scholarly journals 240 Aetiology and Outcomes of Head and Neck Free Flaps in Patients Aged ≥ 65 Years: The Cambridge Experience

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
C Hjalmarsson ◽  
T Chan ◽  
R Chawla ◽  
A Patel
Keyword(s):  
Free Flap ◽  
Free Flaps ◽  
Flap Surgery ◽  
Related Factors ◽  
Flap Failure ◽  
Standard Management ◽  
Free Flap Surgery ◽  
Radial Forearm ◽  
Surgery Department

Abstract Introduction Elderly patients often present to the Head & Neck Plastic Surgery department with complex reconstructive needs, for which free flaps are the gold-standard management. In order to provide appropriate, patient-centred care, it is imperative to understand how increasing age and related factors affect long-term free flap outcomes. Method The authors carried out a retrospective review of all patients 65+ years who underwent free flap surgery at Addenbrooke’s Hospital from 2008-2019. Patient, operative, and flap characteristics, and outcomes, were analysed using Excel and RStudio. Results 163 patients were identified (54F, 109M). The majority were ALT (n = 74), radial forearm (n = 35), and fibula flaps (n = 23). Of pre-operative comorbidities, only neurological comorbidities (n = 16), were significantly associated with long-term flap failure (p = 0.016). There was no significant association between number of comorbidities and flap outcome. There was no association between age group and length of stay. Flap site complications, and particularly venous complications, were significantly associated with later failure (p = 0.001). No other complications were statistically associated with flap failure. Conclusions The high success rate supports the use of free flaps in the 65+ population. This data supports a case-by-case approach to assessing fitness for free flap surgery rather than excluding patients on the basis of age or specific comorbidities.

scholarly journals Current evidence for outcomes of free-flap reconstruction in factor V Leiden patients

2019 ◽  
Vol 2 (2) ◽  
pp. 58-66
Author(s):  
Isobel Yeap ◽  
Chris Ahn ◽  
Stuart Hoffman ◽  
Rowan Gillies ◽  
John Vandervord
Keyword(s):  
Free Flap ◽  
Factor V Leiden ◽  
Free Flaps ◽  
Current Evidence ◽  
Factor V ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Flap Surgery ◽  
Flap Failure ◽  
Free Flap Surgery

Background: Factor V Leiden is the most common form of inherited thrombophilic syndrome, affecting five per cent of caucasians. While increased rates of venous thromboembolic complications have been regularly reported in factor V Leiden patients, little is known about their risk of microvascular complications or flap failure rates in free-flap surgery. The aim of this review is to qualitatively review the published literature on outcomes of free-flap surgery in patients with factor V Leiden. Methods: MEDLINE®, PubMed, EMBASE and Cochrane were searched from their dates of inception to March 2017. Nine studies of level IV evidence were included in this qualitative review. In total, these studies included 22 patients who underwent 24 free-flap operations. Results: Nine flap failures were reported due to thrombotic complications. Even heterozygous factor V Leiden patients had a relatively high risk of free-flap failure (3/15 free flaps), and patients who were heterozygous for factor V Leiden and had other coexistent thrombophilias had an even higher failure rate (5/6 free flaps). However, the small sample size across the nine studies, as well as the inevitable publication bias, means that definitive conclusions cannot be drawn. Conclusion: Despite factor V Leiden being a relatively common condition in Australia, current evidence for outcomes of free-flap reconstruction in this patient population is lacking.

Microvascular free flaps in head and neck surgery

1994 ◽  
Vol 108 (11) ◽  
pp. 962-968 ◽  
Author(s):  
Marcelle Macnamara ◽  
Sarah Pope ◽  
A. Sadler ◽  
H. Grant ◽  
M. Brough
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Neck Region ◽  
Free Flaps ◽  
Neck Surgery ◽  
Flap Failure ◽  
Free Flap Surgery ◽  
Wide Range ◽  
Radial Forearm ◽  
Microvascular Free Flap

