Microvascular Free Flap Reconstruction Research Articles

Reconstruction in Salvage Surgery for Head and Neck Cancers.

Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers. This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017. The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported. Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor. Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

Association of low skeletal muscle mass and systemic inflammation with surgical complications and survival after microvascular flap reconstruction in patients with head and neck cancer.

BackgroundSkeletal muscle mass (SMM) and chronic inflammation are associated with postoperative complications and survival.MethodsPatients with head and neck cancer (HNC) undergoing microvascular free flap reconstruction were included. SMM and neutrophil‐to‐lymphocyte ratio (NLR) were measured and their association with treatment outcomes analyzed.ResultsFive hundred and fifty‐four patients were included. Predictors for complications were elevated NLR in all flaps (OR 1.5), low SMM in radial forearm flap (OR 2.0), and elevated NLR combined with low SMM in fibula flap surgery (OR 4.3). Patients with solely elevated NLR were at risk for flap‐related complications (OR 3.0), severe complications (OR 2.2), and when combined with low SMM for increased length of hospital stays (LOS) (+3.9 days). In early‐stage HNC, low SMM (HR 2.3), and combined elevated NLR with low SMM (HR 2.6) were prognostics for decreased overall survival.ConclusionsSMM and NLR are predictive for poor outcomes in patients with HNC undergoing microvascular reconstruction.

Regional block pilot for microvascular free-flap breast reconstruction.

e18646 Background: With increasing focus on improving patient outcomes and decreasing narcotic use, healthcare has prioritized the use of multidisciplinary, multimodal, and evidence-based approaches to perioperative management through enhanced recovery after surgery (ERAS) pathways. Currently, microsurgical breast reconstruction with or without concurrent mastectomy commonly may employ regional anesthesia in the preoperative and intraoperative techniques. To optimize perioperative analgesia, an ERAS protocol was piloted at a quaternary care academic center implementing a pre-operative anesthesia placed regional block with preference for anterior quadratum lumborum blocks. Methods: A total of 161 patients were enrolled in this single center Continuous Quality Improvement (CQI) project. The project consisted of 72 baseline, 20 pilot, and 69 after pilot patients who underwent unilateral (n = 65) or bilateral (n = 96) deep inferior epigastric perforator (DIEP) flap reconstruction either immediately (n = 87) or delayed (n = 74) after mastectomy. In the 20 CQI pilot group, anesthesiologists pre-operatively placed bilateral anterior quadratus lumborum blocks (aQLB) under direct ultrasound guidance. After positively observed metrics, the official ERAS pathway was implemented into clinical practice, allowing for subsequent accrual of 69 additional patients. We compared this after pilot group to 72 baseline patients who underwent a surgeon-placed intraoperative transversus abdominus plane (TAP) block using liposomal bupivacaine. Statistics data was tracked using a dedicated clinical EMR dashboard. Baseline patients were matched to the after pilot cohort based on laterality and timing of DIEP flap reconstruction. Results: The ERAS pathway with anesthesia-placed aQLB was associated with lower post-operative daily opioid consumption from 27.2 MME to 10.2 MME. Average pain scores, post-anesthesia care unit (PACU) length of stay, hospital length of stay, as well as re-admissions and complications were not statistically different before and after the implementation of the ERAS pathway. Conclusions: Anesthesia placed pre-operative aQLB is a safe and effective opioid-reducing pain control modality for DIEP flap reconstruction with or without mastectomy. Prospective and controlled studies will be important for the precise impacts of aQLB in DIEP procedures in an ERAS protocol.[Table: see text]

Influence of biological sex on intra- and postoperative course of microvascular free flap reconstructive surgery in the head and neck region: A retrospective analysis involving 215 patients

This retrospective study investigates differences in peri-/postoperative complications/outcomes of head and neck microvascular free flap reconstructions between female (FFP) and male flap patients (MFP).Evaluated variables: biological sex, age, ASA status, tumor type, preoperative radiation/chemotherapy, medical comorbidities; flap type, reconstruction (primary/secondary), operative time; length of stay on ICU, prolonged stay on ICU and its reasons, length of hospitalization, prolonged hospitalization and its reasons; flap success, revisions, overall complications, mortality.N = 215 patients (86 FFP; 129 MFP) were included. MFP exhibited higher nicotine abuse (P < .001), received more large-volume flaps (P < .001), and operative time was longer (P = .013). Sex had no influence on postoperative and outcome variables.Biological sex has no influence on the postoperative course following head and neck microsurgical free flap reconstructions.

Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction.

Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction. Retrospective review of prospectively collected databases. Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n= 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death). The mean age of patients discharged home was lower (60 SD ± 13, n= 1450) compared to those discharged to an SNF (68 SD ± 14, n= 168) or a rehabilitation facility (71 SD ± 14, n= 200; p< 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p< 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p< 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p= 0.006), thromboembolism (59% vs. 80%; p= 0.001), a pulmonary complication (46% vs. 81%; p< 0.0001), a cardiac complication (46% vs. 80%; p< 0.0001), or a cerebral vascular event (25% vs. 80%; p< 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination. There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination. 4 Laryngoscope, 133:95-104, 2023.

Use of Thromboelastography and Rotational Thromboelastometry in Otolaryngology: A Narrative Review.

In the field of otolaryngology—head and neck surgery (ENT), coagulopathies present unique diagnostic and therapeutic challenges. In both hyper- and hypocoagulable patients, management of coagulopathies requires intricate attention to the nature of hemostatic competence. Common coagulation tests (CCTs) offer only a snapshot of hemostatic competence and do not provide a clear insight into the patient’s real-time hemostatic condition. Viscoelastic tests (VETs) offer a holistic and concurrent picture of the coagulation process. Although VETs have found prominent utilization in hepatic transplants, obstetrics, and emergent surgical settings, they have not been fully adopted in the realm of otolaryngology. The objective of this manuscript is to provide an overview of the literature evaluating the current utilization and possible future uses of VETs in the field of otolaryngology. The authors performed a comprehensive literature search of the utilization of VETs in otolaryngology and identified applicable studies that included descriptions of viscoelastic testing. Twenty-five studies were identified in this search, spanning topics from head and neck oncology, microvascular free flap reconstruction, obstructive sleep apnea, adenotonsillectomy, facial trauma, and epistaxis. The applicability of VETs has been demonstrated in head and neck oncology and microvascular free flap management, although their pervasiveness in practice is limited. Underutilization of VETs in the field of otolaryngology may be due to a lack of familiarity of the tests amongst practitioners. Instead, most otolaryngologists continue to rely on CCTs, including PT, PTT, INR, CBC, fibrinogen levels, and thrombin time. Learning to perform, interpret, and skillfully employ VETs in clinical and operative practice can greatly improve the management of coagulopathic patients who are at increased risk of bleeding or thrombosis.

Fibular Free Flap and Iliac Crest Free Flap Mandibular Reconstruction In Patients With Mandibular Ameloblastomas.

Ameloblastoma (AM) is the most common, locally aggressive odontogenic tumor. It comprises about 1% of all head and neck neoplasms. It occurs mainly in young adults in their 3rd and 4th decade of life. It localizes in the mandible in about 80% of the cases. According to the 2017 WHO classification, 4 types of ameloblastoma can be distinguished: ameloblastoma (previously referred to as solid/multicystic-SMA; the "conventional type" AM), unicystic (AM-UA), extraosseous/peripheral (AM-PA), and malignant/metastatic (AM-MA). Solid, multicystic is the most common type. It is characteristic for its aggressiveness and high risk of recurrence. Radical resection with consecutive reconstruction is the treatment of choice of mandibular ameloblastomas.In this study, the authors present their experience in the surgical treatment of mandibular ameloblastomas with vascularized free flap reconstructions. They discuss new technological possibilities that could improve the precision of the reconstructive procedure and therefore result in the better aesthetic outcome.The retrospective study of a group of 21 patients suffering from mandibular ameloblastoma who underwent segmental man-dibulectomy with simultaneous microvascular free flap reconstruction was conducted. A thorough clinical analysis with various aspects was performed. Tumors resected before 2017 were double checked patomorphologically and assigned to the corrected subtype group.Seven patients were admitted to the department due to recurrent ameloblastoma. The most common localization of the tumor was the mandibular body ( n = 6) andbodywith ramus of the mandible ( n = 6). A total amount of 10 iliac crest free flaps and 12 fibular free flaps were performed. Complications were reported in 4 patients. A purulent oro-cutaneus fistula occurred in 3 patients. There was a flap failure in each reconstructive group. The virtual surgical planning with intraoperative cone-beam computed tomography was used in 3 patients. Dentition implantation was conducted in 4 patients (3 simultaneously, 1 postponed). The mean follow-up was 5 years and 8 months.Radical resection that covers radical segmental mandibulect-omy with immediate microvascular free flap reconstruction is a first-line and only effective treatment of mandibular ameloblas-tomas, that eliminates the risk of recurrence. The extent of surgical margins seems not to influence the recurrence rate, yet further investigation with statistical analysis should be performed. The choice of the adequate free flap must be adapted to dimensions and localization of the tumor and to each patient individually.New technologies such as virtual surgical planning with 3D models and intraoperative cone-beam computed tomography can make the reconstruction more accurate, improving patient's quality of life.

