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Impact of venous outflow tract on survival of osteocutaneous free fibula flaps for mandibular reconstruction: A 14-year review
Abstract
Background:
The principle reconstructive modality for segmental mandibulectomy defects is the osteocutaneous free fibula flap. Preoperative CT angiography has been recommended to assess the quality of arterial inflow to the flap and donor limb. However, the impact of the venous system on flap viability has not been explored.
Methods:
A retrospective review of all patients undergoing free fibula flap mandible reconstruction was performed at a single tertiary cancer center from 2002 to 2015. Overall complications, including operative reexploration and total flap losses, were evaluated.
Results:
One hundred seven patients underwent free fibula flap reconstruction of the mandible. Nine patients underwent multiple free flaps and were excluded from this study. Of the remaining 98 patients, 8 patients required operative exploration for microvascular compromise. All patients were found to have venous thrombosis. There were 3 total flaps losses with a salvage rate of 62.5% and overall flap survival of 96.9%. The size of the vena comitantes in the compromised flaps were significantly larger than those of the remaining patients (4.4 mm vs 3.1 mm; P < .0001). Although the total operative times were similar between the 2 groups (585.2 minutes vs 563.3 minutes), the ischemia time was significantly shorter in those cases that required operative takeback (76.5 minutes vs 104.0 minutes; P < .04).
Conclusion:
Venous thrombosis of free fibula flaps is more common than arterial thrombosis. Venous stasis in larger vena comitantes may be a contributing factor to microvascular compromise. Anticoagulation and/or handsewn anastomosis may be beneficial if the veins are larger than 4.0 mm in size.
Objective
We conducted a systematic review and meta‐analysis to compare venous couplers and hand‐sewn techniques for venous anastomosis in head and neck reconstruction.
Data Sources
PubMed/MEDLINE and Scopus, databases were searched for relevant publications. Additionally, a manual search was performed in Google Scholar and through reference lists.
Review Methods
Retrospective and prospective cohort studies were included. Odds ratios (ORs) and mean differences (MD) were calculated with their 95% confidence intervals (CIs) for each study comparing the 2 groups (coupler vs hand). The inverse variance method was used to combine the effect sizes from the individual studies.
Results
A total of 14,053 patients undergoing 14,270 head and neck free flap reconstructions were included from 52 studies. A total of 6080 flaps were performed using a coupling device for the venous anastomoses, while 8190 flaps were performed with the hand‐sewn technique. No significant difference was found for the venous thrombosis rate (OR: 1.06, 95% CI: 0.65‐1.72), and reoperation rate (OR: 0.93, 95% CI: 0.51‐1.70), but a significantly lower failure rate was measured for the coupler group (OR = 0.34, 95% CI: 0.20‐0.58). A nonsignificant lower operative time was found for venous anastomoses (MD: −20.5, 95% CI: −51.7 to 10.7) and total surgery (MD: −23.7, 95% CI: −344.3 to 296.8) for the coupler group.
Conclusion
Despite the slight advantages observed with venous couplers, the overall outcomes of both techniques are excellent, and the choice of anastomotic technique should be guided by surgeon preference.
Introduction:
Few articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction.
Material & methods:
Between 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy.
Results:
In Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days.
Discussion:
Based on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.
Background
To evaluate the relationship between intraoperative ischemia time with acute microvascular free tissue transfer (MFTT) complications in head and neck reconstruction.
Methods
A systematic review using PRISMA guidelines was performed. Inclusion encompassed all available studies published and indexed using PubMed, Medline, and Embase. Meta-analyses were performed using the Cochrane Review Manager tool. Methodological Index for Non-Randomized Studies (MINORS), the Revised Cochrane risk-of-bias tool for randomized trials, and the NIH Study Quality Assessment Tool for non-randomized prospective studies.
Results
A total of 430 citations were reviewed. 25 were included in our overall qualitative analysis, and 14 for meta-analysis. When comparing ischemia times for flaps with and without complications, no significant difference was observed (p = 0.98). Additionally, in a separate cohort, no significant effect was realized when correlating ischemia time to overall rates and total complications.