AbstractThis study is a retrospective review of 60 patients who had microvascular free flap reconstructions in the head and neck region. They were all performed over a 10-year period by a single surgeon. The series includes a wide range of flap types and analyses pre-operative risk factors for flap failure as well as complications and outcome. Smoking and advanced age did not appear to prejudice flap survival but peripheral vascular disease, cardiac disease and alcohol withdrawal were found to increase the likelihood of flap failure. The most frequent complications encountered were thrombosis of one of the anastomosis and haematoma. The most successful flap in terms of survival and function was the fasciocutaneous radial forearm flap. The literature is reviewed in relation to the general principles of microvascular free flap surgery and the results of this series are placed in context.

scholarly journals One Versus 2 Venous Anastomoses in Free Flap Surgery: A Systematic Review and Meta-Analysis

2017 ◽  
Vol 26 (2) ◽  
pp. 91-98
Author(s):  
Jennifer L. K. Matthews ◽  
Noor Alolabi ◽  
Forough Farrokhyar ◽  
Sophocles H. Voineskos
Keyword(s):  
Systematic Review ◽  
Free Flap ◽  
Meta Analysis ◽  
Venous Congestion ◽  
Flap Surgery ◽  
Flap Failure ◽  
Free Flap Surgery ◽  
Significant Difference ◽  
Reoperation Rates ◽  
Venous Flap

Background: The necessity of a second venous anastomosis in free flap surgery is controversial. The purpose of this systematic review is to determine whether venous flap failure and reoperation rates are lower when 2 venous anastomoses are performed. The secondary objective is to determine whether venous flap failure and reoperation rates are lower when the 2 veins are from 2 different drainage systems. Methods: A comprehensive search of the literature identified relevant studies. Investigators independently extracted data on rates of flap failure and reoperation secondary to venous congestion. A meta-analysis was performed; odds ratios (ORs) were pooled using a random-effects model and 95% confidence intervals (CIs). Results: Of 18 190 studies identified, 15 were included for analysis. The mean sample size was 287 patients (minimum = 102, maximum = 564). No statistically significant difference in venous flap failure was found when comparing 1 versus 2 venous anastomoses (OR: 1.35; 95% CI: 0.46-3.93). A significant decrease in reoperation rate due to venous congestion was shown (OR: 3.03; 95% CI: 1.64-5.58). The results favor using 2 veins from 2 different systems over veins from the same system (OR: 0.16; 95% CI: 0.02-1.27). Conclusions: There is low-quality evidence suggesting that the use of 2 venous anastomoses will lower the rate of reoperation due to venous congestion. There are insufficient data published to meaningfully compare outcomes of flaps with 2 venous anastomoses from different systems to flaps with anastomoses from the same system.

Evaluation of hand circulation before radial forearm free flap surgery

2009 ◽  
Vol 119 (9) ◽  
pp. 1679-1681 ◽  
Author(s):  
Afroze S. Khan ◽  
John M. D. Henton ◽  
Titus S. T. Adams ◽  
Raghav C. Dwivedi ◽  
Paul A. Harris
Keyword(s):  
Free Flap ◽  
Radial Forearm Free Flap ◽  
Flap Surgery ◽  
Free Flap Surgery ◽  
Radial Forearm

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

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.

The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

2020 ◽  
Vol 36 (08) ◽  
pp. 556-566 ◽  
Author(s):  
Amir Khosrow Bigdeli ◽  
Benjamin Thomas ◽  
Florian Falkner ◽  
Emre Gazyakan ◽  
Christoph Hirche ◽  
...  
Keyword(s):  
Decision Making ◽  
Free Flap ◽  
Postoperative Outcome ◽  
Free Flaps ◽  
Tissue Perfusion ◽  
Flap Necrosis ◽  
Tissue Necrosis ◽  
Flap Surgery ◽  
Free Flap Surgery ◽  
Flap Design

