Neck Oncologic Defects Research Articles

Reducing morbidity in radial forearm free flap donor site: a review of closure techniques.

Radial forearm free tissue transfer (RFFF) has been an extremely reliable reconstructive option for head and neck oncologic defects for over 30 years. With high reliability, interest has shifted in minimizing donor site morbidity, much of which results from closure techniques. Portable negative pressure wound devices, newer dermal substitutes, and local flap techniques have improved donor site aesthetics and function. Outcomes of the RFFF donor site may benefit from newer techniques in closure.

Virtual Surgical Planning in Free Tissue Transfer for Orbito-Maxillary Reconstruction.

Since its introduction, virtual surgical planning (VSP) has been rapidly adopted as a part of reconstructive surgeon's armamentarium. VSP allows reconstructive surgeons to simulate resection, plan osteotomies, and design custom plates. These unique advantages have been especially beneficial for head and neck reconstructive surgeons as there is small room for error and high technical demand in head and neck reconstruction. Despite its popularity, most surgeons have limited experience in using VSP for orbito-maxillary reconstruction as tumors that involve the midface are relatively rare compared with other head and neck oncologic defects. In our institution, we routinely use VSP for orbito-maxillary reconstruction using free fibula flap to provide support for orbit, to restore normal dental occlusion, and to restore midface projection. In this chapter, we will discuss the role of virtual surgical planning and our algorithmic approach of performing orbito-maxillary reconstruction using free tissue transfer.

Versatility of the subscapular system of flaps in head and neck oncologic reconstruction.

This review analyzes the different ways of applying the subscapular system of flaps (SSSF) as a convenient and versatile solution for a large variety of head and neck oncologic defects. The ventral approach permits safe and efficient harvest of various chimeric SSSF in a supine position, thus allowing simultaneous flap preparation and tumor ablation. Conformational studies have revealed how similar the tip of the scapula is to the hard palate in terms of dimensions, shape, and conformation. This has led to favor horizontal placement of the scapular tip for palate reconstruction in most instances, addressing the vertical extension of the postmaxillectomy defect using denuded bony grafts surrounded by well vascularized chimeric muscular components. The SSSF possesses an unparalleled versatility to efficiently address small-medium sized soft tissue defects up to vast and complex composite resections. The chimeric components of these flaps benefit from a considerable independency provided by the length of the named arteries arising from the thoracodorsal pedicle, offering a high degree of freedom to accomplish the required in-setting. This reconstructive option should be implemented in every head and neck surgical team and offered to suitable patients.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects.

Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient. Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination. Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R2 = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (β = 0.01, P = .003) and RF (β = -0.01, P = .009) were individual predictors of flap volume loss. Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound.

The ability to directly harvest thin and superthin perforator flaps without jeopardizing their vascularity depends on knowledge of the microsurgical vascular anatomy of each perforator within the subcutaneous tissue up to the dermis. In this paper, we report our experience with ultrahigh-frequency ultrasound (UHF-US) in the preoperative planning of thin and superthin flaps. Between May 2017 and September 2018, perforators of seven patients were preoperatively evaluated by both ultrasound (using an 18-MHz linear probe) and UHF-US (using 48- and 70-MHz linear probes). Thin flaps (two cases) and superthin flaps (five cases) were elevated for the reconstruction of head and neck oncologic defects and lower limb traumatic defects. The mean flap size was 6.5×15 cm (range, 5×8 to 7.5×23 cm). No complications occurred, and all flaps survived completely. In all cases, we found 100% agreement between the preoperative UHF-US results and the intraoperative findings. The final reconstructive outcomes were considered satisfactory by both the surgeon and the patients. In conclusion, UHF-US was found to be very useful in the preoperative planning of thin and superthin free flaps, as it allows precise anticipation of very superficial microvascular anatomy. UHF-US may represent the next frontier in thin, superthin, and pure skin perforator flap design.

Risk Factors, Causes, and Costs of Hospital Readmission After Head and Neck Cancer Surgery Reconstruction.

