Neck Free Flap Reconstruction Research Articles

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

IntroductionCoronavirus 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.MethodsThis 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.ResultsData 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.ConclusionDespite 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.Level of Evidence4 Laryngoscope, 2023

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.

Identifying Factors of Operative Efficiency in Head and Neck Free Flap Reconstruction

Head and neck oncological resection and reconstruction is a complex process that requires multidisciplinary collaboration and prolonged operative time. Numerous factors are associated with operative time, including a surgeon's experience, team familiarity, and the use of new technologies. It is paramount to evaluate the contribution of these factors and modalities on operative time to facilitate broad adoption of the most effective modalities and reduce complications associated with prolonged operative time. To examine the association of head and neck cancer resection and reconstruction interventions with operative time. This large cohort study included all patients who underwent head and neck oncologic resection and free flap-based reconstruction in Calgary (Alberta, Canada) between January 1, 2007, and March 31, 2020. Data were analyzed between November 2021 and May2022. The interventions that were implemented in the program were classified into team-based strategies and the introduction of new technology. Team-based strategies included introducing a standardized operative team, treatment centralization in a single institution, and introducing a microsurgery fellowship program. New technologies included use of venous coupler anastomosis and virtual surgical planning. The primary outcome was mean operative time difference before and after the implementation of each modality. Secondary outcomes included returns to the operating room within 30 days, reasons for reoperation, returns to the emergency department or readmissions to hospital within 30 days, and 2-year and 5-year disease-specific survival. Multivariate regression analyses were performed to examine the association of each modality with operative time. A total of 578 patients (179 women [30.9%]; mean [SD] age, 60.8 [12.9] years) undergoing 590 procedures met inclusion criteria. During the study period, operative time progressively decreased and reached a 32% reduction during the final years of the study. A significant reduction was observed in mean operative time following the introduction of each intervention. However, a multivariate analysis revealed that team-based strategies, including the use of a standardized nursing team, treatment centralization, and a fellowship program, were significantly associated with a reduction in operative time. The results of this cohort study suggest that among patients with head and neck cancer, use of team-based strategies was associated with significant decreases in operative time without an increase in complications.

A retrospective analysis of pain and opioid usage in head and neck free flap reconstruction.

Investigate opioid usage and postoperative pain in patients undergoing head and neck free flap surgery. A retrospective review of 100 consecutive patients undergoing head and neck free flap reconstruction at two academic centers was performed. Data captured included demographics, postoperative inpatient pain, pain at postoperative visits, morphine equivalent doses (MEDs) administration, medication history, and comorbidities. Data were analyzed using regression models, χ 2 tests, and student's t-tests. Seventy-three percent of patients were discharged with opioid medication, with over half (53.4%) continuing to take opioids at their second postoperative visit, and over one-third (34.2%) continuing to take them around 4-monthpostoperatively. One out of every five (20.3%) opioid-naïve patients chronically took opioids postoperatively. There was a poor association between inpatient postoperative pain scores and daily MEDs administered (R 2 = 0.13, 0.17, and 0.22 in postoperative Days 3, 5, and 7, respectively). Neither preoperative radiotherapy nor postoperative complications were associated with an increase in opioid usage. For patients undergoing head and neck free flap operations, opioid medications are commonly used for postoperative analgesia. This practice may increase the chance an opioid-naïve patient uses opioids chronically. We found a poor association between MEDs administered and patient-reported pain scores, which suggests that standardized protocols aimed at optimizing analgesia while reducing opioid administration may be warranted. Level of Evidence: 3 (Retrospective cohort study).

