scholarly journals 1119 Readdressing Consent in Head & Neck Free Flap Surgery: The Nottingham Experience

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
A Jivraj ◽  
K Evans ◽  
H Aga ◽  
L Al-Qamachi
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Gold Standard ◽  
Enhanced Recovery ◽  
Neck Surgery ◽  
Consent Process ◽  
Head And Neck Reconstruction ◽  
Free Flap Surgery ◽  
Legal Risks ◽  
Eras Protocol

Abstract Aim The Montgomery vs NHS Lanarkshire case in 2015 led to a paradigm shift in the consent process within surgery. It became incumbent upon clinicians to outline all “material risks” prior to a procedure. Within head and neck surgery, the Enhanced Recovery After Surgery (ERAS) pathway addresses this obligation through a multi-disciplinary approach. The aim of this audit was to assess the effect of the existing ERAS pathway on the consent process. Method 35 head and neck oncology cases involving free flap reconstruction were identified across two audit cycles. Cases pre- and post-introduction of the ERAS pathway were analysed to assess whether the existing pathway led to improvement in consent quality. 8 key consent elements were identified based on a review of current literature and guidelines. This was our gold standard. A tick-box system was devised, and each case assigned a percentage score based on compliance with these criteria. A consent checklist was introduced within the ERAS pathway file alongside multi-disciplinary documentation which would follow the patient from the pre-operative environment through to discharge. Results Prior to the introduction of the ERAS pathway, there was a 58% compliance with the gold standard. Upon implementation of the ERAS protocol, compliance rose to 65%. Following introduction of the checklist, compliance rose further to 85%. This resulted in an overall increase in compliance of 27%. Conclusions We recommend the introduction of a focused consent checklist within any unit providing major head and neck reconstruction procedures in order to ensure informed consent, mitigating medico-legal risks post-operatively.

scholarly journals Late Free Flap Failure in Head and Neck Reconstruction: A Systematic Review

2018 ◽  
Vol 97 (7) ◽  
pp. 213-216 ◽  
Author(s):  
David Forner ◽  
Blair A. Williams ◽  
Fawaz M. Makki ◽  
Jonathan R.B. Trites ◽  
S. Mark Taylor ◽  
...  
Keyword(s):  
Systematic Review ◽  
Head And Neck ◽  
Free Flap ◽  
Neck Surgery ◽  
Head And Neck Surgery ◽  
Head And Neck Reconstruction ◽  
Time To Failure ◽  
Close Monitoring ◽  
Flap Failure ◽  
Vascular Compromise

Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.

Does Postoperative Anticoagulation Therapy Lead to a Higher Success Rate for Microvascular Free-Tissue Transfer in the Head and Neck? A Systematic Review and Meta-Analysis

2017 ◽  
Vol 34 (02) ◽  
pp. 087-094 ◽  
Author(s):  
Jinglong Liu ◽  
Quan Shi ◽  
Shuo Yang ◽  
Bo Liu ◽  
Bin Guo ◽  
...  
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Meta Analysis ◽  
Anticoagulation Therapy ◽  
Head And Neck Reconstruction ◽  
Thromboembolic Events ◽  
Flap Surgery ◽  
Neck Reconstruction ◽  
Flap Loss ◽  
Free Flap Surgery

Background Due to limited evidence, it is unclear whether postoperative anticoagulation therapy may lead to higher success rates for microvascular free-flap surgery in the head and neck. This review evaluated whether postoperative anticoagulation therapy can lead to a better result in head and neck reconstruction. Methods PubMed, Embase, and the Cochrane Library were used to search for articles on the efficacy of postoperative antithrombotic therapy in free-flap transfer during head and neck reconstruction without language restrictions in February of 2017. A random-effects model was used to estimate the relative risk ratio (RR) with 95% confidence intervals (CIs). The measured outcomes were flap loss, thromboembolic events, and hematoma formation. Results A total of 2,048 free-flap surgery procedures in the head and neck were analyzed. There was no significant difference in the occurrence of flap loss and thromboembolic events in the anticoagulation group compared with the nonanticoagulation group (RR = 1.25, 95% CI = 0.85–1.81, p = 0.26; and RR = 1.05, 95% CI = 0.74–1.48, p = 0.79, respectively). The risk of hematoma was twice as high in the anticoagulation group than the nonanticoagulation group, which was statistically significant (RR = 2.02, 95% CI = 1.08–3.76, p = 0.03). Conclusion The findings from our meta-analysis indicate that postoperative anticoagulation therapy barely decreases the risks of flap loss and thromboembolic events in free-flap surgery in the head and neck. However, it may significantly increase the risk of hematoma formation. Considering the limitations of this meta-analysis, additional high-quality, multicenter, prospective, randomized controlled studies are needed to confirm these findings.

Avoiding Complications in Free Flap Surgery

1995 ◽  
Vol 112 (5) ◽  
pp. P38-P38
Author(s):  
Neal D. Futran ◽  
Jeffrey R. Haller
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Postoperative Care ◽  
Preoperative Planning ◽  
Head And Neck Reconstruction ◽  
Flap Surgery ◽  
Educational Objectives ◽  
Neck Reconstruction ◽  
Free Flap Surgery

Educational objectives: To avoid complications in microvascular head and neck reconstruction by having a better understanding of patient and flap selection, preoperative planning, postoperative care, and monitoring and to delineate the techniques and procedures to manage free flap complications when they occur.