Thirty-day hospital readmissions have substantial direct costs and are increasingly used as a measure of quality care. However, data regarding the risk factors and reasons for readmissions in head and neck cancer surgery reconstruction are lacking. To describe the rate, risk factors, and causes of 30-day readmission in patients with head and neck cancer following free or pedicled flap reconstruction. This retrospective, population-based cohort study analyzed medical records from the Nationwide Readmissions Database of 9487 patients undergoing pedicled or free flap reconstruction of head and neck oncologic defects between January 1, 2010, and December 31, 2014. Data analysis was performed in October 2017. Pedicled or free flap reconstruction of an oncologic head and neck defect. The primary outcome was 30-day all-cause readmissions. Secondary outcomes included risk factors, causes, and costs of readmission. Multivariate regression analyses were conducted to determine factors independently associated with 30-day readmissions. Among 9487 patients included in the study (6798 male; 71.7%), the median age was 63 years (interquartile range, 55-71 years), and the 30-day readmission rate was 19.4% (n = 1839), with a mean cost per readmission of $15 916 (standard error of the mean, $785). The most common indication for readmission was wound complication (26.5%, n = 487). On multivariate regression, significant risk factors for 30-day readmission were median household income in the lowest quartile (vs highest quartile: odds ratio [OR], 1.58; 95% CI, 1.18-2.11), congestive heart failure (OR, 1.68; 95% CI, 1.14-2.47), liver disease (OR, 2.02; 95% CI, 1.22- 3.33), total laryngectomy (OR, 1.40; 95% CI, 1.12-1.75), pharyngectomy (OR, 1.47; 95% CI, 1.08-2.01), blood transfusion (OR, 1.30; 95% CI, 1.04-1.64), discharge to home with home health care (vs routine: OR, 1.32; 95% CI, 1.04-1.67), and discharge to a nursing facility (vs routine: OR, 1.77; 95% CI, 1.30-2.40). Using the Nationwide Readmissions Database, we demonstrate that approximately 1 in 5 patients undergoing head and neck cancer surgery reconstruction is readmitted within 30 days of surgery. Readmissions are most commonly associated with wound complications. Socioeconomic status, complex ablative procedures, and patient comorbidities are independent risk factors for readmission. These findings may be useful to clinicians in developing perioperative interventions aimed to reduce hospital readmissions and improve quality of patient care.

Evolution of the anterolateral thigh free flap.

To review the recent literature on the evolution and advanced uses of the anterolateral thigh (ALT) free flap in reconstruction of oncologic defects of the head and neck. The ALT free flap is a versatile flap that can be harvested in a chimeric fashion with independent, vascularized skin, muscle, fascia, nerve and bone. Various techniques for chimeric flap harvest and flap inset have been described for reconstruction of pharyngocutaneous, oromandibular and radical parotidectomy defects. These reports expand the indications for the ALT free flap while demonstrating good functional and aesthetic outcomes. The ALT free flap remains popular for reconstruction of head and neck oncologic defects because of its versatility. Continued evolution in chimeric flap harvest techniques for pharyngocutaneous, osseous and radical parotidectomy defects highlights novel advanced reconstructive uses for the ALT free flap.

Non-Union Rates in Fibula Free-Flap Reconstruction of Head and Neck Oncologic Defects

The microvascular free tissue transfer of the fibula is a well-established and predictable method of providing reconstruction for mandibular and maxillary defects that arise from the resection of benign and malignant disease or traumatic injury. The purpose of this study is to evaluate our experience with the fibula free flap in 20 cases and describe the rate of non-union after reconstruction.

Head & neck reconstruction: Predictors of readmission

Unplanned hospital readmission following head and neck cancer surgery is common and associated with significant negative consequences. Because of the vital role that microvascular free tissue transfer plays in the management of head and neck oncologic defects, its relationship to unplanned hospital readmission requires attention. In this review, the incidence of, risk factors for, and reasons for unplanned readmission in patients undergoing free flap reconstruction for head and neck cancer are analyzed. The role of free flap reconstruction as a separate risk factor for unplanned readmission in patients with head and neck cancer is described. Limitations of the existing literature, strategies to decrease unplanned readmissions, and direction for future research are addressed.

