Principles of head and neck reconstruction: an algorithm to guide flap selection.
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ABSTRACT:
SUBMITTER: Chim H
PROVIDER: S-EPMC3324247 | biostudies-other | 2010 May
REPOSITORIES: biostudies-other
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Project description:IntroductionHistorically, there were concerns vasopressors impair free flap outcomes, but recent studies suggest vasopressors are safe. Here we investigate this controversy by (1) evaluating vasopressors' effect on head and neck free-flap survival and surgical complications, and (2) performing soft tissue and bony subset analysis.Patients and methodsPost hoc analysis was performed of a single-blinded, prospective, randomized clinical trial at a tertiary care academic medical center involving patients ≥18 years old undergoing head and neck free flap reconstruction over a 16-month period. Patients were excluded if factors prevented accurate FloTrac™ use. Patients were randomized to traditional volume-based support, or goal-directed support including vasopressor use. Primary data was obtained by study personnel through intraoperative data recording and postoperative medical record review.ResultsForty-one and 38 patients were randomized to traditional and pressor-based algorithms, respectively. Flap survival was 95% (75/79). There was no significant difference between the pressor-based and traditional protocols' flap failure (1/38 [3%] vs. 3/41 [7%], RR 0.36, 95% CI of RR 0.04-3.31, p = .63) or flap-related complications (12/38 [32%] vs. 18/41 [44%], RR 0.72, 95% CI 0.40-1.29, p = .36) Soft tissue flaps had surgical complication rates of 12/30 (40%) and 9/27 (33%) for traditional and pressor-based protocols, respectively. Bony flaps had surgical complication rates of 6/11 (55%), and 3/11 (27%) for traditional and pressor-based protocols, respectively.ConclusionsIntraoperative goal-directed vasopressor administration during head and neck free flap reconstruction does not appear to increase the rate of flap complications or failures.
| S-EPMC8396078 | biostudies-literature
Project description:In reconstructions of mandibles and condyles, free fibular flaps and metallic condylar heads (CH) are often used after resection. However, in conventional reconstructions, it is difficult to fix the metallic CH on the same preoperative position because the position is determined visually. Therefore, we have made an original computer-aided design and manufacture (CAD/CAM) guide for mandibular condyle reconstruction, combining a metallic CH with a free fibular flap. A 71-year-old woman with gingival carcinoma underwent hemimandibulectomy. We reconstructed the mandible and condyle with a metallic CH and a free fibular flap. We placed a mark on the CAD/CAM guide showing the correct position for fixing the CH to the fibular blocks. We also designed a surface for attaching to the healthy edge of the mandible. The fibular blocks and metallic CH were fixed as 1 unit before separating the flap from the leg and replacing the diseased tissue. Reconstruction was completed by fixing the attachment surface to the healthy side of the mandible. The guide marks solved the difficulty of conventional reconstruction; during surgery, we fixed the metallic CH to the same position as the original bone using these marks. The postoperative deviation of the condyle from the virtual plan was 4.3 mm, whereas the reported deviation of such prostheses was 3.8 mm (range 1.3-6.7); so our guide was acceptably accurate. Furthermore, it appears that the CAD/CAM guide is more useful for reconstruction after hemimandibulectomy including the condyle than after segmental resection without including condyle.
| S-EPMC7544273 | biostudies-literature
Project description:BackgroundAdherence to guidelines for antibiotic prophylaxis is often poor and is an important target for antimicrobial stewardship programs. Prescribing audits that suggested poor adherence to guidelines in a plastic surgery department led to a targeted education program to bring antibiotic prescriptions in line with hospital guidelines. We reviewed whether this intervention was associated with changed perioperative prescribing and altered surgical outcomes, including the rate of surgical site infections, specifically looking at clean-contaminated head and neck tumor resections with free flap reconstruction.MethodsA retrospective cohort study was performed on 325 patients who underwent clean-contaminated head and neck tumor resection and free flap reconstruction from January 1, 2013, to February 19, 2019. Patients were divided into 2 groups, those before (pre-intervention) and after (postintervention) the education campaign. We analyzed patient demographic and disease characteristics, intraoperative and postoperative factors, and surgical outcomes.ResultsPatients pre-intervention were prescribed longer courses of prophylactic antibiotics (median [interquartile range], 9 [8] vs 1 [1]; P < .001), more topical chloramphenicol ointment (21.82% vs 0%; P < .001), and more oral nystatin (36.9% vs 12.2%; P < .001). Patients postintervention had higher rates of recipient infections (36.11% vs 17.06%; P < .001) and donor site infections (6.94% vs 1.19%; P = .006).ConclusionsFollowing the education campaign, patients were prescribed shorter courses of prophylactic antibiotics, more of the recommended cefazolin-metronidazole regimen, and fewer topical antibiotics. However, patients also had a higher rate of surgical site infections.