Conclusion
Ischemia time was not significantly different between those with and without acute flap complications.
Background Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels.
Methods We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels.
Results A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates.
Conclusion Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.
Transfer of a vascularized fibular graft is the first choice for reconstruction of defects of long bones in the upper extremity. In particular, the vascularized fibula head graft is preferred for patients with bone defects of the upper limb involving the distal radius. The fibular epiphysis has similar shape and size with distal radius. It allows gradual remodeling of the articular surface with proximal carpal row resulting in increased range of motion and stability of the wrist.
Background
Fibula osteocutaneous flap is associated with a higher rate of reexploration in mandible reconstruction due to limited space for the fixation of various tissue components on multiple segments of the fibula flap. To maintain optimal circulation to the flap and to prevent negative outcomes because of partial or total flap loss, we shared our experiences on salvaging the free fibula flap with vascular compromise in the first reexploration and we developed an algorithm.
Methods
From 1992 to 2018, 12 patients between the ages of 48 to 63 (mean: 52.5) who had presented with oral squamous cell carcinoma (n = 10) followed by osteoradionecrosis of the mandible (n = 2) were explored. The operative findings were; (1) occlusions of vein (3 cases); (2) occlusions of artery (4 cases); and (3) occlusions of both artery and vein (5 cases). After correcting the kinking or evacuating the hematoma, the arterial inflow was initially reestablished by anterograde flow. If this was nonfunctional, retrograde flow from the distal end of the peroneal artery was provided. For the vein, anterograde venous drainage was reestablished. If the thrombus extended deep into the peroneal vein, regular venous return was blocked on the anterograde side, and the flap remained congested therefore retrograde venous drainage was performed regardless of the valves in the vein. However, the two ends of the peroneal artery were anastomosed to prevent thrombosis of the artery.
Results
The success rate of revised cases was 75% (9/12). All failed cases had presented with both artery and vein occlusion (three cases). Pectoralis major musculocutaneous flap and anterolateral thigh flap were needed for the external surface in two cases. Skin graft was required for seven cases to restore intraoral lining. Six patients underwent dental rehabilitation with prosthetic implants.
Conclusion
Immediate reexploration is mandatory to salvage the flap.
The most serious complication of free flap transfer is total flap necrosis, which is usually due to a microvascular problem. The development of a microsurgical instrument has greatly lowered the prevalence of postoperative vascular trouble to a rate of 1% to 3%. However, necrosis of the transferred flap in head and neck reconstruction can cause serious complications and postoperative functional deficiency. Therefore, for blood circulation disorder of the flap following free flap transfer, it is necessary to perform re-operation, as soon as possible, in order to attempt salvaging the flap after the disorder has been diagnosed.
The goal of this study was to analyze the microsurgery for head and neck reconstruction. The author, with an experience of more than 500 microsurgical anastomoses, discusses microsurgery in head and neck reconstruction through the choices of recipient vessels, aspects that require attention in order to prevent vascular complications, and correspondence when complications occur.
Objective
To determine the frequency at which patients with osteocutaneous free flap reconstruction of the head and neck develop long-term complications and identify predisposing perioperative factors.
Study Design
A prospectively maintained database of free flaps performed at a single institution over a 10-year period was queried.
Setting
Single tertiary care referral center.
Subjects and Methods
In total, 250 osseous or osteocutaneous free flaps (OCFFs) for mandibular or maxillary reconstruction were analyzed. Data were collected on demographics, preoperative therapy, resection location, adjuvant treatment, complications, and subsequent surgeries, and multivariate analysis was performed. Subgroup analysis based on perioperative factors was performed.
Results
The median follow-up time was 23 months. In 185 patients with at least 6 months of follow-up, 17.3% had at least 1 long-term complication, most commonly wound breakdown, fistula or plate extrusion (13.5%), osteoradionecrosis or nonunion (6.5%), and infected hardware (5.9%). Prior chemoradiotherapy and cancer diagnosis predisposed patients to long-term complications. At the 5-year follow-up, 21.7% of patients had experienced a long-term complication.
