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Purpose: Defining the predictive factors associated with prolonged operative time may reduce post-operative complications, improve patient outcomes, and decrease cost of care. The aims of this study are to 1) analyze risk factors associated with prolonged operative time in head and neck free flap patients and 2) determine the impact of lengthier operative time on surgical outcomes., Methods: This retrospective cohort study evaluated 282 head and neck free flap reconstruction patients between 2011 and 2013 at a tertiary care center. Perioperative factors investigated by multivariate analyses included gender, age, American Society of Anesthesiologists class, tumor subsite, stage, flap type, preoperative comorbidities, and perioperative hematocrit nadir. Association was explored between operative times and complications including flap take back, flap survival, transfusion requirement, flap site hematoma, and surgical site infection., Results: Mean operative time was 418.2 ± 88.4 (185-670) minutes. Multivariate analyses identified that ASA class III (beta coefficient + 24.5, p = .043), stage IV tumors (+34.8, p = .013), fibular free flaps (-44.8, p = .033 for RFFF vs. FFF and - 67.7, p = .023 for ALT vs FFF) and COPD (+36.0, p = .041) were associated with prolonged operative time. History of CAD (-43.5, p = .010) was associated with shorter operative time. There was no statistically significant association between longer operative time and adverse flap outcomes or complications., Conclusion: As expected, patients who were medically complex, had advanced cancer, or underwent complex flap reconstruction had longer operative times. Surgical planning should pay special attention to certain co-morbidities such as COPD, and explore innovative ways to minimize operative time. Future research is needed to evaluate how these factors can help guide planning algorithms for head and neck patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: In recent years, the submental island flap has demonstrated decreased cost and morbidity as compared with free tissue transfer and has been widely applied to a range of head and neck defects. Several studies, however, continue to report a high rate of submental flap complications including partial necrosis and venous congestion. The object of this report is to describe a technical modification to the submental flap harvest which increases efficiency and reliability., Methods: Single institutional case series with chart review. The essential technical details and technique modifications of the submental flap harvest are described, and a case example is discussed., Results: Between January 2018 through January 2019, 24 submental island flaps were performed. All flaps included the mylohyoid muscle which was delineated with manual blunt dissection. Reconstructive indications included oral cavity and oropharyngeal wounds as well as facial cutaneous and lateral skullbase defects. There were no flap-related complications., Conclusions: Manual blunt dissection of the mylohyoid muscle and its inclusion in the submental island flap increases efficiency and reliability.

Palatal fistulae represent a pathological connection from the oral cavity through the hard or soft palate to the nasal cavity and can present a significant reconstructive dilemma. Surgical correction of palatal fistulae is often limited by prior treatment, including ablative procedures and radiotherapy, or previous reconstructive attempts. In light of these challenges, the nasoseptal flap represents an excellent adjacent source of vascularized tissue which may be suitable for palatal fistula repair with minimal donor site morbidity, low associated risks, and a short recovery period. The purpose of this study was to fully understand the potential utility of this reconstructive option, including the ability to harvest a composite flap including both septal cartilage and contralateral mucoperichondrium. In this single institution prospective study consisting of a series of 5 cadaver dissections, primary outcome measures were the anterior reach of the flap as compared to the anterior nasal spine and the size of the palatal defect that the nasoseptal flap could be used to successfully reconstruct. Composite flaps were successfully harvested in continuity with a disc of septal cartilage and contralateral mucoperichondrium, providing structural integrity to the reconstruction and the ability to anchor the flap to the native hard palate mucosa. The nasoseptal flap's maximum anterior reach was within 2.0 cm (standard deviation of 0.1 cm) from the anterior nasal spine and could reliably reconstruct palate defects of 2.5 cm or less. The nasoseptal flap provides a viable regional option for reconstructing defects of the hard palate. Prospective clinical trials are needed to investigate long-term reconstructive and functional outcomes of the composite nasoseptal flap in palatal reconstruction.

