Neck Reconstructive Surgery Research Articles

Head and neck reconstruction surgery with microvascular free tissue transfer performed by head and neck surgeons

Head and neck reconstruction surgery with microvascular free tissue transfer performed by head and neck surgeons

Anterolateral thigh free flaps and radial forearm free flaps in head and neck reconstruction: A 20-year analysis from a single institution.

BackgroundReconstruction after removal of a malignant tumor in the head and neck region is crucial for restoring tissue integrity, function, and aesthetics. We retrospectively analyzed patients who underwent intraoral reconstruction surgery using radial forearm free flaps (RFFF) and anterolateral thigh free flaps (ALT) at a single institution to provide more information supporting the choice of a reconstruction method after removal of head and neck cancer.MethodsThe charts of 708 patients who underwent head and neck reconstruction between 1998 and 2018 at the Department of Plastic and Reconstructive Surgery at our institution were retrospectively reviewed. Patients’ age, sex, and history of radiation therapy, diabetes mellitus, and smoking were retrieved. The primary cancer site, types of defects, and complications were investigated.ResultsOverall, 473 and 95 patients underwent reconstruction surgery with RFFF and ALT, respectively. RFFF was more often used in patients with cancers of the pharynx, larynx, esophagus, or tonsil, while ALT was more frequently used in patients with cancers of the mouth floor with tonsil or tongue involvement. The proportion of patients undergoing ALT increased gradually. Flap failure and donor site morbidities did not show significant differences between the two groups.ConclusionsRFFF and ALT flaps resulted in similar outcomes in terms of flap survival and donor site morbidity. ALT can be an option for head and neck reconstruction surgery in patients with large and complex defects or for young patients who want to hide their donor site scars.

The prospective evaluation and risk factors of dysphagia after surgery in patients with oral cancer

BackgroundThis prospective study investigated the change of swallowing ability using the Swallowing Ability Scale System (SASS) and swallowing-related quality of life (QOL) by Performance Status Scale for Head and Neck Cancer patients (PSS-H&N). This study also investigated the risk factors for postoperative dysphagia in patients who received reconstructive surgery for oral cancer.Subjects and MethodsThis study included 64 patients (33 men and 31 women) who underwent radical surgery with neck dissection and reconstructive surgery for oral cancers between July 2014 and February 2018. We evaluated risk factors for poor swallowing ability after treatment, including demographic factors, preoperative factors and perioperative factors, with univariate and multivariate analyses. The change of swallowing ability by the SASS and swallowing-related QOL by PSS-H&N were evaluated prospectively prior to the initiation of surgery within 1 week and at 1 and 3 months after treatment.ResultsAdvanced T stage (T3, 4) (odds ratio (OR) = 79.71), bilateral neck dissection (OR = 20.66) and the resection of unilateral or bilateral suprahyoid muscles (OR = 17.00) were associated with poor swallowing ability after treatment. The scores for time for food intake and Eating in Public were associated with decrease of QOL in the poor group.ConclusionsWe propose that clinicians consider the risk factors identified in this study and pay close attention to the management of oral cancer patients with reconstructive surgery.Graphical abstract

The Role of Hyperbaric Oxygen in Head and Neck Reconstruction and Facial Cosmetic Surgery.

Hyperbaric oxygen (HBO) is a treatment modality with the primary mechanism of therapy being the delivery of oxygen to hypoxic tissues. A review of HBO applications in the field of head and neck reconstruction and facial cosmetic surgery is provided. HBO can be useful in the management of radiation sequelae and treatment of compromised flaps and grafts. It may also have application in tissue compromise following cosmetic surgery and dermal fillers. We provide evidence from the available literature as well as highlight our experience in using HBO in head and neck reconstruction.

Nerve Grafting in Head and Neck Reconstruction.

