Neck Reconstructive Surgery Research Articles

Increased plate and osteosynthesis related complications associated with postoperative concurrent chemoradiotherapy in oral cancer

Plate osteosynthesis is a widely used technique in head and neck reconstructive surgery. The objective of this study was to determine whether postoperative chemoradiotherapy, which was recently introduced for high-risk head and neck cancer, affects plate and osteosynthesis related complications. Fifty-two consecutive patients, who had undergone plate osteosynthesis for mandibular reconstruction between October 2003 and September 2006, were included in the study. The patients were divided into 3 groups: (1) surgery alone (n = 19), (2) surgery with postoperative radiotherapy (n = 14), and (3) surgery with concurrent chemoradiotherapy (n = 19). Outcome measures included any bone or plate related complications. The plate and osteosynthesis related complications occurred in 10.5% of patients in surgery-alone group, 28.6% in surgery with postoperative radiation group, and 63.2% in surgery with postoperative concurrent chemoradiotherapy group. The differences in the complication rates among these 3 groups were statistically significant (p = .003). In univariate analysis, postoperative radiation (p = .007) and concurrent chemotherapy (p = .003) were found to be significantly associated with complications. In multivariate analysis, only concurrent chemotherapy was found to be statistically significant (p = .002) with odds ratio of 7.72. Postoperative concurrent chemoradiotherapy significantly increases plate and osteosynthesis related complications in oral cancer.

The utility of microvascular anastomotic devices in head and neck reconstruction

The use of microvascular anastomotic devices remains controversial in head and neck reconstructive surgery. Although more acceptable in venous anastomosis, their use in arterial anastomosis remains limited. We review the literature to evaluate the evidence both for and against their use, in both venous and arterial anastomoses. The current literature supports the use of anastomotic coupling devices in head and neck reconstructive surgery. They have been reported as consistently reducing the anastomotic time with an associated reduction in cold ischaemic time. There is no evidence available to date that shows different thrombotic rates between anastomotic devices and hand sewing or between the different anastomotic devices available in the market. The current literature would support the use of these devices in both arterial and venous anastomoses. Many microvascular surgeons would prefer to maintain their skills with hand sewing, as the use of an anastomotic coupling device is not always possible. Therefore, a hand-sewn arterial anastomosis and coupled venous anastomosis is a good compromise until larger series of results are available.

Steven L. Moran, M.D., and Deepak Kademani, D.M.D., M.D., F.A.C.S.

I want to thank Dr. Steven L. Moran and Dr. Deepak Kademani for sharing the responsibility as guest editors for this issue of Seminars in Plastic Surgery entitled “New Horizons in Vascularized Bone Grafts” and the invited authors for sharing their experience. Dr. Moran is an associate professor of plastic and orthopedic surgery at the Mayo Medical School in Rochester, Minnesota, and is a consultant in the Division of Plastic and Reconstructive Surgery and in Hand and Microvascular Surgery at the Mayo Clinic. He obtained his medical degree from the Rochester School of Medicine and Dentistry. Dr. Moran completed his general and plastic surgery residencies at the University of Rochester Medical Center and secured additional training by completing a hand and microsurgery fellowship at the Mayo Clinic. He is board certified by the American Board of Plastic Surgery and has an interest in hand and microsurgery, with specific interests in disorders of the wrist, congenital malformations, and soft tissue reconstruction of the upper and lower extremities. During his academic career, Dr. Moran has authored numerous articles and book chapters and is a leader in the field of vascularized bone grafts. He recently guest edited an issue of Orthopedic Clinics of North America on the topic of “Advancements in Vascularized Bone Grafting.” Dr. Deepak Kademani holds the post of assistant professor of surgery at the Mayo Clinic and is a consultant in the Division of Oral Diagnosis and Oral and Maxillofacial Surgery in the Department of Surgery at the Mayo Clinic in Rochester, Minnesota. Prior to receipt of his medical degree from the University of Pennsylvania, Dr. Kademani received his doctor of dental medicine degree and later completed an oral and maxillofacial surgery residency and a general surgery residency at the University of Pennsylvania Medical Center. He also completed fellowships in head and neck tumor and reconstructive surgery at Legacy Emanuel Hospital and Oregon Health Sciences University. Dr. Kademani is board certified by the American Board of Oral and Maxillofacial Surgery. His interests are in benign and malignant head and neck pathology, salivary gland disease, head and neck reconstruction, obstructive sleep apnea, vascular malformations of the head and neck, and temporomandibular joint reconstruction. For someone so early in their career, Dr. Kademani has published extensively in journals, produced several book chapters, and is a reviewer for nine journals.

Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice

There is considerable variation in the post-operative management of head and neck free flaps in the UK. We undertook a national postal survey of maxillofacial surgical units in the UK who perform free flap reconstruction following ablative head and neck surgery. Questions were asked about the routine postoperative care of a hypothetical, straightforward patient undergoing free flap reconstruction to determine whether there were any trends in managing these patients. There was considerable variation in the number of free flaps performed by each unit per year. The majority of patients (87%) are managed in either an intensive care or high dependency unit. The routine use of a tracheostomy is common (69%). There was also variation in the management of these cases, particularly with the requirement for ventilation. Few units routinely use dextran or dobutamine infusions, although one-to-one nursing and invasive cardiovascular monitoring are commonplace. Alternative provision of postoperative care is discussed.

Diabetes as Main Risk Factor in Head and Neck Reconstructive Surgery With Free Flaps

The aim of our study was to demonstrate the role of certain risk factors in reconstructive head and neck surgery with free flaps. The data taken from the charts of all patients who received free flap for head and neck reconstruction in our department between January 2001 and December 2004 were analyzed. We evaluated the association of preexisting risk factors with the onset of surgical complications such as orocutaneous fistulae, flap infections, hematomas, thrombosis, and necrosis. One hundred and twenty-two free flaps have been used for the reconstruction of head and neck area in 118 patients. Preoperative risk factors included smoking habit (77 patients), alcohol use (6 patients), hypertension (9 patients), diabetes mellitus (8 patients), family history positive for vascular disorders (27 patients), and hypercholesterolemia/hypertriglyceridemia (5 patients). The percentage of full flap survival was 95.08%. Statistical analysis showed that diabetes mellitus (P < 0.01) is significantly associated with a negative prognosis for free flap reconstructive operation, whereas a smoking habit seemed to be at the verge of statistical significance. Therefore, our current practice is to prefer as much as possible the use of local flaps as opposed to free flaps in the reconstruction of head and neck defects in diabetic patients.

PREVENTING POSTOPERATIVE HAEMATOMAS IN MICROVASCULAR RECONSTRUCTION OF THE HEAD AND NECK: LESSONS LEARNT FROM 126 CONSECUTIVE CASES

Free tissue transfer has become a safe and reliable means for repairing soft tissue and bony defects of the head and neck. Although operative success has reached 98%, the incidence of significant postoperative complications is also relatively high (32%). One common and significant complication is haematoma formation, occurring at both donor and recipient sites, and yet there are minimal published studies on its incidence, aetiology or outcome. A retrospective analysis of both donor- and recipient-site wound haematoma was carried out to identify causative factors and the effect on patient outcome. A 5-year review of 132 consecutive microvascular free tissue transfers to head and neck defects at The Royal Melbourne Hospital, for the period February 2001 to February 2006, was conducted. Of 126 included cases, 27 postoperative haematomas resulted. Statistically significant associations were found for each of smoking, non-steroidal anti-inflammatory drug use and the use of corticosteroids preoperatively with the incidence of postoperative haematoma formation. Postoperative blood pressure control and the adequacy of primary tumour excision at the flap recipient site were also found to have significant associations with haematoma formation. Drain tube outputs served as accurate indicators for haematoma. There are significant reversible factors that contribute to the development of postoperative haematomas in head and neck reconstructive surgery. Preoperative modifications should, therefore, be sought. Similarly, close monitoring of patient blood pressure during the initial 24 h postoperative period by theatre and recovery staff is important, as is the adequacy of postoperative analgesia.

頭頸部再建における切除と再建の連携―切除の立場から―

頭頸部再建における切除と再建の連携―切除の立場から―

Regenerative Medicine in head and neck reconstructive surgery

Autologous transplantation is regarded as the gold standard in the treatment of congenital or acquired deformities. However, the availability of autologous tissue for transplantation is often limited. Regenerative medicine aims to activate individuals' own intrinsic regenerative mechanisms and embraces tissue engineering, cell/system biology, gene therapy and stem-cell biology. Most approaches in tissue engineering are based on the expansion of small autologous cell aggregates. Tissue engineering supplemented by isolated and amplified stem cells is another very promising option for producing autologous transplants and getting over the limited availability. The association of stem cell-based tissue engineering and gene therapy allows the creation of regenerative tissue in the optimal ambience of regulatory proteins. This leads to great opportunities in the transplantation of skin, bones or cartilage. This paper presents the current status and the possible benefits, but also the limitations, of regenerative medicine in reconstructive surgery of the head and neck.

Prone positioning for head and neck reconstructive surgery

Certain head and neck surgical cases require the patient to be positioned prone. Such positioning carries with it an attendant subset of risks and complications not otherwise encountered in more traditional supine positioning. Gaining awareness of these risks and complications, and developing proactive positioning strategies, will enable the surgical team to position the patient optimally for the procedure and provide for every consideration of patient safety. This article consists of a specific literature review of those issues directly related to the anatomical and physiological concerns arising from prone positioning. Particular attention is paid to the cardiopulmonary, renal, ophthalmologic, and neurological vulnerabilities unique to this position. Proper planning by the surgical team and utilization of the correct equipment are a necessity. A tailored approach to the needs of the individual patient and an intimate awareness of the potential pitfalls will contribute to better outcomes when using the prone position.

