Use of liposuction for secondary revision of irradiated and nonirradiated free flaps

A number of patients with free tissue transfer require secondary revision to improve contour and regional definition to maximize function or appearance. However, there is controversy with regard to whether irradiated free flaps can be revised safely using liposuction. The purpose of this study was to compare the outcomes of revisionary procedures requiring liposuction in irradiated versus nonirradiated flaps. From December 1992 to July 2001, office and hospital records were reviewed retrospectively to identify patients who had undergone free tissue transfer and subsequent flap revision at a single institution. The number of revisions, amount of fat aspirated, timing of revision and the postoperative complications including infection, hematoma, wound dehiscence, and flap loss were reviewed. A total of 41 flap revisions using liposuction alone or with direct excision were performed on 33 free flaps (31 head and neck, 1 chest wall, and 1 extremity). The rectus musculocutaneous flap was the most commonly revised (88%). The average length of time to secondary revision of patients who had received postoperative radiotherapy to their flaps was significantly higher that those whose flaps had not been irradiated (P < 0.05). There were no postoperative complications except for 1 partial (20%) flap loss in a patient whose flap was irradiated. The difference in complication rates between the irradiated and nonirradiated group was not statistically significant. Secondary free flap revision using liposuction and direct excision is a safe technique for recontouring free flaps. There was no significant difference in complication rates for irradiated and nonirradiated flaps. Postoperative radiation therapy is therefore not a contraindication to secondary revision. However, these procedures should be delayed for several months after the acute effects of radiation have resolved.     

A comparison of ipsilateral pedicled TRAM flap with and without previous irradiation

Due to concerns for increased complications, there is reluctance to use the ipsilateral pedicled TRAM for breast reconstruction in the presence of previous chest wall irradiation. This study will assess whether the ipsilateral pedicled TRAM is a safe and effective option when the pedicle is part of the irradiation field. Consecutive cases of ipsilateral pedicled TRAM flap procedures from 1997-2003 were reviewed. Patients with and without previous irradiation were compared on several vascular indicators. There were 123 and 124 patients in the irradiated and nonirradiated groups, respectively. These groups were demographically similar, except the nonirradiated group was significantly older. The irradiated group had a significantly higher rate of minor wound problems related to mastectomy flap healing (8.9% versus 1.6%). All other flap vascular complications were equivalent. The ipsilateral pedicled TRAM flap is a safe and effective option for breast reconstruction in an irradiated field in terms of the pedicle to the flap.     

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.     

Successful prosthetic breast reconstruction after radiation therapy

Radiation has been considered a relative contraindication to prosthetic breast reconstruction. While this dogma has been challenged by recent reports, the data on radiation and immediate prosthetic reconstruction remain contradictory. We performed a controlled retrospective review of one surgeon's 7-year experience with 21 irradiated patients who underwent tissue expander/implant breast reconstruction. When compared with nonirradiated patients, irradiated patients experienced a higher rate of seroma formation, infection, delayed healing, implant exposure, and systemic complications. The rate of capsular contracture, while significantly higher in the irradiated group, was comprised mostly of mild to moderate capsules. Hematoma formation, implant rupture, and operative revision rates were similar between the 2 groups and complication rates among irradiated patients remained overall low. This study supports prosthetic reconstruction as a reasonable option for many radiation patients. Although irradiated patients remain at higher risk for complications, overall complication rates are low and rates of successful reconstruction are high.     

Endoscopic assisted harvest of the pedicled pectoralis major muscle flap.

The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring.     

Factors predicting free flap complications in head and neck reconstruction.

In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.     

Muscle-sparing abdominal free flaps in head and neck reconstruction

BACKGROUND: Our aim in this retrospective case series was to review the indications, results, and complications of abdominal muscle-sparing free flaps in head and neck cancer reconstruction. METHODS: A retrospective review of all head and neck cancer defects reconstructed with abdominal muscle-sparing free tissue transfers from 1999 to 2004 was performed. Data collected included patient demographics, etiology and site of the defect, reconstructive technique, flap size, recipient vessels, complications, reconstructive technique, and clinical follow-up. RESULTS: Sixteen patients underwent reconstruction with the deep inferior epigastric perforator (DIEP) flap (n = 11), the superficial inferior epigastric artery (SIEA) flap (n = 4), or the superficial circumflex iliac artery (SCIA) flap (n = 1). Average age was 61 years (range, 41-77 years). The average hospital stay was 7.6 days (range, 6-14 days). The average defect size was 74.5 cm(2) (range, 30-240 cm(2)). No subsequent abdominal wall hernias or other donor site complications occurred after a mean follow-up of 21 months. CONCLUSIONS: Muscle-sparing abdominal free flaps are attractive options for head and neck cancer reconstruction. The SIEA and SCIA free flaps have the distinct advantage of eliminating abdominal hernias and other morbidity related to the excision of rectus abdominus fascia or muscle. In addition, the incisions are very low on the abdomen and are more cosmetically pleasing to the patient.     

Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck.

The pectoralis major myocutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant donor site deformity, especially in women. This study compared 30 patients with major head and neck cancer-related defects who underwent reconstruction with a rectus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was significantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruction methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.     

EVALUATION OF 250 FREE-FLAP RECONSTRUCTIONS AFTER RESECTION OF TUMOURS OF THE HEAD AND NECK

Background : Microvascular free-tissue transfer is now the primary method of reconstruction in many centres. The aim of this study was to evaluate the applications, complications and limitations of free-flap reconstruction in a series of patients with tumours of the head and neck. Methods : This study reviewed prospectively accessioned computerized records in a dedicated head and neck database. Patients treated between 1987 and 1995 with a minimum of a 1-year follow-up were reviewed. There were 242 patients with a mean age of 58 years (172 men and 70 women). The most common tumour sites were oral cavity (42%), oropharynx (32%) and hypopharynx (11%). Mucosal squamous carcinoma accounted for 87% of primary cancers. Results : Among the 250 free flaps, the radial forearm flap (205) and free jejunum (25) predominated. There were 21 episodes of vascular occlusion (8%), failure of 10 flaps (4%) and two patients died perioperatively (0.8%). A second free flap was used in five of 10 cases of flap failure. The fistula rate was 4.4% among 203 patients at risk for this complication, which comprised four of 178 forearm flaps and five of 25 free jejunal grafts. Four of 16 jaw reconstructions failed. Conclusions : A 96% success rate was achieved using free-tissue transfer for head and neck reconstruction. The overall complication rate was low but jaw reconstruction and free jejunal grafts posed the greatest problems because of failure of radial bone and fistulas, respectively. The radial forearm septocutaneous flap was very reliable and remains our mainstay for oral reconstruction.     

Use of the internal mammary vessels as recipient vessels for an omental flap in head and neck reconstruction

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.     

Analysis of the morbidity associated with immediate microvascular reconstruction in head and neck cancer patients

Free tissue transfer has become an important adjunct in the reconstruction of head and neck cancer patients. Despite the success, the added time required to perform free flap reconstructions continues to be a concern for some head and neck surgeons. In order to investigate whether this added time increases the risk of medical complications to the patient, 20 consecutive free flap patients were compared to 20 age-, site-, and histology-matched controls. These patients were analyzed for demographic data, American Society of Anesthetic risk scores, stage, tumor site, and pre- and postoperative medical problems. The mean occurrence of medical problems preoperatively was 1.1 occurrences per patient for the flap group and 1.5 occurrences per patient for the control group. Postoperatively, there were 0.75 occurrences per flap group and 0.9 occurrences for the control group. Neither of these was statistically significant. The length of hospitalization was 13.5 days for the control group and 15.9 days for the flap group. Again, this was not statistically significant. The only significant statistic difference was the length of the procedure: 6.95 hours for the control group and 11.0 hours for the flap group, which had a p value of less than 0.001. In conclusion, this study indicates that length of procedure alone should not be a determining factor in deciding whether or not to use immediate microvascular reconstruction in head and neck cancer patients.     

Head and neck reconstruction with anterolateral thigh flap.

OBJECTIVE: Our goal was to present our experience with the free anterolateral thigh flap for reconstruction of various cutaneous and mucosal defects of the head and neck. STUDY DESIGN: We conducted a retrospective review of 37 patients who underwent reconstruction between 1994 and 2002. Outcome measures included ethnicity, flap harvest technique, vascular anatomy, flap success, general surgical complications, and donor site morbidity. RESULTS: The majority of our patients were white (n = 33). The size of the 39 free anterolateral thigh flaps varied from 24 to 252 cm(2). There was 1 arterial failure and flap loss (2.6%) and 2 venous occlusions that were both salvaged. The donor site was closed primarily in 37 cases and with a split-thickness skin graft in 2 cases. CONCLUSIONS: This is the first report on using the free anterolateral thigh flap in whites. This free transfer has proved to be a versatile and reliable flap for reconstruction of the head and neck.     

