Joseph J. Disa

Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.

Osseous free flaps have become the preferred method for reconstructing segmental mandibular defects. Of 457 head and neck free flaps, 150 osseous mandible reconstructions were performed over a 10-year period. This experience was retrospectively reviewed to establish an approach to osseous free flap mandible reconstruction. There were 94 male and 56 female patients (mean age, 50 years; range 3 to 79 years); 43 percent had hemimandibular defects, and the rest had central, lateral, or a combination defect. Donor sites included the fibula (90 percent), radius (4 percent), scapula (4 percent), and ilium (2 percent). Rigid fixation (up to five osteotomy sites) was used in 98 percent of patients. Aesthetic and functional results were evaluated a minimum of 6 months postoperatively. The free flap success rate was 100 percent, and bony union was achieved in 97 percent of the osteotomy sites. Osseointegrated dental implants were placed in 20 patients. A return to an unrestricted diet was achieved in 45 percent of patients; 45 percent returned to a soft diet, and 5 percent were on a liquid diet. Five percent of patients required enteral feeding to maintain weight. Speech was assessed as normal (36 percent), near normal (27 percent), intelligible (28 percent), or unintelligible (9 percent). Aesthetic outcome was judged as excellent (32 percent), good (27 percent), fair (27 percent), or poor (14 percent). This study demonstrates a very high success rate, with good-to-excellent functional and aesthetic results using osseous free flaps for primary mandible reconstruction. The fibula donor site should be the first choice for most cases, particularly those with anterior or large bony defects requiring multiple osteotomies. Use of alternative donor sites (i.e., radius and scapula) is best reserved for cases with large soft-tissue and minimal bone requirements. The ilium is recommended only when other options are unavailable. Thoughtful flap selection and design should supplant the need for multiple, simultaneous free flaps and vein grafting in most cases.

Free flap reexploration: Indications, treatment, and outcomes in 1193 free flaps

Background: Microvascular free tissue transfer is a reliable method for reconstruction of complex surgical defects. However, there is still a small risk of flap compromise necessitating urgent reexploration. A comprehensive study examining the causes and methods of avoiding or treating these complications has not been performed. The purpose of this study was to review the authors’ experience with a large number of microvascular complications over an 11-year period. Methods: This was a retrospective review of all free flaps performed from 1991 to 2002 at Memorial Sloan-Kettering Cancer Center. All patients who required emergent reexploration were identified, and the incidence of vascular complications and methods used for their management were analyzed. Results: A total of 1193 free flaps were performed during the study period, of which 6 percent required emergent reexploration. The most common causes for reexploration were pedicle thrombosis (53 percent) and hematoma/bleeding (30 percent). The overall flap survival rate was 98.8 percent. Venous thrombosis was more common than arterial thrombosis (74 versus 26 percent) and had a higher salvage rate (71 versus 40 percent). Salvaged free flaps were reexplored more quickly than failed flaps (4 versus 9 hours after detection; p = 0.01). There was no significant difference in salvage rate in flaps requiring secondary vein grafting or thrombolysis as compared with those with anastomotic revision only. Conclusions: Microvascular free tissue transfer is a reliable reconstructive technique with low failure rates. Careful monitoring and urgent reexploration are critical for salvage of compromised flaps. The majority of venous thromboses can be salvaged. Arterial thromboses can be more problematic. An algorithm for flap exploration and salvage is presented.

Predicting Complications following Expander/Implant Breast Reconstruction : An Outcomes Analysis Based on Preoperative Clinical Risk

Background: Complications following postmastectomy reconstruction can cause significant morbidity. The compound effect of individual risk factors on the development of complications following expander/implant reconstruction has not, however, been well delineated. This study evaluated the impact of clinical risk factors to predict complications following postmastectomy expander/implant reconstruction. Methods: From 2003 through 2004, 1170 expander/implant reconstructions were performed at a single center. A prospectively maintained database was reviewed. Variables including age, smoking status, body mass index, history of diabetes, hypertension, chemotherapy and/or radiation, as well as timing and laterality of reconstruction were evaluated. The primary endpoint was the development of a complication; the secondary endpoint was failure of reconstruction. Results: Over the 2 year study period, 1170 expander/implant reconstructions were performed in 884 patients. The odds of developing complications was 2.2 times greater in smokers (p < 0.001) and 2.5 times greater in women over 65 (p = 0.008). Patients who were obese were at nearly two times the odds of having complications (p = 0.02), as were patients with hypertension (p = 0.02). Similarly, the odds of reconstructive failure were five times greater in smokers (p < 0.001). Age was not a significant predictor of reconstructive failure (p = 0.09); yet, failure was nearly seven times greater in obese patients (p < 0.001), and four more times likely in those who were hypertensive (p = 0.005). Conclusions: Smoking, obesity, hypertension, and age over 65 were independent risk factors for perioperative complications following expander/implant breast reconstruction. Smoking, obesity, and hypertension were similarly associated with reconstructive failure. This information can be used to evaluate overall procedural risks and individualize reconstructive options.

Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases.

Conventional free flap monitoring techniques (clinical observation, hand-held Doppler ultrasonography, surface temperature probes, and pinprick testing) are proven methods for monitoring free flaps with an external component. Buried free flaps lack an external component; thus, conventional monitoring is limited to hand-held Doppler ultrasonography. Free flap success is enhanced by the rapid identification and salvage of failing flaps. The purpose of this study was to compare the salvage rate and final outcomes of buried versus nonburied flaps monitored by conventional techniques. This study is a retrospective review of 750 free flaps performed between 1986 and 1997 for reconstruction of oncologic surgical defects. There were 673 nonburied flaps and 77 buried flaps. All flaps were monitored by using conventional techniques. Both buried and nonburied flaps were used for head and neck and extremity reconstruction. Only nonburied flaps were used for trunk and breast reconstruction. Buried flap donor sites included jejunum (n = 50), fibula (n = 16), forearm (n = 8), rectus abdominis (n = 2), and temporalis fascia (n = 1). Overall flap loss for 750 free flaps was 2.3 percent. Of the 77 buried flaps, 5 flaps were lost, yielding a loss rate of 6.5 percent. The loss rate for nonburied flaps (1.8 percent) was significantly lower than for buried flaps (p = 0.02, Fishers exact test). Fifty-seven (8.5 percent) of the nonburied flaps were reexplored for either change in monitoring status or a wound complication. Reexploration occurred between 2 and 400 hours postoperatively (mean, 95 hours). All 44 of the salvaged flaps were nonburied; these were usually reexplored early (<48 hours) for a change in the monitoring status. Flap compromise in buried flaps usually presented late (>7 days) as a wound complication (infection, fistula). None of five buried flaps were salvageable at the time of reexploration. The overall salvage rate of nonburied flaps (77 percent) was significantly higher than that of buried flaps (0 percent, p<0.001, chi-square test). Conventional monitoring of nonburied free flaps has been highly effective in this series. These techniques have contributed to rapid identification of failing flaps and subsequent salvage in most cases. As such, conventional monitoring has led to an overall free flap success rate commensurate with current standards. In contrast, conventional monitoring of buried free flaps has not been reliable. Failing buried flaps were identified late and found to be unsalvageable at reexploration. Thus, the overall free flap success rate was significantly lower for buried free flaps. To enhance earlier identification of flap compromise in buried free flaps, alternative monitoring techniques such as implantable Doppler probes or exteriorization of flap segments are recommended.

a Review of 716 Consecutive Free Flaps for Oncologic Surgical Defects: Refinement in Donor-site Selection and Technique

&NA; Free‐tissue transfer has become an important method for reconstructing complex oncologic surgical defects. This study is a retrospective review of a 10‐year experience with 716 consecutive free flaps in 698 patients. Regional applications included the head and neck (69 percent), trunk and breast (14 percent), lower extremity (12 percent), and upper extremity (5 percent). Donor sites included the rectus abdominis (195), fibula (193), forearm (133), latissimus dorsi (69), jejunum (55), gluteus (28), scapula (26), and seven others (17). Microvascular anastomoses were performed to large‐caliber recipient vessels using a continuous suture technique; end‐to‐end anastomoses were preferred (75 percent). Flaps were designed to avoid the need for vein grafts. Conventional postoperative flap monitoring methods were used. These included clinical observation supplemented by Doppler ultrasonography, surface temperature probes, and pin prick testing. Buried flaps were either evaluated with Doppler ultrasonography or not monitored. The overall success rate for free‐flap reconstruction of oncologic surgical defects was 98 percent. Fifty‐seven flaps (8 percent) were reexplored for either anastomotic or infectious problems. Reexplored flaps were salvaged in 40 cases (70 percent). Surviving flaps resulted in a healed wound and did not delay postoperative radiation or chemotherapy. The incidence of major and minor postoperative complications was 34 percent. The mean duration of hospitalization was 20 days, and the average cost was

Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications.

40,224. The results of this study support the need for only seven donor sites to solve the majority (98 percent) of oncologic problems requiring microsurgical expertise. The evolution of preferred donor sites for specific regional applications is illustrated in this 10‐year experience. Technical refinements have simplified performing the microsurgical anastomoses and essentially eliminated the need for vein grafts. Conventional monitoring has led to the rapid identification of vascular compromise and subsequent flap salvage in the majority of non‐buried free flaps. (Plast. Reconstr. Surg. 102: 722, 1998.)

