Neck Free Flap Reconstruction Research Articles

Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism.

To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Retrospective cohort study. Single tertiary care center. All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses. Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission. Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

The use of machine learning for predicating complications of free flap head and neck reconstruction.

e18633 Background: The use of machine learning (ML) in plastic and reconstructive surgery has increased over the last decade. However, its use to predict surgical outcomes in head and neck reconstruction has not been well studied. The goal of this study is to assess the performance of ML algorithms trained to predict surgical outcomes of head and neck free flap reconstruction. Methods: Our study cohort included routinely collected data from 4000 patients who underwent free flaps for reconstruction of head and neck defects between January 2005 and December 2018. We developed and tested nine supervised ML algorithms to predict three outcomes of a.) any complication, b.) any major recipient-site complication, and c.) total flap loss. Results: In our sample, 33.7% of patients experienced any complication, 26.5% experienced a major complication at the recipient site and 1.7% experienced total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = .61, sensitivity = .60). Regularized regression had the best performance for predicting major recipient site complication (AUROC=.68, sensitivity = .66), and decision trees were the best predictors of total flap loss (AUROC = .66, sensitivity = .50). Conclusions: We demonstrated that ML models trained using routinely collected data can make clinical useful predictions about who will experience complications. Our models correctly identified between half and two-thirds of patients who experienced post-surgical complications including total flap loss. These models can be applied to readily available clinical and perioperative data to facilitate decision making. Further performance improvements are likely possible with the inclusion of additional variables related to patient health and behavior.

The Impact of Healthcare-Associated Infections in Patients Undergoing Oncological Microvascular Head and Neck Reconstruction: A Prospective Multicentre Study.

Simple SummaryHealthcare-associated infections (HAIs) result in an increased morbidity and a delay in adjuvant therapy—thus increasing the cancer recurrence rates—in patients undergoing oncological microvascular head and neck reconstruction. HAIs also result in a cost increase for the Health System. We prospectively analysed the incidence, clinical characteristics, risk factors and impacts of these infections in 65 patients undergoing head and neck free-flap reconstruction in three third-level university hospitals in Madrid (Spain). The three of them implemented the same antibiotic prophylactic regimen for surgical interventions. The rate of HAIs was 61.54%. The following complications were significantly more frequent in patients with HAIs: need to reoperate (p = 0.009), duration of hospital admission (p < 0.001) and delay in starting radiotherapy (p = 0.009). This manuscript aims to point out the importance of preventing HAIs in head and neck cancer patients, as they have shown a higher risk of postoperative complications.(1) Background: Healthcare-associated infections (HAIs) after head and neck free-flap reconstruction are a common postoperative complication. Risk factors for HAIs in this context and their consequences have not been adequately described. (2) Methods: Ongoing prospective multicentre study between 02/2019 and 12/2020. Demographic characteristics and outcomes were analysed, focusing on infections. (3) Results: Forty out of 65 patients (61.54%) suffered HAIs (surgical site infection: 52.18%, nosocomial pneumonia: 23.20%, bloodstream infection: 13% and urinary tract infection: 5.80%). Methicillin-resistant Staphylococcus aureus (MRSA) and resistant Pseudomonas aeruginosa, Klebsiella pneumoniae and Enterobacter cloacae were the most frequently implicated. The significant risk factors for infection were: previous radiotherapy (Odds ratio (OR): 5.42; 95% confidence interval (CI), 1.39–21.10), anaemia (OR: 8.00; 95% CI, 0.96–66.95), salvage surgery (eight out of eight patients), tracheostomy (OR: 2.86; 95% CI, 1.01–8.14), surgery duration (OR: 1.01; 95% CI, 1.00–1.02), microvascular reoperation <72 h (eight/eight) and flap loss (eight/eight). The major surgical complications were: a need to reoperate (OR: 6.89; 95% CI, 1.42–33.51), prolonged hospital admission (OR: 1.16; 95% CI, 1.06–1.27) and delay in the initiation of postoperative radiotherapy (OR: 9.07; 95% CI, 1.72–47.67). The sixth month mortality rate in patients with HAIs was 7.69% vs. 0% in patients without HAIs (p = 0.50). (4) Conclusions: HAIs were common after this type of surgery, many of them caused by resistant microorganisms. Some modifiable risk factors were identified. Infections played a role in cancer prognosis by delaying adjuvant therapy.

