Objectives/Hypothesis
Free tissue transfer has success rates greater than 95%. Approximately 10% will require reexploration for vascular compromise. Return to the operating room within 48 hours ...yields the highest rate of successful salvage. Our aim was to determine whether an implantable Doppler used for intraoperative/postoperative monitoring would 1) alter the pattern of detecting flap failure and 2) alter the overall incidence of flap survival.
Study Design
Prospective analysis.
Methods
Generic and study specific data was collected. Note was made at the end of the case if revision of the vascular anastomosis was performed. Data was collected for flap outcomes in the postoperative period.
Results
A total of 1,236 free tissues transfers from 2001 through 2011 were analyzed. Ninety‐four were outside the head and neck or the Doppler was not used/inadvertently discontinued. A total of 1,142 flaps make up the study cohort. One hundred thirty‐four (11.7%) intraoperative flow problems were detected, all successfully revised. Of these, 15 (11%) required postoperative revision and five (33%) were successfully salvaged, with an overall survival 93%. A total of 1,008 flaps did not require intraoperative revision, 62 required reexploration (6.1%), and 38 (61%) were salvaged. The overall survival was 97.6%. There were eight false positive (no intervention) and 10 false negatives. Sensitivity was 87% with specificity 99%.
Conclusion
Intraoperative Doppler's increase the detection of immediate/incipient vascular problems. Patients requiring revision in the operating room require revision more often in the postoperative period (P = .03) and are less likely to have successful salvage and a lower flap survival rate (P = .05).
Level of Evidence
N/A. Laryngoscope, 124:S1–S12, 2014
Sarcopenia, or the loss of muscle mass, is associated with poor treatment outcomes in a variety of surgical fields. However, the association between sarcopenia and long-term survival in a broad ...cohort of patients with head and neck cancer (HNC) is unknown.
To determine whether sarcopenia is associated with long-term survival in patients undergoing major head and neck surgery for HNC.
A retrospective medical records review was conducted at a tertiary care academic hospital. Two hundred sixty patients undergoing major head and neck ablative procedures with cross-sectional abdominal imaging performed within 45 days prior to surgery were included in the analysis. The study was conducted from January 1, 2005, to December 31, 2016. Data analysis was performed from June 1, 2018, to February 28, 2019.
Measurement of cross-sectional muscle area at the L3 vertebra level.
Two- and 5-year overall survival were the primary outcomes.
Of the 260 patients included in the study, 193 were men (74.2%); mean (SD) age was 61.1 (11) years. Sarcopenia was present in 144 patients (55.4%). Two-year overall survival was 71.9% of the patients (n = 82) in the sarcopenia group compared with 88.5% of the patients (n = 85) in the nonsarcopenia group (odds ratio OR, 0.33; 95% CI, 0.16-0.70). At 5 years, overall survival was 36.5% in patients (n = 23) with sarcopenia and 60.5% in patients (n = 26) without sarcopenia (OR, 0.38; 95% CI, 0.17-0.84). On multivariate analysis, sarcopenia was a significant negative predictor of both 2-year (OR, 0.33; 95% CI, 0.14-0.77) and 5-year (OR, 0.38; 95% CI, 0.17-0.84) overall survival.
Sarcopenia appears to be a significant negative predictor of long-term overall survival in patients with HNC undergoing major head and neck surgery. Sarcopenia may be accurately assessed on cross-sectional imaging and may be useful clinically as a prognostic variable and as an area for intervention to improve treatment outcomes.
Objectives
Highlight the use of fluorescent angiography in free flap reconstruction of the head and neck. Qualify how fluorescent angiography can be selectively added to management paradigms for head ...and neck free flap reconstruction.
Methods
Retrospective chart review of 993 free flaps completed from the time the SPY Elite® system first became available at our institution between September 2013, until August 2020. Cases that used the SPY Elite® system were grouped into three broad categories: evaluation during initial flap harvest while still attached to the donor site, evaluation after anastomosis in the head and neck area, and evaluation post‐operatively for questionable flap viability.
Results
The SPY Elite® system was used in 64 cases. Forty flaps were evaluated intraoperatively during initial harvest and before anastomosis to the head and neck area. Of these, 20 had signs of poor perfusion of the entire skin paddle, 12 had large myogenous or skin flaps with questionable perfusion of the distal aspect, and 8 were evaluated for other reasons. In this group the use of SPY Elite® changed the management of the patient in 20 cases (50%). Ten flaps were evaluated intraoperatively after anastomosis to the head and neck to ascertain adequate flow to the entire flap. In this group management was changed in two (20%). Fourteen flaps were evaluated 3–5 days post operatively due to suspected failure of a component. In five cases (36%), the use of SPY Elite® determined management with either trimming or discarding the flap.
Conclusion
Assessment of flap perfusion via fluorescent angiography during initial flap harvest or when flap compromise is suspected post‐operatively can guide decision making in free flap reconstruction of the head and neck and can be added to existing planning and management paradigms.
Level of Evidence
4 Laryngoscope, 133:1388–1393, 2023
A retrospective study of the use of fluorescent angiography in free flap reconstruction of the head and neck shows that although the use of this technology in every free tissue transfer is not justifiable, it can guide the clinical course in challenging scenarios.
