Perfusion of microvascular free flaps in head and neck reconstruction after prior neck dissection and irradiation

Microvascular free flaps are frequently used for head and neck reconstruction after prior neck dissection (ND) and neck irradiation (RTX). The aim of this study was to investigate the influence of ND and RTX on flap perfusion as a critical factor for flap success. Overall, 392 patients reconstructed with a microvascular fasciocutaneous flap (FF) or perforator flap (PF) in the head and neck region between 2011 and 2020 were analysed retrospectively. Flap perfusion measured intraoperatively and postoperatively with the O2C tissue oxygen analysis system was compared between patients who had received neither ND nor RTX (controls), patients who had received ND but no RTX (ND group), and patients who had received both ND and RTX (ND+RTX group). Intraoperative and postoperative flap blood flow was decreased in FFs in ND group patients compared to controls (median 66.3 AU vs 86.0 AU, P = 0.023; median 73.5 AU vs 93.8 AU, P = 0.045, respectively). In the multivariable analysis, these differences showed a tendency to persist (P = 0.052 and P = 0.056). Flap success rates were similar in control patients, ND patients, and ND+RTX patients (98.7%, 94.0%, and 97.6%, respectively). Flap perfusion is not reduced in FFs and PFs in patients who have undergone ND or ND and RTX. This indicates that neck dissection and neck irradiation should not be contraindications for microvascular free flap reconstruction.     

Development of the clinical use of distant flaps for head and neck reconstruction

The reconstruction of hard and soft tissue defects, mainly after ablative oncologic surgery in the head and neck area, is an evolving field. The use of free flaps for reconstruction of the head and neck is considered to be the surgical standard. In our analysis of more than 1000 free flaps we give an overview of the development of the use of different types of free tissue transfer to the head and neck area over the last 25 years. We show that the evolving field of head and neck reconstruction raises new possibilities with new types of flaps, whereas other types of flaps disappear in the everyday clinical use. The spectrum of reconstruction possibilities broadens with the number of different flap types available to the head and neck surgeon.     

The impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap: a systematic review and meta-analysis

Reconstructive surgery with a free vascularised tissue flap is indicated in large defects in the head and neck region, which arise mostly because of head and neck cancer. Tobacco smoking is a major risk factor for head and neck cancer, and many patients undergoing reconstructive surgery in the head and neck have a history of smoking. The objective of this meta-analysis was to determine the impact of smoking on surgical complications after head and neck reconstructive surgery with a free vascularised tissue flap. A systematic review was undertaken for articles reporting and comparing the incidence of overall surgical complications after reconstructive surgery with a free vascularised tissue flap between smokers and nonsmokers. Relevant articles were searched using PubMed, Cochrane, and Embase databases, and screened for eligibility according to the PRISMA guidelines. The risk of bias analysis was conducted using the Newcastle-Ottawa quality assessment scale. A meta-analysis was performed to quantitatively compare the incidence rate of overall surgical complications, flap failure, surgical site infection, fistula, and haematoma between smokers and nonsmokers using OpenMetaAnalyst (open source) software. Only qualitative analysis was performed for wound dehiscence, bleeding, nerve injury, and impaired wound healing. Forty-six articles were screened for eligibility; 30 full texts were reviewed, and 19 studies were included in the quantitative meta-analysis. From the 19 studies, 18 were retrospective and 1 was a prospective study. In total, 2155 smokers and 3124 nonsmokers were included in the meta-analysis. Smoking was associated with a significantly increased risk of 19.12% for haematoma (95% Confidence Interval (CI): 4.75–33.49; p < 0.01), and of 4.57% for overall surgical complications (95% CI: 1.97–7.15; p < 0.01). No significant difference in risk was found for flap failure (95% CI: ?4.33–9.90; p = 0.44), surgical site infection (95% CI: ?0.88–2.60; p = 0.33) and fistula formation (95% CI: ?3.81–3.71; p = 0.98) between smokers and nonsmokers. Only for flap failure was a significant heterogeneity found (I² = 63.02%; p = 0.03). Smoking tobacco was significantly associated with an increased risk of overall surgical complications and haematoma, but did not seem to affect other postoperative complications. Encouraging smoking cessation in patients who need reconstructive head and neck surgery remains important, but delaying surgery to create a non-smoking interval is not needed to prevent the investigated complications. More high-quality retrospective or prospective studies with a standardised protocol are needed to allow for definitive conclusions.     