Tracheostomy in free-flap reconstruction of the oral cavity: can it be avoided? A cohort study of 187 patients.

Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy. A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation. A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P=0.007), segmental mandibulectomy (P=0.04), lip-split (P=0.05), floor of mouth resection (P < 0.001), lingual release (P=0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P=0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P=0.04) were associated with tracheostomy use. A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.

Clinical consequences of head and neck free-flap reconstructions in the DM population

Diabetes mellitus (DM) is a common comorbidity and risk factor for postoperative complications in head and neck (H&N) microsurgical reconstructions. Our study focused on the association between DM and individual complications regarding both surgical and medical aspects. A meta-analysis of English-language articles comparing a series of complications between DM and non-DM H&N free-flap recipients was performed by comprehensive meta-analysis (CMA). Twenty-seven articles presented 14,233 H&N free-flap reconstructions, and a subset of 2329 analyses including diabetic cases was included for final analysis. Total postoperative (RR = 1.194, p < 0.001; OR = 1.506, p = 0.030) and surgical (RR = 1.550, p = 0.001; OR = 3.362, p < 0.001) complications were increased in DM subjects. Free-flap failure/necrosis (RR = 1.577, p = 0.001; OR = 1.999, p = 0.001) and surgical site infections (OR = 2.414, p < 0.001) were also increased in diabetic recipients. However, return to the operating room, dehiscence, fistulas, plate exposures, readmissions, and mortalities were not increased in DM patients. DM increased various complications in H&N free-flap reconstructions. Surgical indications should be cautiously evaluated, and aggressive treatments should be implemented for high-risk recipients.

Mortality Within 30 Days After Head and Neck Free Flap Reconstruction: A Systematic Review.

The aim of this systematic review is to analyze the 30-day postoperative mortality in patients undergoing free flap reconstruction for head and neck cancer published in literature and to identify associated factors. The authors performed a literature search between January 1950 and February 2020 in PubMed, EMBASE, and Scopus, using a combination of Medical Subject Headings headings and text keywords related to head and neck cancer; microsurgery or free flap reconstruction; and 30-day mortality. Inclusion criteria were: original studies in English reporting on 30-day mortality after head and neck free flap reconstruction in adult population. Thirty-one publications reported on a total of 13,447 patients who underwent head and neck free flap reconstruction. The published 30-day postoperative mortality ranged from 0% to 6.3%, with an average of 1.21%. A number of studies examined the association between mortality and body mass index, American Society of Anesthesiologists, and comorbidity score and age. One study found that underweight patients had significantly higher mortality. Two studies found no association between the American Society of Anesthesiologists score and 30-day postoperative mortality; however, 1 study reported significantly higher mortality with increased comorbidity score. Regarding association with age, 3 studies found significant higher mortality in older patients, while 5 studies found no difference. The average 30-day postoperative mortality in patients undergoing head and neck free flap reconstruction is 1.21% and is; therefore, not negligible. Careful patient selection and preoperative optimization are essential in order to reduce mortality in head neck free flap reconstruction.

High-definition three-dimensional exoscope for head and neck reconstruction: Prospective analysis of 27 consecutive patients.

To analyze the advantages and disadvantages of a three-dimensional (3D) operating exoscope (OE) in head and neck free flap reconstruction. Twenty-seven consecutive patients (females: 8; mean age: 57.0) were included. After each procedure, both surgeon and nurse were asked to fill out a tailored questionnaire on a three-point Likert scale including 12 items. All microvascular anastomoses were successfully completed, and no related complications were detected with a final free flap survival rate of 100% (mean follow-up of 5.6 months, SD: 3.1 months). The ergonomics, the ease of use, and the possibility to share the view among all the OR members were the best-rated items by the surgeons, while the luminance of the surgical field and the eye strain determined by the 3D glasses can still be improved. Further comparative clinical studies are needed to clarify its real value in substitution to a conventional operating microscope.

