Eric Santamaria

Factors associated with complications in microvascular reconstruction of head and neck defects.

The use of microvascular free tissue transfer has allowed the reconstruction of increasingly complex defects in higher risk patients after head and neck cancer resections. However, the combination of these factors also gives rise to a higher risk for the development of complications. This study was performed to establish the pretreatment factors associated with complication development after microvascular free tissue transfer for the reconstruction of defects resulting from head and neck cancer ablations, with particular attention to the role of comorbid conditions. A retrospective cohort study was conducted including 200 consecutive microvascular free tissue transfers performed for the reconstruction of surgical defects in the head and neck region at a single tertiary care institution. Comorbidity severity was assessed using the Charlson comorbidity index, a novel approach to comorbid staging in this setting. The flap survival rate was 98 percent. Complications developed in 56 cases (28 percent), with multiple complications occurring in 21 of these cases (10.5 percent). Univariate analysis revealed that prior radiation treatment (p = 0.03), anesthesia time over 10 hours (0.05), and advanced Charlson comorbidity grade (0.002) were associated with an increased risk for the development of complications. However, only the presence of advanced Charlson grade proved significant after multivariate analysis (odds ratio 3.9; 95 percent CI = 1.5 to 10.1). In addition, increasing Charlson grade (p = 0.003) and age over 70 years (p = 0.04) correlated with increasing complication severity. Systemic complications occurred in 28 patients (14 percent), with advanced Charlson grade being the only significant factor associated with the development of complications after controlling for confounding factors (odds ratio 3.8; 95 percent CI = 1.5 to 9.7). In patients over 70 years of age, increasing operative time also impacted on the development of systemic complications (p = 0.002), especially in patients with advanced Charlson grades (0.01). Recipient site complications occurred in 30 patients (15 percent), with history of prior radiation therapy being the only factor associated with increased risk by multivariate analysis (odds ratio 2.5; 95 percent CI = 1.1 to 5.7). No factors predicted the development of donor-site complications, which occurred in 11 cases (5.5 percent). The median hospital stay for the entire population was 16 days. The development of complications increased the median hospital stay by 7.5 days (p < 0.001). The effect of the development of complication on hospital stay remained significant even after controlling for the effects of confounding variables (relative risk = 9.87; 95 percent CI = 5.9 to 19.9). Microvascular surgery is a highly successful and relatively safe method for the reconstruction of large head and neck defects. The Charlson comorbidity index grading may be useful for identifying patients at increased risk for the development of complications after microvascular reconstruction, allowing for improved perioperative planning. In addition, patients with prior radiation exposure have a significantly higher risk for developing complications at the recipient site. Although advanced age is not associated with an increased risk for complications, older patients may be more sensitive to the effects of prolonged anesthesia and are likely to develop more severe complications.

A classification system and algorithm for reconstruction of maxillectomy and midfacial defects.

Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues becomes essential. This study reviews all maxillectomy defects reconstructed immediately using pedicled and free flaps to establish (1) a classification system and (2) an algorithm for reconstruction of these complex problems. Over a 5-year period, 60 flaps were used to reconstruct defects classified as the following: type I, limited maxillectomy (n = 7); type II, subtotal maxillectomy (n = 10); type IIIa, total maxillectomy with preservation of the orbital contents (n = 13); type IIIb, total maxillectomy with orbital exenteration (n = 18); and type IV, orbitomaxillectomy (n = 10). Free flaps (45 rectus abdominis and 10 radial forearm) were used in 55 patients (91.7 percent), and the temporalis muscle was transposed in five elderly patients who were not free-flap candidates. Vascularized (radial forearm osteocutaneous) bone flaps were used in four of the 60 patients (6.7 percent) and nonvascularized bone grafts in 17 (28.3 percent). Simultaneous reconstruction of the oral commissure using an Estandler procedure was performed in 10 patients with maxillectomy and through-and-through soft-tissue defects. Free-flap survival was 100 percent, with reexploration in five of 55 patients (9.1 percent) and partial-flap necrosis in one patient. Seven of the 60 patients (11.7 percent) had systemic complications, and four died within 30 days of hospitalization. Fifty patients had more than 6 months of follow-up with a mean time of 27.7 (±15.6) months. Postoperative radiotherapy was administered in 32 of these patients (64.0 percent). Chewing and speech functions were assessed in 36 patients with type II, IIIa, and IIIb defects. A prosthetic denture was fixed in 15 of 36 patients (41.7 percent). Return to an unrestricted diet was seen in 16 patients (44.4 percent), a soft diet in 17 (47.2 percent), and a liquid diet in three (8.3 percent). Speech was assessed as normal in 14 of 36 patients (38.9 percent), near normal in 15 (41.7 percent), intelligible in six (16.7 percent), and unintelligible in one patient (2.8 percent). Globe and periorbital soft-tissue position was assessed in 14 patients with type I and IIIa defects. There were no cases of enophthalmos, and one patient had a mild vertical dystopia. Ectropion was observed in 10 of 14 patients (71.4 percent). Oral competence was considered good in all 10 patients with excision/reconstruction of the oral commissure; however, two patients (20 percent) developed microstomia after receiving radiotherapy. Aesthetic results were evaluated at least 6 months after reconstruction in 50 patients. They were good to excellent in 29 patients (58 percent) for whom cheek skin and lip were not resected, and poor to fair (42 percent) when the external skin or orbital contents were excised. Secondary procedures were required in 16 of 50 patients (32.0 percent). Free-tissue transfer provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects. The rectus abdominis and radial forearm flaps in combination with immediate bone grafting or as osteocutaneous flaps reliably provide the best aesthetic and functional results. An algorithm based on the type of maxillary resection can be followed to determine the best approach to reconstruction.

reconstruction of Total Maxillectomy Defects with Preservation of the Orbital Contents

&NA; Reconstruction after total maxillectomy with preservation of the orbital contents is technically more challenging than when the maxillectomy is combined with orbital exenteration. Reconstruction of such defects should (1) provide support to the orbital contents, (2) obliterate any communication between the orbit and nasopharynx, (3) reconstruct the palatal surface, and (4) achieve facial symmetry and a good aesthetic result. We report our experience in performing reconstructive surgery on 14 patients who had a total maxillectomy and preservation of the orbital contents using nonvascu‐larized bone grafts for reconstruction of the orbital floor and maxilla, in conjunction with a soft‐tissue free flap or pedicled muscle flap. The orbital floor was reconstructed using split ribs in six cases (42.9 percent), split calvaria in six cases (42.9 percent), and iliac crest graft in two cases (14.3 percent). A myocutaneous rectus abdominis free flap was used for soft‐tissue reconstruction and resurfacing of the palatal mucosa in twelve patients (85.7 percent), and a temporalis muscle transposition was used in two elderly patients (14.3 percent). One patient died 2 days after surgery. Mean follow‐up and aesthetic and functional results were assessed in the remaining 13 patients a minimum of 6 months postoperatively. In 9 of these 13 patients (69.2 percent), postoperative radiotherapy was administered. No reexplorations or free flap failures were observed. One rectus flap developed partial necrosis of the skin island intraorally without affecting the final result. All patients had adequate functional vision. One patient had a mild vertical dystopia; there were no cases of enoph‐thalmos. Ectropion was the most common undesirable result and was present in 10 of 13 cases (76.9 percent). It was graded as mild in four cases (40.0 percent), moderate in four cases (40.0 percent), and severe in the remaining two cases (20.0 percent). Speech was considered normal in six cases (46.2 percent), near normal in six cases (46.2 percent), and intelligible in one case (7.7 percent). Chewing function was considered good (soft to unrestricted diet) in all cases except for one patient who was only able to eat a puréed diet. Aesthetic results after immediate reconstruction were considered good in nine cases (69.2 percent) and fair in four cases (30.8 percent). Primary reconstruction of total maxillectomy defects with orbital content preservation remains a complex problem without a perfect solution. The combination of nonvascularized bone grafts for orbital/maxillary reconstruction with a soft‐tissue free flap is a safe, reliable, and effective method of maximizing postoperative functional and aesthetic results. (Plast. Reconstr. Surg. 102: 1874, 1998.)

