The Superficial Circumflex Iliac Artery Perforator Flap for Head and Neck Reconstruction.

Head and neck defects present a unique challenge in reconstructive surgery due to the complex anatomy of this area. Different defects often require a variety of reconstructive techniques. The superficial circumflex iliac artery perforator (SCIP) flap is particularly notable for its versatility in this context. It provides a thin, pliable skin island that can be integrated with bone, muscle, fascia, and other structures. Additionally, the morbidity associated with the donor site of the SCIP flap is generally low and well tolerated. This article offers a comprehensive overview of the evolution of this technique.

The Role of Deep Inferior Epigastric Perforator and Thoracodorsal Artery Perforator in Head and Neck Reconstruction.

Head and neck reconstruction has evolved to a more accurate replacement of the missing tissues for aesthetic and functional benefits, besides a concern with the morbidity caused in the donor site. This has led us to the use of perforator flaps. Deep inferior epigastric perforator flap allows the harvest of a large well-vascularized skin paddle with adequate bulk for large and voluminous defects reconstruction. Its main uses described in the literature are: tongue reconstruction, orbitomaxillary reconstruction, and scalp reconstruction. Thoracodorsal artery perforator flap is derived from the subscapular system and allows the harvest of a large array of chimeric flaps.

Preoperative Hypoalbuminemia Predicts 30-day Complications in Head and Neck Microvascular Surgery.

INTRODUCTION: Hypoalbuminemia, a marker for poor nutritional status, has been associated with postoperative complications, including head and neck cancer surgery. This study investigates the impact of hypoalbuminemia on head and neck microvascular free tissue transfer reconstruction. METHODS: This retrospective cohort study queried the 2005-2021 American College of Surgeons National Surgical Quality Improvement Program databases. Reconstructive cases performed by otolaryngologists (CPT: 15756, 15757, 15758, 15842, 20955, 20956, 20957, 20962, 20969, 20970, 20972, 20973, 43116, 43496, 49006, and 49906) with available preoperative albumin, BMI, and age were included. Hypoalbuminemia was defined as a preoperative albumin <3.5 g/dL. Univariate and multivariable logistic regression were performed. RESULTS: A total of 3,886 cases met the inclusion criteria, of which 835 (21.5%) had hypoalbuminemia. The hypoalbuminemia cohort was older, had lower BMI, had higher ASA classification, and had worse functional health status. Adjusted multivariable logistic regression showed that hypoalbuminemia was associated with unplanned return to the operating room within 30 days (OR: 1.36, p < 0.01), unplanned reoperation (OR: 1.36, p < 0.01), any complication (OR: 1.77, p < 0.01), surgical complications (OR: 1.94, p < 0.01), and medical complications (OR: 1.34, p = 0.01). Hypoalbuminemia was correlated with a longer hospital stay, superficial surgical site infection, wound dehiscence, transfusion, deep vein thrombosis, and acute renal failure. CONCLUSION: Hypoalbuminemia is a risk factor for postoperative complications after microvascular free tissue transfer for head and neck reconstruction. This study suggests that preoperative optimization of hypoalbuminemia may be beneficial for these patients. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Comparison of Reconstruction of Maxilloalveolar Resections in Head and Neck Cancers with Chimeric Anterolateral Thigh Flap (ALT) versus Standard ALT Flap.

Background Oral malignancy that presents at a locally advanced stage needs complex surgical resections in which the maxillary cavity is usually left open. The constant maxillary secretions lead to problems like poor healing, fistula formation, and flap necrosis, causing longer hospital stays, delayed adjuvant therapy, and additional surgeries. Several methods have been tried to ameliorate this, each faced with its own difficulties. This study describes the use of chimeric free anterolateral thigh (ALT) with vastus lateralis (VL) muscle to tackle this problem. Materials and Methods With the aim to assess the advantage of reconstruction of maxillo-alveolar resections using chimeric ALT + VL, we analyzed data from 20 cases reconstructed with chimeric free ALT + VL over a year. We compared them with twenty matched controls reconstructed with standard ALT. Analysis was done with respect to intraoperative ease, adequacy of maxillary sinus fill, postoperative secretions, length of hospital stay, duration to adjuvant therapy, and postoperative complications tabulated using the modified Clavien-Dindo classification. Results It was found that chimeric ALT + VL gave greater freedom of movement to plug the maxillary cavity easily. The chimeric arm patients had fewer complications and a shorter mean hospital stay. Most of them received adjuvant therapy within their optimal time window. Conclusion Chimeric ALT with vastus lateralis muscle is a reliable option for reconstructing complex defects, especially with dead space cavities like the maxillary sinus. Effective plugging of the maxillary sinus during the primary surgery results in better patient outcomes and must be done routinely.