Conclusions
Long-term complications after OCFF occurred in 17% of patients. In this series, a preoperative history of chemoradiation and those undergoing maxillary reconstruction were at high risk for the development of long-term complications and thus warrant diligent follow-up. However, OCFFs can often enjoy long-term viability and survival, even in the case of perioperative complications and salvage surgery.
Background Large segmental bone and composite tissue defects often require vascularized osseous flaps for definitive reconstruction. However, failed osseous flaps due to inadequate perfusion can lead to significant morbidity. Utilization of indocyanine green (ICG) fluorescence angiography has been previously shown to reliably assess soft tissue perfusion. Our group will outline the application of this useful intraoperative tool in evaluating the perfusion of vascularized osseous flaps. Methods A retrospective review was performed to identify those osseous and/or osteocutaneous bone flaps, where ICG angiography was employed. Data analyzed included flap types, success and failure rates, and perfusion-related complications. All osseous flaps were evaluated by ICG angiography to confirm periosteal and endosteal perfusion. Results Overall 16 osseous free flaps utilizing intraoperative ICG angiography to assess vascularized osseous constructs were performed over a 3-year period. The flaps consisted of the following: nine osteocutaneous fibulas, two osseous-only fibulas, two scapular/parascapular with scapula bone, two quadricep-based muscle flaps, containing a vascularized femoral bone component, and one osteocutaneous fibula revision. All flap reconstructions were successful with the only perfusion-related complication being a case of delayed partial skin flap loss. Conclusions Intraoperative fluorescence angiography is a useful adjunctive tool that can aid in flap design through angiosome mapping and can also assess flap perfusion, vascular pedicle flow, tissue perfusion before flap harvest, and flap perfusion after flap inset. Our group has successfully extended the application of this intraoperative tool to assess vascularized osseous flaps in an effort to reduce adverse outcomes related to preventable perfusion-related complications.
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: In designing an osteocutaneous fibula flap, poor planning, aberrant anatomy, or inadequate perforators may necessitate modification of the flap design, exploration of the contralateral leg, or additional flap harvest. The authors studied the predictive power of computed tomographic angiography in osteocutaneous fibula flap planning and execution.
: The authors studied a prospective cohort of 40 consecutive patients who underwent preoperative computed tomographic angiography mapping of the peroneal artery and its perforators and subsequent free fibula flap reconstruction of mandibular or maxillary defects. The authors compared their analysis of perforator anatomy, peroneal artery origin, and fibula length with intraoperative clinical findings.
: Overall, computed tomographic angiography identified 94.9 percent of the cutaneous perforators found intraoperatively. Clinically, perforators were located an average of 8.7 mm from their predicted locations. The peroneal artery origin from the tibioperoneal trunk averaged 6.0 mm from its predicted location. The average length of the fibula differed from the predicted length by 8.0 mm. Computed tomographic angiography accurately predicted perforators as either septocutaneous or musculocutaneous 93.0 percent of the time. Perforator size was accurately predicted 66.7 percent of the time. Skin islands and osteotomies were modified in 25.0 percent of the cases on the basis of computed tomographic angiography findings. Two patients had hypoplastic posterior tibial arteries, prompting selection of the contralateral leg. There were no total flap or skin paddle losses.
: Computed tomographic angiography accurately predicted the course and location of the peroneal artery and perforators; perforator size was less accurately estimated. Computed tomographic angiography provides valuable information to facilitate osteocutaneous fibula flap harvest.
: Diagnostic, II.
Risk factors and techniques for free flap salvage in head and neck (HN) reconstruction are poorly described.
Retrospective review of all HN free flaps performed from 2000-2010.
Overall, 151 (6.6%) of 2296 flaps underwent salvage for microvascular complications. Age, comorbidities, and surgeon experience (p=0.88), vein grafts and supercharging (p=0.45) did not affect flap salvage. Muscle-only flaps (p=0.002) were associated with significantly worse outcomes. Coupled venous anastomoses were superior to hand-sewn anastomoses (p=0.03). Arteriovenous thromboses had worse outcomes than a venous or arterial thrombosis alone (p<0.0001). Anticoagulation, thrombolytics, and thrombectomy did not improve survival. Multiple takebacks (p=0.003) and late takebacks (>3 days) had significantly worse outcomes (p=0.003). Flap salvage was 60.3% successful with 60 total flap losses (2.6%).
