Consensus of free flap complications: Using a nomenclature paradigm in microvascular head and neck reconstruction

BackgroundWe aim to define a set of terms for common free flap complications with evidence‐based descriptions.MethodsClinical consensus surveys were conducted among a panel of head and neck/reconstructive surgeons (N = 11). A content validity index for relevancy and clarity for each item was computed and adjusted for chance agreement (modified kappa, K). Items with K < 0.74 for relevancy (i.e., ratings of “good” or “fair”) were eliminated.ResultsFive out of nineteen terms scored K < 0.74. Eliminated terms included “vascular compromise”; “cellulitis”; “surgical site abscess”; “malocclusion”; and “non‐ or mal‐union.” Terms that achieved consensus were “total/partial free flap failure”; “free flap takeback”; “arterial thrombosis”; “venous thrombosis”; “revision of microvascular anastomosis”; “fistula”; “wound dehiscence”; “hematoma”; “seroma”; “partial skin graft failure”; “total skin graft failure”; “exposed hardware or bone”; and “hardware failure.”ConclusionStandardized reporting would encourage multi‐institutional research collaboration, larger scale quality improvement initiatives, the ability to set risk‐adjusted benchmarks, and enhance education and communication.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/170285/1/hed26789.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/170285/2/hed26789_am.pd

Long-term Functional Outcomes of Total Glossectomy With or Without Total Laryngectomy

The optimal reconstruction of total glossectomy defects with or without total laryngectomy is controversial. Various pedicled and free tissue flaps have been advocated, but long-term data on functional outcomes are not available to date. To compare various total glossectomy defect reconstructive techniques used by multiple institutions and to identify factors that may lead to improved long-term speech and swallowing function. A multi-institutional, retrospective review of electronic medical records of patients undergoing total glossectomy at 8 participating institutions between June 1, 2001, and June 30, 2011, who had a minimal survival of 2 years. Total glossectomy with or without total laryngectomy. Demographic and surgical factors were compiled and correlated with speech and swallowing outcomes. At the time of the last follow-up, 45% (25 of 55) of patients did not have a gastrostomy tube, and 76% (42 of 55) retained the ability to verbally communicate. Overall, 75% (41 of 55) of patients were tolerating at least minimal nutritional oral intake. Feeding tube dependence was not associated with laryngeal preservation or the reconstructive techniques used, including flap suspension, flap innervation, or type of flap used. Laryngeal preservation was associated with favorable speech outcomes, such as the retained ability to verbally communicate in 97% of those not undergoing total laryngectomy (35 of 36 patients) vs 44% (7 of 16) in those undergoing total laryngectomy (P < .001), as well as those not undergoing total laryngectomy achieving some or all intelligible speech in 85% (29 of 34 patients) compared with 31% (4 of 13) undergoing total laryngectomy achieving the same intelligibility (P < .001). In patients with total glossectomy, feeding tube dependence was not associated with laryngeal preservation or the reconstructive technique, including flap innervation and type of flap used. Laryngeal preservation was associated with favorable speech outcomes such as the retained ability to verbally communicate and higher levels of speech intelligibility

Free Flap Reconstruction Monitoring Techniques and Frequency in the Era of Restricted Resident Work Hours

Importance: Free flap reconstruction of the head and neck is routinely performed with success rates around 94% to 99% at most institutions. Despite experience and meticulous technique, there is a small but recognized risk of partial or total flap loss in the postoperative setting. Historically, most microvascular surgeons involve resident house staff in flap monitoring protocols, and programs relied heavily on in-house resident physicians to assure timely intervention for compromised flaps. In 2003, the Accreditation Council for Graduate Medical Education mandated the reduction in the hours a resident could work within a given week. At many institutions this new era of restricted resident duty hours reshaped the protocols used for flap monitoring to adapt to a system with reduced resident labor. Objectives: To characterize various techniques and frequencies of free flap monitoring by nurses and resident physicians; and to determine if adapted resident monitoring frequency is associated with flap compromise and outcome. Design, Setting, and Participants: This multi-institutional retrospective review included patients undergoing free flap reconstruction to the head and/or neck between January 2005 and January 2015. Consecutive patients were included from different academic institutions or tertiary referral centers to reflect evolving practices. Main Outcomes and Measures: Technique, frequency, and personnel for flap monitoring; flap complications; and flap success. Results: Overall, 1085 patients (343 women [32%] and 742 men [78%]) from 9 institutions were included. Most patients were placed in the intensive care unit postoperatively (n = 790 [73%]), while the remaining were placed in intermediate care (n = 201 [19%]) or in the surgical ward (n = 94 [7%]). Nurses monitored flaps every hour (q1h) for all patients. Frequency of resident monitoring varied, with 635 patients monitored every 4 hours (q4h), 146 monitored every 8 hours (q8h), and 304 monitored every 12 hours (q12h). Monitoring techniques included physical examination (n = 949 [87%]), handheld external Doppler sonography (n = 739 [68%]), implanted Doppler sonography (n = 333 [31%]), and needle stick (n = 349 [32%]); 105 patients (10%) demonstrated flap compromise, prompting return to the operating room in 96 patients. Of these 96 patients, 46 had complete flap salvage, 22 had partial loss, and 37 had complete loss. The frequency of resident flap checks did not affect the total flap loss rate (q4h, 25 patients [4%]; q8h, 8 patients [6%]; and q12h, 8 patients [3%]). Flap salvage rates for compromised flaps were not statistically different. Conclusions and Relevance: Academic centers rely primarily on q1h flap checks by intensive care unit nurses using physical examination and Doppler sonography. Reduced resident monitoring frequency did not alter flap salvage nor flap outcome. These findings suggest that institutions may successfully monitor free flaps with decreased resident burden

Soft tissue management in open fractures of the lower leg: the role of vacuum therapy

The management of severe open fractures of the lower leg continues to challenge the treating surgeon. Major difficulties include high infection rates as well as adequate temporary soft tissue coverage. In the past, these injuries were commonly associated with loss of the extremity. Today, vacuum therapy provides not only safe temporary wound coverage but also conditioning of the soft tissues until definitive wound closure. Amongst other advantages, bacterial clearance and increased formation of granulation tissue are attributed to vacuum therapy, making it an extremely attractive tool in the field of wound healing. However, despite its clinical significance, which is underlined by a constantly increasing range of indications, there is a substantial lack of basic research and well-designed studies documenting the superiority of vacuum therapy compared to alternative wound dressings. Vacuum therapy has been approved as an adjunct in the treatment of severe open fractures of the lower leg, complementing repeated surgical debridement and soft tissue coverage by microvascular flaps, which are still crucial in the treatment of these limb-threatening injuries. Vacuum therapy has in general proven useful in the management of soft tissue injuries and, since it is generally well tolerated and has low complication rates, it is fast becoming the gold standard for temporary wound coverage in the treatment of severe open fractures of the lower le