Objective: Blood product utilization is monitored to prevent unnecessary transfusions. Head-and-neck pedicled flap reconstruction transfusion-related outcomes were assessed., Methods: One hundred and thirty-six pedicled flap patients were reviewed: 64 supraclavicular artery island flaps (SCAIF), 57 pectoralis major (PM) flaps, and 15 submental (SM) flaps. Outcome parameters included flap-related complications, medical complications, length of stay (LOS), and flap survival. Multivariable logistic regression analyses were performed. Multivariable logistic regression analyses were performed to adjust for relevant pre- and perioperative factors., Results: Of all head-and-neck pedicled flap patients included in our analyses (n = 136), 40 (29.4%) received blood transfusions. The average pretransfusion hematocrit (Hct) was 24.3% ± 0.5%, with 2.65 ± 0.33 units transfused and a posttransfusion Hct increase of 5.0% ± 0.6%. Transfusion rates differed with PM (47.4%), SCAIF (17.2%), and SM (13.3%) flaps (P < 0.005). Patients undergoing PM reconstruction trended toward higher transfusion requirements (PM 2.89 ± 0.47 units, SC 2.18 ± 0.28 units, and SM 2.00 ± 0.0 units), with transfusion occurring later in the postoperative course (4.9 ± 1.3 days vs. 2.4 ± 0.1 days for all other flaps; P = 0.08). Infection, dehiscence, fistula, or medical complications were not different. Transfusion thresholds of Hct < 21 versus Hct < 27 exhibited no difference in LOS, flap-survival, or medical/flap-related complications., Conclusion: Transfusion is not associated with surgical or medical morbidity following head and neck pedicled flap reconstruction. There were no differences in outcomes between transfusion triggers of Hct < 21 versus Hct < 27, suggesting that a more conservative transfusion trigger may not precipitate adverse patient complications. Our data recapitulate findings in free flap patients and warrant further investigation of transfusion practices in head and neck flap reconstruction., Level of Evidence: 4. Laryngoscope, 128:E409-E415, 2018., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Unplanned 30-day readmission rate following hospital discharge is an important metric of healthcare quality. This study sought to characterize the rate, risk factors, and common causes of readmission in head and neck cancer patients following free or pedicled flap reconstruction., Study Design: Retrospective cohort study., Methods: Charts were reviewed of all patients who underwent free or pedicled flap reconstruction following resection of head and neck cancer at the Massachusetts Eye and Ear Infirmary 2009 to 2014. Readmission risk factors were evaluated by univariate and multivariate analysis., Results: Of 682 patients with free (76%) or pedicled flap reconstruction, 135 patients (19.8%) were readmitted. Factors not associated with readmission included age, gender, American Society of Anesthesiologists status, operative time, prior radiation therapy, primary cancer site, and free (vs. pedicled) flap type. Significant readmission risk factors included surgical site infections (SSI) (45.2% vs. 9.9%), use of hardware (18.5% vs. 11.3%), and clean-contaminated or contaminated surgery (15.2% vs. clean 8.2%). Surgical site infections (P < 0.001) and use of hardware (P = 0.03) remained predictive of readmission on multiple regression analysis. Primary reasons for readmission included wound complications (61.5%) and supportive care (15.6%). The median time to readmission was 8 days, and 41% of readmissions occurred within 1 week. Seventy percent of readmissions occurred within 2 weeks, including 77% of readmissions for SSIs and 86% for supportive care., Conclusion: Readmissions occurred in nearly one-fifth of patients following flap surgery. SSIs and use of hardware were risk factors, whereas wound complications were the most common cause of readmission., Level of Evidence: 4. Laryngoscope, 128:343-349, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Patients with head and neck cancer who undergo reconstructive surgery are at risk for deep venous thrombosis (DVT), but the risk profile for patients undergoing major flap reconstruction is highly variable. Herein, we report our findings from a retrospective analysis of head and neck cancer patients (n = 517) who underwent free (n = 384) or pedicled (n = 133) flap reconstructive operations at a major tertiary care center from 2011 to 2014. DVTs developed perioperatively in 9 (1.7%) patients. Compared with pedicled flap patients, free flap patients had a longer mean operative time (421.4 ± 4.4 vs 332.7 ± 10.7 min, P < .0001), but the DVT incidence did not differ significantly between free and pedicled flap patients (1.6% vs 2.2%, respectively, P = .28). These data suggest that perioperative DVT risk in head and neck oncology patients may be largely similar regardless of the reconstructive strategy pursued.

