Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis

Miller, Henry; Bush, Kathryn; Delancy, Matthew M; Leo, Nicholas De; Joshi, Hansa; Saracco, Benjamin; Adams, Amanda; Gaughan, John; Bonawitz, Steven C.

doi:10.1016/j.bjps.2021.09.050

Cited by 13 publications

(8 citation statements)

References 46 publications

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“…The data in this study showed that flap outcomes were not associated with medical comorbidities, smoking, or postoperative complications. Prior literature showed that a history of radiation therapy, smoking, and wound infection were associated with free flap compromise in primary reconstructions . To our knowledge, there are no data regarding flap outcomes for secondary reconstructions.…”

Section: Discussionmentioning

confidence: 92%

“…Prior literature showed that a history of radiation therapy, smoking, and wound infection were associated with free flap compromise in primary reconstructions. [14][15][16][17] To our knowledge, there are no data regarding flap outcomes for secondary reconstructions. A systematic review by Herle et al 15 demonstrated increased rates of flap compromise and wound complications in patients with a history of radiation therapy; furthermore, higher doses of radiation were correlated with increased rates of flap failure.…”

Section: Discussionmentioning

confidence: 99%

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Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

Slijepcevic

Young

Shinn

et al. 2022

JAMA Otolaryngol Head Neck Surg

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free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown.OBJECTIVE To assess the outcomes of a second revascularization attempt for compromised free flaps. DESIGN, SETTING, AND PARTICIPANTSThis multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. MAIN OUTCOME AND MEASUREFlaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts.RESULTS A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage. CONCLUSIONS AND RELEVANCEIn this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.

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Section: Discussionmentioning

confidence: 92%

Section: Discussionmentioning

confidence: 99%

Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

Slijepcevic

Young

Shinn

et al. 2022

JAMA Otolaryngol Head Neck Surg

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“…No correlation could be identified in the present work either. However, an increased risk of complications in previously irradiated patients is widely acknowledged, showing that patients with previous XRT were at an increased risk of total flap failure [ 33 ], partial flap failure, and overall postoperative complications including local infection, plate exposure, and wound dehiscence [ 31 , 34 , 35 , 36 ]. Regarding the occurrence of malperfusion, there is a positive correlation with reconstruction timing, as delayed procedures (>15 weeks after XRT) are associated with a higher rate of vascular complications [ 36 ].…”

Section: Discussionmentioning

confidence: 99%

The Perfect Timing—Immediate versus Delayed Microvascular Reconstruction of the Mandible

Thiem,

Siegberg,

Vinayahalingam

et al. 2024

Cancers

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In this retrospective study, the clinical and economic implications of microvascular reconstruction of the mandible were assessed, comparing immediate versus delayed surgical approaches. Utilizing data from two German university departments for oral and maxillofacial surgery, the study included patients who underwent mandibular reconstruction following continuity resection. The data assessed included demographic information, reconstruction details, medical history, dental rehabilitation status, and flap survival rates. In total, 177 cases (131 male and 46 females; mean age: 59 years) of bony free flap reconstruction (72 immediate and 105 delayed) were included. Most patients received adjuvant treatment (81% with radiotherapy and 51% combined radiochemotherapy), primarily for tumor resection. Flap survival was not significantly influenced by the timing of reconstruction, radiotherapy status, or the mean interval (14.5 months) between resection and reconstruction. However, immediate reconstruction had consumed significantly fewer resources. The rate of implant-supported masticatory rehabilitation was only 18% overall. This study suggests that immediate jaw reconstruction is economically advantageous without impacting flap survival rates. It emphasizes patient welfare as paramount over financial aspects in clinical decisions. Furthermore, this study highlights the need for improved pathways for masticatory rehabilitation, as evidenced by only 18% of patients with implant-supported dentures, to enhance quality of life and social integration.

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“…Multiple systematic reviews have shown that preoperative radiotherapy is associated with an increased risk in postoperative complication rates, including flap failure and recurrent fistula formation. [18][19][20] Surgical reconstruction options are based on the size, location, and extent of surrounding tissue involvement. However, each of these defects in previously reconstructed irradiated palates is unique.…”

Section: Reconstruction Principles Of Palatal Defectsmentioning

confidence: 99%

Section: Reconstruction Principles Of Palatal Defectsmentioning

confidence: 99%

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

et al. 2022

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Palatal fistulas have significant effects on quality of life. Traditional prosthetic rehabilitation and surgical reconstruction of palate defects in radiation-naïve tissues are well described. However, palatal fistulas developing after initial tumor extirpation, free-flap reconstruction, and adjuvant radiation or chemoradiation are associated with challenging secondary tissue effects. In this review, we will discuss the management of palatal fistulas after surgical reconstruction and radiotherapy.

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Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis

Cited by 13 publications

References 46 publications

Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

The Perfect Timing—Immediate versus Delayed Microvascular Reconstruction of the Mandible

Management of Palatal Defects after Free-Flap Reconstruction and Radiotherapy

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