Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care

2018 ◽  
Vol 34 (06) ◽  
pp. 597-604 ◽  
Author(s):  
Jacob D'Souza ◽  
Wendy King ◽  
Michael Bater ◽  
Daniel van Gijn
Keyword(s):  
Free Flap ◽  
Microvascular Complications ◽  
Free Tissue Transfer ◽  
Congenital Defects ◽  
Head And Neck Reconstruction ◽  
Functional Rehabilitation ◽  
Immediate Reconstruction ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring

AbstractMicrosurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances in microsurgical techniques have helped balance the restoration of both form and function—decreasing the significant morbidity once associated with large ablative, traumatic, or congenital defects—while providing immediate reconstruction enabling early aesthetic and functional rehabilitation. There are a multitude of perioperative measures and considerations that aim to maximize the success of free tissue transfer. These include nutritional support, tight glycemic control, acknowledgment of psychological and psychiatric factors, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology. While the success rates of free tissue transfer in experienced hands are comparable to alternative options, the consequences of flap failure are catastrophic—with the potential for significant patient morbidity, prolonged hospital stay (and associated increased financial implications), and increasingly limited options for further reconstruction. Success is entirely dependent on a continuous arterial inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial and represents a dynamic process from the potentially reversible failing flap to the necrotic irreversibly failed flap—necessitating debridement, prolonged wound care, and ultimately decisions concerned with future reconstruction. The overriding goal of free flap monitoring is therefore the detection of microvascular complications prior to permanent injury occurring—identifying and intervening within that critical period between the failing flap and the failed flap—maximizing the potential for salvage. With continued technique refinement, microvascular free flap reconstruction offers patients the chance for both reliable functional and aesthetic restoration in the face of significant ablative defects. The caveat to this optimism is the requirement for considered perioperative care and the optimization of those factors that may offer the difference between success and failure.

scholarly journals Postoperative Free-Flap Monitoring Techniques

2019 ◽  
Vol 33 (01) ◽  
pp. 013-016 ◽  
Author(s):  
Scott Kohlert ◽  
Alexandra Quimby ◽  
Masoud Saman ◽  
Yadranko Ducic
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Potential Complication ◽  
Postoperative Monitoring ◽  
Monitoring Techniques ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring ◽  
Flap Monitoring

AbstractFree tissue transfer is commonly employed in the reconstruction of large or complicated defects. Postoperative flap failure from microvascular compromise is an uncommon but major potential complication of this procedure. As such, many postoperative monitoring techniques devices have been developed. This paper provides an overview of the wide variety of options available for surgeons today.

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion

2018 ◽  
Vol 34 (08) ◽  
pp. 610-615 ◽  
Author(s):  
Min Ji Kim ◽  
Kyong-Je Woo ◽  
So Ra Kang ◽  
Bo Young Park
Keyword(s):  
Risk Factors ◽  
Blood Transfusion ◽  
Free Flap ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Free Tissue Transfer ◽  
Control Group ◽  
Flap Failure ◽  
Tissue Transfer ◽  
The Impact

Background Microsurgical free tissue transfer is a popular technique nowadays. Because of its considerably exquisite procedure, various risk factors can affect surgical outcome. However, current key practices, especially those in blood transfusion, are in contention due to the lack of enough evidence. Therefore, the objective of this study was to investigate the impact of perioperative blood transfusion on microsurgical complication. Methods Data of a total of 168 patients who underwent microvascular free tissue transfer from 2013 through 2016 were retrospectively reviewed. Age, comorbidity, anatomical surgical site, preoperative and postoperative lowest hemoglobin (Hb) level, estimated blood volume loss, and final clinical flap outcome were compared between patients with and without transfusion treatment. Factors with a significance of p < 0.05 in univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. Results Of 168 patients, 72 (43%) were in the transfusion group. Cross analysis statistics showed that flap failure in the transfusion group was 3.6 times higher (p = 0.018) than that in the control group. Multivariable analysis revealed that age (p = 0.083) and perioperative lowest Hb level (p = 0.021) remained as significant predictors of flap failure. Receiver-operating characteristic curve analysis showed that the appropriate lower limit of transfusion commencement of Hb was 8.75 g/dL (area under the curve: 0.721). Conclusion A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.

