Microvascular Free Tissue Transfer Reconstruction Research Articles

Patient Experience of Head and Neck Surgery With Free Flap Reconstruction

Major head and neck surgery with microvascular free tissue transfer reconstruction is complex, with considerable risk of morbidity. Little is known about patients' experiences, including decision-making prior to, and regret following, free flap surgery. To characterize patient experiences and decision regret of patients undergoing head and neck reconstructive free flap surgery. This mixed-methods cohort study comprising semistructured interviews was conducted June to August 2021 at a single tertiary academic cancer center. Participants underwent head and neck reconstructive surgery with microvascular free tissue transfer (flap) more than 3 months before recruitment (range, 3 months to 4 years). Interview transcripts were qualitatively analyzed for themes. Participants also completed a Decision Regret Scale questionnaire. Microvascular free flap surgery for head and neck reconstruction. Thematic analysis of interviews, decision regret score. Seventeen participants were interviewed. Median (IQR) age was 61 (52-70) years. Overall, 7 participants were women (49%), and 10 of 17 were men (59%). The most common free flap was fibula (8/17, 47%). Three major themes with 9 subthemes were identified: theme 1 was the tremendous effect of preoperative counseling on surgical decision-making and satisfaction, with subthemes including (1) importance of clinical care team counseling on decision to have surgery; (2) emotional context colors preoperative understanding and retention of information; (3) expectation-setting affects satisfaction with preoperative counseling; and (4) desire for diversified delivery of preoperative information. Theme 2 was coexisting and often conflicting priorities, including (1) desire to survive above all else, and (2) desire for quality of life. Theme 3 was perception of surgery as momentous and distressing, including (1) surgery as a traumatic event; (2) centrality of mental health, emotional resolve, and gratitude to enduring surgery and recovery; and (3) sense of accomplishment in recovery. On the Decision Regret Scale, most participants had no regret (n = 8, 47%) or mild regret (n = 5, 29%); 4 had moderate-to-severe regret (24%). In this mixed-methods cohort study, patient experiences surrounding major head and neck reconstructive free flap surgery were described. Opportunities to improve support for this complex and vulnerable population, and to mitigate decision regret, were identified.

Perforator-based chimeric ulnar forearm microvascular free tissue transfer reconstruction of post-radiated tracheoesophageal puncture fistulae.

Tracheoesophageal puncture (TEP) performed during total laryngectomy in the primary treatment of laryngeal cancer is the standard method for voice restoration. Following adjuvant radiotherapy, the TEP site can experience complications resulting in a tracheoesophageal fistula (TEF) with chronic leakage making oral alimentation unsafe due to aspiration. Here, we describe a technique using chimeric ulnar artery perforator forearm free flaps (UAPFF) in the reconstruction of these complex deformities. Four patients underwent chimeric UAPFF reconstruction of TEP site TEFs following primary TL with TEP and adjuvant radiotherapy. No flap failures or surgical complications occurred. Average time from end of radiotherapy to persistent TEF was 66 months (range 4-190 months). All patients had resolution in their TEF with average time to total oral diet achievement of 22 days (14-42 days). Chimeric UAPFF reconstruction is a safe and effective method to reconstruct recalcitrant TEP site TEFs.

Outcome Comparison of Functional Laryngectomy for the Dysfunctional Larynx to Salvage Laryngectomy.

To compare functional outcomes of total laryngectomy (TL) with microvascular free tissue transfer (MVFTT) reconstruction in the treatment of dysfunctional larynx (DL) versus salvage therapy for locally recurrent disease in patients with a history of laryngeal squamous cell carcinoma (SCC). Retrospective review from a tertiary medical center between August 2015 and August 2022. Sixty-nine patients underwent TL with MVFTT following primary laryngeal radiation or chemoradiation; 15 (22%) patients underwent functional laryngectomy (FL) and 54 (78%) underwent a salvage laryngectomy (SL). There were no total flap failures. Four (6%) patients developed a pharyngocutaneous fistula; one (7%) FL patient and 3 (6%) in the SL cohort. There was no significant difference in average hospital length of stay (LOS) between the cohorts (8.6 ± 3.0 days vs. 12.8 ± 10.1 days, p = 0.12). All patients (100%) in the FL cohort achieved a total oral diet compared to 41 (76%) in the SL cohort (p = 0.03). Two (13%) and 10 (19%) patients developed pharyngoesophageal stenosis in the FL and SL cohorts, respectively (p = 1.0). Nine (60%) and 23 (43%) patients in the FL and SL cohorts underwent tracheoesophageal puncture (TEP) placement, with 89% and 91% achieving fluency, respectively (p = 0.23). Although the role of TL for the definitive treatment of laryngeal SCC has decreased over the past 30 years, organ-preservation protocols can impact speech, swallowing, and airway protection with life-threatening consequences. The use of elective FL with MVFTT for the treatment of DL results in similar or better functional outcomes compared to SL for recurrent disease. 3 Laryngoscope, 134:222-227, 2024.