颞浅动脉及静脉作为头颈部游离瓣移植受区血管的可靠性探讨

目的 探讨颞浅动、静脉作为头颈部游离瓣移植受区血管的可靠性和应用价值.方法2001年5月至2008年6月采用颞部血管作为受区血管的头颈部游离瓣移植25例,分析游离瓣的受区血管、术中及术后的血管危象及游离瓣的成活情况.结果 25例患者中,23块游离瓣采用颞浅静脉作为受区静脉,2例采用颞深静脉作为受区静脉,全部游离瓣均采用颞浅动脉作为受区动脉.全部游离瓣术后均未出现血管危象,游离瓣均获成活.结论本组结果表明,颞浅动、静脉是头颈部游离瓣移植可靠的受区血管.     

Infrahyoid myocutaneous flap in head and neck reconstruction: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to analyse the literature on the infrahyoid myocutaneous flap (IHMCF) and evaluate its clinical outcomes. The MEDLINE, Embase, Web of Science, Cochrane Library, and Scopus databases were searched (inception to December 31, 2021). Meta-analyses were then conducted to estimate the overall rates of partial flap loss, total flap loss, salivary fistula, and surgical revision. The 21 studies that met the inclusion criteria included 768 patients undergoing head and neck reconstruction with 773 IHMCF. The oral cavity (77.7%) and oropharynx (13.0%) were the most reconstructed sites. The meta-analyses estimated a pooled partial flap loss rate of 10.4% (99% confidence interval (CI) 5.4–16.7%), total loss rate of 1.8% (99% CI 0.8–3.2%), salivary fistula rate of 3.0% (99% CI 1.3–5.3%), and surgical revision rate of 1.9% (99% CI 0.7–3.7%). Fast flap harvesting and low donor site morbidity were other flap features. Previous thyroid surgery or neck dissection and advanced lymph nodal stage were considered contraindications to IHMCF reconstruction by most authors, while prior neck radiotherapy was reported as a relative contraindication. This pedicled cervical flap is a versatile and reliable reconstructive option for medium-sized head and neck defects. Careful preoperative assessment of the neck condition allows for its safe use.     

微血管吻合器在头颈部游离皮瓣移植动脉吻合中的初步应用

目的 探讨在头颈部缺损游离皮瓣移植手术中应用微血管吻合器吻合动脉的可靠性。方法 选择2013—2014年间行游离皮瓣修复头颈部肿瘤切除后缺损的患者21例,分别采取腓骨肌皮瓣、股前外侧皮瓣、前臂皮瓣同期修复缺损。动脉均采用微血管吻合器做端-端吻合,动脉吻合共应用21枚吻合器,观察其吻合时间及吻合后血管通畅情况。结果 21例患者术中吻合口均通畅无渗血;1例于术后第1天因皮瓣苍白行手术探查,术中见动脉血栓形成,重新行手工吻合,吻合后血管通畅。应用吻合器吻合时间较手工缝合明显缩短,平均约4~6 min。结论 微血管吻合器在适宜情况下可用于头颈部缺损游离皮瓣修复中的动脉端-端吻合,能够明显缩短吻合时间,操作简便,吻合质量可靠。     

Outcomes of reconstruction after temporal bone resection for malignancy

Reconstruction after temporal bone resection (TBR) is challenging due to the lack of consensus on an optimal approach. Records of the Keck Hospital of USC were searched to identify, collect and group data on patients who underwent TBR for malignancy. Chi-square analysis was used for categorical variables, and ANOVA was used for continuous variables. Forty TBR including 27 lateral (LTBR), 8 total (TTBR), and 5 subtotal (STBR) temporal bone resections were performed at our institution over a ten year time period (2003–2013) and reconstructed with free, regional, and local flaps and tissue grafts. TTBR was associated with postoperative complications as was presence of a dural defect, though other traditionally poor prognostic factors such as age, comorbidity status, and history of irradiation were not. Patients who underwent auriculectomy or parotidectomy were more likely to require free flap reconstruction. We conclude that TBR and reconstruction can be performed successfully on many patients including those who are older or who have more aggressive disease. We recommend free tissue transfer for the large defects created by TTBR, parotidectomy and auriculectomy.     