Objective: To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery., Methods: Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison., Results: Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors., Conclusions: The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI., (© The Author(s) 2016.)

Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.

Background: Surgical site infections can adversely affect flaps in head and neck reconstruction. The purpose of this study was to evaluate the risk factors of surgical site infections in supraclavicular artery island flap reconstructions., Methods: Records of patients undergoing head and neck surgery from 2011 to 2014 with supraclavicular artery island flap reconstruction at a single specialty hospital were reviewed; surgical site infections ≤30 days postoperatively were noted., Results: Of 64 patients, 86% underwent resection for malignancy, 55% previously received radiation. Sixty-three percent of surgeries were clean-contaminated. Seven patients (11%) developed recipient site surgical site infections, all in patients who underwent clean-contaminated surgery for malignancy. There was no complete flap loss. No significant differences in demographics or perioperative factors were noted. Oral cavity and laryngeal reconstructions (p = .014) and clean-contaminated surgery (p = .04) were factors associated with increased surgical site infection risk on univariate but not multivariate analysis. Patients with surgical site infections had longer hospitalizations (p = .003)., Conclusion: The supraclavicular artery island flap can be used for head and neck reconstruction with a low rate of surgical site infection. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016., (© 2016 Wiley Periodicals, Inc.)

Background: Compliance with Surgical Care Improvement Project (SCIP) parameters regarding antibiotic prophylaxis may affect surgical site infection rates. The purpose of this study was for us to report SCIP compliance, surgical site infection rates, and risk factors in a large series of head and neck free flap surgeries., Methods: A retrospective review of 480 free flap cases was performed. Surgical site infections occurring within 30 days postoperatively were noted., Results: Surgical site infection occurred in 13.3% of cases. Prophylaxis was given in 99.8% of cases; ampicillin-sulbactam (83%) and clindamycin (9%) were most common. Prophylaxis was "on-time" in 92.3% of cases. There were no significant associations between surgical site infection and tumor stage, American Society of Anesthesiologists (ASA) classification, tumor subsite, or flap type. Prior radiation was a risk factor for surgical site infection in patients treated for malignancy., Conclusion: A surgical site infection rate of 13.3% was noted. In this cohort, with a compliance rate with prophylactic antibiotic measures, prior radiation was found to be a risk factor only in patients with cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E392-E398, 2016., (© 2015 Wiley Periodicals, Inc.)