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.

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 Inset Techniques in Salvage Laryngopharyngectomy Repair: Impact on Fistula Formation and Function.

To characterize pharyngocutaneous fistula (PCF) rates and functional outcomes following microvascular free tissue transfer (MVFTT) reconstruction of salvage total laryngectomy (STL) with a review of two different flap inset techniques and a review of the literature. Retrospective review. Review of the literature revealed 887 patients who underwent STL MVFTT from 14 references. Ninety-six STL MVFTTs were performed by the authors, with 36 (38%) patients undergoing multilayer fascial underlay (MLFU) closure and 60 (62%) a standard single layer closure (SLC). One (3%) PCF occurred in the MLFU group compared to 12 (20%) in the SLC cohort (P = .03). Postoperative gastrostomy (G)-tube dependence was lower following MLFU closure compared to SLC (25% vs. 57%, P < .01), whereas pharyngoesophageal stricture (PES) (28% vs. 38%), tracheoesophageal puncture (TEP) placement (42% vs. 42%), and TEP usage (87% vs. 88%) did not significantly differ (P > .05). Compared to pooled rates from the literature, patients who underwent a MLFU MVFTT inset technique demonstrated significantly lower PCF incidence (3% vs. 23%, P < .01) without significant differences in PES (28% vs 23%, P = .55), G-tube dependence (25% vs. 23%, P = .25), or TEP placement (42% vs. 59%, P = .09). Despite MVFTT reconstruction after STL, G-tube dependence, PCF formation, and limitations of speaking rehabilitation (TEP) remain a significant issue. Modification of MVFTT inset may provide an opportunity to reduce PCF incidence without affecting other functional outcomes. 4 Laryngoscope, 131:E875-E881, 2021.

Prognostic factors associated with achieving total oral diet following osteocutaneous microvascular free tissue transfer reconstruction of the oral cavity

IntroductionOsteocutaneous microvascular free tissue transfer (OMFTT) is the current standard in reconstruction of large bony defects of the oral cavity. Although being able to swallow ranks as a top priority for patients undergoing OMFTT, factors associated with achieving an oral diet following surgery remain unclear. We sought to describe the rate of total oral diet achievement, and to identify possible pre-, intra-, and post-operative factors associated with achievement in patients undergoing OMFTT. MethodsRetrospective review between January 1, 2010 and March 31, 2018 at two tertiary academic centers. Results249 patients (67% male, mean age 58 years) met inclusion criteria, with a median follow up of 15 months. Overall, 142 (57%) of patients achieved a total PO diet post-operatively, with median time to achievement of 3.2 months. Multivariate analysis identified that lack of concurrent glossectomy (SHR 1.72 [1.09–2.70], p = 0.02), N0/1 disease (SHR 1.92 [1.16–3.13], p = 0.011), avoidance of post-operative fistula formation (SHR 1.96 [1.22–3.23], p = 0.005), pre-operative G-tube independence (SHR 3.33 [1.69–6.25], p < 0.001), and successful dental rehabilitation (SHR 2.08 [1.43–3.03], p < 0.001) are independently associated with total oral diet achievement. ConclusionsBony resections not requiring glossectomy, limited nodal disease burden, pre-operative gastrostomy-independence, avoidance of post-operative fistula, and dental rehabilitation are independently associated with achievement of total oral diet following OMFTT reconstruction of the oral cavity. Counseling patients on associated risk factors is important in guiding post-treatment expectations. Minimization of post-operative fistula, and maximization of dental rehabilitation may significantly improve total oral diet achievement in this patient population.

