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Objective: Photodynamic therapy (PDT) may be used as an adjuvant intraoperative treatment to improve locoregional control. PDT has been shown both to delay wound healing and to have a deleterious effect on flap survival after a primary ischemic insult. This delay in wound healing may make the flap dependent on its pedicled blood supply for a prolonged period. Long-term flap loss may be experienced. The effect of PDT on flap revascularization, with subsequent dependence on its vascular pedicle, is evaluated. Study Design: Randomized controlled trial using a rodent model. Methods: A rat fasciocutaneous flap was used. Study groups were as follows: group I received no treatment; group II received treatment with 630-nm light; groups IH and IV were given Photofrin (in group III, loupes without a fiberoptic light source were used for flap elevation, and in group IV, light source was employed); and group V was given Photofrin and 630-nm light. Primary ischemic times of 2 or 4 hours were used. Vascular pedicles were ligated on postoperative day (POD) 5, 6, or 7, and percentage of flap survival was evaluated 7 days later. Results: With 2 hours of ischemia, revascularization was decreased in the PDT group on POD 6 (P < .05) and on day 7 (P < .005) when compared with the other groups. With 4 hours of ischemia, revascularization was decreased in the PDT group on PODs 5 (P < .001), 6 (P < .01), and 7 (P < .005). Conclusion: Intraoperative PDT decreases revascularization of a rat fasciocutaneous flap. [ABSTRACT FROM AUTHOR]

Objective: To study the physiologic effect of acute thyroid hormone depletion on hearing and the function of outer hair cells.Design: Audiologic and otoacoustic emission testing of subjects undergoing total thyroidectomy before surgery and up to 6 weeks after surgery. Magnitude of thyroxin depletion monitored by serum thyroid-stimulating hormone levels.Setting: Hearing research laboratory at a state university.Subjects: Ten patients undergoing total thyroidectomy.Main Outcome Measures: Detection of hearing loss on audiogram and decrease or disappearance of otoacoustic emissions as a result of acute thyroxin depletion.Results: No significant changes in the audiogram and otoacoustic emission configurations were detected, although thyroid-stimulating hormone levels became elevated after total thyroidectomy.Conclusion: Although thyroid hormone is thought to play a role in the physiology of hearing in humans, no deleterious effects on hearing can be identified up to 6 weeks after thyroxin depletion. [ABSTRACT FROM AUTHOR]

Background: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated.Objective: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy.Study Design: Prospective study (1991-1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection.Methods: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y).Results: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottic, and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries).Conclusions: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Vocal rehabilitation of patients who have undergone laryngectomy is best accomplished by a tracheoesophageal puncture. Optimal function of the prosthesis requires an adequate stoma. Patients with tracheostomal stenosis require revision of the stoma if vocal rehabilitation is to take place. Revision and tracheoesophageal placement are usually done as two separate procedures. Creating a tracheoesophageal fistula at the time of stomal revision has not been addressed in the literature.Study Design: Prospective analysis and follow-up of 10 patients undergoing simultaneous tracheoesophageal puncture and stomal revision for tracheostomal stenosis between 1991 and 1996.Methods: Ten patients were reviewed. An inferiorly based V-Y advancement flap was used so as not to interfere with the tracheoesophageal puncture. All patients had received radiation prior to revision and tracheoesophageal puncture. Patients were followed for a minimum of 2 years (range, 2-6 y; median, 3 y).Results: All patients maintained an adequate stoma without stenting. Eight of ten patients (80%) developed and maintained good tracheoesophageal speech. Two patients had their speech fistulas removed. There were no intraoperative or postoperative complications.Conclusions: Creation of a tracheoesophageal fistula at the time of stomal revision allows for vocal rehabilitation with a single visit to the operating room. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: Normal salivary flow is important for maintaining good oral hygiene. Lack of normal flow predisposes to an increased incidence of dental caries and symptomatic xerostomia. The submandibular glands are responsible for 70% of resting salivary flow. Removal of the submandibular gland is most commonly performed for sialolithiasis, chronic sialoadenitis, or as part of a neck dissection. The effect of unilateral gland resection for benign disease on resting salivary flow has not been well examined in the literature.Study Design: Case controlled study involving patients who had undergone a unilateral submandibular gland resection matched with normal control subjects.Method: Stimulated and unstimulated salivary flow rates in surgical and control subjects were measured in a controlled setting.Results: Unstimulated salivary flow rates were 0.805 mL/min in the control group and 0.405 mL/min in the surgical group (P = .01). Stimulated salivary flow rates were not significantly different between the two groups (P > .05). Fifty-seven percent of patients in the surgical group and 14% in the control group had xerostomia (P < .05).Conclusion: Unilateral submandibular gland excision results in a decreased rate of resting salivary flow and an increase in subjective xerostomia. [ABSTRACT FROM AUTHOR]

