Preventing postoperative haematomas in microvascular reconstruction of the head and neck: lessons learnt from 126 consecutive cases

Background: 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. Methods: 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. Results: 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. Conclusion: 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.     

Safety trial of Floseal(®) haemostatic agent in head and neck surgery

INTRODUCTION

Floseal® (Baxter, Hayward, CA, US) can be of value in reducing blood loss and haematoma rates. The manufacturer’s warnings include allergic reaction, poor wound healing and intravascular thrombosis. We aimed to determine whether Floseal® is safe to use in various head and neck surgery (HNS) procedures.

METHODS

A prospective trial was conducted using Floseal® in 42 various consecutive head and neck surgery procedures. Adverse incidents were used as the main outcome measure, including allergic reaction, wound breakdown, wound infection and thrombosis. Secondary outcome measures included haematoma formation, hospital stay, drain times and output.

RESULTS

No adverse incidents were recorded in the trial period. Two patients developed haematomas and required surgical exploration where a bleeding vessel was identified and dealt with.

CONCLUSIONS

Floseal® is safe to be used in head and neck surgery with no adverse effects. A larger number and a control group are required to ascertain its value in reducing blood loss, haematoma formation, drain usage and hospital stay.     

Short-term pre-operative smoking cessation intervention does not affect postoperative complications in colorectal surgery: a randomized clinical trial

Background Smokers have a higher risk of complicated tissue and wound healing after surgery than nonsmokers. We tested the hypothesis that short‐term pre‐operative cessation of smoking in colorectal surgery decreases the incidence of postoperative tissue and wound complications. Methods From February 1998 to March 2001, 60 patients, who smoked daily, undergoing colorectal resection were randomly assigned 2–3 weeks before scheduled surgery to either abstinence from smoking, counselling and nicotine replacement therapy or maintenance of daily smoking habits. Postoperative tissue and wound complications necessitating surgical or medical treatment were evaluated at discharge and 30 days after surgery by blinded outcome assessment. Results In the pre‐operative period of 15 days (8–24) (median, interquartile range (IQR)), 89% of the patients in the intervention group vs. 13% in the control group abstained from smoking or reduced by more than half (P < 0.05). In the postoperative period of 11 days (10–13), the corresponding figures were 92% and 50%, respectively (P < 0.05). Postoperative tissue and wound complications occurred in 33% (9 of 27) of the patients in the intervention group compared to 27% (8 of 30) in the control group (NS). Likewise, no difference in overall postoperative complication rate was found between the groups. Conclusion Short‐term cessation of smoking does not reduce the risk of complicated tissue and wound healing or other complications in colorectal surgery.     

Use of negative pressure dressings in head and neck reconstruction

BACKGROUND: Head and neck microvascular surgery commonly requires management of complex wounds of the upper aerodigestive tract and donor sites. Negative pressure dressings have been reported to promote healing in compromised wounds. METHODS: Between February 2001 and June 2004, data were collected in a retrospective manner on 23 patients who underwent treatment with negative pressure dressings at two tertiary care institutions. RESULTS: Twenty-three patients underwent negative pressure wound treatment for donor site complications (n = 9) or head and neck wounds (n = 14) with a minimum of 5 months follow-up. Average duration of treatment was 6.5 days. Indications for use in wound complications included wound breakdown (n = 3), fistula with carotid exposure (n = 4), tendon exposure of donor site (n = 6), and others (n = 3). On average, granulation tissue was promoted in across 93% of the wound bed over the course of treatment. Two patients with anterior mandibular hardware exposure were managed successfully with negative pressure dressings. Large split-thickness skin grafts (average size, 135 cm2) at mobile sites were bolstered with negative pressure dressings in seven patients with an overall take rate of 74%. CONCLUSION: Although of limited use as a bolster for split-thickness skin grafts, negative pressure dressings are safe and effective in the management of complex head and neck wounds and in the treatment of donor site complications.     

Ulnar versus radial forearm flap in head and neck reconstruction: an experimental and clinical study.

BACKGROUND: To consider the pros and cons of the microvascular ulnar forearm flap compared with its radial counterpart, this study compares the use of these two flaps for head and neck reconstruction. METHODS: In 75 patients, 51 ulnar and 24 radial forearm flaps were used. Both groups were compared regarding flap dissection, suitability of the flap for the recipient region, complication rate, and secondary morbidity in the donor region. Furthermore, in 40 healthy volunteers, the thickness of the subcutaneous tissue layer was measured by use of ultrasonography. RESULTS: Flap survival rate, respectively wound healing, in the recipient region showed no differences. Clinical and experimental results demonstrated a thinner subcutaneous layer in the ulnar aspect of the forearm. Compared with its radial equivalent, closure of the ulnar donor side by skin grafting resulted in a significantly lower complication rate. CONCLUSIONS: The ulnar forearm flap is favored because of the less hairy skin of the ulnar forearm region, the thinner layer of subcutaneous tissues, and the more conveniently located donor area. The ulnar forearm pedicle is long compared with alternative transplants but shorter than the radial equivalent.     