•Vasopressor usage in head and neck reconstruction is controversial.•The majority of the literature would suggest vasopressor usage has no deleterious effect on free flap survival.•Vasopressin usage ...should be considered to maintain hemodynamic stability.•Use of anticoagulation regimes in the postoperative setting are varied.•Most anticoagulation regimes are associated with increased patient morbidity and no improvement in flap survival.
Given the high stakes for microvascular reconstruction, the majority of reconstructive surgeons have developed paradigms for pre, intra, and postoperative management that have proven to result in individual high success rates. Much has been done to identify and avoid perioperative factors that could potentially increase flap failure rates. Two example of this practice has been the generalized use of anticoagulation in free tissue transfer and the prohibition against vasopressor use in patients that are undergoing free tissue transfer. This manuscript will discuss these issues.
Objective
Investigate current practice patterns of head and neck microvascular reconstructive surgeons when removing an implantable Doppler after free flap surgery.
Study Design
Cross‐sectional ...survey study.
Methods
Survey distributed to head and neck microvascular reconstructive surgeons. Data regarding years performing free tissue transfer, case numbers, management of implantable Doppler wire, and complications were collected.
Results
Eighty‐five responses were analyzed (38,000 cases). Sixty‐six responders (77.6%) use an implantable Doppler for postoperative monitoring, with 97% using the Cook‐Swartz Doppler Flow Monitoring System. Among this group, 65.2% pull the wire after monitoring was complete, 3% cut the wire, and 31.8% have both cut and pulled the wire. Of those who have cut and pulled the wire, 48% report cutting and pulling the wire with equal frequency, 43% formerly pulled the wire and now cut the wire, and 9% previously cut the wire but now pull the wire. Of those who pull the wire, there were two injuries to the pedicle requiring return to the operating for flap salvage, and one acute venous congestion. Of the nine who previously pulled the wire, six (67%) cited concerns with major bleeding/flap compromise as the reason for cutting the wire.
Conclusion
In this study, most surgeons use an implantable Doppler for monitoring of free flaps postoperatively. In extremely rare instances, pulling the implantable Doppler wire has resulted in flap compromise necessitating revision of the vascular anastomosis. Cutting the wire and leaving the proximal portion in the surgical site has been adopted as a management option.
Level of Evidence
4 Laryngoscope, 132:554–559, 2022
Reconstruction of mandibular defects is best accomplished by composite bony tissue. When the fibula is not available other sources must be used. Occasionaly tumor recurence will neccesitate a further ...resection and bony reconstruction. We report two cases in which osteocutaneous radial forearm free tissue transfer was used for secondary reconstructio after prior bony free flap reconstruction. Laryngoscope, 132:2177–2179, 2022
Abstract
Innovation in surgical care is a complex procedure. When you reflect on how your practice has changed, whether it be 5 years or over decades, it can be enlightening to not only see the ...change but also conceptualize how it came about. Examining one's practice as part of Pittsburgh Sleep Quality Index or as a result of reading the literature, attending a meeting, or some other educational activity can lead one to question if there is a better method available. In this manuscript, I will describe how outside influences initiated a paradigm shift that ultimately benefited patient care, the system, and my practice. The methodology has been used over the course of my career to influence and modulate practice patterns.
Objectives
Iatrogenic injury of the fibula free flap pedicle is rare. Postoperative flap survival and reconstructive outcomes following intraoperative pedicle severance are unknown. This study ...assesses free flap outcomes following accidental severance of the peroneal vessels.
Methods
Multi‐institutional retrospective chart review from 2000 to 2020.
Results
Of 2975 harvested fibula free flaps, 26 had a history of pedicle severance during surgical reconstruction. Reasons for intraoperative pedicle severance included transection during muscular dissection 10/26 (39%), accidental severance with the bone saw 12/26 (46%), and other 4/26 (15.6%). The surgeon responsible for pedicle severance included residents 5/26 (19%), fellows 10/26 (39%), attendings 10/26 (39%), and unknown 1/26 (3.9%). The pedicle artery and vein were severed 10/26 (39%), artery 8/26 (31%), and vein 8/26 (31%). Truncated pedicle vessels were used 3/26 (11.7%), intraoperative anastomoses were performed 23/26 (89%). Postoperative revision in the OR within 7 days of surgery was required 6/26 (23%); 4 flaps were salvaged and 2 flaps failed, both arterial thrombosis. Flap failure was attributed to vascular thrombosis. Long‐term flap survival and successful reconstructions were reported 24/26 (92%).
Conclusion
Accidental severance of fibula free flap pedicle vessels can be corrected with intraoperative repair, without affecting long‐term flap survival or reconstructive outcomes. Protecting the flap vessels while using the bone saw and during intramuscular dissection prevents accidental severance.
The palatal island rotation flap is a rarely used reconstructive technique. The tissue is robust and the morbidity is low. It can be used as a primary reconstructive technique in patients with ...limited oral cavity/pharynx lesions. Healing is uneventful. In radiated pateints healing is prolonged and should be avoided.
We describe 14 patients where the flap was used to reconstruct local defects. Patients with no history of radiation all healed quickly and well. Those with a history of radiatiuon had prolonged pain and delayed healing. Laryngoscope, 134:2718–2720, 2024
Palatal island flap is a rarely used reconstructive option for limited oral cavity or oropharyngeal defect. This flap should be avoided in patients with history of radiation, smoking, through‐and‐through defects or in cases with neck exposure.
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