对提高头颈部游离组织瓣移植成功率的探讨

目的：探讨如何提高头颈部游离组织瓣移植的成功率。方法：2004年1月至2004年12月间，由同一手术小组完成的连续194例患者的200块游离组织瓣移植．分析所采用组织瓣的类型、受区血管、游离瓣成活情况及术后并发症的发生情况，并探讨提高游离瓣可靠性的重要环节。结果：本组共采用7种游离瓣，包括腓骨瓣、前臂皮瓣、大腿前外侧皮瓣、空肠瓣、腹直肌皮瓣、肩胛瓣和背阔肌皮瓣。游离瓣的临床成功率为99．5％，术后血管危象的发生率为2％，抢救成功率为75％：受区和供区总并发症发生率为24．2％。结论：合理选择游离瓣、熟练的游离瓣制备技术、选择理想的受区血管、简化实用的血管吻合技术及游离瓣术后的有效监测，是提高头颈部游离瓣移植成功率的重要环节。如果各个环节处理得当。头颈部游离组织瓣移植的成功率应当接近100％。     

影响头颈部游离皮瓣移植成活的因素分析

目的：分析影响头颈部游离皮瓣移植成活的相关因素。方法：对我院2005.9—2009.11期间进行的124例游离皮瓣移植资料进行回顾,分析年龄,吸烟和（或）饮酒、手术技术及抗凝药物和扩血管药物等因素对游离皮瓣移植成功的影响。采用SPSS17.0软件包对数据进行连续性校正χ2检验和Fisher确切检验。结果：皮瓣移植的成功率为97.5%（121/124）,与手术技术有明显相关性,而与年龄、是否吸烟和（或）饮酒、是否有高血压和（或）糖尿病以及是否全身应用抗凝药物等无相关性;术后皮瓣危象发生率为4.0%（5/124）,静脉栓塞是主要原因（80%）,手术探查3例,抢救成功2例,成功率为66.7%。结论：精良的显微外科技术以及血管蒂的处理和保护是提高皮瓣游离移植成功率的关键,而性别、年龄、吸烟、饮酒及全身应用抗凝药物和扩张血管药物等均不是影响头颈部游离皮瓣移植成活的关键因素。     

The importance of in-hospital mortality for patients requiring free tissue transfer for head and neck oncology

Mortality is a rare but disastrous complication of microvascular head and neck reconstruction. The investigators attempt to identify the procedure-related mortality cases and analyse the causes of death. A retrospective analysis of 804 consecutive free flap procedures during a 19-year period was performed and fatal cases were identified (n = 42 deaths). Multivariate logistic regression was employed to determine the association of in-hospital mortality with patient-related characteristics. The 30-day post-operative mortality rate was 1% (8 out of 804 patients), and the in-hospital mortality rate (post-operative deaths in-hospital before or after the 30th post-operative day without discharge) was 5.2% (42 out of 804 patients). Cancer recurrence and metastases related pneumonia were the most common causes of death (n = 26, 62%), followed by cardiac, pulmonary, infectious and hepatic/renal aetiologies. Logistic regression analysis revealed that patients with stage IV disease and an operation time of >9 h were significantly associated with post-operative mortality. Malignancy-related conditions were the most common causes of death following free flap transfer for head and neck reconstruction. For patients with stage IV head and neck cancer, this aggressive surgical approach should be cautiously justified due to its association with post-operative mortality. To shorten the operation time, experienced microsurgical operation teams are necessary.     

