Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database

Abstract Background Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years. Methods Patients undergoing head and neck reconstruction were identified in the 2011–2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay. Results A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02–6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52–5.71, p = 0.001), and infection (OR = 2.03, CI 1.39–2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50–0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12–0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps. Conclusion Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

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Assessment of the NSQIP Surgical Risk Calculator in Predicting Microvascular Head and Neck Reconstruction Outcomes

Otolaryngology ◽

10.1177/0194599818789132 ◽

2018 ◽

Vol 160 (1) ◽

pp. 100-106 ◽

Cited By ~ 4

Author(s):

Yue Ma ◽

Benjamin M. Laitman ◽

Vir Patel ◽

Marita Teng ◽

Eric Genden ◽

...

Keyword(s):

Postoperative Complications ◽

Head And Neck ◽

Area Under The Curve ◽

Free Flaps ◽

Hospital Length Of Stay ◽

Head And Neck Reconstruction ◽

Risk Calculator ◽

Improvement Program ◽

Surgical Risk ◽

Neck Reconstruction

Objective This study evaluated the accuracy of the Surgical Risk Calculator (SRC) of the ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) in predicting head and neck microvascular reconstruction outcomes. Study Design Retrospective analysis. Setting Tertiary medical center. Subjects and Methods A total of 561 free flaps were included in the analysis. The SRC-predicted 30-day rates of postoperative complications, hospital length of stay (LOS), and rehabilitation discharge were compared with the actual rates and events. The SRC’s predictive value was examined with Brier scores and receiver operating characteristic area under the curve. Results A total of 425 myocutaneous, 134 osseous (84 fibula, 47 scapula, and 3 iliac crest), and 2 omental free flaps were included in this study. All perioperative complications evaluated had area under the curve values ≤0.75, ranging from 0.480 to 0.728. All but 2 postoperative complications had Brier scores >0.01. SRC-predicted LOS was 9.4 ± 2.38 days (mean ± SD), which did not strongly correlate with the actual LOS of 11.98 ± 9.30 days ( r = 0.174, P < .0001). Conclusion The SRC is a poor predictor for surgical outcome among patients undergoing microvascular head and neck reconstruction.

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Fibula Free Flap in Head and Neck Reconstruction: Identifying Risk Factors for Flap Failure and Analysis of Postoperative Complications in a Low Volume Setting

Craniomaxillofacial Trauma & Reconstruction ◽

10.1055/s-0038-1651515 ◽

2019 ◽

Vol 12 (3) ◽

pp. 183-192 ◽

Cited By ~ 1

Author(s):

Pieter-Jan Verhelst ◽

Flore Dons ◽

Pieter-Jan Van Bever ◽

Joseph Schoenaers ◽

Lloyd Nanhekhan ◽

...

Keyword(s):

Risk Factors ◽

Postoperative Complications ◽

Head And Neck ◽

Free Flap ◽

Head And Neck Reconstruction ◽

Neck Reconstruction ◽

Flap Failure ◽

Fibula Free Flap ◽

Tertiary Center ◽

Low Volume

The fibula free flap (FFF) has been a workhorse in maxillofacial reconstruction. High success rates of this technique are reported. However, identifying risk factors for flap failure and analyzing complications can open the way to better patient care. A retrospective analysis was conducted of all FFFs performed over a 20-year period at a low-volume single tertiary center to identify risk factors and postoperative complications. A total of 129 FFFs were included (122 mandible, 7 maxilla). Complete flap failure occurred in 12.4% and partial flap failure in 7.8% of patients. A significant relation was found between younger age and flap failure, and most failures were associated with venous thrombosis. In-hospital surgical complications occurred in 60.5%, in-hospital medical complications in 49.6%, and out-of-hospital complications in 77.5% of patients. The in-hospital reintervention rate was 27.1%, and including salvaged flaps, flap survival rate was 87.6%. Osteomyocutaneous FFF failure (complete 12.4%; partial 7.8%) is an important clinical reality in a low-volume head and neck reconstruction center resulting in an in-hospital reintervention rate of 27.1%. Postoperative complications are frequent, both surgical and out-hospital complications. These results provide a better understanding of the limitations of the FFF in a low-volume center and can be used to optimize care in this kind of setting.