吻合血管的阔筋膜瓣移植修复手指软组织缺损

目的 总结吻合血管的阔筋膜瓣移植修复手指软组织缺损的临床应用结果.方法 修复8例手指软组织缺损,行一期阔筋膜瓣移植加中厚网状游离植皮,供区直接缝合,阔筋膜瓣的血管蒂与受区的血管行端端吻合.结果 1例术后发生远端小片植皮坏死,经更换敷料逐渐自行愈合.7例术后经过顺利,全部成活,取得了满意的治疗效果.结论 该筋膜瓣以旋股外侧动脉降支为血供,血运丰富、血管解剖恒定、血管蒂长易于切取,而且较薄,适宜修复手指软组织缺损.     

吻合血管的阔筋膜瓣移植修复足部软组织缺损

目的总结吻合血管的阔筋膜瓣移植修复足部软组织缺损的临床应用结果。方法修复8例足部软组织缺损，阔筋膜瓣的血管蒂与受区的血管行端端吻合。结果阔筋膜瓣术后全部成活，取得了满意的临床效果。1例阔筋膜瓣术后发生远端尖部小片植皮坏死，经交换敷料逐渐自行愈合。供区没有发生明显的功能障碍。结论阔筋膜瓣以旋股外侧动脉降支为血供，血运丰富、血管解剖恒定、血管蒂长以及切取容易，而且较薄，适宜修复足部软组织缺损。     

Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck

BACKGROUND: Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vessel-depleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction. METHODS: We reviewed 5 cases of free tissue transfers to the head and neck in which extensive prior treatment precluded the use of more traditional recipient vessels in the neck or upper chest. RESULTS: A variety of free flaps were transferred for different reconstructive problems which included: chin/lower lip (n = 2), closure of widely patent tracheoesophageal puncture sites (n = 2), and pharyngoesophageal reconstruction following staged repair of a severe stenosis (n = 1). The radial forearm free flap was transferred in 4 patients and the rectus abdominus free flap in 1 patient. The IMA/V on the right side was prepared in all cases. All free flaps were successfully revascularized without the need for vein grafts and without the need for any microvascular revision procedures. CONCLUSION: The internal mammary artery and vein provide reliable, easily accessible recipient vessels for microvascular reconstruction in the vessel-depleted neck. The selection of free flap donor sites with long donor vessels facilitates the microvascular repair.     

Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency

Postoperative epidural analgesia is effective and widely utilised after major abdominal surgery. Spinal haematoma is a rare and devastating complication after epidural analgesia. Well‐established risk factors for the development of spinal haematoma after neuraxial procedures have been documented. We present the case of a patient with normal pre‐operative coagulation parameters who developed a spinal haematoma more than 24 h after removal of an epidural catheter; she had been without oral intake for only 4 days during which time she developed vitamin K‐deficient coagulopathy. Clinicians should consider pre‐operative screening of coagulation (International Normalised Ratio), or giving vitamin K supplementation, before performing neuraxial procedures in patients who are at risk of developing vitamin K deficiency or coagulopathy in the peri‐operative period.     

A PROSPECTIVE RANDOMIZED STUDY TO EVALUATE CLINICALLY AND RADIOLOGICALLY THE EFFECTS OF DRAINS ON PATIENTS AFTER THYROIDECTOMY

Aim: To evaluate prospectively the usefulness of routine drainage of the neck following thyroid surgery and its effect on patient comfort. Method: Consecutive patients who underwent elective thyroid surgery were randomized to receive suction drainage or no drainage of the neck at the end of the operation. Drains were removed on the first postoperative day and all patients underwent sonographic examination of the neck to determine the dimension of the remaining haematoma. Pain relating to the operation was assessed at 6 hours post operation and on Day 1 by visual analogue scale (VAS). Pain caused by drain removal was also assessed similarly. Postoperative complications and the lengths of hospital stay were also recorded. Results: 60 patients were recruited and randomized, an equal number of patients with similar demographic characteristics were present in each group. The table below shows a summary of the results. The mean pain score for pain caused by drain removal was 3.1 (range: 0–6). There was no difference for complication rate and the postoperative lengths of hospital stay for the two groups. Conclusion: Routinely draining the neck for thyroid surgery not only failed to reduce the amount of postoperative haematoma and complication but also resulted in greater patient discomfort. Drains should therefore not be used routinely following thyroid surgery.     

