Neck Free Flap Reconstruction Research Articles

Intraoperative Use of Vasopressors Is Safe in Head and Neck Free Tissue Transfer

The purpose of this study is to identify whether intraoperative use of vasoactive medications increases the risk of free flap failure or complications through a systematic review and meta-analysis. PubMed/MEDLINE, EMBASE, and Scopus databases were searched for studies published through January 2015. English publications that met the following criteria were included: (1) adult patients undergoing head and neck free flap reconstruction; (2) comparison of patients with and without intraoperative vasopressor administration; and (3) documentation of flap failure rate and/or flap complications. The primary outcome was the incidence of flap failure. The secondary outcome was the incidence of overall flap complications. Meta-analysis was performed to obtain pooled odds ratios (ORs) of the effect of intraoperative use of vasopressors on flap failure and complication rates. Four cohort studies met inclusion criteria. All studies were of high methodological quality with an average Methodological Index for Non-Randomized Studies score of 18.75 (range 16-23). A total of 933 patients undergoing head and neck free flap reconstruction were included. Meta-analysis demonstrated no statistically significant difference in the incidence of flap failure (2.9 vs. 3.6%; OR, 0.68; 95% confidence interval [CI], 0.23-1.99; p = 0.48) or incidence of flap complications (16.8 vs. 18.6%; OR, 0.92; 95% CI, 0.60-1.42; p = 0.71). Based on the current evidence, intraoperative use of vasopressors has no impact on the incidence of flap failure or flap complications.

Vascular Complications After Radiotherapy in Head and Neck Free Flap Reconstruction: Clinical Outcome Related to Vascular Biology.

Radiotherapy as a risk factor for free flap failure has been widely debated. The purpose of this study was to investigate vascular complications in free flap surgery at a center advocating preoperative radiotherapy. On the basis of previous experimental studies, we also aimed to investigate temporal aspects of vascular complications in both arteries and veins. Furthermore, we aimed to study the effect of tissue plasminogen activator (tPA), because irradiated microvascular recipient vessels are associated with impaired fibrinolysis.A retrospective review was conducted for 344 consecutive head and neck microvascular reconstructions. Radiotherapy was administered previously in 283 (82%) of the cases, median dose 64 Gy. Flap outcome, vascular complications, and salvage attempts were identified, along with time elapsed from completed radiotherapy, described as early (<6 weeks), delayed (6-15 weeks) and late (>15 weeks) reconstructions.Total flap loss was more common in irradiated cases (P = 0.035), among which flap failure increased with time elapsed from the last radiotherapy session to surgery (P = 0.021). Among 30 registered vascular complications, venous thrombosis was the most common type and increased in delayed, compared to early, reconstructions (P = 0.012). Increased salvage rates were observed when tPA was administered intraoperatively (P = 0.015).The present study indicates that previous radiotherapy is a risk factor for head and neck free flap failure, especially in delayed reconstructions. This may be linked to previous findings of impaired fibrinolysis in irradiated microvascular recipient veins, which is further supported by the beneficial effect of tPA during salvage surgery. We emphasize the importance of early reconstruction after radiotherapy and suggest that there is a role for fibrinolytic agents during free flap salvage surgery in previously irradiated subjects.

Loupe magnification for head and neck free flap reconstruction in a developing country