The Anterolateral Thigh Flap in Head and Neck Reconstruction.

The anterolateral thigh (ALT) free flap has become a workhorse for head and neck reconstruction. This paper offers a thorough introduction to the ALT flap, covering its anatomy, surgical technique, adaptable designs, and use in a range of clinical settings along with case studies. With its long vascular pedicle and tissue versatility, the ALT flap is well-suited for matching varied defects. Still, understanding possible anatomic variances and managing complications are critical to its success. With this paper as a comprehensive guidance, surgeons can apply the ALT flap for difficult head and neck reconstructions and achieve the best possible results.

Perforator Flaps and Robotic Surgery for Head and Neck Reconstruction.

Head and neck cancer (HNC) is the sixth most common cancer across the world. Despite a general reduction in tobacco consumption and therefore reduction in risk exposure there has been an increasing incidence of oropharyngeal squamous cell carcinoma. Progress made in the past decades in free tissue transfer reconstruction and robotic surgery have merged into transoral robotic reconstruction with free perforator flaps for head and neck. We reviewed and discussed indications and contraindications for this type of procedure, as well as potential limits refinements.

Pedicled and Perforator Flaps from the Facial and the Superficial Temporal Vessels.

This article illustrates the use of locoregional perforator and pedicled flaps from the 2 main vascular systems of the head and neck area. The 2 authors combine their experiences and research findings to highlight clinical scenarios for these useful refined reconstructions and discuss their pros and cons.

Free flap reconstruction following head and neck trauma.

BACKGROUND: Free flap (FF) reconstruction of traumatic injuries to the head and neck is uncommon. METHODS: Multi-institutional retrospective case series of patients undergoing FF reconstruction for a traumatic injury (n = 103). RESULTS: Majority were gunshot wounds (GSW; 85%, n = 88) and motor vehicle accidents (11%, n = 11). Majority underwent osseous reconstruction (82%, n = 84). FF failures (9%, n = 9/103) occurred in GSW patients (100%, n = 9/9) and when multiple subsites were injured (89%, n = 8/9). Preoperative antibiotics correlated with lower rates of a neck washouts (4% vs. 19%) (p = 0.01) and 30-day readmissions (4% vs. 17%) (p = 0.02). CONCLUSIONS: All FF failures occurred in the setting of a GSW and the majority involved multiple subsites. Preoperative antibiotics correlated with lower rates of postoperative washout procedures and 30-day readmission.

Applications of Synthetic Hybrid-Scale Fiber Matrix in Head and Neck Reconstruction: A Case Series.

Introduction: Patients with head and neck cancer often necessitate complex reconstructions, considering both functional and esthetic concerns. Reconstructions are further complicated by previous radiation therapy and patient co-morbidities, which impair wound healing. A recently introduced synthetic hybrid-scale fiber matrix has been shown to provide durable wound coverage and promote tissue healing as an alternative to traditional biologic allogenic and xenogenic skin substitutes. Case Presentation: Thirteen patients were treated at a single academic hospital between December 1, 2021, and May 1, 2023 with the synthetic matrix in head and neck reconstructions. Reconstructions included exposed muscle, scalp wounds, intra-oral defects, and radial forearm free flap donor sites. Wound sizes ranged from 2 × 2 cm to 18 × 10 cm. Serial photographs were taken to evaluate wound healing at 1, 4, 8, 12, and 16 weeks timepoints after application. Outcomes measured at each timepoint included wound size, presence of granulation tissue, and extent of epithelialization. No hematomas or wound complications were encountered. Complete wound healing was noted between 6 and 12 weeks, dependent on wound size. The synthetic matrix significantly promoted wound healing via early granulation tissue formation and epithelialization, or mucosalization, in all head and neck applications. Scar formation and contracture were acceptable in all cases. Conclusion: The use of synthetic hybrid-scale fiber matrix promotes wound healing and avoids patient morbidity associated with traditional allogenic and biogenic treatments, such as split-thickness skin grafts. This synthetic matrix has been demonstrated to be a valuable asset in the head and neck reconstructive armamentarium.

