Advanced Head and Neck Reconstruction; A Seven-Year Experience in Iran

Free flap reconstruction in head and neck cancer patients with prior tumor resection, neck dissection, and irradiation is clinically challenging. The purpose of this study was to investigate the reliability and outcome of using the anterolateral thigh (ALT) flap and transverse cervical recipient vessels for microvascular reconstruction in patients with depleted vessels in the head and neck region caused by previous surgery and irradiation. Between January 2015 and December 2017, microsurgical head and neck reconstruction was performed using the ALT flap and transverse cervical artery (TCA) as the recipient vessel in 15 patients who had undergone previous neck dissections and irradiation for cancer treatment. All patients had a "vessel-depleted neck" resulting from severe scarring and radiation fibrosis. Clinical data of each patient were recorded. All ipsilateral TCAs were found to be damage free. Subsequently, free ALT flaps were revascularized using the TCAs. One patient developed venous thrombosis, and another patient developed arterial thrombosis. They were both salvaged within 6 hours postoperatively. No flap failure or mortalities were reported within the 30-day postoperative period. Two patients developed orocutaneous fistula and were further managed with wound care. The mean follow-up time was 11.9 ± 6.0 months (range, 5-23 months). Five patients died during the follow-up period from cancer progression. The use of the free ALT flap and TCA as the recipient vessel provides favorable microsurgical outcomes in patients with depleted recipient vessels in the head and neck region caused by previous neck dissections and radiation therapy.

Head and neck cancers are one of the leading causes of morbidity and mortality in Indian population. Reconstruction and restoration of function are also of paramount importance in these patients. The aim of this study was to report outcomes for free flaps and pedicle flaps in patients with oral cavity cancers. A retrospective analysis of 628 patients with oral cavity cancers who underwent reconstruction with either free flaps or pedicle flaps during 2014-2020 was done. The median age of the cohort was 49years. The free flap reconstruction was performed in 481 (76%) and pedicle flap in 147 (24%) patients. Among free and pedicle flaps, 27 (5.6%) and 3 (2.1%) respectively had major flap complications and 25 (5.1%) and 14 (9.9%) respectively had minor complications. CCI score > 4 was associated with higher events (p = 0.02) in free flap group. The outcomes of free flaps are similar in comparison to pedicle flaps in patients with oral cavity cancers. The higher CCI score is significantly associated with increased flap-related complications for the free flap group.

Background and Objective: A significant revolution in head and neck reconstruction occurred with advent of free flap transfer. The objective of this study was to review our experience during 14 years in performing 36 free flap for head and neck region. Materials and Methods: A retrospectively hospital chart review of in 35 free flap cases between February 1993 and July 2006 was done. Patient’s sex, age, T stage, type of free flap, flap success rate, post operative complications were evaluated. Results: 34 (94%) of 36 free flap were success. 2 cases partial tissue necrosis happened due to venous congestion, so local free flap was done. Post operative complications were happened 7 cases. 4 cases were seen fistulas, 1 case was seen wound dehiscence, 1 case was seen infection, 1 case was seen hematoma. Conclusion: In review of our experience, free flap reconstruction in head and neck defect has useful procedure in high success outcomes and cosmetics aspect. (J Clinical Otolaryngol 2006;17:223–227)

The objectives of this study were to classify and analyze perioperative complications following free flap reconstruction in the head and neck and investigate potential predictors of these complications. A retrospective chart analysis of 304 consecutive free flap reconstructions for defects in the head and neck were examined. Patient and operative characteristics as well as complications were recorded prospectively and analyzed using ordinal logistic regression. The overall complication rate was 32.6% with a perioperative mortality rate of 0.3%. The flap loss rate was 2.0% and the partial flap necrosis rate was 1.0%. Multivariate analysis demonstrated a significant correlation between perioperative complication and tumor stage as well as reconstruction site. The rate and grade of complications with free flap reconstruction in the head and neck were found to be low. Higher tumor stage and pharyngoesophageal reconstruction were found to be associated with increased complication grades, whereas preoperative radiation alone and chemoradiation were not. Smoking and alcohol use, age, diabetes mellitus, peripheral vascular disease, and preoperative myocardial infarction as well as preoperative cerebrovascular accident were not found to be associated with increased complications. No statistically significant difference in complication grades was found with different flap types or indications for reconstruction.