Anterolateral thigh flap with a central hole for the repair of extensive oral defects in patients treated for chemotherapy-induced trismus

Trismus is a rare complication of chemotherapy. The usefulness of a modified anterolateral thigh (ALT) flap for the repair of extensive oral defects in patients treated for chemotherapy-induced trismus was evaluated. Between 2019 and 2021, three patients with chemotherapy-induced trismus underwent scar excision. A thinned ALT flap with a central hole was designed to repair the resultant oral mucosal defects. The patients were followed up for a mean 9.3 months (range 4–18 months). The mean pre- and intraoperative maximum inter-incisal opening (MIO) was 0.7 cm (range 0–2.0 cm) and 3.6 cm (range 3.4–3.7 cm), respectively, indicating a significant operative effect. MIO at the latest follow-up was 2.4 cm (range 1.5–3.5 cm). All of the flaps survived without complications. All patients achieved a good diet and were satisfied with the aesthetics. Thorough excision of the perioral scar and restoration with a modified ALT flap achieved satisfactory mouth opening and cosmetic effects in patients with chemotherapy-induced trismus.     

游离腓肠内侧动脉穿支皮瓣修复头颈部缺损的初步研究

目的 探讨游离腓肠内侧动脉穿支皮瓣在头颈部缺损修复中的应用.方法 2010年4月至2011年1月16例患者头颈部肿瘤切除后拟用游离腓肠内侧动脉穿支皮瓣修复组织缺损,术前采用超声多普勒血流仪或彩色多普勒超声检测穿支血管,设计皮瓣,术中记录皮瓣大小、穿支血管的数目和血管蒂长度,术后观察游离瓣成活情况,随访记录供区愈合情况及评价术后并发症.结果 最终完成游离腓肠内侧动脉穿支皮瓣修复16例,15例皮瓣术后成活,1例术后因静脉危象手术探查后皮瓣部分存活.供区15例直接缝合,1例植皮.15例供区Ⅰ期愈合,1例因术后供区肌肉坏死行清创手术后愈合.14例术后随访3～ 12个月,所有患者供区除因瘢痕致远端皮肤触觉异常外,远期无明显功能障碍.结论 游离腓肠内侧动脉穿支皮瓣供区并发症轻微,适用头颈部中小型缺损修复.     

Intraoperative ICG-based fluorescence-angiography in head and neck reconstruction: Predictive value for impaired perfusion of free flaps

The aim of this study was to prove the hypothesis that intraoperative fluorescence-angiography using indocyanine-green (ICGFA) can be used to predict the occurrence of perfusion-associated complications following microvascular reconstruction.Consecutively perioperative data of patients who received microvascular reconstruction of the head and neck region and underwent ICGFA immediately after anastomosis was established were analyzed. The flow parameters analyzed in the investigation were (1) the baseline (Int_Min) and (2) peak intensity (Int_Max) of fluorescence, (3) the quotient of the two aforementioned parameters (F_max/min) as an expression of the relative total increase, (4) the absolute difference in the two parameters (Diff_Int) in terms of amplitude, (5) the duration of the intensity increase (T_Rise) until the peak, and (6) the percent intensity increase per second (Rise/sec_rel). Within the first 2 weeks postoperatively, every flap complication was documented. Subsequently, statistical analysis of the flap outcome was performed based on the flow parameters obtained intraoperatively.Data of 67 patients (male/female: 41/26) with an average age of 64 years (range 29–84 years) were analyzed. In 10 of these patients, postoperative perfusion-associated complications were observed (arterial/venous/microcirculatory: 4/3/3; p = 0.12). The analysis of the intraoperatively obtained flow parameters showed a significant difference in the ratio of maximum and minimum intensity in arterial pedicle perfusion (F_max/min) of patients with and without complications (with vs. without complications: 2.3 ± 1.0 vs. 5.0 ± 4.9; p < 0.01) and strong correlation of the mentioned parameter with the occurrence of perfusion-associated complications (odds ratio = 0.27; p = 0.01).The ratio of maximum and minimum intensity (F_max/min) is a predictor for postoperative venous stasis, arterial hypoperfusion and impaired microcirculation of a microvascular flap. Anastomoses with F_max/min <2.85 should be revised. However, a high technique sensitivity has to be considered, due to which sufficient hemostasis and reduction of motion artefacts have to be taken into account in order to obtain useable data.     

