Microvascular Reconstructive Surgery Research Articles

Reconstructive Head and Neck Microsurgery in a High-Volume Cancer Center—Long-Term Impact of an Early Experience

Objectives The aim of this study was to evaluate a 16-year-long outcome of an evolving practical approach to reconstructive microsurgery in a high volume, resource-constrained, head and neck cancer care setting. Patients and Methods Seventy-three consecutive cases of free flap reconstruction done by the Head and Neck Surgical Oncology team of Regional Cancer Centre, Thiruvananthapuram, from October 2004 to May 2020 were prospectively studied for flap viability, cosmesis, morbidity, and oncologic safety. The cases were selected based on their “emphatic” superiority to the conventional alternative as determined by two or more surgeons of the head and neck team or the recommendations of the head and neck tumor board. Results With the long-term results, this article discusses and validates our strategy for controlled patient recruitment for reconstructive microsurgery to ensure the best resource utilization in a tertiary cancer care center. Conclusions Adequate training and optimal application are the key factors determining success in microvascular reconstructive surgery in resource-constrained, high-volume cancer care facilities.

Is the Use of Dexmedetomidine Upon Emergence From Anesthesia Associated With Neck Hematoma Formation Following Head and Neck Microvascular Reconstruction?

Dexmedetomidine (DEX) is a highly selective alpha-2-receptor agonist, and its use has not been well studied in major microvascular reconstructive surgery of the head and neck. The purpose is to measure the association between DEX and neck hematoma formation in subjects undergoing head and neck microvascular reconstructive surgery. The investigators implemented a retrospective cohort study on subjects undergoing microvascular head and neck reconstruction for benign and malignant pathology at the University of Alabama at Birmingham from 2014 to 2021. Patients with unresectable tumors were excluded. The predictor variable was the intraoperative use of DEX upon emergence from general anesthesia. Subjects received standard anesthetic drugs and DEX, while control subjects received only standard anesthetic drugs. The primary outcome was postoperative neck hematoma formation necessitating a return to the operating theater. The secondary outcome was the length of stay (LOS). The covariates were demographic, operative, and oral morphine equivalents of anesthesia drugs. Bivariate analyses were performed using the Student's t-test and the χ2 test for continuous and categorical variables. Multivariate regression analyses were conducted to assess for associations between DEX and the outcomes adjusted for confounding variables when present. P values of < .05 were regarded as statistically significant. A total of 297 subjects (mean age, 59.6years, and standard deviation [SD], 14.9) with 61.6% male received DEX, and 304 subjects (mean age, 58.9years, and SD, 14.6) with 60.2% male served as controls (P>.5). A total of 11 postoperative neck hematoma occurred in the control group when compared to 2 in the DEX (relative risk=5.4, 95% confidence interval [CI], 1.2 to 24, P=.02). The mean LOS was 7.7 (SD, 4.3) and 9.4 (SD, 8.1) for the DEX and control groups (95% CI, 0.7 to 2.8, P<.01). After adjusting for tobacco history, tracheostomy, and neck dissection, DEX (Beta coefficient (B)=-1.7, 95% CI -2.7 to -0.7, P<.01) and neck dissection (B=2.2, 95% CI 1.0 to 3.4, P<.01) were statistically associated with LOS. The use of intraoperative DEX upon emergence from general anesthesia was associated with lower postoperative neck hematoma formation and a shorter length of stay following microvascular head and neck reconstruction.

Postoperative infections associated with microvascular free flaps in head and neck reconstruction: Analysis of risk factors and results with a standardized prophylaxis protocol

Currently, large defects of the head and neck regions are mainly reconstructed using microvascular free flap. Postoperative infections, including surgical site infections (SSIs) and medical postoperative infections (MPI), are important causes of morbidity and worsening of surgical outcomes. The authors aimed to analyze the results obtained using a standardized prophylaxis protocol in a series of 100 consecutive patients who underwent microvascular reconstruction surgery between 2016 and 2021 at a single institution, to identify the risk factors, which could be overcome, to minimize the incidence of infectious complications. In this study, 24 patients developed infectious complications. Higher American Society of Anesthesiologists(ASA) score was statistically associated with higher risk of infectious complications (p=0.01), need for postoperative transfusions (p=0.01), and higher T and N stage (p=0.03 and p=0.02, respectively) in patients with cancer. We also found a correlation between the increase in surgery duration, hospitalization, and intensive care unit (ICU) stay with higher risk of infection (p=0.03, p=0.01, and p=0.001, respectively). Nine patients reported partial or total flap necrosis and in this group of patients, a higher incidence of infectious complication was recorded (p=0.001). Our experience shows that SSIs and MPIs affect the global and surgical outcomes of patients and both their incidences can be reduced by correcting potential risk factors preoperatively (e.g., anemia), intraoperatively (amount of blood loss and duration of surgery), and postoperatively (duration of hospitalization and ICU stay and early elimination of potential sources of infection).