| S-EPMC8743122 | biostudies-literature
Project description:Abstract Objectives Investigate opioid usage and postoperative pain in patients undergoing head and neck free flap surgery. Methods A retrospective review of 100 consecutive patients undergoing head and neck free flap reconstruction at two academic centers was performed. Data captured included demographics, postoperative inpatient pain, pain at postoperative visits, morphine equivalent doses (MEDs) administration, medication history, and comorbidities. Data were analyzed using regression models, χ2 tests, and student's t‐tests. Results Seventy‐three percent of patients were discharged with opioid medication, with over half (53.4%) continuing to take opioids at their second postoperative visit, and over one‐third (34.2%) continuing to take them around 4‐month postoperatively. One out of every five (20.3%) opioid‐naïve patients chronically took opioids postoperatively. There was a poor association between inpatient postoperative pain scores and daily MEDs administered (R2 = 0.13, 0.17, and 0.22 in postoperative Days 3, 5, and 7, respectively). Neither preoperative radiotherapy nor postoperative complications were associated with an increase in opioid usage. Conclusions For patients undergoing head and neck free flap operations, opioid medications are commonly used for postoperative analgesia. This practice may increase the chance an opioid‐naïve patient uses opioids chronically. We found a poor association between MEDs administered and patient‐reported pain scores, which suggests that standardized protocols aimed at optimizing analgesia while reducing opioid administration may be warranted. Level of Evidence: 3 (Retrospective cohort study).
| S-EPMC10296052 | biostudies-literature
Project description:We assessed the feasibility and safety of free flap reconstruction in children undergoing extensive surgical excision of malignant head and neck tumors. We performed a retrospective review in a tertiary referral center of all patients aged 18 years or younger who underwent free flap reconstruction following resection of malignant head and neck tumors at our institution. Main outcome measures included complications at the primary and donor sites, functional and esthetic outcome, and tumor control. Eight of the 237 (3.4%) free flap reconstructions were performed on children. All tumors were malignant sarcomas. Ablative surgery was via a transfacial (n = 4) or a combined approach (n = 4). Transferred free flaps were the rectus abdominis (n = 3), gracilis (n = 3), fibula (n = 1), and anterolateral thigh (n = 1). The mean follow-up was 25.5 months. The overall early and late complication rates were 50% and 25%, respectively. There were no flap losses and no donor site complications. Functional outcome, including mastication, deglutition, and speech, was satisfactory. Local tumor control rate at last follow-up was 87.5%. Free flap reconstruction is an efficient and relatively safe technique for reconstructing surgical defects of the head and neck in children undergoing extensive surgery for malignant disease.
| S-EPMC3312108 | biostudies-other
Project description:Surgery with free flap reconstruction is a standard treatment for head and neck cancer (HNC). Because of the complexity of HNC surgery, recovery can be challenging, and complications are common. One of the foundations of enhanced recovery after surgery (ERAS) is early postoperative mobilization. The ERAS guidelines for HNC surgery with free flap reconstruction recommend mobilization within 24 h. This is based mainly on evidence from other surgical disciplines, and the extent to which mobilization within 24 h improves recovery after HNC surgery has not been explored. This retrospective analysis included 445 patients from the Calgary Head and Neck Enhanced Recovery Program. Mobilization after 24 h was associated with more complications of any type (OR = 1.73, 95% CI [confidence interval] = 1.16-2.57) and more major complications (OR = 1.76; 95% CI = 1.00-3.16). When accounting for patient and clinical factors, mobilization after 48 h was a significant predictor of major complications (OR = 2.61; 95% CI = 1.10-6.21) and prolonged length of stay (>10 days; OR = 2.85, 95% CI = 1.41-5.76). This comprehensive analysis of the impact of early mobilization on postoperative complications and length of stay in a large HNC cohort provides novel evidence supporting adherence to the ERAS early mobilization recommendations. Early mobilization should be a priority for patients undergoing HNC surgery with free flap reconstruction.
| S-EPMC8227616 | biostudies-literature
Project description:Objectives To establish the implications of frailty as a predictor of outcome in patients with head and neck cancer requiring flap repair. Design Retrospective cohort. Data source We captured data from patients above 60 years old undergoing head and neck tumour resection and free flap reconstruction surgery between June 2019 and June 2020 at the Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University. The data contain all treatment information. Outcome variables Surgery repeated in 30 days, postoperative complications, hospital length of stay, postoperative main biochemical standards. Exposure variables Age, sex, smoking history, alcoholism history, American Society of Anesthesiologists score, National Nosocomial Infection Surveillance score and Clinical T staging were exposure variables. The frailty index is the main variable. Result A total of 254 patients were included in this study. Among them, 124 patients were classified as frail, while 130 patients were classified as non-frail. We found that frail patients stayed in the hospital longer than non-frail patients after surgery (p=0.018). According to the data of 26 frail patients who directly entered the intensive care unit (ICU), we found that these patients had a lower leucocyte count (p=0.005). Conclusions Frailty is a useful predictor of outcomes in patients undergoing head and neck cancer surgery with flap reconstruction. Frailty can be a clinical tool used to identify high-risk patients and guide perioperative care to optimise patient outcomes. Frail patients have better outcomes if they directly enter the ICU.
