A deployable curriculum with 3D printed skills trainers for altered airway management.

BACKGROUND: Altered Airway Anatomy (AAA), including tracheostomies and laryngectomies, may represent an area of unease for non-Otolaryngology trainees, due to a lack of exposure, structured education, or dedicated training in altered airway management. Inability to effectively stabilize an altered airway is associated with significant risk of patient morbidity and mortality. This study aims to assess the efficacy of a concise curriculum using three-dimensional (3D) printed airway models for skill training in improving Anesthesiology trainees' competency in AAA management. METHODS: A prospective cohort of 42 anesthesiology residents at a tertiary care institution were guided through a 75-min curriculum on AAA, including case discussion, surgical video, and hands-on practice with tracheostomy and laryngectomy skills trainers. Pre- and post- course surveys assessing provider confidence (Likert scale) and knowledge (multiple choice questions) were administered. Additionally, an observed skills competency assessment was performed. RESULTS: Self-perceived confidence improved from a summative score across all domains of 23.65/40 pre-course to 36.39/40 post-course (n = 31, p < 0.001). Technical knowledge on multiple choice questions improved from 71 to 95% (n = 29, p < 0.001). In the completed skills competency assessment, 42/42 residents completed 5/5 assessed tasks successfully, demonstrating objective skills-based competency. CONCLUSIONS: This study demonstrates an improvement in anesthesiology resident self-assessed confidence, objective knowledge, and skills based competency surrounding management of patients with AAA following a 75-min simulation-based curriculum.

Medical Student Mentorship in the COVID-19 Era.

Background: The Covid-19 pandemic led to a reduction of in-person, guided mentorship due to social distancing and an emphasis on virtual meetings. The effect of these changes on medical students' experiences and specialty choice has yet to be studied in a large-scale manner. Objective: To determine the perspective of third- and fourth-year medical students regarding the impact of the COVID-19 pandemic on mentorship. Design: The authors distributed a modified Likert scale questionnaire (score: 1-10) to assess responses. Participants: Third- and fourth-year medical students at two large US allopathic medical schools. Main Measures: Responses to each survey item were analyzed to characterize the impact of the COVID-19 pandemic on mentorship relationships in medical school. A score of 1-5 was considered "disagree" and a score of 6-10 was considered "agree." Key Results: A total of 144 responses were collected with a response rate of 16.2%. Overall, 80.6% (n = 116) of respondents agree that the COVID-19 pandemic has had a negative impact on their medical school experience. Nearly half (41.0%, n = 59) expressed concern over the lack of mentorship opportunities, and 66.0% (n = 95) reported that the pandemic has made it more difficult to form or maintain connections with their mentors. Importantly, 43.6% (n = 61) of respondents reported that having close mentoring relationships reduced the impact of the pandemic on their medical training. While many respondents (79.9%, n = 114) did not change career plans due to the pandemic, most students are concerned about evaluating prospective residency programs (88.9%, n = 128). Notably, M3s have much lower confidence than M4s in their ability to choose a specialty (5.9 vs. 8.2, p = 6.43e - 08). Conclusions: This investigation illustrates the concerns that medical students have regarding access to mentorship opportunities due to the COVID-19 pandemic. We hope that these findings encourage medical schools to evaluate and expand their current mentorship programs. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01838-4.

Recurrent respiratory papillomatosis disease course in immunosuppressed populations.

OBJECTIVE: Recurrent respiratory papillomatosis is a benign manifestation of human papillomavirus types 6 and 11 in the respiratory tract. Disease is recurrent, and factors predicting these recurrences and severity of disease are incompletely characterised. This retrospective cohort study examined the relationship of immunosuppression with recurrent respiratory papillomatosis morbidity. METHODS: A retrospective cohort of 97 adult patients with recurrent respiratory papillomatosis treated at a tertiary referral centre from 2005 to 2020 was conducted. Measures assessed included inter-surgical interval, Voice Handicap Index ('VHI-10') and anatomical Derkay scores. RESULTS: Bivariate analyses comparing average inter-surgical interval, Voice Handicap Index and Derkay scores in immunosuppressed and healthy patients were insignificant. When controlling for diabetes mellitus and comparing immunosuppressed to healthy patients, inter-surgical interval and Voice Handicap Index change were insignificant (p = 0.458 and p = 0.465, respectively). CONCLUSION: Recurrent respiratory papillomatosis morbidity for immunosuppressed patients did not significantly differ from that of immunocompetent patients.