While flap salvage should be attempted, multiple attempts are not recommended especially for muscle-only flaps. Combined arteriovenous and late thromboses have a dismal prognosis regardless of different salvage techniques. This article is protected by copyright. All rights reserved.
© 2015 Wiley Periodicals, Inc.
This study represents the surgical experience of 4481 microvascular free flap cases performed at the authors' institution in China, between 1979 and 2013. Four thousand four hundred and eighty-one patients underwent reconstruction with 4640 flaps: 56% radial forearm flaps, 8% iliac crest flaps, 13% fibula flaps, 10% anterolateral thigh flaps, and other flaps. In the overwhelming majority of cases, the flap transfer was required following tumour resection (97.5%). Three hundred and twenty minor complications (6.9%) occurred. One hundred and eighteen major complications (2.5%) were encountered: 114 cases of failure (2.4%) and four deaths. Among the 118 cases with major complications, 26 - 22.0% - had received radiotherapy; this proportion was higher than the 6.9% in the minor complications group and 8.1% in the non-intervention group. Venous thrombosis was the most common complication at the recipient site and was the main cause of flap failure. When a compromised flap is identified, surgical re-exploration should not be delayed. This study confirms that free flaps are reliable in achieving successful reconstruction in the head and neck region; however this technique requires extensive clinical experience. Owing to the large number of flap options, microsurgeons should always pay attention to the details of the different surgical defects and choose the most appropriate flap.
Copyright © 2015 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
The free fibula flap is the preferred reconstructive method for oncologic defects of the mandible. Arterial inflow of the extremity is routinely evaluated with several modalities; however, venous screening is rarely performed. Patients with cancer are at elevated risk of occult deep venous thrombosis (DVT). An asymptomatic thrombus encountered during free fibula reconstruction is a serious concern. Although such cases have been reported, we suspect the incidence of DVT during fibula free flap harvest is underappreciated. This monograph uses a case example to review risk factors for occult DVT, present a strategy for preoperative assessment, and provide a reconstructive algorithm to for mandibular reconstruction in such instances.
Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.
Background:
Free tissue transfer has become the preferred option for complex reconstructions in head and neck cancer ablation. This study reviewed the surgical outcome and analyzed the evolution of microsurgical head and neck reconstruction over 20 years in single institute.
Patients and methods:
A total of 1,918 patients underwent microsurgical head and neck reconstructions in 20-year period. The surgical outcome and complications among these 2,019 flaps (1,223 anterolateral thigh flaps, 372 fibula flaps, 353 radial forearm flaps, 12 jejunal flaps, and 59 others) were retrospectively reviewed and analyzed.
Results:
A total of 201 cases required emergent surgical re-exploration and the overall flap success rate was 96.2%. Venous insufficiency was the most common cause for re-exploration. Other major complications included fistula formation (5.4%), partial flap necrosis (7.5%), and infection (17.8%). The fibula flap had frequent complications compared with soft tissue flaps. The familiarity to the ALT flap had minimized complications and allowed for widely versatile uses.
Conclusion:
Free tissue transfer is shown to be highly reliable option for head and neck reconstruction. For soft tissue defect, ALT flap is the first choice. Fibula flap is ideal for bone defect reconstruction. In case of complex composite defects, double flaps, which include ALT and fibula flaps could reconstruct bone and soft tissue defects simultaneously with high success rate.
Learning objectives:
After reading this article, the participant should be able to: 1. Discuss the principles behind the choice of reconstructive techniques for all major head and neck regions. 2. Differentiate between the optimal choices for reconstruction of the different mandibulectomy defects. 3. List the requirements for successful reconstruction of the skull base. 4. Further study new and evolving head and neck reconstruction techniques and options.
