Supplemental Regional Block Anesthesia Reduces Opioid Utilization Following Free Flap Reconstruction of the Oral Cavity: A Prospective, Randomized Clinical Trial.

PURPOSE: Regional anesthesia has been shown to effectively manage acute pain and reduce opioid utilization in the early postoperative period following colorectal, orthopedic, and thoracic surgeries. The same effect, however, has not been demonstrated in major head and neck surgery. The purpose of this study is to determine whether supplemental regional anesthesia reduces opioid utilization following microvascular free flap reconstruction of the oral cavity. METHODS: A prospective, randomized clinical trial was conducted for patients undergoing oral cavity reconstruction using microvascular free tissue transfer between January 2020 and March 2022. The predictor variable was a regional anesthetic nerve block, delivered preoperatively, at the flap donor site. The primary and secondary outcomes were opioid utilization, measured in oral morphine equivalent (OME), from postoperative day 1 to 5, and hospital length of stay (LOS), respectively. Covariates included age, sex, tobacco and alcohol history, prior radiation therapy, pathology, oral site, flap type, tracheostomy, and neck dissection. Student's t test, χ2 test, and linear regression models were computed using correlations with 95% confidence intervals (CIs). For all statistical tests, P values of <.05 were regarded as statistically significant. RESULTS: Ninety-eight participants completed the study. The mean age was 56 years with 55% male. Forty-eight patients received a presurgical regional anesthesia block, and 50 patients served as control subjects. Bivariate analysis demonstrated an even distribution of all study variables. Total OME utilization was significantly less in the treatment group compared to the control group, (166.32 vs 118.43 OME; 95% CI, 1.32 to 94.45; P = .04). The LOS was comparable (6.60 vs 6.48 days; 95% CI, -0.53 to 0.77; P = .71). Tobacco use had a positive effect (B = 0.28; 95% CI, 21.63 to 115.31; P = .005) while the block had a negative effect with total OME, (B = -0.19; 95% CI, -90.39 to -0.59; P = .047). The extent of the neck dissection (B = 0.207; 95% CI, 0.026 to 1.403; P = .042) was a positive predictor for LOS. Overall, there were no adverse events associated with the regional block throughout the study period. CONCLUSIONS: Supplemental regional anesthesia is safe and associated with reduced opioid utilization in patients undergoing vascularized free flap reconstruction of composite oral cavity defects and does not prolong the length of hospitalization.

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty.

PURPOSE OF REVIEW: Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF). RECENT FINDINGS: Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes. SUMMARY: There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Current Practices in Microvascular Reconstruction by Oral and Maxillofacial Surgeons.

PURPOSE: Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons' (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. METHODS: The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. RESULTS: Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n = 39) male and worked in private (n = 8), combination (n = 10), and academic practices (n = 23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year, respectively. The 2-team approach was used by 88.2% of surgeons. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n = 2) of private practice surgeons and 70% (n = 14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n = 24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n = 23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings, respectively. CONCLUSION: This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.

Impact of Fibromyalgia Phenotype in Temporomandibular Disorders.

BACKGROUND: Mounting evidence suggests that central nervous system amplification, similar to that seen in fibromyalgia (FM), contributes to the pain experience in a subset of patients with temporomandibular disorders (TMD). METHODS: In this prospective observational study, patients with TMD completed the 2011 FM survey questionnaire, a surrogate measure of "centralized" pain. The influence of centralized pain on TMD pain, dysfunction, and disability was assessed dichotomously by determining the incidence of FM-positive cases in the sample and by using FM survey scores as a continuous measure of "fibromyalgia-ness" ("FM-ness"). RESULTS: The patients meeting criteria for FM diagnosis (17 of 89) had significantly more disease burden on numerous measures. FM-ness was positively associated with pain at rest, negative mood, tenderness to palpation, perceived jaw functional limitation, and pain-related disability, and it was negatively associated with comfortable pain-free jaw opening. The impact of FM-ness on perceived jaw functional limitation and disability was mediated by levels of spontaneous, ongoing pain in the orofacial region. Importantly, this pattern of findings was still present even in those not meeting the criteria for FM diagnosis. CONCLUSION: Together, these results imply that higher FM-ness increases TMD patient burden by amplifying spontaneous pain and further hampering painless jaw function, even in patients who do not meet criteria for FM diagnosis. These results are highly relevant for the clinical management of TMD, as they imply that targeting the central nervous system in the treatment of patients with TMD with evidence of pain centralization may help ameliorate both pain and jaw dysfunction.