The submental artery island flap for head and neck reconstruction

Background : Following excisional surgery for head and neck cancer, most complex defects are reconstructed using microvascular free tissue transfer. These methods offer many advantages; however, they are of increasing complexity with attendant risks of flap loss and donor site problems. The submental artery island flap is a recently described local flap that may be used for reconstruction of the lower and middle thirds of the face and oral cavity, and offers the advantages of simplicity, reliability and excellent cosmesis. We have been using this flap as an alternative to free tissue transfer, and in this paper we present our series of 11 cases, after a review of the recent literature, anatomy and surgical technique. The advantages and limitations of the use of this flap are presented. Methods : A consecutive series of 11 patients in which this reconstruction was performed was reviewed retrospectively, and the results studied. Advantages and disadvantages of this reconstructive method were determined to define appropriate indications and contra‐indications for its use. Results : We have used this flap in 11 patients for post‐excisional soft tissue reconstruction of the head and neck, both as skin and as a mucosal replacement. In all but two patients the results were satisfactory, with excellent cosmesis when used as skin replacement. One patient required secondary debulking and one had complete flap loss. In all, the donor site was satisfactory. Conclusions : The Submenal Artery Island Flap is a useful addition to the reconstructive surgeon’s options and has definite advantages over distant flaps in terms of ease of dissection, final cosmetic appearance and donor site appearance.     

Parascapular free flaps for head and neck reconstruction

We report our experience with single-stage, primary reconstruction of the head and neck in 29 consecutive patients using parascapular free flaps. The commonest indications were for craniofacial defects (9), oropharyngeal soft tissue defects (10), and combined mandibular and soft tissue losses (4). Ablative surgery was performed for squamous carcinoma (22), melanoma (2), and malignant fibrous histiocytoma (2). Seven patients died of recurrent disease during a 3 1/2 year follow-up. Seven patients are alive with recurrence. Flap complications included total loss (2) due to unsalvageable microvascular thrombosis, wound breakdown with oropharyngeal fistula (2), mandibular osteomyelitis (1), trismus (2), neck contracture (1), and donor site wound dehiscence (1). The overall success of this reconstruction was 93%. Primary wound healing was the general rule with lower morbidity than with other reconstructive techniques. The flap is thin, pliable, and conforms well to three-dimensional defects. The lateral border of the scapula can be incorporated on the same vascular pedicle for single-stage mandibular reconstruction. No muscle is sacrificed, and the posterior donor defect is an added advantage. The parascapular flap is our first choice for reconstruction of major defects in the head and neck.     

股前外侧游离穿支皮瓣修复头面部和四肢肿瘤切除后软组织缺损

目的探讨应用股前外侧穿支皮瓣,修复头面部和四肢肿瘤切除术后的方法及其效果。方法2004年4月-2006年4月,收治头面部及四肢肿瘤切除术后造成的软组织缺损,采用股前外侧穿支皮瓣游离移植共16例,男13例,女3例;年龄26-72岁。头面部肿瘤9例,其中头顶部基底细胞癌1例,面部鳞状细胞癌4例（包括肿瘤复发1例）,腮腺癌4例;软组织缺损范围8cm×6cm-20cm×13cm,病程6-24个月。四肢肉瘤7例,其中上肢2例,下肢4例,小腿复发1例;软组织缺损范围10cm×7cm-21cm×12cm,病程2-18个月。结果16例应用股前外侧穿支皮瓣游离移植修复,15例皮瓣全部成活,1例皮瓣远端约2.5cm宽范围缺血坏死;14例创口期愈合;2例创口期愈合,其中1例经切除坏死组织,直接缝合后期愈合,另1例创口有3cm裂口,经换药后期愈合。术后随访1-18个月,肿瘤无复发,供受区外观良好,平整,无明显瘢痕及功能影响;受区修复效果满意。结论股前外侧穿支皮瓣游离移植,修复效果好,对供区损伤小,是一种较理想的修复头面和四肢肿瘤切除术后软组织缺损的方法。     