Prognostic factors associated with achieving total oral diet after glossectomy with microvascular free tissue transfer reconstruction

ObjectivePrimary surgery followed by adjuvant therapy is the current standard of care in the multidisciplinary management of squamous cell carcinoma (SCC) of the oral tongue. Additionally, salvage glossectomy is used to treat recurrent base of tongue SCC. Microvascular free tissue transfer reconstruction (MVFTT) is utilized to maximize functional outcomes such as swallowing. We sought to identify prognostic factors related to achievement of a total oral diet in patients that underwent glossectomy with MVFTT. MethodsRetrospective review at a tertiary care center from 2010 to 2015. Results200 patients (69% male, mean age 60 years) met inclusion criteria. Extent of glossectomy was categorized as partial or hemiglossectomy (39%), tongue base resection with or without hemi-oral glossectomy (23%), composite resection with mandibulectomy (18%), and subtotal or total glossectomy (21%). Flap success rate was 96%. Median follow-up time was 14 months. A total oral diet was achieved by 49% of patients with median time to achievement of 31 days (IQR 9-209). Multivariate analysis identified body mass index < 25 kg/m2, prior radiation therapy, adjuvant chemoradiation, and resection requiring subtotal or total glossectomy or concurrent mandibulectomy as independent risk factors for worse total oral diet achievement. ConclusionSwallowing dysfunction represents a significant morbidity following glossectomy in the treatment of SCC. High BMI, smaller resection fields, and absence of prior radiation therapy or adjuvant chemoradiotherapy correlated with improved likelihood of obtaining a total oral diet. Patients should be appropriately counseled of this risk with emphasis placed on aggressive swallow rehabilitation in the post- treatment setting.

Olfactory and gustatory functions after free flap reconstruction and radiotherapy for oral and pharyngeal cancer: a prospective follow-up study.

The senses of smell and taste can be adversely affected by both tumour- and treatment-related factors amongst head and neck cancer patients. The consequences may negatively impact nutritional status as well as quality of life in this patient population. This prospective longitudinal follow-up study is consisted of 44 patients treated for oral cavity, oropharyngeal or hypopharyngeal cancer with tumour resection and microvascular free tissue transfer reconstruction at the Helsinki University Hospital, Helsinki, Finland. Thirty-nine (89%) of them also received radiotherapy. The senses of smell (odour detection, identification and threshold test) and taste (electrogustometry) and quality of life (UW-QOL) were evaluated preoperatively, and at 6weeks, 3months, 6months and 12months, postoperatively. There were higher scores in the odour detection values in the 6-week and 3-month tests compared with preoperative values for the tumour side. Other detection scores did not differ statistically from the preoperative values neither in the tumour nor the contralateral side. However, in the odour identification test, all posttreatment values were statistically significantly higher than pretreatment ones. In the olfactory threshold test, no statistically significant differences were found between pre- and posttreatment values. Electrogustometry values for the taste on the tumour side were statistically significantly impaired at 6weeks (p < 0.05) and at 3months (p < 0.01) compared with the pretreatment results. They were also impaired at 6months and at 12months, although the differences were not statistically significant. The quality of life was impaired after treatment in this patient series. However, the correlation between quality of life and sense of tastewas found only at one time point (3months) and only with contralateral side measurements. We conclude that in oral and pharyngeal cancer patients the postoperative taste problems are related to the impairment on the taste sensation in the tongue but not with the sense of smell. Moreover, the impairment in the quality of life is not clearly related to the impaired sense of taste.

Comparison of clinical and histological tumour diameter in non-melanoma skin malignancy of the Head and Neck

Purpose: Reconstruction of complex defects of the head and neck region utilizing micro-vascular free tissue transfer reconstruction has become invaluable. Early detection of vascular compromise and its prompt correction is critical to its success. The use of intra-operative fluorescent angiography (ICG) may facilitate surgeons in being objective when assessing micro-vascular anastamosis patency and flap perfusion. Method: 231 head and neck free tissue transfer cases on 228 patients performed by a single surgeon between 20032013 were reviewed for type of flap, flap success and complications. In 62 of the head and neck free tissue transfer cases, intra-operative ICG was performed with SPY Elite (Lifecell) for assessment of micro-vascular anastomosis patency and analysis of adequacy of blood supply to inset flap. Conventional subjective patency test and clinical inspection were performed for the remaining 169 cases. Results: Overall success rate was 95%. When ICG analysis was performed, the success rate was 97%. In the conventional group, the success rate was 94%. Overall complication rate was 11%. Post-operative complications included hematoma, venous thrombosis, infection, partial flap necrosis, and hemorrhage. In the ICG analysis cases, the overall complication rate was 5% with hematoma 3% and partial flap necrosis 2%. In the conventional subjective analysis group, the overall complication rate was 14% with post op complications of hematoma 7%, venous thrombosis 4%, infection 1%, partial flap necrosis 1% and hemorrhage 1%. Conclusions: Routine implementation of intraoperative ICG analysis can further increase the reliability of free tissue transfer reconstruction of the head and neck region.