| S-EPMC9743268 | biostudies-literature
Project description:Head and neck reconstructive surgeons have recently explored new perspectives in bone restoration using periosteum carrier flaps. Following this idea, we explored the possibility of harvesting a galeo-pericranial flap. The present work studies the vascular supply of the pericranial temporo-parietal region in order to assess the possibility of harvesting a galeo-pericranial flap based on the superficial temporalis vascularization. Anatomical dissections were performed at the Anatomical Institute of the University of Bologna on eight donor cadavers. Then we performed the harvesting of the flap in vivo on eight patients. We introduced augmented reality (AR) to facilitate anatomical visualisation during free flap harvesting. Augmented reality merges virtual and actual objects, allowing direct observation of patient anatomy and the surgical field. No post-operative major or minor complications occurred. We encountered no post-operative functional issues on the donor or recipient sites, and good clinical healing was observed in all patients. In conclusion, we believe that the galea-pericranium flap could represent a new donor site for the harvesting of a periosteum carrier flap.
| S-EPMC7408700 | biostudies-literature
Project description:BackgroundPoor nutritional status among patients with advanced stage head and neck squamous cell carcinoma (HNSCC) is common. Albumin is a common indicator of nutritional status and has been shown to be a predictor of oncological outcomes and perioperative morbidity. This study aims to determine the prognostic value of the serum albumin level among patients with advanced HNSCC undergoing surgery with simultaneous free flap reconstruction.MethodsA total of 233 patients with advanced head and neck cancer undergoing tumor resection and immediate microvascular free flap reconstruction in a tertiary referral center were enrolled retrospectively between January 2009 and December 2011. Statistical analyses including Pearson's chi-squared test were used to determine whether there was a significant difference between each selected clinical factors and postoperative major wound infection. Multiple regression analysis was performed to reveal the relationship between postoperative major wound infection and clinical factors. Kaplan-Meier curves and multivariate Cox regression were applied to analyse survival outcome for overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS).ResultsPostoperative serum albumin level (p < 0.001) and tumor location were both significantly associated with postoperative major wound infection (p = 0.018) in univariate analysis. Multiple regression analysis showed a higher risk of postoperative major wound infection among patients with postoperative hypoalbuminemia than in their counterparts (odds ratio [OR] 9.811, 95% CI [2.288-42.065], p = 0.002). Patients with a tumor located over the hypopharynx experienced increased risk of postoperative major wound infection (OR 2.591, 95% CI [1.095-6.129], p = 0.030). With respect to oncological outcomes, preoperative serum albumin level is a significant independent prognostic factor for overall survival (OS), disease-specific survival (DSS) and disease-free survival (DFS).ConclusionsPostoperative hypoalbuminemia is a useful indicator for the development of postoperative complications. In addition, preoperative hypoalbuminemia is a negative prognostic factor for patients who have undergone tumor excision and free flap reconstruction for the advanced stage of HNSCC.
| S-EPMC5853599 | biostudies-literature
Project description:Both free posterior tibial flap (FPTF) and free radial forearm flap (FRFF) are commonly used for head and neck defects. They have many similarities in embryology, histology, and anatomy, but their advantages and disadvantages in head and neck repair have not been fully recognized. This study aimed to compare the cadaveric anatomy and clinical application of FPTF and FRFF for the reconstruction of head and neck defects after tumor resection. Anatomical dissection was performed on 10 fresh adult cadavers. The general characteristics of both flaps and the sites of recipients and donors were collected. A total of 31 and 25 patients underwent FPTF and FRFF construction, respectively. The patient medical records were assessed to obtain the clinical characteristics. Characteristics of the flap such as size, pedicle length, and clinical process data were collected and compared. The appearance, sensory disturbance, and effect on quality of life and daily activity were evaluated. The posterior tibial artery was present and observed in all patients. The posterior vascular pedicle was longer than the radial artery. There was no difference between the diameters of arteries of FPTF and FRFF; however, the diameters of their veins differed. In terms of flap characteristics, FPTF was significantly larger and had a longer vascular pedicle than FRFF (40.68±11.07 vs. 53.77±29.02 cm2, P=0.03; 8.48±1.66 vs. 11.10±2.39 cm, P=0.00). Patients in the FPTF group had a significantly shorter total hospital stay (FRFF: 26.48±8.33 d; FPTF: 18.58±6.68 d), postoperative hospital stay (FRFF: 17.60±5.53 d; FPTF: 10.94±3.62 d), and flap harvest time (FRFF: 87.00±20.92 min; FPTF: 65.00±17.56 min) than FRFF group. There were far more complications of the donor site in the FRFF group than in the FPTF group. Also, according to the patients' subjective evaluations of the donor site, FPTF was superior to FRFF (P=0.00). FPTF is a reliable alternative to FRFF for head and neck reconstruction. These techniques share similar certain embryogenesis and anatomical characteristics but FPTF possesses unique aesthetic and clinical application advantages.
| S-EPMC9761164 | biostudies-literature