Free Flap Reconstruction Research Articles

The Free Flap Reconstruction of Facial Defects after Squamous Cell Carcinoma Excision.

Background and Objectives: Cutaneous squamous cell carcinoma is the second most common skin cancer. There are many methods for the reconstruction of facial subunit defects after skin cancer excision. The face is vital to a person's life and should be reconstructed considering functional and aesthetic aspects. Despite a variety of flap types and techniques, it is still challenging to meet the various demands. The aim of this study was to compare free flaps for facial reconstruction after resection of cutaneous squamous cell carcinoma. Materials and Methods: This study included 14 patients from January 2021 to June 2023. Patients who underwent facial SCC resection and subsequent reconstruction using free flaps were analyzed retrospectively. Age, sex, and localization were recorded. Follow-ups ranged from 5 to 21 months, with an average of 13 months. Results: All free flaps survived well except one case of partial flap necrosis. In most patients, good to excellent functional and aesthetic results were obtained. The donor site healed uneventfully in all patients. Conclusions: Free flap reconstruction is an excellent choice in wide skin oncologic defects. In terms of texture, it also could be a good surgical method. The use of a fraxel laser can progressively facilitate improved color matching with the surrounding skin.

Factors affecting the risk of trismus following maxillary ablative surgery comparing free flap reconstruction to prosthetic obturation: a retrospective observational study

The reconstruction of post-ablative maxillary defects is controversial. It is accepted that quality of life indicators are poorer for maxillary reconstruction compared with mandibular reconstruction. One factor highlighted is that of post-treatment trismus. Rates of trismus are reviewed comparing free tissue transfer to that of prosthetic obturation. A retrospective review was undertaken comparing rates of trismus at twelve months post-surgery between free tissue transfer and prosthetic obturation. A total of 85 patients were identified who met the inclusion criteria. Both reconstruction techniques were significant for developing trismus, with a higher rate in the free flap reconstruction cohort than the prosthetic obturation cohort by a factor of 2.51. Modern reconstructive head and neck surgery has moved away from ‘filling a hole’ to a more bespoke, patient-specific reconstruction. The evidence presented here should allow the reconstructive surgeon to better discuss outcomes with patients when considering surgical options for Class II maxillary defects.

The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer.

Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients. A 20-year retrospective case-control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis. Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12-5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders. Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population.

Feasibility of Obtaining Patient-Reported Outcome Measures in a High-Volume Multidisciplinary Surgical Limb Salvage Center.

Completion of patient-reported outcome measures (PROMs) is labor-intensive but paramount in improving patient-centered care, allowing for advancement of techniques and scrutinization of outcomes. We report the feasibility of PROM collection and reporting for patients seen in a high-volume, multidisciplinary, tertiary limb salvage center to determine pain and functionality outcomes. The center received grant funding resources for large-scale PROM collection. Patients completed either tablet or paper surveys. Functionality and pain PROMs included 1) Neuro-QoL Lower Extremity Function-Mobility, 2) Numerical Rating Scale, 3) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity, and 4) PROMIS Pain Interference. Research assistants attended clinic daily to administer surveys. Patients were categorized into the following groups: amputation, flap reconstruction, other surgical management, and nonsurgical management. Five hundred sets of each survey were administered to 420 patients across 2 months, with 16% of patients (n = 80) completing multiple sets at separate visits. The completion rate among eligible patients was 90% or greater for each PROM. Of the respondents, 133 (31.7%) were seen for previous amputation, 32 (7.6%) for local or free flap reconstruction, 68 (16.2%) for other surgical management (eg, debridement, arthroplasty), and 295 (70.2%) for nonsurgical management (eg, lymphedema, hidradenitis). We report that integration of PROM collection in a high-volume limb salvage center is feasible. These metrics allow measurement of the impact and effectiveness of salvage or amputation surgeries from patients' perspectives, providing quantification of satisfaction and aspects of health-related quality of life, improved patient advocacy, and an evidence-based approach to surgical management.