Intraoperative fluorescent angiography analysis for head and neck micro-vascula free flap reconstruction- a preliminary experience

Purpose: Reconstruction of complex defects of the head and neck region utilizing micro-vascular free tissue transfer reconstruction has become invaluable. Early detection of vascular compromise and its prompt correction is critical to its success. The use of intra-operative fluorescent angiography (ICG) may facilitate surgeons in being objective when assessing micro-vascular anastamosis patency and flap perfusion. Method: 231 head and neck free tissue transfer cases on 228 patients performed by a single surgeon between 20032013 were reviewed for type of flap, flap success and complications. In 62 of the head and neck free tissue transfer cases, intra-operative ICG was performed with SPY Elite (Lifecell) for assessment of micro-vascular anastomosis patency and analysis of adequacy of blood supply to inset flap. Conventional subjective patency test and clinical inspection were performed for the remaining 169 cases. Results: Overall success rate was 95%. When ICG analysis was performed, the success rate was 97%. In the conventional group, the success rate was 94%. Overall complication rate was 11%. Post-operative complications included hematoma, venous thrombosis, infection, partial flap necrosis, and hemorrhage. In the ICG analysis cases, the overall complication rate was 5% with hematoma 3% and partial flap necrosis 2%. In the conventional subjective analysis group, the overall complication rate was 14% with post op complications of hematoma 7%, venous thrombosis 4%, infection 1%, partial flap necrosis 1% and hemorrhage 1%. Conclusions: Routine implementation of intraoperative ICG analysis can further increase the reliability of free tissue transfer reconstruction of the head and neck region.

Microvascular Reconstruction in the Setting of Difficult Vascular Anatomy: The Reverse Arterial Flow Technique

Objectives: We present one case where challenging vascular anatomy was circumvented by changing the conventional vascular dissection and geometry successfully. Methods: Variations in the quality and suitability of donor vessel anatomy can significantly impact microvascular free tissue transfer reconstruction and may require innovative approaches to allow successful revascularization. Although greatest variability is noted in the venous system of transferred tissue segments, arterial anatomy and quality can also be severely limiting. However, unlike the recipient vessels where multiple options may be available, there is only one available donor artery. In the setting of unfavorable physical properties of the artery, the reconstructive surgeon is often forced to sacrifice the flap in favor for a second harvest. Results: In our case, the artery was affected by Monckeberg’s arteriosclerosis, which is a process of arterial calcification classically described as calcification of the tunica media of the arterial wall. This creates a hardened wall through which microvascular suture cannot be passed and microvascular anastomosis is not successful. Conclusions: In our case, the fibula free flap was salvaged by using the distal end of the artery for anastamosis to create reverse flow perfusion of the flap. We present the details of the technique required for harvest and inset of a reverse arterial flow fibula free flap.

OP105: Intraoperative fluorescent angiography analysis for head and neck micro-vascular free flap reconstruction – A preliminary experience