In head and neck reconstructive surgery, especially of the mandible, the long-span processed nerve allograft (PNA) is a technological advancement that provides improved quality of life for patients who require ablative surgery by allowing for functional sensory recovery (FSR) in the majority of patients treated with immediate reconstruction. Recently published clinical prospective and retrospective multisite controlled cohort studies of immediate nerve reconstruction at the time of ablative surgery, including pediatric patient populations, were reviewed for valid and predictable outcomes of FSR following the reconstruction of the inferior alveolar nerve using > 5-cm PNA allografts. Both adult and pediatric patients demonstrate high percentages of FSR within 1 year. Pediatric patients demonstrate robust recovery with 100% reaching FSR within 1 year, whereas 89% of adults achieved FSR during the same time span; the pediatric patient population reached FSR earlier when compared with adults. Control, nonallograft nerve repair patients never achieved FSR, reaching only S2 levels in both adults and pediatric groups. There were no adverse events; in fact, no patients demonstrated the occurrence of neuropathic pain when the nerve repair was performed immediately in contrast to delayed repair states. Long-span (> 5-cm) nerve allografts provide FSR in pediatric patients and the majority of adult patients and should be used in patients who require ablation of the mandible for head and neck reconstruction.

Internal jugular vein thrombosis and pulmonary thromboembolism after head and neck reconstructive surgery

Free flap failure secondary to internal jugular vein thrombosis (IJVT) is a significant complication after head and neck reconstructive surgery. A consensus has not yet been reached among reconstructive surgeons regarding the treatment of IJVT. We retrospectively evaluated the incidence of IJVT in 118 patients who underwent free flap reconstruction at Hyogo Cancer Center, Akashi, Japan. The occurrence of IJVT-related flap circulation crisis and pulmonary thromboembolism (PTE) was studied. This study was approved by the institutional ethics committee, and written informed consent was obtained from each patient. From 118 patients who underwent head and neck reconstructive surgery, we included 116 internal jugular veins (IJVs) preserved after neck dissection in the present study. IJVT was confirmed in 25 (21.6%) IJVs from 23 patients. One patient (0.8%) developed venous congestion due to IJVT, which resulted in total flap necrosis. Two patients (1.7%) exhibited PTE associated with IJVT. They were treated with direct oral anticoagulants for 3 months and were discharged without any sequelae. Our results suggest that IJVT after head and neck reconstructive surgery caused not only flap circulation crisis but also PTE. Reconstructive surgeons should be aware of the potential risks due to serious complications associated with IJVT.

Yadranko Ducic, MD, FRCS(C), FACS.

I want to thank Dr. Yadranko Ducic for serving as guest editor for this issue of Seminars in Plastic Surgery on “Complications and Secondary Management in Head and Neck Reconstructive Surgery.” We also appreciate the efforts made by each outstanding author for contributing to this issue.

A Protocol for Safe Head and Neck Reconstructive Surgery in the COVID-19 Pandemic.

SummaryThe COVID-19 pandemic has had significant implications for citizens globally and for the healthcare system, including plastic surgeons. Operations of the upper aerodigestive tract, including head and neck reconstruction and craniomaxillofacial procedures, are of particularly high risk because they may aerosolize the virus and lead to severe surgeon and surgical team illness. Until the virus is eradicated or widespread vaccination occurs, we recommend certain precautions to safely perform these operations. We propose evolving algorithms for head and neck reconstruction and facial trauma surgeries to maintain provider safety. Central to these guidelines are preoperative COVID-19 testing, appropriate personal protective equipment, and operative techniques/principles that minimize operative time and aerosolization of the virus. We aim to provide efficient care to our patients throughout this pandemic, while maintaining the safety of plastic surgeons and other healthcare providers.

Reconstruction Using Facial Artery System-based Flaps. One Vascular System for Multiple Purposes in Head and Neck Reconstructive Surgery

ObjectiveTo review the modifications and advances in reconstructive surgery of the soft tissues of the oral cavity exclusively based on flaps that depend on the facial artery system. MethodsReview of the literature regarding oral cavity reconstructions based on main facial artery system flaps. DiscussionThe reconstruction of the soft tissues of the oral cavity, based on facial artery system flaps, offers satisfactory results and allows limited reconstructions avoiding the use of pedicled regional flaps or free flaps. ConclusionsKnowledge of reconstructive options using the facial artery system in oral cavity surgery allows expanding reconstructive options for head and neck surgeons, enabling safe, high quality and effective reconstructions, with limited resources consumption.