面颈部严重缺损畸形的皮瓣修复

目的：探讨对严重面颈部缺损的修复，在局部功能恢复的同时，如何使其外观与正常相近似，才能让患者和社会予以接受。方法：依据缺损创面的部位、形状、缺损面积的大小、受区和供区色泽反差等，选择吻合血管的皮瓣或真皮下血管网皮瓣、传统皮瓣或带蒂的真皮下血管网皮瓣、岛状皮瓣和扩张后皮瓣转移，修复面颈部各种不同的皮肤软组织缺损。结果：对鼻、眼睑、眉毛的再造效果较佳；对颏颈Ⅲ－Ⅳ度粘连者，被修复区的皮肤柔软，颜色与周围皮肤色泽相近；对肿瘤切除或深度烧伤创面修复，皮瓣外观平整，不显臃肿。结论：应用外科皮瓣在不同部位进行修复，能取得良好的临床效果。     

Acute renal failure early after heart transplantation: risk factors and clinical consequences

Gude E, Andreassen AK, Arora S, Gullestad L, Grov I, Hartmann A, Leivestad T, Fiane AE, Geiran OR, Vardal M, Simonsen S. Acute renal failure early after heart transplantation: risk factors and clinical consequences.
Clin Transplant 2010: 24: E207–E213. © 2010 John Wiley & Sons A/S. Abstract: Limited information exists about acute renal failure (ARF) early after heart transplantation (HTx). We correlated pre‐, per‐, and post‐operative patient and donor parameters to the risk of developing ARF. We also analyzed the consequences of ARF on kidney function after HTx, risk of later need for chronic dialysis or kidney transplantation, and mortality. In a retrospective study from 1983 to 2007, 145 (25%) of 585 HTx recipients developed ARF, defined as ≥26.4 micromol/L or ≥50% increase in serum creatinine from pre‐operatively to the seventh day post‐HTx and/or the need of early post‐operative dialysis. Independent risk factors for ARF were intravenous cyclosporine immediately post‐operatively (odds ratio [OR] 2.16, 95% CI 1.34–3.50, p = 0.02), donor age (OR 1.02, 95% CI 1.00–1.04, p = 0.02), and pre‐operative cardiac output (OR 1.38, 95% CI 1.12–1.71, p = 0.003). The development of ARF was a predictor for short‐term survival (≤3 months) ranging from 98% for patients who improved their creatinine after HTx vs. 79% for those in need of dialysis (p < 0.001). However, ARF did not predict subsequent end stage renal disease in need of dialysis or renal transplantation. ARF is a common complication post‐HTx. As ARF is associated with short‐term survival, post‐operative strategies of preserving renal function have the potential of reducing mortality. Of avoidable risk factors, the use of intravenous CsA should be discouraged.     

Retroperitoneal haematoma and related organ injury--management approach

Retroperitoneal haematoma following blunt or penetrating trauma may arise from injuries to bone, major vascular structures, hollow viscera or solid organs. Clinical significance varies from inconsequential to fatal. Although the guidelines for exploration are clear-cut during laparotomy for associated intra-abdominal injuries, this is not the case with isolated retroperitoneal haematoma. Lateral and pelvic haematomas may be selectively explored and central haematomas always need exploration. All penetrating wound tracts should be explored, irrespective of the site of the haematoma, to exclude vital structural injury.     

Should we still stitch the subcutaneous fat layer? A clinical and ultrasound assessment in 50 hip operations.

Wound haematoma is an undesirable complication of surgery. We report a prospective trial to establish whether a subcutaneous fat stitch affects haematoma formation in hip surgery. A series of 50 patients undergoing hip surgery were randomised to have either a fat stitch or no fat stitch during wound closure. The wounds were assessed clinically with a minimum follow-up of 5 weeks. Subcutaneous haematomas were seen more easily with the patient standing. As clinical assessment for haematoma formation may be unreliable, each patient also had an ultrasound scan. Although the incidence of subcutaneous haematoma was slightly higher in the no fat stitch group (36% compared with 24% in the fat stitch group) this difference was not statistically significant (chi 2 test, P < 0.5). There were no significant differences in the incidence of wound infection and healing rate. From our study we also showed that ultrasound examination was twice as sensitive as clinical examination in diagnosing subcutaneous haematomas and that subcutaneous haematomas are common after hip surgery.     

Pediatric microvascular reconstruction: a report from the Microvascular Committee.