Donor-site local anaesthetic infusion catheter as an opioid-sparing agent in free flap reconstruction of the head and neck: a valuable adjunct to an enhanced recovery protocol

This paper presents the results of a retrospective case-controlled cohort study to investigate the effectiveness of a donor-site local anaesthetic infusion protocol to reduce opioid requirements, length of intensive therapy unit (ITU) stay, and incidence of postoperative delirium. Adult free flap head and neck patients were identified from a prospective database (n = 86). There was a significant reduction in mean opioid requirements (p < 0.001). Postoperative delirium was observed in 12 of 35 patients before introduction of the protocol, and in 10 of 51 patients after its introduction (p = 0.139). Donor-site local anaesthetic infusion reduces opioid requirements for patients undergoing head and neck free flap reconstruction, and is a valuable adjunct to an enhanced recovery protocol.

41. Impact of the Development of a Perioperative Antibiotic Pathway on Antibiotic Duration of Therapy, C.difficile Infection Rates and Surgical Site Infection Rates in the Adult Facial Reconstruction Population

BackgroundThere is variability in the duration of peri-operative antibiotic prophylaxis for free flap reconstructions (FFRs) of the head and neck. Complications of FFRs such as surgical site infections (SSIs), can be devastating and lead to vessel thrombosis and flap loss. Infection rates for head and neck free flap reconstructions have been reported to be as high as 20–50% of cases.1Despite recommendations from ASHP, IDSA and CDC, postoperative antibiotics are often prolonged at the clinician’s discretion, with many clinicians administering >24 hours of prophylactic antibiotics in cases of FFRs.MethodsThe departments of infectious disease, otorhinolaryngology and antimicrobial stewardship, developed a pathway for perioperative antibiotics for adult patients undergoing FFRs. Patients with criteria that put them at high risk for SSIs post-operatively, were given up to 72 hours of antibiotics. Patients without these risk factors, were allowed a maximum of 24 hours of antibiotics post-operatively.Next, dissemination and education of the pathway occurred. Our group then collected post –intervention data on antibiotic duration of therapy, C. difficile infections and SSIs in these patients. We collected data over a 6 month period (10/1/2018 to 3/31/2019) for patients undergoing FFRs who received ampicillin/sulbactam (n=33) and compared it to our baseline/pre-intervention data.Perioperative Antibiotic Recommendations for Adult Facial Reconstructive Surgery Pathway ResultsThe mean duration of ampicillin-sulbactam usage decreased from 6.82 days to 4.24 days (p=0.0039). The hospital acquired C.difficile rate decreased from 6.06% to 0% (p=0.4923). The rate of SSIs increased from 3.13% pre-intervention to 9.09%, but this did not reach statistical significance (p=0.6132). One patient in the pre- intervention group and one patient in the post intervention group required a return to the operating room due to SSIs.ConclusionIn conclusion, through the development of a pathway for perioperative antibiotics for adult patients undergoing FFRs, the duration of postoperative antibiotic therapy decreased significantly. The rates of SSIs increased after the pathway was introduced, but this was not statistically significant. The rates of C.difficile infections decreased, but this did not reach statistical significance.Disclosures All Authors: No reported disclosures

Enhanced recovery after surgery for head and neck free flap reconstruction: A systematic review and meta-analysis.

Head and neck free flap reconstruction requires multidisciplinary and coordinated care in the perioperative setting to ensure safe recovery and success. Several institutions have introduced enhanced recovery after surgery (ERAS) protocols to attenuate the surgical stress response and improve postoperative recovery. With multiple studies demonstrating mixed results, the success of these interventions on clinical outcomes has yet to be determined. To evaluate the impact of ERAS protocols and clinical care pathways for head and neck free flap reconstruction. We searched PubMed, SCOPUS, EMBASE, and grey literature up to September 1st, 2020 to identify studies comparing patients enrolled in an ERAS protocol and control group. Our primary outcomes included hospital length of stay (LOS) and readmission. Mortality, reoperations, wound complication and ICU (intensive care unit) LOS comprised our secondary outcomes. 18 studies met inclusion criteria, representing a total of 2630 patients. The specific components of ERAS protocols used by institutions varied. Nevertheless, patients enrolled in ERAS protocols had reduced hospital LOS (MD -4.36days [-7.54, -1.18]), readmission rates (OR 0.64 [0.45;0.92]), and wound complications (RR 0.41 [0.21, 0.83]), without an increase in reoperations (RR 0.65 [0.41, 1.02]), mortality (RR 0.38 [0.05, 2.88]), or ICU LOS (MD -2.55days [-5.84, 0.74]). There is growing body of evidence supporting the role of ERAS protocols for the perioperative management of head and neck free flap patients. Our findings reveal that structured clinical algorithms for perioperative interventions improve clinically-meaningful outcomes in patients undergoing complex ablation and microvascular reconstruction procedures.