Objectives/hypothesis: Determine the time of onset and microbiology of surgical site infections (SSIs) following head and neck free flap reconstructive surgeries., Study Design: Retrospective cohort study., Methods: All 504 free flap surgical cases (484 patients) performed April 1, 2009 to September 30, 2013 were reviewed; SSIs occurring ≤30 days postoperatively were evaluated. Admission screening for methicillin-resistant Staphylococcus aureus (MRSA) colonization was performed on all patients., Results: Flap-recipient site infections (flap SSIs) occurred in 67 cases (13.3%), one-third week 1 postoperatively, one-third week 2, one-third days 15 to 30; 45% occurred after hospital discharge. Wound cultures were polymicrobial, but 25% grew only normal oral flora, whereas 75% grew pathogens not part of normal oral flora, such as gram-negative bacilli (44% of cases), MRSA (20%), and methicillin-sensitive S aureus (MSSA) (16%). The frequency of these pathogens did not vary significantly by the time of SSI onset. In 67%, cultures included at least one pathogen resistant to the prophylactic antibiotic used. Clindamycin prophylaxis was a significant risk factor for flap SSI and for early partial or complete flap loss from infection. Donor SSIs occurred in 22 cases (4.4%), 95% >1 week postoperatively, and MRSA or MSSA were the primary pathogens in 89%. Of the 25 patients colonized with MRSA on admission, 40% developed a flap or donor SSI, a rate significantly higher than in non-colonized patients., Conclusions: Gram-negative bacilli, MRSA, and MSSA were significant SSI pathogens, and late onset of infection was common. Better screening, decolonization, and prophylaxis may reduce SSI rates., Level of Evidence: 2b, (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The supraclavicular artery island flap (SCAIF) is a pedicled fasciocutaneous flap used for head and neck reconstruction. In recent years, its use has significantly increased as a result of several advantageous characteristics, including pliability, an excellent color and texture match, ability to reconstruct a variety of skin and aerodigestive tract defects, and short harvest times. Clinical experience suggests that donor site complications are relatively infrequent and typically self-limiting, and there have been no documented cases of prolonged or permanent shoulder dysfunction. However, formal studies have not been performed to assess this outcome. The goal of this study was to evaluate the effects of SCAIF flap harvest on postoperative shoulder strength and flexibility., Study Design: Prospective cohort pilot study., Methods: Data was gathered prospectively during routine follow-up and surveillance. The Penn Shoulder Score and Constant Shoulder Scale were used to measure subjective and objective outcomes. Physical therapists performed testing for strength and flexibility., Results: Ten patients were evaluated from January to July, 2013. Subjective self-reporting of shoulder function and satisfaction was good to excellent in most patients. The majority of patients demonstrated limitations in range of motion for one or more shoulder movements. Muscle strength was preserved postoperatively., Conclusion: Harvest of the SCAIF appears to have limited postoperative morbidity. Postoperative shoulder strength and function appears to be very good; however, some limitation of range of motion was observed., Level of Evidence: 4, (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

The supraclavicular artery island flap (SCAIF) is increasingly employed for laryngectomy reconstruction with excellent success. Although tracheoesophageal puncture (TEP) with intraoperative prosthesis placement is also positively reported, this is not described in patients following SCAIF. We review our experience with primary TEP with prosthesis placement and voice outcomes in patients after SCAIF reconstruction. Seven patients underwent SCAIF with primary TEP after laryngectomy from 2011 to 2013. Five underwent total laryngectomy (TL) and 2 underwent TL with partial pharyngectomy. All patients had 16 French Indwelling Blom-Singer prostheses placed intraoperatively without complications. Six patients achieved tracheoesophageal voice (median time = 1.5 months). Two patients required cricopharyngeal segment Botox injections. One patient remained aphonic. One patient developed prosthesis leakage addressed with prosthesis replacement. Our preliminary data demonstrate that similar to free tissue transfer reconstruction, primary TEP with intraoperative placement of the voice prosthesis at the time of SCAIF reconstruction is safe and effective., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014.)

Objectives/hypothesis: Report on the successful use of the supraclavicular flap for reconstruction following total laryngectomy and highlight the utility and versatility of the supraclavicular flap for reconstruction after total laryngectomy., Study Design: Retrospective review of a single institution experience., Methods: A single institution database was reviewed to identify patients undergoing total laryngectomy and supraclavicular flap reconstruction. The following data were collected: indication for reconstruction, flap viability, flap size, reconstruction site complication, and donor site complication., Results: Forty-six supraclavicular flaps were identified in the database from July 2011 to September 2013. Fifteen of these were used following total laryngectomy. Ten flaps were used for patch graft pharyngeal reconstruction, three flaps for cutaneous defects related to previous tracheotomy, one flap for cutaneous and tracheal reconstruction following resection of a recurrence in the stoma, and one flap as a pharyngeal interposition graft. Twelve of these cases were performed in the salvage setting after previous radiation. Three cases had significant oropharyngeal resection that required reconstruction. There was one near complete flap loss. Three patients developed pharyngocutaneous fistula. One patient required an additional surgical procedure to address a complication. Three patients had minor incisional dehiscence. All minor complications resolved with basic wound care. No significant donor site morbidity was identified., Conclusions: The supraclavicular flap can be successfully used for multiple purposes following total laryngectomy. This has been successfully used for reconstruction of limited pharyngeal defects, extensive pharyngeal resection, and skin reconstruction following previous tracheotomy. This flap can be successfully used following previous radiation and with limited morbidity., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

