Impact of comorbidities on immediate post-operative complications in oral cavity free flap patients.

PURPOSE: To examine the relationship between comorbidities and the development of immediate post-operative complications in patients undergoing oral cavity composite resection (OCCR) with free flap (FF) reconstruction. MATERIALS AND METHODS: Retrospective analysis was completed on all consecutive OCCRs with FF reconstruction performed at a single quaternary care facility between 1999 and 2020. Comorbidities, immediate post-operative complications, patient demographics, and tumor characteristics were collected. Odds ratios (OR) with 95 % confidence intervals were calculated for associations between comorbidities and immediate post-operative complications. RESULTS: 320 patients who underwent OCCR with FF reconstruction were included. One hundred twenty-one (37.8 %) patients developed a post-operative complication during their initial hospital admission. The most common complications were non-pneumonia cardiopulmonary events (14.1 %), pneumonia (9.4 %), and wound infection (8.4 %). Other complications included flap compromise, bleeding, and fistula. On multivariate analysis, patients without comorbid conditions were less likely to develop a post-operative complication (OR 0.64; 0.41-0.98). Atrial fibrillation (OR 2.94; 1.17-7.39) and cerebrovascular disease (OR 2.28; 1.08-4.84) were associated with increased odds of developing any complications. Furthermore, cerebrovascular disease (OR: 2.33; 1.04-5.39) and peripheral vascular disease (OR: 2.7; 1.2-6.08) were independently associated with pneumonia. CONCLUSION: In this retrospective review of patients undergoing OCCR with FF reconstruction for oral cavity SCC, lack of identifiable comorbidities appeared to be protective for post-operative complications while atrial fibrillation and cerebrovascular disease were associated with increased odds of any complication. Pre-existing vascular disease was also associated with an increased risk of pneumonia.

Delayed Upper Aerodigestive Tract Perforation from Anterior Cervical Spine Hardware: Treatment and Swallowing Outcomes.

Delayed upper aerodigestive tract (UADT) perforation is a rare complication of anterior cervical spinal hardware. The purpose of this study was to investigate swallowing outcomes between treatment approaches for delayed UADT perforation. A retrospective chart review was performed on patients with anterior cervical hardware and delayed UADT perforation who were treated at a single tertiary care center between 2000 and 2020. Of the twelve patients identified, most patients presented with dysphagia (n = 9, 75%) and/or neck pain (n = 7, 58%). Perforations generally occurred at the level of C6 (n = 6, 50%) and C7 (n = 4, 33%) and spanned only one spinal level (n = 8, 67%). The majority (n = 8, 67%) of patients were past or current cigarette users. Operative approaches included primary repair (n = 5, 42%) and rotational flap (n = 4, 33%); the rotational flap harvest sites included supraclavicular fasciocutaneous (n = 2), infrahyoid muscle (n = 1), and sternocleidomastoid muscle (n = 1). While most patients demonstrated penetration and/or aspiration on first post-operative swallow study (n = 6), this resolved completely within a median time of 31 days. There were no differences in swallowing outcomes between repair approaches. Patient smoking history appears to be a clear risk factor for the development of delayed UADT perforation from anterior cervical spine hardware. A variety of techniques can be used to repair these perforations, and there were no differences in swallowing outcomes between repair approaches.

Impact of COVID-19 on presentation, staging, and treatment of head and neck mucosal squamous cell carcinoma.