Sensation recovery on innervated radial forearm flap for hemiglossectomy reconstruction by using different recipient nerves

The objectives of this study were (1) to determine the extent of sensory recovery on hemitongues reconstructed with innervated radial forearm flaps and (2) to assess the influence of various clinical and surgical factors over the return of sensation, including the use of different recipient nerves for neurorrhaphy. Twenty-eight patients with tongue cancer who underwent hemiglossectomy and primary reconstruction with innervated radial forearm flaps over a 3-year period were studied. Mean postoperative follow-up was 18.2 months (range 6 to 32 months). Sensory recovery was assessed in a blind manner by two examiners that used (1) static two-point discrimination, (2) light touch sensation, (3) pain perception, and (4) hot and cold temperature perception. Different surfaces were assessed with each method on the reconstructed hemitongue and on the intact contralateral hemitongue (used as control). The following factors and their relationship with flap sensory recovery were analyzed: age, smoking history, size of the reconstructed defect, administration of postoperative radiation therapy, recipient nerve, and neurorrhaphy technique. Comparative statistical analysis (p < 0.05) between both hemitongues was performed using paired t test followed by Bonferroni correction for static two-point discrimination and light touch sensation. Fisher exact test analysis was used for pinprick and hot and cold temperature perception. The control side was ignored in analyzing the effects of the risk factors. The tip, dorsal aspect, ventral surface, and floor of mouth on the reconstructed hemitongue had comparable static two-point discrimination when compared with the intact hemitongue. Light touch sensation was also similar in the tip and dorsal aspect of both hemitongues; however, a statistically significant difference (p < 0.05) was observed on the ventral surface and floor of mouth of the reconstructed hemitongues. Likewise, pain perception was significantly decreased in the floor of the mouth, compared with other surfaces. No clearly dependent association was established between return of flap sensation and age, tobacco use, and size of the reconstructed defect. Light touch sensation, pain, and temperature perception were significantly decreased when the patients had received postoperative radiation therapy. In addition, all four sensory tests were significantly diminished (p < 0.05) when the recipient nerve used for neurorrhaphy was a nerve other than the lingual or the inferior alveolar nerve, and also when an end-to-side nerve repair was used. Sensation recovery of the innervated radial forearm flap after hemitongue reconstruction approaches normal compared with the contralateral intact hemitongue. Lower return of sensation may be anticipated in patients who receive postoperative radiotherapy. Good recovery of sensation is predictable when either the lingual or inferior alveolar nerve is used for neurorrhaphy, in contrast to using other recipient nerves.

The role of microsurgery in reconstruction of oncologic chest wall defects.

&NA; Regional pedicled myocutaneous flaps are usually the best choice for soft‐tissue coverage of full‐thickness chest wall defects. As defects increase in size, microsurgical techniques are necessary to augment blood flow to pedicled flaps or to provide free flap coverage from distant sites. This study retrospectively reviews all microsurgical procedures performed at one institution for the coverage of full‐thickness chest wall defects. Twenty‐five cases of fullthickness chest wall reconstruction are reviewed. There were 20 free flaps and five supercharged pedicled flaps. A rectus abdominis myocutaneous flap (free or supercharged) was used in 20 cases, and a filet free flap following forequarter amputation was used in five patients. Large skeletal defects were repaired with a Marlex mesh/methylmethacrylate sandwich prosthesis. There was 100 percent flap survival and one case of minor, partial flap loss. The prosthesis remained effectively covered in all cases. Five patients required ventilatory support for up to 10 days postoperatively. There were three perioperative deaths due to multisystem failure. Microsurgical techniques are extremely useful for reconstruction of complicated, composite chest wall defects. They are indicated when regional pedicled flap options are unavailable or inadequate. These flaps have a 100 percent success rate and uniformly result in stable soft‐tissue coverage. (Plast. Reconstr. Surg. 108: 1924, 2001.)

