Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database.

BACKGROUND: Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years. METHODS: Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay. RESULTS: A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps. CONCLUSION: Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

Early postoperative outcomes in implant, pedicled, and free flap reconstruction for breast cancer: an analysis of 23,834 patients from the ACS-NSQIP datasets.

INTRODUCTION: Many patients seek breast reconstruction following mastectomy. Debate exists regarding the best reconstructive option. The authors evaluate outcomes comparing implant, free flap, and pedicled flap reconstruction. METHODS: Patients undergoing implant, pedicled flap, and free flap reconstruction were identified in the 2011-2016 NSQIP database. Demographics were analyzed and covariates were balanced using overlap propensity score. Logistic regression was used for binary outcomes and Gamma GLM for length of stay (LOS). RESULTS: Of 23,834 patients, 87.7% underwent implant, 8.1% free flap, and 4.2% pedicled flap reconstruction. The implant group had the lowest mean operative time (206 min, SD 85.6). Implant patients had less pneumonia (OR 0.09, CI 0.02-0.36, p < 0.01), return to operating room (OR 0.62, CI 0.50-0.75, p < 0.01), venous thromboembolism (VTE) (OR 0.33, CI 0.14-0.79, p = 0.01), postoperative bleeding (OR 0.10, CI 0.06-0.15, p < 0.01), and urinary tract infections (UTI) (OR 0.21, CI 0.07-0.58, p < 0.01) than free flap patients. Pedicled flap patients had less postoperative bleeding (OR 0.69, CI 0.49-0.96, p = 0.03) than free flap patients. Pedicled flap patients had more superficial surgical site infections (p = 0.03), pneumonia (p = 0.02), postoperative bleeding (p < 0.01), VTE (p = 0.04), sepsis (p = 0.05), and unplanned reintubation (p = 0.01) than implant patients. Implant patients had the lowest LOS (1.6 days, p < 0.01). CONCLUSION: Implant reconstruction has less short-term postoperative complications than free flaps and pedicled flap reconstructions. The overall complication rate among all reconstructive modalities remains acceptably low and patients should be informed of all surgical options.

A Theoretical Model Describing the Dynamics of Venous Flow in the DIEP Flap.

BACKGROUND: The deep inferior epigastric artery flap is an integral component of autologous breast reconstruction. The technical aspects of performing the flap have been well-established. A prior mathematical model suggested using the largest perforator and concluded that the inclusion of additional perforators may decrease resistance and increase flow, but at the downside of increased tissue trauma. Many complications may result from inadequate venous drainage of the flap and the same mathematical concepts may be applied. We attempt to give a mathematical model, based on the physics of flow and properties of circuits, to explain clinical observations regarding venous drainage of the flap and the complications that may arise. METHODS: We compare the different possible venous drainage systems of a perforator flap to a complex circuit with multiple resistances. Multiple venous perforators will be represented by resistances in parallel, while the deep and superficial drainage systems will be represented by a complex circuit loop. RESULTS: Drainage of the flap may be optimized through the deep drainage system if the venous perforators are of sufficient size. Inclusion of additional perforators may decrease resistance and enhance drainage. Salvage procedures may be necessary when the venous perforators are insufficient in size or when there are insufficient connections between the deep and superficial systems. CONCLUSION: A single large sized vessel may provide adequate drainage in most DIEP flaps, while the use of multiple vessels may enhance drainage upon the encounter of smaller vessels. Salvage procedures may be needed to relieve venous congestion as the design of the venous system becomes more complicated.

A Novel Approach to Reducing Splash Exposure in Pulsatile Lavage.

Pulsatile lavage is utilized to copiously irrigate contaminated wounds; however, the current devices can cause significant splashing and increase the risk of contaminated fluid exposure to healthcare professionals. To create a larger splash guard for the standard pulsatile lavage device, we use heavy scissors to remove the end of a plastic light handle. We then place the nozzle of the lavage device through the open end to create a larger splash guard. This method provides a quick, accessible way to decrease the risk of splash exposure due to pulsatile lavage irrigation.

Breast Reconstruction in Inflammatory Breast Cancer: An Analysis of Predictors, Trends, and Survival from the National Cancer Database.

INTRODUCTION: Survival for women diagnosed with inflammatory breast cancer (IBC) has improved with advances in multimodal therapy. This study was performed to evaluate trends, predictors, and survival for reconstruction in IBC patients in the United States. METHODS: Women who underwent mastectomy with or without reconstruction for IBC between 2004 and 2016 were included from the National Cancer Database. Predictors for undergoing reconstruction and association with overall survival were determined. RESULTS: Of 12,544 patients with IBC who underwent mastectomy, 1307 underwent reconstruction. Predictors of reconstruction included younger age, private insurance, higher income, performance of contralateral prophylactic mastectomy, and location within a metropolitan area (P < 0.001). The proportion of women having reconstruction for IBC increased from 7.3% to 12.3% from 2004 to 2016. Median unadjusted overall survival was higher in the reconstructive group l [93.7 months, 95% confidence interval (CI) 75.2-117.5] than the nonreconstructive group (68.1 months, 95% CI 65.5-71.7, hazard ratio = 0.79 95% CI 0.72-0.88, P < 0.001). With adjustment for covariates, differences in overall mortality were not significant, with hazard ratio of 0.95 (95% CI 0.85-1.06, P = 0.37). CONCLUSIONS: Reconstruction rates for IBC are increasing. Women with IBC who undergo reconstruction tend to be younger and are not at the increased risk of all-cause mortality compared to those not having reconstruction. The National Cancer Database does not differentiate immediate from delayed reconstruction. However, the outcomes of immediate reconstruction in carefully selected patients with IBC should be further studied to evaluate its safety. This could impact current guidelines, which are based largely on an expert opinion.

The Application of Skin Adhesive to Maintain Seal in Negative Pressure Wound Therapy.

BACKGROUND: Optimal wound healing in negative pressure wound therapy (NPWT) depends on a properly sealed vacuum system. Anatomically difficult wounds disrupt the adhesive dressing, resulting in air leaks that impair the integrity of this system. Several techniques have been used in previous reports to prevent air leaks, including the addition of skin adhesives (eg, Skin-Prep [Smith and Nephew, St. Petersburg, FL] or compound tincture of benzoin), hydrocolloid dressings, silicone, and stoma paste. The purpose of this case report is to demonstrate the effectiveness of using a cyanoacrylate tissue adhesive, dermaFLEX (FLEXCon, Spencer, MA), in maintaining an airtight, durable seal in NPWT. MATERIALS AND METHODS: The authors present a patient with a difficult to manage anogenital wound where efforts to maintain an airtight seal in NPWT proved difficult. It was decided during the course of treatment to use the cyanoacrylate tissue adhesive to create an airtight, durable seal. The tissue adhesive was applied circumferentially to the skin surrounding the wound edge. After placement of vacuum-assisted closure foam over the wound, the adhesive dressing was applied with its edges overlapping the skin area where the tissue adhesive was applied. RESULTS: The size of the wound was visibly reduced at each dressing change. An airtight seal was consistently maintained for 3 days at a time, surviving the difficult environment of the wound and maximizing the life of each adhesive dressing. CONCLUSION: For wounds in anatomically challenging locations, the use of the tissue adhesive appears to be a safe and viable option in creating a durable seal in NPWT.