\u201cMYH9 mutation and squamous cell cancer of the tongue in a young adult: a novel case report\u201d

BackgroundThe incidence of tongue cancer in young adults is on the rise. This trend is more pronounced in females. Although the aetiology is still unclear, there is mounting evidence that genetic syndromes can play a key role in development of oral cancers in this patient group. We report the first case of oral squamous cell carcinoma (oSCC) in a young adult with an MYH9-related disorder (MYH9-RD).Case presentationA 19-year-old female with a germline MYH9 variant (missense variant in exon 2: c.287C > T, (p.Ser96Leu)) was referred to the head and neck surgery department for investigation of a painful, thick right tongue ulcer. She was diagnosed with Epstein syndrome, an MYH9-RD, at 12 years of age. Her main phenotypic features were profound thrombocytopenia and marked renal impairment. The tongue biopsy confirmed SCC. Preoperative positron emission tomography (PET) revealed avidity in the right tongue and ipsilateral level 2A neck lymph node. With substantial preoperative multidisciplinary input, she underwent cancer ablation and microvascular free flap reconstruction. Her pathology showed a 35 mm diameter, 14 mm thick moderately differentiated SCC with perineural and lymphovascular invasion. Two out of 38 right neck nodes were positive for metastasis with extranodal extension. None of the 34 left neck nodes was involved.She had an uneventful recovery and was discharged home on day 6 postoperative day. On day 15 postoperative day, she had catastrophic bleeding in the neck with a respiratory arrest after a forceful cough. She required an emergency tracheostomy and returned to the theatre for haemostasis. Following a short inpatient stay, she was again discharged home and underwent adjuvant therapy consisting of external beam radiotherapy of 60Gy in 30 fractions. On clinical examination and PET at 6 months after surgery, she had no evidence of disease recurrence.ConclusionsMYH9-RD can present with advanced locoregional oral cavity malignancy at an early age. The combination of profound thrombocytopenia and marked renal impairment can impact heavily on routine major head and neck cancer surgery and adjuvant treatment. This rare and challenging condition underlines the importance of early detection of cancer and multidisciplinary team input.

Six-year experience of microvascular free-flap reconstruction of head and neck neoplasms.

Microvascular free-flap reconstruction is one of the treatment options after large resection of head and neck neoplasms. The objectives of this study are to identify short-term outcomes and risk factors for flap complication in patients who underwent neoplasms resection of head and neck with microvascular free-flap reconstruction. Retrospective study of patients who underwent surgery for head and neck neoplasm with microvascular free-flap reconstruction between January 2014-2020. Complications were studied at 30-days follow-up and divided into medical and flap complications. Factors independently associated with flap complication were analyzed. We included 31 patients (15 men). The mean age was 60 years. Reconstruction was performed with radial-forearm flap in 74% (n=23) and with free-fibula flap in 26% (n=8). Mean surgical time was 420 minutes. Median hospital length of stay was 7 days. Medical complications were of 23%. Minor complications were of 35% and major of 32%. There was no mortality in 30-days follow-up. Flap complications were of 35%. Reintervention was of 29%, surgical site infection of 9%, dehiscence of 29% and flap loss of 9.7%. Surgical site infection was independently associated with prolonged surgical time (Odds ratio [OR]=1.03, IC95%=0.98-1.04, p=0.02) and body mass index equal to or greater than 30 (OR=1.38, IC95%=0.84-2.26, p=0.04) while flap loss was associated with prolonged surgical time (OR=1.02, IC95%=0.99-1.04, p=0.01). Microsurgical free-flap reconstruction should be considered in our population in patients with large head and neck neoplasms. Preoperative assessment of the risk of postoperative complications is essential before selecting patients for this surgery.