Versatility of the Radial Forearm Free Flap in Head and Neck Reconstruction. A Study of 58 Cases

IntroductionThe radial forearm free flap (RFFF) is a widely used tool in head and neck reconstructive surgery. It stands out as a relatively simple flap to achieve; it is versatile and has features that enable the reconstruction of complex head and neck defects. The aim of the study was to present our results using the RFFF in the reconstruction of seated defects in the head and neck area. Material and methodsA retrospective, observational and analytical study that included 58 cases of RFFF interventions, performed between January 2002 and July 2019. The data studied were the age and sex of the patients, location of the tumour, histological type, previous radiation therapy (RT), number of venous anastomoses performed in the surgery and body temperature in the immediate postoperative period, at 24 and 48 h following surgery. ResultsThe percentage of viable RFFF was 82.8%. None of the variables analysed appear to be a risk factor for flap failure. The most frequent cause of flap failure was venous thrombosis. ConclusionsMicrovascularised flaps play an important role in reconstructive surgery, the RFFF being one of the most interesting for head and neck reconstruction. It is a very versatile tool that allows the reconstruction of many of the sites where the head and neck surgeon operates.

Association between blood transfusions and complications in head and neck reconstruction: a systematic review and meta-analysis.

The aim of this meta-analysis is to assess the correlation between blood transfusions and the medical/surgical complications after head and neck reconstructive surgery. The PRISMA protocol was used and the literature search was performed on Pubmed, Scopus, Cochrane Library and Web of Science up to March 13, 2020. The risk of bias in individual studies was assessed through the Newcastle Ottawa Scale. A total of 1219 records were screened after the electronic search, 22 of which were included in the qualitative analysis. Of there 22 scores, 18 articles were included in the meta-analysis. The OR for medical and surgical complications of transfused patients was 1,64 (95% CI 1.23-2.21); while, the OR for hospital readmission was 1.53 (95% CI 1.29-1.81). The results of this meta-analysis suggested that blood transfusions are associated with both an increased risk of surgical and medical complications of head and neck flaps and with the hospital readmission.

Postoperative Delirium is Associated With Prolonged Head and Neck Resection and Reconstruction Surgery: An Institutional Study

Delirium is a recognized complication of surgery. It has a deleterious effect on a patient's postoperative recovery and well-being. The purpose of this study was to estimate the frequency and identify the risk factors for the development of postoperative delirium (POD) in a cohort of patients who underwent extensive head and neck surgery (HNS) of greater than five hours duration. The authors undertook a retrospective cohort study of patients who underwent HNS of greater than five hours duration. The primary predictor variables comprised a set of risk factors (sociodemographic, disease-specific, duration of surgery, and duration of inpatient stay) that were thought to be associated with the development of POD. The primary outcome variable was the development of POD. Descriptive, bivariate, and multivariate statistical analysis was undertaken, and significance was set at P<.05. One hundred and seventy patients were included in the study. There were 124 males and 46 females. Forty patients (23.53%) developed POD: 30 documented and 10 inferred. The mean age of the POD cohort was 65years (SD 13), with a median age of 69years. The occurrence of POD was statistically related to increased age, mental health status, American Society of Anesthesiologists (ASA) score, and drug dependence (either illicit or prescription). POD and operative duration were statistically associated. POD and length of stay were not statistically associated. Delirium did occur postoperatively in 23.53% of our patients who underwent extensive and prolonged HNS. POD may go unrecognized by treating teams. As POD has a deleterious effect on the cognitive function, it is important to identify and aggressively treat episodes of POD that occur during a patient's postoperative recovery.

