T.K. Blackburn

Preoperative Doppler assessment of perforator anatomy in the anterolateral thigh flap

Despite its many evident merits as a donor site, the principal disadvantage of the anterolateral thigh flap is the variability in its vascular anatomy. Preoperative assessment by Doppler of the vascular perforators has been advocated as routine. We report the accuracy of this method, and describe the strategy for rescue where adequate perforators are not evident. Eighty-six consecutive patients were marked preoperatively using hand-held Doppler and the pattern was compared with intraoperative findings. Assessment by Doppler predicted a median of 3 (range 0-8) perforator signals, and a median of 2 (range 0-5) was found intraoperatively. This overall trend towards false positives was exaggerated in thin thighs, but in the obese there were more false negative results. In 79% of cases explored medially it would have been possible to raise an apparently viable anteromedial thigh flap. As this can be done without extending the incision, it is the option of choice for rescue, although use of more proximal perforators may often be possible.

Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) free flap.

We retrospectively reviewed 15 cases of pharyngolaryngectomy for advanced laryngeal carcinoma reconstructed with the anterolateral thigh (ALT) free flap. Thirteen patients had primary surgery and adjuvant treatment (radiotherapy or chemoradiotherapy), and two had salvage surgery. Thirteen had stage III or IV disease, and eight had cervical nodal extracapsular spread. In this series all the flaps survived, and at median follow-up of 14.5 months (range 3.7-31.2), 12 of the 15 patients were alive. One patient developed a chronic pharyngocutaneous fistula, and five required repeat balloon dilatations for late pharyngeal strictures. Six patients enjoyed restoration of full oral intake, seven were able to take a soft diet, and two were dependent on feeding by percutaneous endoscopic gastrostomy. Four patients developed adequate tracheo-oesophageal speech, and one successfully developed oesophageal speech. In this series many of the surgical problems associated with pharyngolaryngectomy reconstruction were addressed successfully by the ALT, but late dysphagia remained troublesome in an appreciable minority. While adjuvant radiotherapy could have contributed to this, future innovations will focus on the reduction of late strictures.

Safety of a regimen for thromboprophylaxis in head and neck cancer microvascular reconstructive surgery: non-concurrent cohort study

We aimed to assess bleeding complications after increasing the thromboprophylactic dose of dalteparin from 2500 to 5000 units 12h preoperatively in line with guidance on risk stratification and appropriate pharmacological thromboprophylaxis. We evaluated two groups of patients for confounding factors and bleeding, a prospective consecutive high dose group (n=29), and a retrospective low dose group (n=30) who had had ablative and microvascular reconstructive surgery for oral or oropharyngeal cancer. The bleeding index over 5 days (range 40-60) was used as an objective measure of perioperative bleeding. The null hypothesis was that there was no difference in the bleeding index between the two groups. We found no significant difference in the mean bleeding index between the two groups (p=0.56) (mean (SD) bleeding index in the high dose group 45.3 (26.1), and 48.7 (18.1) in the low dose group). The 95% confidence interval (CI) was -1.51 lower to 0.83 higher in the high dose group. Five patients (2 (7%) in the high dose, and 3 (10%) in the low dose group) were returned to theatre with bleeding complications. There was a trend to a higher failure rate of free flaps in the high dose group (4 (13%) complete, and 1 partial failure compared with 1 (3%) complete and 1 partial failure in the low dose group). There were no symptomatic thromboembolic events in either group. An increased dose of dalteparin did not seem to increase conventional surgical bleeding complications, which was consistent with the null hypothesis at evidence level 2b, but a larger sample is needed to explore its impact on venous thromboembolic events and on the failure of microvascular free flaps.

Valaciclovir in combination with prednisolone for Bell's palsy

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Microdialysis monitoring of a craniofacial microvascular free flap reconstruction detected critical brain swelling

Abstract Microdialysis is one of several methods described for monitoring the anastomosis and blood flow to the donor tissue in microvascular-free tissue transfer for craniofacial reconstructive surgery. A case is presented where a microdialysis free flap monitoring system detected metabolic aberrations within the free flap secondary to a rise in intracranial pressure, which the intracranial pressure monitor had failed to detect.