Iron Pill-Induced Chemical Laryngitis.

OBJECTIVE: To discuss the presentation and management of pill-induced chemical laryngitis by illustrating a rare case. METHODS: We report a unique case of a patient with iron pill-induced laryngitis. RESULTS: A 71-year-old male presented for evaluation of dysphonia. Five weeks prior, the patient had reportedly aspirated an iron pill. The pill was lodged in his throat for several hours before being coughed up, soft but still intact. Since that event, the patient noted complete voice loss and in clinic was found to have a very breathy and asthenic voice. Stroboscopy revealed aperiodicity with severe false fold compression and significant ulceration of the infraglottic region associated with thick exudate. Vocal folds were mobile but atrophic, with overlying crusted secretions. A sensory deficit was suspected based on scope tolerance. The patient was treated with nebulized ciprodex and humidified air with some improvement in mucosal crusting but had persistent glottic insufficiency and dysphonia, prompting bilateral hyaluronic acid injection. CONCLUSIONS: Pill-induced laryngitis is an extremely rare phenomenon. While typically associated with bisphosphonates, this condition should be considered in any patient presenting with dysphonia and history of aspiration of a pill, including iron supplements. Regardless of the inciting medication, pill-induced laryngitis may be treated with humidified air, nebulized steroids, and antibiotics. Injection augmentation of the vocal folds may be made considered when glottic insufficiency and weak cough contribute to the presentation.

Altered Airway Anatomy Course Using 3D-Printed Models for Medical Students.

OBJECTIVE: Many non-airway-trained personnel are uncomfortable managing altered airway anatomy (AAA), including tracheostomy and total laryngectomy (TL) patients. Significant morbidity and mortality have resulted from first responders' inability to stabilize the airway until expert airway providers arrive. All medical school graduates should demonstrate competency of this life-saving skill. Our hypothesis was hands-on interactive simulation using 3-dimensional (3D)-printed models would improve AAA knowledge and confidence. STUDY DESIGN: Blinded, prospective cohort study. SETTING: The Ohio State University College of Medicine. METHODS: A novel curriculum was designed to teach all third-year medical students AAA fundamentals via case-based discussions, surgical videos, and hands-on student demonstration of competency by inserting a tracheostomy and endotracheal tube through 3D-printed tracheostoma models. Pre- and postcourse 5-item Likert scale surveys and AAA knowledge assessments were administered. RESULTS: Students (n = 258) felt more comfortable with knowledge of AAA equipment (3.99 vs 1.38, P < .0001), ability to stabilize AAA patients until expert airway providers arrive (3.67 vs 1.37, P < .0001), and AAA overall (3.75 vs 1.49, P < .0001) postcourse vs precourse. AAA knowledge assessment scores improved from 34.3% precourse to 75.6% postcourse (P < .0001). Interestingly, 30.7% chose bag-mask ventilation over mouth and nose and/or transoral/transnasal intubation for a total laryngectomy patient precourse vs 5.5% postcourse (P < .0001). In total, 86.7% reported inadequate exposure to AAA in medical school and 98.4% found the course to be a valuable experience. CONCLUSION: This hands-on course significantly increases medical student knowledge and comfort managing AAA patients. The course can be expanded to various trainees and providers to further promote AAA education and ultimately improve patient safety.

Near-Total Ear Avulsion Repaired With Primary Closure and Hyperbaric Oxygen: A Case Series and Review of the Literature.

INTRODUCTION: Near-total ear avulsion is a rare and challenging problem to repair with many techniques described; primary repair is an attractive option but is not always successful. Healing may be augmented with postoperative hyperbaric oxygen therapy (HBOT), but this technique is under-reported, and an ideal regimen is not known. The study objective is to discuss the role of HBOT in the management of ear avulsion by reviewing 2 unique cases. METHODS: Case report and review of the literature. A Pubmed search using the terms ear avulsion and postoperative hyperbaric oxygen was performed. RESULTS: Two pediatric patients presented with near-total avulsion of the auricle after suffering a dog bite. Various management options were discussed including observation, primary repair, post-auricular cartilage banking, graft reconstruction with periauricular tissue or rib cartilage, or microsurgical replantation. The decision was made to perform primary reattachment, followed by adjuvant hyperbaric oxygen therapy (HBOT). The patients achieved favorable esthetic results and continue to maintain the function of the reattached ear. Photo documentation was obtained throughout the process. DISCUSSION: There is no consensus on the management of near-total ear avulsion. Primary repair is ideal from a cosmetic and ease-of-operation standpoint but does not always yield viable tissue. The use of postoperative HBOT is an attractive option that may boost success rates, but the ideal HBOT regimen is unknown. These cases represent a successful application of this innovative technique in a pediatric patient.