Does preoperative wound infection impact outcomes of lower extremity salvage via microvascular free flap reconstruction? A cohort study

We sought to identify preoperative wound characteristics associated with a higher risk of adverse outcomes in patients undergoing lower extremity (LE) reconstruction with microvascular free flaps. A retrospective review of patients undergoing free flap reconstruction of the LE at a single academic institution between 2010-2021 was conducted. Preoperative wound culture results were classified by Gram stain, aerobe status, multi-drug resistance (MDR), and presence of multiple bacteria. Outcomes studied included flap viability at 60, 120, and 180 days, as well as flap dehiscence, partial and full necrosis, sepsis, and amputation. A total of 218 LE free flap reconstructions were performed during the study period. 152 (69.7%) of patients were male. Rate of secondary amputation following attempted limb salvage was 4.6%. LE reconstructions utilized either fasciocutaneous (79.4%) or muscular flaps (20.6%). The type of free flap used for reconstruction had no effect on reconstructive outcomes or flap viability. Preoperative bacterial wound cultures were obtained in 102 (46.8%) patients; 80 cultures (78.4%) were positive for bacterial growth. Of these, 33 (41.2%) grew Gram-positive bacteria, 14 (17.5%) grew Gram-negative bacteria, and 33 (41.2%) grew multiple organisms. Positive preoperative wound culture was independently associated with flap failure at 120 days ( p = 0.04) when compared to wounds with no infection. Among patients with positive cultures, polymicrobial infection was significantly associated with higher rates of amputation ( p = 0.04) compared to single Gram-positive or Gram-negative infectious agents. Identification and management of positive wound cultures may play an important role in outcomes of microvascular free flap reconstruction. • Positive preoperative wound culture is associated with free flap failure at 120 days. • Positive wound culture is not associated with flap dehiscence or necrosis. • Polymicrobial infection was associated with higher rates of amputation.

Performance of different osteosynthesis materials in microvascular fibula free flap reconstruction

Fibular free flap (FFF) is the main reconstructive choice for large mandibular defects. Recent improvements have been made regarding planning and surgical procedure, but choice of osteosynthesis material (OSM) for segment-fixation remains controversial. A retrospective cohort study obtained clinical and radiological data from FFF-patients. Data were screened for OSM, surgical procedure and complications as OSM fractures, loosening, exposure, or insufficient osseous consolidation. Eighty patients with FFF were included. Planning was CAD/CAM (n=29), Recon Guide (n=26) or without planning (n=25). OSM was 2.0mm-miniplates in standard (n=26), preformed (n=6), CAD/CAM (n=14) or ReconGuide (n=23) variation and 2.3mm-reconstruction-plates in standard (n=5) or CAD/CAM (n=6) variation. Complications were observed in 21 cases, fractures occurred 10 times overall, but with low rates for preformed (n=1), ReconGuide (n=3) and none for CAD/CAM. Analysis detected significant correlations between used OSM and plate exposure (p = 0.000), but none regarding fracture (p = 0.275), loosening (p = 0.714) or insufficient osseous consolidation (p = 0.208). No correlations were observed between complications and OSM (p = 0.609) or diagnosis (p = 0.716). Fixation of FFF segments for reconstruction is possible with various OSM providing good clinical outcome. No significant differences were detected regarding prevention of complications by any osteosynthesis material (miniplate vs. macroplate). Although no differences were detected, miniplate usage is advocated whenever clinically reasonable, due to easier reintervention possibilities and reduced implanted foreign material. Nevertheless, decision for ideal OSM must remain patient-specific and cannot be generalised.