Processed nerve allografts in reconstructive microneurosurgery after ablative head and neck surgery: an overview

: Peripheral nerve reconstruction has become increasingly important in functional rehabilitation in head and neck surgery in recent years. Important neural structures can be damaged or sacrificed in the treatment of malignant and benign pathology, and can result in significant morbidity for patients postoperatively, impacting their quality of life. Restoration of nerve function represents an important tool in head and neck reconstructive surgery, with advances in microneurosurgical techniques and the introduction of biologics including conduits, connectors, and processed allogenic nerve grafts, permitting surgeons to optimize results without additional morbidity to the patient. We present an overview of nerve repair and reconstruction in the head and neck for post-ablative defects, with a focus on the lingual and inferior alveolar nerves of the trigeminal system. A review of various methods of management of neural structures in different types of pathology, as well as operative techniques in nerve reconstruction is presented, with a focus on the use of processed nerve allografts for this purpose. This manuscript highlights that nerve preservation should only be performed if it permits an “oncologically-safe” procedure, with minimal to no risk of leaving pathology behind. Immediate or delayed nerve reconstruction can be performed; however, the former allows for a technically easier procedure and more predictable results. Nerves can either be repaired primarily, or reconstructed with “conduit-assisted” and/or interpositional grafting, with the goal of having a tension-free and well-aligned coaptation. In gaps larger than 6mm, grafting with either autogenous or allogenic nerves yields more optimal results, with processed nerve allografts showing excellent outcomes in this setting. In conclusion, nerve reconstruction has gained significant ground in the restoration and rehabilitation of head and neck defects. There exist several techniques for nerve reconstruction, however the use of processed nerve allografts has significantly improved results while eliminating the morbidity associated with autogenous grafting. Head and neck oncologic and reconstructive surgeons should be aware of the predictability of nerve reconstruction techniques to optimize patients’ functional recovery in the postoperative period.

Risk-adjustment models in patients undergoing head and neck surgery with reconstruction.

With the current focus on value-based outcomes and reimbursement models, perioperative risk adjustment is essential. Specialty surgical outcomes are not well predicted by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP); the Head and Neck-Reconstructive Surgery NSQIP was created as a specialty-specific platform for patients undergoing head and neck surgery with flap reconstruction. This study aims to investigate risk prediction models in these patients. The Head and Neck-Reconstructive Surgery NSQIP collected data on patients undergoing head and neck surgery with flap reconstruction from August 1, 2012 to October 20, 2016. Multivariable logistic regression models were created for 9 outcomes (postoperative ventilator dependence, pneumonia, superficial recipient surgical site infection, presence of tracheostomy/nasoenteric (NE)/gastrostomy/gastrojejunostomy(G/GJ) tube 30days postoperatively, conversion from NE to G/GJ tube, unplanned return to the operating room, length of stay>7days). External validation was completed with a more contemporary cohort. A total of 1095 patients were included in the modelling cohort and 407 in the validation cohort. Models performed well predicting tracheostomy, NE, G/GJ tube presence at 30days postoperatively and conversion from NE to G/GJ tube (c-indices=0.75-0.91). Models for postoperative pneumonia, superficial recipient surgical site infection, ventilator dependence>48h, and length of stay>7days were fair (concordance [c]-indices=0.63-0.69). The predictive model for unplanned return to the operating room was poor (c-index=0.58). Reliable and discriminant risk prediction models were able to be created for postoperative outcomes using the specialty-specific Head and Neck-Reconstructive Surgery Specific NSQIP.

The Early Effects of Coronavirus Disease-2019 on Head and Neck Oncology and Microvascular Reconstruction Practice: A National Survey of Oral and Maxillofacial Surgeons Enrolled in the Head and Neck Special Interest Group