Reconstruction of complex defects of the head and neck region utilizing micro-vascular free tissue transfer reconstruction has become invaluable. Early detection of vascular compromise and its prompt correction is critical to its success. The use of intra-operative fluorescent angiography (ICG) may facilitate surgeons in being objective when assessing micro-vascular anastamosis patency and flap perfusion. 201 head and neck free tissue transfer cases on 198 patients performed by a single surgeon between 2003 and 2012 were reviewed for type of flap, flap success and complications. In 32 of the head and neck free tissue transfer cases, intra-operative ICG was performed with SPY Elite (Lifecell) for assessment of micro-vascular anastomosis patency and analysis of adequacy of blood supply to all zones of the inset flap. Conventional subjective patency test and clinical inspection were performed for the remaining 169 cases. Overall success rate was 95% (191/201) with eight flap failures and two partial flaps necrosis. When intra-operative ICG analysis was performed, the success rate was 97% (31 out of 32) with 1 partial flap necrosis. In the conventional subjective analysis group, the success rate was 94% (160/169) with eight flap failures and one partial flap necrosis. Overall complication rate was 12% (25/201). Post-operative complications included hematoma, venous thrombosis, infection, partial flap necrosis, and hemorrhage. In the intraoperative ICG analysis cases, the overall complication rate was 6% (2/32 cases) with 3% (1/32) hematoma and 3% (1/32) partial flap necrosis. In the conventional subjective analysis group, the overall complication rate was 16% (23/169) with post op complications of hematoma 7% (12/169), venous thrombosis 4% (7/169), infection 1% (2/169), partial flap necrosis 1% (2/169) and hemorrhage 0.6% (1/169). Routine implementation of intraoperative ICG analysis can further increase the reliability of free tissue transfer reconstruction of the head and neck region.

CT and duplex scanning: A comparison of imaging techniques for evaluation of the carotid tree in head and neck cancer patients

Carotid artery disease is a common condition which, like head and neck cancer, is primarily smoking related. Internal carotid stenosis may result in cerebro-vascular complications, while severe stenosis of the external carotid can potentially compromise microvascular free tissue transfer reconstruction. We were interested to see whether any co-existing carotid artery disease could be assessed on the neck CT scan by comparing it to definitive duplex scanning in head and neck cancer patients. CT and duplex scanning of the common, internal and external carotid arteries was compared in 30 patients (180 vessels). The arterial phase of the neck CT scans were reviewed by two radiologists and all duplex scans were performed by one vascular technician to minimise inter-operator variability. The respective findings were blinded. Significant correlations were found between CT and duplex in confirming stenosis of the common and internal carotid arteries (P<0.001). There was a weak correlation between CT and duplex in the assessment of the external carotid system (P=0.02 and P=0.08), with CT under-estimating the true extent of stenosis in this vessel. The sensitivity and specificity of CT compared to duplex was 77% and 94% respectively. CT is useful not only for imaging the neck of head and neck cancer patients, but also in screening for carotid stenosis. Duplex scanning is more accurate than CT in assessing the external artery, and is useful for evaluating patients with significant stenosis of the carotid tree.

Reconstrução tridimensional da face nos tumores avançados com invasão da fossa craniana anterior

OBJETIVO: Analisar as indicações cirúrgicas e o seguimento pós operatório, ressaltando as complicações e efetividade da abordagem multidisciplinar, para os tumores avançados da base do crânio. MÉTODO: Análise retrospectiva de 46 prontuários de pacientes submetidos à ressecção de tumores invadindo a fossa craniana anterior e reconstruídos com retalhos microcirúrgicos, operados entre março de 1990 e julho de 2002. Todos os pacientes foram operados pelo núcleo de cirurgia de base do crânio do INCA. RESULTADOS: As estruturas mais envolvidas na ressecção foram por ordem: a órbita (76,5%), seio maxilar (76,5%), seio esfenoidal (63,8%), paredes da cavidade nasal (59,5%) e palato (42,5%). A dura-máter estava acometida em 32,6% dos casos. A reconstrução microcirúrgica utilizando os retalhos do músculo reto abdominal foi empregada em 93,5 % dos casos. A taxa de sucesso dos transplantes livres foi de 97,8%. As complicações ocorreram em 58,6% dos pacientes e as mais freqüentes foram: infecções locais (21,7%), fístulas liquóricas (15,2%), meningite (6,5%) e hematoma (6,5%). CONCLUSÕES: A reconstrução com técnica microcirúrgica permite que se realizem ressecções alargadas destes tumores com limites seguros e índices de complicações aceitáveis, permitindo a estes pacientes uma melhoria da qualidade de vida e da sobrevida, com baixo índice de recidiva.