游离大腿前外侧皮瓣修复头颈部缺损的初步观察

目的探讨游离大腿前外侧皮瓣在头颈部缺损修复中的应用。方法回顾研究2002年1月至2006年1月完成的22例游离大腿前外侧皮瓣移植。分析采用组织瓣的设计、穿支血管的数目和类型、受区血管、血管吻合方式和技术、游离瓣成活情况及术后并发症，并分析有可能影响组织瓣成活的各种因素。结果22例中，皮瓣面积（7cm×5cm）～（16cm×8cm），平均11．1cm×6．9cm，除4块皮瓣携带2个穿支外，其余18块皮瓣均携带1个穿支。26个穿支中，20个为肌皮穿支，另外6个为隔皮穿支。1例游离瓣术后48h出现静脉危象，经抢救未成功后去除皮瓣。其余皮瓣术中、术后均未出现血管危象，并且全部成活。所有供区均直接拉拢缝合，除1例供区术后创口感染致二期愈合外，其余供区均一期愈合。结论游离大腿前外侧皮瓣克服了传统的前臂皮瓣和腹直肌皮瓣的缺点，在头颈部缺损的修复中具有较大的灵活性，值得进一步应用和观察。     

21例儿童头颈部恶性肿瘤患者游离皮瓣修复临床分析

目的: 分析儿童头颈部肿瘤患者术区缺损游离皮瓣修复重建的临床特点。方法: 回顾2009—2011年于上海交通大学医学院附属第九人民医院口腔颌面-头颈肿瘤科接受头颈部恶性肿瘤切除以及游离皮瓣修复、年龄≤14岁患者的临床、病理及影像学资料。采用SPSS 17.0软件包对收集的数据进行统计学分析。结果: 最终纳入患者21例,其中男14例,女7例;17例为ASA Ⅰ级,4例为ASA Ⅱ级。中位手术时间480 min,中位术中出血量500 mL。6例患者接受气管切开。发生内科并发症7例,包括肺部感染4例,腹泻3例;外科并发症4例,包括皮瓣下血肿1例,创面裂开2例,腺瘘1例。气管切开术与内科并发症发生直接相关（P=0.035）,与总体并发症（P=0.064）发生具有潜在关联。结论: 游离皮瓣对于儿童头颈恶性肿瘤患者术区缺损修复具有极高价值,术后并发症是影响此类患者预后的主要负面因素,气管切开与术后并发症发生关系较大,需谨慎使用。     

Comparison between the radial forearm and superficial circumflex iliac artery perforator free flaps for oral soft tissue reconstruction

The radial forearm free flap (RFFF) is widely used for oral reconstruction. The superficial circumflex iliac artery perforator (SCIP) flap is an increasingly utilized alternative. The cases of 165 patients who received either an RFFF or SCIP flap for oral reconstruction at Chris O′Brien Lifehouse, Sydney were reviewed. The aim was to report on patient, pathology, treatment, and outcome variables and to compare these between the two flap groups. A RFFF was used in 126 patients and a SCIP flap in 39 patients. SCIP flap patients were younger (P < 0.001) and had shorter operative times (P < 0.001), shorter anaesthetic times (P < 0.001), and more frequent recipient site dehiscence (P = 0.005) when compared to RFFF patients. The SCIP flap was significantly less frequently used for composite resections including bone when compared to the RFFF (P < 0.001). The primary site distribution was more even for RFFF patients (P < 0.001). There were no SCIP flap failures; three RFFF failures occurred. SCIP flaps performed comparably in terms of operative and clinical outcomes. Most SCIP flaps were utilized in younger patients with partial glossectomy defects.     