OBJECTIVES: During the COVID-19 pandemic, maintenance of safe and timely oncologic care has been challenging. The goal of this study is to compare presenting symptoms, staging, and treatment of head and neck mucosal squamous cell carcinoma during the pandemic with an analogous timeframe one year prior. MATERIALS AND METHODS: Retrospective cohort study at a single tertiary academic center of new adult patients evaluated in a head and neck surgical oncology clinic from March -July 2019 (pre-pandemic control) and March - July 2020 (COVID-19 pandemic). RESULTS: During the pandemic, the proportion of patients with newly diagnosed malignancies increased by 5%, while the overall number of new patients decreased (n = 575) compared to the control year (n = 776). For patients with mucosal squamous cell carcinoma (SCC), median time from referral to initial clinic visit decreased from 11 days (2019) to 8 days (2020) (p = 0.0031). There was no significant difference in total number (p = 0.914) or duration (p = 0.872) of symptoms. During the pandemic, patients were more likely to present with regional nodal metastases (adjusted odds ratio (OR) 2.846, 95% CI 1.072-3.219, p = 0.028) and more advanced clinical nodal (N) staging (p = 0.011). No significant difference was seen for clinical tumor (T) (p = 0.502) or metastasis (M) staging (p = 0.278). No significant difference in pathologic T (p = 0.665), or N staging (p = 0.907) was found between the two periods. CONCLUSION: Head and neck mucosal SCC patients presented with more advanced clinical nodal disease during the early months of the COVID-19 pandemic despite no change in presenting symptoms.

Existing Predictive Models for Postoperative Pulmonary Complications Perform Poorly in a Head and Neck Surgery Population.

Postoperative pulmonary complications (PPCs) are common following major surgical procedures. Risk stratification tools have been developed to identify patients at risk for PPCs. While otolaryngology cases were included in the development of common predictive tools, they comprised small percentages in each tool. It is unclear how these tools perform in patients undergoing major head and neck surgery with free flap reconstruction. This retrospective review studied all free flap reconstructions in head and neck surgery over a 12-year period at a single institution in the southeastern US. Baseline demographic and medical information were included for each case. All cases were reviewed for development of major PPCs, including pneumonia and respiratory failure. The cohort underwent risk stratification using the ARISCAT and Gupta pulmonary risk indices. Performance of these predictive models for head and neck surgery was determined through receiver-operator curve comparison. 794 patients were identified with a median age of 62 years (IQR 41-83). Sixty-five percent were male. Forty-three (5.4%) developed pneumonia, 23 patients developed respiratory failure (2.9%), and 38 patients developed both (4.8%), resulting in a total PPC proportion of 13.1% (n = 104). Both ARISCAT and Gupta pulmonary risk indices demonstrated low discrimination to predict PPCs in head and neck free flap reconstruction, with areas under the curve of 0.60 and 0.65, respectively. Two major indices for prediction of postoperative pulmonary complications do not accurately identify risk in patients undergoing major head and neck surgery. Further studies are needed to develop predictive tools for PPCs in this high-risk population.

Free dermal fat graft reconstruction of the head and neck: An alternate reconstructive option.

OBJECTIVES: Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects. STUDY DESIGN: Non-randomized retrospective analysis. METHODS: The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction. RESULTS: Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site. CONCLUSIONS: From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.

Remote orbital recurrence of olfactory neuroblastoma (esthesioneuroblastoma).

Olfactory neuroblastoma is a rare and often locally aggressive malignancy that invades the orbit via local destruction. It is known to recur in a delayed fashion, particularly to the neck lymph nodes. This is a case of a 65-year-old gentleman who presents with recurrence in the orbit and a neck lymph node 19 years after treatment for his initial disease. This report describes the longest known interval in orbital recurrence and should alert the monitoring physician that extreme delays in recurrence can occur.

Primary tracheal adenoid cystic carcinoma: A case report and analysis of the tumor immune microenvironment using single cell RNA sequencing.

BACKGROUND: Tracheal adenoid cystic carcinoma (ACC) is a slow growing yet aggressive malignancy with high rates of local recurrence as well as distant metastasis. Tracheal ACC exhibit a low mutation burden along with high mutational diversity, and generally do not respond well to chemotherapeutics. METHODS: We present a rare case of primary tracheal ACC initially presenting with nonspecific cervicalgia and globus sensation that was ultimately treated with tracheal resection followed by chemoradiation. Immune profiling of intratumoral T-cell receptor (TCR) repertoire was subsequently performed using single cell RNA sequencing (scRNAseq). RESULTS: We describe a rare case of primary tracheal adenoid cystic carcinoma highlighting several management principles as well as providing new insights into intratumor T cell populations. CONCLUSIONS: Primary tracheal ACC is most commonly treated with surgical resection followed by adjuvant therapy. Further characterization of the tumor immune microenvironment is necessary to better understand ACC disease biology and to identify potential therapeutic targets.