Retrospective case series of primary and secondary microvascular free tissue transfer reconstruction of midfacial defects

Statement of Problem. Midfacial defects arising from tumor extirpation or trauma may involve any portion of the central area of the face, including the palate, maxilla, orbit, lip, and/or nose. Speech, mastication, swallowing, and cosmesis are significantly impaired and present a unique challenge to the reconstructive surgeon. Purpose. This study evaluated the functional and cosmetic success of both soft tissue and osteocutaneous free flap reconstruction of the midface. Material and Methods. A retrospective chart review of 34 patients who underwent primary and secondary free flap reconstruction of the midface was conducted. The main outcome measures were perioperative complications, diet, speech intelligibility, type of dental restoration, and cosmetic result. Results. Fifteen patients underwent soft tissue free flap reconstruction of the midface. Six of these patients also had additional nonvascularized free cranial bone grafts to improve restoration of the orbitozygomatic region. Nineteen patients who might have required osseointegrated implants to anchor a dental prosthesis underwent osteocutaneous free flap reconstruction. Thirty-three of 34 free flaps survived, and wound complications were minimal. After surgery, 20 patients were able to eat a regular diet and 14 a soft diet. All patients had intelligible speech over the telephone. Ten patients used a dental prosthesis (5 conventional and 5 implant-borne). Cosmesis was judged to be excellent in 12 patients, good in 15 patients, fair in 5 patients, and poor in 2 patients. Conclusion. In the patients reviewed, free flap reconstruction of the midface was completed in a single stage and created a reproducible, permanent separation of the oral and sinonasal cavities with adequate speech and swallowing. (J Prosthet Dent 2001;86:369-76.)

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to "low-volume" defects.

Predictive factors for functional recovery after free tissue transfer oromandibular reconstruction

BACKGROUND: Recovery of upper aerodigestive tract function after reconstruction of segmental oromandiblectomy defects is frequently incomplete. The purpose of this study was to quantitate postreconstruction function and define variables that predict functional outcome in this population. METHODS: A prospective study of 21 patients who underwent microvascular free tissue transfer reconstruction of segmental oromandibular defects was performed. Measures of swallowing, speech, bite, and oral intake were performed preoperatively and at 1, 3, 6, and 12 months postoperatively or until plateau. Preoperative versus maximal postoperative measures were compared and correlated with nine potentially predictive variables. Univariate and multivariate analyses were performed to determine the most significant predictive factors. RESULTS: Baseline function in the study population was abnormal. Postoperative bite force improved, but swallowing, speech, and oral intake were worse than preoperative. Significant (univariate) predictors of outcome included diagnosis of cancer, tongue resection, pharynx resection, and flap skin paddle area. Only tongue resection remained significant in multivariate analysis. CONCLUSIONS: Increasing need for oropharyngeal lining replacement, especially after tongue resection, is the most important predictor of functional outcome in reconstruction of segmental mandible defects.

The Four-Poster Halo Vest for Protection of a Microvascular Free-Tissue Transfer Reconstruction of the Scalp

Use of a four-poster halo and corset jacket provides complete protection, access, and mobility for patients undergoing free-flap scalp reconstruction. This technique was used in a patient who required a total scalp reconstruction with a compound latissimus/serratus muscle free flap with good success. The case and technique are presented for review.

Tumor-Ablative Surgery, Microvascular Free Tissue Transfer Reconstruction, and Postoperative Radiation Therapy for Advanced Head and Neck Cancer

The objectives of this study were to determine whether the combination of complex tumor-ablative surgery and microvascular free tissue transfer reconstruction delays the onset of postoperative radiation therapy, whether free tissue transfers are lost after a course of radiation therapy, and what patterns of tumor recurrence and survival rates are present in patients who undergo this type of multidisciplinary treatment. A retrospective review was conducted in 37 patients who underwent tumor-ablative surgery and reconstruction between November 1987 and August 1991. Of the 30 men and 7 women who underwent tumor-ablative surgery, microvascular free tissue transfer reconstruction, and postoperative radiation therapy, recurrent or T4 primary tumors were treated in 84%. Sixty-two percent of the patients had nodal metastatic disease. The median dose of postoperative irradiation was 60 Gy (range, 32.4 to 76.8). Follow-up in all patients was until death (21 patients) or for a median of 17.5 months (range, 4.1 to 43.2). The median duration of overall survival and the 2-year overall survival rate were 17 months and 46%, respectively. For cause-specific survival, the median duration and 2-year rate were 17 months and 50%, respectively. Local recurrence developed in 8 patients, neck recurrence in 10, and distant metastatic disease in 11. No microvascular free tissue transfers failed. Radiation therapy can begin in most patients within 8 weeks postoperatively, microvascular free tissue transfers seem to tolerate postoperative radiation therapy well at the doses administered, and the rates of local and neck control are reasonable relative to the advanced stage of the cancers treated.