Rectus Flap Reconstruction Decreases Perineal Wound Complications After Pelvic Chemoradiation and Surgery: A Cohort Study

Background: Little information exists on the incidence of complications after acellular human dermis implantation in two-stage tissue expander breast reconstruction. The purpose of this study was to evaluate the incidence of postoperative adverse events and identify significant predictors of complications in acellular human dermis tissue expander breast reconstruction. Methods: This study accrued all patients from January of 2004 through April of 2008 undergoing two-stage immediate tissue expander breast reconstruction using acellular human dermis. A total of 153 expanders were placed. Complications were assessed. Univariate and multivariate logistic regression modeling was performed. Comparison of complication rates using the traditional (non–acellular human dermis) technique from concurrent (2004 to 2008) and consecutive time periods (2001 to 2003) for 2910 and 1170 expanders, respectively, is provided. Results: A total of 153 expanders were implanted in 96 women: 39 unilateral and 57 bilateral. Eleven (7.2 percent) were removed due to infection (n = 5, 3.3 percent), exposure (n = 4, 2.6 percent), or patient preference (n = 2, 1.3 percent). Other complications included cellulitis (3.9 percent), seroma (7.2 percent), hematoma (2.0 percent), mastectomy flap necrosis (4.6 percent), and leak/failed expansion (0.0 percent); 92.8 percent were successfully expanded and exchanged for a permanent implant. Eleven seromas (7.2 percent) were identified; nine underwent aspiration. None of these resulted in infection or reconstructive failure. Univariate analysis revealed age, body mass index, axillary dissection, and postoperative chemotherapy to be associated with reconstructive failure (p < 0.05). Multivariate analysis revealed that age, body mass index, and axillary dissection are independent risk factors for developing complications (p < 0.05). Conclusion: Acellular human dermis is a useful adjunct for intraoperative pocket development in immediate tissue expander reconstruction but can result in an increased risk of complications, in particular, seroma and reconstructive failure.

Simplifying microvascular head and neck reconstruction: A rational approach to donor site selection

BackgroundA major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population.MethodsThe study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher’s exact test, and comparison of means was performed with Wilcoxon’s test.ResultsPerineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group.ConclusionsPerineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.

A paradigm shift in U.S. breast reconstruction: Part 2. The influence of changing mastectomy patterns on reconstructive rate and method.

The purpose of this study was to review the authors’ 13-year experience with free tissue transfer for head and neck oncology patients. This study was a retrospective review of 728 free flaps performed in 698 patients. Recipient sites were subdivided by region into the mandible (N = 253), mid face/orbit (N = 190), hypopharynx (N = 134), oral cavity (N = 104), skull base (N = 36), and scalp (N = 11). The overall free flap success rate was 98.6%. Seventy-nine flaps (10.9%) were reexplored for vascular compromise. Ten flaps (1.4%) were lost in their entirety. The overall complication rate was 17.5%. Four donor sites (forearm, fibula, rectus, and jejunum) were used for 92% of the patients. The results of the study confirm the efficacy of free tissue transfer in the reconstruction of oncological head and neck defects. In this series the free forearm, fibula, rectus, and jejunum flaps have become the workhorse donor sites for the vast majority of defects.Disa JJ, Pusic AL, Hidalgo DH, et al. Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection. Ann Plast Surg 2001;47:385–389

Microvascular reconstruction of the hypopharynx: defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases.

Background: The aims of the current study were to (1) measure trends in the type of mastectomy performed, (2) evaluate sociodemographic/hospital characteristics of patients undergoing contralateral prophylactic mastectomy versus unilateral mastectomies, and (3) analyze reconstruction rates and method used following different mastectomy types. Methods: Mastectomies from 1998 to 2008 were analyzed using the Nationwide Inpatient Sample database. Mastectomies (n = 178,603) were classified as either unilateral, contralateral prophylactic, or bilateral prophylactic. Reconstructive procedures were categorized into either implant or autologous. Longitudinal trends were analyzed with Poisson regression and sociodemographic/hospital variables were analyzed with logistic regression. Results: Unilateral mastectomies decreased 2 percent per year, whereas contralateral and bilateral prophylactic mastectomies increased significantly by 15 and 12 percent per year, respectively (p < 0.01). Independent predictors for contralateral prophylactic mastectomy (compared with unilateral mastectomy) were patients younger than 39 years, Caucasian and Hispanic race, private insurance carriers, treated in teaching hospitals, and from South and Midwest regions. Contralateral prophylactic mastectomy is the only group with increased reconstruction rates throughout the study period (p < 0.01). Although implant use increased for all mastectomy types, it remains greater in bilateral and contralateral prophylactic mastectomy. Conclusions: There is increasing use of bilateral mastectomies in the United States, particularly in patients with unilateral cancer. Although implant use has increased for all mastectomy types, they are used most commonly following bilateral and contralateral prophylactic mastectomies. Changing mastectomy patterns are one factor underlying the paradigm shift away from autologous tissue to implant-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.