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.

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S147 – Pectoralis Major Flaps: A Workhorse in Today's Free Flap Era

Otolaryngology ◽

10.1016/j.otohns.2008.05.320 ◽

2008 ◽

Vol 139 (2_suppl) ◽

pp. P125-P126

Author(s):

Barrie Yau-Boon Tan ◽

Mark Khoo

Keyword(s):

Head And Neck ◽

Free Flap ◽

Wound Dehiscence ◽

Pectoralis Major ◽

Head And Neck Reconstruction ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Recipient Site ◽

Neck Reconstruction ◽

Flap Failure

Objectives To study the use, complication rate, and efficacy of pedicled local regional flaps for head and neck reconstruction, and to compare these results with those of microvascular free flap reconstruction. Methods Retrospective analysis of all head and neck oncologic resections requiring flap reconstruction in a tertiary head and neck surgery centre over a 6-year period from 2001–2007. Results In total, 77 operations with flap reconstruction were performed. 44 resections employed pedicled locoregional flaps, comprising 33 pectoralis major, 3 trapezius, 3 cervical rotation, 1 deltopectoral, 1 temporalis muscle, 2 nasolabial, 1 cheek rotation, and 2 bilobed rotation flaps. 2 patients had a combination of 2 regional flaps. There was 1 flap failure. Minor complications occurred in 25% of patients comprising wound seromas (3), wound dehiscence (6), fibrotic band formation (1) and pharyngocutaneous fistula (1). 33 resections employed free flap microvascular reconstructions, comprising 22 free radial forearm, 7 free rectus abdominis, 1 free jejunal, 1 free fibular, and 2 anterolateral thigh flaps. There was 1 flap failure. Minor complications occurred in 33% of patients, comprising donor site wound dehiscence (4), recipient site wound dehiscence or seroma (4), plate extrusion (1), abscess and wound breakdown (2). Conclusions Despite the ready access to free flap reconstruction today, pedicled flaps, especially the pectoralis major flap, remain a major workhorse in head and neck reconstruction. They are hardy, reliable, cost-effective, and can be done in a short operative time. Moreover, for several regions, the functional outcome is no worse than free flap reconstruction.

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Intraoral Hirudotherapy for Venous Congestion following Free Flap Head and Neck Reconstruction: Novel Intraoral Technique

ORL ◽

10.1159/000516576 ◽

2021 ◽

pp. 1-4

Author(s):

Ameen Amanian ◽

Oleksandr Butskiy ◽

Kevin Zhao ◽

Donald W. Anderson

Keyword(s):

Head And Neck ◽

Free Flap ◽

Venous Congestion ◽

Healthcare Team ◽

Head And Neck Reconstruction ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Healthcare Teams ◽

Neck Reconstruction ◽

Novel Technique

Intraoral hirudotherapy is traditionally used for venous congestion following head and neck free flap reconstruction. Many institutions and healthcare teams have been reluctant to use intraoral leech therapy due to risks such as migration into the airway, increased infection from intraoral manipulation, and patient discomfort. Several protocols recommend blocking the path to the oropharynx via gauze or leaving a tracheotomy in place to protect the airway. This report presents a novel technique for intraoral hirudotherapy that is safe and simple for treatment of free flap venous congestion. The base of a clear cup or a plastic lid is utilized, and the leech is attached onto the inside of the lid with 2 sutures near each end. Several cups with leeches attached are made at a time to reduce delay and difficulty of application by less experienced clinical staff. The leech is then applied onto the compromised flap and then simply removed once it has unlatched from the flap. This method allows the leech to be applied with ease by multiple members of the healthcare team, decreases the need for intraoral manipulation, and reduces the risk of migration into the aerodigestive tract. Future prospective studies are warranted to assess the efficacy of this technique.

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Scapula osteocutaneous free flap reconstruction of the head and neck: Impact of flap choice on surgical and medical complications

Head & Neck ◽

10.1002/hed.20540 ◽

2007 ◽

Vol 29 (5) ◽

pp. 446-452 ◽

Cited By ~ 15

Author(s):

Russell B. Smith ◽

Douglas K. Henstrom ◽

Lucy H. Karnell ◽

Kristi C. Chang ◽

David P. Goldstein ◽

...

