidity related to free tissue transfer. Free nonvascularized bone grafts have much lower morbidity. Surgeons believe that free bone grafts greater than 6.0 cm are prone to failure. The aims of this study was to assess whether bone grafts greater than 6.0 cm in length have a high risk of failure. A retrospective study was performed on all patients who had free bone grafts greater than 6.0 cm in length at Birmingham, UK, and Florida, the United States. None of the patients received radiotherapy. A total of 14 patients had undergone bone grafts for mandibular defects greater than 6.0 cm in length; 13 of the bone grafts were successful. Of these 13, none were infected and there was radiographic evidence of bony union. Some of the patients have been dentally rehabilitated with implants. Contrary to much of the literature and many surgeons belief, our study has shown that long mandibular defects (>6.0 cm) are not a contraindication to the use of free bone grafts. Key principles to achieve success are discussed in this article.

[Comparing the free fasciocutaneous flap with free jejunium in reconstruction for hypopharyngeal and cervical esophageal defects]

Objective:To investigate the application of the reconstruction methods for hypopharyngeal and cervical esophageal defects due to the resection of hypopharyngeal cancer and advanced laryngeal cancer between free fasciocutaneous flaps and free jejunium transfer.We compared the superiorities and inferiorities of these two reconstruction methods. Method:Retrospective review of the archives of 56 patients from 2000 to 2010 who underwent pharyngoesophageal reconstruction with free flaps (n=32) or free jejunal transfer(n=24),comparison of indications,complications, hospitalization duration, swallowing function recovery and postoperative survival time. Result:The overall 3 year survival rate of free flap group and free jejunal transfer group was 59.3%,55.7% respectively; the overall 5 year survival rate was 38.5%,37.1% respectively. The overall rate of complication rate was 18.8%, 16.7% respectively. The patients with free flaps had higher incidence rate of fistula and scarring in the donor site and lower incidence rate of hues and stricture than the ones with free jejunal transfers. The mean hospitalization duration was (15.00±7.06) days and(13.00±6.75) days. The mean time of first oral food intake was(13.00±5.83)days and (11.00±6.67) days. The differences between two groups had no statistical significance(P>0.05). Conclusion:Free flaps and free jejunium transfer are the two most common reconstruction methods for the hypopharyngeal and cervical esophageal defects. Each has its own advantages and disadvantages respectively. We should choose reconstruction method according to the site and extent of the hypopharyngeal and cervical esophageal defects, preoperative and postoperative radiotherapy requirement.

Leech Therapy For The Treatment Of Venous Congestion In Flaps, Digital Re-Plants And Revascularizations - A Two-Year Review From A Regional Centre

BACKGROUND

Leeches are a well-recognized treatment for congested tissue. This study reviewed the efficacy of leech therapy for salvage of venous congested flaps and congested replanted or revascularized hand digits over a 2-year period.

METHODS

All patients treated with leeches between 1 Oct 2010 and 30 Sep 2012 (two years) at Queen Elizabeth Hospital, Birmingham, UK were included in the study. Details regarding mode of injury requiring reconstruction, surgical procedure, leech therapy duration, subsequent surgery requirement and tissue salvage rates were recorded.

RESULTS

Twenty tissues in 18 patients required leeches for tissue congestion over 2 years: 13 men and 5 women. The mean patient age was 41 years (range 17-79). The defect requiring reconstruction was trauma in 16 cases, following tumour resection in two, and two miscellaneous causes. Thirteen cases had flap reconstruction and seven digits in six patients had hand digit replantations or revascularisation. Thirteen of 20 cases (65%) had successful tissue salvage following leech therapy for congestion (77% in 10 out of 13 flaps, and 43% in 3 of 7 digits). The rate of tissue salvage in pedicled flaps was good 6/6 (100%) and so was in digital revascularizations 2/3 (67%), but poor in digital re-plants 1/4 (25%) and free flaps 0/2 (0%).

CONCLUSIONS

Leeches are a helpful tool for congested tissue salvage and in this study, showed a greater survival benefit for pedicled flaps than for free flaps or digital replantations.

