Complications and Outcomes of Chimeric Free Flaps: A Systematic Review

2019 ◽  
Vol 161 (4) ◽  
pp. 568-575 ◽  
Author(s):  
Abhinav R. Ettyreddy ◽  
Collin L. Chen ◽  
Joseph Zenga ◽  
Laura E. Simon ◽  
Patrik Pipkorn
Keyword(s):  
Head And Neck ◽  
Complication Rate ◽  
Operative Time ◽  
Donor Site ◽  
Locally Advanced ◽  
Major Complication ◽  
Free Flaps ◽  
Controlled Vocabulary ◽  
Cochrane Central Register ◽  
Complication Rates

ObjectiveAblations of locally advanced or recurrent head and neck cancer commonly result in large composite orofacial defects. Chimeric flaps represent a unique surgical option for these defects, as they provide diverse tissue types from a single donor site. The purpose of the study was to consolidate the literature on chimeric flaps with regard to postoperative complication rates to help inform surgical decision making.Data SourcesThe librarian created search strategies with a combination of keywords and controlled vocabulary in Ovid Medline (1946), Embase (1947), Scopus (1823), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Clinicaltrails.gov (1997).Review MethodsCandidate articles were independently reviewed by 2 authors familiar with the subject material, and inclusion/exclusion criteria were uniformly applied for article selection. Articles were considered eligible if they included patients who received a single chimeric flap for reconstruction of head and neck defects and if they provided data on complication rates.ResultsA total of 521 chimeric flaps were included in the study. The major complication rate was 22.6%, while the minor complication rate was 14.0%. There were 7 flap deaths noted in the series. Median operative time and harvest time were 15.0 and 2.5 hours, respectively.ConclusionChimeric flaps represent a viable option for reconstruction of complex head and neck defects and have complication rates similar to those of double free flaps and single free flaps with locoregional flap while only modestly increasing total operative time.

‘Sit and tilt’ preparation for subscapular system free flaps

2018 ◽  
Vol 132 (2) ◽  
pp. 180-183 ◽  
Author(s):  
J Mark ◽  
H Patwa ◽  
M S Costello ◽  
Y Patil
Keyword(s):  
Head And Neck ◽  
Operative Time ◽  
Donor Site ◽  
Three Dimensional ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Head And Neck Reconstruction ◽  
Advanced Head ◽  
Neck Reconstruction ◽  
Harvesting Technique

AbstractBackground:The ablation of advanced head and neck cancer often results in large three-dimensional defects that require free tissue transfer to optimally address functional and cosmetic issues. The subscapular system is a highly versatile donor site for flaps used for head and neck reconstruction. Traditional methods of harvesting subscapular flaps require repositioning and re-preparing, which significantly increases the operative time and prevents simultaneous harvesting of the flap.Method:This paper presents our experience of a single-stage ‘sit and tilt’ technique, which provides a convenient method for harvesting subscapular system free flaps without significant repositioning.Results and conclusion:This technique was used for a variety of head and neck defects, and body habitus did not seem to affect free tissue harvesting. It is hoped that utilisation of this preparation and harvesting technique will make head and neck surgeons more willing to take advantage of the subscapular system.

scholarly journals Free Periosteal Flaps with Scaffold: An Overlooked Armamentarium for Maxillary and Mandibular Reconstruction

Cancers ◽  
2021 ◽  
Vol 13 (17) ◽  
pp. 4373
Author(s):  
Remo Accorona ◽  
Luca Gazzini ◽  
Roberto Grigolato ◽  
Enrico Fazio ◽  
Letizia Nitro ◽  
...  
Keyword(s):  
Head And Neck ◽  
Donor Site ◽  
Locally Advanced ◽  
Free Flaps ◽  
Mandibular Reconstruction ◽  
Cochrane Library ◽  
Medical Subject Headings ◽  
Promising Tool ◽  
Mesh Terms ◽  
Radial Forearm