Simple SummaryBased on the proven benefits of goal directed therapy (GDT) in the perioperative management of different surgical procedures and in high-risk patients, we hypothesised that this approach would also be beneficial in microvascular free flap reconstruction in head and neck cancer. In this study, we investigated whether GDT would directly benefit flap viability in addition to improving morbidity and mortality. As this reconstructive technique is gradually being introduced in more specialist fields, particularly radical oncological surgery, the benefits of GDT in this context could be extended to numerous procedures.(1) Background: Surgical outcomes in free flap reconstruction of head and neck defects in cancer patients have improved steadily in recent years; however, correct anaesthesia management is also important. The aim of this study has been to show whether goal directed therapy can improve flap viability and morbidity and mortality in surgical patients. (2) Methods: we performed an observational case control study to analyse the impact of introducing a semi invasive device (Flo Trac®) during anaesthesia management to optimize fluid management. Patients were divided into two groups: one received goal directed therapy (GDT group) and the other conventional fluid management (CFM group). Our objective was to compare surgical outcomes, complications, fluid management, and length of stay between groups. (3) Results: We recruited 140 patients. There were no differences between groups in terms of demographic data. Statistically significant differences were observed in colloid infusion (GDT 53.1% vs. CFM 74.1%, p = 0.023) and also in intraoperative and postoperative infusion of crystalloids (CFM 5.72 (4.2, 6.98) vs. GDT 3.04 (2.29, 4.11), p < 0.001), which reached statistical significance. Vasopressor infusion in the operating room (CFM 25.5% vs. GDT 74.5%, p < 0.001) and during the first postoperative 24h (CFM 40.6% vs. GDT 75%, p > 0.001) also differed. Differences were also found in length of stay in the intensive care unit (hours: CFM 58.5 (40, 110) vs. GDT 40.5 (36, 64.5), p = 0.005) and in the hospital (days: CFM 15.5 (12, 26) vs. GDT 12 (10, 19), p = 0.009). We found differences in free flap necrosis rate (CMF 37.1% vs. GDT 13.6%, p = 0.003). One-year survival did not differ between groups (CFM 95.6% vs. GDT 86.8%, p = 0.08). (4) Conclusions: Goal directed therapy in oncological head and neck surgery improves outcomes in free flap reconstruction and also reduces length of stay in the hospital and intensive care unit, with their corresponding costs. It also appears to reduce morbidity, although these differences were not significant. Our results have shown that optimizing intraoperative fluid therapy improves postoperative morbidity and mortality.

BackgroundThe free flap surgical method is useful for the reconstruction of head and neck defects. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 30 years.MethodsBetween 1989 and 2018, a total of 866 free flap procedures were performed on 859 patients with head and neck defects, including 7 double free flaps. The causes of vascular crisis and salvage rate were analyzed, and the total flap survival rate calculated among these patients. Additionally, the survival and complication rates for each flap type were compared.ResultsThe 866 cases included 557 radial forearm flaps, 200 anterolateral thigh flaps, 39 fibular osteocutaneous flaps, and 70 of various other flaps. The incidence of the vascular crisis was 5.1%; its most common cause was venous thrombosis (52.3%). Salvage surgery was successful in 52.3% of patients, and the total flap survival rate was 97.6%. The success rate of the radial forearm flap was higher than of the anterolateral flap (p<0.01), and the primary sites of malignancy were the tongue, tonsils, and hypopharynx, respectively.ConclusionThe free flap technique is the most reliable method for head and neck reconstruction; however, the radial forearm free flap showed the highest success rate (98.9%). In patients with malignancy, flap failure was more common in the anterolateral thigh (5.5%) and fibular (5.1%) flaps.

The use of the free tissue transfers Improves the functional and cosmetic results of the head and neck reconstruction. Because a large composite defect or bilateral defects can not be reconstructed with a single free flap in one-staged operation, simultaneous double free flaps are used to achieve the reconstructive goals. Iii 1999, five patients of head and neck defects were reconstructed immediately with two free flaps. Four patients of primary buccal cancer and one recurrent tongue cancer were all squamous cell carcinoma The combined free anterolateral thigh flap and free fibular osteocutaneous flap were used for the large through-and- through oromandibular defects after the buccal cancei resection as well as for the oropharyngeal-mandibular defect after the ablation of the recurrent tongue cancer One patient of synchronous bilateral buccal cancers underwent the reconstruction with bilateral free anterolateral thigh flaps. Nine of the 10 flaps survived. One anterolateral thigh flap in the patient of bilateral buccal cancers suffered from venous thrombosis, which had been explored but failed. The radial forearm flap was salvaged and survived well later, Minor complications including one wound infection and one skin graft loss of donor site were noted and healed after debridement and skin graft. The combined anterolateral thigh flap and fibular flap have played an important role in the reconstruction of the oromandibular composite defects.