Free tissue transfer has become the standard of care for the reconstruction of head and neck oncological defects. The Groote Schuur Hospital provides a microsurgical reconstructive service in a resource-limited setting, without access to venous couplers, invasive monitoring devices, modern microscopes or sophisticated pre-operative imaging. The reconstructive surgeons perform all anastomoses under ×4.5 loupe magnification. A retrospective chart review was undertaken of cases performed by the service over a 3-year period. Demographic factors, indications for flap cover, operative details (flap used, duration and lowest recorded temperature), intensive care and hospital length of stay, and other outcomes were recorded and evaluated (including flap and systemic complications, donor site morbidity, haematomas as well as returns to theatre). Over a 36-month period, 109 flaps for head and neck reconstruction were performed. The main indication for surgery was squamous cell carcinoma of the oral cavity. The mean operating time for resection and reconstruction was 6.02 h (range of 4 to 12 h). Virtually, all reconstructions were performed using one of either radial forearm, free fibula or anterolateral thigh flaps. We report a complete flap loss rate of 6 %. All four successful salvages were undertaken in the early (less than 24 h) post-operative period. Hypothermia intra-operatively appears to correlate very closely with pejorative outcomes. By restricting reconstructive options to three main ‘workhorse’ flaps and by utilising a simultaneous two-team approach for tumour ablation and flap elevation, success rates comparable to international standards have been achieved. Limited resources should not be regarded as an impassable barrier to providing a successful microvascular head and neck reconstructive service. Level of Evidence: Level III, risk/prognostic study.

Antibiotic Prophylaxis in Patients Undergoing Head and Neck Free Flap Reconstruction.

Evidence supports short courses of perioperative antibiotics for patients receiving minor head and neck procedures. Few studies have addressed antibiotic prophylaxis for patients undergoing free flap reconstruction of head and neck defects. To determine ideal antibiotic prophylaxis in patients undergoing head and neck free flap reconstruction. Retrospective cohort study of 427 adults receiving free flap reconstruction of head and neck defects at 2 affiliated tertiary care academic hospitals between January 1, 2006, and January 28, 2013. Prophylactic antibiotic type and duration were recorded from patient records. Outcome data were abstracted from patients' medical records including infection at the surgical sites and distant nonsurgical sites and flap site complications including flap compromise, dehiscence, or fistula. Multivariate logistic regression was used to determine the association of risk factors with the primary outcome of any infection within 30 days of surgery. Ninety-six patients (22.5%) received prophylactic antibiotics for 24 hours or less, and 331 patients received prolonged courses of prophylactic antibiotics. The majority of patients received ampicillin-sulbactam alone for prophylaxis (53.2%), while 36.5% received clindamycin alone and 10.3% received an alternative regimen. Postoperative infections occurred in 46% of patients, and 22% of patients had an infection at the flap inset site or neck incision. The use of clindamycin (odds ratio [OR], 2.54; 95% CI, 1.25-5.14 [P = .01]) was associated with an increased risk of postoperative infection; extended duration of antibiotics (OR, 0.63; 95% CI, 0.34-1.19 [P = .18]) was not associated with increased risk of postoperative infection. By multivariate analysis, use of clindamycin (OR, 6.71; 95% CI, 1.83-24.60 [P = .004]) and oral tobacco use (OR, 1.20; 95% CI, 1.04-1.39 [P = .02]), but not extended course of prophylactic antibiotics (OR, 0.75; 95% CI, 0.30-1.86 [P = .53]), were associated with a higher risk of postoperative flap or neck infections. The choice of antibiotic appears to affect the rate of all postoperative infections and flap site infections more than the duration of antibiotics following head and neck free flap reconstruction. At our institutions, ampicillin-sulbactam is the preferred prophylactic antibiotic for major clean-contaminated head and neck procedures when possible.

Liposuction Contouring After Head and Neck Free Flap Reconstruction

Resection of bulky head and neck tumors is typically followed by microvascular free flap reconstruction. The latter has shown an acceptable success rate but often requires a secondary revision with a free tissue transfer reconstruction to improve outcome; both cosmetic and functional. Direct surgical revision via electrocautery/scalpel poses a high risk of flap perfusion compromise. Suction assisted lipectomy on the other hand is a feasible and safe technique that offers favorable contouring with comparable restoration cosmetic and functional outcomes. In this article, we review the indications and advantages of this technique and provide an outlook on its safety and pitfalls.