Immediate Implants in Fibulas: Does the Implant to Fibula Osteotomy Distance Impact Early Implant Failure?

BackgroundWhen placing dental implants in the free fibula flap, the osteotomy cut edge poses a unique challenge in that an optimal distance has not yet been established. PurposeThe study aimed to measure the association between implant-to-fibula osteotomy edge distance and early implant failure in patients who received free fibula flap reconstruction with immediate implants. Study DesignA retrospective cohort study was designed and implemented. The study population was composed of patients who underwent free fibula flap transfer with immediate dental implant placement for the treatment of benign or malignant conditions of the head and neck from 2015 to 2022 at John Peter Smith Hospital. Subjects were excluded if the implant was in the middle of the free flap bordered by adjacent implants, was >10mm from the osteotomy edge, or had insertional torque values of ≤30 Ncm. Predictor VariablePrimary predictor variable was the implant distance in millimeters from the fibula osteotomy edge. Outcome VariablePrimary outcome variable was early implant failure, defined as implant exfoliation noted by the patient or failure due to implant movement or pain necessitating explantation within 6 months of placement. CovariatesThe covariates were age, sex, diabetes diagnosis, American Society of Anesthesiologists classification, smoking status, history of head and neck radiation, pathology treated, and if postoperative radiation treatment was received. AnalysesA generalized estimating equations (GEE) model was used to assess the relation between the primary predictor and outcome. A p-value of <0.05 was considered statistically significant. ResultsThe sample was composed of 48 subjects who had 130 implants placed, with early failures occurring in 5 implants (3.9%) in 3 subjects. The mean age of the sample was 49 years (SD 20) and 29 (60%) were male. The mean implant distances for early failures and non-failures were 3.5 mm (SD 1.04) and 4.3 mm (SD 1.5), respectively. There was a statistically significant relation between implant distance and early implant failure (P = .005, OR 0.6, 95% CI 0.39 to 0.85). ConclusionsThis study found that shorter distances between the implant and the edge of the fibula osteotomy are associated with early implant failure.

Potential of the Thoracoepigastric Vein as a Drainage Vein in Breast Reconstruction With a Free Flap: An Anatomical Study Using Computed Tomography.

The recipient vessel choice is very important when performing free-flap breast reconstructions. Usually, the concomitant vein of the recipient artery is anastomosed, and mismatches in the diameter are occasionally observed. We consider the thoracoepigastric vein (TEV) as a potential useful recipient vein. The use of the TEV is not a novel technique. It has been used by surgeons for free-flap anastomoses in the axillary region, but usually as an anastomotic site for the second vein. However, anatomical findings such as TEV diameter, its deficiency rate, and influence on mastectomy are not clear. In this study, computed tomography (CT) was performed to evaluate the use of the TEV as a recipient vein for breast reconstruction. The medical records of patients who underwent breast reconstruction with free-flap transfer were retrospectively evaluated. In most cases, CT was performed using a tissue expander inserted after mastectomy. The TEV was considered suitable if its diameter on the mastectomy side was >1 mm and the vertical distance from the most distal slice level where the TEV could be seen at the third costal cartilage height of the parasternal region was <50 mm. Sixty-six sides of 33 patients were evaluated. The mean age of the patients was 49.3 ± 5.1 years. The TEV was used in five flaps. TEV diameters were not significantly different between the left and right sides (1.85 ± 0.53 vs. 1.82 ± 0.6, respectively, p = 0.836). On the mastectomy side, eight (25%) TEVs were injured, but only three (8.6%) were considered unavailable. On the healthy side, 96.4% TEVs were available. TEVs may be a good choice as vein anastomosis targets for breast reconstruction with a free flap because of their relatively large vessel diameter. UMIN-CTR: R000061573.

