Neck Free Flap Reconstruction Research Articles

Is the Sublingual Artery a Reliable Alternative for Intraoral Anastomoses in Head and Neck Free-Flap Reconstruction? Anatomical Basis and Preliminary Results

Background/Objectives: Head and neck free-flap reconstructions are often required to treat tumors or extensive post-traumatic jaw defects. The facial artery is the standard receiving vessel for intraoral microvascular anastomoses. However, its use is associated with several disadvantages, such as lesions of buccal nerve branches of the facial nerve or the parotid duct, as well as variability in course and diameter. The aim of this study is to investigate whether branches of the sublingual artery can be considered as an alternative intraoral supply vessel to the facial artery to avoid these drawbacks. Methods: Twelve formalin-fixed cadaveric heads with 24 sides (n = 24) were dissected. The origin, course, branching pattern, and distribution of the sublingual artery were examined. In addition, the diameters of the branches of the sublingual artery were assessed to identify potential supply vessels for anastomoses. Results: In ten of the twenty-four cases (41.7%), the sublingual artery originated from the lingual artery, and in nine cases (37.5%), the lingual artery originated from the facial artery. The main trunk of the sublingual artery was present in the floor of the mouth in all cases (100%), with a diameter of ≥0.9 mm in vitro (1 mm in vivo). In 15 of the 24 half heads (62.5%), branches of the sublingual artery with ≥0.9 mm were identified in this space, with the main branch being considerably stronger. Conclusions: The large diameter of the sublingual artery in the floor of the mandible suggests that this vessel or its branches could be considered as alternative pedicles for intraoral anastomoses in mandibular microvascular free-flap grafts.

The Effect of Evaluating Perfusion with Infrared Fluorescent Angiography on Flap Survival in Head and Neck Free Flap Reconstruction.

Intraoperative fluid management is one of the most important factors affecting optimal perfusion in the microcirculatory area in patients that undergo flap surgery. While insufficient fluid administration in the intraoperative period leads to flap complications and organ dysfunction, volume load can cause complications such as edema in the denervated flap tissue, the opening of the sutures, or fat necrosis. The Infrared Fluorescent Angiography Perfusion Evaluation Device (SPY) is one of the many noninvasive techniques that evaluate the well-being of microcirculation at the tissue level. This device monitors and scores the perfusion distribution in the flap area. This retrospective study aimed to investigate the effect of fluid resuscitation in head and neck free flap transfer surgery on flap quality and patient outcomes according to the change in SPY scores. This study included 39 ASA I-II patients who were aged 18-60 years and underwent simultaneous free flap reconstruction of the head and neck between 2015 and 2021. Patients' blood pressure, body temperature, hemoglobin, pH, and lactate values were recorded at both baseline and end of the operation. Also, the SPY "Infrared Fluorescent Angiography Perfusion Evaluation Device" scores, the amount of intraoperative fluid and transfusion, bleeding and urine output, and the duration of mechanical ventilation, anesthesia and surgery, and the duration and amount of drainage, the length of stay in hospital and intensive care unit, and the presence of flap infection, detachment, necrosis and loss, and re-exploration rate were recorded for the patients. The difference between the first and last measured SPY values was observed to be positively correlated with the length of stay in the hospital and intensive care unit and the duration of drainage. There was a positive correlation between the length of stay in the hospital and intensive care unit and the duration of drainage, the amount of drainage, as well as the duration of anesthesia and the duration of surgery (p < 0.001). A positive correlation was found between the amount of drainage and the amount of crystalloid solution administered (r = 0.36, p < 0.05). In patients with flap infection, the difference between SPYfirst and SPYlast, the duration of anesthesia, and the duration of surgery were significantly higher. The amount of crystalloid solution given and bleeding and the duration of anesthesia and surgery were found to be significantly higher in mechanically ventilated patients (p < 0.05). It has been concluded that SPY-guided fluid management can be beneficial in preventing morbidities, such as extended hospital and intensive care stay, by reducing flap infection, mechanical ventilation duration, and drainage, with early diagnosis of insufficient perfusion.

Free Latissimus Dorsi Flaps in Head and Neck Reconstruction at a Modern High-Volume Microsurgery Center.

