Scapular Tip Free Flap for Head and Neck Reconstruction

Objectives

Head and neck reconstruction is still challenging in terms of esthetic and functional outcomes. This study investigated the feasibility of the angular branch-based scapular tip free flap (STFF).

Methods

This was a retrospective study of 17 patients undergoing maxillectomy and mandibulectomy and either primary or secondary reconstruction by STFF. This study included surgical, esthetic, and functional outcomes, and detailed data are presented regarding the flap, such as pedicle length, size of the harvested bone, and failure rate. Medical photographs were used to estimate the esthetic outcome, and computed tomography was used to check the flap status postoperatively.

Results

The data were collected from April 2013 to April 2014. Eight patients underwent maxillary reconstruction, and nine underwent mandibular reconstruction. Maxillary defects usually included unilateral alveolar structures and the palate; mandibular defects were usually those involving mandibular angle and short segment. Vein grafting was not required in any of the patients. Flap failure occurred in one of the 17 patients (5.9%) with successful reconstruction after revision. Of the eight maxillectomy patients, orbital revisions for diplopia after maxillary reconstruction were performed in two patients (25%), and oroantral fistula repair was performed in one patient (12.5%).

Conclusion

This study demonstrated the reconstructive advantages of the angular branch-based STFF, long pedicle, low flap failure, 3-dimensional nature of bone and soft tissues (chimeric flap), and small rate of donor site morbidity with free ambulation. This flap is an excellent option for use in complex three-dimensional head and neck reconstruction.     

Length of Stay After Free Flap Reconstruction of the Head and Neck

Objectives: To analyze the incidence and timing of postoperative complications after free tissue transfer (FTT) and relate that to length of stay (LOS.) Study Design: We reviewed one surgeon's experience with 97 patients undergoing 100 head and neck reconstructions via FTT for a variety of traumatic and ablative defects. Methods: Charts were reviewed for demographic data, type of defect and flap, complications, LOS, length of intensive care unit (ICU) stay, date of decannulation, and first oral intake, any readmission to the hospital, and preoperative radiation status. Results: Using strict guidelines, 31% of patients had some form of complication, including a 9% flap failure rate. Average postoperative LOS for all patients was 11 days. Average LOS for uncomplicated cases was 9 and for complicated cases was 16 days. For cases with flap‐related complications the average LOS rose to 20 days. All reconstructive failures (defined as patients requiring subsequent surgical procedures after a flap‐related complication, regardless of outcome) occurred within the first 7 postoperative days. Three patients were readmitted for various reasons: a partial flap dehiscence (postoperative day [POD] 9), meningitis (POD 24), and orocutaneous fistula (POD 22), for a 3.2% readmission rate. Fourteen percent of patients were on a regimen of oral intake, and 13% had decannulation by the time of discharge. Resumption of oral intake and tracheostomy decannulation were accomplished on an outpatient basis in the remainder of patients. Conclusions: There were no preventable complications associated with early hospital discharge, nor was there evidence of adverse patient outcome. We conclude that early hospital discharge is feasible after FTT reconstruction and is consistent with quality care.     

Results of Free Flap Reconstruction After Ablative Surgery in the Head and Neck

Objectives

Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve.

Methods

The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed.

Results

The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases.

Conclusion

The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.     

The Extended Lateral Arm Free Flap for Head and Neck Reconstruction

The lateral arm free flap (LAFF) has been chosen by some head and neck reconstructive microsurgeons to be their fasciocutaneous free flap of choice. The qualities of this flap have been suggested to include its consistent vascular anatomy, its thin and pliable nature, and its reinnervation capabilities, as well as its low donor site morbidity and ease of closure. During the past year we have performed 14 head and neck reconstructions using the extended LAFF (ELAFF). We present our indications for its use and review its shortcomings. Although the ELAFF does have its limitations, including variability in its flap thickness and donor vessel size, it unquestionably is an important flap in head and neck reconstruction and is our flap of choice for soft tissue reconstruction.     

The Platysma Myocutaneous Flap: Underused Alternative for Head and Neck Reconstruction

Objectives The use, advantages, and disadvantages of the platysma flap were assessed. Study Design Retrospective review of the medical records of patients undergoing platysma flap reconstruction of the upper aerodigestive tract from 1987 to 2001. Methods Information regarding the tumor, surgical procedure, flap design, and outcome emphasizing complications and function was extracted. Associations between putative risk factors for flap failure and outcome were assessed using the χ² test. Results Thirty‐four patients underwent reconstruction with platysma flaps. Surgical defects included the oropharynx, oral cavity, and hypopharynx. Nine patients had had prior radiation therapy and all had some dissection of the ipsilateral neck. There were 5 postoperative fistulas (15%), flap desquamation was noted in 6 cases (18%), and 2 patients experienced loss of the distal skin closing the donor site. Complications were not associated with prior radiation. Hospital stay ranged from 5 to 21 days (mean, 10 d). There were no returns to the operating room or need for additional reconstruction. All but 1 patient resumed a normal diet within 3 months of surgery. There were no recurrences of cancer in the dissected neck regions. Conclusions The platysma flap is simple and versatile with properties similar to the radial forearm free flap. The rate of complications is similar to other published series, and problems encountered were manageable using conservative methods with excellent functional and cosmetic outcomes. These facts support the contention that the platysma myocutaneous flap can serve as a viable alternative to free tissue transfer and has advantages over pectoralis major pedicled flaps for reconstruction of many head and neck defects.     