Comparison Between the Impact of Vasopressors and Goal-Directed Fluid Therapy on the Management of Free Flap Reconstruction of Head and Neck and Monitoring in ICU.

Head and neck reconstructions are often accompanied with complex long surgical procedures. Free flap tissue transfer is a standard reconstruction method that reestablishes severe tissue defects after resection due to trauma or cancer. Imbalanced fluid resuscitation can extremely harm the outcome of the flap either due to hypoperfusion or edema. Flap-related postoperative complications mainly flap failure necessitates the administration of a large amount of intravenous fluids perioperatively especially with lengthy operative time. Therefore, vasopressors may be used to preserve hemodynamic stability without excessive fluids use. Nevertheless, these vasopressors have long been disfavored as they may provoke anastomosis vasoconstriction leading to graft hypoperfusion and finally flap failure. However, according to recent guidelines, they are now well-thought to be safe. Of note, inotropes have been confirmed to increase blood flow in the anastomosis hence they can replace vasoconstrictors. Recently, goal-directed fluid therapy (GDFT) has been proven to be excellent in high-risk head and neck free tissue transfer surgery as it decreases prolonged intensive care unit (ICU) admission hospitalization and complication rate. Today, GDFT is highly suggested as one of the enhanced recoveries after surgery protocols for major head and neck free flap reconstruction surgery.

The impact of early oral feeding following head and neck free flap reconstruction on complications and length of stay.

Although the concept of maintaining a period of 'nil by mouth' following head and neck reconstruction is commonly held ideas on delaying function have changed dramatically since the introduction of peri-operative care recovery programmes. This study sought to evaluate the outcomes of early feeding on patients undergoing free flap reconstruction of oral defects with particular emphasis on post-operative complications and length of stay. Data was gathered prospectively on two cohorts of patients treated in a tertiary referral centre comparing those undergoing a five-day post-operative period of 'nil by mouth' with a second group in which the aim was to start fluids and soft diet on the day following surgery. Complications and length of stay were evaluated. Both early and late feeding groups comprised of 200 patients. No significant differences were observed in terms of age, gender, smoking and alcohol use or tumour T and N stages between the two groups. 8% of patients had complications at the recipient site but no difference was observed in the rates of flap dehiscence or fistula formation between the two groups. Early feeding was associated with a statistically reduced length of hospital stay (mean 11.6days vs 20.6days, p<0.01). Early oral feeding following head and neck free flap reconstruction is not associated with an increase incidence of peri-operative complications but reduces hospital stay. The latter may have far-reaching implications for patients' physical and psychological well-being in addition to health care resources.

Modified Clavien-Dindo Classification and Outcome Prediction in Free Flap Reconstruction among Patients with Head and Neck Cancer.

Because of limitations caused by unique complications of free flap reconstruction, the Clavien–Dindo classification was modified to include grade “IIIc” for “partial or total free flap failure.” From 2013 to 2018, 116 patients who had undergone free flap reconstruction for head and neck cancer with grade III or higher postoperative complications were grouped using the “Modified” Clavien–Dindo classification. Alcoholism displayed significant predictive effects between grade IIIb and IIIc (72.7% vs. 50%, p = 0.028). Significant differences were observed between grade IIIb and IIIc in the duration of hospital stay (23.1 ± 10.1 vs. 28.6 ± 11.9 days, p = 0.015), duration of intensive care unit stay (6.0 ± 3.4 vs. 8.7 ± 4.3 days, p = 0.001), reoperation times during the current hospitalization (1.4 ± 0.8 vs. 2.0 ± 1.0 times, p < 0.001), and wound infection rate (29.9% vs. 62.5%, p = 0.002). The severity levels were significantly positively correlated with reoperation times during the current hospitalization (p < 0.001), ICU stay (p = 0.001), and hospital stay (p < 0.001). The modified Clavien–Dindo classification with grade IIIc describes the perioperative complications of head and neck free flap reconstruction to predict clinical outcomes based on severity.

Prevalence of Multidrug-Resistant Organisms in Patients Undergoing Free Flap Reconstruction.