Postoperative Sedation in Free Microvascular Tissue Transfer in Head and Neck Cancer: A Comparison of Fentanyl and Morphine

Background and Aims: Head-and-neck cancer surgeries with microvascular free flap reconstruction require endotracheal tube retention for 24–48 h postoperatively. Many regimes have been used for analgesia and sedation. The efficacy of fentanyl and morphine for post-operative analgosedation was compared by evaluating the need for additional sedatives to achieve optimum sedation scores. The secondary objective included analgesia, haemodynamic stability and a re-exploration rate. Methods: This was an open-label prospective study. A sample size of 36 was calculated in each group with α = 0.05 and a power of 80% to detect a 50% difference between the groups. Ninety adult patients were allocated to receive either fentanyl (Group F) or morphine (Group M). The Richmond agitation sedation score, Behavioural pain scale score, requirement of rescue hypnotic drug, pulse rate, systolic and diastolic blood pressures and re-explorations were recorded postoperatively. Haemodynamic parameters and sedation were analysed by two-way repeated measures of analysis variances. Pain scores were analysed using the Chi-square test. Results: When titrating to optimal sedation, in Group M, more patients needed intravenous midazolam boluses (n = 42, 93.3%) as compared to Group F (n = 33, 73.3%) (P = 0.011). More subjects in Group M required propofol infusion (n = 15, 33.3%) than in Group F (n = 4, 8.9%) (P = 0.009). Mean behavioural pain scores were significantly higher in Group M (score 1: P = 0.005 and score 2: P =0.001). The difference in the mean systolic, diastolic blood pressure, pulse rate, respiratory rate and re-exploration rate between the two groups was statistically insignificant. Conclusion: For analgesia-based sedation of spontaneously breathing intubated patients after head-and-neck cancer reconstructive surgeries, fentanyl is more effective than morphine in terms of ease of titration, sedation quality and analgesia. Both are safe for post-operative sedation regarding haemodynamic stability, tube retention and maintenance of spontaneous respiration.

Predicting Complications in Head and Neck Surgery: Comparing Calculators to Surgeons.

Objectives: Surgical outcomes determine national ranking, reputation, and funding, and are often assessed with objective surgical risk calculators (SRCs). Surgeons' assessments are not considered. This study aims to determine if surgeons or SRCs are more accurate in predicting outcomes. Methods: This prospective cohort study identified a surgeon's assessment on a patient's risk preoperatively. The patient's risk was also calculated using the SRC. Predictions were compared to patient outcomes and to each other to assess whether surgeons or the SRC were more accurate. Results: Of the 101 patients included, 37 (36.6%) experienced a complication of any kind and 18 (17.8%) experienced a serious complication. Smoking resulted in a 2.49 times higher overall complication rate (P = .04). Laryngectomy patients experienced the highest rate of complications (P = .02) compared to those undergoing free flap reconstruction [odds ratio (OR) 0.9] or any other surgery (OR 0.26). Both surgeons and the American College of Surgeons (ACS) tool performed poorly on the prediction of the outcome of any complication, with a receiver operating characteristic (ROC) area under the curve (AUC) of 0.51 [95% confidence interval (CI): 0.39-0.62] and 0.58 (95% CI: 0.47-0.70), respectively, which was not statistically significant (P = .34). For the prediction of the outcome of serious complication, the AUC for surgeons and the ACS tool were 0.55 (95% CI: 0.41-0.69) and 0.60 (95% CI: 0.46-0.74), respectively, which was not statistically significant (P = .58). Conclusions: Neither validated risk calculators nor surgeons are accurate in predicting perioperative risk. The only risk factor that contributes to improving predictions for complications is preoperative smoking, although age and type of surgery are also significant predictors. Risk calculators may therefore not be appropriate metrics for assessing hospital performance. These findings can help guide preoperative counseling and may help in the development of more accurate predictive tools as the healthcare field continues to incorporate artificial intelligence into surgical planning.