游离股前外侧皮瓣与改良胸大肌皮瓣在修复头颈肿瘤术后缺损中的选择与改进

目的探讨游离股前外侧皮瓣与改良胸大肌皮瓣在头颈肿瘤术后缺损修复中的应用及效果。方法2011年11月至2016年11月湖南省肿瘤医院头颈外科收治头颈部肿瘤患者394例,男性286例,女性108例,年龄25~79岁。分别采用游离股前外侧皮瓣(306例)、改良胸大肌皮瓣(88例)修复头颈肿瘤术后缺损。采用t检验法分析不同方法修复的效果及患者生存质量,总结2种皮瓣修复的优缺点及适应证。结果本组394例,游离股前外侧皮瓣组皮瓣成活率97.1%(297/306),改良胸大肌皮瓣组成活率97.7%(86/88);手术总时间2组相近,游离股前外侧皮瓣组3~4 h,改良胸大肌皮瓣组1.5~2.5 h;术后1年,UW-QOL评分游离股前外侧皮瓣组与胸大肌皮瓣组相比,在外观、言语功能及肩部运动方面有显著优势,差异有统计学意义(P<0.05)。结论头颈部肿瘤术后缺损修复中,游离股前外侧皮瓣及改良胸大肌皮瓣都具有较高的成功率,游离股前外侧皮瓣适用于复杂缺损的修复,改良胸大肌皮瓣对血管条件、全身状况不佳的患者,更具有安全性。     

Role of the anterolateral thigh flap in head and neck reconstruction: advantages of moderate skin and subcutaneous thickness

Skin-flap thickness is an important consideration when choosing a free flap for head and neck reconstruction. The anterolateral thigh flap, the rectus abdominis flap, and the radial forearm flap, which included the epidermis, the dermal, and the subcutaneous layers, were measured using ultrasonography in 31 patients. The mean skin and subcutaneous thickness of the anterolateral thigh flap was 7.1 mm; the rectus abdominis flap was 13.7 mm; and the radial forearm flap was 2.1 mm. Further analysis revealed a statistically significant difference among the skin and subcutaneous thickness of the three flap groups. Of the 44 anterolateral thigh flap transfers done for head and neck reconstruction after cancer ablative surgery, 41 (93.2 percent) were transferred successfully. The anterolateral thigh flap creates a moderately thick skin flap, and is less variable in thickness across its area than is the rectus abdominis flap. The flap is adaptable for reconstruction of head and neck soft-tissue defects.     

Free flaps for head and neck cancer reconstruction: Does the use of both large cervical vessels as recipient vessels and the employment of end-to-side technique enhance flap survival?

This study specifically investigates whether the use of both large cervical vessels (the external carotid artery and the internal jugular vein) as recipient vessels with end-to-side anastomosis enhance free flap survival in head and neck cancer reconstruction, when compared with the use of other standard smaller neck recipient vessels and end-to-end anastomosis. A total of 84 consecutive patients were included and were divided into two groups (42 in each group) according to the recipient vessels. The overall vessel thrombosis rate was 6% (five of 84 cases) and the overall flap loss rate was 2.4% (two of 84 cases) yielding a flap salvage rate of 60%. Vessel thrombosis occurred in three cases of the smaller vessels group and in two cases of the large cervical vessels group. This was not statistically significant.     

Is the recipient vein really the main concern? A cohort study of head and neck reconstruction

The aim of this study was to verify the role of the venous drainage system in the pathogenesis of complications in microsurgical head and neck reconstruction. In a nonrandomized cohort study, 52 consecutive cases of complex head and neck microsurgical reconstruction were evaluated. The patients were divided in two groups based on the treatment: the deep (DVDG; n = 30) and superficial (SVDG; n = 22) venous drainage groups. The complications evaluated included vascular obstruction with partial or total loss of the microsurgical flap, inadequate healing (fistulas or suture dehiscence), and infections. The arterial anastomotic site, neoplastic recurrence, use of medications and neoadjuvant radiotherapy, flap selection, tumor histology, smoking/alcoholism, and systemic diseases had no effect on postoperative complications, while the venous component influenced the overall complication rate (chi‐square test, P = 0.006). A protective effect was achieved in the DVDG when the overall complication rate was considered—relative risk (RR) 0.65, 95% confidence interval (CI) 0.45–0.94. The recipient vein should be the surgeon's main concern as it influenced the outcomes of patients undergoing complex microsurgical head and neck reconstruction. A protective effect was observed when the internal jugular vein drainage system was used for this purpose. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Impact of vasopressors on outcomes in head and neck free tissue transfer