Summary:
Management of head and neck cancer has undergone many significant changes during the past two decades. This article gives an overview of the major areas in the head and neck, highlighting current practice and more recent trends in reconstruction choices. Further detail is given in the related videos. The five attached videos depict individual techniques of mandibular reconstruction, showing the technique of fibular dissection and osteotomy: endoscopic skull base reconstruction through a transpterygoid/lateral canthotomy approach, scalp reconstruction using a latissimus dorsi free flap and skin graft, maxillary reconstruction using the deep circumflex iliac artery iliac crest and internal oblique flap, and pharyngoesophageal reconstruction using an anterolateral thigh flap.
Background:
Transit-time flow volume measurement, a non-Doppler-based ultrasound technology, has been shown to accurately evaluate the quality of coronary artery bypass grafts and improve outcomes of cardiac surgery. The authors hypothesized that it would also improve decision making in microvascular free tissue transfer procedures.
Methods:
The authors measured transit-time flow volume in 52 consecutive free flaps at three times: measurement 1 (in situ), after flap elevation and isolation on its pedicle; measurement 2 (time 1), immediately after anastomosis and reperfusion; and measurement 3 (time 2), 30 minutes after anastomosis and reperfusion. Intraoperative decisions based on transit-time flow volume were documented.
Results:
Arterial inflow was on average 1.5 times greater than venous outflow, and arterial resistance was 3.59 times greater than venous resistance. Free transverse rectus abdominis musculocutaneous flaps had the highest venous and arterial flows, and free radial forearm flaps had the lowest. Compared with the baseline (in situ) measurement, all flaps had higher flows immediately after transfer (time 1) (p < 0.0001), but no significant differences were seen 30 minutes later (time 2) (p = 0.68). Arterial resistance, however, increased during that interval (p = 0.006). Operative decisions, including selection of the higher flow vena comitans (sometimes the smaller of the two) and when to revise an anastomosis, were modified on the basis of volume findings in 19 of 52 cases (36.5 percent).
Conclusions:
Transit-time flow volume provides novel physiologic flap data and identifies flawed anastomoses and higher flow venae comitantes. These data have clinical value in microsurgery and might reduce microvascular complications and improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCDE: Diagnostic, IV.
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.
Venous thromboembolism is a major patient safety issue. The Plastic Surgery Foundation-sponsored Venous Thromboembolism Prevention Study examined whether postoperative enoxaparin prevents symptomatic venous thromboembolism in adult plastic surgery patients.
In 2009, four sites uniformly adopted a clinical protocol. Patients with a Caprini score of 3 or higher received postoperative enoxaparin prophylaxis for the duration of inpatient stay. Venous Thromboembolism Prevention Study historical control patients had an operation between 2006 and 2008 but received no chemoprophylaxis for 60 days after surgery. The primary study outcome was symptomatic 60-day venous thromboembolism.
Three thousand three hundred thirty-four patients (1876 controls and 1458 enoxaparin patients) were included. Notable risk reduction was present in patients with a Caprini score greater than 8 (8.54 percent versus 4.07 percent; p=0.182) and a Caprini score of 7 to 8 (2.55 percent versus 1.15 percent; p=0.230) who received postoperative enoxaparin. Logistic regression was limited to highest risk patients (Caprini score≥7) and demonstrated that length of stay greater than or equal to 4 days (adjusted odds ratio, 4.63; p=0.007) and Caprini score greater than 8 (odds ratio, 2.71; p=0.027) were independent predictors of venous thromboembolism. When controlling for length of stay and Caprini score, receipt of postoperative enoxaparin was protective against venous thromboembolism (odds ratio, 0.39; p=0.042).
In high-risk plastic surgery patients, postoperative enoxaparin prophylaxis is protective against 60-day venous thromboembolism when controlling for baseline risk and length of stay. Hospitalization for 4 or more days is an independent risk factor for venous thromboembolism.
Therapeutic, III.
