Free Tissue Transfer Reconstruction Research Articles

Postoperative serum interleukin-6 level as a risk factor for development of hyperactive delirium with agitation after head and neck surgery with free tissue transfer reconstruction

ObjectiveOccurrence of hyperactive postoperative delirium (POD) with agitation after head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) is associated with the risk of life-threatening complications. The relationships between occurrence of hyperactive POD after HNS-FTTR and inflammatory markers reflecting the surgical stress response, represented by postoperative interleukin-6 levels, are not fully understood. MethodsA retrospective study was conducted on 221 consecutive patients who underwent HNS-FTTR at our department between September 2016 and December 2021. Potential risk factors for POD were examined, including age, operation time, intraoperative blood loss, and postoperative serum levels of blood parameters such as interleukin-6, C-reactive protein, and neutrophil-to-lymphocyte ratio. ResultsHyperactive POD with agitation was observed in 54 subjects (24.4%). The postoperative hospital stay in the POD group was significantly longer than that in the non-POD group (median: 32.5 days vs. 28 days; p=0.0129). Multivariate logistic regression analysis identified age (in years) (odds ratio: 1.102; p<0.0001), operation time (min) (odds ratio: 1.004; p=0.0359), and postoperative serum interleukin-6 level (pg/mL) (odds ratio: 1.005; p=0.0384) as significant risk factors for development of POD. In a receiver operating characteristic curve and area under the curve analysis, the cut-off value for postoperative serum interleukin-6 level to predict POD development was 82.5 pg/mL. The postoperative serum interleukin-6 ≥82.5 pg/mL group developed hyperactive POD with agitation significantly more often than the postoperative serum IL-6 <82.5 pg/mL group (odds ratio: 4.400; p<0.0001). The postoperative serum IL-6 ≥82.5 pg/mL group also had significantly longer postoperative hospital stay (41.58 ± 33.42 days vs. 31.73 ± 22.89 days; p=0.0151), older age (68.60 ± 9.99 years vs. 64.30 ± 12.58 years; p=0.0054), and longer operation time (625.4 ± 114.05 min vs. 575.5 ± 98.73 min; p=0.0009) than the postoperative serum IL-6 <82.5 pg/mL group. ConclusionPostoperative serum interleukin-6 level, as well as age and operation time, were identified as significant independent risk factors for development of hyperactive POD with agitation after HNS-FTTR. Inflammation is a potential target for the prevention and treatment of POD after HNS-FTTR.

Use of a Synthetic Dermal Matrix for Reconstruction of 55 Patients with Nongraftable Wounds and Management of Complications.

The aim of this study was to investigate the role of a completely synthetic dermal matrix (Biodegradable Temporizing Matrix [BTM]) for staged reconstruction of complex wounds. The authors defined complex wounds as wounds not amenable to reconstruction with skin grafting alone due to an inherent avascularity such as the presence of bare bone, tendinous, or neural structures. A retrospective review of a prospectively maintained database of complex wounds as defined above was carried out. Fifty-five patients were identified who underwent staged BTM and autologous skin graft reconstruction for complex wounds affecting a wide variety of patient demographics, treatment indications, and body sites. Wound etiology included burn injury and nonburn-related trauma such as degloving injury or infective complications. Caveats relating to the successful application of staged dermal matrix reconstruction, techniques, tips, prevention, and management of complications are outlined. This large consecutive case series demonstrates the integral role dermal substitutes play in providing biological wound cover for avascular wound beds which may otherwise require complex distant flap or free tissue transfer for reconstruction. Staged synthetic dermal matrix reconstruction has proven robustness in the face of unfavorable wounds compared with nonsynthetic dermal matrices, physiologically covering avascular structures, allowing for early graft take, expediting rehabilitation, and mobilization with good scar cosmesis and limited contracture formation.

A comparative analysis of fasciocutaneous versus muscle free flaps in peripheral vascular disease patients.