The impact of preoperative psychiatric intervention for postoperative delirium after major oral and maxillofacial surgery with free flap reconstruction

BackgroundPostoperative delirium (POD) is a severe complication associated with various adverse outcomes, especially in older patients. Although the incidence and risk factors for POD have been explored in general surgery, they have not been fully elucidated. Early identification of high-risk patients and active preoperative intervention are considered essential for the prevention of POD. Recently, psychiatric consultation intervention have been shown to prevent delirium. This study investigated the effect of preoperative psychiatric interventions on preventing POD in our specific surgical context. Materials and MethodsThis retrospective, single-center observational study included 86 patients who underwent major oral and maxillofacial surgery with free flap reconstruction between 2016 and 2023. The effect of psychiatric intervention were compared between patients with and without delirium. ResultsPreoperative psychiatric intervention did not reduce the incidence of POD. The incidence of POD was 29.1 %. Univariate analyses showed no significant associations between POD and any clinical variables. ConclusionThere was no difference in the incidence of POD between patients who received preoperative psychiatric intervention and those who did not, and further investigation is needed to determine the efficacy of preoperative psychiatric intervention in the prevention of POD.

Use of Free Anterolateral Thigh Flap and Free Latissimus Dorsi Myocutaneous Flap in Head and Neck Reconstruction: Comparison of Complications and Costs.

Free anterolateral thigh flap (ALT) and latissimus dorsi myocutaneous flap (LDMF) are well-defined flaps frequently used to reconstruct head and neck defects. Our study aimed to compare the advantages and disadvantages of these flaps regarding esthetics, complications, and cost burden. The authors retrospectively evaluated 10 patients who applied to our clinic between January 2016 and December 2021 and required free flap reconstruction for the defect in the head and neck region. The first group consisted of 5 patients with ALT flaps, and the second group had 5 patients with LDMF flaps. The average cost burden of the first group was calculated as 18,373 TL, and the second group's was 23,362 TL. Our study found that the cost and complication rates were statistically higher in the LDMF flap group, and using an ALT flap was more reasonable due to its advantages.

Fully Telemetric Robotic Microsurgery: Clinical Experience With 23 Cases.

Recently, there is an ongoing trend in plastic surgery with robotic-assisted microsurgery and supermicrosurgery devices being developed. Combining a telemetrically controlled robotic microscope with an also telemetrically controlled microsurgery robot unlocks synergistic effects with complete disconnection of the operating surgeon from the operating field. Here, we report the first clinical free flap reconstructions using this setup. Twenty-three surgeries were performed with the combined remote approach using the Symani Surgical System and the RoboticScope in open microsurgery procedures. Anastomosis time and ischemia time were recorded. The surgical performance for anastomoses was assessed using the modified Structured Assessment of Microsurgical Skills (SAMS) score. Subjective satisfaction was evaluated by the surgeons in comparison with conventional microsurgery. To evaluate the learning curve, the senior authors first four (first group) and last four (last group) procedures were compared. Overall, flap survival was 95.7%. The average arterial anastomosis time was 36.7 ± 10.9 min. Total time of surgery was 277.7 ± 63.8 min, and ischemia time was 100.6 ± 24.9 min. Most SAMS score parameters were significantly higher in the last group of surgical procedures compared with the first operations. Subjective satisfaction was equal or better with the combined robotic-assisted approach in most categories. Our data demonstrates safety and feasibility of the use of a combined remote approach. Robotic systems for microsurgical procedures may hold promising potential for improvement of surgical quality and open up new frontiers in microsurgery.

Social Determinants of Health Impact Complications Following Free-Flap Reconstruction for Head and Neck Cancer.

Head and neck cancers (HNCs) have increased in prevalence and often require free-flap reconstruction (FFR) after tumor ablation. Postoperative complications following FFR can be high, occurring in as many as 48% and 71% of cases. HNC patients also have many disparities in Social Determinants of Health (SDOH), but the potential impact of SDOH disparities on postoperative complications following FFR has not been formally assessed. Retrospective cohort review. Academic Tertiary Care Institution in Northeast United States. Patients that underwent head and neck FFR between January2018 and December2021 were analyzed to determine associations between quartiles of the national Area Deprivation Index (ADI), a proxy for SDOH disparity, and various medical and surgical postoperative complications. Associations were assessed using χ2analysis. Two hundred four patients were included in the study, and 61 patients had 97 complications. Significant associations between higher national ADI quartile and incidence of several postoperative complications were identified, including any surgical complication (P = .0419), wound dehiscence (P = .0494), myocardial infarction (MI) (P = .0215), and sepsis (P = .0464). There are significant associations between SDOH disparities and postoperative surgical complications, wound dehiscence, MI, and sepsis following head and neck FFR. Addressing SDOH disparities in HNC is pivotal to enhance postoperative outcomes and promote holistic patient care.