The presence of cervical lymph node metastasis in patients with head and neck cancer is associated with an unfavorable prognosis. Reports vary as to whether various conventional radiographic studies, such as computed tomography (CT) and magnetic resonance imaging, confer an advantage over physical examination in the patient without clinical findings of cervical metastasis (N0). Positron emission tomography (PET) is a functional imaging modality that has recently been used for head and neck neoplasms. The use of PET in the evaluation of the N0-staged neck in 14 consecutive patients with squamous cell carcinoma (SCC) of the upper aerodigestive tract is reported. Seven patients (50%) undergoing 13 neck dissections had pathologic evidence of disease. PET scans were positive in five patients with pathologically confirmed cervical metastasis. PET scans were negative in seven patients (11 neck dissections) with no pathologic evidence of disease. PET scans were positive for unilateral cervical metastasis in two of three patients with involvement of a single lymph node. PET scans were positive in two of three patients with more than two lymph nodes involved. PET had an accuracy of 100% in the eight patients with SCC of the oral cavity. In patients with oropharyngeal or hypopharyngeal carcinoma PET localized cervical metastasis in two of four patients with neck metastasis. In the patient with an N0-staged neck on clinical examination, PET was found to have an overall sensitivity of 78%, specificity of 100%, positive predictive value of 100%, negative predictive value of 88%, and accuracy of 92%. CT demonstrated sensitivity of 57%, specificity of 90%, positive predictive value of 80%, negative predictive value of 75%, and accuracy of 76%. PET showed a trend in increased accuracy (P = 0.11) over CT. PET appears to be a promising diagnostic aid that may be applied when evaluating the N0-staged neck, especially for SCC of the oral cavity. [ABSTRACT FROM AUTHOR]

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm2 (mean, 128 cm2). The flap size ranged from 7 x 10 to 15 x 15 cm. The majority of flaps were 10 x 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on the flaps (> 120 cm2) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this. [ABSTRACT FROM AUTHOR]

Introduction: Coronavirus disease 2019 (COVID-19) affects the vascular system, subjecting patients to a hypercoagulable state. This is of particular concern for the success of microvascular free flap reconstruction. This study aims to report head and neck free flap complications in patients with COVID-19 during the perioperative period. We believe these patients are more likely to experience flap complications given the hypercoagulable state., Methods: This is a multi-institutional retrospective case series of patients infected with COVID-19 during the perioperative period for head and neck free flap reconstruction from March 2020 to January 2022., Results: Data was collected on 40 patients from 14 institutions. Twenty-one patients (52.5%) had a positive COVID-19 test within 10 days before surgery and 7 days after surgery. The remaining patients had a positive test earlier than 10 days before surgery. A positive test caused a delay in surgery for 16 patients (40.0%) with an average delay of 44.7 days (9-198 days). Two free flap complications (5.0%) occurred with no free flap deaths. Four patients (10.0%) had surgical complications and 10 patients had medical complications (25.0%). Five patients (12.5%) suffered from postoperative COVID-19 pneumonia. Three deaths were COVID-19-related and one from cancer recurrence during the study period., Conclusion: Despite the heightened risk of coagulopathy in COVID-19 patients, head and neck free flap reconstructions in patients with COVID-19 are not at higher risk for free flap complications. However, these patients are at increased risk of medical complications., Level of Evidence: 4 Laryngoscope, 134:4521-4526, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Cervical spine defects result in spinal instability, putting the spinal cord and vertebral arteries at risk of damage and possibly devastating neurological injuries. The fibula free flap can span the spinal defects for stability. There is a paucity of literature on this technique., Method: Multi-institutional retrospective case series reviewing patients who underwent cervical spine reconstruction with a fibula free flap. Patient demographic information, comorbidities, characteristics of cervical spine defects, and free flap complications were collected., Results: A total of 1187 fibula free flaps across 10 different institutions were reviewed. Thirteen patients (1.09%) underwent cervical spine reconstruction with a fibula free flap. Average age was 52.3 years old with an age range of 12-79 years. There were six males (46.1%) and seven females (53.8%). The most common defect etiology was infection (n = 6, 46.1%). Most commonly involved cervical spine level of the defect was C5 (n = 10) followed by C6 (n = 9) and C4 (n = 8). The majority of reconstructed defects spanned three or more cervical levels, (n = 9, 69.2%). Facial artery was the most common arterial anastomosis (n = 8). Eight patients (61.5%) required a tracheostomy during their postoperative course. None of the patients had symptomatic or radiographic nonunion., Conclusion: This case series demonstrates that a vascularized fibula flap is a potential reconstructive option for cervical spine defects, especially in defects greater than three cervical levels, in the setting of infection, and previously radiated patients., Level of Evidence: 4 Laryngoscope, 134:4923-4928, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Assess the long-term plate complications with patient-specific plates (PSPs) created with computer-aided design (CAD) and computer-aided manufacturing (CAM) for fibula free flap reconstructions for mandibular defects., Methods: Retrospective chart review from January 2010 to July 2022 of patients who underwent mandibular reconstruction with a fibula free flap and PSP. Primary outcome was plating-related complications, defined as plate exposure, fracture, loose screws, and plate removal., Results: A total of 221 patients underwent PSP fibula reconstruction. Average age was 59.8 + 14.3 years old with male to female ratio of 2:1. Squamous cell carcinoma of the mandible was the most common reason for resection, 47.5%, n = 105. Plate removal occurred in 11% of patients (n = 25) about 17.4 months after the initial surgery. Plates were removed due to exposure (76%, n = 19) or screw loosening (24%, n = 6). Malignancy was associated with an increased risk of plate complications when compared to benign tumor (odds ratio [OR] 9.04, confidence interval [CI] 1.36-3.85), osteonecrosis (OR 1.38, CI 0.59-3.48), and trauma (OR 1.26, CI 0.23-12.8). Postoperative radiation therapy (OR 2.27, CI 1.07-4.82, p = 0.026) and surgical site infection (OR 9.22, CI 4.11-21.88, p = 0.001) were associated with more plate complications., Conclusions: CAD creates PSPs that remain stable in the majority of patients over the long term. Plate removal is less compared to non-PSP reconstruction. Consideration of the soft tissue envelope over the plate and management of perioperative infection at the time of surgery should be entertained., Level of Evidence: 4 Laryngoscope, 134:4929-4934, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