Chronic lower extremity (LE) wounds are common in patients with peripheral vascular disease (PVD). Free tissue transfer (FTT) provides healthy soft tissue for wound coverage and additional blood supply to promote wound healing. Given previous studies demonstrate increased complications in LE fasciocutaneous flaps, it was hypothesized that low vascular resistance in muscle flaps may be more advantageous for wound healing in PVD patients. Therefore, this study compared outcomes in PVD patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. Retrospectively reviewed PVD patients undergoing FTT between 2011 and 2021. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included complications, flap success, post-reconstruction vascular interventions, limb salvage, and ambulatory status. One hundred thirteen patients with PVD were identified, of which 60.2% received fasciocutaneous (n= 68) and 39.8% received muscle flaps (n= 45). Forty-two patients (37.2%) underwent pre-flap endovascular interventions. Flap success rate was 98.2% (n= 111). Overall complication rate was 41.2% following fasciocutaneous flaps compared to 24.4% in muscle flaps (p= 0.067). Fasciocutaneous flaps had higher odds of ulceration requiring repeat angiogram within 1 year of reconstruction compared to muscle flaps (OR 3.4, 95% CI: 1.07-10.95, p= 0.047), and higher odds of requiring repeat angiogram overall (OR 3.4, 95% CI: 1.07-10.95, p= 0.047). No difference in requiring procedures in the operated limb within 1 year was observed (p= 0.155). At mean follow-up, there was no difference in limb salvage, ambulatory, and mortality rate between groups. This study demonstrates that fasciocutaneous flaps had higher postoperative complication rates and more commonly required repeat arteriograms following LE FTT reconstruction due to recurrent ulcerations, suggesting greater utility of muscle flaps for FTT reconstruction in PVD patients.

Postoperative pulmonary complication as an emerging complication in major head and neck cancer surgery: A retrospective study.

Postoperative pulmonary complications (PPCs) are one of the most significant complications following head and neck cancer surgery (HNCS). Patients requiring tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) may have a high incidence of PPCs. This study aimed to identify the most likely situations for developing PPCs in HNCS. A retrospective analysis of 40 patients who had undergone HNCS has been conducted. We individually traced each patient for 7 days postoperatively and collected data on various parameters. The incidence of PPCs after HNCS is more with free flap reconstruction. Patient-related risk factors with PPCs were advanced age, smoking, body mass index (BMI) >25, and bilateral or unilateral neck dissection. Postoperative ICU stay was significantly related to an increased incidence of PPCs. In terms of specific surgical sites, both the maxilla and mandible also showed significant relationship with PPCs. Tracheostomy was also considered a related factor in developing PPCs. To reduce PPCs in HNCS, patients with one or more of these risk factors should be subjected to exaggerated postoperative pulmonary care.

Preoperative serum interleukin-6 level in head and neck cancer reflects systemic inflammatory response and is a predictor of postoperative prognosis.

The outcome of head and neck cancer has improved in recent years but survival is not yet satisfactory. Interleukin (IL)-6 is a representative inflammatory cytokine and inducer of systemic inflammatory response. It is not known whether preoperative serum level of IL-6 is a prognostic factor in head and neck cancer surgery. We studied 181 consecutive patients who underwent head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) between September 2016 and December 2020. Whether preoperative serum IL-6 level was a prognostic risk factor was retrospectively investigated by univariate and multivariate analyses. We also investigated the association between preoperative IL-6 level and representative systemic inflammatory response markers. The preoperative IL-6≥8pg/mL group had a significantly worse prognosis than the preoperative IL-6<8pg/mL group (overall survival [OS]: hazard ratio [HR] 3.098, P=0.0006; disease-specific survival [DSS]: HR 3.335, P=0.0008). In multivariate analysis, IL-6≥8pg/mL and age≥70years were independent poor prognostic factors for OS (HR 1.860, P=0.0435 and HR 1.883, P=0.0233, respectively). The only independent poor prognostic factor for DSS was IL-6≥8pg/mL (HR 2.052, P=0.0329). Serum albumin was significantly lower and serum C-reactive protein and neutrophil-to-lymphocyte ratio were significantly higher in the IL-6≥8pg/mL group than in the IL-6<8pg/mL group (all P<0.0001). Preoperative serum IL-6 level is an independent poor prognostic factor for both OS and DSS after HNS-FTTR, reflecting the degree of preoperative systemic inflammatory response.