Over the past two decades, with the introduction of the perforator flap concept and advances in flap dissections, lower extremities have emerged as the preferred soft tissue flap donor sites. As a modern and high-volume microsurgical center, and the senior author being one of the pioneers and advocates for the use of lower extremity flap donor sites, we aim to investigate the role of latissimus dorsi (LD) free flap in head and neck reconstruction within our current practice. All free LD flaps used for head and neck reconstruction performed by a single surgeon between January 2010 and June 2023 were reviewed for their indications and immediate and short-term outcomes. A total of 1,586 head and neck free flap reconstructions were performed, and 33 free LD flaps were identified. The patients' median age was 53 (interquartile range [IQR] 48.5-63.5) years. Twenty-nine (87.9%) flaps were used to reconstruct oro-maxillo-facial and four (12.1%) flaps were used to reconstruct scalp defects. Most patients had prior radiation (n = 28, 84.8%), neck dissection (n = 24, 72.7%), and multiple previous head and neck flap reconstructions with a median of 3.0 (IQR 3.0-3.5) previous flaps. Six (18.2%) LD flaps were used to replace failed flaps from other donor sites. No major complications such as total flap failure or takebacks, and no need for vein grafts but three (9.1%) had flap marginal necrosis. Other complications included one flap dehiscence (3.0%), one orocutaneous fistula (3.0%), two wound infections (6.1%), three plate exposures (9.1%), and three patients who developed local recurrence (9.1%). The median patient follow-up time was 16 (IQR 5-27) months. This retrospective study demonstrates the role of LD free flap in head and neck reconstruction as a reliable and versatile backup soft tissue flap when workhorse flaps from lower extremity donor sites are either unavailable or unsuitable.

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

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

Head and neck free flap reconstruction under the COVID-19 pandemic.

High perioperative mortality and complication rates during the coronavirus disease 2019 (COVID-19) pandemic have been reported. In head and neck reconstruction, not only is patient safety important, but the prevention of infection introduced by the surgical team is also important because the procedure is performed in close proximity to the upper respiratory tract. In addition, recent studies have reported an increased risk for thrombus formation after infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 vaccination, which is problematic for microsurgical reconstruction procedures. At the authors' institution, patients undergoing head and neck reconstruction are requested to stay home for 2 weeks and undergo screening tests for COVID-19 before admission. Surgeons use standard personal protective equipment during surgery. There was no significant difference in the rate of total flap necrosis between the COVID-19 and non-pandemic periods or large difference of perioperative complication rates between vaccinated and non-vaccinated patients. No surgery-related infections among the surgical staff were also found.

Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index.

Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors. A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications. A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003). The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.

Donor site scar preference in head and neck free flap reconstruction: The patient point of view

BackgroundSeveral free flaps are nowadays available for functional reconstruction after hemi-glossectomy in head and neck oncologic surgery. Radial forearm free flap (RFFF) and anterolateral thigh (ALT) have been played a workhorse role until recent years, when other valuable options such as Medial Sural Artery Perforator (MSAP) flap and Profunda Artery Perforator (PAP) flap demonstrated to be suitable contenders and are increasingly taken into account. This study aims to investigate the preference of the donor site in the light of esthetical and functional outcomes. MethodsThe participants attended a one-to-one interview with a surgeon explaining a standardized head and neck oncological procedure requiring a soft tissue reconstruction. The donor site preference in terms of esthetical, functional and overall outcomes among these four flap options was investigated. ResultsUnivariable and multivariable analysis were performed comparing the donor site preference between the two most widespread free flap RFFF vs ALT. Subsequently, the analysis was performed comparing RFFF, ALT, MSAP and PAP. ConclusionsThe study illustrated that a diverse group of patients exhibits similarly diverse preferences and expectations. As we observe a shift in the age distribution of patients with OSCC from the fifth-sixth decade towards the two extremes, and an increased incidence in the female population, it becomes essential to enhance reconstructive options provided to patients. This ensures that, while maintaining an equivalent functional outcome, we maximize patient satisfaction to the fullest extent possible.

Microvascular anastomosis in head and neck free flap reconstruction using the RoboticScope

Microvascular anastomosis in head and neck free flap reconstruction using the RoboticScope

Malnutrition in Head and Neck Free Flap Reconstruction as a Predictor of Adverse Outcomes.