ObjectivesOwing to the functional and structural complexity of the head and neck area, the reconstruction of defects in these areas is challenging. Free flap surgery has become standard for the reconstruction of the head and neck with improvements in microvascular surgery. The aim of this study was to use the cumulative sum (CUSUM) method to evaluate the learning curve for free-flap head and neck reconstruction performed by a single surgeon.MethodsWe retrospectively reviewed the medical records of 47 patients who underwent free-flap reconstruction from 2017 to 2021. The clinical demographics and surgical outcomes were analyzed. The total operation time was analyzed using the CUSUM method, which is an analytical approach for visualizing patterns in data by converting raw data into an accumulation of deviations from the average value.ResultsCUSUM analysis showed two phases of the learning curve: phase 1 (cases 1–22) and phase 2 (cases 23–47). The operative time in phase 1 (579.9±128.2 minutes) was significantly longer than that in phase 2 (418.6±80.9 minutes) (P<0.001). The re-exploration rate was higher in phase 1 (31.8%) than in phase 1 (4%) (P=0.018). The flap failure rate was higher in phase 1 (9.1%) than in phase 1 (4%), but this difference was not statistically significant (P=0.593).ConclusionThe learning curve of free-flap head and neck reconstruction seems to stabilize after approximately 20 cases.

BackgroundFree flap surgery for head and neck defects has gained popularity as an advanced microvascular surgical technique. The aims of this study are first, to determine whether the known risk factors such as comorbidity, tobacco use, obesity, and radiation increase the complications of a free flap transfer, and second, to identify the incidence of complications in a radial forearm free flap and an anterolateral thigh perforator flap.MethodsWe reviewed the medical records of patients with head and neck cancer who underwent reconstruction with free flap between May 1994 and May 2012 at our department of plastic and reconstructive surgery.ResultsThe patients included 36 men and 6 women, with a mean age of 59.38 years. The most common primary tumor site was the tongue (38%). The most commonly used free flap was the radial forearm free flap (57%), followed by the anterolateral thigh perforator free flap (22%). There was no occurrence of free flap failure. In this study, risk factors of the patients did not increase the occurrence of complications. In addition, no statistically significant differences in complications were observed between the radial forearm free flap and anterolateral thigh perforator free flap.ConclusionsWe could conclude that the risk factors of the patient did not increase the complications of a free flap transfer. Therefore, the risk factors of patients are no longer a negative factor for a free flap transfer.

Outcomes of anastomotic venous flow couplers in head and neck free flap reconstruction – five-year experience in a single centre

Evidence supports short courses of perioperative antibiotics for patients receiving minor head and neck procedures. Few studies have addressed antibiotic prophylaxis for patients undergoing free flap reconstruction of head and neck defects. To determine ideal antibiotic prophylaxis in patients undergoing head and neck free flap reconstruction. Retrospective cohort study of 427 adults receiving free flap reconstruction of head and neck defects at 2 affiliated tertiary care academic hospitals between January 1, 2006, and January 28, 2013. Prophylactic antibiotic type and duration were recorded from patient records. Outcome data were abstracted from patients' medical records including infection at the surgical sites and distant nonsurgical sites and flap site complications including flap compromise, dehiscence, or fistula. Multivariate logistic regression was used to determine the association of risk factors with the primary outcome of any infection within 30 days of surgery. Ninety-six patients (22.5%) received prophylactic antibiotics for 24 hours or less, and 331 patients received prolonged courses of prophylactic antibiotics. The majority of patients received ampicillin-sulbactam alone for prophylaxis (53.2%), while 36.5% received clindamycin alone and 10.3% received an alternative regimen. Postoperative infections occurred in 46% of patients, and 22% of patients had an infection at the flap inset site or neck incision. The use of clindamycin (odds ratio [OR], 2.54; 95% CI, 1.25-5.14 [P = .01]) was associated with an increased risk of postoperative infection; extended duration of antibiotics (OR, 0.63; 95% CI, 0.34-1.19 [P = .18]) was not associated with increased risk of postoperative infection. By multivariate analysis, use of clindamycin (OR, 6.71; 95% CI, 1.83-24.60 [P = .004]) and oral tobacco use (OR, 1.20; 95% CI, 1.04-1.39 [P = .02]), but not extended course of prophylactic antibiotics (OR, 0.75; 95% CI, 0.30-1.86 [P = .53]), were associated with a higher risk of postoperative flap or neck infections. The choice of antibiotic appears to affect the rate of all postoperative infections and flap site infections more than the duration of antibiotics following head and neck free flap reconstruction. At our institutions, ampicillin-sulbactam is the preferred prophylactic antibiotic for major clean-contaminated head and neck procedures when possible.