Effect of injection laryngoplasty material on outcomes in pediatric vocal fold paralysis.

Background: While injection laryngoplasty is becoming increasingly common in children, there has not been clearly established guidelines for the choice of injection material. This study evaluates for variability in post-surgical outcomes between different materials used for injection laryngoplasty in the treatment of pediatric unilateral vocal cord paralysis. Methods: In this cohort study, a retrospective chart review was performed for all patients undergoing injection laryngoplasty for unilateral vocal cord paralysis at our tertiary-care children's hospital between January 2010 and December 2019. Patients with vocal cord paresis or bilateral vocal cord paralysis were excluded from this study. Demographics, pre- and post-injection clinic visits, and operative reports were reviewed to compare outcomes between injection materials, including the number of injections required, inter-surgical interval, and rate of vocal improvement. Results: Forty-four patients were included in the analysis. Half of the patients were female, and half were male. A total of 97 injections were observed, with 32 patients receiving multiple injections. The mean age at first injection was 7 years. The most common causes of vocal fold paralysis were iatrogenic (n=21, 48%) and idiopathic (n=9, 20%). Thirty-nine percent (n=17) had a history of cardiac surgery. Forty-five percent of injections used Radiesse® voice/Prolaryn® plus, 35% used Radiesse®/Prolaryn® voice Gel, and 20% used Cymetra™. The material used was not associated with a difference in post-operative outcomes, including number of injections, (P=0.10; 0.29), inter-surgical interval (P=0.27; 0.29), or rate of voice improvement (P=0.86; 0.36). Conclusions: Neither material choice nor demographic factors were associated with a difference in outcomes following injection laryngoplasty or a change in the inter-surgical interval. Further research is needed to develop standardized protocols for injection laryngoplasty in this population.

Recognition and Management of Nonaccidental Esophageal Perforation.

Nonaccidental trauma is a common pediatric concern that often goes unrecognized. Although most patients present with bruising, burns, fractures, and head trauma, it is critical that physicians be able to diagnose and treat atypical presentations such as pharyngeal and esophageal trauma. In this report, we describe the presentation and management of a 5-week-old girl with an inflicted esophageal perforation.

Survival of Toddler with Aortoesophageal Fistula after Button Battery Ingestion.

Button batteries (BBs) are found in many households and are a source of esophageal foreign body in the pediatric population. Upon ingestion, significant caustic injury can occur within 2 hours leading to tissue damage and severe, potentially fatal sequelae. Aortoesophageal fistula (AEF) is a rare complication that nearly always results in mortality. We report a rare case of a toddler who developed an AEF after BB ingestion and survived following staged aortic repair. There should be a high index of suspicion for this complication with the history of BB ingestion and presence of hematemesis, hemoptysis, or melena.

Current management of button battery injuries.