Retrospective review of Osteoradionecrosis cases treated with virtual surgical planning following review of received irradiation dose to the mandible

Osteoradionecrosis of the mandible represents a cohort of patients that are notoriously difficult to treat. Complications are commonplace following free tissue transfer reconstructive surgery, including non-osseous union at the osteotomy site.We retrospectively reviewed a cohort of patients that were treated with fibula free tissue transfer reconstruction utilising virtual surgical planning. It was possible to deform previously delivered radiation dosimetry data onto the virtual mandible and superimpose the osteotomy site. This enabled the delivered radiation dose at the osteotomy site to be determined, plus the volume of mandible remaining that had received above 50Gy of irradiation.Two out of the four patients with appropriate follow up demonstrated evidence of bony consolidation at the osteotomy site between the native mandible and the composite fibula reconstruction. On retrospective review of the dosimetry mapping, one patient's resection margins were performed in areas of the mandible with a received irradiation dose of less than 50Gy. The second patient had a received dose of just over 50Gy at the resection margin, with only 0.1 cm [3] of affected mandible remaining at the osteotomy site.Two patients demonstrated a non-osseous union at a resection margin through an area of the mandible that received an irradiation dose way in excess of 50Gy, with one patient demonstrating a high volume of retained mandible receiving a radiation dose in excess of 50Gy.In this known cohort of difficult to manage patients, any technique that aids in the reduction of complications is a welcome addition.

Risk factors for evaluating early mortality after microvascular reconstruction of head and neck cancers.

Free tissue transfer reconstruction carries significant complication rates in surgical head and neck oncology. A registry-based approach offers a possibility to investigate the factors affecting increased morbidity and early mortality, that is, death within 6 months of treatment. A retrospective registry review was conducted on a series of 317 consecutive microvascular free tissue transfers in head and neck cancer patients performed during 2013-2017 at the Helsinki University Hospital (Helsinki, Finland). All surviving patients had a minimum follow-up of 2 years (range 24-84 months). Overall, 36 (11.4%) early deaths occurred in this series. In multivariable logistic regression analysis, patients aged 75 years and older (p = 0.019), Adult Comorbidity Evaluation-27 (ACE-27) score of 3 (p = 0.048), tumor class T3 (p = 0.005), lymph node class N2 (p = 0.014), or thrombocyte count of 360 (× 109 L) or more (p = 0.001) were more likely to die within 6 months of surgery. Of these 36 patients, 27 (75%) had a complication warranting hospital care and most (n = 22, 61%) had several complications. Early postoperative mortality most frequently affects patients aged 75 years and above, with a high ACE-27 score, advanced tumor stage, or high thrombocyte count. Therefore, preoperative assessment and patient selection should have a crucial role in this patient population.

Factors determining postoperative length of stay and time to resumption of feeding following free flap reconstruction for oral cancer

Microvascular free tissue transfer reconstruction following resection of oral cancer is commonly chosen as the first line of treatment due to its superior functional outcomes. Multiple patient and surgical factors impact the length of postoperative stay, and the time taken for patients to recommence oral feeding. This study aimed to identify factors that increase the length of stay and time to resumption of feeding. We retrospectively evaluated 100 cases from March 2015 to October 2020, and identified variables associated with increased length of stay (LOS) and time to resumption of feeding in univariate and multivariate analyses. Factors found to be associated with increased LOS in multivariate analysis were increasing age, elective tracheostomy, tumours originating from the floor of the mouth and mandible, a longer operating time, and use of fibular free flaps (p<0.05). Tracheostomy, increasing age, and female gender were strongly associated with delays in resumption of some types of oral feeding, and an integrated critical care unit (ICCU) stay of two or more days was associated with a longer time to resumption of free fluids. This information can be used to anticipate extensions to typical LOS, to produce cost analyses, develop individual patient risk stratification, manage patient expectations, and target the use of enhanced recovery programmes.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p= 0.043). Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes

Suicide by firearm remains one of the leading causes of violence-related injury death in the United States each year. The mortality rate from these injuries is high, resulting in a paucity of outcome data in the literature regarding injuries to the maxillofacial region. This has largely been attributed to a lack of funding for research in this area compared to other leading causes of mortality in the United States. The aim of this study was to detail the authors’ experience and approach to complex maxillofacial reconstruction using both local reconstructive methods and microvascular free tissue transfer. A retrospective cohort study was designed, including patients who sustained self-inflicted gunshot wounds to the maxillofacial region between January 1, 2012 and May 1, 2020. Forty-one patients met the inclusion criteria. The majority of the patients were male (87.8%). Mean patient age was 44.2 ± 16.6 years. Alcohol or drugs, and a psychiatric history were present in a majority of the cases. The most involved anatomical region was the midface (75.6% of cases). Seven patients required free tissue transfer for reconstruction, with many needing multiple flaps. Self-inflicted gunshot wounds represent challenging reconstruction scenarios, often in the setting of severe psychological trauma, and require a multidisciplinary team to ensure the optimal outcome.

54. Implementation of a Risk-stratified Anticoagulation Protocol Increases Free Flap Success in Thrombophilic Patients With Chronic Lower Extremity Wounds

Purpose: A hypercoagulable state is one of the most challenging preoperative conditions that reconstructive microsurgeons face. Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and to achieve high rates of microsurgical success in patients undergoing lower extremity (LE) free tissue transfer (FTT). At our institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. After six years of experience with this protocol, we present an updated analysis of surgical outcomes and the utility of risk-stratified AC in thrombophilic patients who underwent FTT reconstruction for chronic LE wounds. Methods: We conducted a retrospective review of patients who underwent FTT to the LE at our institution from January 2012 to August 2021. Patients were preoperatively assessed for hypercoagulability based on history and a screening panel. Our risk-stratification AC protocol was implemented in July 2015. Low-risk (<3 hypercoagulable traits) and moderate-risk (>3 hypercoagulable traits or history of venous thromboembolism) patients were anticoagulated with subcutaneous heparin (SQH). Any intraoperative risk factor (thrombosis, anastomotic revision, presence of calcified vessels) upstaged patients to high microvascular risk. High-risk patients received heparin infusion titrated to a goal PTT of 50-70 seconds. Prior to July 2015, non-stratified patients were treated with SQH for uncomplicated microvascular anastomoses, while patients with microvascular compromise were converted to a low-dose heparin infusion (500 units/hour). Patients were divided into two cohorts (non-stratified and risk-stratified) based on the date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success. Results: A total of 219 hypercoagulable patients who underwent FTT to LE were treated with either non-stratified (n=26) or risk-stratified (n=193) thromboprophylaxis. Overall flap success rate was 96.8% (n=212). Lower rates of flap loss (1.6% vs. 15.4%, p=0.004) were observed among risk-stratified patients, which paralleled a significant reduction in the prevalence of postoperative thrombotic events (2.6% vs. 15.4%, p=0.013). Flap salvage, in the setting of postoperative thrombosis, was accomplished in 80% of cases in the risk-stratified cohort compared to 0% in the non-stratified group (p=0.048). Bleeding complications and transfusion requirements were similar among the two cohorts. On multivariate analysis, intraoperative anastomotic revision (OR: 3.10; p<0.001) and non-risk stratification (OR: 11.2; p=0.001) were independently associated with flap failure. Non-risk stratification for thromboprophylaxis was an independent predictor of perioperative microvascular thrombosis (OR: 3.71; p=0.041). Conclusion: Hypercoagulability can significantly impact microsurgical outcomes. Preoperative identification of hypercoagulable traits and intraoperative risk factors can successfully guide perioperative thromboprophylaxis. Implementation of a risk-stratified AC protocol at our institution has contributed to significant improvements in flap success without creating an increased need for blood transfusion.

QS27. Surgical Outcomes of Postoperative Intensive Care Unit Versus General Floor Management Following Lower Extremity Free Flap Reconstruction in the Comorbid Chronic Wound Population