Airway management following head and neck microvascular reconstruction: is tracheostomy mandatory?

ObjectivesAirway management following maxillofacial microvascular reconstruction is a fundamental part of the perioperative management. In oral cavity microvascular reconstruction, the airway is potentially compromised by airway edema, flap edema or bulkiness, hematoma formation, or upper airway sequelae from surgery. Classical teaching advocates elective tracheostomy in patients undergoing maxillofacial free flap reconstruction, while others keep patients intubated overnight (delayed extubation). The optimal method for perioperative airway management is still debated. This study aim was to evaluate the morbidity associated with elective tracheostomy in patients undergoing maxillofacial microvascular reconstruction and to recognize those patients who can avoid elective tracheostomy. MethodsRetrospective review of patients who underwent maxillofacial microvascular free flap reconstruction, between November 1st 2010 and October 31st 2019 in our center. ResultsOne-hundred and nine patients underwent microvascular reconstruction in the maxillofacial region. Sixty-one patients underwent an elective tracheostomy upon the primary surgery. Forty-eight patients were left intubated overnight. Seven patients underwent a late tracheostomy which was performed upon a neck re-exploration for postoperative complications, except for one patient which was due to failed extubation attempt. Patients who didn’t receive an elective tracheostomy were younger and had a shorter duration of postoperative hospitalization. Seven patients suffered from tracheostomy- related complications, all of them underwent elective tracheostomy and none were from the late tracheostomy group. ConclusionsOur results suggest, the routine use of elective tracheostomy in maxillofacial microvascular free flap reconstruction is unnecessary. Elective tracheostomy should be considered on case-to-case basis. Level of evidence4.

Comparison between an Operating Surgical Microscope and High Magnification Surgical Loupes in Microvascular Reconstruction of Head and Neck Defects in a Tertiary Healthcare Centre.

Microvascular free tissue transfers have become an important method of reconstruction following head & neck oncological resection. The objective of this study was to evaluate the efficacy of surgical loupes against surgical operating microscope, which is the gold standard for microvascular anastomosis and also to explore the possibility of surgical loupes as an essential cost-effective armamentarium in head and neck reconstruction. This prospective randomized study included 40 patients diagnosed with head and neck malignancies, requiring microvascular free flap reconstruction. A total of 20 patients who underwent free flap reconstruction following oncologic/maxillofacial defects using high magnification surgical loupes & the other 20 patients were subjected to reconstruction under an operating surgical microscope. The efficacy was assessed based on the following parameters. 1. Total operating time taken for completing anastomosis. 2. Overall fatigue. 3. Free flap failure rate. The microscope group took an overall mean time of 34.26min considering its limited degree of freedom in adjusting intraoperatively whereas the loupes group had a shorter mean anastomosis time 33.29min considering its ease of operator adjustability. Overall, fatigue was compared using Mann-Whitney Test and found to be statistically significant with P value of 0.17, the loupe group was found to be better with mean score of 6.90 in 21 patients than microscope with mean score of 6.21in 19 patients. Flap survival rate in the loupe group had two cases of venous obstruction at 24h follow-up and microscope group had 1 case of venous.obstruction. The success with loupe only free tissue transfer can be attributable considering expertise with the microscope and the loupes can be a cost-effective alternative to microscope.

Editorial introductions.

Editorial introductions.

Risk Factors and Complications Associated with Early Oral Intake in Patients Undergoing Microvascular Free Flap Reconstruction of the Oral Cavity: A Single-institution, Retrospective Study