Impact of Flap Size and Comorbidities on Supraclavicular Artery Island Flap Outcomes.

Objective: Use of the supraclavicular artery island flap (SCAIF) in head and neck reconstruction has increased in recent years. Limited but improving experience among reconstructive surgeons with the procedure have exposed numerous issues associated with flap success. The objective of this study is to examine the role of flap size on viability. Study Design: Retrospective case series. Setting: Tertiary Academic Medical Center. Methods: Review of patients undergoing SCAIF reconstruction between January 2014 and March 2022 was performed. Flap failure was defined as >50% skin paddle loss. The total flap surface area was examined. Multivariable analysis was performed to evaluate the association of other variables associated with flap failure. Results: Eighty-nine supraclavicular island flaps were reviewed. Mean patient age was 63.2 ± 11.4 years. Fifty-five (61.2%) were male. Forty-five flaps (50.6%) were used for the reconstruction of defects of the skin of the neck/face. Twenty-nine flaps (32.6%) were utilized for defects of the pharynx/oropharynx, and 15 (16.9%) were utilized for oral cavity defects. Flap success rate was 94% (73/89). Flap site was not associated with flap failure (P = .46). Flaps >25 cm2 were 75% more likely to be successful. Multivariable logistic regression to assess the association of flap size in the context of other co-morbidities indicated flaps >25 cm2 were 3.6 times more likely to succeed regardless of co-morbidities, and patients with chronic obstructive pulmonary disease (COPD) have a 7-fold risk of flap failure (odds ratio: 7.3, 1.72-30.98, P = .007). Conclusion: An association with improved flap outcomes and larger skin paddles was observed in this series. The applicability of these observations to smaller flaps and larger series with more surgeons requires further study. Co-morbidities, particularly, COPD, continue to impact flap outcomes.

Unveiling the Extraordinary: A Rare Type IIIA Infra-Popliteal Arterial Variation in a Free Fibula Osteocutaneous Flap for Mandibular Reconstruction.

The free fibula flap (FFF), based on the peroneal artery (PA) system, is the gold standard for mandibular reconstruction. Various anatomical variations in the infra-popliteal lower limb vascular system exist. These variations present as an intraoperative surprise to surgeons even after an unremarkable clinical vascular examination of the leg. Here, we report one such case, where we performed successful mandibular reconstruction after encountering a Type IIIA variation of infra-popliteal arterial vasculature.

Tubed myocutaneous pectoralis major flap: A rescue option in esophagus reconstruction.

This article presents a complex case of total pharyngoesophageal defect reconstruction in a patient with recurrent supraglottic squamous cell carcinoma. After failed attempts with free microsurgical techniques due to complications, a tubed myocutaneous pectoralis major flap was successfully employed. The procedure aimed to achieve alimentary continuity, speech, and swallowing functionality. Despite initial challenges and concerns about stenosis, the reconstruction of a total pharyngolarygectomy defect resulted in a good functional outcome, although minor deficits in neck mobility and aesthetic donor zone deformities were noted. The case highlights the broad armamentarium of reconstruction techniques that plastic and aesthetic surgery teams must be trained, namely the myocutaneous pectoralis major flap which in selected cases can be the end solution.

Neurotized profunda artery perforator flap for subtotal tongue reconstruction - Prospective case series.

