Outcomes Following Treatment for Carotid Blowout in Head and Neck Cancer Patients.

OBJECTIVE: The aim of the study was to determine outcomes after interventional radiology treatment of carotid blowout. METHODS: Patients with head and neck cancer and who received interventional radiology treatment for carotid blowout between 2000 and 2022 were included. Pre-treatment, treatment, and post-treatment variables were evaluated. RESULTS: Fourteen patients met inclusion criteria. Eleven patients (78.6%) had a history of radiation. Twelve (85.7%) blowouts occurred within 6 months of recent intervention. Initial treatment was with stenting (n = 9, 64.3%), coil embolization (n = 4, 28.6%), or both (n = 1, 7.1%). Six patients (42.9%) underwent subsequent carotid bypass. Morbidity following treatment included stroke (n = 1) and rebleeding (n = 4). Six-month survival was 57.1%. Of the patients who survived past six months, 5/8 were treated with carotid bypass and coverage. Four patients died of cancer progression, three of rebleeding, and three of medical complications. CONCLUSION: The majority of carotid blowout occurs within 6 months of surgery or radiation. Many who survive will die of cancer progression or medical illness. Carotid bypass with flap coverage may be a worthwhile treatment for carotid blowout and should be considered as an adjunct to endovascular treatment. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:695-700, 2024.

Use of Perioperative Virtual Reality Experiences on Anxiety and Pain: A Randomized Comparative Trial.

OBJECTIVE: To evaluate the effect of different virtual reality (VR) experiences on perioperative anxiety and pain among patients undergoing head and neck surgery. METHODS: Prospective, randomized, comparative trial among patients undergoing outpatient head and neck surgery from December 2021 to April 2022 at a single academic institution. Group 1 utilized a preoperative VR gaming experience and a postoperative VR mindfulness experience, while Group 2 utilized the same interventions in the reverse order. Anxiety and pain were measured using visual analog scales (VAS). Primary outcomes were changes in post-intervention anxiety and pain. Secondary outcomes included vital sign changes and subjective patient experiences using a 5-point Likert scale. RESULTS: There were 32 patients randomized for inclusion, with 16 patients per group. The majority of patients were female (65.6%) and mean (standard deviation) age was 47.3 (16.7) years. After outlier exclusion, there were no differences in post-intervention preoperative anxiety reduction (Group 1 vs. Group 2, median [IQR]: -12.0 [15] vs. -10.5 [13], p = 0.62). There were minor differences in vital sign changes (p < 0.05). Among the 10 patients in Group 1 and 12 patients in Group 2 who completed postoperative VR use, there were no differences in post-intervention pain reduction (-8.5 [22.3] vs. -7.5 [19.3], p = 0.95) or vital sign changes (p > 0.05). There were no differences in questionnaire responses, with high satisfaction in both groups (p > 0.05). No adverse events encountered. CONCLUSIONS: Use of different VR experiences among patients undergoing outpatient head and neck surgery appears associated with similar reductions in perioperative anxiety and pain. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1197-1202, 2024.

Considering the Interaction between Surgical Approach and Timing on Complication Rates of Complex Orbital Fracture Repair.

OBJECTIVE: The optimal approach and timing of complex orbital fracture repair is an unresolved issue that is complicated by unique clinical presentations and patient-specific considerations. Early surgical repair in less than 14 days is associated with fewer complications; however, there are no guidelines addressing the optimal timing for surgical repair. This study assesses the time of surgical repair and surgical outcomes of complex orbital fractures. METHODS: Retrospective chart review from 2010 to 2022. Adult patients with orbital fractures are treated with surgical repair. RESULTS: In all, 94 patients presented with orbital fractures and were treated with 108 surgeries. Postoperative complications: vision disturbance 33/108 (30.6%), gaze restriction 12/108 (11.1%), lid malposition 10/108 (9.3%), globe complication 13/108 (12.0%), and hardware issues 14/108 (13.0%). Postoperative complications were not significantly associated with the surgical approach used for fracture repair or the time of surgical repair. CONCLUSION: Postoperative complications following surgical repair of orbital fractures are not associated with surgical approach or time of repair following the initial injury.

Time to Mohs Reconstruction: A Systematic Review Comparing Complication Rates between Immediate and Delayed Repair.