Analysis of Flap Failures in Microvascular Head and Neck Reconstructions: 11-Year Single-Center Results

AbstractBackground Free flap reconstruction is the gold standard in head and neck reconstructions. The current article analyzes failed free flaps in the head and neck region during an 11-year period in a single center aiming to discover factors that could be influenced in order to reduce the risk for flap failure.Methods During the 11-year study period, 336 patients underwent free flap reconstruction at Tampere University Hospital, Tampere, Finland. The patients' average age was 62 years (range 14–92 years). Note that 201 (61.5%) of the patients were women and 135 (38.5%) men. Medical records were reviewed for demographics, comorbidities, neoadjuvant and adjuvant therapies, free flap type, area of reconstruction, and intraoperative and postoperative complications. Statistical analyses were performed.Results Ten (3%) of the 336 free flaps failed. Patients' age, comorbidities, smoking, dosage of anticoagulation, free flap type, or the location of the defect did not influence the risk of flap failure. All lost flaps were postoperatively followed by clinical monitoring only. In contrast, 89% of all flaps had both Licox (Integra LifeSciences Corp, NJ) and clinical follow-up postoperatively. In six (60%) of the failed cases, a second free flap surgery was performed as a salvage procedure, with a survival rate of 83.3%.Conclusion Our free flap success rate of 97% is in accordance with that of other centers that perform head and neck reconstructions. According to our findings, free flap reconstructions can be successfully performed on elderly patients and patients with comorbidities. Smoking did not increase the flap loss rate. We encourage the use of other methods in addition to clinical monitoring to follow the flaps after head and neck free flap reconstructions. All flap types used have high success rates, and reconstruction can be conducted with the most suitable flaps for the demands of the defect.

Preoperative low-molecular weight heparin chemoprophylaxis in head and neck free flap reconstruction

BackgroundThe safety of presurgical thromboprophylaxis using low molecular weight heparin (LMWH) has not been well described in head and neck oncologic surgery with free tissue transfer (HNS-FTT). MethodsRetrospective chart review of HNS-FTT patients receiving versus not receiving presurgical subcutaneous enoxaparin (Px-LMWH) was performed. Outcomes included estimated blood loss (EBL), hematoma, flap compromise, DVT or pulmonary embolus (PE). Fisher's exact test and Wilcoxon Rank Sum test were performed to compare groups. Odds ratios and associated 95 % confidence intervals were provided as appropriate. Results43 of 128 patients (34 %) received Px-LMWH. There was no significant difference in EBL, hematoma, or flap complications between groups. Patients without Px-LMWH had higher rates of DVT and PE, although the difference did not reach statistical significance (p = 1.00, 0.095, respectively). ConclusionPresurgical Px-LMWH can be used in major head and neck reconstructive surgery without increased intraoperative blood loss or postoperative complications. Larger studies will need to be done to determine the impact of Px-LMWH on DVT and PE in this patient population. Level of evidence3.

Clinical assessment of early mobilization after head and neck free flap reconstruction: A retrospective case-control study.

We examined whether there were any differences in perioperative complications between patients who mobilized on the first postoperative day (early mobilization) and those who mobilized on the second postoperative day after head and neck reconstruction using free tissue transfer. In the control group (n=74), patients were instructed to mobilize on the second postoperative day (April 2019-March 2020), while in the early mobilization group (n=101), patients were instructed to mobilize on the first postoperative day (April 2020-March 2021). Mobilization was defined as maintaining a standing position or walking. Clinical data were collected from medical records and retrospectively analyzed. There were no significant differences in clinical background factors, with the exception of intraoperative blood loss volume. The proportion of patients who successfully mobilized on the day of instruction was significantly lower in the early mobilization group (89.1% vs. 98.7%). One case of total flap loss and four cases of partial flap loss occurred in the control group, and three cases of partial flap loss occurred in the early mobilization group. There was no significant difference in partial or total flap loss between the two groups. There were no significant differences in other perioperative complications (wound infection, postoperative bleeding, and delirium) between the two groups. The median postoperative hospital stay was 24.5 and 25.0 days in the control and early mobilization groups, respectively. In this study, early mobilization on the first day after head and neck free flap reconstruction was safe and feasible.