PurposeData on early oral intake (PO) after free flap reconstruction of the oral cavity have been limited. Recent studies have shown that resumption of PO after free flap reconstruction does not lead to increased morbidity and has resulted in decreased hospital stay.1,2 The objective of the study is to assess postoperative complications associated with early PO after free flap reconstruction of the oral cavity and to define clinical predictors for early PO. Materials and methodsA retrospective study was designed and implemented to capture all patients who were treated from 2014 to 2019 at a tertiary hospital and academic medical center. Inclusion criteria included oral cavity defects as a result of malignant or benign disease, trauma, osteoradionecrosis, and medication-related osteonecrosis that required a vascularized free flap reconstruction. Exclusion criteria included unresectable tumors, pharyngeal or laryngeal defects, and facial defects with minimal intraoral involvement (i.e., skin cancer). Clinical and surgical variables were collected and analyzed. The treatment group received PO within 4 days postoperatively. The control group had PO after 4 days postoperatively. The primary outcome was an early complication during the primary hospitalization. Secondary outcomes included late complications and length of stay (LOS). Student's T-test and Chi-square test were used to compare continuous and categorical variables, respectively. In cases where an unequal distribution or a small sample size is present, Mann-Whitney U or Fisher's Exact test was performed. Study variables that were statistically associated with the primary outcome in the bivariate analysis were selected as independent variables for logistic regression analysis. Multivariable logistic regression analysis was used to control for demographic and clinical variables that were statistically significant in the simple logistic regression analysis. Odds ratios (ORs) with 95% confidence intervals (CIs) were recorded and interpreted for the regression analysis. For all tests, P values of < .05 were statistically significant. ResultsA total of 457 free flap reconstructions were screened for eligibility. The study sample composed of 423 reconstructions in 164 females and 259 males with the mean age of 59 (range 14-88 years) and mean follow-up duration of 25 months. Sixteen percent of the sample had prior radiotherapy or chemoradiotherapy, and 70% were treated for malignant disease. The majority underwent a tracheostomy (81.6%) and unilateral neck dissection (75.4%). Half had a gastrostomy tube (G-tube) during their hospitalization. The flap success rate was 98%. Patients in the treatment group were less likely to have a tracheostomy, bilateral neck dissection, and g-tube compared to the control group (P < .01) (Table 1). Defect volumes were significantly smaller in the treatment group compared to the control group (P < .01) with buccal and maxillary defects being more common in the treatment group (P < .01). Early PO was associated with decreased LOS (P < .01) and comparable complications (P > .10) in the treatment group compared to the control group (Table 2). Patients in the control group had a higher incidence of neck infection and salivary leak during the primary hospitalization compared to the treatment group. Late complications such as exposed hardware or bone, neck infection, and orocutaneous fistula were more frequent in the control group compared to the treatment group (Table 3). Multivariable regression analysis showed that tracheostomy and defect volume were significant predictors for early PO (P < .01). ConclusionEarly PO after free flap reconstruction of the oral cavity decreases LOS and does not lead to worse outcomes with regards to early and late complications. However, factors such as defect location, defect volume, and tracheostomy may increase the risk for complications and can help guide surgeons in deciding the optimal timing for postoperative PO.

Differences in free flaps' reconstructions with and without coupling device for venous anastomosis.

&lt;br&gt;&lt;b&gt;Introduction:&lt;/b&gt; Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Aim:&lt;/b&gt; The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Methods:&lt;/b&gt; The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 - anterolateral thigh flap (ALTF); 51 - fibula free flap (FFF); 15 - iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Results:&lt;/b&gt; The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P&lt;0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P&gt;0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.&lt;/br&gt; &lt;br&gt;&lt;b&gt;Conclusions:&lt;/b&gt; The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.&lt;/br&gt.

662 MICROVASCULAR MYOCUTANEOUS AND CUTANEOUS FREE FLAP RECONSTRUCTION FOR PATIENTS WITH TERMINAL ESOPHAGOSTOMY AFTER COMPLICATED ONCOLOGICAL ESOPHAGUS RESECTION

Abstract Persisting anastomotic leak after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and need for artificial nutrition quality of life is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative. Methods This retrospective cohort study presents seven patients treated between March 2017 and November 2020 at our surgical department, with terminal esophagostomy after complicated oncological esophagus resection without further feasible treatment options. All Patients received anastomotic MFF reconstruction. We have examined postoperative outcomes, complications according to Clavien-Dindo-Classification and patient contentment with a questionnaire. Additionally, we described important procedure related facts. Results The included seven male patients had median age of 65.15 years (range: 48–75). MFF function was adequate in six out of seven patients, graft rejection appeared in one patient. Five patients initially had good results, surgical revision was performed in one patient to ensure graft function. Postoperative complications appeared in 6/7 patients (Table 1). Mean duration of inpatient care was 63 days (Range: 24–156). At time of evaluation, one patient has died cancer related. No more additional nutrition was needed in 3/6 patients with adequate graft function. The majority of patients reported an improved quality of life compared to preoperatively. Conclusion MFF free flap can be a safe and feasible treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options or in patients with complicated postoperative course with complex combined defects. The renewed ability of oral food intake results in a significant improvement of quality of life for the patients. No procedure related mortality was observed. Number of patients with regained ability of oral intake is encouraging.