Introduction: Head and neck bone reconstruction is a challenging surgical scenario. Although several strategies have been described in the literature, bone free flaps (BFFs) have become the preferred technique for large defects. Revascularized free periosteal flaps (FPFs) with support scaffold represents a possible alternative in compromised patient, BFF failure, or relapsing cancers as salvage treatment. However, only few clinical applications in head and neck are reported in literature. Purpose of the study was to systematically analyse the results of functional and oncologic maxillary and mandibular reconstruction with FPF with scaffold. Materials and Methods: A comprehensive review of the dedicated literature was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, Cochrane Library, Embase, Researchgate and Google Scholar databases using relevant keywords, phrases and medical subject headings (MeSH) terms. An excursus on the most valuable FPF’ harvesting sites was also carried out. Results: A total of 7 studies with 55 patients were included. Overall, the majority of the patients (n = 54, 98.1%) underwent an FPF reconstruction of the mandibular site. The most used technique was the radial forearm FPF with autologous frozen bone as scaffold (n = 40, 72.7%). The overall rate of complications was 43.7%. The success rate intended as scaffold integration resulted to be 74.5%. Conclusions: Maxillary and mandibular reconstruction with FPF and scaffold is a possible alternative in patient unfit for complex BFF reconstruction and it should be considered as a valid alternative in the sequential salvage surgery for locally advanced cancer. Moreover, it opens future scenarios in head and neck reconstructive surgery, as a promising tool that can be modelled to tailor complex 3D defects, with less morbidities to the donor site.

scholarly journals A comparison of the Thunderbeat and standard electrocautery devices in head and neck surgery: a prospective randomized controlled trial

2021 ◽  
Author(s):  
N. C. Kuipers ◽  
B. J. de Kleijn ◽  
J. Wedman ◽  
B. F. A. M. van der Laan ◽  
B. E. C. Plaat ◽  
...  
Keyword(s):  
Randomized Controlled Trial ◽  
Blood Loss ◽  
Head And Neck ◽  
Complication Rate ◽  
Operative Time ◽  
Controlled Trial ◽  
Neck Surgery ◽  
Head And Neck Surgery ◽  
Randomized Controlled ◽  
Standard Instrumentation

Abstract Purpose New energy-based sutureless vessel ligation devices, such as the Thunderbeat (Olympus Medical Systems Corp., Tokyo, Japan), could reduce operative time and limit blood loss in head and neck surgery; however, efficacy and safety in major head and neck surgery have not been investigated in a prospective, randomized study. Methods This prospective, double-arm, randomized controlled trial consisted of two parts: total laryngectomy (TL) and neck dissection (ND). Thirty patients planned for TL were randomized in two groups. For the ND part, forty-two operative sides were likewise randomized. In both parts, Thunderbeat was used in addition to the standard instrumentation in the intervention groups, while only standard instrumentation was used in the control groups. Primary outcome values were blood loss, operative time and complication rate. Results For the TL part there was no difference in mean blood loss (p = 0.062), operative time (p = 0.512) and complications (p = 0.662) between both hemostatic techniques. For the neck dissection part, there was a reduction in blood loss (mean 210 mL versus 431 mL, p = 0.046) and in operative time (median 101 (IQR 85–130) minutes versus 150 (IQR 130–199) minutes, p = 0.014) when Thunderbeat was used. There was no difference in complication rate between both hemostatic systems (p = 0.261). Conclusion The Thunderbeat hemostatic device significantly reduces operative blood loss and operative time for neck dissections, without increase in complications. In TL, blood loss using Thunderbeat was comparable with the standard technique, but the operative time tended to be shorter. Trial registration UMCG Research Register, Reg. no. 201700041, date of registration: 18/1/2017

scholarly journals Factors increasing the risk of flap complications following pectoralis major myocutaneous flap reconstruction for head and neck cancers

2020 ◽  
Vol 6 (6) ◽  
pp. 1138
Author(s):  
Subbiah Shanmugam ◽  
Syed Afroze Hussain ◽  
Rajiv Michael
Keyword(s):  
Radiation Therapy ◽  
Head And Neck ◽  
Radiation Treatment ◽  
Demographic Data ◽  
Major Complication ◽  
Pectoralis Major ◽  
Head And Neck Reconstruction ◽  
Complication Rates ◽  
Flap Reconstruction ◽  
Operative Care