Tissue engineering in head and neck reconstructive surgery: what type of tissue do we need?

Craniofacial tissue loss due to congenital defects, disease or injury is a major clinical problem. The head and neck region is composed of several tissues. The most prevalent method of reconstruction is autologous grafting. Often, there is insufficient host tissue for adequate repair of the defect side, and extensive donor site morbidity may result from the secondary surgical procedure. The field of tissue engineering has the potential to create functional replacements for damaged or pathologic tissues.

Vakuumassistierte Therapie zur Wundbehandlung im Kopf-Hals-Bereich

Chronic wounds are characterized by slow or nonexistent wound healing. Usually their treatment is expensive. Therefore new concepts in management are of interest in order to reduce treatment time and costs. One option is vacuum sealing. The concept of topical negative pressure is not new, and many chronic nonhealing wounds could be closed successfully with the help of vacuum sealing. Until now, there has been no documented case of vacuum sealing in head and neck reconstructive surgery. Our case shows the effectiveness of a vacuum-assisted device in successful closure of a chronic nonhealing wound in this region.

P80 Blood usage in major head and neck oncological and reconstructive surgery

P80 Blood usage in major head and neck oncological and reconstructive surgery

Head and neck reconstructive surgery with free flaps and quality of life: A prospective study

Head and neck reconstructive surgery with free flaps and quality of life: A prospective study

A new combined approach to the nasopharynx in head and neck plastic surgery: technique and application

This article presents a combined approach to the nasopharynx, which has not been previously described. The technique is applicable to cases of recurrent nasopharyngeal carcinoma which exhibit lateral extension. We describe the technique and report a case in which it was used. A review is presented of all other techniques currently described. The authors would not advocate the use of a combined approach to the nasopharynx in all cases, but there certainly appears to be a place for this technique.

Use of free microvascular flaps in the management of the head and neck defects

In the field of contemporary head and neck reconstructive surgery, free vascularized tissue transfer is becoming a gold standard. The aim of this study was to review our clinical results and experience, with use of free microvascular flaps and compare them with the recently published patient series. During the period from 2001 to 2005, 37 patients underwent microsurgical reconstruction after the tumor ablation in the region of head and neck. Flap viability was monitored intraoperatively with the Ackland test and postoperatively by the clinical observation and mini-Doppler test. The overall success rate was 83.8%. The complications that appeared were: one complete flap necrosis due to venous thrombosis, and five late flap ischemic necroses, in the period from the 10th to 14th postoperative day. Free flap reconstruction of the head and neck is a surgical technique that provides the reconstruction of complex and extensive defects, that could not be performed by using local or regional flaps.

A Triple-Blinded Randomized Trial Comparing the Hemostatic Effects of Large-Dose 10% Hydroxyethyl Starch 264/0.45 Versus 5% Albumin During Major Reconstructive Surgery

In Canada, hydroxyethyl starch 264/0.45 (HES 264/0.45; molar weight 264 kDa, molar substitution 0.45) has largely replaced albumin as the colloidal fluid of choice for perioperative intravascular volume expansion. The maximum recommended dose of HES 264/0.45 is 28 mL/kg; however, there are no clinical data supporting this limit. In this study we compared the hemostatic effects of HES 264/0.45 versus 5% albumin in doses up to 45 mL/kg over 24 h during major reconstructive head and neck surgery. Fifty patients were randomized to receive HES 264/0.45 or 5% human albumin from the induction of anesthesia until 24 h thereafter. Both albumin and HES 264/0.45 effectively maintained physiologic variables in the perioperative and postoperative periods. The partial thromboplastin time and international normalized ratio were significantly increased in the HES 264/0.45 group compared with the albumin group after infusion of 30 mL/kg and 45 mL/kg (P < 0.05). Factor VIII activity and von Willebrand factor level were significantly reduced in the HES 264/0.45 group compared with the albumin group after infusion of 15 mL/kg, 30 mL/kg, and 45 mL/kg (P < 0.05). Significantly more subjects in the HES 264/0.45 group received allogeneic red blood cell transfusions (P < 0.02). We conclude that HES 264/0.45 infusions >30 mL/kg over 24 h impair coagulation to a greater extent than albumin, possibly leading to more allogeneic transfusions.