Sarcopenia and microvascular free flap reconstruction.

This article reviews the recent literature regarding the impact of sarcopenia on microvascular free flap reconstruction outcomes. Malnutrition, and consequent muscle loss, is a prevalent issue among head and neck cancer patients. However, diagnosis remains challenging due to a paucity of reliable objective measures. Traditional markers, such as albumin, have been used in the past to assess nutritional status, but cancer-related inflammation limits their predictive value. Recently, developments in the diagnosis of sarcopenia through the novel use of computed tomography (CT) cross-sectional muscle mass indices to evaluate body composition have proven effective and accessible. Literature shows compelling evidence that sarcopenia is associated with higher rates of surgical complications that delay recovery and increase mortality. The use of CT imaging to quantify muscle loss offers an objective way to evaluate nutritional status, which is predictive of postoperative rates of complications. Research on ways to optimize muscle mass prior to surgery is limited, however, immunonutrition is emerging as a promising intervention that can attenuate sarcopenia-related inflammation to improve outcomes.

Effects of Pre-Operative Risk Factors on Intensive Care Unit Length of Stay (ICU-LOS) in Major Oral and Maxillofacial Cancer Surgery.

Simple SummaryThis study aimed to investigate the effect of certain pre-operative parameters from the clinical routine directly on the post-operative intensive care unit (ICU)-length of stay (LOS) after major oral and maxillofacial cancer surgery. This study was performed to identify at-risk patients that are expected to need prolonged specialized care management post-operatively to these aforementioned operations. A homogenous cohort of 122 patients over a five year period was included in this study. At-risk patients are prone to need a significantly longer specialized care management than others. These patients are those with pre-operative severe renal dysfunction, peripheral vascular diseases and/or increasing heart failure stage categories. Confounding parameters that contribute to a prolonged specialized post-operative management in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.Objective: This study aimed to investigate the effect of certain pre-operative parameters directly on the post-operative intensive care unit (ICU)-length of stay (LOS), in order to identify at-risk patients that are expected to need prolonged intensive care management post-operatively. Material and Methods: Retrospectively, patients managed in an ICU after undergoing major oral and maxillofacial surgery were analyzed. Inclusion criteria entailed: age 18–90 years, major primary oral cancer surgery including tumor resection, neck dissection and microvascular free flap reconstruction, minimum operation time of 8 h. Exclusion criteria were: benign/borderline tumors, primary radiation, other defect reconstruction than microvascular, treatment at other centers. Separate parameters used within the clinical routine were set in correlation with ICU-LOS, by applying single testing calculations (t-tests, variance analysis, correlation coefficients, effect sizes) and a valid univariate linear regression model. The primary outcome of interest was ICU-LOS. Results: This study included a homogenous cohort of 122 patients. Mean surgery time was 11.4 (±2.2) h, mean ICU-LOS was 3.6 (±2.6) days. Patients with pre-operative renal dysfunction (p < 0.001), peripheral vascular disease-PVD (p = 0.01), increasing heart failure-NYHA stage categories (p = 0.009) and higher-grade categories of post-operative complications (p = 0.023) were identified as at-risk patients for a significantly prolonged post-operative ICU-LOS. Conclusions: At-risk patients are prone to need a significantly longer ICU-LOS than others. These patients are those with pre-operative severe renal dysfunction, PVD and/or high NYHA stage categories. Confounding parameters that contribute to a prolonged ICU-LOS in combination with other variables were identified as higher age, prolonged operative time, chronic obstructive pulmonary disease, and intra-operatively transfused blood.

Impact of patients’ gender on microvascular lower extremity reconstruction

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients’ gender: male vs. female. Retrospective data analysis evaluated patients’ demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.