Free Flap Outcomes in Previously Irradiated Patients: A Meta‐analysis

Objectives: (1) Understand the types of complications affecting head and neck free flap reconstructions. (2) Compare the incidence of flap complications between patients with and without prior irradiation. Methods: Systematic review and meta-analysis of all studies of head and neck free flap reconstructions between January 1993 and October 2013. Studies that included separate data for patients with and without prior irradiation were analyzed for differences in demographics, flap type, and complications using Poisson regression and odds ratios. Results: Fourteen studies encompassing 701 free flaps in irradiated patients and 328 free flaps in nonirradiated patients were included. The 2 groups were comparable in age ( P = .45), sex ( P = .45), and types of reconstructions. Postoperative complications such as complete flap failure (incidence rate ratio [95% confidence interval] 1.10 [0.59-2.05]; P = .74), fistula (1.93 [0.23-16.19]; P = .24), dehiscence (1.45 [0.70-2.97]; P = .15), infection (1.43 [0.37-5.34]; P = .46), vascular thrombosis (2.24 [0.20-24.46]; P = .27), hematoma (1.98 [0.312-12.57]; P = .27), partial flap loss (2.38 [0.334-17.02]; P = .18), and other complications including vascular compromise and hardware/bone exposure (1.33 [0.63-2.78]; P = .41) were not statistically different between the 2 groups. However, previously irradiated patients demonstrated a higher overall complication rate (46.3% vs 30.5%; 1.57 [1.02-2.41]; P = .001) when all complications were considered together. Conclusions: Head and neck free flap reconstruction in irradiated patients carries an increased risk of complications. The largest effect sizes were seen in risk of fistula, vascular thrombosis, hematoma, and partial flap loss, although these did not individually reach statistical significance. However, overall flap survival was similar in patients with and without radiation.

Head and Neck Free Flap Reconstruction in Patients Older than 80 Years

Free tissue transfer is a reliable method for reconstruction of head and neck defects. With the growing number of octogenarians in the population, it is important to understand how these patients respond to these procedures. Through a retrospective chart review of patients who underwent a free-flap reconstruction from 2000 to 2010 at an academic medical center, 48 patients, aged 80 years and older, were compared with a control group consisting of 97 similar patients, aged younger than 80 years. We compared the intensive care unit (ICU) length of stay, overall hospital stay, and the incidence of perioperative complications between the cohorts. The average length of stay in the ICU was significantly longer for the octogenarian group as compared with the younger group (101 vs. 41 hours, p-value = 0.007). The average length of hospital stay was not significantly different between the two groups (difference = 40 hours, p-value = 0.102). The incidence of perioperative complication was 75% in the octogenarian group and 60% in the younger group (p-value = 0.095). There were two flap failures in the younger group, and none in the octogenarian group. There was a significantly higher rate of death within 30 days in the octogenarian group. Microvascular free tissue transfer is a reliable and safe method of reconstruction of head and neck defects in patients over 80 years of age. Patients should be counseled about the potential risks of increased incidence of medical complications, ICU length of stay, and rate of perioperative death when recommended to undergo free tissue transfer reconstruction.

Success of sequential free flaps in head and neck reconstruction

The need for additional free flaps following an initial free flap reconstruction sometimes arises. However, there is understandable hesitation to perform subsequent free flaps due to concerns regarding recipient vessel availability, flap loss, and other complications. An analysis of patients undergoing one or more sequential head and neck free flap reconstructions between 2000 and 2012 was performed. Two hundred seventy-three free flaps were performed on 117 patients over the course of 2, 3, or 4 surgeries, with 23 patients receiving 2 or 3 simultaneous free flaps in a single surgery. The success rate of subsequent free flaps was 98.7% compared to 99.1% for initial free flaps in the same patients (p=1.00). The complication rate following subsequent free flaps was 42.9% compared to 36.8% following initial free flaps (p=0.46). Flap success rates for double/triple simultaneous free flaps were 97.8% compared to 99.1% for single flaps (p=0.41) and the complication rate for double/triple simultaneous free flaps was 34.6% compared to 47.8% for single flaps (p=0.20). In patients receiving oral or pharyngeal sequential free flap reconstructions, 90.1% demonstrated at least 80% speech intelligibility and 81.6% remained feeding tube-independent. The 5-year survival of patients undergoing sequential free flaps was 75.4%. Multiple sequential free flaps are feasible and reliable in appropriately selected patients. These findings suggest that the ability to perform free flap reconstruction should rarely limit a patient's candidacy for resection of recurrent cancers or consideration for surgery intended to improve patient aesthetics or function.