The purpose of this study is to evaluate the relationship between antibiotic prophylaxis and prevalence of multidrug-resistant organisms (MDRO) in patients undergoing head and neck cancer reconstruction. Retrospective Chart Review. Retrospective review of patients who underwent head and neck free flap reconstruction at our institution between 2009 to 2016. Of the 145 patients that underwent head and neck tumor removal surgery using free tissue flaps to cover the defect and therafter received antibiotic prophylaxis, 30 (20.7%) developed postoperative surgical site (n = 17, 55.7%) or distant (n = 13, 43.4%) infections. Seven had a multidrug-resistant infection, the most common with Methicillin-Resistant Staphylococcus aureus (MRSA). There was no significant relationship between antibiotic spectrum or duration to the development of postoperative infections or MDRO. Pseudomonas and MRSA infections were low overall with only one multidrug-resistant Pseudomonas infection. The choice of antibiotic prophylaxis should cover organisms these patients are at highest risk for including anaerobes and Gram-negative organisms. A shorter duration of antibiotic prophylaxis should be considered given no increased risk of postoperative infection nor MDRO. Finally, one must be aware of the potential threat of multidrug-resistant Pseudomonas and MRSA amongst this vulnerable population and identity these with culture driven treatment. 4 Laryngoscope, 131:E1881-E1887, 2021.

Intraoperative vasopressors in head and neck free flap reconstruction.

Historically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis. Post hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review. Forty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively. Intraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.

Impact of Prior Oncologic Treatment on Complications and Functional Outcomes in 1751 Head and Neck Free Flap Reconstruction Patients: An Institutional Analysis Using American College of Surgeons National Surgical Quality Improvement Program Methodology

PURPOSE: Patients with head and neck squamous cell carcinoma (HN-SCC) frequently present with locally advanced disease, and many develop locoregional recurrence. Treatment of locally advanced or recurrent HN-SCC often involves neoadjuvant chemotherapy and/or radiation. However, a knowledge gap exists regarding the interplay of toxicities from prior oncologic treatments on successful reconstruction. The aim of this study was to evaluate the effect of prior oncologic treatment, including chemotherapy, radiation, and/or surgery, on long-term outcomes and functional status after head and neck free flap reconstruction utilizing a prospectively maintained database modeled on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). METHODS AND MATERIALS: This is a retrospective review of all head and neck free flap reconstructions at our institution from 2012 to 2019. Data were retrieved from our database, which utilizes NSQIP methodology modified to track major head and neck oncologic reconstructive outcomes. In contrast to the NSQIP, which limits prior treatment to 3 months before the index procedure, our database includes any prior oncologic treatment. RESULTS: One thousand seven hundred fifty-one patients were identified, 1093 of whom received prior oncologic treatment before the principal operative procedure for tumor extirpation and immediate free flap reconstruction. Patients without prior treatment were more likely to be active smokers (25% versus 18%; P < 0.0001) and have body mass index ≥25 (67% versus 53%; P <0.0001), hypertension (55% versus 47%; P < 0.0001), and diabetes (18% versus 12%; P < 0.001). Patients receiving prior treatment had higher rates of steroid use (8% versus 5%; P = 0.019) and preoperative G-tube placement (15% versus 3%; P < 0.0001). On multivariate analysis, prior treatment did not increase the risk of postoperative complications including: flap loss, fistula, infection, hematoma, seroma, reoperation, or readmission (P > 0.05). However, there was a significant increase in the risk of transfusion (odds ratio [OR], 2.01; 95% CI, 1.60–2.53), death within 12 months (OR 1.43; 95% CI, 1.05–1.95), G-tube dependency at 3 months postoperative (OR, 1.42; 95% CI, 1.11–1.81), and poor speech scores (OR, 1.40; 95% CI, 1.01–1.95). When comparing prior surgery versus chemotherapy versus radiation, multivariate analysis indicated that chemotherapy was associated with the highest risk of: transfusion (OR, 2.51; 95% CI, 1.96–3.22), death within 12 months (OR, 1.67; 95% CI, 1.20–2.33), and G-tube dependency at 3 months postoperative (OR, 1.78; 95% CI, 1.37–2.32). Prior radiation as associated with the highest risk of poor postoperative speech scores at 3 months (OR, 1.82; 95% CI, 1.27–2.61). CONCLUSIONS: The goals of HN-SCC treatment and reconstruction include disease stabilization, prolonging survival, and improving quality of life. This study demonstrates prior oncologic treatment is not associated with flap loss or postoperative wound-healing complications, after controlling for confounding factors. It is associated with higher mortality and worse functional outcomes, which may reflect disease burden. Our results demonstrate that free flap head and neck reconstruction is a reasonable choice for well-selected patients with advanced and recurrent HN-SCC, even in the setting of multiple prior treatments, and has the potential to improve quality of life and reduce functional deficits.