Abstract Background Reliable perfusion of the distal portions of free flaps is decisive for the reconstructive success. Indocyanine green near-infrared video angiography (ICG-NIR-VA) has been adopted for objective assessment of free flap tissue perfusion but is thus far not used on a routine basis. Therefore, we investigated its intraoperative impact on decision-making and postoperative outcome. Methods From January 2017 to June 2019, 88 consecutive adipo- or fasciocutaneus free flaps were performed in conjunction with intraoperative ICG-NIR-VA. Free flap tissue perfusion was first assessed clinically and then compared with ICG-NIR-VA findings. Based on the results, the decision for intraoperative trimming of critically perfused flap zones was made. The way of decision-making, flap success, and failure rates as well as intra- and postoperative complication rates were analyzed. Results The overall free flap success rate was 92.0%. Partial flap necrosis occurred in five cases (5.7%) and total flap necrosis in two cases (2.3%). ICG-NIR-VA aided decision-making and flap design in 34 cases (38.6%) and led to complication-free postoperative courses. When ICG-NIR-VA was relied on (82 out of 88 flaps; 93.2%), there was no unpredicted postoperative tissue necrosis (overestimation). When ICG-NIR-VA was not relied on (6 out of 88 flaps; 6.8%), there were five cases of postoperative partial flap necrosis and one case of uneventful healing (underestimation). The sensitivity of ICG-NIR-VA was 100% (95% confidence interval [CI]: 64.6–100) and the specificity was 98.8% (95% CI: 93.3–100) with a positive predictive value of 87.5% (95% CI: 52.9–99.4) and a negative predictive value of 100% (95% CI: 95.4–100). Conclusion Intraoperative ICG-NIR-VA objectified free flap perfusion and thus refined surgical decision-making on flap design in all cases. It could always predict tissue necrosis and subjectively improved outcomes in free flap surgery at our institution. Furthermore, it could be easily implemented in intraoperative routine, only adding minimal additional operative time.

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis

2019 ◽  
Vol 35 (07) ◽  
pp. 529-540 ◽  
Author(s):  
Cindy S.L. Goh ◽  
Marcus J.M. Ng ◽  
David H. Song ◽  
Adrian S.H. Ooi
Keyword(s):  
Systematic Review ◽  
Free Flap ◽  
Meta Analysis ◽  
Head And Neck Reconstruction ◽  
Complication Rates ◽  
Flap Surgery ◽  
Flap Failure ◽  
Free Flap Surgery ◽  
Vasopressor Use ◽  
The Impact

Background The use of vasopressors in free flap surgery has traditionally been avoided due to the presumed risk of pedicle vasospasm leading to flap failure. However, there is a lack of strong clinical evidence to suggest that their administration during microvascular surgery is absolutely contraindicated. The aim of this study is to clarify the impact of perioperative vasopressor use on free flap outcomes. Methods A systematic review was performed of all English-language articles that have compared free flap outcomes between patients who received vasopressors and those who did not. The outcome measures were total flap failure, pedicle thrombosis, and overall flap complications. Meta-analysis was performed using Mantel–Haenszel fixed-effects and DerSimonian and Laird random-effects models. Results From a total of 130 citations, 14 studies representing 8,653 cases were analyzed. Majority of these did not find any negative effects of vasopressor use irrespective of dose, timing of administration, and method of delivery. Meta-analysis demonstrated that vasopressors were associated with less total flap failure overall (odds ratio, [OR]: 0.71, p = 0.05) and less pedicle thrombosis in head and neck reconstruction specifically (OR: 0.58, p = 0.02). Flap complication rates were similar across all defect types (OR: 0.97, p = 0.81) but appeared to be increased in breast reconstruction (OR: 1.46, p = 0.01). Conclusion Perioperative vasopressor administration does not appear to be as detrimental to free flap survival as has been previously feared. Their role in optimizing hemodynamic stability may have a more beneficial effect on overall flap perfusion and in minimizing the complications of iatrogenic fluid overload.

scholarly journals Combining free tissue transfer with pedicled flap in reconstruction of extensive oromandibular malignancy defects: a clinical study

2020 ◽  
Vol 7 (2) ◽  
pp. 376
Author(s):  
Naveen Narayan ◽  
Kamal Kumar Manakchand
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Pedicled Flap ◽  
Team Approach ◽  
One Stage ◽  
Free Flap Surgery ◽  
Ablative Surgery ◽  
Free Fibula ◽  
Radial Forearm