Unlabelled:
Fibular osteotomy remains a challenging aspect of mandibular microsurgical reconstruction, dependent largely on surgeon experience, intraoperative judgment, and technical speed. Virtual surgical planning and stereolithographic modeling is a relatively new technique that can allow for reduction in the learning curve associated with neomandible contouring, enhanced levels of accuracy, and acceleration of a time-consuming intraoperative step. The authors present a video (narrated and edited from planning sessions and intraoperative use of technique to illustrate the technology) and describe their favorable results. Five patients underwent composite resection of the mandible and free fibula osteocutaneous reconstruction over a 6-month period (December of 2009 to June of 2010) at a single institution using a virtual planning session and stereolithographic modeling. Outcomes assessed included technical accuracy, aesthetic contour, and functional outcomes. All patients achieved negative margins with cutting guide-directed resection. Use of this technique eliminated the need for intraoperative measurement and yielded fibular segments with excellent apposition and faithful duplication of the preoperative plan. Minimal adjustments were needed for inset. Flap survival was 100 percent. All patients have maintained preoperative occlusion and a symmetric mandibular contour on Panorex study, three-dimensional computed tomography, and clinical examination. Accuracy of the reconstructed contour was confirmed using computed tomographic image overlay. This virtual surgical planning technique combined with stereolithographic model-guided osteotomy is the mainstay of the authors' approach to fibular osteotomy when dealing with patients requiring mandibular reconstruction. The authors feel this technology facilitates realization of technical accuracy, aesthetic contour, and functional outcomes and may be particularly useful if free fibular mandibular reconstruction is performed less frequently.
Clinical question/level of evidence:
Therapeutic, IV.
The Institute of Medicine has identified a "quality chasm" between existing evidence and actual clinical practice. The Venous Thromboembolism Prevention Study has shown that enoxaparin prophylaxis is a safe and effective way of preventing postoperative venous thromboembolism. This article presents a "how-to" guide for implementation of a venous thromboembolism prophylaxis protocol.
The Venous Thromboembolism Prevention Study prophylaxis protocol included provision of postoperative, prophylactic dose enoxaparin for the duration of inpatient stay. Compliance was considered at the individual patient level and defined as appropriate provision of protocol-appropriate enoxaparin prophylaxis. Multiple simultaneous interventions to improve protocol compliance were undertaken. Both physician and physician assistant "champions" were identified. Interventions included staff and surgeon educational sessions, discussion of venous thromboembolism-themed articles at journal club, and monthly e-mail reminders specific to the protocol, among others. Compliance rates over time were compared using the chi-square test.
The authors reviewed medical records from 945 consecutive admissions to the plastic surgery service who met Venous Thromboembolism Prevention Study eligibility criteria over a 30-month period. Initial education sessions significantly increased compliance over baseline (55 percent versus 10 percent; p<0.001). After formal protocol adoption, compliance increased steadily over the first 9 months and peaked by 1 year. In the absence of any direct intervention, compliance remained stable at 90 percent for the final 12 months of the study. This was significantly increased when compared with the period of time immediately following protocol adoption (90 percent versus 77 percent; p<0.001).
This article provides readers with a practical approach for implementation of a venous thromboembolism prophylaxis protocol at their hospital.
With the increased use of radiotherapy in the treatment of head and neck cancers, free tissue transfer in an irradiated field is now common. Reported outcomes with free tissue transfer reconstructions in irradiated areas are often unclear and contradictory. This is attributable in part to small sample size and heterogeneity in patients and procedures. The goals of this study were, first, to determine the outcome of head and neck reconstructions in an irradiated field using a large retrospective cohort and, second, to identify negative outcome predictors that could potentially be modified to reduce the morbidity in these procedures.
Patients undergoing free flap reconstruction in irradiated head and neck regions between July of 2005 and July of 2007 were identified. Charts, including operative and radiotherapy records, were reviewed. Multiple logistic regressions were performed to identify negative outcome predictors.
During the study period at the authors' institution, 984 patients underwent head and neck free flap reconstruction. Of these, 137 had free tissue transferred to irradiated fields. Patients received an average radiotherapy dose of 64.5 Gy. The overall flap success rate was 96.4 percent. The postoperative complication rate was 47 percent. There was an overall 22 percent reoperation rate and a 28 percent infection rate. Segmental mandibulectomy, larger flap size, and infection were found to be significant negative outcome predictors.