The osteocutaneous radial forearm free flap: A multidisciplinary review of the evidence.

The osteocutaneous radial forearm (OCRFF) is a versatile free flap option for bony defects of the head and neck, given the thinness and pliability of the forearm cutaneous paddle, pedicle length, reliability, lack of atherosclerosis, and functional concerns common to other osseous donor sites. The OCRFF was once associated with a high risk of radial fracture, in addition to concerns about the quality and durability of bone stock for osseous reconstruction, particularly for the mandible. Following the introduction of prophylactic plating of the radius, the incidence of symptomatic radial fracture has drastically decreased. Furthermore, modifications of the bony osteotomies and other evolutions of this flap harvest have increased the use of the OCRFF throughout the head and neck. Despite these advantages, the OCRFF is not widely utilized by microvascular reconstructive surgeons due to perceived limitations and risks. Herein, we present a multidisciplinary, contemporary review of the harvest technique, outcomes, and perioperative management for the OCRFF.

You Can't Be What You Can't See: The Progression of Women in Otolaryngology-Head and Neck Surgery.

Objective: To examine trends in the gender composition of residents and faculty in Otolaryngology-Head and Neck Surgery residency programs in the United States and to investigate the correlation between women's representation in leadership positions and the proportion of women faculty and residents. Methods: A literature review was first performed to analyze trends in the gender composition of residents and faculty in Otolaryngology-Head and Neck Surgery (OHNS) residency programs. Current residency programs were then identified using the Electronic Residency Application Service 2023 Participating Specialties and Programs website. The following data was collected from each program website: gender of associated medical school dean, gender of department chair, gender of residency program director, and total number and gender of fellowship directors, faculty, and residents. Wilcoxon rank sum test and Fischer's exact test were used to analyze relationships between the number of women in leadership positions and the proportion of women faculty and residents. Results: An increase in the number of women chairs, residency program directors, residents, and faculty over the past decade is documented across published literature. One hundred twenty-three current academic residency programs were identified. Women accounted for 42%, 30%, 27%, and 8% of current residents, residency program directors, faculty, and department chairs, respectively. Department chair gender was significantly correlated with number of women faculty (P = .01). Any women in a leadership position were correlated with a statistically significant increase in median percent of women faculty (P = .006). Conclusion: Further understanding of how the mentorship of women promotes gender equity is necessary to promote gender diversity in OHNS.

Comparative Outcomes for Microvascular Free Flap Monitoring Outside the Intensive Care Unit.

OBJECTIVE: There is a trend towards nonintensive care unit (ICU) or specialty ward management of select patients. Here, we examine postoperative outcomes for patients transferred to a general ward following microvascular free flap (FF) reconstruction of the head and neck. STUDY DESIGN: Retrospective quality control study. SETTING: Single tertiary care center. METHODS: Consecutive patients who underwent FF of the head and neck before and after a change in protocol from immediate postoperative monitoring in the ICU ("Pre-protocol") to the general ward setting ("Post-protocol"). Outcomes included overall length of stay (LOS), ICU LOS, FF compromise, and postoperative complications. RESULTS: A total of 150 patients were included, 70 in the pre-protocol group and 80 in the post-protocol group. There were no significant differences in age, sex, comorbidities, tumor stage, or type of FF. Mean LOS decreased from 8.18 to 7.68 days (P = .4), and mean ICU LOS decreased significantly from 5.2 to 1.7 days (P < .01). There were no significant differences in postoperative or airway-related complications (P = .6) or FF failure rate (2.9% vs 2.6%, P > .9). There was a non-significant increase in ancillary consults in the post-protocol group (45% vs 33%, P = .13) and a significant increase in rapid response team calls, a nurse-driven safety net for abnormal vitals or mental status (19% vs 3%, P = .003). CONCLUSION: We show the successful implementation of a protocol shifting care of FF patients from the ICU to a general ward postoperatively, suggesting management on the floor with less frequent flap monitoring is safe and conserves ICU beds. Additional teaching and familiarity with these patients may over time reduce the rapid response calls.