Important considerations in chest wall reconstruction

Chest wall reconstruction represents one of the most challenging tasks in plastic surgery. Over the past several decades, a more profound understanding of surgical anatomy and physiology along with tremendous advances in surgical technique have resulted in substantial improvements in postoperative outcomes. Conceptually, the reconstructive goals include dead space obliteration, restoration of skeletal stability with protection of intrathoracic structures, and stable soft tissue coverage. Ideally, these goals are achieved with minimal aesthetic deformity. J. Surg. Oncol. 2016;113:913-922. © 2016 Wiley Periodicals, Inc.

Factors associated with failure of free gracilis flap in reconstruction of acute traumatic leg defects

BACKGROUND

Possible factors associated with failure of free gracilis flaps were studied.

MATERIALS AND METHODS

All gracilis free flaps used to reconstruct acute traumatic leg defects in a 5 year period were collected. This included open fractures of the tibia and/or fibula in which a gracilis free flap was used for reconstruction. Pre-op factors included age, ethnicity, gender, presence of diabetes, ischaemic heart disease, peripheral vascular disease, or coagulation disorders; days from trauma to flap surgery, Gustilo class, presence of a concurrent ipsilateral femur fracture, and use of CT angiogram to determine adequacy of blood supply. Intra-op factors included type of arterial anastomosis (end to side or end to end), presence of arterial transection, initial arterial anastomotic failure, initial venous anastomotic failure, use of systemic vasoconstrictors by anaesthetists for correction of hypotension, and use of modulators of the coagulation mechanism (dextran/heparin). Post-op factors included post-op day when flap was removed and use of modulators of the coagulation mechanism.

RESULTS

Patients with a concurrent ipsilateral femur fracture had a 9.67 (95% CI of OR = 1.32-70.96) times increased risk of flap failure compared to patients without an associated femur fracture.

CONCLUSION

The finding of increased risk of free gracilis flap failure for coverage of leg defects in patients with ipsilateral femur fractures has implications on flap selection and pre-operative counselling. In such a situation, a non-microvascular option could be safer if it is available as an alternative.

Reconstructive Indications of Anterolateral Thigh Free Flaps in Head and Neck Reconstruction

Anterolateral thigh (ALT) free flap is a common flap with multitude of indications. The purpose of this article is to review the reconstructive indications of the flap in head and neck defects. This is a retrospective study of 194 consecutive ALT flaps. Data including patient characteristics (age, sex, comorbidities), disease characteristics (histology, T stage), and flap characteristics (size of the flap, type of closure of ALT donor site) were collected. The outcome in terms of flap success rate, surgical, and donor site morbidity were studied. A total of 194 flaps were performed in 193 patients over a period of 10 years. Mean age of the patients was 55 years (range 16-80 years). Out of the 193 patients, 91 (47.1%) patients had oromandibular defects, 52 (26.9%) had tongue defects, 15 (7.7%) had pharyngeal defects, 17 (8.8%) had skull base defects, 4 (2%) had scalp defects, and 14 (7.2%) had contour defects of the neck. The overall flap success rate was 95.8% (8 total flap loss out of 194). Hypertrophic scar was the commonest donor site problem seen in 20 (10.3%) patients. This study shows the versatility of free ALT flap in head and neck reconstruction. It is a reliable and safe. Donor site morbidity is minimal.

Free flap reconstruction experience and outcomes at a low-volume institution over 20 years

OBJECTIVE

Assess the efficacy of free flap reconstruction performed at a low-volume program and evaluate how volume and outcomes have changed over 20 years.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

A retrospective chart review was performed at a tertiary care academic program on all free tissue flaps from the primary reconstructive surgeon over 20 years (1993-2013). In total, 136 procedures were obtained from operative notes, billing codes, and chart databases. Outcome variables included procedure success and complications. Patients stayed in general intensive care unit and hospital floor units.

RESULTS

Flap success was 92.6% of all cases. In the past 13 years, 70 flaps were performed with 3 failures (96% success rate). Take-back rate was 16% of total cases with a flap recovery rate of 60%. Postoperative failure occurred after 72 hours in 60% of cases. Nearly 60% of patients experienced a complication of any type or severity. Twenty percent had a flap complication while maintaining viability, with half of these being partial dehiscence. Systemic complications affected 20% of all cases. The average hospital stay for noncomplicated patients was 13 days. There was 1 postoperative mortality. Fibula and radial forearm were the most common flaps at 44% and 26%, respectively.

CONCLUSION

Free flap reconstruction of the head and neck can be performed by appropriately skilled surgeons with acceptable outcomes in low-volume settings. Success rate appears to increase as clinical experience is gained.