Rapid awakening protocol in complex head and neck reconstruction

Patients undergoing complex head and neck free flap reconstructions are commonly maintained on mechanical ventilation in an intensive care unit (ICU). This study reviews indications and outcomes of such patients undergoing a rapid awakening protocol (RAP). We retrospectively reviewed consecutive patients who underwent head and neck microvascular reconstructions by a single surgeon between 2001 and 2013. Seventy-five patients underwent RAP and 605 received mechanical ventilation. Overall complications were significantly higher in mechanical ventilation patients than in the RAP cohort (61% vs 31%, respectively; p < .001). Univariate analysis demonstrates mechanical ventilation, age, and aerodigestive tract involvement are significant risk factors for a complication and longer hospital stay. Multivariate logistic regression model demonstrates RAP patients had significantly less risk of a complication (odds ratio [OR] = 0.32; 95% [CI] = 0.19-0.54; p < .001). The recovery of select patients with early extubation/spontaneous breathing is superior to maintenance on mechanical ventilation.

Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta‐analysis

We performed a systematic review and meta-analysis to determine whether diabetic patients have an increased rate of postoperative complications compared to nondiabetic patients after head and neck free flap reconstruction. A systematic review of PubMed Database between 1966 and 2012 was performed. RevMan 5.0 was used for meta-analysis. A retrospective medical chart review of 7890 patients to identify those who had a failed microsurgical reconstruction of the head and neck region at Chang Gung Memorial Hospital was also carried out. The result revealed that patients with diabetes mellitus have a 1.76 increased risk of complications (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.11-2.79) with minimal heterogeneity (I( 2) = 22%; p = .28). The prevalence of diabetes mellitus in patients with failed free flaps for head and neck reconstruction is 15%. The incidence of diabetes mellitus in these patients with failed free flaps is 2.3 times higher than in the general population.