Consideration of Antifungal Coverage in Treating Infections Related to Delayed Esophageal Perforation from Anterior Cervical Spine Hardware.

(1) Background/Objectives: Delayed esophageal perforation following anterior cervical (spine) discectomy and fusion (ACDF) is rare but can lead to serious infectious complications. The treatment usually involves hardware explanation and prolonged intravenous antibiotics; however, there are scarce reports about the microbiology of these infections and corresponding targeted therapy. (2) Methods: Patients diagnosed or treated for delayed esophageal perforation after anterior cervical fusion between 2000-2020 at a tertiary medical center were studied. (3) Results: Seven patients with delayed esophageal perforation following ACDF were identified. The most common bacteria isolated included Streptococcus, Haemophilus, and Mycobacterium species. The cultures from five patients grew fungal species, including Candida albicans and C. glabrata. All the patients received several weeks of broad-spectrum antibiotics, and, notably, 5/7 patients received antifungal therapy targeting Candida. (4) Conclusions: Although the incidence of delayed esophageal perforation following ACDF is low, providers should remain aware of this entity due to the serious infectious complications. Most infections are polymicrobial in nature, and providers should consider empiric antifungal coverage specifically targeting Candida species when treating patients with this complication.

Virtual 3D Specimen Mapping in Head & Neck Oncologic Surgery.

OBJECTIVES: Virtual 3D specimen mapping of oncologic surgical specimens provides a visual record of the specimen and margin sampling sites which can be utilized in a variety of cancer care settings. Our objective was to perform a retrospective review of head and neck surgical oncology cases where the specimen was mapped post-operatively and to evaluate the utility of these 3D specimen maps amongst the multidisciplinary cancer care team. METHODS: A retrospective review of our 3D specimen model biorepository was performed. Surgical specimens were 3D scanned and then graphically annotated (or "mapped") during routine pathologic processing. The resulting 3D specimen maps were distributed to the multidisciplinary oncologic care team. Final margin status and any use of the 3D specimen maps were recorded. RESULTS: A total of 28 cases were included. Virtual 3D specimen maps were utilized by the cancer care team in 8 cases (29%), including 2 positive margin cases, 2 close margin cases, and 4 indeterminate margin cases. 3D specimen maps were used to visualize positive margin sites for pathologist-surgeon communication as a visual reference during tumor board discussions and to inform radiation treatment planning. CONCLUSION: Post-operative virtual 3D specimen mapping of oncologic specimens creates a permanent visual record of the specimen and the margins sampled and may serve as a beneficial tool for communication amongst the multidisciplinary cancer care team. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:191-197, 2024.

Visual pathology reports for improved collaboration at multidisciplinary head and neck tumor board.

PURPOSE: Multidisciplinary tumor boards (TB) are the standard for discussing complex head and neck cancer cases. During TB, imaging and microscopic pathology is reviewed, but there is typically no visualization of the resected cancer. METHODS: A pilot study was conducted to investigate the utility of visual pathology reports at weekly TB for 10 consecutive weeks. Faculty-level participants completed a pre-survey and post-survey to assess understanding of resected cancer specimens. RESULTS: Providers (n = 25) across seven medical specialties completed pre-survey and post-survey. Following intervention, providers reported significant improvement in understanding of anatomic orientation of the specimen and sites of margin sampling (mean 47.4-96.1, p < 0.001), ability to locate the site of a positive margin (mean 69.5-91.1, p < 0.001), and confidence in treatment plans created (mean 69.5-89.2, p < 0.001) with the addition of visual pathology reports. CONCLUSIONS: Visual pathology reports improve provider understanding of resected cancer specimens at multidisciplinary TB.

Wnt/ß-catenin signaling is a therapeutic target in anaplastic thyroid carcinoma.