The palatal island rotation flap is a rarely used reconstructive technique. The tissue is robust and the morbidity is low. It can be used as a primary reconstructive technique in patients with limited oral cavity/pharynx lesions. Healing is uneventful. In radiated pateints healing is prolonged and should be avoided. We describe 14 patients where the flap was used to reconstruct local defects. Patients with no history of radiation all healed quickly and well. Those with a history of radiatiuon had prolonged pain and delayed healing. Laryngoscope, 134:2718-2720, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Microvascular free tissue transfer is routinely used for reconstructing midface defects in patients with malignancy, however, studies regarding reconstructive outcomes in invasive fungal sinusitis (IFS) are lacking. We aim to describe outcomes of free flap reconstruction for IFS defects, determine the optimal time to perform reconstruction, and if anti-fungal medications or other risk factors of an immunocompromised patient population affect reconstructive outcomes., Methods: Retrospective review of reconstruction for IFS (2010-2022). Age, BMI, hemoglobin A1c, number of surgical debridements, and interval from the last debridement to reconstruction were compared between patients with delayed wound healing versus those without. Predictor variables for delayed wound healing and the effect of time on free flap reconstruction were analyzed., Results: Twenty-seven patients underwent free flap reconstruction for IFS. Three patients were immunocompromised from leukemia and 21 had diabetes mellitus (DM). Patients underwent an average of four surgical debridements for treatment of IFS. The interval from the last IFS debridement to flap reconstruction was 5.58 months (±5.5). Seven flaps (25.9%) had delayed wound healing. A shorter interval of less than 2 months between the last debridement for IFS and reconstructive free flap procedure was associated with delayed wound healing (Fisher Exact Test p = 0.0062). Other factors including DM, BMI, HgA1c, and bone reconstruction were not associated with delayed wound healing., Conclusion: Patients with maxillectomy defects from IFS can undergo microvascular-free flap reconstruction with good outcomes while on anti-fungal medication. Early reconstruction in the first 2 months after the last IFS debridement is associated with delayed wound healing., Level of Evidence: 4 Laryngoscope, 134:1642-1647, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the effect of different virtual reality (VR) experiences on perioperative anxiety and pain among patients undergoing head and neck surgery., Methods: Prospective, randomized, comparative trial among patients undergoing outpatient head and neck surgery from December 2021 to April 2022 at a single academic institution. Group 1 utilized a preoperative VR gaming experience and a postoperative VR mindfulness experience, while Group 2 utilized the same interventions in the reverse order. Anxiety and pain were measured using visual analog scales (VAS). Primary outcomes were changes in post-intervention anxiety and pain. Secondary outcomes included vital sign changes and subjective patient experiences using a 5-point Likert scale., Results: There were 32 patients randomized for inclusion, with 16 patients per group. The majority of patients were female (65.6%) and mean (standard deviation) age was 47.3 (16.7) years. After outlier exclusion, there were no differences in post-intervention preoperative anxiety reduction (Group 1 vs. Group 2, median [IQR]: -12.0 [15] vs. -10.5 [13], p = 0.62). There were minor differences in vital sign changes (p < 0.05). Among the 10 patients in Group 1 and 12 patients in Group 2 who completed postoperative VR use, there were no differences in post-intervention pain reduction (-8.5 [22.3] vs. -7.5 [19.3], p = 0.95) or vital sign changes (p > 0.05). There were no differences in questionnaire responses, with high satisfaction in both groups (p > 0.05). No adverse events encountered., Conclusions: Use of different VR experiences among patients undergoing outpatient head and neck surgery appears associated with similar reductions in perioperative anxiety and pain., Level of Evidence: 2 Laryngoscope, 134:1197-1202, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The aim of the study was to determine outcomes after interventional radiology treatment of carotid blowout., Methods: Patients with head and neck cancer and who received interventional radiology treatment for carotid blowout between 2000 and 2022 were included. Pre-treatment, treatment, and post-treatment variables were evaluated., Results: Fourteen patients met inclusion criteria. Eleven patients (78.6%) had a history of radiation. Twelve (85.7%) blowouts occurred within 6 months of recent intervention. Initial treatment was with stenting (n = 9, 64.3%), coil embolization (n = 4, 28.6%), or both (n = 1, 7.1%). Six patients (42.9%) underwent subsequent carotid bypass. Morbidity following treatment included stroke (n = 1) and rebleeding (n = 4). Six-month survival was 57.1%. Of the patients who survived past six months, 5/8 were treated with carotid bypass and coverage. Four patients died of cancer progression, three of rebleeding, and three of medical complications., Conclusion: The majority of carotid blowout occurs within 6 months of surgery or radiation. Many who survive will die of cancer