This study confirms that free flap transfer to previously irradiated head and neck areas has a success rate comparable to that of transfer to nonirradiated zones. However, previously irradiated patients have a high risk of complications. Infection, as a modifiable risk factor, should be treated aggressively.
The fibula osteoseptocutaneous flap is an excellent option for the reconstruction of segmental mandibular defects. This study was conducted to investigate the relationship between ischemia time and outcome of the fibula flap, thus establishing the critical ischemia time for this procedure.
Between February of 2003 and March of 2005, 114 patients who underwent 116 fibular osteoseptocutaneous flaps for head and neck reconstruction were reviewed retrospectively. Complications were classified as acute, subacute, or chronic based on the time at which they were detected postoperatively. Outcomes among different ischemia time groups were evaluated: group A, less than 3 hours; group B, 3 to 4 hours; group C, 4 to 5 hours; and group D, 5 to 7 hours.
The mean success rate of the fibula osteoseptocutaneous flap was 98.3 percent. Mean flap ischemia time was 3.6±0.97 hours. Sixty-six patients (56.9 percent) experienced one or more complications at different stages (86 complications total). There were no statistically significant differences in acute, subacute, and chronic complications among the four groups (p=0.6, p=0.6, and p=0.2, chi-square test). The overall complication rate was significantly higher in group D (81.8 percent) (p=0.03, chi-square test). The partial flap loss rate was also statistically higher in group D (45.5 percent) compared with the other three groups (12.1, 12.2, and 8.7 percent) (p=0.02, chi-square test).
: Using the fibula osteoseptocutaneous flap for head and neck reconstruction, ischemia times less than 5 hours do not increase complication rates in different postoperative stages. However, the critical ischemia time of the fibula osteoseptocutaneous flap should be limited to 5 hours to reduce partial skin paddle loss and overall complications.
The free fibula osteoseptocutaneous flap remains the first choice for segmental mandible and contiguous soft-tissue defect reconstructions in most situations.
Several important principles are described that should be respected during skin paddle design: fibula contouring, insetting, and fixation, and dental implant osseointegration. Recent advancements that address difficulties in height contouring, particularly at the anterior segment, are highlighted.
The presented methods can help provide an optimal mandibular reconstruction that restores mechanical functions, facial aesthetics, and complete dental competence.
Efficient interdisciplinary communication and teamwork are necessary throughout the longitudinal care of the patient if optimal results are to be achieved.
Understanding how pedicle blood velocities change after free tissue transfer may enable microvascular surgeons to predict when thrombosis is most likely to occur. A 20-MHz Doppler probe was used to measure arterial and venous blood velocities prior to pedicle division and 20 minutes after anastomosis in 32 microvascular free flaps. An implantable Doppler probe was then used to measure arterial and venous blood velocities daily for 5 days. Peak arterial blood velocity averaged 30.6 cm/s prior to pedicle division and increased to 36.5 cm/s 20 minutes after anastomosis ( P < 0.05). Peak venous blood velocity averaged 7.6 cm/s prior to pedicle division and increased to 12.4 cm/s 20 minutes after anastomosis ( P < 0.05). Peak arterial blood velocities averaged 34.0, 37.7, 43.8, 37.9, 37.6 cm/s on postoperative days (PODs) 1 through 5, respectively. Peak venous blood velocities averaged 11.9, 14.5, 18.2, 16.8, 17.7 cm/s on PODs 1 through 5, respectively. The peak arterial blood velocity on POD 3, and peak venous blood velocities on PODs 2, 3, and 5 were significantly higher than 20 minutes after anastomosis ( P < 0.05). Arterial and venous blood velocities increase for the first 3 postoperative days, potentially contributing to the declining risk for pedicle thrombosis during this time period.
The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction.
We retrospectively reviewed 1310 free flap reconstructions for head and neck defects performed between July 1995 and June 2006.