Primary reconstruction of complex midfacial defects with combined lip-switch procedures and free flaps.

Free flaps are generally the preferred method for reconstructing large defects of the midface, orbit, and maxilla that include the lip and oral commissure; commissuroplasty is traditionally performed at a second stage. Functional results of the oral sphincter using this reconstructive approach are, however, limited. This article presents a new approach to the reconstruction of massive defects of the lip and midface using a free flap in combination with a lip-switch flap. This was used in 10 patients. One-third to one-half of the upper lip was excised in seven patients, one-third of the lower lip was excised in one patient, and both the upper and lower lips were excised (one-third each) in two patients. All patients had maxillectomies, with or without mandibulectomies, in addition to full-thickness resections of the cheek. A switch flap from the opposite lip was used for reconstruction of the oral commissure and oral sphincter, and a rectus abdominis myocutaneous flap with two or three skin islands was used for reconstruction of the through-and-through defect in the midface. Free flap survival was 100 percent. All patients had good-to-excellent oral competence, and they were discharged without feeding tubes. A majority (80 percent) of the patients had an adequate oral stoma and could eat a soft diet. All patients have a satisfactory postoperative result. Immediate reconstruction of defects using a lip-switch procedure creates an oral sphincter that has excellent function, with good mobility and competence. This is a simple procedure that adds minimal operative time to the free-flap reconstruction and provides the patient with a functional stoma and acceptable appearance. The free flap can be used to reconstruct the soft tissue of the intraoral lining and external skin deficits, but it should not be used to reconstruct the lip.

Effects of vasoactive medications on the blood flow of Island musculocutaneous flaps in swine

Pedicled flaps and microsurgical free tissue transfers are increasingly being used for reconstruction in the elderly and poorer risk patient. The use of systemically administered vasoactive agents to date has been avoided because of the fear that systemic levels of these agents perioperatively (particularly the vasopressors) might decrease blood flow and compromise the viability of the flap. There are no large-animal, real-time hemodynamic studies that support or disprove this belief. The objectives of this study were to (1) develop a musculocutaneous flap model in the pig that allows accurate, simultaneous monitoring of systemic and flap hemodynamic parameters such as flow and resistance and (2) identify the effects of commonly used vasoactive substances (dopamine, dobutamine, and phenylephrine) at clinically used levels on systemic and flap pressure/flow relationships. Vertically based rectus abdominis musculocutaneous flaps were raised in 8 anesthetized, 50− to 55-kg pigs, and a flow probe was placed around the artery. Catheters within the pulmonary artery and aorta were used to measure cardiac output and aortic root pressures. Measures of arterial blood pressure, cardiac output, and musculocutaneous flap flow were obtained at baseline and during the administration of varying doses of dopamine dobutamine and phenylephrine. Cardiac output increased significantly with low and high doses of dopamine and dobutamine, but decreased with increasing doses of phenylephrine. Flap flow, on the other hand, is increased only with dobutamine but remains unchanged with dopamine despite increased cardiac output. Flap flow decreases with high doses of phenylephrine. Flap flow also decreases relative to cardiac output with both dopamine and dobutamine. We conclude that (1) phenylephrine clearly affects flap flow adversely in a large-animal musculocutaneous model and therefore should be avoided, (2) dopamine does not affect total flap flov; at either low or high doses despite increasing cardiac output, (3) dobutamine increases both flap flow and cardiac output, and (4) both dopamine and dobutamine should still be used with caution because the flap flow is not equally increased relative to total cardiac output. Possible changes in systemic and flap metabolic demand induced by these vasopressor drugs may therefore still be injurious to the flaps.