progression or medical illness. Carotid bypass with flap coverage may be a worthwhile treatment for carotid blowout and should be considered as an adjunct to endovascular treatment., Level of Evidence: 4 Laryngoscope, 134:695-700, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps., Objective: To determine the factors associated with implant exposure., Design: Multi-institutional retrospective review of 82 patients, 2000-2020, repaired with cranial implants and free flap coverage., Results: Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0-0.35) and total flap atrophy OR 0.34 (95% CI 0.02-19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0-0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications., Conclusions: Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time., Level of Evidence: 4 Laryngoscope, 133:2954-2958, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Highlight the use of fluorescent angiography in free flap reconstruction of the head and neck. Qualify how fluorescent angiography can be selectively added to management paradigms for head and neck free flap reconstruction., Methods: Retrospective chart review of 993 free flaps completed from the time the SPY Elite® system first became available at our institution between September 2013, until August 2020. Cases that used the SPY Elite® system were grouped into three broad categories: evaluation during initial flap harvest while still attached to the donor site, evaluation after anastomosis in the head and neck area, and evaluation post-operatively for questionable flap viability., Results: The SPY Elite® system was used in 64 cases. Forty flaps were evaluated intraoperatively during initial harvest and before anastomosis to the head and neck area. Of these, 20 had signs of poor perfusion of the entire skin paddle, 12 had large myogenous or skin flaps with questionable perfusion of the distal aspect, and 8 were evaluated for other reasons. In this group the use of SPY Elite® changed the management of the patient in 20 cases (50%). Ten flaps were evaluated intraoperatively after anastomosis to the head and neck to ascertain adequate flow to the entire flap. In this group management was changed in two (20%). Fourteen flaps were evaluated 3-5 days post operatively due to suspected failure of a component. In five cases (36%), the use of SPY Elite® determined management with either trimming or discarding the flap., Conclusion: Assessment of flap perfusion via fluorescent angiography during initial flap harvest or when flap compromise is suspected post-operatively can guide decision making in free flap reconstruction of the head and neck and can be added to existing planning and management paradigms., Level of Evidence: 4 Laryngoscope, 133:1388-1393, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective(s): Patients with intracranial tumors have a higher risk of thromboembolic events. This risk increases at the time of surgical intervention. We have noted an anecdotal increase in perioperative flap thrombosis in patients undergoing free tissue transfer for intracranial tumor resection. This study aims to formally evaluate this risk., Methods: A multi-institutional retrospective chart review was performed of patients who underwent free tissue transfer for scalp/cranial reconstruction. Perioperative thrombosis and free flap outcomes were evaluated., Results: The 209 patients who underwent 246 free tissue transfers were included in the study. The 28 free flap scalp reconstructions were associated with intracranial tumors, 19 were performed following composite cranial resections with associated dural resection/reconstruction, and 199 were performed in the absence of intracranial tumors (control group). There was a significantly higher incidence of perioperative flap thrombosis in the intracranial tumor group (11/28, 39%) when compared to controls (38/199, 19%) (p = 0.0287). This was not seen when scalp tumors extended to the dura alone (4/19, 21%, p = 0.83). Therapeutic anticoagulation used for perioperative thrombosis (defined as intraoperative or in the immediate postoperative phase up to 5 days) was associated with a lower risk of flap failure, although this was not statistically significant (p = 0.148). Flap survival rates were equivalent between flaps performed for intracranial pathology (93.3%) and controls (95%)., Conclusion: There is an increase in perioperative flap thrombosis in patients with intracranial tumors undergoing free tissue scalp reconstruction. Anticoagulation appears to mitigate this risk., Level of Evidence: This recommendation is based on level 3 evidence (retrospective case-control studies, systematic review of retrospective studies, and case reports) Laryngoscope, 133:1103-1109, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Educational Objective: Assess outcomes of pediatric facial reconstruction with fibula free flaps., Objectives: Free flap reconstruction of complex maxillofacial defects in pediatric patients is rare. Post-operative complications, donor site morbidity, impact on craniofacial growth, and oro-dental rehabilitation are unknown. Our study assesses the outcomes of pediatric maxillofacial reconstruction with composite fibula free flaps., Study Design: Retrospective chart review., Methods: Multi-institutional retrospective chart review from 2000 to 2020 on pediatric patients undergoing maxillomandibular reconstruction with fibula free flaps., Results: Eighty-seven patients underwent 89 surgeries; 5 maxillary and 84 mandibular defects. Median age: 12 years. Defects were acquired following resection of sarcoma/carcinoma 44% or benign tumors 50%. 73% of cases had immediate free flap reconstruction. Closing osteotomies were reported in 74%; 1 in 40%, 2 in 27%, and more than 2 in 6.7%. Hardware was used in 98% and removed in 25%. 