In Situ Pedicle Lengthening of the Anterolateral Thigh Flap

Sir: Having a wide range of applications, the anterolateral thigh flap has almost been the most representative soft tissue with minimal donor-site morbidity.1 Most important of all, with the vascular pedicle mostly arising from the descending branch of the lateral circumflex femoral artery, it can offer a sufficient length for microanastomosis to recipient vessels, especially in the field of head and neck reconstruction. Nevertheless, the complexity of the local vasculature of the anterolateral thigh flap has been well documented. Several studies have pointed out the possibility of no sizable perforators, even with Doppler vascular mapping preoperatively. Also, microsurgeons may need a backup procedure or an alternative.2 In addition, a substantial number of reported variations concerning the lateral circumflex femoral artery plus its branches emphasize the unpredictability of the perforators’ origin. If the only sizable perforator arises from the proximal thigh, it can only provide pedicle length that is less than 10 cm.3 The patient, a 42-year-old man, had been diagnosed with secondary right maxillary squamous cell carcinoma. Due to previous flap surgery, preoperative angiography was performed and only left-side neck vessels were relatively available for the recipient site. The desired pedicle length was determined to be 18 to 20 cm from the right-side upper face to the left superior thyroid artery and external jugular vein. A planned right anterolateral thigh flap was dissected. Nonetheless, the only sizable perforator that could be found was located at 7 cm proximal to the midpoint of the thigh. The perforator retrogradely originated from the oblique branch of the lateral circumflex femoral artery. The pedicle was estimated to be only 6 cm. In order to elongate the pedicle of the anterolateral thigh flap, the perforator was traced to the very beginning of the oblique branch and cut without influencing the blood flow of the descending branch of the lateral circumflex femoral artery. In addition, the descending branch was dissected to the most distal part as a vascular bundle bridge. Without separating the flap in advance, a one-artery and two-venae comitantes anastomosis was performed in situ of the anterolateral thigh incision wound (Fig. 1; Fig. 2, left and center). Utilizing this innovative method, we effectively elongated the pedicle from 6 cm to 18 cm (Fig. 2, right). Without sacrificing any other tissue or incising any other wound for vascular grafts, we successfully lengthened the pedicle of the anterolateral thigh flap and overcame the problems (Fig. 3). No complications were encountered postoperatively, and the flap survived completely.Fig. 1: In situ lengthening of the anterolateral thigh flap pedicle. The original pedicle length is supposed to be (a + c). After dissection of the descending branch of the lateral circumflex femoral artery (b) and performing the new one-artery and two-venae comitantes anastomosis, the pedicle is elongated to (a+ b + c) without extra flap ischemic time.Fig. 2: (Left) Dissecting and identifying the sizable anterolateral thigh perforator originating from the oblique branch of the lateral circumflex femoral artery. Dissecting the descending branch to the most distal part. (Center) In situ anastmosis of the most proximal part of the perforator to the most distal part of the descending branch of the lateral circumflex femoral artery. (Right) The pedicle in situ is successfully lengthened from 6 cm to 18 cm without any extra flap ischemic time.Fig. 3: The pedicle was successfully anastomosed from the right maxillary area to the left lower neck area.Even though the vein graft interposition is a traditionally accepted pedicle bridging technique for microvascular reconstruction, vein grafting of the head and neck free flap reconstruction has rarely been addressed and might have higher failure rates.4 To avoid merely vein grafting, numerous studies have reported harvesting the descending branch of the lateral circumflex vessels for vascular bundle bridging.5 These reports offer the advantage of equal-caliber vessels with adequate length that are not critical to the blood supply of the leg. At this point, we emphasize an “in situ” elongation of the pedicle without consuming extra flap ischemic time. This idea is worth offering as an alternative solution for insufficient anterolateral thigh pedicles. ACKNOWLEDGMENT Special thanks go to Sang-Ju Lin for her assistance in correcting the article’s grammar. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Yu-Hao Huang, M.D. Tung-Ying Hsieh, M.D. Chung-Sheng Lai, M.D., Ph.D. Sin-Daw Lin, M.D. Kao-Ping Chang, M.D., Ph.D. Division of Plastic and Reconstructive Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University Kaohsiung, Taiwan

The role of meperidine in reduction of postanesthetic shivering and its possible impact on flap outcomes

Postoperative vascular compromise is a common but critical complication requiring emergent re-exploration, and remains a chief cause of free flap failure. This study investigated the relationship between postanesthetic shivering (PAS) and the development of postoperative complications associated with free flap reconstruction. One hundred thirty-six patients who underwent head and neck cancer resection and free flap reconstruction were retrospectively enrolled. Fifteen patients were assigned to the PAS group, while the others were assigned to the non-PAS (NPAS) group. The odds ratios of acute re-exploration or total failure of the free flap in the PAS group was 3.5 and 14.9, respectively. The dose of meperidine was positively correlated with PAS prevention in our statistical ROC curve analysis. The minimum effective dose of meperidine for PAS prevention was 0.35 mg/kg with 75% sensitivity and 60% specificity. These findings indicate that an optimal dose of meperidine could prevent PAS, which is shown to be associated with a decrease in the incidence of the early post-surgical re-exploration rate of these free flaps related to circulatory compromise.