The Feasibility of Free Flap Surgery in Foreign Medical Missions

Objectives The aim of this randomized prospective trial was to evaluate indications, advantages, disadvantages, and complications of the usage of anterolateral thigh (ALT) flap as a free flap in head and neck reconstruction. Background Reconstruction of the head and neck continues to pose a formidable challenge for maxillofacial and plastic surgeons.The free ALT flap has emerged as a popular option for the reconstruction of head and neck defects. The present study evaluates the usage of free ALT flap in head and neck reconstruction. Materials and methods From January 2012 to January 2013, patients who had extensive soft-tissue defect in the head and neck and had been reconstructed by free ALT flap have been reported. Flap data (type, length, and width), duration of flap elevation, donor-site morbidity, postoperative complications, and follow-up data including aesthetic and functional outcome were recorded. Results The mean total harvest time of the flap was 113 min, the mean skin paddle width in our study was 10 cm (range, 7-15 cm), and length was 13 cm (range, 10-16 cm). The donor site in all cases had been closed directly. Failure of microvascular anastomosis occurred in one flap (from a total of three cases in the study), although no significant donor morbidity has been reported. Conclusion The ALT flap can be reliably harvested without incurring serious donor morbidity. It possesses workhorse attributes (no repositioning, remote from defect, and long pedicle) and is extremely versatile, making it ideal for the heterogeneous group of extensive soft-tissue head and neck defects.

This study aims to systematically compare free flaps and pedicled flaps in patients with head and neck cancer. By tracking postoperative complications, psychosocial adaptation, and quality of life through long-term follow-up, this research seeks to provide evidence-based, individualized flap repair strategies to reduce complications and improve overall treatment outcomes and quality of life. In this single-center, clinical data of head and neck cancer patients undergoing flap reconstruction (2018–2024) were retrospectively extracted. Psychological and quality-of-life outcomes were prospectively collected at 1, 3, and 6 months postoperatively using validated scales (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Head and Neck Module 35, Zung Self-Rating Depression Scale, Zung Self-Rating Anxiety Scale). Variables were selected based on clinical relevance. The Mann-Whitney U test, chi-square test, Univariate and multivariate logistic regression analyses were conducted to evaluate the risk factors for postoperative complications and length of hospital stay after flap reconstruction. Among 736 head and neck cancer patients undergoing flap reconstruction, 178 (24.2%) and 558 (75.8%) received free and pedicled flaps, respectively. Complications occurred in 234 (31.8%) of patients, with flap-related and systemic complications accounting for 127 (17.3%) and 155 (21.1%). Multivariate logistic regression analysis identified Prothrombin time (OR = 1.26, 95% CI [1.01–1.58], p = 0.037) as a significant predictor of flap-related complications. Hypertension (OR = 1.85, 95% CI [1.22–2.82], p = 0.0039) increases the risk of systemic complications. Surgical duration exceeding three hours (OR = 2.4, 95% CI [1.21–4.79], p = 0.012; OR = 1.75, 95% CI [1.01–3.04], p = 0.045), N3 stage (OR = 1.76, 95% CI [0.74–4.17], p = 0.2; OR = 3.2, 95% CI [1.47–6.95], p = 0.00341) experience a higher incidence of both flap-related and systemic complications. Psychological health assessments showed that the pedicled flap group had significantly higher Zung Self-Rating Depression Scale score than the free flap group at both three and six months post-surgery (42.3 ± 6.1 vs. 40.1 ± 7.3, p = 0.025; and 44.7 ± 5.5 vs. 41.6 ± 6.7, p = 0.002, respectively). Evaluations using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 and Head and Neck Module 35 scales confirmed that flap type did not affect any quality of life dimension. This study identified predictors of postoperative flap-related complications in head and neck reconstruction, including prolonged prothrombin time, surgery duration exceeding 3 h, hypertension, and advanced T stage. Furthermore, it revealed that patients receiving pedicled flaps reported higher postoperative depression scores, highlighting the importance of psychological considerations in surgical planning. Collectively, these findings provide a multidimensional evidence base for developing personalized preoperative reconstruction strategies.

Severe atherosclerosis of the radial artery in a free radial forearm flap precluding its use