9.2% demonstrated long-term hardware exposure, greater than 3 months following reconstruction. Short-term complications: wound infection 6.7%, flap salvage/failure 2.2%, fistula 1.1%, and compromised craniofacial growth: 23%. Two patients developed trismus. Long-term fibula donor site complications: hypertrophic scarring: 3.4%, dysesthesia: 1.1%, and long-term gait abnormality: 1.1%. Dental rehabilitation was performed in 33%. Post-operative speech outcomes showed 94% with fully intelligible speech., Conclusion: Pediatric maxillary and mandible defects repaired with fibula free flaps demonstrated complication rates comparable to the adult free flap population. Long-term follow-up did not demonstrate adverse outcomes for craniofacial growth. Hardware for flap retention was utilized and remained in place with minimal exposure. Post-operative gait abnormality is rare., Level of Evidence: 3 Laryngoscope, 133:302-306, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction., Study Design: Retrospective review of prospectively collected databases., Methods: Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n = 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death)., Results: The mean age of patients discharged home was lower (60 SD ± 13, n = 1450) compared to those discharged to an SNF (68 SD ± 14, n = 168) or a rehabilitation facility (71 SD ± 14, n = 200; p < 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p < 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p < 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p = 0.006), thromboembolism (59% vs. 80%; p = 0.001), a pulmonary complication (46% vs. 81%; p < 0.0001), a cardiac complication (46% vs. 80%; p < 0.0001), or a cerebral vascular event (25% vs. 80%; p < 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination., Conclusion: There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination., Level of Evidence: 4 Laryngoscope, 133:95-104, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Determine if age correlated with surgical or medical complications following head and neck free flap reconstruction., Study Design: Retrospective review of prospectively collected databases., Methods: Patients undergoing head and neck free flap reconstruction at three tertiary care institutions were included (n = 1972). Cohorts were based on age (<65, 65-75, 75-85, and >85). Outcomes reviewed operative duration, length of stay, surgical complications (free flap failure, fistula, hematoma, dehiscence, and infection), and medical complications (thromboembolism, stroke, cardiac, and pulmonary)., Results: Anatomic site (P < .0001) and donor site varied by age (P < .0001). There was no difference in operative duration (P = .3) or length of hospitalization (P = .8) by age. The incidence of medical complications increased with increasing age. Pulmonary complication rates: <65 (3.9%), 65 to 75 (4.8%), 75 to 85 (7.1%), and >85 (11%) (P = .02). Cardiac complication rates: <65 (2.0%), 65 to 75 (7.3%), 75 to 85 (6.1%), and >85 (16.4%) (P < .0001). Mortality increased with age: <65 (0.4%), 65 to 75 (0.8%), 75 to 85 (1.1%), and >85 (4.1%) (P < .003). Medical complications correlated with mortality rates: pulmonary (3.5% vs. 0.6%; OR: 5.5; 95% CI: 1.5-20.0; P = .004); cardiac (3.3% vs. 0.6%; OR: 6.0; 95% CI: 1.6-21.8; P = .002); thromboembolism (4.6% vs. 0.7%; OR: 7.3; 95% CI: 1.6-33.6; P = .003); stroke (42% vs. 0.5%; OR: 149; 95% CI: 40-558; P < .0001); and sepsis (5% vs. 0.7%; OR 7.5; 95% CI: 1.0-60.5; P = .03). Age did not correlate with free flap success (P = .5), surgical complications (hematoma, P = .33; fistula, P = .23; infection, P = .07; and dehiscence, P = .37), or thirty-day readmission (P = .3)., Conclusion: Following free flap reconstruction, patient age did not correlate with development of a surgical complication. Patient age did correlate with development of a medical complication. Postoperative medical complications were found to correlate with perioperative mortality., Level of Evidence: 4 Laryngoscope, 132:772-780, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Investigate current practice patterns of head and neck microvascular reconstructive surgeons when removing an implantable Doppler after free flap surgery., Study Design: Cross-sectional survey study., Methods: Survey distributed to head and neck microvascular reconstructive surgeons. Data regarding years performing free tissue transfer, case numbers, management of implantable Doppler wire, and complications were collected., Results: Eighty-five responses were analyzed (38,000 cases). Sixty-six responders (77.6%) use an implantable Doppler for postoperative monitoring, with 97% using the Cook-Swartz Doppler Flow Monitoring System. Among this group, 65.2% pull the wire after monitoring was complete, 3% cut the wire, and 31.8% have both cut and pulled the wire. Of those who have cut and pulled the wire, 48% report cutting and pulling the wire with equal frequency, 43% formerly pulled the wire and now cut the wire, and 9% previously cut the wire but now pull the wire. Of those who pull the wire, there were two injuries to the pedicle requiring return to the operating for flap salvage, and one acute venous congestion. Of the nine who previously pulled the wire, six (67%) cited concerns with major bleeding/flap compromise as the reason for cutting the wire., Conclusion: In this study, most surgeons use an implantable Doppler for monitoring of free flaps postoperatively. In extremely rare instances, pulling the implantable Doppler wire has resulted in flap compromise necessitating revision of the vascular anastomosis. Cutting the wire and leaving the proximal portion in the surgical site has been adopted as a management option., Level of Evidence: 4 Laryngoscope, 132:554-559, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications., Study Design: Retrospective review at three tertiary care institutions., Methods: Database review., Results: Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P = .003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications., Conclusions: In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations., Level of Evidence: 3-Non randomized cohort study 4 Laryngoscope, 131:2465-2470, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The literature on outcomes of end-to-side (ETS) anastomoses for microvascular reconstruction of the head and neck is limited. This series reviews ETS in free tissue transfer (FTT) across multiple institutions to better understand their usage and associated outcomes., Study Design: Retrospective review of 2482 consecutive patients across three tertiary