Feasibility and Outcomes of the Third or More Episodes of Sequential Microvascular Reconstruction for Recurrent or Second PrimaryOral Cancer.

This study was a robust examination of the clinical outcomes and technical feasibility of sequential microvascular reconstruction for recurrent or second primary oral cancer. A retrospective, cross-sectional analysis of adult patients undergoing microvascular reconstruction of head and neck oncologic defects was performed at Chang Gung Memorial Hospital, spanning 10years. The patients were divided into three groups as follows: first episode, second episode, and third or more episodes of reconstruction. Demographics, operative details, and clinical outcomes were compared. The study cohort included 3186, 319, and 62 patients who respectively received first, second, and third or more episodes of reconstruction. The most common tumor sites were the tongue (36.9%) and the buccal region (36.8%), with squamous cell carcinoma as the prevalent histology. The anterior lateral thigh was the most popular donor site used (76.1%). The third or more episodes of microvascular reconstruction were associated with an increased incidence of flap failure (8.1%) relative to the first (1.9%; p=0.003) and the second (1.6%; p=0.01) episodes. Re-exploration of venous occlusion (9.7 vs. 3.2%), neck wound infections (53.2 vs. 35.5%), fistula (17.7 vs. 8.1%), and hospital stay (28.9±14.6 vs. 25.3±10.1) also showed significantly higher values for the third or more episodes group than for the first episode group. Sequential microvascular reconstruction for recurrent or second primary oral cancer is associated with an increased incidence of postoperative complications. However, in appropriate candidates for repeat ablation, microvascular reconstruction remains the gold standard for attaining functional and cosmetic outcomes.

Clinical experience with the supraclavicular flap to reconstruct head and neck defects

To evaluate the efficacy of pedicled supraclavicular artery island flaps for head and neck reconstruction. Reconstructive surgeries for head and neck oncologic defects were performed with the pedicled supraclavicular artery island flaps in 10 patients from May 2013 to December 2014 and the cases were review. Among them, 6 were performed for hypopharyngeal cancer, 2 for oral tongue cancer, 1 for oral base cancer and 1 for cervical esophageal cancer. The size of the flaps was measured in (5-8) cm × (6-12) cm. Seven flaps survived, one flap failured and two flaps had partial necrosis. Donor sites were closed primarily without morbidity. The pedicled supraclavicular artery island flap is an easy harvesting and reliable for head and neck reconstruction, especially suitable for otolaryngo-head and neck surgeon and maxillofacial surgeon in the local hospital.

Regional Myocutaneous Flaps for Head and Neck Reconstruction: Experience of a Head and Neck Cancer Unit.

Background:Pectoralis major myocutaneous pedicle flap and other regional myocutaneous pedicle flaps (RMF), despite the superiority shown by free flaps, have remained relevant in the reconstruction of major head and neck oncologic defects. It has continued to find relevance as the preferred reconstruction of choice in some general head and neck reconstructive applications. While its role has been defined in developed environment, the same cannot be said for developing environment. The aim thus, was to review our experiences with RMFs in head and neck reconstructions, with a view to evaluating the indications and outcomes in a limited opportunity environment with some free flaps expertise.Materials and Methods:This was a retrospective cohort study from records of RMF cases performed for head and neck reconstruction, at the study institution. Eligibility for study inclusion comprised case cohorts with advanced head and neck diseases requiring ablative surgery and reconstruction with pectoralis major flaps and other RMFs.Results:A total of 17 cases were treated with RMFs. 10 were pectoralis major flaps while 7 were other RMFs. The main indications were failed free flaps and financial constraints. No regional pedicle flap failure was recorded; however, complication rate was 35.5% (6/17).Conclusion:Pectoralis major flaps and other RMFs were very reliable option for head and neck reconstruction. Free flap failure and financial constraints were the main indications for RMF reconstruction indications in head and neck reconstruction in a developing environment with some free flap expertise.