Purpose: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted towards admitting FTT patients to the general floor postoperatively instead of the ICU. This is the first study to compare surgical outcomes in patients admitted to the floor versus ICU immediately following free flap reconstruction for chronic LE wounds. Methods: A retrospective review was performed of patients undergoing FTT to LE from 2011 to 2021 by the senior author (K.K.E.). In March 2020, our institution began admitting our free flap patients to the general floor post-operatively. In patients admitted to the floor postoperatively, flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or specialty floor in the immediate postoperative period. Primary outcomes were postoperative complications, hospital length of stay (LOS), flap takeback and salvage, and flap success. Statistical significance was set at values of p < 0.05. Results: A total of 255 patients underwent FTT to LE during the 10-year period. Forty-two patients (16.5%) were admitted to the floor postoperatively and 213 patients (83.5%) went to the ICU. Average age and body mass index were 55.8 years and 29.4 kg/m2, respectively. Comorbidities among the two groups were similar, except floor patients had a higher prevalence of diabetes (69.0% vs. 49.3%, p=0.019). Overall microsurgical success rate was 97.3%, which was similar for floor and ICU patients (100% vs. 96.7%, p=0.604). Flap takeback occurred in 3 floor patients (1.2%) and 13 ICU patients (5.1%) (p=0.733). Flap salvage was higher in floor patients, although not statistically significant (7.1% vs. 3.3%, p=0.250). Average hospital LOS did not significantly differ among patients admitted to the floor versus ICU (16.1 vs. 17.7 days, p=0.628). Conclusion: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. Efforts should be focused on training floor nurses to use the Cook Doppler and ViOptix devices to monitor flaps. While we expect hospital costs to decrease with floor admission, future studies should focus on the cost impact of postoperative floor management in this patient population.

Outcomes of Free Flap Reconstruction for Chronic Venous Ulceration in the Lower Limb: A Systematic Review.

The mainstay of treatment for venous ulceration is conservative wound management and lifelong compression therapy. For patients with recalcitrant ulcers, free flap reconstruction has been proposed as a treatment option to reconstruct the diseased soft tissues as well as the underlying insufficient venous system. This review systematically evaluates the outcomes of free flap reconstruction for chronic venous ulcers in the lower limb. A protocol was developed a priori and registered on the PROSPERO database. A systematic search of literature was performed in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinical trials registries, and OpenGrey from inception to April 2020 according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies of patients undergoing free tissue transfer reconstruction for chronic venous ulcers in the lower limb were included. A total of 5 noncomparative cohort studies featuring 56 patients with 62 recalcitrant venous ulcers treated with 64 free flaps who had a mean age of 50 years (range, 17-76 years) were included, and a narrative analysis undertaken. Mean defect size following ulcer debridement was 153.3 cm 2 (range, 24-600 cm 2 ). Defects were reconstructed with muscle (n = 39 [60.9%]), fasciocutaneous (n = 23 [35.9%]), and visceral (n = 2 [3.1%]) free flaps, with latissimus dorsi (n = 16, 25%) and rectus abdominis flaps (n = 16, 25%) being the most frequently used. Mean follow-up ranged from 24 to 125 months. Pooled flap survival rate was 95%. No recurrence within the territory of the flap was reported, but there were 20 instances (35.7%) of new ulcers outside of the flap boundaries. There is currently an absence of evidence to support the use of free flap reconstruction for recalcitrant venous ulcers compared with conventional management. Although evidence suggests that it is technically feasible, there is no evidence to suggest it prevents ulceration outside the reconstructed region. Further studies are necessary to evaluate its effectiveness for venous ulcers in the lower limb.

Use of the O-Z flap as an alternative to free tissue transfer for reconstruction of large scalp defects.

The reconstruction of large scalp defects poses both functional and cosmetic challenges. While free tissue transfer remains the standard for defects larger than 30 cm2, prolonged anesthesia and postoperative complications remain significant limitations. The purpose of this study is to evaluate the use of O-Z flaps for the reconstruction of large scalp defects and to describe the techniques employed. This is a retrospective analysis of ten patients who underwent reconstructive surgery using an O-Z flap approach for large scalp defects between July 2017 and June 2019. The parameters included in this study were patient demographics, tumor characteristics, and postoperative management, collected for at least a year after surgery. In this cohort, the mean age was 76.1 years and 90% were male. All patients were treated for neoplastic skin lesions, with 70% located on the vertex and 30% located on the temporoparietal region. The mean size of defect was 52.0 cm2 (range: 38.6 to 63.8 cm2). The maximum hospital stay was two days, and no patients were readmitted within 30 days of surgery. There were no cases of wound infection or flap necrosis. All patients reported pain control with acetaminophen and ibuprofen. Four patients received adjuvant radiation, and there was no delay to receiving treatment following surgery. The O-Z flap is a reliable alternative for the reconstruction of non-irradiated scalp defects in the vertex and temporoparietal regions up to 63 cm2. This technique provides advantages for patients, including hairline preservation, shorter hospital stays, and decreased postoperative complications.