BACKGROUND: Anaplastic thyroid carcinoma (ATC) is a highly aggressive malignancy that has consistently shown Wnt/ß-catenin (canonical) signaling activation in various study populations. There are currently no targetable treatments for BRAF-wildtype ATC and a lack of effective treatment for BRAFV600EATC. Our aim is to identify whether Wnt inhibitors could be potential therapeutic agents for ATC patients with limited treatment options. METHODS: In this Institutional Review Board-approved study, we utilize a cohort of 32 ATCs and 20 non-neoplastic multinodular goiters (MNG). We also use 4 ATC spheroid cell lines (THJ-16T, THJ-21T, THJ-29T, and THJ-11T) and two primary patient-derived ATC organoid cultures (VWL-T5 and VWL-T60). Finally, we use a murine xenograft mouse model of ATC for in vivo treatment studies. RESULTS: Using a large patient cohort, we demonstrate that this near-universal Wnt signaling activation is associated with ligand expression- rather than being mutationally-driven. We show that pyrvinium pamoate, a potent Wnt inhibitor, exhibits in vitro efficacy against both ATC cell lines and primary patient-derived ATC organoids VWL-T5 (p < 0.05) and VWL-T60 (p < 0.01) Finally, using a murine xenograft model of ATC, we show that pyrvinium significantly delays the growth of ATC tumors in THJ-16T (p < 0.005) and THJ-21T (p < 0.001). CONCLUSIONS: We tested Wnt inhibitor treatment, both in vitro and in vivo, as a potential novel therapy for this highly lethal disease. Future large-scale studies utilizing multiple Wnt inhibitors will lay the foundation for the development of these novel therapies for patients with ATC.

Association of social vulnerability on survival, treatment, and presentation in oral cavity cancer.

OBJECTIVE: This study utilized a population database to investigate how social environments are associated with outcomes including stage at diagnosis, multimodal treatment, and disease-specific survival for oral cavity squamous cell carcinomas. METHODS: Retrospective analysis of adults with oral cavity squamous cell carcinoma between 2007 and 2016 from the Surveillance, Epidemiology, End Results (SEER) registry was performed. The CDC's social vulnerability index (SVI) was used to characterize social vulnerability at the county level. Predictors of disease-specific survival, stage at diagnosis, and use of multimodal therapy were identified using Cox regression and logistic regression. RESULTS: Our analysis included 17 043 patients. On adjusted models, patients in the highest SVI quartile (most social vulnerability) exhibited worse disease-specific survival compared to the lowest quartile (HR 1.24, 95% CI 1.12-1.37, p < 0.001), and were more likely to be diagnosed at later stages (OR 1.24, 95% CI 1.11-1.38, p < 0.001) and less likely to receive multimodal therapy (OR 0.84, 95% CI 0.77-0.99, p = 0.037). CONCLUSION: High social vulnerability was associated with worse disease-specific survival and disease presentation in oral cavity cancer patients.

Characterizing gender trends in head and neck fellowship graduates from 2008 to 2018.

OBJECTIVES: Evaluation of potential gender gaps among Head and Neck (H&N) surgeons can highlight areas for increased support of female H&N surgeons and improve gender diversity within the subspecialty. To evaluate gender trends in representation and career trajectory among recent H&N surgery fellowship graduates. METHODS: This cross-sectional analysis included graduates from Head and Neck Surgery fellowships accredited by the American Head and Neck Society (AHNS) from 2008 to 2018. Additional demographic data was collected via publicly available websites including gender, years in practice, practice location, type of practice, h-index, and academic rank. The primary outcomes were the proportion of female Head and Neck fellowship graduates and gender trends in career trajectory and academic productivity (via h-index). RESULTS: Between 2008 and 2018, 449 surgeons graduated from Head and Neck surgery fellowship with females comprising 99 of 449 graduates (22%). Female representation increased from 1 of 30 (3%) graduates in 2008 to 17 of 52 (33%) in 2018. A proportionally similar number of women graduating fellowship also practiced in an academic setting (23%). There were fewer female assistant, associate and full professors compared with their male counterparts. Women had lower h-indices compared with men even when controlling for years in practice (mean 11.4 vs. 8.2, p < 0.03). CONCLUSION: Despite the increase in women graduating from H&N surgery fellowships, gender disparities within academic rank and academic productivity as measured by h-index remain. While a proportional number of women completing fellowship are entering academic practice, additional investigation and support is needed to address the potential gender gaps identified within academic H&N surgery.