Several known factors affect outcomes of Mohs facial defect reconstruction; however, the effect of repair timing on outcomes is ill-defined. The aim of this study was to determine postoperative complication rates between immediate and delayed repair of Mohs facial defects. Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were used. Articles were selected using PICO format-population: Mohs facial defect patients, intervention: defect repair, comparator: immediate (<24 hours), or delayed (>24 hours) repair, outcome: complication rate. PubMed/Medline (1946-2020), EMBASE (1947-2020), Scopus (1823-2020), Web of Science (1900-2020), Cochrane Library, and Clinicaltrials.gov were searched. Two independent reviewers screened abstracts; those in English with human subjects reporting repair timing and complication rates were included. Search criteria yielded 6,649 abstracts; 233 qualified for review. Data were gathered from six studies; they alone contained comparative data meeting inclusion criteria. While many well-written studies were encountered, reported results varied widely. A statistically sound meta-analysis could not be completed due to large heterogeneity between studies, biasing the analysis towards the largest weighted study. Clinically important differences may exist between immediate and delayed Mohs reconstruction, but small study numbers, large heterogeneity, and lack of standardized outcome measures limit definitive conclusions. More studies are needed to perform appropriate meta-analyses, including studies using standardized methods of reporting Mohs outcome data.

Clinical outcomes following intraoperative pedicle disruption in fibula free flaps.

OBJECTIVES: Iatrogenic injury of the fibula free flap pedicle is rare. Postoperative flap survival and reconstructive outcomes following intraoperative pedicle severance are unknown. This study assesses free flap outcomes following accidental severance of the peroneal vessels. METHODS: Multi-institutional retrospective chart review from 2000 to 2020. RESULTS: Of 2975 harvested fibula free flaps, 26 had a history of pedicle severance during surgical reconstruction. Reasons for intraoperative pedicle severance included transection during muscular dissection 10/26 (39%), accidental severance with the bone saw 12/26 (46%), and other 4/26 (15.6%). The surgeon responsible for pedicle severance included residents 5/26 (19%), fellows 10/26 (39%), attendings 10/26 (39%), and unknown 1/26 (3.9%). The pedicle artery and vein were severed 10/26 (39%), artery 8/26 (31%), and vein 8/26 (31%). Truncated pedicle vessels were used 3/26 (11.7%), intraoperative anastomoses were performed 23/26 (89%). Postoperative revision in the OR within 7 days of surgery was required 6/26 (23%); 4 flaps were salvaged and 2 flaps failed, both arterial thrombosis. Flap failure was attributed to vascular thrombosis. Long-term flap survival and successful reconstructions were reported 24/26 (92%). CONCLUSION: Accidental severance of fibula free flap pedicle vessels can be corrected with intraoperative repair, without affecting long-term flap survival or reconstructive outcomes. Protecting the flap vessels while using the bone saw and during intramuscular dissection prevents accidental severance.

Outcomes of Cranioplasty Reconstructions: Review of Cranioplasty Implants and Free Flap Coverage Variables that Affect Implant Exposure.

BACKGROUND: Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps. OBJECTIVE: To determine the factors associated with implant exposure. DESIGN: Multi-institutional retrospective review of 82 patients, 2000-2020, repaired with cranial implants and free flap coverage. RESULTS: Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0-0.35) and total flap atrophy OR 0.34 (95% CI 0.02-19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0-0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications. CONCLUSIONS: Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2954-2958, 2023.

Impact of smoking on donor site following rectus flap harvest for head and neck reconstruction.

OBJECTIVES: The rectus abdominis myocutaneous free flap has been widely used as a reconstructive option in head and neck reconstruction with great success. Challenging the popular assumption, this study sought to examine the effects of smoking on donor site complications in this population. METHODS: Multi-institution retrospective study of 103 patients (50 active smokers, 28 former and 25 never smoked). RESULTS: Overall complication rate was 14.5 %. Hernia rate 4.8 %, evisceration 0 %, dehiscence 2.9 %, infection 6.7 %. Smoking history did not significantlly influence complication rates (chi square test, p = 0.33). Abdominal wall closure technique also did not influence the complication rate (chi square test, p = 0.58). CONCLUSIONS: The rectus abdomonis myocutaneous free flap has an acceptable complication rate that does not appear to be influenced by smoking history. While patients should be counseled regarding smoking cessation, smoking habits should not delay treatment nor obviate consideration of rectus flap utilization.

Analysis of vein grafting versus arteriovenous loop in microvascular head and neck reconstruction: Multicenter series of 36 patients.