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review.

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes. A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All study designs were included. Non-English articles were excluded. Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula. Free tissue transfer for a palatal fistula repair. Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained. Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies. Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Efficacy of superficial femoral artery as a recipient in free flap reconstruction around the knee: Four case reports and a literature review

PurposeReconstructing soft tissue defects around the knee with free flaps presents challenges in recipient vessel selection. Although the superficial femoral artery (SFA) offers exposure ease and anatomical stability, concerns arise regarding its distance from the defect site, difficulty in performing anastomosis and potential peripheral ischaemia. This study aimed to reassess the suitability of SFA as a recipient vessel for knee reconstructions by examining our cases and those from previous reports. MethodsWe reviewed four cases of knee soft tissue defects reconstructed with free flaps using the SFA, detailing surgical techniques and outcomes. Additionally, a comprehensive literature search was conducted for articles on using SFA as a recipient vessel for knee free flaps, using PubMed, Web of Science and EBSCOhost databases. ResultsIn all four cases, latissimus dorsi (LD) flaps were used, with end-to-side anastomosis performed using a large slit-shaped arteriotomy. All flaps demonstrated successful survival without complications. Our analysis included 85 cases, comprising four of our cases and 81 cases from 16 articles. Sarcoma resection was the most common aetiology, followed by total knee prosthesis-related defects, trauma and osteomyelitis. Complete flap necrosis occurred in 5% of cases. The LD flap was the predominant choice, alongside other long-pedicle flaps. The SFA provided coverage for all knee areas except the distal lateral patellar region. ConclusionDespite the limited evidence, the SFA appears to be a reliable recipient vessel for knee soft tissue reconstruction. Comprehensive understanding of the characteristics of the SFA and flaps used enhances the safety and efficacy of soft tissue defect reconstruction around the knee.

Perspectives in Using Multiple Flaps Reconstructions for Advanced Head and Neck Tumors (Scoping Review).

Background and Objectives: Patients with advanced head and neck tumors require salvage surgery as a last resort. These extensive surgeries pose the challenge of complex reconstructions. The head and neck surgeon undertaking such complex cases needs to master different flaps. The team managing these patients needs input from various specialists, along with otorhinolaryngologists, plastic surgeons, maxillofacial surgeons, vascular surgeons, experienced radiologists, dedicated pathologists, oncologists and radiation therapists. We focus on the optimum solution between oncologic resections and the future quality of life of patients and overall survival. Each complex case requires a personalized medicine approach. This scoping review aims to assess the efficacy and outcomes of complex reconstructions using various flaps for head and neck tumors, with a focus on free flaps and emerging techniques. Materials and Methods: A systematic search of the literature was conducted following PRISMA guidelines, resulting in the inclusion of 44 articles that met the predefined criteria in the last 10 years. Results: The included studies encompassed diverse patient populations and evaluated various surgical techniques, outcomes, complications, and advancements in head and neck reconstruction. The review identified a variety of flaps utilized in head and neck tumor reconstruction, including free flaps such as the radial forearm, anterolateral thigh, scapular tip, and myocutaneous flaps, among others. The success rates for free flap reconstructions ranged from 85% to 100%, with notable variations attributed to patient selection, tumor characteristics, and surgical expertise. Conclusions: Complications such as flap necrosis, infection, hematoma, and donor site morbidity were documented across studies, highlighting the importance of meticulous surgical planning and postoperative care. Furthermore, the review revealed emerging techniques such as computer-aided design, virtual surgery, stereolithographic models, customized implants, tissue engineering, and allotransplants, offering promising reconstructive armamentarium. Advances in surgical techniques and emerging technologies hold promise for further enhancing reconstructive outcomes, minimizing morbidity, and improving patient quality of life.