Malnutrition is associated with increased mortality in patients with head and neck (H&N) cancer. Because albumin levels are used as a surrogate for nutritional status, the purpose of this study is to assess whether malnutrition is associated with adverse postoperative outcomes in H&N free flap reconstruction. The 2006-2018 National Surgical Quality Improvement Program Database was queried for patients undergoing flap procedures of the H&N based on Current Procedure Terminology codes. Patients were included if they were operated on by an otolaryngologist or when the primary surgical site was H&N. Nutritional status was categorized as malnourished (preoperative albumin level <3.5 g/dL) or normal (preoperative albumin level ≥3.5 g/dL). Major complications included pulmonary complications, cardiac complications, deep vein thrombosis/pulmonary embolism, and sepsis/septic shock. Minor complications included surgical infection, urinary tract infection, bleeding, and dehiscence. Data were analyzed via univariate chi-square and multivariate regression analyses. Of the patients, 2532 (83.3%) had normal albumin and 506 (16.7%) had hypoalbuminemia. Patients with hypoalbuminemia were more likely to have smoking history (P = 0.008), pulmonary comorbidity (P < 0.001), renal comorbidity (P = 0.018), disseminated cancer (P < 0.001), steroid use (P < 0.001), recent weight loss (P < 0.001), bleeding disorder (P = 0.023), and preoperative transfusion (P < 0.001). After adjustment for preoperative variance, malnourished patients were more likely to experience death (P < 0.001), return to operating room (P < 0.001), free flap failure (P = 0.008), pulmonary complication (P < 0.001), deep vein thrombosis/pulmonary embolism (P = 0.019), wound disruption (P = 0.042), intraoperative transfusion (P < 0.001), minor complication (P < 0.001), major complication (P < 0.001), and extended length of stay (P < 0.001). Of the patients with normal albumin, 2.1% experienced flap failure compared with 6.3% of patients with hypoalbuminemia. It should be noted that malnourished patients were 3.370 times more likely to experience flap failure (95% confidence interval, 1.383-8.212; P = 0.008) and 3.975 times more likely to experience death (95% confidence interval, 1.700-9.626; P = 0.001) than those with normal albumin. Malnutrition is associated with death, flap failure, minor complications, and other major complications following H&N free flap surgery, even after controlling for preoperative variance. Optimizing preoperative nutrition status before free flap procedures may ameliorate morbidity and mortality in H&N patients.

Second sensor to improve near-infrared spectroscopy flap monitor utility: A prospective study.

This study assesses whether use of continuous noninvasive near-infrared spectroscopy (NIRS) sensor on head and neck free flap (FF) with a second sensor on nonoperated tissue improves distinction between systemic hypoperfusion and FF compromise. Single-institution, prospective study of patients undergoing head and neck FF reconstruction from December 2018 to April 2020. FFs were continuously monitored using NIRS on a monitor paddle with a second (control) sensor on the shoulder. Crude StO2 and percent change in StO2 were compared between the FF and control sensors on each patient, and percent change and percent difference between the control and the monitor paddle were documented to assess for congruity. Sentinel events (e.g., hypotension and hematoma) were documented to assess the association with change in StO2. These events and timing of StO2 changes were noted to assess associations with change in StO2. A total of 48 patients had complete data. Donor sites included 35 soft-tissue FFs and 13 fibula FFs. Average StO2 was 73.7 ± 5.5 for FFs and 71.4 ± 5.0 for control sensors. There were seven sentinel events during the study. At the time of the events, StO2 dropped significantly more for the FF than the control sensor (FF = 52.2% drop; control = 6.2% drop; p = .016). NIRS signal denoted change prior to changes in implantable arterial Doppler in all cases. The addition of a second sensor when using NIRS as a primary modality for FF monitoring may improve distinction between FF compromise events and systemic hypoperfusion. By increasing accuracy of the monitor, there is a potential for decreased resident burden and decreased use of higher level of care nursing, which could reduce overall costs.