BACKGROUND: The utilization of an arteriovenous loop is an underreported technique that affords the creation of reliable vascular options. Understanding the efficacy and impacting variables of microvascular reconstruction with an arteriovenous loop can be critical to its use. METHODS: Multi-institutional study of 36 patients who underwent vein grafting or AV loop with free tissue transfer. RESULTS: 58.3% of patients received prior radiation and 38.9% prior flap reconstruction. Flap success for vein grafting was 76% and AV loop was 100% (p = 0.16). Success for the radiated cohort was 90.5% and non-radiated 80% (p = 0.63). Flap success for the radiated, vein grafted patient was 83.3% and 100% flap success rate for radiated, AV loop patient (p = 0.49). Overall flap survival was 83.3% versus 97% overall success rate in the United States. CONCLUSION: The AV loop is a viable modality for vessel-depleted free tissue reconstruction. Radiation and previous surgery do not significantly impact flap success rates.

Management of the Failing Flap.

Free tissue transfer has become the reconstructive modality of choice for replacing composite tissue defects. While the success rate in high-volume centers is reported to be greater than 95%, up to 10% of patients will require revision of their vascular anastomosis secondary to thrombosis or compromise to flow. In the intraoperative setting, immediate revision is successful in the majority of cases. Rarely, the flap cannot be revascularized and a secondary option must be used. In the perioperative setting revision is successful if the patient can be brought back to the operating room in a timely fashion. Revision rates up to 70% are reported. A small number of these patients may then suffer a second episode of compromise where revision is less successful at 30%. In these cases, consideration should be given to secondary reconstruction rather than attempting salvage. Finally, there are a small number of patients whose flaps will fail following discharge from the hospital. These patients can rarely be salvaged and secondary reconstructive options should be explored.

Association of Head and Neck Anatomic Zones with Microvascular Reconstruction Outcomes.

Background: Head and neck free flap survival relies on adequate tissue perfusion from the external carotid artery (ECA), and vessel length is inversely proportional to blood flow rate. Objective: Investigate whether distance from the ECA (as a proxy for pedicle vessel length) predicts flap survival or complications. Methods: Retrospective review of free flaps performed at three academic centers from 9/2006 to 8/2021. Flaps were categorized by distance from the ECA: orbit and above (zone 1), maxilla to parotid (zone 2), and mandible and below (zone 3). Secondary analysis assessed flap outcomes stratified by average historical pedicle length. Results: A total of 2,369 flaps were identified in zones 1 (n = 109), 2 (n = 1878), and 3 (n = 382). Rates of flap failure (4.9%) and perioperative complications (36.3%) did not differ by zone or pedicle length. Zone 3 flaps, most commonly located in the larynx and hypopharynx, had significantly higher rates of fistula and infection. Conversely, 30-day readmission rates were significantly lower in patients with zone 2 flaps (p < 0.001). Rates of all other complications did not differ significantly between zones. Conclusions: Proximity to mucosal anatomic sites was a more powerful predictor of free flap viability than pedicle length or ECA proximity.

A Contemporary Review of the Role of Facial Prostheses in Complex Facial Reconstruction.

BACKGROUND: Maxillofacial prostheses provide effective rehabilitation of complex facial defects as alternatives to surgical reconstruction. Although facial prostheses provide aesthetically pleasing reconstructions, multiple barriers exist that prevent their routine clinical use. The accessibility of facial prostheses is limited by the scarce supply of maxillofacial prosthodontists, significant time commitment and number of clinic appointments required of patients during prosthesis fabrication, short lifespan of prostheses, and limited outcomes data. METHODS: A literature review was completed using PubMed and Embase databases, with search phrases including face and maxillofacial prostheses. Patient cases are included to illustrate the use of facial prostheses to reconstruct complex facial defects. RESULTS: The clinical use of facial prostheses requires a multidisciplinary team including a reconstructive surgeon, a maxillofacial prosthodontist, and an anaplastologist, if available, to provide patients with aesthetically appropriate facial prostheses. Developing technology including computer-aided design and three-dimensional printing may improve the availability of facial prostheses by eliminating multiple steps during prosthesis fabrication, ultimately decreasing the time required to fabricate a prosthesis. In addition, enhanced materials may improve prosthesis durability. Long-term outcomes data using validated measures is needed to support the continued use of facial prostheses. CONCLUSIONS: Facial prostheses can be used to reconstruct complex facial defects, and bone-anchored prostheses are associated with high patient satisfaction. Multiple barriers prevent prostheses from being used for facial reconstruction. New technologies to assist the design and fabrication of prostheses, and cost reduction measures, may allow their use in the appropriately selected patient.

Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction.

OBJECTIVE: Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction. STUDY DESIGN: Retrospective review of prospectively collected databases. METHODS: Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death). RESULTS: The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination. CONCLUSION: There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:95-104, 2023.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS.