<p class="abstract"><strong>Background:</strong> Oral cavity cancer is one of the most common cancers and a leading cause of cancer death in India. Pectoralis major myocutaneous flaps (PMMC) are still widely used for reconstruction of defects in the head and neck, though microvascular free flaps are the ‘gold standard’. This study was aimed to identify the risk factors involved in increasing the post-operative PMMC flap complications.</p><p class="abstract"><strong>Methods:</strong> Patients who underwent surgical resection of primary head and neck cancer with PMMC flap reconstruction were included and their demographic data, pre-operative laboratory values, surgery details and post-operative flap morbidity were collected retrospectively from the master case sheets from January 2013 to December 2019. Factors such as age, gender, stage of disease, pre-operative anemia, hypoprotenemia and radiation therapy, presence of diabetes and size of the flaps were analysed to find their relation in causing flap complications.  </p><p class="abstract"><strong>Results:</strong> Totally 285 patients were included for analysis and 9.82% (n=28) had major flap complications. On analysis we found that pre-operative hypoproteinemia (serum albumin &lt;3.5) (p=0.001) and prior radiation therapy (p=0.02) significantly increased the risk of flap complications. Similarly, patients with larger bipaddled flaps had higher flap complication rates (p=0.0002) and previous radiation treatment further increased the major complication rates in bipaddle flaps.</p><p class="abstract"><strong>Conclusions:</strong> PMMC flaps are still a viable option for head and neck reconstruction especially in patients with multiple comorbidities and where free microvascular flaps are not done routinely. Careful patient selection, pre-operative optimisation and good post-operative care will help to reduce flap complications.</p><p> </p>

scholarly journals Fixation of Ankle Fractures

2018 ◽  
Vol 3 (3) ◽  
pp. 2473011418S0008
Author(s):  
Andrew Molloy ◽  
Samantha Whitehouse ◽  
Lyndon Mason
Keyword(s):  
Complication Rate ◽  
Major Complication ◽  
Ankle Fractures ◽  
Complication Rates ◽  
Junior Staff ◽  
System Changes ◽  
Major Complication Rate ◽  
Group 3 ◽  
Group 2 ◽  
Group 1

Category: Trauma Introduction/Purpose: Ankle fractures are one of the most common fractures. Historically these have been frequently treated by non-specialists and junior staff. In 2011 we presented high malunion rates, which have been mirrored in other departments work. We present the results of system changes to improve the results of ankle fracture fixation Methods: Image intensifier films were reviewed on PACS and scored based on the criteria published by Pettrone et al. At least two blinded assessors assigned scores independently. Patients clinical data was collected from medical records. In 2011 we presented the results of fixation in 94 consecutive patients (Group 1) from 2009. Following this there was period of education in the department to allow change. 68 patients (Group 2) were then reviewed from a 7 month period in 2014 Multiple system changes were introduced in the department including; new treatment algorithms, dedicated foot and ankle trauma lists and clinics, and next day review of all intra-operative radiographs by independent attending. Prospective data was collected on 205 consecutive cases (Group 3) from 01/01/15 – 09/30/16 Results: Patients in group 1 had a malreduction rate of 33%. The major complication rate in this group was 8.5% (8 patients); with only one of these occurred in a correctly reduced fracture. These complications included 4 revision fixations, 2 deep infections and 1 amputation. Following the period of re-education, in Group 2, the mal-reduction rate deteriorated to 43.8%. In this group the major complication rate was 10.9%; including 6 revision fixations and 1 ankle fusion. In Group 3, following overall system changes, the malreduction rate was 2.4%. This result is statistically significant. The major complication rate fell to 0.98%; 1deep infection and 1 amputation (in a polytrauma patient with vascular injury). This result is again statistically significant. Conclusion: Our initial results show that very poor results are a consequence when sufficient attention is not given to what are frequently considered to be ‘simple’ fractures. In group 2 we demonstrated that soft educational changes (eg presentations, emails) are ineffective in improving results. We have demonstrated that hard (institutional system) changes in our department provided statistically significant improvements. These changes allowed the correct surgeon for the fracture in both determining the treatment plan and operating. With these changes, malreduction rates fell from 43.8% to 2.4% and major complication rates from 10.9% to 0.98%

Piezoelectric technology in otolaryngology, and head and neck surgery: a review

2017 ◽  
Vol 131 (S2) ◽  
pp. S12-S18 ◽  
Author(s):  
C Meller ◽  
T E Havas
Keyword(s):  
Learning Curve ◽  
Head And Neck ◽  
Operative Time ◽  
Neck Surgery ◽  
Ease Of Use ◽  
Head And Neck Surgery ◽  
Cochrane Central Register ◽  
Surgical Tool ◽  
Surgical Methods ◽  
Piezoelectric Surgery