To Shrink or Not to Shrink? An Objective Assessment of Free Gracilis Muscle Volume Change in Lower-Extremity Defect Reconstruction.

Background: The use of free gracilis muscle flaps in reconstructive surgery of the lower leg is common practice to cover defects. However, there is still a lack of understanding of the morphometric changes that occur in the transferred muscle and area of interest over time, particularly the characteristic volume decrease that is observed over the course of the first year. This study aimed to assess volume changes in patients with free gracilis muscle flap reconstruction following infection, trauma, or malignancies of the lower extremity. Methods: Three-dimensional surface imaging was performed intraoperatively after 2 weeks, 6 months, and 12 months with the Vectra H2 system. A total of 31 patients were included in this study and analyzed. Results: There was an average volume increase of 146.67 ± 29.66% 2 weeks after reconstruction. Compared to this volume increase, there was a reduction of 108.44 ± 13.62% after 12 months (p < 0.05). Overall, we found a shrinkage to 85.53 ± 20.14% of the intraoperative baseline volume after 12 months. Conclusions: The use of non-invasive 3D surface imaging is a valuable tool for volume monitoring after free flap reconstruction of the lower extremity. The free gracilis muscle flap undergoes different phases of volume change over the first year, with the greatest influence on overall change being the development and decongestion of edema. Precise initial surgical tailoring is crucial for optimal long-term functional and cosmetic results.

Association between blood transfusion and outcomes of free flap head and neck cancer surgery

ObjectiveInvestigate the impact of patient risk factors and blood transfusions in Head and Neck free flap surgeries. Study designRetrospective chart review. SettingSingle tertiary referral center. Methods400 patients were included undergoing free flap reconstruction from 2014 to 2020. The primary outcome measures were red blood cell transfusion and volume transfused. Race, sex, flap location and tissue type, pathology, dependent functional status, length of stay, and cancer recurrence were evaluated for association with red blood cell transfusion intraoperatively and/or postoperatively. Transfusions were indicated on patients with Hemoglobin <7–8 and/or symptomatic anemia. ANOVA and Chi2 statistical analysis were performed. The significance was set at p ≤0.05. ResultsOf the 400 patients included, 58 required red blood cell transfusion. Of these 67.8 % were males, racial demographics included 9.00 % African American, 1.30 % Asian, 1.00 % Hispanic/Latino, 87.8 % White, 1.00 % other. African American patients received a higher volume of transfused red blood cells versus white patients (855.00 mL vs. 437.07 mL, p = 0.005). Length of stay was significantly associated with red blood cell transfusion (5.95 days vs. 7.22 days, p ≤0.001). Dependent functional status and need for red blood cell transfusion were associated (p = 0.002). Type of free flap was associated with need for red blood cell transfusion (p ≤0.001) with anterolateral thigh flaps being the most common resulting in transfusion (34/58). ConclusionRed blood cell transfusion was significantly associated with race, dependent functional status and length of stay. Certain free flaps have a higher risk of blood transfusion.

Comprehensive analysis of risk factors for flap necrosis in free flap reconstruction of postoperative tissue defects in oral and maxillofacial tumors