Microvascular reconstruction for oral cancer in older adult patients: the impact of age on surgical outcomes

Flap complications continue to be a challenge in microsurgical reconstruction for older adults. We aimed to evaluate the impact of age on surgical outcomes after microvascular reconstruction. We retrospectively investigated 103 patients with oral squamous cell carcinoma who had undergone microvascular reconstruction surgery to compare microsurgical reconstruction, common postoperative complications, and flap success rates in geriatric (>75 years) and non-geriatric (<75 years) patients. We also evaluated differences based on the American Society of Anesthesiologists Physical Status score. We found no significant differences between the geriatric and non-geriatric groups in peri-operative, postoperative, or general complications. Conversely, we found that delirium and aspiration pneumonia were significantly more likely to occur in geriatric patients and that multiple medical complications were significantly more likely to occur in geriatric patients with a high American Society of Anesthesiologists score. Microvascular reconstruction can be performed effectively and without excessive complications in geriatric patients, and age should not be considered a contraindication for this procedure. Comorbidities play a stronger role in the prediction of adverse events.

Postoperative Deep Sedation after Microvascular Reconstructive Surgery for Oral Cancer Increases the Risk of Early Postoperative Pneumonia

This study investigated the effect of postoperative deep sedation after oral cancer reconstructive surgery on the occurrence of early postoperative pneumonia and early postoperative delirium. We obtained medical records of 108 consecutive patients who underwent microvascular reconstructive surgery at Tsukuba University Hospital for oral cancer between January 2013 and December 2021. Forty-six of them woke soon after surgery. Ten of these forty-six patients were restless and required immediate sedation within 3 h after surgery. The comparison between sedation group and no sedation group revealed early postoperative pneumonia in the no sedation group; however, sedation was not related to early postoperative delirium. The preoperative albumin levels of patients with postoperative pneumonia were significantly different (p = 0.03) than those of patients without postoperative pneumonia. The performance status (p = 0.02), preoperative albumin level (p = 0.02), and age 75 years or older (p = 0.02) were significantly associated with postoperative delirium. Restless patients and those who could not be sedated experienced delirium and pneumonia. The risk of pneumonia was increased for patients who were difficult to sedate.

Dermatofibrosarcoma protuberans of the scalp: Surgical management in a multicentric series of 11 cases and systematic review of the literature

BackgroundDermatofibrosarcoma protuberans is a rare, slow-growing soft-tissue malignancy originating in the dermis that is characterized by an infiltrating growth pattern with a marked tendency of local recurrence. Complete surgical resection with pathological margin clearance must be achieved to reduce the risk of tumor recurrence. Resulting defects often require extensive reconstructive procedures. Dermatofibrosarcoma protuberans of the scalp poses particular challenges owing to the proximity to the face and brain. This study aims to evaluate treatment options and proposes an algorithm for management of scalp dermatofibrosarcoma protuberans based on a multicentric case series and systematic review of the literature. MethodsA retrospective multicentric chart analysis of 11 patients with scalp dermatofibrosarcoma protuberans who presented within the last 20 years was performed regarding demographic data, pathological tumor characteristics, and surgical management (resection and reconstruction). Additionally, a further 42 patients (44 cases) were identified through a systematic Preferred Reporting Systems for Systematic Reviews and Meta-Analysis–based review of the literature searching the Medline and Embase databases. ResultsIn total, 30 cases were classified as primary and 20 cases as recurring scalp dermatofibrosarcoma protuberans (data from 5 cases were missing). The median tumor size was 24 cm2 (interquartile range 7.8–64), and the median defect size was 55.8 cm2 (interquartile range 48–112). Recurring scalp dermatofibrosarcoma protuberans was more often associated with invasion of deeper layers and required more extensive tumor resection to achieve negative margins. Within the subgroup that was managed with peripheral and deep en face margin assessment, no recurrence was observed. Most patients required local (41. 8%) or free flap (27.8%) reconstruction after dermatofibrosarcoma protuberans resection. ConclusionWhenever possible, peripheral and deep en face margin assessment–based techniques should be preferred for resection of scalp dermatofibrosarcoma protuberans because they provide superior oncological safety while preserving uninvolved tissue. Patients with locally advanced and recurring scalp dermatofibrosarcoma protuberans often require multidisciplinary treatment including neurosurgery, radiotherapy, and microvascular reconstructive surgery and should be referred to a specialized center.