Millions Saved in Head and Neck Free Flap Reconstruction at a High-Volume Center: A Cost Analysis

Background: Within a resource-limited healthcare system, an emphasis on financial accountability is imperative. Over the past decade at our institution, there have been many operational changes employed to improve patient care during oncologic head and neck resections with free flap (HNFF) reconstruction. The objective of this study is to assess whether these changes are associated with cost savings. Methods: A retrospective cohort study that included consecutive patients treated from January 2007 to February 2020 was performed. The perspective of the third payer party was used and direct costs were considered. The peri-operative period was defined as the day of surgery and subsequent admission. Total peri-operative cost was defined as staffing, material, reconstructive surgeon, anesthetist, and admission costs. Costs are represented in Canadian Dollars ($CAD) adjusted for inflation. Results: There were 590 consecutive cases. Average age was 61 with a male proportion of 69% (n = 409). Tumor type, need for tracheostomy, neck dissection, anatomic region resected, 30-day re-operation, and re-admission did not change significantly over the study period ( P &gt; 0.05). The mean total operative time per case decreased by 4.1 h over the study period. The median length of stay per patient decreased by 4.5 days. The total peri-operative cost per patient during the study period decreased by $19,928. Net cost savings to the third-party payer over the study period was $8,142,962. Conclusion: A culture of improvement-focused teamwork allowed for several advances over the study period. These were associated with improved patient care, operative efficiency, and significant cost savings of HNFF reconstruction.

Trends of Microsurgical Head and Neck Free Flap Reconstruction and Safety during the COVID-19 Pandemic

Abstract Background The coronavirus disease 2019 (COVID-19) pandemic poses unprecedented challenges among patients with head and neck (HN) cancer that require oncological and reconstructive surgeries. This study aims to identify differences in postoperative outcomes for patients who underwent microsurgical HN free flap reconstruction prior to versus during the COVID-19 pandemic. Methods A retrospective observational study using the American College of Surgeons National Surgical Quality Improvement Program 2019 to 2020 database to identify patients with HN cancer who underwent a vascularized free tissue transfer was undertaken. Two cohorts were created: pre- and during COVID-19. Fisher's exact test and the unpaired Student's t-test were used to evaluate differences in sociodemographic and clinical characteristics between the cohorts. Multivariable logistic regression was used to assess differences in reoperation rates between groups as well as to identify potential risk factors for reoperation. Results A total of 763 patients were analyzed. The mean age of patients in the overall cohort was 63.6 (standard deviation: 11.5) years. Most patients were white (62.7%). Overall, no statistically significant difference was evidenced between cohorts in terms of immediate postoperative outcomes. Similarly, reoperation rates were similar between groups (p &gt; 0.05). Dependent functional status (p = 0.021) and postoperative infection (p &lt; 0.001) were found to be risk factors for reoperation after holding other factors constant. Conclusion HN flap reconstruction can be performed safely during the COVID-19 era. Standardized protocols for patient selection must be strictly followed to avoid disease progression and optimize surgical outcomes. Further studies assessing long-term outcomes during the pandemic are of utmost importance to elucidate the true impact of the COVID-19 pandemic on this population.

Factors Predicting Discharge Disposition Following Head and Neck Free Flap Reconstruction.

Patients undergoing head and neck free flap reconstruction (HNFFR) may have significant change to their baseline functional status requiring inpatient rehabilitation (IPR) after discharge. We sought to identify patient/procedure characteristics predictive of discharge destination. Patients undergoing elective HNFFR between July 2017 and July 2022 were reviewed for discharge destination. Those discharged to IPR versus home were compared across patient/procedure characteristics and physical/occupational therapy metrics. Significance was assessed via bivariate and multivariable analyses. Of the 531 patients, 102 (19.2%) required IPR postoperatively. Patients discharged to IPR versus home were significantly older (70.1 [11.6] vs. 64.1 [13.1] years; p < 0.001) and more likely to lack family assistance (26.5% vs. 8.6%; p < 0.001), require baseline assistance for activities of daily living (ADLs) (31.4% vs. 9.8%; p < 0.001), have baseline cognitive dysfunction (15.7% vs. 6.1%; p = 0.001), were more likely to have neoplasm as the surgical indication for HNFFR (89.2% vs. 80.0%; p = 0.033) and more likely to have a tracheostomy postop (62.7% vs. 51.7%), and had a significantly longer length of stay (11.2 [8.0] vs. 6.8 [8.3] days; p < 0.001). There was no significant difference in gender, donor site, use of tube feeds, and use of assistive devices between the two groups. Following logistic regression, the strongest predictors of discharge to IPR include lack of family assistance (OR = 3.8; p < 0.001) and baseline assistance for ADLs (OR = 4.0, p < 0.001). Certain patient factors predict the need for discharge to rehab after HNFFR. Perioperative identification of these factors may facilitate patient counseling and discharge planning with potential to reduce hospital length of stay and further optimize patient care. III Laryngoscope, 134:2721-2725, 2024.