AbstractBackground:Piezoelectric technology has existed for many years as a surgical tool for precise removal of soft tissue and bone. The existing literature regarding its use specifically for otolaryngology, and head and neck surgery was reviewed.Methods:The databases Medline, the Cochrane Central Register of Controlled Trials, PubMed, Embase and Cambridge Scientific Abstracts were searched. Studies were selected and reviewed based on relevance.Results:Sixty studies were identified and examined for evidence of benefits and disadvantages of piezoelectric surgery and its application in otolaryngology. The technique was compared with traditional surgical methods, in terms of intra-operative bleeding, histology, learning curve, operative time and post-operative pain.Conclusion:Piezoelectric technology has been successfully employed, particularly in otology and skull base surgery, where its specific advantages versus traditional drills include a lack of ‘blunting’ and tissue selectivity. Technical advantages include ease of use, a short learning curve and improved visibility. Its higher cost warrants consideration given that clinically significant improvements in operative time and morbidity have not yet been proven. Further studies may define the evolving role of piezoelectric surgery in otolaryngology, and head and neck surgery.

Application of Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstructions

2014 ◽  
Vol 151 (5) ◽  
pp. 791-796 ◽  
Author(s):  
Honda Hsu ◽  
Peir-Rong Chen ◽  
Sou-Hsin Chien ◽  
Jiunn-Tat Lee
Keyword(s):  
Head And Neck ◽  
Donor Site ◽  
Tertiary Care ◽  
Case Series ◽  
Functional Results ◽  
Donor Site Morbidity ◽  
Head And Neck Reconstruction ◽  
Complication Rates ◽  
Recipient Site ◽  
The Mean

Objective Analyze the reliability, complications, and donor site morbidity of the proximal lateral leg flap when applied to head and neck reconstruction. Study Design Case series and chart review. Setting Tertiary care teaching hospital. Subjects and Methods Nineteen patients who underwent reconstruction of various head and neck defects with this flap were analyzed. The patient demographics, flap characteristics, method of donor site closure, scars of the donor area, complication rates, as well as functional results at the recipient site were assessed. Results The flap size ranged from 4 × 4 cm to 11 × 8 cm. Vascular pedicle length ranged from 5 to 9 cm. The mean distance of the perforator from the fibula head was 9.2 cm. The mean thickness of this flap was 5.5 mm. All the donor wounds were closed primarily. The flap survival rate was 100%. Conclusion This flap has the advantages of thinness, short harvesting time, minimal donor site morbidity, and primary closure at the donor site when the flap width is less than 6 cm. This flap may be useful for reconstruction in selected patients with small and thin heads and neck defects.

scholarly journals Bone cutter versus plastibell device in neonatal circumcision: A randomized trial

2020 ◽  
Vol 9 ◽  
pp. 24
Author(s):  
Ademola Olusegun Talabi ◽  
Gabriel Unimke Udie ◽  
Oludayo Adedapo Sowande ◽  
Owolabi Oni ◽  
Olusanya Adejuyigbe
Keyword(s):  
Blood Loss ◽  
Randomized Trial ◽  
Complication Rate ◽  
Operative Time ◽  
Urban Setting ◽  
Complication Rates ◽  
Estimated Blood Loss ◽  
Tertiary Teaching ◽  
Neonatal Circumcision ◽  
Perception Score

Background: Several techniques and devices have been described for circumcision each with its own pros and cons. The objective of this study was to compare the outcome of neonatal circumcision between bone-cutter and plastibell devices at our institution. Methods: This is a randomized trial (unregistered) conducted at the Pediatric Surgical Unit of a tertiary teaching hospital situated in a semi-urban setting, between January 2019 and December 2019. The uncircumcised neonates underwent circumcision by either bone-cutter or plastibell device. Demographic characteristics, operative time, estimated blood loss, and postoperative complications were compared. A p-value of <0.05 was considered significant. Results: The age ranged between 7 days and 30 days with a mean of 15.9±5.5 days. The mean age and weight of both groups were well matched (p >0.05). The operative time in the bone cutter technique was 4.2±0.9 minutes compared to 5.8±1.2 minutes in the plastibell device method (p <0.001). Blood loss was lesser with bone cutter (0.27 ±0.32mls versus 0.51 ±0.44mls in the plastibell device, p <0.001). The complication rates were comparable in both study groups (p =1.000). The overall complication rate was 5.8%. The penile perception score and the Hollander wound evaluation score for bone-cutter were 15.7±0.8 and 5.7±0.84 while in the plastibell device were 15.4±1.1 and 5.4±1.1, respectively (p >0.05). Conclusion: Operative time and blood loss were less with bone cutter compared to plastibell device. However, the complication rate, penile perception score, and Hollander wound evaluation scores were similar.