institutions., Methods: Adult patients (> 18) who received a FTT from 2006 to 2019 were included., Results: Two hundred and twenty-one FTT were identified as requiring at least one ETS anastomosis. These ETS cases had a failure rate of 11.2% in comparison to 3.8% in a cohort of end-to-end (ETE) cases (P < .001). ETS cases were significantly more likely to have a prior neck dissection (P < .001), suggesting the ETS method was utilized in select circumstances. A second ETS anastomosis improved survival of the FTT (P = .006), as did utilization of a coupler over suture (P = .002). Failure due to venous thrombosis was significantly more common with one ETS anastomosis instead of two ETS anastomoses (P = .042)., Conclusions: ETS is effective but is often used as a secondary technique when ETE is not feasible; as such, in this series, ETS was associated with higher failure. A second anastomosis and the use of the coupler for completing the anastomoses were associated with lower rates of failure., Level of Evidence: 3 Laryngoscope, 131:1286-1290, 2021., (© 2020 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes., Study Design: Retrospective review of 2482 consecutive patients across three tertiary institutions., Methods: Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised., Results: Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively)., Conclusion: Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure., Level of Evidence: 3 Laryngoscope, 131:1035-1041, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: Up to 800,000 percutaneous injuries involving healthcare workers occur each year. The morbidity of needlestick injuries (NSIs) ranges from nothing to death. The incidence of NSI in otolaryngology residency is deemed to be high based on prior studies. This study aimed at defining the trends in otolaryngology residents regarding sharps exposure., Study Design: Cross-sectional study using survey/questionnaire., Methods: Otolaryngology accredited residency programs in North America were surveyed in 2013 and 2017 regarding their experience with NSI and perceived risk of acquiring a blood-borne infection., Results: Surveys were received from 314 residents (31 programs). There was a total of 509 needlesticks, primarily occurring during junior years (post-graduate year 1-3, 81%). Sixty-eight percent of residents had experienced an NSI. Of the residents that had an injury, the mean number of sticks was 2.37 sticks/resident. Junior residents were less likely to report their injury compared to senior residents (50% vs. 30%). The primary reason for not reporting was the time commitment. Residents underestimated their risk of acquiring human immunodeficiency virus (51% of residents) and overestimated their risk of acquiring hepatitis C virus (90% of residents)., Conclusions: Occupational exposure is high in healthcare and particularly high in surgical trainees. The majority of otolaryngology trainees undergo a needlestick injury in their junior years. There continues to be underreporting of these injuries by residents, who report that the process is too time-consuming. Most residents do not have an accurate understanding of their actual risk of acquiring a blood-borne disease. These findings emphasize the need for education regarding risks and development of strategies to encourage reporting of injuries., Level of Evidence: VI Laryngoscope, 131:E1076-E1080, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives/hypothesis: To review the management of failed free tissue transfers among four large institutions over a 13-year period to provide data and analysis for a logical, algorithmic, experience-based approach to the management of failed free flaps., Study Design: Retrospective case series., Methods: A multi-institutional retrospective chart review of free tissue transfers to the head and neck region between 2006 and 2019 was performed. Patients with a failed free flap during their hospitalization after surgery to the head and neck were identified and reviewed. Patient age, co-morbidities, risk factors, flap characteristics, tumor specifics, and length of hospital stay were reviewed, collected, and analyzed., Results: One hundred eighteen flap failures met criteria. The most common failed flap in this review was the osteocutaneous flap 52/118 (44%). The recipient site of the initial free flap (P < .001) was the only statistically significant parameter strongly correlated with management. Osteocutaneous flap failures, fasciocutaneous, bowel, and muscle-only flaps tended to be managed most commonly with a second free flap. Myocutaneous flap failures were managed equally with either a second free flap or a regional flap., Conclusions: The most important factor in management of a failed free flap is the recipient site. A second free flap is often the preferred treatment, but in the acute setting, local or regional flaps may be viable options depending on the recipient site, circumstances of flap loss, and patient- specific comorbidities. An algorithm for management of the acute flap loss is presented in this review., Level of Evidence: 4 Laryngoscope, 131:518-524, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To demonstrate the application and surgical time savings of the Spider Limb Positioner for subscapular system free flaps in head and neck reconstructive surgery., Methods: Single institution retrospective chart review and analysis of patients between 2011 and 2019 that underwent a subscapular system free flap either with or without use of the Spider Limb Positioner. One hundred five patients in total were reviewed with 53 patients in the Spider group. The surgical times were compared between the two groups. Patient-specific information regarding average age, laterality of donor site, recipient site, gender, and flap type were reviewed., Results: Forty-one patients in both groups underwent a latissimus free flap. Twelve of 53 in the Spider group and 11/52 in the control group underwent a scapula free flap. The average age in the Spider group at the time of surgery was 64 years. The recipient sites for the Spider groups were reviewed. The free flap was ipsilateral to the defect in 81% of cases. The mean surgical time for the 105 patients