Failure of preoperative co-morbidity indices to predict the successful use of the composite scapula free flap for maxillofacial reconstruction in patients with significant medical co-morbidities.

The aim of this study was to evaluate the accuracy of validated preoperative patient co-morbidity assessments, including the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), with the use of the composite scapula free flap (CSFF) in maxillofacial reconstruction in patients with significant medical co-morbidities. A retrospective cohort review was performed at an academic institution, covering the period from July 2010 through January 2019. All patients who underwent reconstruction with a CSFF with significant medical co-morbidities were included. Co-morbidity assessments and risk factors were analyzed by comparing predicted versus observed early and late medical and surgical complications. Forty-five patients met the inclusion criteria. The surgical complication rate was 47%; the medical complication rate was 38%. Over 90% of patients returned to successful function at 3 months post-surgery. The ACS-NSQIP prediction of complications ranged from 58% to 75% for accuracy, 76% to 100% for sensitivity, and 50% to 69% for specificity. The prediction of a serious complication was statistically significant in patients with a Charlson Co-morbidity Index ≥7. Age ≥80 years did not significantly increase the risk of a serious complication (P = 0.23). The ACS-NSQIP failed to predict the successful use of the CSFF for patients with significant co-morbidities undergoing maxillofacial reconstruction. The selection of patients who will tolerate complex reconstruction cannot be based solely on co-morbidity charts and standardized preoperative indices.

Surgical resection and vascularized bone reconstruction in advanced stage medication-related osteonecrosis of the jaw.

A retrospective review of all patients with stage 3 medication-related osteonecrosis of the jaw (MRONJ), treated by surgical resection and immediate vascularized bone reconstruction at a tertiary care medical center, was performed. Eleven patients were included, seven female and four male; their mean age was 65.8 years (range 56-73 years). Mean follow-up was 25 months. Ten patients had received intravenous bisphosphonates. The most common pathology was breast cancer (4/11). Pain (n=8) and pathological fracture (n=7) were the most common presenting symptoms. Microvascular free flaps consisted of seven fibula osteocutaneous flaps and four scapula osteocutaneous free flaps. All patients reported resolution of symptoms, with complete bone union identified radiographically (100%). Complications occurred in three patients (27%). One patient required removal of hardware at 8 months postoperative. Dental implant rehabilitation was completed in two patients. Ten patients are tolerating an oral diet. Ten patients are alive without evidence of MRONJ at any of the surgical sites. One patient died 28 months after surgery from progression of metastatic disease. Advanced MRONJ can be successfully treated in patients using vascularized tissue transfer, including those patients with significant peripheral vascular disease. Dental rehabilitation is a viable option for advanced MRONJ patients treated by vascularized flap reconstruction.

Head and neck cancer surgery in an elderly patient population: a retrospective review.

Should advanced age be a contraindication to the surgical management of head and neck cancer patients? A retrospective chart review was performed of patients aged ≥80 years treated surgically for a head and neck malignancy during the period 1996-2011 in a tertiary care cancer centre. The average follow-up was 32 months. Fifty-three patients were identified (mean age 85 years). Cardiovascular disease was the most prevalent co-morbidity (43%). Forty-five patients (85%) had oral cavity/oropharynx squamous cell carcinoma. Surgeries performed included 40 neck dissections and 12 microvascular free flaps. The average length of hospital stay (LOS) was 6.4 days. An increased LOS was significant in patients requiring free flap reconstruction (P<0.01). There were no perioperative deaths or free flap failures. The most common postoperative complications were cardiovascular (n=8), infection (n=10), and delirium (n=6). Thirty-four patients were discharged directly home. Free flap reconstruction did not adversely affect discharge disposition (P>0.05). More than 75% of patients did not report any major limitations to their activities of daily living. Major head and neck surgical procedures can be tolerated by patients of advanced age using careful patient selection. Age alone should not be a primary factor in the management of head and neck cancer patients.

Analysis of an implantable venous anastomotic flow coupler: experience in head and neck free flap reconstruction.

Monitoring microvascular free flaps can present a difficult challenge. This is especially true in cases of buried or intra-oral free flaps. The authors conducted a retrospective review of 19 consecutive free flaps for head and neck reconstruction using a novel monitoring device, which combines a venous anastomotic coupler and an implantable microdoppler (Synovis Micro Companies Alliance Inc., Birmingham, AL, USA). 20 venous anastomoses were performed and monitored with the venous flow coupler device. Monitoring ranged from intra-operatively to postoperative day 7 (mean 4.2 days). Accurate flow signal interpretation was correct in 18 of 20 anastomoses (90%) but only 14 of the 20 coupled anastomoses (70%) were monitored for the complete period of time as desired by the surgeons. All 19 flaps survived. The venous anastomotic flow coupler appears to be a reliable adjunct to free flap monitoring and may help to improve it, with early detection of flap compromise and salvage.