BACKGROUND: Total or subtotal glossectomy defects cause significant functional deficits in swallowing and speech and subsequently impair patients' quality of life (QOL). Recently, the profunda artery perforator (PAP) flap has emerged as a potential alternative for reconstructing extensive glossectomy defects. While previous studies assessing recovery of neurotized anterolateral thigh (ALT) flaps in head and neck reconstruction reported superior sensory recovery, improved swallow function, and improved overall patient satisfaction in patients with neurotized flaps vs. non-neurotized ALT flap reconstruction, PAP flap neurotization has not been described and systematically assessed in head and neck patients. METHODS: Six patients underwent subtotal tongue reconstruction with neurotized PAP flaps at the authors' institution from May 2022 until August 2023. A branch of the posterior femoral cutaneous nerve of the PAP flap was coaptated to the lingual nerve. Two-point discrimination, Semmes-Weinstein monofilament, pain, and temperature assessments were conducted at 3, 6, and 12 months postoperatively on the neo-tongue. The MD Anderson speech and deglutition scales and the EORTC-QLQ-H&N35 were used to record functional outcomes and QOL. RESULTS: The mean age was 69 ± 4 years, and the mean body mass index was 25 ± 7 kg/m2. Neo-tongue median 2-point discrimination at the tip improved from >10 mm at 3 months to 6 mm at 12 months. All patients had protective pain and temperature perception at the neo-tongue tip at the 6-month follow-up. Speech and swallowing functions were similar at the 12-month follow-up to data on neurotized ALT flaps from literature. No neuropathic pain was reported at the donor site at the 6-month follow-up. CONCLUSIONS: This is the first case series of PAP flap neurotization in head and neck patients, suggesting potential functional advantages with minimal donor-site morbidity. LEVEL OF EVIDENCE: V Case Series.

The Complications of Osseous Reconstruction in the Head and Neck: A Systematic Review and Meta-analysis.

OBJECTIVE: To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck. DATA SOURCES: PUBMED, EMBASE, Cochrane. REVIEW METHODS: A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. A meta-analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications. RESULTS: The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29-1.11, P < .001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (-51.04 minutes, CI: -92.73 to -9.35, P = .016) and OCRFFF over FFF (66.77 minutes, CI: 52.74-80.8, P < .001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types. CONCLUSION: Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long-term complications.

Microvascular reconstruction of midface osteoradionecrosis.

BACKGROUND: Head and neck osteoradionecrosis (ORN) of the midface requiring free flap (FF) reconstruction is uncommon. This multi-institutional study was designed to review outcomes for this rare patient population. METHODS: Retrospective multi-institutional review of FF reconstruction for midface ORN (2005-2022; n = 54). RESULTS: The FF survival rate was 87% (n = 54). Patients were less likely to be tolerating a regular diet at 3 months postoperative if they had a preoperative history of prior head and surgery (80% vs. 95%; p = 0.02), a pathologic fracture (50% vs. 90%; p = 0.04), exposed bone intraorally (43% vs. 94%; p = 0.002), or a fistula (67% vs. 96%; p = 0.03). Mean albumin was higher in patients whose FF survived (3.6 ± 0.5 vs. 2.7 ± 1.4; p = 0.03). Patients with low prealbumin were more likely to undergo a hematoma evacuation (27% vs. 0%; p = 0.02). CONCLUSION: In this series of midface ORN requiring FF reconstruction preoperative nutritional status impacted postoperative complications. Preoperative occurrence of a fistula, pathologic fracture, and intraoral bone exposure correlated with decreased tolerance of a regular diet following reconstruction.

Free fibula mandible reconstruction for osteoradionecrosis is more challenging than for primary cancer.

INTRODUCTION: Osteoradionecrosis (ORN) of the mandible is an unfortunate potential sequela of radiotherapy for head and neck cancer. In advanced cases of ORN, mandibulectomy, and free fibula flap reconstruction are required. We hypothesized that patients undergoing fibula free flap reconstruction and mandibulectomy for ORN pose unique challenges and experience more complications than patients undergoing fibula free flaps after oncologic mandibulectomy. METHODS: After IRB approval, we created a database of all free fibula flaps for mandible reconstruction from April 2005 through February 2019. Medical records were retrospectively reviewed for patient and surgical characteristics and postoperative outcomes. RESULTS: Four-hundred seventy-nine patients met the inclusion criteria (168 ORN vs. 311 non-ORN patients). Propensity-matching was performed based on age, BMI, smoking status, preoperative chemotherapy, and virtual surgery planning use, which yielded 159 patients in each group. ORN patients received more double-skin-island fibula flaps than non-OR patients (20.8% vs. 5.7%, p < 0.001). Recipient artery other than the facial artery was utilized more commonly in ORN patients (42.1% vs. 17.0%, p < 0.001). In the unmatched cohort, ORN patients had higher rates of delayed wound healing (26.2% vs. 16.8%, p = 0.01) and surgical site infections (21.4% vs. 13.2%, p = 0.02). Rates of flap loss, return to the operating room, hematoma, operative time, and length of stay were similar between the groups. On logistic regression analysis, osteoradionecrosis was an independent risk factor for delayed wound healing. CONCLUSION: Based on these data, mandibular reconstruction with fibula flaps for osteoradionecrosis appears more complicated than mandible reconstruction following de novo cancer resection. Surgeons should anticipate employing two skin islands for intraoral and extraoral resurfacing, utilizing unconventional recipient vessels, and managing the delayed wound healing that ensues more commonly than non-ORN patients.