Free Flap Outcomes for Head and Neck Surgery in Patients with COVID-19.

Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state. This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022. Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period. Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications. 4 Laryngoscope, 134:4521-4526, 2024.

Near-Infrared Spectroscopy for Continuous Noninvasive Monitoring of Free Flap in Head and Neck Reconstruction: Systematic Review of the Literature and Personal Experience.

Buried free flaps represent a reconstructive challenge concerning monitoring of vitality, which is fundamental for an early detection of flap failure and prompt surgical salvage. Many flap monitoring techniques have been developed over time, and there is still no consensus concerning the best monitoring technique for buried reconstructions. We performed a systematic review of the literature on NIRS monitoring for head and neck free flaps. Moreover, we presented a case of orbital reconstruction through a buried free myo-fascial anterolateral tight flap (ALTF) in which postoperative monitoring was performed by means of NIRS. Four studies were included with a total of 200 monitored head and neck free flap reconstructions. Flap survival was reported in 96.5% of studies (n = 193/200) with a 3.5% of total flap failure rate (n = 7/200). We monitored the buried myo-fascial ALTF for 7 post-operative days measuring a regional oxygen saturation (rSO2) ranging from 55% to 72% (mean = 66%). This device appeared to be an efficient choice for monitoring buried flaps, thanks to its ability to measure tissue perfusion deep under the skin, to the continuous availability of recorded data on the monitor, and to its low impact on the patient. Further prospective studies are advised in order to standardize this monitoring technique and define warning values.

Team-Based Surgical Approach to Head and Neck Microvascular Free Flap Reconstruction

Because microvascular free flap reconstruction is increasingly used to restore function in patients with head and neck cancer, there is a growing need for evidence-based perioperative care. To assess the association of different team-based surgical approaches with intraoperative and postoperative outcomes for patients undergoing head and neck free flap reconstruction. This retrospective cohort study of 733 patients was conducted at an academic tertiary care medical center. Head and neck oncologic procedures involving microvascular free flap reconstruction with available intraoperative data collected from January 1, 2000, to December 31, 2021, were included. Patient characteristics including demographic characteristics and comorbid conditions, operative variables, length of stay, and postoperative outcomes were measured. Descriptive statistics and effect size measures were performed to compare the 3 intraoperative surgical team approaches, specifically single surgeon, separate 2-team approach, and integrated 2-team approach; 1:1 nearest neighbor matching without caliper was performed to compare single- vs 2-team and separate and integrated 2-team approaches. Effect size measures including Cramer V for dichotomous variables, the Kendall W coefficient of concordance for ordinal variables, and η2 for continuous variables were reported with 95% CIs to describe precision. Among 733 cases, there were no clinically significant differences in patient demographic characteristics, clinicopathologic characteristics, and choice of free flap reconstruction based on intraoperative surgical team approach. The mean (SD) age was 58.7 (12.4) years, and 514 were male (70.1%). In terms of operative and postoperative variables, there was a difference in operative times and intraoperative fluid requirements among the 3 different techniques, with the integrated 2-team approach demonstrating a mean reduction in operative time of approximately 2 hours (η2 = 0.871; 95% CI, 0.852-0.887; mean [SD] operative time = 541 [191] minutes for the single-surgeon approach, 399 [175] minutes for the integrated 2-team approach, and 537 [200] minutes for the separate 2-team approach) and lower fluid requirements of greater than 1 L (η2 = 0.790; 95% CI, 0.762-0.817). In both unadjusted analyses and propensity score matching, there were no clinically significant differences in terms of ischemia time, use of pressors, postoperative complications (including free flap failure, number of return trips to the operating room, length of stay, or 30-day readmission) based on intraoperative team approach. Findings suggest that the integrated 2-team surgical approach for complex head and neck microvascular reconstruction can be used to safely decrease operative time, with no difference in postoperative outcomes.