scholarly journals Flap Failure and Salvage in Head and Neck Reconstruction

2020 ◽  
Vol 34 (04) ◽  
pp. 314-320
Author(s):  
Weitao Wang ◽  
Adrian Ong ◽  
Aurora G. Vincent ◽  
Tom Shokri ◽  
Britney Scott ◽  
...  
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Surgical Techniques ◽  
Free Tissue Transfer ◽  
Head And Neck Reconstruction ◽  
Success Rates ◽  
Neck Reconstruction ◽  
Flap Failure ◽  
Ablative Surgery ◽  
Reconstructive Option

AbstractWith advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.

scholarly journals Perioperative Care of Free Flap Patients

2019 ◽  
Vol 33 (01) ◽  
pp. 005-012 ◽  
Author(s):  
Aurora Vincent ◽  
Raja Sawhney ◽  
Yadranko Ducic
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Fluid Management ◽  
Treatment Algorithm ◽  
Free Tissue Transfer ◽  
Antibiotic Use ◽  
Head And Neck Reconstruction ◽  
Tissue Transfer ◽  
Reconstructive Option ◽  
Vasopressor Use

AbstractMicrovascular free tissue transfer is an indispensable reconstructive option in head and neck reconstruction. Flap failure is relatively rare, but it is nonetheless very morbid and psychologically devastating to patients when it does occur. Further, complications after free tissue transfer to the head and neck remain common. There are numerous ongoing debates about various facets of preoperative, intraoperative, and postoperative care of patients undergoing free flap reconstruction of the head and neck, all ultimately searching for the optimal treatment algorithm to further improve flap success, minimize complications, and maximize patient outcomes. Herein, the authors review current literature surrounding optimal preoperative nutritional support, intraoperative vasopressor use, perioperative fluid management, use of antithrombotic agents, antibiotic use, and other facets of the care of head and neck free flap patients to provide a guide to surgeons.

Free Flap Failures: What to Do Next?

2000 ◽  
Vol 8 (1) ◽  
pp. 30-32 ◽  
Author(s):  
Nadia S Afridi ◽  
Jl Paletz ◽  
Sf Morris
Keyword(s):  
Success Rate ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Success Rates ◽  
Complete Necrosis ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Split Thickness Skin Grafting ◽  
Microvascular Tissue Transfer

Over the past two decades, microvascular free tissue transfer has become a common procedure, usually with predictable results. The overall success rate of free flap surgery has gradually improved, and most recent reviews document an overall success rate between 90% and 95%. The goal of this study was to determine the outcome of those patients who underwent unsuccessful free microvascular tissue transfer. An extensive chart review was carried out on all those patients who underwent free microvascular tissue transfer at the Queen Elizabeth II Health Sciences Centre from 1988 to 1999. One hundred and forty-eight patients underwent free tissue transfer. A total of 164 free flaps were carried out, with an overall success rate of 92%. Free flap failure was defined as complete necrosis of the flap. There were 13 documented flap failures with complete necrosis of the flap requiring debridement. Seven patients underwent repeat free microvascular tissue transfer. These procedures were carried out by the same surgeon or surgical team 12 to 52 days after the first surgery. These secondary microvascular procedures were all successful. Of the remaining patients, five had either debridement and split-thickness skin grafting or regional flap coverage. One patient went on to lower limb amputation. This study reaffirms the success rates of free microvascular tissue transfer. In addition, the success rates of repeat free flaps were evaluated. It appears that patients undergoing repeat microvascular tissue transfers have no innate propensity for flap failure.

scholarly journals Protocolo de avaliação clínica baseado em escore objetivo como preditor de sucesso de retalhos livres e reimplantes

2020 ◽  
Vol 9 (2) ◽  
Author(s):  
Fernanda Ruiz de Andrade ◽  
Rafael Barra Caiado Fleury ◽  
Aleixo Abreu Tanure ◽  
Lauro Toffolo ◽  
Luis Guilherme Rosifini Alves Rezende ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Current Evidence ◽  
Statistical Computing ◽  
Long Term Outcome ◽  
Tissue Transfer ◽  
Free Flap Monitoring ◽  
Flap Monitoring