Use of a nitric oxide precursor to protect pig myocutaneous flaps from ischemia-reperfusion injury.

&NA; Nitric oxide is a radical with vasodilating properties that protects tissues from neutrophil‐mediated ischemiareperfusion injury in the heart and intestine. Previous studies in our laboratory suggested that L‐arginine, a nitric oxide precursor, can protect skin flaps from ischemiareperfusion injury. In this study, we examined the effects of l‐arginine on the survival of myocutaneous flaps in a large animal model and established whether this effect was mediated by nitric oxide and neutrophils. Two superiorly based 15 × 7.5 cm epigastric myocutaneous island flaps were dissected in 15 Yorkshire pigs weighing 45 to 50 kg. One of the flaps was subjected to 6 hours of arterial ischemia and then reperfused for 4 hours (ischemia‐reperfusion flaps), whereas the other flap was used as a non‐ischemic control (non‐ischemia‐reperfusion flaps). The flaps were divided into four groups: control non‐ischemia‐reperfusion flaps that received only saline (group I); ischemia‐reperfusion flaps that were treated with saline (group II); and flaps treated with either larginine (group III) or NSymbol‐nitro‐l‐arginine methylester (L‐NAME), a nitric oxide synthase competitive inhibitor, plus l‐arginine in equimolar amounts (group IV). These drugs were administered as an intravenous bolus 10 minutes before the onset of reperfusion, followed by a 1‐hour continuous intravenous infusion. Full‐thickness muscle biopsies were taken at baseline, 3 and 6 hours of ischemia, and 1 and 4 hours of reperfusion. The biopsies were evaluated by counting neutrophils and measuring myeloperoxidase activity. At the end of the experiment, skeletal muscle necrosis was quantified using the nitroblue tetrazolium staining technique, and a full‐thickness biopsy of each flap was used for determination of water content. Statistical analysis was performed using analysis of variance and the Newman‐Keuls test. Symbol. No caption available. Non‐ischemia‐reperfusion flaps showed no muscle necrosis. Ischemia‐reperfusion flaps treated with saline had 68.7 ± 9.1 percent necrosis, which was reduced to 21.9 ± 13.6 percent with l‐arginine (p < 0.05). L‐NAME administered concomitantly with l‐arginine demonstrated a necrosis rate similar to that of saline‐treated ischemia‐reperfusion flaps (61.0 ± 17.6 percent). Neutrophil counts and myeloperoxidase activity after 4 hours of reperfusion were significantly higher in ischemia‐reperfusion flaps treated with L‐NAME and L‐arginine as compared with the other three groups (p < 0.05). Flap water content increased significantly in ischemia‐reperfusion flaps treated with saline and L‐NAME plus L‐arginine versus non‐ischemia‐reperfusion flaps (p < 0.02) and l‐argininetreated ischemia‐reperfusion flaps (p < 0.05). There was no difference in flap water content between ischemiareperfusion flaps treated with l‐arginine and non‐ischemia‐reperfusion flaps. Administration of l‐arginine before and during the initial hour of reperfusion significantly reduced the extent of flap necrosis, neutrophil accumulation, and edema due to ischemia‐reperfusion injury in a large animal model. This protective effect is completely negated by the use of the nitric oxide synthase blocker L‐NAME. The mechanism of action seems to be related to nitric oxide‐mediated suppression of ischemia‐reperfusion injury through neutrophil activity inhibition. (Plast. Reconstr. Surg. 102: 2040, 1998.)

Barium swallows after free jejunal transfer: should they be performed routinely?