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.

Supraclavicular Artery Flap for Head and Neck Oncologic Reconstruction: An Emerging Alternative

Aim. Head and Neck oncologic resections often leave complex defects which are challenging to reconstruct. The need of the hour is a versatile flap which has the advantages of both a regional flap (viz. reliable and easy to harvest) and a free flap (thin, pliable with good colour match). In this a study we assessed the usefulness of the supraclavicular artery flap in head and neck oncologic defects. Materials and Method. The flap was used as a pedicled fasciocutanous and was based on the transverse supraclavicular artery. We assessed this reconstructive option for complications as well as its and functional out comes. Results. Eleven cases underwent supraclavicular artery flap between 20011-2012 of which 5 were males and 6 females. Mean defect size was 5 cm × 6 cm. Nine donor sites were closed primarily and 1 required split skin grafting. We encountered one complete flap loss which was attributed to a band of constricting skin bridge over the vascular pedicle in a defect involving lateral third of midface. Two patient developed pharyngeocutaneous fistula (without flap loss) out of 3 patients who underwent augmentation pharyngoplasty post Near total laryngectomy. Conclusion. Supra clavicular artery flap is a thin versatile, reliable, easy to harvest, with good cosmetic and functional outcome at both ends (recipient and donor) for reconstructing head and neck oncologic defects.

Poster 71: Supraclavicular Artery Island Flap as a Salvage Flap for Failed Microvascular Free Tissue Transfers

Supraclavicular artery island flap was initially described in 1842, it is a thin, pliable, axially based flap with predictable color match for head and neck oncologic defects. Compared with other flaps, the supraclavicular artery island flap results in minimal donor site morbidity. This flap has now gained popularity when reconstructing defects in the head and neck. Loss of free tissue transfer after composite resection and reconstruction is a devastating consequence. Due to the added morbidity from a second free tissue transfer and the resulting inflammatory tissue bed, a pedicle flap may be a better alternative in these situations. Here, we report our experience with free tissue transfers which have failed and were reconstructed with a supraclavicular artery island flap.

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face.

The Radial Forearm Fasciocutaneous Free Flap for Head and Neck Reconstruction

Sir:FigureFree tissue transfer is a mainstay in head and neck reconstruction following surgical oncologic tumor resection. Perhaps one of the most versatile free flaps that exists for head and neck reconstruction is the radial forearm fasciocutaneous flap, which allows for a thin, pliable piece of tissue to be transferred on a long vascular pedicle with a reliable blood supply.1,2 The reasons for this versatility lie in the aforementioned features, specifically, a long vascular pedicle that allows anastomosis to be performed outside of the zone of resection that may involve irradiated tissues. After obtaining institutional review board approval, a retrospective review of all cases of radial forearm fasciocutaneous free flaps for reconstruction of oncologic head and neck defects performed by the senior author (R.O.D.) between 2001 and 2010 was conducted. The retrospective review returned 55 patients. Of this, 15 (27 percent) were women and 40 (73 percent) were men. The average age of the patients was 58 years (range, 31 to 80 years). The average size of the oncologic defect was 63.1 cm2 (range, 30 to 120 cm2). In total, there were three flap failures (5.5 percent). There were 25 other complications noted in addition to the flap failures. There were 12 complications related to the recipient site other than flap failures. Of the 55 patients, 23 (42 percent) underwent preoperative radiation therapy. A two-sample t test revealed no relationship between the size of the defect and whether or not there was a complication of any nature (p = 0.32) or a complication at the recipient site (p = 0.23). A relationship approaching significance was noted between preoperative radiation therapy and complications at the recipient site (p = 0.052) (Fig. 1).Fig. 1: Comparison of complication rates between those with and without preoperative radiation therapy.The management of oral and airway malignancies is controversial, with radiation therapy and surgery being the favored options. In general, lower grade malignancies are regarded as better treated through radiation therapy alone, whereas higher grade malignancies are treated with surgery. This paradigm presents a problem when surgery is indicated following either failed radiation therapy or recurrent disease after radiation therapy. The competency of the vasculature in the region of the defect is often of concern following radiation therapy. Free flaps to the head and neck have been shown to be adversely affected by radiation therapy.3 Interestingly, in our review, there was no relationship found between preoperative radiation and the occurrence of complications. This may be explained by the extremely long pedicle that is possible with the radial forearm flap that provides the opportunity to bring the site of anastomosis for both the vein and artery away from the field of preoperative radiation and oncologic resection. In general, the vessels outside of this area are likely to be healthier and more suitable for microvascular anastomosis. This is especially important given that this patient population tends to be advanced in age and may suffer from concomitant peripheral vascular disease. Varying degrees of atherosclerosis were noted in each patient in this series. The radial forearm fasciocutaneous free flap remains a reliable and relatively easy flap to use for reconstruction of head and neck oncologic defects. Preoperative radiation therapy does not appear to affect the rate of complications following reconstruction with this flap. The flap's long pedicle allows for the site of anastomosis to be placed outside the area of tissue damage. Ian C. Hoppe, B.A. Priti P. Patel, M.D. Ramazi O. Datiashvili, M.D. Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, N.J. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

