Outcomes of Venous End-to-Side Microvascular Anastomoses of the Head and Neck.

OBJECTIVES/HYPOTHESIS: The literature on outcomes of end-to-side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes. STUDY DESIGN: Retrospective review of 2482 consecutive patients across three tertiary institutions. METHODS: Adult patients (> 18) who received a FTT from 2006 to 2019 were included. RESULTS: Two hundred and twenty-one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end-to-end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042). CONCLUSIONS: ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1286-1290, 2021.

Anastomotic Revision in Head and Neck Free Flaps.

OBJECTIVES/HYPOTHESIS: Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes. STUDY DESIGN: Retrospective review of 2482 consecutive patients across three tertiary institutions. METHODS: Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised. RESULTS: Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively). CONCLUSION: Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1035-1041, 2021.