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.

scholarly journals Alternatives to free flap surgery for maxillofacial reconstruction: focus on the submental island flap and the pectoralis major myocutaneous flap

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
J. K. Meier ◽  
S. Spoerl ◽  
G. Spanier ◽  
M. Wunschel ◽  
M. J. Gottsauner ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Head And Neck ◽  
Free Flap ◽  
Myocutaneous Flap ◽  
Neck Surgery ◽  
Island Flap ◽  
Pectoralis Major Myocutaneous Flap ◽  
Flap Surgery ◽  
Free Flap Surgery ◽  
Submental Island Flap

Abstract Background Microvascular tissue transfer (MTT) has been established as the gold standard in oral- and maxillofacial reconstruction. However, free flap surgery may be critical in multimorbid elderly patients and after surgery or radiotherapy, which aggravate microsurgery. This study evaluates indications and outcome of the submental island flap (SMIF) and the pectoralis major myocutaneous flap (PMMF) as alternatives to the free radial forearm flap (RFF). Methods This retrospective study included 134 patients who had undergone resection and reconstruction with SMIF, PMMF, or RFF at our department between 2005 and 2020. The level of comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). Primary outcome variables were flap success, complications, wound dehiscence, surgery duration, as well as time at the ICU and the ward (hospitalization). Chi-square tests, t-tests, and ANOVA were performed for statistics. Results 24 SMIFs, 52 RFFs, and 58 PMMFs were included in this study. The flap types did not significantly differ in terms of flap success, complications, and healing disorders. The SMIF presented a success rate of 95.8% and was significantly more often used in elderly patients (mean age = 70.2 years; p < 0.001) with increased comorbidities than the PMMF (p < 0.01) and RFF (p < 0.001). SMIF reconstruction reduced surgery duration (p < 0.001) and time at the ICU (p = 0.009) and the ward (p < 0.001) more than PMMF and RFF reconstructions. PMMF reconstruction was successful in 91.4% of patients and was more frequently used after head and neck surgery (p < 0.001) and radiotherapy (p < 0.001) than SMIF and RFF reconstructions. Patients undergoing PMMF reconstruction more frequently required segmental jaw resection and had presented with advanced tumor stages (both p < 0.001). Nicotine and alcohol abuse was more frequent in the RFF and PMMF groups (both p < 0.001) than in the SMIF group. Conclusions The pedicled SMIF represents a valuable reconstructive option for elderly patients with increased comorbidity because of the shorter duration of surgery and hospitalization. On the other hand, the PMMF serves as a solid backup solution after head and neck surgery or radiotherapy. The rates of flap success, complications, and healing disorders of both pedicled flaps are comparable to those of free flap reconstruction.

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 Role of heparin in microvascular free flap surgery in head and neck reconstruction

2015 ◽  
pp. 534-538
Author(s):  
Gunjan Agrawal ◽  
Ashutosh Gupta ◽  
Vivek Choudhary ◽  
Santanu Tiwari ◽  
Kshitij Verma ◽  
...  
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Head And Neck Reconstruction ◽  
Flap Surgery ◽  
Neck Reconstruction ◽  
Free Flap Surgery ◽  
Microvascular Free Flap

scholarly journals Proposed Prediction Model and Nomogram for Systemic Complications in Patients Undergoing Free Flap Head and Neck Reconstruction

2021 ◽  
Vol 8 ◽  
Author(s):  
John-Patrik M. Burkhard ◽  
Roland Giger ◽  
Markus B. Huber ◽  
Benoît Schaller ◽  
Ayla Little ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Head And Neck ◽  
Free Flap ◽  
Neck Surgery ◽  
Head And Neck Reconstruction ◽  
Microvascular Reconstruction ◽  
Flap Reconstruction ◽  
Systemic Complications ◽  
Ablative Surgery ◽  
Ordinal Regression Model

Postoperative complications in head and neck surgery are well-known, but a predictive model to guide clinicians in free flap reconstructions has not been established. This retrospective single-center observational study assessed 131 patients who underwent ablative surgery and received free flap reconstruction. Primary endpoint was the occurrence of systemic complications (PSC). Secondary endpoint was the generation of a nomogram of complications according to the CDC classification. In the ordinal regression model, postoperative administration of furosemide [1.36 (0.63–2.11), p &lt; 0.0001], blood loss [0.001 (0.0004–0.0020), p = 0.004], postoperative nadir hemoglobin [−0.03 (−0.07–0.01), p = 0.108], smoking [0.72 (0.02–1.44), p = 0.043], and type of flap reconstruction [1.01 (0.21–1.84), p = 0.014] as predictors. A nomogram with acceptable discrimination was proposed (Somer's delta: 0.52). Application of this nomogram in clinical practice could help identify potentially modifiable risk factors and thus reduce the incidence of postoperative complications in patients undergoing microvascular reconstruction of the head and neck.

scholarly journals Cost analysis of free flap surgery in head and neck reconstruction

2017 ◽  
Vol 46 ◽  
pp. 193
Author(s):  
K. Tewfik ◽  
P. Chiarelli ◽  
C. Copelli ◽  
L. Cassano ◽  
L. Mangiacotti ◽  
...  
Keyword(s):  
Cost Analysis ◽  
Head And Neck ◽  
Free Flap ◽  
Head And Neck Reconstruction ◽  
Flap Surgery ◽  
Neck Reconstruction ◽  
Free Flap Surgery
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