游离股前外侧穿支皮瓣重建头颈肿瘤术后缺损

目的 探讨应用游离股前外侧穿支皮瓣重建头颈肿瘤切除术后组织缺损的方法及其效果.方法 2006年7月～2011年12月采用游离股前外侧穿支皮瓣修复头颈恶性肿瘤切除术后组织缺损75例,男52例,女23例;最大年龄80岁,最小年龄24岁,其中舌癌42例,颊癌20例,软腭癌2例,扁桃体癌9例,眶部肿瘤1例,外耳道癌1例.组织缺损范围8cm×5cm～18cm×10cm,病程4～24个月.结果 75例应用股前外侧穿支皮瓣游离移植修复,仅2例股前外侧皮瓣远端因静脉回流障碍发生部分坏死,其余均成活,皮瓣成活率97.3％,3例供区部分植皮未成活,延期愈合.术后随访6～24个月,肿瘤无复发,供区外观平整,瘢痕不明显,受区吞咽及言语功能良好,修复重建效果满意.结论 游离股前外侧穿支皮瓣制作方便,对供区损伤小,厚薄适中,适宜修复头颈肿瘤切除术后组织缺损.     

Cumulative Sum Analysis of the Learning Curve of Free Flap Reconstruction in Head and Neck Cancer Patients

ObjectivesOwing to the functional and structural complexity of the head and neck area, the reconstruction of defects in these areas is challenging. Free flap surgery has become standard for the reconstruction of the head and neck with improvements in microvascular surgery. The aim of this study was to use the cumulative sum (CUSUM) method to evaluate the learning curve for free-flap head and neck reconstruction performed by a single surgeon.MethodsWe retrospectively reviewed the medical records of 47 patients who underwent free-flap reconstruction from 2017 to 2021. The clinical demographics and surgical outcomes were analyzed. The total operation time was analyzed using the CUSUM method, which is an analytical approach for visualizing patterns in data by converting raw data into an accumulation of deviations from the average value.ResultsCUSUM analysis showed two phases of the learning curve: phase 1 (cases 1–22) and phase 2 (cases 23–47). The operative time in phase 1 (579.9±128.2 minutes) was significantly longer than that in phase 2 (418.6±80.9 minutes) (P<0.001). The re-exploration rate was higher in phase 1 (31.8%) than in phase 1 (4%) (P=0.018). The flap failure rate was higher in phase 1 (9.1%) than in phase 1 (4%), but this difference was not statistically significant (P=0.593).ConclusionThe learning curve of free-flap head and neck reconstruction seems to stabilize after approximately 20 cases.     

Protein C Deficiency in Microvascular Head and Neck Reconstruction

Objective: To determine the incidence of perioperative protein C deficiency in patients undergoing free flap reconstruction of cancer-related defects in the head and neck. Study Design: Prospective case series. Intervention: Ten patients underwent microvascular reconstruction after surgical therapy of carcinomas of the oral cavity or oropharynx. Coagulation studies were determined in all patients 72 hours after surgery. Setting: Academic tertiary care medical center Results: Protein C deficiency was detected in 70% of patients. One free flap failure was attributed to protein C deficiency. Conclusions: Vitamin K–dependent clotting factors are frequently deficient during the postoperative period after major head and neck surgery, which may result in a state of hypercoagulability. Protein C deficiency should be considered as a possible cause of free flap thrombosis in patients who undergo microvascular head and neck reconstruction.     

Resource Utilization and Patient Morbidity in Head and Neck Reconstruction

Many papers have addressed the technical aspects of free tissue transfer in head and neck cancer patients. However, there has not been a critical assessment of the impact of free tissue transfer on resource utilization and patient morbidity compared with pedicle flap reconstructions. Two cohorts of patients derived from 245 consecutive reconstructions were tightly matched by age, site, stage, and histology, yielding 44 patient pairs differing in method of reconstruction. Patients undergoing free flap reconstruction spent more time in the operating room than those reconstructed with pedicled flaps (993 min vs. 777 min, P < 0.0001). The group with free flap reconstruction spent fewer days in the surgical intensive care unit and hospital (2 days vs. 2.5 days; 18.5 days vs. 22.6 days). This difference is attributed to the paucity of postoperative complications in the group with free flap reconstruction (fistula formation 4.5% vs. 21%, P < 0.04). These data indicate that the continued use of sophisticated reconstructive techniques in head and neck cancer patients is economically sound as assessed by patient morbidity and resource utilization.