Does Early Oral Intake After Microvascular Free Flap Reconstruction of the Oral Cavity Lead to Increased Postoperative Complications?

PURPOSE: Data on timing of oral intake (PO) after free flap reconstruction of the oral cavity have been limited. Recent studies have shown that early PO after free flap reconstruction does not lead to increased morbidity and has resulted in decreased hospital stay. The objective of this study is to assess postoperative complications associated with timing of PO after free flap reconstruction of the oral cavity and to define clinical predictors of postoperative complications. METHODS: This was a retrospective comparative cohort study and comprised of patients who underwent free flap reconstruction of the oral cavity between January 2014 and December 2019 in the Department of Oral and Maxillofacial Surgery at the University of Alabama at Birmingham. The predictor variable was timing of PO grouped into early (<5 days) and late (>5 days), postoperatively. The primary and secondary outcomes were postoperative complications and hospital length of stay (LOS), respectively. Covariates included age, gender, pathology, reconstruction site, flap type, tracheostomy, neck dissection, defect volume (cm3), skin paddle size (cm2), and gastrostomy tube (g-tube). Student's t-test, Chi-squared test, and binary logistic regression models were computed using odds ratios (ORs) with 95% confidence intervals (CIs). For all statistical tests, P values of < .05 were regarded as statistically significant. RESULTS: The sample consisted of 415 patients (253 males and 162 females), with a mean age of 58.8 years (range, 14.4-88.2 years). The majority had malignant pathology (68.9%) with defects involving the mandible (52.3%) and reconstructed with a radial forearm (43.6%), followed by fibula (39%), and osteocutaneous radial forearm (13%). Seventy one "early PO" and 344 "late PO" patients were analyzed. Early PO was associated with lower postoperative complications compared with the late PO group (RR = 0.847, 95% CI 0.747-0.960, P = .031) and shorter hospital LOS (6 vs 9 days, 95% CI 2.2459-3.720, P < .001). A regression model showed a 2% increase for postoperative complications with each unit (cm3) increase of defect volume (OR = 1.002, 95% CI 1.000-1.004, P = .035) and 2.286 times higher odds for postoperative complication in patients with a g-tube (95% CI 1.271-4.110, P = .006). CONCLUSIONS: Early PO after free flap reconstruction of the oral cavity was not associated with increased postoperative outcomes or delayed hospital course. Variables such as defect location, defect volume, and tracheostomy may increase the risk for postoperative complications and can help guide surgeons in deciding the optimal timing for PO postoperatively.

Does the Retromolar Area Provide Adequate Space for an Oral Endotracheal Tube Without Interfering With Intermaxillary Fixation?

PURPOSE: Traumatic maxillofacial injuries requiring intermaxillary fixation (IMF) traditionally necessitate airway management via tracheostomy or submental intubation. The aim of this study is to understand whether the retromolar space can accommodate passage of a reinforced endotracheal tube (ETT) without interfering with establishing IMF, a technique previously described as retromolar intubation. METHODS: A retrospective cross-sectional study was created including previously treated facial trauma patients by our department as the study sample. From this group, 3D reconstructed scans were created and used to estimate that dimensions of the retromolar space. The averages of these dimensions were calculated and compared to the area occupied by different sized reinforced ETTs (6.0, 6.5, 7.0, 7.5, 8.0). A 1-sample t-test was used to compare the retromolar areas to each ETT size for all patients and by gender. RESULTS: Forty-one patients, ages 19-69 years old, treated from July 2010 to November 2018 were included in this study. This included 24 males (21-69yo) and 17 females (19-60yo), with a total of 80 characteristics measured. The retromolar areas calculated were statistically bigger than the reinforced ETT sizes 6.0, 6.5, and 7.0 compared to the average retromolar space area, but not statistically significant for reinforced oral ETT sizes 7.5 and 8.0. CONCLUSION: Our study results suggest the use of 6.0, 6.5 and 7.0 reinforced ETTs can be positioned in the retromolar space, allowing the surgeon to place a patient in IMF without occlusal interference. This technique could provide an alternative option to submental intubation or tracheostomy.