Os retalhos microcirúrgicos e reimplantes necessitam de cuidados específicos que devem ser realizados pelo cirurgião desde o momento da sua indicação, até os dias subsequentes à cirurgia. O trabalho em questão abordou à validação do protocolo utilizado pela equipe de um hospital terciário, desde o ano 2016. Os parâmetros clínicos (temperatura, cor, turgor, tempo de enchimento capilar e sangramento à perfuração) geraram um Escore que pode ser capaz de guiar a decisão do profissional, quanto à necessidade de uma reabordagem cirúrgica no período pós-operatório. Foram revisadas 55 tabelas de escores pós-cirúrgicos e correlacionados o escore obtido pelo paciente e o prognóstico da cirurgia, com o objetivo de definir valores de corte estatisticamente significativos para predição do sucesso da mesma, visando compreender à validade do protocolo em guiar a tomada de condutas. Foram determinados os valores de escores de 1 a 8 que definiram o grupo sem necessidade da intervenção cirúrgica; e aqueles superiores a 8 definiram o paciente com um risco de falha da cirurgia e necessidade da intervenção cirúrgica. Por não necessitar de procedimentos invasivos e exames de alta complexidade, o protocolo proposto torna-se uma eficiente ferramenta no diagnóstico precoce de um possível sofrimento vascular do procedimento microcirúrgico.Descritores: Retalhos Cirúrgicos; Reimplante; Microcirurgia; Protocolo Clínico; Cuidados Pós-Operatórios; Exames Médicos.ReferênciasRoehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg. 2013;132(1):147-58.Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-100.Saint-Cyr M, Wong C, Buchel EW. Free tissue transfers and replantation. Plast Reconstr Surg. 2012;130(6):858-78.Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg. 2009;124(6 Suppl):295-302.Cervenka B, Bewley AF. Free flap monitoring: a review of the recent literature. Curr Opin Otolaryngol Head Neck Surg. 2015;23(5):393-98.Korompilias AV, Lykissas MG, Vekris MD, Beris AE, Soucacos PN. Microsurgery for lower extremity injuries. Injury. 2008;39(Suppl):S103-8.R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria, 2017. Disponível em: https://www.R-project.org/. Acesso em: 01 jan 2019.Bigdeli AK, Gazyakan E, Schmidt VJ. Long-term outcome after successful lower extremity free flap salvage. J Reconstr Microsurg. 2018;1:1-82.Chae MP, Rozen WM, Whitaker IS. Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg. 2015;74(5):621-32.Hidalgo DA, Jones CS. The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases. Plast Reconstr Surg. 1990;86(3):499-501.Giunta R, Geisweid A, Feller AM. Clinical classification of free-flap perfusion complications. J Reconstr Microsurg. 2001;17(5):341-45.

scholarly journals The Use of a CAD/CAM Surgical Obturator Without Impressions to Restore a Maxillectomy Defect

2021 ◽  
Vol 6 ◽  
pp. 247275122199297
Author(s):  
Nicholas Callahan ◽  
Sarah L. Moles ◽  
Michael R. Markiewicz
Keyword(s):  
Surgical Planning ◽  
Tumor Resection ◽  
Free Tissue Transfer ◽  
Digital Impression ◽  
Head And Neck Reconstruction ◽  
Autologous Reconstruction ◽  
Form And Function ◽  
Virtual Surgical Planning ◽  
Tissue Transfer ◽  
Cad Cam

Immediate obturation of the patient undergoing maxillectomy who is not undergoing formal autologous reconstruction is important for immediate form and function of the patient. Exophytic tumors, that are large in dimension can make pre-operative obturator formation challenging. Traditional methods of obturator fabrication involve a physical or digital impression. Preoperative virtual surgical planning for tumor resection and reconstruction using free tissue transfer has become a mainstay in head and neck reconstruction. We describe a variation of this for a patient unable to undergo free tissue transfer where the authors used preoperative virtual surgical planning and CAD/CAM technologies to perform tumor resection, and fabricated an obturator based on the CT imaging alone.

scholarly journals Mechanical Anastomotic Coupling Device versus Hand-sewn Venous Anastomosis in Head and Neck Reconstruction—An Analysis of 1694 Venous Anastomoses

2021 ◽  
Vol 54 (02) ◽  
pp. 118-123
Author(s):  
Rajan Arora ◽  
Kripa Shanker Mishra ◽  
Hemant T. Bhoye ◽  
Ajay Kumar Dewan ◽  
Ravi K. Singh ◽  
...  
Keyword(s):  
Venous Thrombosis ◽  
Head And Neck ◽  
Free Tissue Transfer ◽  
Effective Alternative ◽  
Head And Neck Reconstruction ◽  
Venous Anastomosis ◽  
Neck Reconstruction ◽  
Coupling Device ◽  
Tissue Transfer ◽  
Flap Loss

Abstract Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group (p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes (p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss (p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

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