Safety of microvascular free tissue transfer reconstruction of the head and neck in the setting of chronic pharmacologic immunosuppression.

Patients on chronic pharmacologic immunosuppressive therapy are at increased risk of wound infection and complications after surgery. There is a paucity of data examining perioperative complications after microvascular free tissue transfer (MVFTT) reconstruction of the head and neck in this patient population. Retrospective cohort study performed at two tertiary referral centers between August 2016 and May 2020. Nine hundred and seventy-nine patients underwent MVFTT during the study period; of these 47 (5%) patients were taking chronic immunosuppressive medications. The most common indications for immunosuppression were solid organ transplant and autoimmune disease. Fourteen (30%) patients had surgical complications within 30 days of surgery: 8 (17%) wound dehiscences, 6 (12%) hematomas, and 2 (4%) surgical site infections. There was one total and one partial flap failure with a 30-day reoperation rate of 4%. MVFTT of the head and neck appears to be safe in patients on chronic pharmacologic immunosuppression.

Free flap reconstruction of plantar weight-bearing heel defects: Long-term functional and patient-reported outcomes.

Non-healing plantar weight-bearing heel ulcers are a challenging problem to treat. Free tissue transfer (FTT) reconstruction of the heel is an opportunity for limb salvage to preserve gait and ambulation. The aim of this study is to describe surgical and functional outcomes in patients who underwent FTT to treat chronic heel ulcers. A retrospective review of patients who underwent FTT for plantar heel ulcers from 2011 to 2021 was conducted. Patient demographics, comorbidities, perioperative data, postoperative complications, and long-term outcomes were recorded. Primary outcomes included flap success, complications, postoperative ambulation, patient-reported outcome measures and limb salvage, with patients stratified into limb salvage or eventual amputation groups. Forty-four patients underwent 45 heel reconstructions. Average age and BMI were 57.3 years and 30.1kg/m2 , respectively. Thirty-eight patients (86.4%) had calcaneal osteomyelitis, 35 patients (79.5%) had diabetes, and 18 patients (40.9%) had peripheral vascular disease (PVD). Immediate microsurgical success rate was 95.6%. At mean follow-up of 19.6 ± 20.9months, overall limb salvage rate was 73.3% (n=33). Preoperative albumin levels were higher in limb salvage group compared to the amputation group (3.0 vs. 2.4g/dl, p=.018). Prior stroke history and hypoalbuminemia were significantly higher in the amputation group compared to limb salvage group (p=.012 and p=.018, respectively). Risk for eventual amputation was associated with PVD (OR 4.0, p=.053), hypoalbuminemia (OR 4.9, p=.020), and postoperative infection (OR 6.3, p=.013). Of the 12 amputations that occurred, the most common indication for amputation was infection (n=8, 66.7%), which most often occurred at the original wound location (62.5%). At most recent follow-up, 90.7% of patients (n=39) were ambulatory. FTT is an effective alternative to amputation in patients with chronic heel ulcers. Proper patient selection, preoperative optimization, and postoperative care are imperative to the success of this limb salvage procedure.

Occult Metastases During Salvage Oral Cavity and Oropharyngeal Free Flaps: Oncologic Outcomes.