Patient-specific Prosthetic Appliance for Interim Management of Chronic Orocutaneous Fistula in the Irradiated and Vessel-depleted Head and Neck Patient – A Case Report and Technical Note

The formation and persistence of an orocutaneous fistula as a sequela of major head and neck surgery followed by microvascular reconstructive surgery and adjuvant radiation therapy is a common and frustrating challenge to address. When reconstructive surgical options are exhausted, limited, or with high risk for failure, the fabrication of an oral appliance can provide a temporary to long-term treatment option for the patient. In this case report, an oral appliance was fabricated to decrease salivary incontinence, improve intelligibility, and deglutition in a 60-year-old patient who underwent a subtotal glossectomy with radical mandibulectomy followed by reconstruction with an osteocutaneous radial forearm free flap who developed a chronic orocutaneous fistula following completion of radiation therapy.

Effect of operative time on complications associated with free flap reconstruction of the head and neck.

To evaluate whether prolonged operative time is negatively associated with post-operative complications and length of stay in patients undergoing microvascular free flap reconstruction for complex head and neck defects. 342 consecutive patients undergoing microvascular reconstruction for head and neck defects between 2017-2019 at a single institution were evaluated. Operative outcomes and operative time were compared whilst controlling for patient and treatment related factors. Mean operative time was 551 min and length of stay was 16.2 days. An 11% increase in the risk of a post-operative complication was observed for every additional hour of operative time (OR 1.11, 95% CI 1.03-1.21, p=0.011) after adjusting for patient and treatment factors. A cut-off of 9h yielded a 92% increase in complications on either side of this (OR 1.92, 95% CI 1.18-3.13, p=0.009). Increased operative time was also associated with increased length of stay and return to theatres, but not medical complications. Prolonged operative time is significantly associated with increased surgical complications, length of stay and return to theatres when performing microvascular reconstructive surgery for head and neck defects.

Adjuvant radiotherapy post microvascular reconstructive surgery (MRS) for patients with locally advanced head and neck cancer – when and how?

For many decades palliation (radiotherapy, chemotherapy or symptomatic treatment) was the only therapeutic solu­tion for locally very advanced head and neck cancer. In the mid 70s, H. Buncke carried out pioneering microvascular reconstructive surgery (MRS) as a radical treatment. Since that time, the MRS has been accepted around the world as a successful radical therapy, not only for head and neck (H&amp;N) cancers. A part of the H&amp;N cancers need however post­-MRS radiotherapy (RT). Based on the 20 year experience of the Institute of Oncology in Gliwice with MRS (about 2500 patients), D. Bula has defined local recurrence risk factors. Dutch studies convincingly documented the prognostic value of the estimated molecular profiles of the resected margins as additional risk factors. The use of conventional 2.0 Gy/ fraction post-MRS-RT result in a high risk of the inserted reconstructive flap necrosis or rejection. Therefore, a novel IMRT­-VMAT technique with 50 Gy given in 1.5–1.6 Gy/fraction has been designed which allows to almost eliminate the flap from the irradiated volume and therefore minimizes recurrence and/or flap rejection to almost zero. The present paper shows objectively selected a cluster of patients being the candidate to post-MRS safe and effective VMAT radiotherapy.