Keyword(s):

Head And Neck ◽

Free Flap ◽

Medical Complications ◽

Flap Reconstruction ◽

Free Flap Reconstruction

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Multimodal Analgesia in Head and Neck Free Flap Reconstruction: A Systematic Review

Otolaryngology ◽

10.1177/01945998211032910 ◽

2021 ◽

pp. 019459982110329

Author(s):

Beatrice C. Go ◽

Cammille C. Go ◽

Kevin Chorath ◽

Alvaro Moreira ◽

Karthik Rajasekaran

Keyword(s):

Head And Neck Cancer ◽

Head And Neck ◽

Neck Cancer ◽

Free Flap ◽

Multimodal Analgesia ◽

Cancer Surgery ◽

Medical Complications ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Subjective Pain

Objective Postoperative pain after head and neck cancer surgery is commonly treated with opioids, which are associated with considerable side effects. The objective of this study is to analyze the safety and efficacy of using multimodal analgesia (MMA) for patients undergoing head and neck cancer surgery with free flap reconstruction. Data Sources A systematic search was conducted in PubMed, Cochrane, Embase, Scopus, and clinicaltrials.gov. Review Methods All studies comparing patients receiving MMA (gabapentin, corticosteroids, local anesthetic, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]) vs patients receiving opioids for head and neck cancer surgery with free flap reconstruction were screened. The primary outcome was postoperative opioid usage. Secondary outcomes included length of stay, subjective pain scores, surgical/medical complications, adverse effects, and 30-day outcomes. Results A total of 10 studies representing 1253 patients (MMA, n = 594; non-MMA, n = 659) met inclusion criteria. Gabapentinoids were the most commonly used intervention (72.9%) followed by NSAIDs (44.6%), acetaminophen (44.3%), corticosteroids (25.1%), ketamine (7.2%), and nerve block (3.4%). Eight studies reported a significant decrease in postoperative opioid usage in the MMA groups. Subjective pain had wider variation, with most studies citing significant pain improvement. There were no differences in surgical outcomes, medical complications, adverse effects, or 30-day mortality and readmission rates. Conclusion With the rise of the opioid epidemic, MMA may play an important role in the treatment of postoperative pain after head and neck cancer surgery. A growing body of literature demonstrates a variety of effective perioperative regimens.

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Outcomes in Head and Neck Free Flap Reconstruction Among Patients With a History of Venous Thromboembolism

Otolaryngology ◽

10.1177/01945998211011999 ◽

2021 ◽

pp. 019459982110119

Author(s):

Meghan M. Crippen ◽

Rohan S. Ganti ◽

Vivian Xu ◽

Brian Swendseid ◽

Diana L. Tzeng ◽

...

Keyword(s):

Logistic Regression ◽

Venous Thromboembolism ◽

Head And Neck ◽

Free Flap ◽

Tertiary Care ◽

Binary Logistic Regression ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Increased Risk ◽

History Of

Objective To investigate if a history of venous thromboembolism (VTE) is a risk factor for complications in head and neck free flap surgery by assessing outcomes among patients with a history of deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Study Design Retrospective cohort study. Setting Single tertiary care center. Methods All patients undergoing head and neck free flap reconstruction at our institution between September 1, 2006, and April 2, 2020, were assessed for inclusion. Patients with and without a history of DVT or PE preoperatively were identified and grouped for comparison. Groups were compared for demographics, comorbidities, and 30-day complications. Significance was assessed with chi-square and binary logistic regression analyses. Results Of the 1061 patients meeting inclusion criteria, 40 (3.8%) had a history of VTE. These patients were significantly older (mean [SD], years: 67.8 [11.7] vs 63.0 [14.1], P = .038) and significantly more likely to have history of chemotherapy (35.0% vs 18.7%, P = .010) and stroke (27.5% vs 4.5%, P < .001). After accounting for patient characteristics via binary logistic regression, VTE was independently associated with an increased risk for postoperative thrombosis of the free flap pedicle (odds ratio [95% CI] = 3.65 [1.12-11.90], P = .032) and reoperation (2.45 [1.25-4.80], P = .009). Patients with history of PE had a significantly increased risk for flap failure (7.70 [1.77-33.52], P = .007). Prior VTE was not independently associated with an increased risk for medical complications or readmission. Conclusion Patients with a history of VTE may be at an increased risk for free flap compromise secondary to postoperative pedicle thrombosis. This risk should be considered in preoperative workup and postoperative monitoring.

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