Vertical trapezius musculocutaneous flap: A retrospective study

From 1986 to 2001, 17 patients (aged 26-77 years) were treated using the vertical trapezius musculocutaneous flap. A two-stage procedure was used in 7 and a single-stage island flap in 10. The donor site was closed directly in all patients. Mean length of hospital stay was 16 days (range 12-25). There was no operative mortality. Complications were one partial flap necrosis and two seromas of the donor site, complicated by infection. With a minimum follow-up of more than two years, our study confirms the usefulness of the vertical trapezius musculocutaneous flap in head and neck reconstructive surgery. It is a reliable, thin flap of uniform thickness, which carries hairless skin. The length and thickness of its pedicle allows excellent mobility. The main disadvantage of the flap is the complete sacrifice of the muscle necessary for total mobilisation of the flap, and the intraoperative repositioning of the patient.

Mandible fracture patterns: A suburban trauma center experience

Purpose Mandible fractures are among the most frequently seen injuries in the trauma center setting. Recent shifts in the mechanism and age distribution of patients sustaining these injuries are well documented. This study attempts to define current, predictable patterns of fracture based on patient characteristics and mechanism of injury. Material and methods The charts of 134 patients with 225 mandible fractures treated over a 7-year period by the Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery and Oral-Maxillofacial Surgery services, our institution, were retrospectively reviewed. Patients were categorized based on age, mechanism of fracture, and anatomic location of fracture. Multivariate analysis of data was performed to determine significant relationships among groups. Results Violent crimes such as assault and gunshot wounds accounted for the majority of fractures (50%) in this study, with motor vehicle accidents less likely (29%). Overall, parasymphyseal fractures were most frequent (35%), whereas angle and body fractures were also common (15% and 21%, respectively). There was a statistically significant association of motor vehicle accidents with parasymphyseal fractures (45%), and gunshot wounds with body fractures (36%), whereas assault victims had a higher than predicted frequency of angle fractures (27%) and fewer parasymphyseal fractures (19%). Patients aged 17 to 30 were more likely to suffer from gunshot wounds, whereas older adults (age 31–50) were more likely to be assault victims. Patients over age 50 suffered fractures from falls at a higher than expected rate. Although children and young adults seemed to suffer more parasymphyseal fractures and older adults body fractures, these correlations failed to show statistical significance. Parasymphyseal fractures were most frequently associated with fractures at other sites within the mandible, ipsilateral body fractures being the most common. Conclusions Updated data on the association of patient age and mechanism of injury with fracture pattern can guide treating physicians in anticipating and diagnosing traumatic mandible fractures.

Vascular compromise of the pectoralis major musculocutaneous flap in head and neck reconstruction.

In head and neck reconstructive surgery, the pectoralis major musculocutaneous flap is a major reconstructive tool, both in primary as well as secondary reconstructions. In a few cases the authors have been able to demonstrate that when the pectoralis major musculocutaneous flap is translocated to the mouth through a noncompromised neck tunnel, as is done for head and neck reconstructions, the taut lateral pectoral nerve is seen to compress the vascular pedicle of the flap, adversely affecting its vascularity, which can lead to partial or total necrosis of the flap. The authors explain this feature, very specific to this flap, with the help of a prospective series of patients.

The effect of 2 sealants (FloSeal and Tisseel) on fasciocutaneous flap revascularization.

Fasciocutaneous tissue transfer is one of the most common procedures performed in head and neck reconstructive surgery. These composite tissues can be transferred as either a free flap or a pedicled flap. Free tissue transfer has become the reconstructive modality of choice following head and neck oncologic ablation. Synthetic tissue adhesives and hemostatic agents are rapidly gaining popularity in reconstructive surgery. Their ability to decrease bleeding and promote flap sealing and healing has led to a proliferation in their use. To our knowledge, the short-term effect of these substances on healing, as measured by flap revascularization, has not been systematically investigated. Fifty-six male Sprague-Dawley rats were divided into 3 groups: a control group, a matrix hemostatic sealant (FloSeal) group, and a 2-component fibrin sealant (Tisseel) group. In each group, the rats had a 3 x 6-cm fasciocutaneous flap based on the inferior epigastric artery elevated and exposed to 2 hours of primary ischemia. In the control group, 0.2 mL of isotonic sodium chloride solution was placed between the flap and its bed, while in the experimental groups, 0.5 mL of FloSeal or 0.2 mL of Tisseel was applied to the wound before closure. Each group was then divided into groups of 5 rats. Each of these groups then had their pedicle divided on postischemic day 4, 5, 6, or 7. The percentage survival of the flap was measured 7 days after pedicle ligation. There was no statistical difference in flap survival of rats treated with isotonic sodium chloride solution, Tisseel, or FloSeal. Ligation of the flap pedicle on days 4, 5, 6, or 7 did not result in any difference in flap survival among the 3 groups. The FloSeal and Tisseel demonstrate no short-term detrimental effect on flap survival nor do they seem to affect revascularization in a fasciocutaneous free flap model.