PurposeThe coronavirus disease-2019 (COVID-19) pandemic has affected healthcare systems across the nation. The purpose of this study is to gauge the early effects of the COVID-19 pandemic on head and neck oncology and reconstructive surgery (HNORS) practice and evaluate their practice patterns especially ones that might be impacted by COVID-19 and compare them to the current literature.MethodsThis study is a cross-sectional study that surveyed fellowship-trained oral and maxillofacial surgeons in HNORS. This cohort of surgeons was contacted via a generated email list of surgeons enrolled in the American Association of Oral and Maxillofacial Surgeons pathology special interest group. An electronic survey contained 16 questions to assess the COVID-19 effect on HNORS practice and capture their practice patterns from mid-March to mid-April 2020. Statistical analysis was performed to analyze counts, percentages, and response rates.ResultsWe had a 60% response rate (39 of 64); 72% of our responders worked at academic institutions, 18% marked themselves as hybrid academic/private practice, and only 10% were considered hospital-based surgeons. Only 8% of the survey respondents were requested to pause head and neck cancer surgery, whereas 24% were requested to pause free flap surgery during the pandemic. Fifty-five percent agreed that the head and neck and reconstructive surgery should be conducted during a pandemic. Finally, 45% thought that two weeks was a reasonable delay for head and neck cancer cases, whereas 29% thought they should not be delayed for any amount of time. Regarding practice patterns, microvascular reconstruction was the favored method (100%). Respondents generally admitted patients to an intensive care unit postoperatively (92%) and were kept on a ventilator (53%).ConclusionThe COVID-19 pandemic had a small impact on the surgical treatment of patients with head and neck oncology. Most HNORS surgeons are practicing in accordance with recently published literature.

National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility.

To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. Cross-sectional analysis of US national database. American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Virtual surgical planning in fibula flap mandibular reconstruction

: Mandibular reconstruction is one of the workhorse in head and neck reconstructive surgery, with the free fibula flap currently considered the gold standard technique. The last two decades have seen considerable developments and a surge in popularity of virtual surgical planning (VSP) and Computer-aided design and manufacturing (CAD-CAM). Starting with virtual performing of the surgery, the possibilities that this technology offers are enormous. Stereolithographic models, customized bone cut guides and pre-bent reconstruction plates are very useful intraoperative tools. In spite of the high costs of this technology, it is helpful to surgeons in the following ways: (I) During ablative oncological surgery, cleaner bone margins are easily obtained due to bone cut accuracy enhancement; and (II) the efficiency of reconstructive surgery is improved by simplifying the otherwise time-consuming reconstructive steps associated with the traditional free-hand technique. The aim of this article is to describe our experience and to share the tips and pitfalls than we have found along these years with this technology which is producing a paradigm shift in bone graft reconstruction. In conclusion, our recommendation is to use a case-by-case evaluation to select those patients for whom VSP and CAD-CAM will help to obtain the best aesthetical and functional outcomes.

Impact of the COVID-19 Global Pandemic on the Otolaryngology Fellowship Application Process.

On March 11, 2020, the World Health Organization declared coronavirus disease 2019 a global pandemic. In addition to massive social disruption, this pandemic affected the traditional fellowship interview season for otolaryngology subspecialties, including head and neck surgical oncology, facial plastic and reconstructive surgery, laryngology, rhinology, neurotology, and pediatric otolaryngology. The impact on the fellowship interview process, from the standpoint of the institution and the applicant, necessitated the use of alternative interview processes. This change may alter the future of how interviews and the match proceed for years to come, with nontraditional methods of interviewing becoming a mainstay. While the impact this pandemic has on the fellowship match process is not yet fully realized, this commentary aims to discuss the challenges faced on both sides of the equation and to offer solutions during these unprecedented times.

An analysis of unplanned readmissions after head and neck microvascular reconstructive surgery

The 30-day readmission rate is a highly scrutinized metric of quality surgical care, because readmission is costly and perceived to be avoidable with planning and patient education. Head and neck surgery patients generally have multiple risk factors for readmission, as readmitted patients are generally older, with more co-morbidities, lower socio-economic status, and a history of multiple emergency department visits and readmissions. A retrospective cohort study was implemented to determine the incidence and etiology of 30-day readmission after microvascular head and neck reconstructive surgery, focusing on social risk factors. Data were analyzed by χ2 test, analysis of variance, t-test, and logistic regression, with statistical significance set at P<0.05. Of 209 patients included in this study, 35 (16.7%) had a 30-day readmission. Increased needs at discharge were associated with increased readmission, while other social risk factors were less significant for a readmission in this study.

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.