Utility of PET-CT in Newly Diagnosed HPV-Associated Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVE: To compare the utility of positron emission tomography-computed tomography (PET-CT) versus contrasted CT neck combined with routine chest imaging for disease staging and treatment planning in human papillomavirus (HPV) associated oropharyngeal squamous cell carcinoma (OPSCC) with clinically evident sites of primary disease. METHODS: All adult patients with primary HPV-associated OPSCC at a single quaternary care cancer center from 2018 to 2019 were reviewed, and those with images available for re-review were included. Primary outcomes included concordance in clinical staging between the 2 imaging modalities of interest (PET-CT vs CT), as well as independent agreement of each with pathologic staging. Analysis was performed via ordinal logistic regression. A secondary outcome was treatment selection after diagnostic imaging, analyzed via chi-squared testing. RESULTS: In total, 100 patients were included for evaluation, of which 89% were male, 91% Caucasian, and mean age was 61.2 years (SD 9.6). Clinical disease staging agreed between imaging modalities in 95% of cases (54 of 57 patients). Pathologic staging agreed with clinical staging from CT neck in 93% of cases (25 of 27 patients; P = .004), and with PET-CT in 82% (14 of 17 patients; P =.003). No differences were observed between the 2 imaging modalities for subsequent treatment selection (P = .39). CONCLUSION: In uncomplicated HPV-associated OPSCC, CT offers equivalent diagnostic accuracy to that of combined whole-body PET-CT for clinical staging, and has no appreciable impact on treatment selection. A reduced reliance on routine PET-CT during initial workup of HPV-associated OPSCC may be favorable for otherwise healthy patients with clinically evident sites of primary disease.

Head and Neck Necrotizing Fasciitis: Abbreviated SOFA Score Associated With Death and Infection Spread.

Objective: Describe features unique to head and neck (H&N) necrotizing fasciitis (NF) compared to other anatomic regions and specify a prognostic score associated with death and descending necrotizing mediastinitis (DNM). Study Design: Retrospective cohort. Setting: Tertiary care, level 1 trauma center. Methods: A single-institution database identified 399 confirmed cases of NF between 2006 and 2021, 33 of which involved the H&N. Patients with confirmed H&N NF were sorted into cohorts based on clinical outcomes, with the "poor" outcomes group defined by death and/or DNM. Results: Thirty-three patients with H&N NF were included. Compared to NF of other regions, patients with H&N NF had a significantly lower mortality rate (6.06% vs 20.8%, p = .041) and significantly lower rates of obesity (27.3% vs 63.7%, p < .001) and hypertension (42.4% vs 60.9%, p = .038). Within the H&N group, there were 2 deaths (6.06%) and 8 cases of DNM (24.2%). Diabetes was associated with poor outcomes (p = .047), as was an abbreviated sequential organ failure assessment score for necrotizing fasciitis (nfSOFA) of 2 or greater (p = .015). Conclusion: H&N NF is unique among other forms of NF, with a lower mortality rate and lower rates of obesity and hypertension in affected patients. Within the H&N cohort, worse outcomes were associated with diabetes as well as a nfSOFA score of 2 or greater. Timely surgical debridement alongside broad-spectrum antibiotics remains the mainstay of treatment for NF; however, this simple prognostic score may play a role during the early stages of care for patients with H&N NF.

Preoperative Predictors of Free Flap Failure.

OBJECTIVE: Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure. STUDY DESIGN: Retrospective cohort study of 1070 patients. SETTING: Head and neck surgical oncology service at a tertiary care center from 2005 to 2019. METHODS: Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery). RESULTS: In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure. CONCLUSION: Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.