Fistula formation after free jejunal transfer for pharyngoesophageal reconstruction is a serious complication with potentially critical consequences. Barium swallow is used postoperatively to check for anastomotic competence before feeding but has been unreliable as a predictor of leak at our institution. The objective of this study was to evaluate the role of routine postoperative barium swallow in 41 consecutive jejunal transfers. Thirty-nine patients who underwent 41 consecutive free jejunal transfers had a routine barium swallow performed between postoperative days 12 and 17. Radiologic findings and clinical outcome were evaluated and correlated. All barium swallows were reviewed by a single experienced radiologist in a blinded fashion. One total and one partial flap failure necessitated a second free jejunal transfer. Pharyngocutaneous fistulae developed after nine free jejunal transfers, of which the barium swallow was normal in four (44 percent) and showed a leak in five (56 percent). In the 32 free jejunal transfers with no clinical leaks, 6 (19 percent) had radiologic leakage of contrast. Thus, barium swallow was normal in 30 patients and showed leakage in 11 patients. Normal barium swallow correlated with uncomplicated clinical course in 26 of 30 cases. In the remaining four cases (13 percent), however, a delayed fistula developed, which was secondary to flap necrosis in one case (negative predictive value 87 percent). On the other hand, radiologic leaks corroborated clinical fistula in 5 of 11 cases (45 percent), whereas no fistula developed in 6 cases (positive predictive value 46 percent). Of the five patients with clinical fistulae, four had early leaks (within 1 week), and the barium swallow did not provide additional information. The fifth patient developed a delayed leak 2 weeks after the barium swallow. Review of these barium swallows at the time of this study reversed the initial report of leakage in three patients, improving the predictive value to 63 percent. These patients had an uncomplicated clinical course. The positive predictive value of clinical assessment alone was 63 percent. We conclude that barium studies following free jejunal transfers can be difficult to interpret, but an experienced radiologist can improve their accuracy. A normal barium swallow, however, does not ensure an uneventful clinical course. Similarly, radiologic leaks do not imply a clinical complication of fistula. Clinical judgment should therefore be exercised in initiating oral intake after free jejunal transfer. Barium swallow should be used only as an adjunct to aid in patient management.

Prevention of ischemia-reperfusion injury in a rat skin flap model: the role of mast cells, cromolyn sodium, and histamine receptor blockade.

The objective of this study was to examine the role of mast cells and their principal product, histamine, in ischemia/reperfusion injury. Cromolyn sodium, diphenhydramine, and cimetidine were administered to ischemic flaps just before reperfusion and evaluated for flap survival, mast cell count, neutrophil count, and myeloperoxidase levels. Epigastric island skin flaps were elevated in 49 rats; they were rendered ischemic by clamping the artery for 10 hours. Thirty minutes before reperfusion, the rats were treated with intraperitoneal saline (n = 11), cimetidine (n = 11), diphenhydramine (n = 11), or cromolyn sodium (n = 10). Flap survival was evaluated at 7 days. Neutrophil counts, mast cell counts, and myeloperoxidase levels were evaluated 12 hours after reperfusion. Flap necrosis in the sham group of animals (n = 6) was 0.0 percent, as expected, whereas the control group (saline-treated animals) had 47.3 ± 33.4 percent necrosis. Animals treated with diphenhydramine and cimetidine demonstrated a significant decrease in flap necrosis to 17.7 ± 8.8 percent and 19.4 ± 14.7 percent, respectively. This protective effect was not seen with cromolyn sodium (44.3 ± 35.6 percent). Both neutrophil and mast cell counts were significantly decreased in flaps from antihistamine-treated and sham animals versus both saline- and cromolyn sodium–treated groups. The administration of diphenhydramine and cimetidine before reperfusion can significantly reduce the extent of flap necrosis and the neutrophil and mast cell counts caused by ischemia/reperfusion. This protective effect is not seen with cromolyn sodium. The protective effect of antihistamines on flap necrosis might be related to the decrease in neutrophils and, possibly, mast cells within the flap.