BACKGROUND: Free tissue transfer is an integral part of modern head and neck surgery in the adult population. Its use in the pediatric population has not been well described. Recently, there has been an increase in the application of these techniques in the pediatric population. The morbidity of free tissue transfer in small pediatric patients and its effect on growth has not been well described. OBJECTIVE: To evaluate the utility of microvascular reconstruction techniques in the pediatric population. STUDY DESIGN: A consensus study was performed by the microvascular committee of the American Academy of Otolaryngology-Head and Neck Surgery. Thirty active microvascular surgeons reviewed their databases to find patients less than 21 years of age who underwent free tissue transfer. RESULTS: 49 free tissue transfers performed between 1999 and 2005. The mean age was 12.1 years (age range, 3-21). The types of flaps transferred were radial forearm (10), fibula (21), rectus abdominus (7), scapula (1), latissimus dorsi (3), groin (1), gracillus (4), and jejunum (2). Morbidity at the donor site was relatively minimal. Five patients developed wound breakdown. One of these required return to the operating room. Morbidity at the reconstructed site was also rare. Patients were followed for an average of 49 months (range, 1-131 months), and no problems were noted with growth at the donor or recipient sites. CONCLUSIONS: Free flaps in the pediatric population have morbidity and survival similar to those in the adult population. SIGNIFICANCE: While indications differ from those in the adult population, these techniques are viable and valuable and should be considered in the pediatric reconstructive paradigm.     

The value of suction wound drain after carotid and femoral artery surgery: a randomised trial using duplex assessment of the volume of post-operative haematoma.

BACKGROUND: The use of vacuum suction drains after carotid endarterectomy (CEA) and groin dissection for arterial reconstruction surgery remains controversial. A large multicentre prospective randomised trial would be needed to show any difference if clinical end points (infection and haematoma) are used. Therefore, we conducted a study to evaluate the value of wound drainage using accurate duplex measurement of haematoma expecting a 25% difference in volume between drained and non-drained wounds. PATIENTS AND METHODS: Seventy consecutive patients undergoing CEA and 73 patients who underwent 106 groins dissection were separately and blindly randomised into two groups: group (a) with wound drain and group (b) without wound drain. A duplex scan was carried out post-operatively to document the presence and volume of any wound haematoma. RESULTS: The majority of wounds did not show any evidence of collections. 1. In the CEA patients duplex scan revealed wound haematoma in 8 patients with a median volume of 25 ml (5-65) in group (a) in comparison to 7 wound haematomas 31 ml (3-72) in group (b). Median suction drain drainage was 42 ml (10-120) when used. There was no significant difference between the two groups. Three patients 4.3% (two from the drain group) underwent evacuation of haematoma post-operatively.2. In the groin dissection patients most of the documented collections were trivial. Ultrasound scans showed 21 collections (20%), of these 7 (34%) were in group (a) and 14 (66%) were in group (b). There was no significant difference in wound collections between the two groups (p = 0.28). Only 5 collections (75%) exceeded 10 ml, three of them were in the drain group. One patient (1%), who did not have a drain, developed a wound collection, which needed re-exploration. When a drain was used the median drainage was 64.5 ml (range 10-220). CONCLUSION: These results based on accurate measurement of wound collection suggest that there is no benefit in terms of reduction of the volume of haematoma on wound drainage after CEA or arterial reconstruction surgery involving the groin. A selective policy of use of drainage is therefore recommended.     

Risk factors for complications in clean-contaminated head and neck surgical procedures

Background. Contamination of a head and neck surgical wound with oropharyngeal secretions has been shown to dramatically increase the incidence of wound complications. Appropriate perioperative antibiotic prophylaxis has significantly reduced contaminated wound infection rates in several previous reports. The current study examined multiple patient parameters to determine risk factors for all perioperative complications following clean-contaminated head and neck surgical procedures. Methods. Retrospective review of medical records from 159 patients who underwent clean-contaminated major head and neck surgical procedures at the University of Washington between 1985 and 1991. More than 30 preoperative and operative parameters were evaluated, and all complications were recorded. The data were examined using a multivariate statistical analysis. Results. An overall complication rate of 63% included 22% with wound infections (oro/pharyngocutaneous fistula or purulent drainage), 22% with other types of infections, and 51% with noninfectious complications. The overall perioperative mortality rate was 1.2% (two patients). Prior radiotherapy, operative time, perioperative transfusion, and flap reconstruction were all associated with a significantly higher overall complication rate (p ≤ 0.05). Only prior radiotherapy therapy correlated with an increase in wound infection rate (p = 0.05). Conclusions. Prior radiotherapy significantly increases the risk of perioperative complications and wound infections following clean-contaminated head and neck surgical procedures. Other factors reflecting the complexity of the procedure also influence the overall complication rate. © 1995 Jons Wiley & Sons, Inc.