Preoperative Computed Tomography Angiography for ALT Flaps Optimizes Design and Reduces Operative Time

2021 ◽  
Author(s):  
Christopher M. Schneider ◽  
Patrick A. Palines ◽  
Daniel J. Womac ◽  
Charles T. Tuggle ◽  
Hugo St Hilaire ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Operative Time ◽  
Donor Site ◽  
Vascular Anatomy ◽  
Complication Rates ◽  
Anterolateral Thigh ◽  
Extremity Reconstruction ◽  
Alt Flap ◽  
Selection Of

Abstract Background Computed tomography angiography (CTA) has been widely used for perforator mapping in abdominal-based reconstruction, but it is less widespread in the anterolateral thigh (ALT) flap. However, CTA may be quite useful for ALT planning, as this flap has demonstrated substantial variability in intrapatient bilateral vascular anatomy. This study investigated whether standard use of preoperative CTA resulted in selection of the donor extremity with preferential perforator anatomy, and whether this affected operative time and postoperative outcomes. Methods A retrospective review of 105 patients who underwent proposed ALT flap reconstruction was performed. Seventy-nine patients received bilateral lower extremity CTAs, which were evaluated for dominant perforator anatomy (septocutaneous, musculoseptocutaneous, or musculocutaneous). Donor extremity selection was noted, and predicted perforator anatomy was compared with that encountered intraoperatively. Results Among the 73 patients who received bilateral imaging and ultimately received an ALT, congruent findings between imaging and surgical exploration were observed in 51 (69.8%) patients. Thirty (37.9%) patients had asymmetric perforator anatomy between their bilateral extremities on imaging. Among these, the leg with optimal perforator anatomy was selected in 70% of cases. There were no significant reductions among postoperative complication rates, but selection of the donor site with preferential anatomy was associated with a decrease in operative time (p = 0.049) among patients undergoing extremity reconstruction. Conclusion CTA is a useful tool for optimizing donor site selection for ALT flaps and reducing operative time. We believe that standard use of preoperative CTA in ALTs warrants further consideration.

Are Orthopedic Hand Surgeons Undercompensated for Time Spent in the Operating Room? A Study of Relative Value Units

Hand ◽  
2022 ◽  
pp. 155894472110643
Author(s):  
Trevor Simcox ◽  
Sakib Safi ◽  
Jacob Becker ◽  
Jason Kreinces ◽  
Adam Wilson
Keyword(s):  
Complication Rate ◽  
Operative Time ◽  
Major Complication ◽  
Hand Surgery ◽  
Reoperation Rate ◽  
Orthopedic Procedures ◽  
Improvement Program ◽  
Relative Value ◽  
American Society ◽  
American Society Of Anesthesiologists

Background: This study aims to investigate whether compensation is equitable among the most commonly performed orthopedic hand surgeries and when compared with general orthopedic procedures. Methods: The National Surgical Quality Improvement Program database was queried for all orthopedic procedures, from 2016 to 2018, performed more than 150 times using Current Procedural Terminology (CPT) codes. Physician work relative value unit (wRVU) data were obtained from the 2020 US Centers for Medicare and Medicaid Services fee schedule. Linear regressions were used to determine whether there was an association among wRVU, operative time, and wRVU per hour (wRVU/h). Reimbursement for hand surgery CPT codes was compared with that of nonhand orthopedic CPT codes. The CPT codes were stratified into quartile cohorts based on mean operative time, major complication rate, mortality rate, American Society of Anesthesiologists class, reoperation rate, and readmission rate. Student t tests were used to compare wRVU/h between cohorts. Results: Forty-two hand CPT codes were identified from 214 orthopedic CPT codes, accounting for 32 333 hand procedures. The median wRVU/h was significantly lower for procedures in the longest operative time quartile compared with the shortest operative time quartile ( P < .001). Compared with hand procedures, nonhand procedures were found to have significantly higher mean operative time ( P < .001), mean complication rate ( P < .001), mean wRVU ( P = .001), and mean wRVU/h ( P = .007). Conclusions: The 2020 Physician wRVU scale does not allocate proportional wRVUs to orthopedic hand procedures with longer mean operative times. There is a decrease in mean reimbursement rate for hand procedures with longer mean operative time. When compared with general orthopedic procedures, hand procedures have a lower mean wRVU/h and complication rate.

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