Objectives/Hypothesis: The primary objective of the study was to determine the frequency of intraoperative vasopressor administration among patients undergoing free tissue transfer for head and neck reconstruction, and the secondary objective was to determine the impact of intraoperative vasopressor on free tissue transfer outcomes, including the impact of cumulative vasopressor dose and timing of intraoperative vasopressor administration. Study design/Methods: A retrospective review was performed of all patients undergoing free tissue transfer for head and neck reconstruction at the University Health Network between 2004 to 2008. Results: From 2004 to 2008 inclusive, 485 patients underwent 496 free tissue transfers for head and neck reconstruction. The complete failure rate was 2.2% (11 of 485 patients). The partial failure rate was 1.4%, and the operative take‐back rate for venous congestion or arterial thrombosis was 1.6%. This gave a total major flap complication rate of 5.2%, which was used as the primary free tissue transfer outcome measure. Of the 485 patients who underwent free tissue transfer, 320 (66.0%) received intraoperative vasopressor. Of these patients, the majority (97.5%) received phenylephrine and/or ephedrine. There was no significant relationship between receiving intraoperative vasopressor and major free flap complications, which were defined as complete failure, partial failure, or operative take‐back for venous congestion or arterial thrombosis. Conclusion: Intraoperative vasopressors are used routinely in free tissue transfer for the reconstruction of head and neck defects. The use of intraoperative vasopressors does not appear to adversely affect free tissue transfer outcomes. © 2011 Wiley Periodicals, Inc. Microsurgery, 2012.     

Staging rectourinary fistulas to guide surgical treatment

PURPOSE: Surgical management for rectourinary fistulas remains a reconstructive challenge. There are few guidelines to direct the surgeon to the most successful and least morbid technique. We developed a rectourinary fistula staging system that allows selection of the most appropriate technique for the patient. We present the details of the staging system and surgical outcomes. MATERIALS AND METHODS: From July 1999 to July 2005 we treated 14 male patients with rectourinary fistula. Mean patient age was 68 years (range 62 to 73). Etiology was rectal injury during open radical prostatectomy in 5 patients, laparoscopic prostatectomy in 1, radiation induced fistula for prostate cancer treatment (brachytherapy and external beam radiation therapy) in 2, neoadjuvant external beam radiation therapy in 2, ischial decubitus ulcer in 3 with spinal cord injury, and cryotherapy and external beam radiation therapy in 1. Cases were staged as stage I--low (less than 4 cm from anal verge and nonirradiated), stage II--high (more than 4 cm from anal verge and nonirradiated), stage III--small (less than 2 cm irradiated fistula), stage IV--large (more than 2 cm irradiated fistula) and stage V--large (ischial decubitus fistula). Diverting colostomy was performed for stages III to V 6 weeks before definitive therapy. RESULTS: Patients were discharged home after 48 hours. A 22Fr urethral catheter maintained bladder drainage for 3 weeks until cystogram confirmed rectourinary fistula closure. Complications were superficial wound infection and postoperative reexploration of the gracilis flap due to bleeding in 1 case each. All patients were cured after a single operation. CONCLUSIONS: The surgical challenges of a variety of rectourinary fistula repairs can be managed with minimal morbidity and a high success rate using proper staging to guide urinary tract reconstruction.     

The versatility of the pectoralis major myocutaneous flap

A consecutive group of 50 patients requiring pectoralis major myocutaneous flap reconstruction after head and neck surgery is presented. The tissue defects for reconstruction are divided into five groups to identify any defects in which the flap is more likely to be at risk of complication. Other risk factors such as preoperative radiotherapy, chemotherapy plus radiotherapy, and septic recipient site are analyzed. Its particular use in a "Third World" type population is noted.     

Octogenarian free flap reconstruction: complications and cost of therapy.

OBJECTIVE: The study goal was to document the reliability, incidence of complications, and cost of therapy for patients older than 80 years who undergo microvascular head and neck reconstruction. PATIENTS AND METHODS: Thirteen octogenarians underwent free flap reconstruction of defects resulting from the treatment of head and neck cancer at an academic tertiary care medical center. The incidence of medical and reconstructive complications and the cost of hospitalization were compared with those for 99 younger patients who were treated during the same time period. RESULTS: There were no cases of free flap failure or significant reconstructive complications in the octogenarians. The incidence of medical complications was 62% in the octogenarians and 15% in the younger patients. The average cost of therapy was $54,702 per octogenarian patient compared with $30,397 per younger patient. The increased incidence of medical complications and increased cost arose primarily from an increased severity of preoperative systemic illness in the octogenarians. However, controlling for comorbidity did not eliminate the discrepancy in medical complications between the octogenarians and the younger patients. CONCLUSIONS: Although microvascular head and neck reconstruction in the elderly is very reliable, the incidence of medical complications and the cost of therapy are significantly increased in octogenarians.