Venous Flow Coupler in Head and Neck Free Flap Reconstruction.

To describe the utility of venous flow couplers in monitoring free tissue flaps in the immediate postoperative setting. Retrospective case series. Otolaryngology department at a single tertiary care institution. A retrospective case series of free flap reconstructions in which venous flow couplers were employed to supplement flap monitoring. All free flap cases performed over the past 4 years were reviewed. Inclusion criteria were venous flow coupler and arterial flow Doppler monitored for 5 days postoperatively. From July 2014 through May 2018, the venous flow coupler was used with the arterial flow Doppler and clinical monitoring in 228 cases. Eleven cases did not meet criteria for inclusion; thus, 217 cases were analyzed. Twenty cases (9.2%) returned to the operating room with concern for flap compromise, and 16 were salvaged. The combination of venous flow coupler and arterial flow Doppler identified 19 of these flaps. Venous flow couplers identified 5 compromised flaps before there was an arterial signal change, and all were salvaged. Additionally, there was a 24.1% false-positive rate when 2 venous flow couplers were used in parallel. For the venous flow coupler, the positive predictive value was 64.3% and the negative predictive value, 98.9%. The false-positive rate in the series was 5.1%. The sensitivity was 90% and the specificity, 94.9%. The venous flow coupler is able to detect venous thrombosis in the absence of arterial thrombosis and may contribute to improved flap salvage rates.

Age Is Associated With Pain Experience and Opioid Use After Head and Neck Free Flap Reconstruction.

To describe pain experience and opioid use after major head and neck reconstructive surgery. Retrospective cohort study. Patients undergoing major head and neck surgery with microvascular free tissue transfer (free flaps) at a tertiary academic center were included. Pain scores (0-10) and demographic and clinical data were ascertained from medical records. Discharge opioid prescriptions and refills obtained within 30 days were recorded. Patient characteristics were compared with pain scores using nonparametric rank-sum tests and with likelihood of refill using logistic regression models to calculate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). The study population comprised 445 patients. Median age was 60 years (interquartile range 50-68). Most patients had cancer (N = 350, 78%). The majority of free flaps were fibula (N = 153, 34%) or radial forearm (N = 159, 36%). Older patients reported significantly lower pain scores, whereas patients with opioid tolerance, anxiety, current smokers, and those undergoing larger volume resections or boney free flaps reported significantly higher pain scores. One-quarter (N = 115, 26%) of patients obtained opioid refills. Patients aged ≥ 60 years had one-half the odds of obtaining a refill compared with patients aged < 60 years (adjusted odds ratio [aOR] = 0.52, 95% confidence interval [CI] = 0.33-0.84), whereas surgical defect volume ≥ 100 cm3 (aOR = 1.92, 95% CI = 1.21-3.07) and higher pain score (aOR = 1.19, 95% CI = 1.07-1.32 per 1 point increase) increased the odds of refill. Continued opioid use after discharge is common among patients undergoing major head and neck reconstruction, particularly for younger patients and after more extensive surgery. Older patients reported lower pain intensity and were less likely to obtain opioid refills, highlighting the wisdom of judicious opioid use for this vulnerable population. IV Laryngoscope, 130: E469-E478, 2020.

Posterior external jugular vein: a useful alternative recipient vessel in head and neck free flap reconstructions

In a case of radical cancer ablation, the external jugular vein (EJV) and internal jugular vein (IJV) are sometimes inevitably eliminated. We report the utilization of posterior external jugular veins (PEJV) for recipients in head and neck microvascular free flap reconstruction. This is a report of two male patients, who had defects successfully reconstructed using posterior external jugular veins (PEJV) as recipient vessels. Since the IJV, EJV and adjacent veins had been totally excised in both cases, PEJV were utilized as recipient vessels without any complications. The cases pioneer use of PEJV as alternative recipient vessels in head and neck microvascular reconstruction. Level of evdence: Level V, therapeutic study