Forty-nine cases of flap compromise due to vascular obstruction (3.7%) were identified, and 27 flaps were lost (2%). Arterial occlusions occurred in 12 flaps, with a salvage rate of 33%. Eight flaps failed within the first 24 hours, and only 1 of these was salvageable. Five of the 8 flaps had intraoperative thrombosis due to technical difficulties. Venous occlusions occurred in 31 flaps, with a salvage rate of 58%. Twenty-two venous occlusions occurred within the first 72 hours. The main reason for venous failure was mechanical obstruction due to compression, twisting, kinking, or stretching of the vein. The most common cause of late failures (after 7 days) was unrecognized failure of a buried flap owing to the lack of reliable monitoring. Overall, there was no correlation between surgeon experience and flap failure, but the flap failure rate was lower in surgeons who had performed more than 70 free flap procedures.
Precise surgical techniques, avoidance of mechanical obstruction, and better monitoring of buried flaps may further improve the success rate of free tissue transfer in complex head and neck reconstruction.
The use of miniplate fixation in free flap mandible reconstruction was reviewed in a series of 27 patients. Flap donor sites included the radius, scapula, and fibula. The bone defect ranged from 5 to 16 cm (mean, 11.5 cm). The number of fixation sites per graft ranged from 2 to 6 (mean, 3.96). Three to 10 (mean, 5.51) titanium miniplates (Wurzburg) were used for fixation. All free flaps survived. In no patient did the plate pressure on the periosteum or the multiple screws through the bone compromise flap circulation to a critical degree. Nonunion occurred in 2 of 107 osteotomy sites. Wound healing problems that required plate removal occurred in 4 patients. In each patient the plates were retained until bone healing was complete. Intermaxillary fixation was not necessary for purposes of additional stability. Miniplates have the advantages of ease of application, decreased fixation time, and the lack of need for additional forms of fixation. Their small size and malleable nature allow precise graft contouring. This contributes to a superior aesthetic result.
The fibula was investigated as a donor site for free-flap mandible reconstruction. It has the advantages of consistent shape, ample length, distant location to allow a two-team approach, and low donor-site morbidity. It can be raised with a skin island for composite-tissue reconstruction. Twelve segmental mandibular defects (average 13.5 cm) were reconstructed following resection for tumor, most commonly epidermoid carcinoma. Five defects consisted of bone alone, and four others had only a small amount of associated intraoral soft-tissue loss. Eleven patients underwent primary reconstructions. At least two osteotomies were performed on each graft, and miniplates were used for fixation in 11 patients. Six patients received postoperative radiation, and two patients received postoperative chemotherapy. The flaps survived in all patients. All osteotomies healed primarily. The septocutaneous blood supply was generally not adequate to support a skin island for intraoral soft-tissue replacement. The aesthetic result of the reconstruction was excellent in most patients, particularly in "bone only" defects. There was no long-term donor-site morbidity.
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.
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.
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 peri-operatively (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.
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.
To determine the incidence and causes of perioperative complications in patients who undergo microvascular free flap procedures for reconstruction of the head and neck.
Academic tertiary care medical center. Patients and
A total of 400 consecutive microvascular free flap procedures were performed for reconstruction of the head and neck, with 95% of the defects arising after the treatment of malignancies. Flap donor sites included radial forearm (n = 183), fibula (n = 145), rectus abdominis (n = 38), subscapular system (n = 28), iliac crest (n = 5), and a jejunal flap. Patient-related characteristics (age; sex; diagnosis; comorbidity level; tumor stage; defect site; primary vs secondary reconstruction; and history of surgery, radiation therapy, or chemotherapy) and the incidence of perioperative complications were recorded prospectively over a 7-year period.
The perioperative mortality was 1.3%. Overall, perioperative complications occurred in 36.1% of all cases. Free flaps proved to be extremely reliable, with a 0.8% incidence of free flap failure and a 3% incidence of partial flap necrosis. Perioperative medical complications occurred in 20.5% of cases, with pulmonary, cardiac, and infectious complications predominating. Multivariate statistical analysis showed significant relationships between the incidence of perioperative complications and preoperative comorbidity level as indicated by American Society of Anesthesiologists (ASA) status (P =.02).
The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of perioperative complications is related to preoperative comorbidity level.