Background: Extensive composite defects of the oromandibular site involve skin, mandible, soft tissue and oral mucosa. Though many opine that with the coming on of free flap surgery, the pedicled flap is an outdated surgical option, the latter still has its uses. Free flaps are criticized as being medically risky, expensive, and time-consuming. Combining both these flaps in a single surgery would bring in the baggage of all negatives along with the benefits of these flaps.Methods: Over a period of 3 years, 13 patients with expected large composite oral defects after ablative surgery for malignancy were included in the study requiring both skin cover and mucosal lining. A one-stage reconstructive procedure employing combination of free and pedicled flaps was used. Data was abstracted pertaining to cancer demography and surgical outcome.Results: The free fibula osteocutaneous flap (FFOCF)- deltopectoral fasciocutaneous flap (DPF) combination was most commonly used (n=5), secondly by free radial forearm flap (FRAFF)-DPF combination (n=4), FRAFF- pectoralis major myocutaneous flap (PMMF) amalgamation and FFOCF-PMMF (n=2). The complete flap survival rate was 88.5 percent with 3.8% percent total (1 of 26 flaps) and 7.7% partial (2 of 26 flaps) flap failures. Minimum follow-up period was 6 months with 2 (7.7%) recurrences and 2 (7.7%) mortalities.Conclusions: We believe that in combined use of free-flap and pedicled flap procedure for one-stage reconstruction of massive mandibular defects with through-and-through cheek defects is justified because it is safe and effective and improves the quality of life for these patients albeit a bit prolonged surgery which can effectively be shortened with 2 reconstructive team approach as in our study.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

2021 ◽  
Vol 53 (04) ◽  
pp. 349-355
Author(s):  
Jin Li ◽  
Hewei Xiong ◽  
Gongchi Li ◽  
Pan Zhou ◽  
Fangxin Ai ◽  
...  
Keyword(s):  
Success Rate ◽  
Free Flap ◽  
Pediatric Patients ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Functional Improvement ◽  
Flap Surgery ◽  
Global Functioning ◽  
Free Flap Surgery

Abstract Background Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients. Methods From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). Results A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100). Conclusion The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

Predictors of Adverse Outcomes in Free Flap Reconstruction: A Single-Institution Experience

2018 ◽  
Vol 159 (6) ◽  
pp. 973-980 ◽  
Author(s):  
Douglas R. Farquhar ◽  
Maheer M. Masood ◽  
Andrew K. Pappa ◽  
Samip N. Patel ◽  
and Trevor G. Hackman
Keyword(s):  
Free Flap ◽  
Revision Surgery ◽  
Medical Center ◽  
Adverse Outcomes ◽  
Flap Surgery ◽  
Flap Survival ◽  
Major Complications ◽  
Free Flap Surgery ◽  
Radial Forearm ◽  
Poor Outcomes

Objective Understanding the independent predictors of poor outcomes in free flap surgery is essential for patient selection. We aim to determine the independent predictors of major complications, flap survival, and extended hospital stays. Study Design Retrospective cohort study. Setting Tertiary medical center. Subjects and Methods We reviewed medical records from all vascularized tissue transfers in the head and neck between 2007 and 2014 at our institution. We recorded demographics, medical comorbidities, disease characteristics, flap characteristics, and intraoperative events. We defined outcomes as major complications in the 30-day postoperative period, flap death or partial flap survival, and a length of stay ≥14 days. We used bivariate and multivariate methods to test for associations. Results Of 170 free flap operations, 44% had major complications; 11% fully or partially failed; and 27% required an extended hospital stay. Independent predictors of major complications were age ≥60 years (odds ratio [OR], 3.7; P = .001), revision surgery (OR, 3.5; P = .004), and a prior neck dissection (OR, 3.5; P = .004). Independent predictors of flap failure were revision surgery (OR, 4.1, P = .01) and the use of a plate (OR, 3.7; P = .03). Revision surgery was independently associated with a longer stay (OR, 3.0; P = .01), and the use of a radial forearm flap was associated with a shorter stay (OR, 0.3, P = .047). Conclusion These results underscore that caution is warranted in revision flap surgery, patients with prior neck operations, and patients aged ≥60 years.

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