Effects of ischemic conditioning on head and neck free flap oxygenation: a randomized controlled trial

Flap failure after microvascular reconstructive surgery is a rare but devastating complication caused by reperfusion injury and tissue hypoperfusion. Remote ischemic conditioning (RIC) provides protection against ischemia/reperfusion injury and reduces tissue infarction. We hypothesized that RIC would enhance flap oxygenation and exert organ-protective effects during head and neck free flap reconstructive surgery. Adult patients undergoing free flap transfer surgery for head and neck cancer were randomized to receive either RIC or sham-RIC during surgery. RIC consisted of four cycles of 5-min ischemia and 5-min reperfusion applied to the upper or lower extremity. The primary endpoint, tissue oxygen saturation of the flap, was measured by near-infrared spectroscopy on the first postoperative day. Organ-protective effects of RIC were evaluated with infarct size of rat hearts perfused with plasma dialysate from patients received RIC or sham-RIC. Between April 2018 and July 2019, 50 patients were randomized (each n = 25) and 46 were analyzed in the RIC (n = 23) or sham-RIC (n = 23) groups. Tissue oxygen saturation of the flap was similar between the groups (85 ± 12% vs 83 ± 9% in the RIC vs sham-RIC groups; P = 0.471). Myocardial infarct size after treatment of plasma dialysate was significantly reduced in the RIC group (44 ± 7% to 26 ± 6%; P = 0.018) compared to the sham-RIC group (42 ± 6% to 37 ± 7%; P = 0.388). RIC did not improve tissue oxygenation of the transferred free flap in head and neck cancer reconstructive surgery. However, there was evidence of organ-protective effects of RIC in experimental models.Trial registration: Registry number of ClinicalTrials.gov: NCT03474952.

Postoperative care in ICU versus non-ICU after head and neck free-flap surgery: a systematic review and meta-analysis

ObjectiveAdmission to the intensive care unit (ICU) has long been considered as routine by most head and neck surgeons after microvascular free-flap transfer. This study aimed to answer the question...

Trends in Number of Women Speakers at the American Head and Neck Society Meetings, 2007-2019

The number of female speakers at American Head and Neck Society (AHNS) conferences should ideally be consistent with the number of women entering head and neck surgery fellowships to ensure gender equity in the field. Yet the presence of women speakers at the annual AHNS meetings, which is specific to the field of head and neck cancer, endocrine and microvascular reconstructive surgery, has yet to be studied. To determine whether the proportion of female speakers at the AHNS has increased in a manner consistent with the numbers of women entering fellowships since 2007. This qualitative study assessed 13 final meeting programs from AHNS national/international conferences from 2007 to 2019. The number of male and female participants in different roles throughout the meeting were retrospectively tracked. Participants were male and female speakers at AHNS national/international conferences who took part in the roles of scientific session presenter, scientific session moderator, expert panelist, miscellaneous moderator, and named lecturers/keynote speaker. Gender of the speaker was determined by searching names on the internet and using available published pronouns. Number of speaking opportunities for men and women in different roles from 2007 to 2019 as well as number of men and women entering AHNS fellowships since 2007 and new active AHNS members since 2012. In this qualitative study, from 2007 to 2019, 4059 speakers were identified. Of these speakers, 902 (22%) were women and 3157 (78%) were men. Overall, there was a strong correlation between increasing years and number of women speakers from 2007 to 2019 (ρ = 0.75; 95% CI, 0.72-0.78). There were 2096 invited speaking roles that excluded research presentations, of which 400 were offered to female participants (19.1%) across the study period. There were 131 different women that made up all 400 of the opportunities that were offered to women in the years surveyed. There was a strong correlation in the proportion of women as presenters for oral abstracts, expert panelists, and miscellaneous moderators between the years but no correlation in scientific session moderators and named lecturers/keynote speakers. Of the 45 named lecturers/keynote speakers in the programs tracked, only 2 were women. In this study, from 2007 to 2019, the presence of women at ANHS has increased overall, reflecting the changing demographic characteristics of those entering in head and neck oncology and microvascular surgery fellowships. However, a strong disparity continues to exist for preeminent speaking opportunities.

Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer

We aimed to describe the prevalence of postoperative complications and evaluate its relationship with underweight, obesity, preoperative nutritional status, and systemic inflammation status in patients undergoing microvascular reconstruction for oral and maxillofacial cancer. Patients who were ≥20 years old and underwent microvascular reconstruction surgery between January 2009 to June 2019 were investigated. Patient demographics including body mass index, prognostic nutritional status, and neutrophil-lymphocyte ratio were collected. Logistic regression analysis was applied to evaluate these impacts on postoperative complications. A postoperative complication was defined as a Clavien–Dindo classification more than or equal to II. Of the 145 patients included in the analysis, 83 patients (57.2%) experienced postoperative complications, belonging to a Clavien–Dindo classification Ⅱ (n=71), Ⅲb (n=11), and Ⅳa (n=1). Multiple logistic regression revealed that a body mass index less than 18.5 kg/m2 (odds ratio 6.19, 95% confidential interval 1.34–28.6, P=0.02) was related to postoperative complications. Another multiple logistic regression model including all explanatory factors found that underweight (P=0.03) was related to postoperative complications. This retrospective study showed that preoperative underweight was associated with postoperative complications as evaluated by the Clavien–Dindo classification.

Flap Failure and Salvage in Head and Neck Reconstruction.

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.

Quality of life in patients with oral hard or soft tissue defects after reconstructive microsurgery

With current advances in medicine, many surgical methods have emerged for the reconstruction of soft and hard tissue defects of the head and neck. Current literature provides only a limited amount of evidence in studies addressing differences in quality of life for specific therapeutic measures in microvascular reconstruction. The validated University of Washington quality of life questionnaire version 4 (UW-QoL v4), a distress thermometer, and two questions addressing donor-site morbidity were sent to 134 patients at a tertiary care centre. All participants had undergone a type of microvascular reconstructive surgery of the head and neck. They were distributed into three groups according to the defect and type of treatment: defects reconstructed by soft-tissue microvascular tissue transfer, defects involving the hard tissue and treated by alloplastic reconstruction, and hard tissue defects receiving microvascular osseous reconstruction. A total of 82 patients completed the questionnaire in full and returned it. Patients from all the groups showed improved distress thermometer values postoperatively. Those who underwent osseous microvascular reconstruction had better functional items than those who had alloplastic reconstruction plates. Donor-site morbidity was rated low in all groups. Microvascular osseous reconstructive surgery might help to improve functional outcomes in patients with osseous defects more than alloplastic reconstruction.

An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery

The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ2 test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.

Head and neck ablative and microvascular reconstructive surgery in the UK: current operating team composition.

We sought to explore the current landscape of team composition in the provision of major head and neck ablative and reconstructive surgery in the UK. We conducted a survey of maxillofacial surgery units and compiled data on the operating model adopted at each institution. Our survey confirmed 54 active maxillofacial units undertaking microvascular free flap reconstructive surgery, with 44 (82%) hospitals adopting a two-team operative approach. We found no significant association between hospital type and volume of free flaps undertaken and prevailing operating team model. Our study provides an interesting snapshot of the current head and neck microvascular reconstructive practice in the UK.

A prehabilitation protocol to reduce blood transfusion requirement in head and neck microvascular reconstructive surgery

Introduction The surgical management of head and neck tumours and osteonecrosis of the mandible, often involves reconstructive surgery with free tissue transfer. There is evidence that blood transfusion increases rates of, cancer recurrence, treatment associated morbidity and prolonged hospital stay, with additional cost. This project was designed to identify the risk factors associated with increased blood transfusion requirement, and to develop a prehabilitation protocol to reduce blood transfusion requirement.

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery.

Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck. To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck. In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018. Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked. Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications. Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit. NA.

Pilot study on microvascular anastomosis: performance and future educational prospects.

SUMMARYThe introduction of microvascular free flaps has revolutionised modern reconstructive surgery. Unfortunately, access to training opportunities at standardised training courses is limited and expensive. We designed a pilot study on microvascular anastomoses with the aim of verifying if a short course, easily reproducible, could transmit microvascular skills to participants; if the chosen pre-test was predictive of final performance; and if age could influence the outcome. A total of 30 participants (10 students, 10 residents and 10 surgeons) without any previous microvascular experience were instructed and tested during a single 3 to 5 hour course. The two microanastomoses evaluated were the first ever performed by each participant. More than the half of the cohort was able to produce both patent microanastomoses in less than 2 hours; two-thirds of the attempted microanastomoses were patent. The pretest predicted decent scores from poor performances with a sensitivity of 61.5%, specificity of 100%, positive predictive value of 100% and negative predictive value of 40%. Students and residents obtained significantly higher scores than surgeons. Since our course model is short, cost-effective and highly reproducible, it could be introduced and implemented anywhere as an educational prospect for preselecting young residents showing talent and natural predisposition and having ambitions towards microvascular reconstructive surgery.