Button batteries (BB) are found in common household items and can lead to significant morbidity and mortality in the pediatric population when ingested. BBs are made of various chemistries and have a unique size and shape that yield significant injury when lodged in the pediatric esophagus. BBs create a local tissue pH environment of 10 to 13 and can induce liquefactive necrosis at the negative pole. This initial injury can progress with further tissue breakdown even after removal. Unfortunately, patients may present with vague symptoms similar to viral illnesses and there is not always a known history of ingestion. Plain film X-ray can be diagnostic. Exposure can lead to caustic injury within 2 hours. Thus, timely endoscopic removal is the mainstay of treatment. Novel mitigation and neutralization strategies have been implemented into treatment guidelines. These include the preremoval ingestion of honey or sucralfate and intraoperative irrigation with acetic acid. Depending on the severity of injury following removal, careful consideration should be given for potential delayed complications including fistulization into major vessels which often leads to death. The National Button Battery Taskforce and several industry members have implemented prevention strategies such as educational safety outreach campaigns, child-resistant packaging changes, and warning labels. Governmental regulation and industry changes are key to limit not only the amount of BB ingestions, but also the devastating consequences that can result. Anonymous reporting of BB injuries through the Global Injury Research Collaborative has been made convenient and centralized through the advent of a user-friendly smartphone iOS/App Store and Android/GooglePlay application called the "GIRC App"; all specialists who manage foreign body cases should contribute their cases to help prevent future injuries. BB ingestion must be recognized and treated promptly using a multidisciplinary approach to optimize outcomes for these patients. Ultimately, a safer BB technology is critically needed to reduce or eliminate the severe and life-threatening injuries in children. LEVEL OF EVIDENCE: 5.

Patient-Directed Home Drain Removal in Head and Neck Surgery.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to evaluate the efficacy and safety of at home drain removal in head and neck surgery patients. METHODS: The study population included patients who underwent head and neck surgery at an academic tertiary care center between February 2020 and November 2020 and were discharged with one to four drains with instructions for home removal. Prior to discharge, patients received thorough drain removal education. Patients were prospectively followed to evaluate for associated outcomes. RESULTS: One hundred patients were evaluated in the study. There was record for ninety-seven patients receiving education at discharge. The most common methods of education were face-to-face education and written instructions with educational video link provided. Of 123 drains upon discharge, 110 drains (89.4%) were removed at home while 13 (10.6%) were removed in office. Most drains were located in the neck (86.4%). There was one seroma, two hematomas, two drain site infections, and five ED visits; however, none of these complications were directly associated with the action of drain removal at home. Calculated cost savings for travel and lost wages was $259.82 per round trip saved. CONCLUSIONS: The results demonstrate that home drain removal can provide a safe and efficacious option for patients following head and neck surgery. This approach was safe and associated with patient cost savings and better utilization of provider's time. Furthermore, patients and healthcare providers avoided additional in-person encounters and exposures during the COVID-19 pandemic. Our findings warrant further investigation into cost savings and formal patient satisfaction associated with home drain removal. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2471-2477, 2021.

Pediatric nasal septoplasty outcomes.

BACKGROUND: Corrective nasal surgery has historically been avoided in the pediatric population out of concerns surrounding the potential disruption of nasal growth centers. There is a paucity of data on the rate of complications or revision surgery following septoplasty in this population. As such, the purpose of this study is to review the long-term outcomes of a large cohort of children who underwent nasal septoplasty and to compare outcomes of septoplasty patients under the age of 14 to those 14 years and older. METHODS: A retrospective review was performed on all patients who received nasal septoplasty at our tertiary care pediatric referral center between October 2009 and September 2016. All patients who underwent septoplasty for a deviated nasal septum and were 0-18 years of age at the time of surgery were included in this analysis. Outcomes were compared between patients under the age of 14 to those 14 years and older. Demographic, surgical, and follow-up data were collected including complications and the need for revision surgery. RESULTS: A total of 194 pediatric patients were identified as meeting inclusion criteria for the study. Mean age for the total cohort was 14.6 years (0-18 years), with a mean of 15.9 years in the older group and 10.6 years in the younger group. Revision septoplasty was performed more frequently in the younger group. However, no significant difference in the rate of complications was seen between the two groups. CONCLUSIONS: To the best of our knowledge, this is the largest retrospective study examining outcomes following septoplasty in pediatric patients. We also specifically examine outcomes of very young septoplasty patients, a population for which limited evidence exists. Further retrospective studies are needed to validate the use of nasal septoplasty in the pediatric population.

Presentation of an iatrogenically displaced third molar into the maxillary sinus in a 14-year-old patient successfully removed with an endoscopic approach: a case report and a review of the literature.

Oral surgeons remove third molars (wisdom teeth) to prevent impaction. Given the close anatomical relationship to the maxillary sinus, perforation and displacement of third molars into the maxillary sinus is a well-known phenomenon that is typically removed with a buccal mucoperiosteal flap or through a Caldwell-Luc approach. However, a less invasive route of endoscopic removal has been utilized to success in one report. A literature review shows few reports of displaced molars into the maxillary sinus and no reported patient below the age of 18. A 14-year-old patient presented with a displaced third molar into her maxillary sinus following third molar extraction with her oral surgeon. The tooth was removed successfully, utilizing endoscopic sinus surgery (ESS) with a transition to transoral retrieval to prevent nasal trauma. This is the first reported case of displaced third molar into the right maxillary sinus in a pediatric patient that was removed via ESS.