without the Spider was 568 minutes versus 486 minutes with a Spider P-value of .003478., Conclusion: Use of the Spider Limb Positioner allows for a simultaneous two-team approach during free flap elevation of the subscapular system, which eliminates both dependence on an assistant to support the arm and time consuming positioning changes during flap elevation., Level of Evidence: 3 Laryngoscope, 131:525-528, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: To demonstrate the safety and compatibility of microvascular couplers in patients undergoing postoperative magnetic resonance imaging (MRI) scans., Study Design: Retrospective case series., Methods: A consecutive review of 1,252 patients undergoing free tissue transfer for head and neck reconstruction at Oregon Health and Sciences University (OHSU) between 2010 and 2017 who had microvascular coupler Synovis, Baxter Deerfield, IL (Synovis Life Technologies, Saint Paul, MN) implantation were reviewed. One hundred fifteen patients had a subsequent MRI scan, which consisted of a variety of Phillips (Amsterdam, Netherlands) MRI machines ranging from 1.0 to 3.0 Tesla (T) in magnetic strength., Results: These 115 patients underwent 121 free flaps with 131 couplers (including 32 flow couplers) utilized for venous anastomoses. Couplers ranged in size from 1.5 to 4.0 mm (3.0 mm [42%] followed by 3.5 mm [21%], 2.5 mm [19%], 2.0 mm [10%], 4.0 mm [6%], and 1.5 mm [2%]. Three hundred fifty-nine MRI scans (2 days to 91 months postoperatively) were obtained with 233 MRIs for cancer surveillance, and the remaining were obtained for neurologic disease, injury, or evaluation for metastases. No complications occurred related to the MRI and the metallic components of the coupler or other metal implants, such as reconstruction bars, vascular clips, or metallic surgical mesh. Additionally, no radiology report commented on MRI distortion due to the coupler placement, which contrasts the distortion seen with the other metallic implants., Conclusion: Microvascular couplers and their constitutive stainless-steel pins have not been found to cause any complications in a large series of consecutive patients undergoing multiple MRIs with magnetic strength up to 3 T. The U.S. Food and Drug Administration advocates medical alert notification for patients with couplers; however, hesitation regarding potential MRI scanning for surveillance or otherwise is unwarranted., Level of Evidence: 4 Laryngoscope, 130:1428-1430, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction., Study Design: Retrospective multi-institutional review of prospectively collected databases at tertiary care centers., Methods: Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history., Results: Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002)., Conclusion: This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures., Level of Evidence: 4 Laryngoscope, 130:347-353, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: The anterolateral thigh (ALT) free flap is a soft tissue flap used in head and neck reconstruction. Occasionally, its perforators to the skin paddle are absent or too small to support the flap. Salvage options in this scenario have not been well described for head and neck reconstruction., Methods: Multicenter review of 1,079 cases of planned ALT flaps where 28 initial flaps (2.6%) were discarded for nonviable skin paddle or lack of cutaneous perforators. Iatrogenic perforator injury was calculated separately. The total flap loss rate was 3.2%., Results: In 12 cases, no perforators were noted after performing the anterior incision (early). Sixteen ALT flaps were discarded immediately before pedicle ligation (late). Reconstruction was salvaged by seven anteromedial thigh (AMT), six radial forearm, five contralateral ALT, four rectus abdominus myocutaneous, three vastus lateralis, three profunda artery perforator, two tensor fascia lata, one rectus femoris, two pectoralis major, one cervicofacial rotational, and one fibula flap. Of the 28 cases, 12 salvage cases did not involve an additional wound for the patient. Five of the seven AMT flaps were harvested after the ALT was identified as nonviable in the early time point. Two patients had no viable ALT flaps on bilateral lower extremities., Conclusion: The ALT flap is a reliable soft tissue flap, and rarely cutaneous perforators are not adequate to support the skin paddle. Multiple options exist to salvage the reconstruction without significant additional morbidity to the patient if said inadequacy is identified early., Level of Evidence: 4 Laryngoscope, 130:343-346, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Acute invasive fungal sinusitis (AIFS) is a frequently fatal infection for which extensive and debilitating surgical debridement is a mainstay of therapy. Resulting defects are often composite in nature, mandating free tissue-transfer reconstruction. Outcomes data for free flap reconstruction are limited. The purpose of this study was to examine surgical outcomes and survival in patients undergoing free flap transfer following invasive fungal sinusitis., Study Design: Retrospective case series., Methods: Between 1995 and 2015, patients undergoing operative debridement for AIFS were identified. Surgical records were used to identify survivors of acute infection who subsequently underwent free flap reconstructive surgery. Patient demographics, cause of immune compromise, defect description, flap type, perioperative complications, indications for revision surgery, functional outcomes, and long-term survival were reviewed., Results: Forty-four patients were treated for AIFS, of those, 30 (68%) survived acute infection. Ten patients underwent maxillectomy, six with orbital exenteration, and were designated candidates for reconstruction. Eight patients underwent reconstruction. Median time from debridement to reconstruction was 67.5 days. Flap types included latissimus dorsi, scapula, anterolateral thigh, rectus, radial forearm, and fibula. Median follow-up was 7.7 months. No perioperative complications were encountered, and all subjects remained disease-free, able to speak and eat normally without prosthetic supplementation. Seven patients (87%) are currently alive., Conclusion: Reconstruction of defects left by invasive fungal sinusitis using free-tissue transfer resulted in successful flap survival, with no disease recurrence for all defects and flap types reviewed. Survivors of AIFS are able to tolerate midface reconstruction, with favorable functional outcomes and survival rates., Level of Evidence: 4. Laryngoscope, 127:815-819, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The radial forearm osteocutaneous free flap (RFOCFF) provides a thin pliable skin paddle with up to 11 cm of bone. A limitation of this flap is the thin bone that is obtained and the lack of suitability for dental implants. A minimum depth of 5 mm and height of 10 mm is required for a bony flap to accept osteointegrated implants. We propose that by double barreling the radial bone, it is possible to reconstruct osseous defects with bone of sufficient caliber to accept dental implants., Study Design: Retrospective review of our experience with double-barreled RFOCFF., Methods: We reviewed all free flaps performed from July 2000 to September 2014 and analyzed patients in whom a radial forearm osteocutaneous flap was used. We then reviewed those who had an osteotomy to form a double-barrel reconstruction. Descriptive data and outcomes were tabulated., Results: A total of 458 osteocutaneous free flaps were performed; 75 were RFOCFF and 18 of these were double barreled. All 18 flaps survived. The reconstructed defect size was between 2.6 and 6.8 cm. One patient had dental implants placed at time of surgery that successfully osteointegrated. Postoperative computed tomography scans were available in nine patients and were used to calculate bone dimensions. Bone depth ranged from 7.91 to 13.22 mm, with a mean of 9.77 ± 1.53 mm. Bone height ranged from 8.42 to 17.81 mm, with a mean of 13.82 ± 3.2 mm., Conclusions: The double-barreled RFOCFF provides dependable long-lasting bone with adequate bone dimensions to support osteointegrated dental implants., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Standard operating procedures have been developed in many surgical practices to ensure quality of care as it relates to specimens removed from the body. Most of these specimens are sent to pathology. Some, such as calvarial bone harvested during craniotomy are replaced in the body. Free tissue transfer involves harvesting tissue from one body site, storage for a variable period of time outside of the body, and then insertion in another location. As with any system there is ample opportunity for accidental "misplacement." We undertook a multi-institutional study to examine the incidence, etiology, and opportunity for process improvement., Study Design: Retrospective review., Methods: A retrospective review was performed at five institutions (8,382 free flaps)., Results: Thirteen (0.15%) flaps were dropped or wrapped in a towel/sponge and placed in a waste bucket. Eight radial forearm, three fibula, one latissimus dorsi, and one anterolateral thigh flap were misplaced. All flaps were retrieved, washed in saline/betadine, and implanted into the patient. All flaps survived; no altered outcomes were encountered. The etiology of the misplacement of the free tissue from the sterile field included miscommunication among nursing staff (seven), miscommunication among medical staff (two), and dropping the flap (four). As a result of these events, changes in the handling procedures were instituted including standard labeling methodologies and communication strategies., Conclusions: Inadvertent misplacement of free tissue from the sterile field does occur in a sporadic fashion. Process improvement evaluation at all institutions led to improved strategies for prevention. No long-lasting altered outcomes were encountered., Level of Evidence: 4, (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Prefabricated composite free flaps for complex airway reconstruction have been described for an adult series at our institution. We extended this approach to a pediatric patient with lifelong subglottic stenosis who had failed previous open airway reconstructions. A staged procedure was utilized in which a composite graft was created using conchal cartilages and a radial forearm free flap. This reconstruction improved the patency of her airway and decreased her dependency on intermittent airway dilations. Airway reconstruction with prefabricated conchal cartilage composite free flaps may be used as a salvage procedure for complex pediatric airway reconstruction when other methods have failed., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Hematomas may develop in the postoperative setting after free tissue transfer. When hematomas occur, they can exert pressure on surrounding tissues. Their effect on the vascular pedicle of a free flap is unknown. We describe our incidence of hematoma in free flaps and outcomes when the flap is compromised., Study Design: Retrospective chart review of 1,883 free flaps performed between July 1998 and June 2014 at a tertiary referral center., Methods: Patients with free flap compromise due to hematoma were identified. Etiology, demographic data, and outcomes were evaluated., Results: Eighty-eight (4.7%) patients developed hematomas. Twenty (22.7%) of those had flap compromise. Twelve compromises (60%) showed evidence of pedicle thrombosis. The salvage rate was 75% versus 54% in 79 flaps with compromise from other causes (P = .12). Mean time to detection of the hematoma was 35.3 hours in salvaged flaps compared to 91.6 hours in unsalvageable flaps (P = .057). Time to operating room (OR) from detection was 2.8 hours in salvageable flaps compared to 12.4 hours in nonsalvageable flaps (P = .053). The salvage rate for flaps that returned to the OR in <5 hours was 93.3% compared to 20% (P = .0049) for those that did not. Vascular thrombosis reduced salvage rate to 58.3% from 100% (P = .002) when there was no thrombosis., Conclusions: In our series hematomas developed rarely. When they did, 23% went on to develop flap compromise. Prompt recognition and re-exploration allowed for a high salvage rate. Vessel thrombosis predicted inability to salvage the flap., Level of Evidence: 4, (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)