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Studies Look at New Options in Reconstructive Surgery

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Bradley R. Lawson, MD, presented ‘Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap: Indications, Outcomes and Technical Considerations.’

Eight studies were reviewed September 24 during “Scientific Oral Presentations: Head and Neck Reconstruction.” Studies examined flap reconstruction options, dealing with facial nerve paralysis, the perception of faces after reconstruction, a comparison of flaps constructed at low-volume and high-volume centers, whether age affects outcomes in patients receiving flaps, the relation of fluid to post-surgery complications, and the effectiveness of an imaging agent in detecting tumors.

Reconstruction of the NOE with OCRFF

A retrospective study of patients suffering from naso-ethmoid-orbital (NOE) defects examined the effectiveness of using osteocutaneous radial forearm flap reconstruction (OCRFF).

The study looked at 15 patients with NOE defects to assess the overall aesthetic results and success of treatment of the nasal airway, diplopia, and enophthalmus. Another objective of the study was to determine whether OCRFF reconstruction is sufficient to get patients to adjuvant therapy when needed as a single operation.

Researchers concluded that OCRFF for NOE could serve as a one-step reconstructive modality to quickly get patients to adjuvant therapy. Also, in those patients who had NOE cancer, revisions can be delayed until the cancer is treated. Finally, the study concluded that the airway will be poor, but satisfaction with appearance is generally favorable.

Facial Reanimation Techniques for Facial Nerve Paralysis Following Cancer Resection and Radiation

Two reconstruction and facial reanimation procedures for 30 patients treated for cancer that involved facial nerve sacrifice were compared in a prospective study. Eighteen patients received static sling suspension and 12 received temporalis tendon transfer.

The study found that five patients had complications unrelated to cosmesis. Two of the patients required revision because of infection and failure of the sling, and the other three patients were treated with oral or IV antibiotics and local wound care.

Researchers concluded that sling procedures could be successfully performed in patients with facial nerve palsy secondary to cancer resection and radiation therapy with a low revision rate and few complications.

Evidence-Based Soft Tissue Reconstruction: Incorporating Lessons Learned from Social Perception

A prospective, randomized controlled study tested the hypothesis that surgical reconstruction of facial lesions will increase attractiveness and reduce negative facial perception.

Researchers collected photographs of patient faces with lesions before and after reconstruction and placed the faces into four categories based on lesion size and location. Eventually, 16 demographically matched normal faces were selected for use in a survey. The photos were shown to 120 observers in four surveys.

The study concluded that:

  • Facial lesions induce significant, measurable penalties on social facial perception
  • Surgical reconstruction of facial lesions increases attractiveness and decreases negative facial perception, an impact that varies with preoperative lesion size and location
  • The results of the surveys support using high-quality surgical reconstruction of facial lesions and suggest avenues for future research
  • It is helpful to counsel patients about the impact of their lesions and reconstruction based on social perception

Free Flap Reconstruction Experience and Outcomes in a Low-Volume Setting during 20 Years

A retrospective review of the work of a single surgeon during 20 years was used to examine whether free flaps could be safely constructed at a low-volume center by comparing those results with the results from higher volume centers.

The study defined a high-volume center as one that performs at least one free flap procedure a day. Low-volume centers were defined as those performing fewer than 20 flap procedures a year, which is 20 percent of programs. The single surgeon studied performed 136 flaps during 20 years.

Researchers concluded that the success of free flap reconstruction varied greatly, with a success rate of 92 percent to 99 percent. Complication rates also varied greatly, from 25 percent to 70 percent, and they were infrequently reported. They concluded that free flap procedures at low-volume institutions were safe, reliable, and reasonable.

Head and Neck Reconstruction with Chimeric Anterolateral Thigh Free Flap: Indications, Outcomes, and Technical Considerations

The free anterolateral thigh (ALT) flap is a common reconstructive technique for complex head and neck defects, so a study examined whether free chimeric ALT flaps would be a suitable option. Chimeric ALT flaps are composed of multiple skin paddles or muscular components.

Researchers used a retrospective chart review of 24 consecutive ALT free flap procedures to document clinical outcomes of patients undergoing microvascular head and neck reconstruction and to identify patient and technique-related variables that could serve as outcome predictors.

They concluded that chimeric ALT flaps are an excellent alternative for reconstruction of complex defects, but found that patients with malnutrition and congestive heart failure are at a higher risk of partial flap loss.

Free Flap Reconstruction Outcomes among Elderly Patients

An increasing number of elderly patients require major reconstructive surgery, and the aging population is growing, so researchers studied whether advanced age is a factor in failures or complications in these surgeries.

The retrospective review focused on patients who were 80 and older, looking at the flap success rate, length of say, discharge disposition, and complications. In the study, 66 patients older than 80 were placed in one group and 66 patients with an average age of 60.6 years were placed in a control group. Patients also were stratified into high- and low-comorbidity groups.

Researchers concluded that outcomes between the two age groups were similar, with a 96-percent success rate and no differences in complications or lengths of stay. Comorbid diseases were not associated with higher complication rates, and the study concluded that free tissue transfer is a viable option for major head and neck reconstruction in patients older than 80.

Post-Operative Fluid Management in Head and Neck Microvascular Reconstruction

The relation of fluids to post-operative complications was examined in a retrospective chart review of 87 patients to test the hypothesis of researchers that post-operative volume replacement is associated with post-operative complications.

The study looked at patients with a median age of 61.66 years treated for a variety of conditions, but 85 percent of the patients had head and neck squamous cell carcinoma (HNSCC) and a total of 89 flaps were constructed among the 87 patients.

Researchers concluded that post-operative volume is associated with post-operative complications, length of ICU stay and days on ventilator, but is not associated with flap failure, length of hospital stay or surgical re-exploration. They did conclude that intraoperative fluid volume is associated with increased ICU and hospital length of stay and that post-operative volume status is as important as intra-operative volume status.

Intraoperative Tumor Imaging with Indocyanine Green in Head and Neck Cancer Patients

Surgeons rely on visual and tactile information to distinguish tumors from normal tissue, so researchers studied the use of indocyanine green (ICG) as an imaging agent for improved identification of head and neck tumors.

For the study, five patients with HNSCC were given 7.5 mg of ICG three hours before tumor removal. A near-infrared intraoperative imaging system was used prior to resection. Histologic analysis was performed with a head and neck cancer board-certified pathologist.

They found that ICG accumulated in HNSCC tumors, likely because of the enhanced permeability and retention effect, and that ICG is not specific for cancer. They also concluded that targeted dyes might offer improved specificity.