Posterior tibial artery flap versus radial forearm flap in oral cavity reconstruction and donor site morbidity

The repair of soft tissue defects after oral cavity cancer resection is challenging. The aim of this study was to compare the outcomes and donor site morbidity of the radial forearm free flap (RFF) and posterior tibial artery perforator flap (PTAF) for oral cavity reconstruction after cancer ablation. All patients who underwent oral cavity reconstruction with a RFF or PTAF between January 2017 and December 2019 were included retrospectively in this study. All flaps were harvested with a long adipofascial extension. The donor site defects were closed with a triangular full-thickness skin graft harvested adjacent to the flap. Flap outcomes and donor site complications were recorded and compared. The study included 145 patients; 30 underwent reconstruction with a RFF and 115 with a PTAF. No significant difference between the PTAF and RFF was observed concerning the flap survival rate (98.3% vs 96.7%), flap harvest time (53.39 vs 49.28 min), hospital stay (12.3 vs 15.2 days), or subjective functional and cosmetic outcomes. The PTAF showed a larger vascular calibre (P < 0.05), greater flap thickness (P = 0.002), and lower frequency of surgical site infection (P = 0.055) when compared to the RFF. No significant difference was observed between the pre- and postoperative ranges of ankle and wrist movements. The PTAF is an excellent alternative to the RFF for the repair of oral cavity defects, with the additional advantages of a well-hidden scar on the lower extremity, larger vascular calibre, and lower frequencies of postoperative donor site morbidities.     

Outcomes of osseointegrated implants in patients with benign and malignant pathologies of the head and neck: a 10-year single-centre study

The surgical management of head and neck pathologies involving the maxilla and mandible results in significant functional and aesthetic deficits, and ultimately reduced quality of life. Composite free flaps used for reconstruction address many of these deficits and create a foundation for the use of osseointegrated implants to support prosthetic replacement of the dentition. There are few comparative studies examining outcomes of implants in native and reconstructed bone in head and neck cancer patients. The aim of this retrospective cohort study was to compare survival rates and the effects of risk factors between implants placed in native and reconstructed bone. The Kaplan–Meier method estimated cumulative 1- and 5-year implant survival rates of 99.5% and 95% for native bone and 96% and 88% for reconstructed bone. Multivariate Cox regression found an increased risk of implant failure in reconstructed bone (hazard ratio (HR) 9.9, 95% confidence interval (CI) 3.4–29.7, P < 0.001). Subgroup analysis of the cohorts found an increased risk of failure in the reconstructed group associated with radiotherapy (HR 6.4, 95% CI 1.8–22.3, P = 0.004), current smoking (HR 23.2, 95% CI 2.7–198.6, P = 0.004), and previous smoking (HR 9.0, 95% CI 1.1–71.9, P = 0.038). There was no effect in the native bone group. Implants placed into reconstructed bone had higher rates of failure, and smoking status and radiotherapy increased the risk of implant failure.     

Accurate occlusion-driven maxillary reconstruction with deep circumflex iliac artery flap using computer-assisted techniques and intraoral anastomosis: a case series

The aim of this study was to evaluate the feasibility and accuracy of occlusion-driven maxillary reconstruction with the deep circumflex iliac artery (DCIA) flap, using computer-assisted design and manufacturing (CAD/CAM) technology and intraoral anastomosis. The data of 11 patients who underwent occlusion-driven maxillary reconstruction with this method between December 2018 and December 2020 in the Department of Oral and Maxillofacial Surgery, Peking University School and Hospital of Stomatology were reviewed retrospectively. Postoperative complications and functional and aesthetic outcomes were recorded. The accuracy of the postoperative restoration was assessed using Geomagic Control 2014. Reconstruction was successful in nine patients; all were satisfied with their aesthetic and functional outcomes. One patient underwent extraoral anastomosis after failure of intraoral anastomosis. In another patient, the DCIA flap had to be removed after the operation because of flap failure. Among the 10 patients with DCIA flap success, colour map analysis showed a mean deviation of 0.40 ± 0.08 mm between the preoperative and postoperative craniomaxillary models. Thus, occlusion-driven maxillary reconstruction with the DCIA flap, using CAD/CAM technology and intraoral anastomosis, appears to be a feasible and accurate method for the repair of maxillary defects.