Laryngotracheal injuries after intubation in pediatric seizure patients: A case series and a review of the literature.

Acute management of seizures may require intubation with an endotracheal tube (ETT) in addition to benzodiazepine administration. Although necessary for management at times, intubation can lead to laryngotracheal injury as has been reported at length in both the adult and pediatric populations. A review of the literature shows no prior reports of laryngotracheal injuries following intubation in actively seizing pediatric patients. We share our experience with two pediatric patients who had laryngotracheal injuries after being emergently intubated with large ETT's during management of their seizures. We describe two unique cases in the pediatric seizure population associated with laryngotracheal injuries with the goal of emphasizing appropriate ETT sizing for intubation.

ENT Mentorship Program for Preclinical Medical Students.

OBJECTIVE: To provide preclinical medical students early access to otolaryngologists to learn about the specialty, facilitate acquisition of clinical skills, and provide one-on-one mentorship. METHODS: Students are matched with a single otolaryngology faculty mentor from The Ohio State University/Nationwide Children's Hospital and attend 8 hours per month in the clinic or operating room, monthly lectures, and rounds, and they give a final presentation. Mentors complete performance evaluations, and surveys are administered longitudinally until Match Day. RESULTS: Thirty-five students and 17 faculty members have participated in the program since 2015. All mentors and students found the program to be a valuable experience. When compared to nonparticipating students, participants had significantly higher confidence scores for clinical performance, knowledge of anatomy, and familiarity with the department of interest. All students felt the program prepared them well for third and fourth years, and all 8 of the initial program participants successfully matched into residency with 4 entering otolaryngology. DISCUSSION: Medical students face a competitive residency application process in otolaryngology with limited exposure, which creates an opportunity for guidance in the pursuit of matching into this field. This novel preclinical mentorship program prepares students for their clinical years and residency by facilitating acquisition of various competencies. Students gain hands-on clinical exposure in a field of interest and support for navigating the application process. IMPLICATIONS FOR PRACTICE: The structure of this program can be applied to other medical schools or specialties if the individual departments contain adequate resources of teaching faculty willing to participate.

Antibodies against the DNABII protein integration host factor (IHF) inhibit sinus implant biofilms.

OBJECTIVES: Chronic rhinosinusitis is a common, costly condition often treated with endoscopic sinus surgery and intraoperative placement of intranasal sinus implant materials. Whereas these materials aid in postoperative healing, they also support bacterial biofilm formation and thus contribute to negative outcomes. This study examined pretreatment of sinus implant materials with antibody against an essential bacterial biofilm structural component, the DNABII family of DNA-binding proteins, as a strategy to prevent biofilm formation. METHODS: Sinus implant materials were equilibrated in immunoglobulin G (IgG)-enriched antiserum against the DNABII protein integration host factor (IHF), individually or in combination with amoxicillin-clavulanate prior to inoculation with nontypeable Haemophilus influenzae (NTHI), a predominant pathogen of chronic rhinosinusitis. After 16 hours, the bacterial burden was quantitated and compared to pretreatment with saline, IgG-enriched naive serum, or amoxicillin-clavulanate alone. RESULTS: NTHI readily formed biofilms on all three materials in vitro. However, pretreatment of each material with IgG-enriched anti-IHF resulted in a significant decrease in bacterial burden compared to controls (P ≤ 0.05). Moreover, a significant and synergistic outcome was achieved with a cocktail of anti-IHF plus amoxicillin-clavulanate (P ≤ 0.05) with complete inhibition of NTHI biofilm formation on all three materials. CONCLUSIONS: Biofilm formation was well supported in vitro on three sinus implant materials that vary in composition and resorption characteristics; however, pretreatment of each with DNABII protein targeted antibodies in combination with a previously ineffective antibiotic was highly effective to prevent the formation NTHI biofilms. These data demonstrate the potential for clinical utility of pretreatment of sinus implant and additional surgical materials with anti-DNABII antibodies. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1364-1371, 2020.