To define rates of occult metastases in salvage oral cavity and oropharyngeal cancer resection requiring free flap, to examine the location of occult metastases, and to determine associations between occult metastasis and survival. Retrospective cohort study. Two tertiary care referral centers. We identified previous cases of irradiation with recurrent or second primary oral cavity or oropharyngeal squamous cell carcinoma that had no evidence of regional metastasis and required free tissue transfer reconstruction of the primary site. Patients who underwent elective neck dissection or exploration were reviewed. The main outcome measures were the presence and location of occult nodal metastasis. Disease-free survival and overall survival were measured. Odds ratios and hazard ratios were used for analysis. A total of 83 patients were included: 52 with oral cavity primary tumors and 31 with oropharynx. An overall 78 (94%) underwent elective salvage neck dissection. Occult metastases were found in 9 (11.5%) patients. The most common nodal station for occult metastasis was level 2. Neither elective neck dissection nor the presence of occult metastasis was significantly associated with regional disease-free or overall survival. Oropharyngeal primary tumors were associated with higher risk of occult metastasis (odds ratio, 1.38; P < .01) and worse overall survival (hazard ratio, 2.09; P = .01). There is a low incidence of occult metastasis in postradiated recurrent or second primary oral cavity and oropharyngeal tumors. Elective neck dissection and occult nodal metastases were not associated with regional or overall survival. This series may help surgeons make decisions regarding the extent of neck surgery after prior radiation, especially when free flap reconstruction is required.

Safety of the “incidental” neck dissection or exploration during free tissue transfer after head and neck irradiation

ImportancePatients with either local recurrence of head and neck cancer or osteoradionecrosis after prior radiation treatment often require free tissue transfer for optimal reconstruction. In this setting, neck exploration for vessels is necessary, and an “incidental” neck dissection is often accomplished despite clinically negative cervical lymph nodes. While neck surgery in the post-radiated setting is technically challenging, the safety of post-radiated elective neck dissection or neck exploration for vessels is not well-studied, especially for patients undergoing non-laryngectomy salvage resections. ObjectiveTo define intraoperative and postoperative surgical complications for patients undergoing elective neck dissection or exploration with free tissue transfer reconstruction in the post-radiated setting, with attention to complications from neck surgery. DesignRetrospective cohort study. Patient charts from May 2005 to April 2020 were reviewed. SettingTertiary care referral center. ParticipantsPatients underwent free tissue transfer after prior head and neck irradiation for non-laryngeal local cancer recurrence or second primary, osteoradionecrosis, or for sole reconstructive purposes. Patients with clinically positive neck disease were excluded. Main outcomes and measuresIntraoperative and postoperative complications including unplanned vessel or nerve injury, hematoma, chyle leak, wound dehiscence, wound infection, fistula formation, flap failure, and perioperative medical complications. Neck exploration and neck dissection patient outcomes were compared by Fisher exact test. ResultsSeventy-two patients (56 men and 16 women) of average age sixty-one (range 34–89) were identified with average follow-up 25.7 months. Most patients (78%) underwent salvage neck dissection, and the rest underwent neck exploration for vessels only. There were five intraoperative neck complications: three vessel injuries and two nerve injuries. There were twenty-six postoperative surgical complications among eighteen patients. There was no difference in surgical complications whether patients underwent neck dissection or exploration only. Two partial and two complete flap failures occurred. There were nine perioperative medical complications among six patients. Conclusions and relevanceElective neck dissection or exploration among patients undergoing free tissue transfer in the post-radiated setting carries a risk of both intraoperative and postoperative surgical complications. The present study defines risk of complications and helps to inform patient discussions for risk of complications in the post-radiated setting.

Multi-domain analysis of non-surgical risk factors amenable to pre-operative optimization in microvascular head and neck surgery

PurposeThe goal of this study was to conduct a multi-domain, organ system-based analysis of non-surgical comorbidities amenable to pre-operative optimization in patients undergoing free tissue transfer, in order to better understand factors that influence patient outcomes. Study designRetrospective review. SettingsTertiary academic center. Materials and methodsA retrospective analysis of 546 patients in a prospectively maintained database who underwent free tissue transfer reconstruction between 2007 and 2016 was performed. Analysis of the relationship between binary-coded system-based domains and log-transformed length of stay (LOS), rehabilitation requirement, 30-day readmission, and post-operative complications was conducted with multiple linear regression or logistic regression models. ResultsPoor nutritional status and the presence of anxiety/depression independently increased median hospital LOS. Endocrine and metabolic deficits, poor nutrition status, and psychiatric comorbidities were significant predictors for rehabilitation facility requirement upon discharge. ConclusionInterventions targeted to patient psychiatric and nutritional health may yield substantially improved outcomes in the head and neck cancer population receiving free tissue transfer surgery.

Microvascular Free Tissue Transfer for Reconstruction of Complex Abdominal Wall Defects.

Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects. Therapeutic, IV.