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Primary thrombolysis for free flap surgery in head and neck reconstruction: a case report and review

Archives of Plastic Surgery ◽

10.5999/aps.2021.00171 ◽

2021 ◽

Vol 48 (5) ◽

pp. 511-517

Author(s):

Steven Liben Zhang ◽

Hui Wen Ng

Keyword(s):

Head And Neck ◽

Free Flap ◽

Arterial Thrombosis ◽

Free Flaps ◽

Recombinant Tissue Plasminogen Activator ◽

Head And Neck Reconstruction ◽

Flap Surgery ◽

Neck Reconstruction ◽

Free Flap Surgery ◽

Flap Perfusion

The use of free flaps is an essential and reliable method of reconstruction in complex head and neck defects. Flap failure remains the most feared complication, the most common cause being pedicle thrombosis. Among other measures, thrombolysis is useful when manual thrombectomy has failed to restore flap perfusion, in the setting of late or established thrombosis, or in arterial thrombosis with distal clot propagation. We report a case of pedicle arterial thrombosis with distal clot propagation which occurred during reconstruction of a maxillectomy defect, and was successfully treated with thrombolysis using recombinant tissue plasminogen activator. We also review the literature regarding the use of thrombolysis in free flap surgery, and propose an algorithm for the salvage of free flaps in head and neck reconstruction.

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Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Journal of Reconstructive Microsurgery ◽

10.1055/s-0037-1598618 ◽

2017 ◽

Vol 33 (05) ◽

pp. 318-327 ◽

Cited By ~ 6

Author(s):

Michael Chu ◽

Jonas Nelson ◽

Marten Basta ◽

Patrick Gerety ◽

Suhail Kanchwala ◽

...

Keyword(s):

Regression Analysis ◽

Head And Neck ◽

Free Flap ◽

Free Flaps ◽

Head And Neck Reconstruction ◽

Venous Anastomosis ◽

Factors Associated ◽

Neck Reconstruction ◽

Arterial Complications ◽

The Impact

Background Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. Methods A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Results Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (p < 0.001), emergent take-backs (p = 0.034), and major surgical (p = 0.002) and respiratory (p = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues (p = 0.001). Regression analysis revealed that African American race (OR = 5.5, p < 0.009), use of vasopressors (OR = 6.0, p = 0.024), end-to-side venous anastomosis (OR = 4.0, p = 0.009), and use of internal fixation hardware (OR =3.5, p = 0.013) were significantly associated with arterial complications. Conclusion Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

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Head and neck reconstruction with pedicled flaps in the free flap era

Acta Otorhinolaryngologica Italica ◽

10.14639/0392-100x-1153 ◽

2016 ◽

Vol 36 (6) ◽

pp. 459-468

Author(s):

R. Mahieu ◽

G. Colletti ◽

P. Bonomo ◽

G. Parrinello ◽

A. Iavarone ◽

...

Keyword(s):

Head And Neck ◽

Free Flap ◽

Head And Neck Reconstruction ◽

Pedicled Flaps ◽

Neck Reconstruction ◽

Sono Stati

La trasposizione di lembi liberi microvascolari rappresenta oggi la procedura maggiormente diffusa nelle ricostruzioni del distretto testacollo. Tuttavia, non tutti i pazienti sono candidati ideali per ricostruzioni microvascolari, né tutti i difetti richiedono necessariamente lembi microvascolari per ottenere buoni risultati funzionali. Lo scopo di questo studio è quello di valutare se la ricostruzione di difetti del distretto testa-collo mediante lembi peduncolati sia inferiore alle ricostruzioni microvascolari in termini di complicanze, outcome funzionale e prognosi. In una coorte di pazienti consecutivi che sono stati sottoposti a resezione maggiore per carcinomi del distretto testa collo, abbiamo confrontato i dati delle ricostruzioni mediante lembi peduncolati con quelli delle ricostruzioni microvascolari. Tutti gli interventi sono stati eseguiti da un unico chirurgo dal 2006 al 2015. Sono stati inclusi un totale di 93 pazienti, la maggior parte dei quali affetti da carcinoma del cavo orale (n = 59), di cui 64 hanno subito ricostruzione tramite lembo peduncolato (69%). Nei due gruppi non si sono registrate differenze significative in termini di necrosi del lembo, complicanze ed outcome funzionale. Lanalisi multivariata ha mostrato che le comorbidità preoperatorie rappresentano lunico fattore significativo per il rischio di complicanze nella guarigione del lembo (p = 0,019). Nei due gruppi lanalisi di sopravvivenza e lanalisi di regressione proporzionale al rischio di recidiva di malattia o metastasi a distanza non hanno mostrato differenze significative. In questo studio retrospettivo di coorte, non randomizzato, i lembi peduncolati non sono risultati significativamente inferiori rispetto ai lembi liberi in termini complicanze, outcome e prognosi.

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