OBJECTIVES: Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS. METHODS: A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected. RESULTS: A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality. CONCLUSIONS: Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:576-587, 2023.

Post-operative Outcomes in Pediatric Patients Following Facial Reconstruction With Fibula Free Flaps.

EDUCATIONAL OBJECTIVE: Assess outcomes of pediatric facial reconstruction with fibula free flaps. OBJECTIVES: Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps. STUDY DESIGN: Retrospective chart review. METHODS: Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps. RESULTS: Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech. CONCLUSION: Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:302-306, 2023.

Perioperative Hypercoagulability in Free Flap Reconstructions Performed for Intracranial Tumors.

OBJECTIVE(S): Patients with intracranial tumors have a higher risk of thromboembolic events. This risk increases at the time of surgical intervention. We have noted an anecdotal increase in perioperative flap thrombosis in patients undergoing free tissue transfer for intracranial tumor resection. This study aims to formally evaluate this risk. METHODS: A multi-institutional retrospective chart review was performed of patients who underwent free tissue transfer for scalp/cranial reconstruction. Perioperative thrombosis and free flap outcomes were evaluated. RESULTS: The 209 patients who underwent 246 free tissue transfers were included in the study. The 28 free flap scalp reconstructions were associated with intracranial tumors, 19 were performed following composite cranial resections with associated dural resection/reconstruction, and 199 were performed in the absence of intracranial tumors (control group). There was a significantly higher incidence of perioperative flap thrombosis in the intracranial tumor group (11/28, 39%) when compared to controls (38/199, 19%) (p = 0.0287). This was not seen when scalp tumors extended to the dura alone (4/19, 21%, p = 0.83). Therapeutic anticoagulation used for perioperative thrombosis (defined as intraoperative or in the immediate postoperative phase up to 5 days) was associated with a lower risk of flap failure, although this was not statistically significant (p = 0.148). Flap survival rates were equivalent between flaps performed for intracranial pathology (93.3%) and controls (95%). CONCLUSION: There is an increase in perioperative flap thrombosis in patients with intracranial tumors undergoing free tissue scalp reconstruction. Anticoagulation appears to mitigate this risk. LEVEL OF EVIDENCE: This recommendation is based on level 3 evidence (retrospective case-control studies, systematic review of retrospective studies, and case reports) Laryngoscope, 133:1103-1109, 2023.

Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction.

Importance: Incidence of perioperative free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown. Objective: To assess the outcomes of a second revascularization attempt for compromised free flaps. Design, Setting, and Participants: This multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. Main Outcome and Measure: Flaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts. Results: A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage. Conclusions and Relevance: In this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.

Perforator Phase Contrast Angiography of Deep Inferior Epigastric Perforators: A Better Preoperative Imaging Tool for Flap Surgery than Computed Tomographic Angiography?

OBJECTIVE: The aim of this study was to demonstrate the feasibility of in vivo perforator visualization by a newly proposed magnetic resonance-based perforator phase contrast angiography (pPCA) technique for deep inferior epigastric perforator (DIEP) flap surgery and to prospectively compare its image quality and clinical value with computed tomographic angiography (CTA), the state-of-the-art perforator imaging technique. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. DIEP pPCA and CTA data were acquired in 10 female patients before DIEP flap surgery. Image findings were compared between the two techniques and with literature reports. RESULTS: The overall image quality is negatively correlated with patient BMI for CTA, but positively correlated with BMI for pPCA. Compared with CTA, pPCA has significantly better image quality (P = 0.005), signal-to-noise ratio (P < 0.001), and contrast-to-noise ratio (perforator-to-muscle, P < 0.001; perforator-to-fat, P = 0.014). It also has preferable clinical value ratings, although not statistically significant (P = 0.388). There is a good agreement (84%) between perforators detected by pPCA and CTA. Perforator location deviations between pPCA and CTA are compatible with the precision required for plastic surgery. Perforator size measured by pPCA seems to be more accurate than CTA, as it is 0.8 ± 0.3 mm smaller (P < 0.001), consistent with the reported 0.5 to 1.2 mm overestimation by CTA. There is no significant difference in perforator intramuscular course assessment (P = 0.415). CONCLUSIONS: The developed magnetic resonance-based pPCA technique presents superior image quality, better vessel contrast, and more accurate perforator anatomy than the x-ray-based CTA. pPCA has the potential to emerge as the preferred preoperative planning tool for perforator flap reconstructive surgery.