Free flap reconstruction for postoperative tissue defects in oral and maxillofacial tumors is a critical component of reconstructive surgery. Identifying risk factors for flap necrosis is essential for improving surgical outcomes and patient quality of life. A retrospective study was conducted on patients who underwent free flap reconstruction between January 2020 and December 2023. Patients were included if they had comprehensive medical records and at least a six-month follow-up. We excluded those with a history of flap necrosis, uncontrolled systemic diseases, non-adherence to postoperative care, or concurrent malignancy treatments. Data on demographics, comorbidities, flap characteristics, and operative details were collected and analyzed using univariate analysis and logistic regression tests. Univariate analysis did not find a significant correlation between flap necrosis and factors such as hyperlipidemia, lymph node metastasis, or flap type. However, diabetes mellitus, oral infections, and albumin levels below 35 g/L were significantly associated with flap necrosis. Multivariate logistic regression showed diabetes mellitus increased the odds of flap necrosis by approximately ninefold, and oral infection increased it by over tenfold. Diabetes mellitus, oral infection, and low albumin levels are significant risk factors for flap necrosis in free flap reconstruction after oral and maxillofacial surgery. Prompt identification and management of these factors are crucial to mitigate the risk of flap necrosis.

The Influence of Vasopressors on Free Flap Outcomes in Head and Neck Cancer Patients.

To compare free flap outcomes between those who received and did not receive vasopressors (VPs) at the time of free flap reconstruction. This retrospective cohort study includes patients from January 2013 to January 2023. This multicenter cohort study utilized data from the TriNetX Research Network which includes 80 health care organizations. Head and neck cancer patients older than 18 years who underwent free flap reconstruction were separated into those who received or did not receive VPs on the day of surgery. The primary outcomes were flap failure defined by need for secondary free flap procedures, blood vessel repair, and other flap revision procedures. After propensity score matching, 7446 patients were analyzed. The VP group included 3723 patients (mean age [SD], 62.9 [11.4] years; 2511 males [67.4%]). The non-VP group included 3723 patients (mean age [SD], 63.0 [11.2] years; 2479 males [66.6%]). Free flap outcomes were not statistically different between groups (secondary free flap: 166 [4.5%] VP vs 155 [4.2%] non-VP, P = .04; vessel repair: 314 [8.4%] vs 319 [8.6%], P = .06; other flap revision procedures: 416 [11.2%] vs 449 [12.1%], P = .02). Bony flaps were found to have decreased rates of vessel repair in the VP group (47 [6.1%] vs 69 [9.0%], P = .003]. For secondary outcomes, pneumonia (173 [4.6%] vs 231 [6.2%], P = .0002), urinary tract infection (34 [1.0%] vs 59 [1.6%], P = .0007), and deep vein thrombosis (93 [2.5%] vs 122 [3.3%], P = .004) were significantly different. VP use is not significantly associated with free flap complications. These results imply that VP use on the same day as surgery may be safe if clinically necessary.

Impact of Microsurgical Reconstruction Timing on the Risk of Free Flap Loss in Acute Burns: Systematic Review and Meta-Analysis.

Free tissue transfer is usually considered as a last resort in severe burn cases, when skin substitutes and local flaps are not viable options. Prior studies have demonstrated a free flap loss rate ranging from 0% to 44%. The aim of this study is to identify the ideal timing to perform free flap reconstruction in acute burn-related injuries to minimize free flap loss. A systematic review and meta-analysis was performed and reported according to PRISMA guidelines. PubMed, Embase, Web of Science, and Cochrane Library databases were queried. The review protocol was registered on PROSPERO database (CRD42023404478). Three time intervals from day of injury were identified: (1) 0-4 days, (2) 5-21 days, and (3) 22 days-6 weeks. The primary outcome was total free flap loss. A total of 17 articles met inclusion criteria. The analysis included 275 free flaps performed in 260 patients (88% men, 12% women) affected by acute burn injuries. The pooled prevalence of free flap failure in the three time intervals (0-4 days, 5-21 days, and 22 days-6 weeks) were 7.32% [95% confidence interval (CI): 2.38%-20.37%], 16.55% (95% CI: 11.35%-23.51%), and 6.74% (95% CI: 3.06%-14.20%), respectively. Free flap reconstruction carries a high risk of failure in patients with acute burn. However, timing of the reconstruction appears to influence surgical outcomes. Free flap reconstruction performed between 5 and 21 days from burn injury had a trend toward higher flap loss rates and should be discouraged.