Strap Muscle Type I Thyroplasty After Gore-Tex Implant Extrusion: Case Report and Literature Review.

OBJECTIVES: To discuss the presentation and management techniques of implant extrusion following type I thyroplasty and to illustrate the potential of strap muscle for augmentation following implant removal. METHODS: We report a unique case of a patient with late Gore-Tex implant extrusion after type I thyroplasty treated with removal and autologous strap muscle graft for augmentation. RESULTS: A 41-year-old female nearly 3.5 years status post Gore-Tex type I thyroplasty for left vocal fold paralysis presented for evaluation of dysphonia. Upon flexible laryngoscopy, erythema, edema, and granulation tissue were identified at the left vocal fold and ventricle. The patient subsequently underwent removal of her implant. Intraoperatively, a free portion of sternothyroid muscle was dissected free and placed into the paraglottic space. One month following surgery, the patient reported an improvement in her Voice Handicap Index (VHI) score from 40 to 0. In addition, no major complications were observed and complete glottic closure was achieved. Nine months postsurgery, she continued to function well with a VHI score of 0. At 50 months postop, the patient still reports a VHI score of 0. CONCLUSIONS: Implant extrusion is a rare complication of type I thyroplasty usually occurring in the first few months after surgery and more commonly presenting in females. Current management options consist of observation or augmentation with autologous fat or vocal fold injection following implant removal. This is the first report of a successful strap muscle free graft revision thyroplasty following implant extrusion. The patient's excellent long-term outcome highlights the potential of strap muscle augmentation as a feasible management option for implant extrusion.

Identification of essential biofilm proteins in middle ear fluids of otitis media with effusion patients.

OBJECTIVES: Otitis media with effusion (OME) is a common disease of childhood that is largely asymptomatic. However, middle ear fluid can persist for months and negatively impact a child's quality of life. Many cases of OME remain chronic and require surgical intervention. Because biofilms are known to contribute to the persistence of many diseases, this study examined effusions collected from children with chronic OME for the presence of essential biofilm structural components, members of the DNABII family of bacterial DNA-binding proteins. METHODS: Middle ear effusions were recovered from 38 children with chronic OME at the time of tympanostomy tube insertion. A portion of each specimen was submitted for microbiology culture. The remaining material was assessed by immunoblot to quantitate individual DNABII proteins, integration host factor (IHF), and histone-like protein (HU). RESULTS: Sixty-five percent of effusions (24 of 37) were culture-positive for bacterial species or yeast, whereas 35% (13 of 37) were culture-negative. IHF was detected in 95% (36 of 38) at concentrations from 2 to 481 ng/µL effusion. HU was detected in 95% (36 of 38) and quantitated from 13 to 5,264 ng/µL effusion (P ≤ 0.05 compared to IHF). CONCLUSION: Because DNABII proteins are essential structural components of bacterial biofilms, these data lend further support to our understanding that biofilms are present in the vast majority of chronic middle ear effusions, despite negative culture results. The presence and ubiquity of DNABII proteins in OME specimens indicated that these proteins can serve as an important clinical target for our novel DNABII-directed strategy to treat biofilm diseases such as chronic OME. LEVEL OF EVIDENCE: NA Laryngoscope, 130:806-811, 2020.

Free flap salvage from venous thrombosis by creation of a venocutaneous fistula: Case report and review of the literature.

BACKGROUND: Venous congestion is the most frequently reported complication of free flap tissue transfer in head and neck patient with cancer. Numerous methods are utilized and prompt correction is necessary to prevent flap failure. METHODS: A 77-year-old woman underwent oral cavity resection and neck dissection for squamous cell carcinoma followed by radial forearm free flap for reconstruction. Three days later, the flap became congested and surgical exploration revealed extensive venous thrombosis throughout the free flap venous system and internal jugular vein. The flap vein was evacuated and flowing, and a venocutaneous fistula was created thereafter. RESULTS: Venocutaneous fistula resulted in flap decongestion and successful salvage. The patient was discharged from the hospital with no further flap or surgical complications. CONCLUSION: When anatomical revision of the venous anastomosis is not feasible in a venous-congested free flap, the creation of a venocutaneous fistula should be considered as a viable option for salvage.