Influence of perioperative blood pressure regulation on postoperative delirium in patients undergoing head and neck free flap reconstruction

BackgroundPostoperative delirium (POD) is a serious complication in patients undergoing microvascular head and neck reconstruction. Whether intraoperative and postoperative blood pressure regulation are risk factors for POD remains unclear. This study aimed to highlight the relationships between intraoperative and postoperative blood pressure regulation and POD in microvascular head and neck reconstruction.MethodsData from 433 patients who underwent microvascular head and neck reconstruction at our department of oral and maxillofacial surgery between 2011 and 2019 were retrospectively analyzed. The 55 patients with POD were matched with 55 patients without POD in terms of tracheotomy, flap type, and flap location, and the intraoperative and postoperative systolic and mean blood pressure values were compared between the two groups.ResultsPatients with POD showed lower intraoperative and postoperative minimum mean arterial pressure (MAP) values than patients without POD (60.0 mmHg vs. 65.0 mmHg, p < 0.001; and 56.0 mmHg vs. 62.0 mmHg, p < 0.001; respectively). A lower intraoperative minimum MAP value was identified as predictor for POD (odds ratio [OR] 1.246, 95% confidence interval [CI] 1.057–1.472, p = 0.009). The cut-off value for intraoperative MAP for predicting POD was ≤ 62.5 mmHg (area under the curve [AUC] 0.822, 95% CI 0.744–0.900, p < 0.001).ConclusionsMaintaining a stable intraoperative minimum MAP of > 62.5 mmHg could help to reduce the incidence of POD in microvascular head and neck reconstruction.

Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa.

With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option. Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints. With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.

Deep Abscess Formation After Head and Neck Free Flap Reconstruction: A Critical Appraisal of Current Guidelines for Prophylactic Antibiotics in Head and Neck Surgery

Postoperative infections have a major impact on patient recovery, especially when a second surgical procedure is required. In this study, 342 cases from a retrospective cohort of patients undergoing microvascular free flap reconstruction of head and neck defects, were evaluated with respect to the development of deep abscesses. Two different perioperative antibiotic prophylaxis protocols based on amoxicillin-clavulanate and cefazolin with metronidazole were compared. Streptococcus anginosus was found to be the causative pathogen for the development of abscesses in the head and neck region in all cases in this series. An association for the development of abscesses was found with the use of osteosynthesis material and the use of cefazolin with metronidazole.

Is Head and Neck Free Flap Reconstruction Feasible in Jehovah’s Witness Patients?

Jehovah's Witnesses (JW) population are members of a religious group that refuses blood transfusion. This presents a dilemma for surgical teams when performing major surgical procedures on these patients. This study aimed to assess the safety and feasibility of undergoing microvascular free flaps for maxillofacial reconstruction in JW patients and whether the type of underlying pathology impacts outcomes. This was a multi-institutional retrospective cohort study. The sample consisted of all JW patients who have undergone microvascular free tissue transfer for maxillofacial pathology between January 2016 and January2021. The primary predictor variable was the underlying pathology for which patients underwent head and neck free flap reconstruction; this was benign versus malignant disease. The primary outcome variables were safety, defined as discharge from the hospital with no mortality, and feasibility defined as successful free flap reconstruction. Other variables included age, race, sex, length of surgery, length of hospital stay, and intraoperative use of vasopressors. Data analysis was performed utilizing t-tests for means and χ2 for proportions. Alpha was setat< 0.05. A total of 12 participants from 7 participating sites met the inclusion criteria. There were 9 males and 3 females with a mean age of 58.3±8.3years. There were no deaths in this cohort and all patients were discharged from the hospital. All 12 free flap reconstructions were successful with no incidents of free flap loss; none of the patients received any blood transfusions or any other blood products. Subgroup analysis showed that patients treated for malignant disease versus benign disease had longer operations (11.2±2.9 vs 6.3±0.2hours, P<.01) and a longer hospital length of stay (11.8±4.9 vs 5.3±0.5days, P=.04). Our series supports the safety and feasibility of maxillofacial free flap reconstruction in this challenging subset of patients. Microvascular reconstructive surgeries for malignant diseases often result in longer operative times and hospital stays.