Negative Pressure Wound Therapy with Instillation and Dwell Time for Pharyngocutaneous Fistula.

Pharyngocutaneous fistula is a critical complication of head and neck cancer reconstruction and it is often difficult to manage. We herein report two cases of pharyngocutaneous fistulas that developed after oropharyngeal reconstruction and were successfully treated with negative pressure wound therapy with instillation and dwell time (NPWTi-d), an advanced form of traditional NPWT. NPWTi-d may be a useful nonsurgical treatment for pharyngocutaneous fistula. Laryngoscope, 2024.

Retrospective cross-sectional study to evaluate outcome of loco-regional flaps in head and neck reconstruction in Sudanese patients.

Introduction: The soft tissue of the head and neck region poses both esthetic and functional aspects and must be retorted simultaneously, as any defect will be easy recognizable and will affect the quality of patient's life. Reconstruction by local- regional flap still the most popular approach used and outcome also better than other options. Objectives: To assess the outcome of loco-regional flaps in head and neck reconstruction in Sudanese patients. Patients and methods: Retrospective cross-sectional, multicenteric study (Soba University Hospital, Khartoum North Teaching Hospital and an associated specialized hospital) - Khartoum, Sudan, 84 patients underwent head/neck reconstruction during the period from 2017 up to 2021 were included. Results: Out of 84 patients, 47.6% were female and 52.4% were male. The etiology of head and neck defects in the majority (69%) was neoplastic, and in 11.9% it was trauma. According to site of defect, in 23.8% of patients was Cheek unit, 21.4% was nasal site, and 16.7% was neck site. Surgery in 85.7% of patients were primary, while in 14.3 was delayed. Fasciocutaneous flaps were used in 64.3%, followed by myocutaneous flap in 28.6%; functional outcome was excellent in 61.9%, adequate in 35.7%, and was inadequate in only 2.4%. The majority of patients 66.2% did not develop any complications. Conclusion: Loco-regional flaps are ideally useful in covering head and neck defects. It has an acceptable esthetic and functional outcome in the majority of cases. It can be considered as a reliable option for reconstruction especially in resource constrained centers.

Effect of Preoperative Neck Radiotherapy on the Reconstruction of Head and Neck Defects With the Supraclavicular Artery Island Flap.

Purpose: The supraclavicular artery island (SAI) flap is commonly used in the reconstruction of head and neck defects. However, the safety of SAI flaps for neck irradiated patient needs to be verified. To investigate the safety of using the SAI flap for patients who have undergone neck radiotherapy, as well as the risk factors for flap complications. Materials and Methods: Sixty-one patients (16 irradiated and 45 nonirradiated) with SAI flap-reconstructed head and neck defects were included, and relevant data were collected retrospectively. The gender, age, body mass index, presence of diabetes mellitus, preoperative albumin level, and flap size between irradiated and nonirradiated patients had no significant difference. Results: No significant difference was observed in the incidence of complications (total, mild, or severe) between the radiotherapy and nonradiotherapy groups. In univariate analysis, preoperative radiotherapy was not associated with postoperative complications of the SAI flap procedure (P = 1.00), while a low preoperative albumin level was a significant risk factor for postoperative complications (P < .05). Conclusions: Our data suggest that preoperative radiotherapy does not increase the risk of SAI flap postoperative complications compared with surgical reconstruction alone.