Supraclavicular Artery Island Flap for Head and Neck Oncologic Reconstruction: Indications, Complications, and Outcomes

The supraclavicular island flap has been used successfully for difficult facial reconstruction cases, providing acceptable results without using microsurgical techniques. The authors use this regional flap in reconstructing various head and neck oncologic defects that normally require traditional regional or free flaps to repair surgical wounds. A pedicled supraclavicular artery flap was used to reconstruct head/neck oncologic defects. Complications and functional outcomes were assessed. Head and neck oncologic patients underwent tumor resection followed by immediate reconstruction using a supraclavicular artery island flap. Ablative defects included neck, tracheal-stomal, mandible, parotid, and pharyngeal walls. All flaps (n = 18) were harvested in less than 1 hour. All ablative wounds and donor sites were closed primarily and did not require additional surgery. Major complications included a complete flap loss when the vascular pedicle was inadvertently divided and pharyngeal leaks. The leaks resolved without surgical intervention, and both patients regained the ability to swallow using their neo-esophagus. Minor complications included donor-site wound dehiscence and cellulitis. None of the patients reported functional donor-site morbidity. This thin flap is easy and quick to harvest, has a reliable pedicle, and has minimal donor-site morbidity. It is now the authors' flap of choice for many common head and neck reconstructive problems. Early experience using the supraclavicular artery island flap suggests that it is an excellent flap option for head and neck oncologic disease patients.

The temporalis muscle flap for reconstruction after head and neck oncologic surgery.

To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects. Fresh cadaver dissection and 5-year retrospective chart review. A fresh cadaver dissection was performed to illustrate the surgical anatomy of the temporalis muscle flap with attention to specific techniques useful in avoiding donor site morbidity (facial nerve injury and temporal hollowing). A chart review was performed for 13 consecutive patients from the last 5 years who underwent temporalis muscle flap reconstruction after oncologic resection of the lateral and posterior pharyngeal wall, hard and soft palate, buccal space, retromolar trigone, and skull base. Patient follow-up ranged from 2 to 45 months. Nine patients had radiation therapy. There were no cases of flap loss. Resection of the zygomatic arch followed by wire fixation facilitates flap rotation and minimizes trauma to the flap during placement into the oropharynx. Preservation of the temporal fat pad attachment to the scalp flap decreases temporal hollowing and protects the facial nerve. Replacing the zygoma and preserving the anterior third of the temporalis muscle in situ further diminishes donor-site hollowing. Compared with other regional flaps, such as the pectoralis myocutaneous flap, the temporalis muscle flap is associated with low donor-site esthetic and functional morbidity and offers great flexibility in reconstruction. The temporalis muscle flap is a useful, reliable flap that belongs in the armamentarium of surgeons who are involved with reconstruction of head and neck tissue defects.