An alternative option to overcome difficult venous return in head and neck free flap reconstruction

The frozen neck secondary to prior neck irradiation and surgery is not uncommon in head and neck surgery. Identifying the optimal and alternative recipient vein in patients with difficult necks is one of most important steps in preceding a free flap for head and neck reconstruction. This is a retrospective study. From January 2006 to October 2011, the authors performed 544 cases of free flap reconstruction for head and neck cancer. The indications for choosing the retrograde limb of the superficial temporal vein as recipient vein were: (1) the flap pedicle contained only one vein 'and' (2) the patient had frozen neck or vessel-depleted neck from surgery. Amongst them, 10 patients with difficult neck where the retrograde limb of the superficial temporal vein was used as the only recipient vein for outflow were collected for the study. The mean age was 51.7 years. The types of flaps included the anterolateral thigh (ALT) flap (n=6), anteromedial thigh (AMT) flap (n=1), medial sural perforator flap (n=1) and trapezius perforator flap (n=1). One flap needed take-back due to haematoma compression of the pedicle. All nine flaps survived completely. The retrograde limb of the superficial temporal vein used as the only recipient vein served as an alternative option for venous return to precede a successful free flap reconstruction in difficult neck cases. The presence of valves in the vein system in the head and neck does not seem to preclude the use of retrograde flow anastomosis in patients with frozen neck.

PP153: Safety and efficacy of Low Molecular Weight Dextran (Dextran 40) in head and neck free flap reconstruction

Purpose Antithrombotic agents have been used in microvascular surgeries. Low Molecular Weight Dextran (Dextran 40) though used, is not without complications. Materials and methods Retrospective analysis of 172 consecutive flaps. A comparison was done between two groups of patients (86 flaps each) with and without the use of Dextran 40, in terms of safety and efficacy. Results 168 patients underwent 172 microvascular free flaps for reconstruction of head and neck oncologic defects during the study period. The mean age was 55.6 years (range 18–85 years). The groups were comparable in terms of pulmonary, cardiac co-morbidity and history of any prior radiotherapy. Of the 172 flaps, 26 flaps required re-exploration. 21 flaps could be salvaged. There were five total flap failures. The free flap survival rate was 95.9%. The five free flap failures included one radial forearm free flap, two fibular free flaps and two antero-lateral thigh flaps. There were six partial flap losses. Fourteen flaps had venous thrombosis. Four flaps had arterial thrombosis, of which one each in both the groups could not be salvaged. There were seven patients with postoperative hematoma requiring surgical intervention. All of these free flaps survived after hematoma evacuation. None of the patients developed ARDS or required prolonged ventilator support. No patient had dextran related anaphylactoid reactions. 38 patients (43.7%) in Group A had post-operative atelectasis and 21 (25.6%) patients in Group B had this complication. This difference was statistically significant ( p = 0.01). Six patients in Group A developed post-operative pneumonia while five patients in Group B developed this complication. This difference was statistically not significant ( p = 0.93). The mean duration of intensive care unit stay was 6.8 and 6.9 h respectively for the Groups A and B. Similarly, the mean hospital stay was 14.1 and 13.4 days respectively for the groups A and B. These differences were also not significantly different among the groups. Conclusions Though Dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a post operative antithrombotic agent in head and neck oncologic defect reconstruction with free tissue transfer.

Safety and Efficacy of Low Molecular Weight Dextran (Dextran 40) in Head and Neck Free Flap Reconstruction

Antithrombotic agents have been used in microvascular surgeries. Low molecular weight dextran (dextran 40), though used, is not without complications. Retrospective analysis of 172 consecutive flaps. A comparison was made between two groups of patients (86 flaps each) with and without the use of dextran 40, in terms of safety and efficacy. The free flap survival rate was 95.9%. The flap survival rates were comparable between the groups. Total flap loss in Group A (patients who received dextran 40) was 3.5% compared with 2.3% in Group B (patients who did not receive dextran 40) (p = 1.00). There was no statistically significant difference in the incidence of thrombotic flap complications between the groups. None of the patients developed acute respiratory distress syndrome or required prolonged ventilator support. No patient had dextran-related anaphylactoid reactions. Thirty-eight patients (43.7%) in Group A had postoperative atelectasis and 21 (25.6%) patients in Group B had this complication (p = 0.01). Six patients in Group A developed postoperative pneumonia, and five patients in Group B developed this complication (p = 0.93). Though dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a postoperative antithrombotic agent in head and neck oncologic reconstruction with free tissue transfer.

Impact of preoperative radiotherapy on head and neck free flap reconstruction: A report on 429 cases

The primary objective of this study was to evaluate the impact of preoperative radiotherapy on the outcomes of head and neck microvascular reconstruction. The secondary objective was to assess the specific effects of irradiation doses (IDs) ≥60Gy on the outcomes of head and neck microvascular reconstruction. All patients who underwent head and neck free-flap reconstruction in our institution between 2000 and 2010 were included in this retrospective study. A total of 429 patients were enrolled including 136 patients previously irradiated on the head and neck. The impact of preoperative radiotherapy on free-flap success, local and general complications, postoperative mortality, time of decannulation, duration of enteral nutrition and length of stay was assessed in univariate and multivariate analyses. In multivariate analysis, preoperative radiotherapy (irrespective of ID) was a significant risk factor for fistula formation (p=0.003) and wound infection (p=0.005). Previous neck irradiation at doses ≥60Gy was associated with an increased risk of free-flap failure (p=0.04), overall local complications (p=0.05), haematoma (p=0.04) and longer duration of enteral nutrition (p=0.006) and hospital stay (p=0.004). Preoperative radiotherapy, particularly for ID≥60Gy, is one of the main determinants of the outcomes of head and neck microvascular reconstruction.

Impact of patient comorbidities on head and neck microvascular reconstruction. A report on 423 cases

The aim of this study was to assess the impact of the different subtypes of patient comorbidities on the outcomes of head and neck microvascular reconstruction. A total of 423 patients who underwent head and neck free flap reconstruction in our institution between 2000 and 2010 were included in this retrospective study. The impact of the different subtypes of patient comorbidities (as defined by the Kaplan-Feinstein Index) and other global health status-related factors on free flap success, local and general complications, postoperative mortality and length of stay was assessed in univariate and multivariate analysis. We found no correlation between patient comorbidities and free flap failure. In multivariate analysis, we demonstrated a significant correlation between tobacco consumption (p = 0.04) and local complications. Gastro-intestinal comorbidity (p = 0.005) and malnutrition (p = 0.02) were associated with a higher risk of fistula formation. Diabetes mellitus (p = 0.003), gastro-intestinal (p = 0.02), systemic (p = 0.02) and cardiac comorbidities (p = 0.03) were significant predictors of medical complications. We concluded that the different subtypes of patient comorbidities were relevant predictors of complications in head and neck microvascular reconstruction.

The Accuracy of Clinical Assessment for Postoperative Monitoring after Head and Neck Free Flap Reconstruction

The Accuracy of Clinical Assessment for Postoperative Monitoring after Head and Neck Free Flap Reconstruction

Evidence-Based Analysis of Vein Graft Interposition in Head and Neck Free Flap Reconstruction

Evidence-Based Analysis of Vein Graft Interposition in Head and Neck Free Flap Reconstruction

Analysis of an implantable venous anastomotic flow coupler: experience in head and neck free flap reconstruction

Monitoring microvascular free flaps can present a difficult challenge. This is especially true in cases of buried or intra-oral free flaps. The authors conducted a retrospective review of 19 consecutive free flaps for head and neck reconstruction using a novel monitoring device, which combines a venous anastomotic coupler and an implantable microdoppler (Synovis Micro Companies Alliance Inc., Birmingham, AL, USA). 20 venous anastomoses were performed and monitored with the venous flow coupler device. Monitoring ranged from intra-operatively to postoperative day 7 (mean 4.2 days). Accurate flow signal interpretation was correct in 18 of 20 anastomoses (90%) but only 14 of the 20 coupled anastomoses (70%) were monitored for the complete period of time as desired by the surgeons. All 19 flaps survived. The venous anastomotic flow coupler appears to be a reliable adjunct to free flap monitoring and may help to improve it, with early detection of flap compromise and salvage.