IMPORTANCE This study demonstrates the versatility of the supraclavicular artery (SCA) flap in head and neck reconstruction and offers technical highlights to improve the efficiency of flap harvest. OBJECTIVES To report our series of diverse reconstructions utilizing the SCA flap and to highlight several technical aspects of flap harvest that make the procedure more safe, reliable, and efficient. DESIGN, SETTING, AND PARTICIPANTS A retrospective review was conducted from July 2011 to December 2012 on all patients who had undergone SCA flap reconstruction of a head and neck defect at a tertiary referral center. The average follow-up time was 8 months. INTERVENTION OR EXPOSURE Supraclavicular artery flap reconstruction of defects at various head and neck subsites. MAIN OUTCOME AND MEASURE Reconstructive outcomes and complications were assessed and cases were reviewed to identify key aspects of flap harvest. RESULTS Twenty-four SCA flaps were performed on defects at multiple head and neck subsites. Several technical modifications were developed to increase the safety and efficiency of flap harvest. Complications were typically self-limited and were successfully managed nonsurgically. CONCLUSIONS AND RELEVANCE The SCA flap is a versatile and reliable reconstructive option for head and neck defects. There are 4 key steps to making the harvest of this flap safe, reliable, and efficient. LEVEL OF EVIDENCE 4.

Objectives/hypothesis: To compare free flap reconstructive cases from 1999 and 2009 with respect to patient characteristics, surgical characteristics, outcomes, and complications; and to discuss the evolution in free flap reconstruction at a single institution during this time period., Study Design: Retrospective cohort comparison., Methods: Free flap reconstruction cases from 1999 and 2009 were collected into two cohorts. Retrospective chart review was performed to extract patient characteristics, surgical characteristics, and outcomes. Cohorts were compared with respect to extracted data with statistical significance set at P < .05., Results: There were 39 free flap reconstructions performed in 1999 and 81 performed in 2009. Patients in the 2009 cohort had higher American Society of Anesthesiologists scores and incidence of cardiovascular disease (P = .009 and .0045, respectively). Median operative time decreased from 12 hours in 1999 to 9 hours in 2009 (P < .0001). Median length of stay decreased from 14 to 9 days (P = .0006). The rate of perioperative return to the operating room to manage complications decreased from 30% to 17% (P = .103). There were five unsalvaged flap failures in 1999 (12.8%) compared to two failures in 2009 (2.5%) (P = .036)., Conclusions: Patients undergoing free flap reconstruction are increasingly older and have more medical comorbidities. Despite these challenges, increased efficiency and teamwork stemming from accumulated institutional experience have led to decreased operative times, length of stay, and complication rates and increased overall success rates., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: To determine the utility of calvarial bone grafting in multiple reconstructive settings. In particular to examine the success of calvarial bone grafting of the nasofacial skeleton in a compromised wound bed., Study Design: Case series., Methods: A retrospective review was performed to identify patients undergoing calvarial bone graft reconstruction of the nasofacial skeleton. Patients were identified from operative records and the medical record was reviewed to identify age, gender, site of defect, indication for the operation, size of bone graft harvested, postoperative and delayed complications, radiation exposure, need for additional soft tissue, and graft loss., Results: Eighty-seven patients who underwent split calvarial bone grafts were identified and had a complete medical record available for review. Ninety grafts were harvested. Five subsites in the nasofacial skeleton were identified as sites for reconstruction. Forty cases were performed for revision of a previous complication, including 13 who had a previous alloplastic implant. Twenty-four additional cases were performed in a compromised wound bed and 64% of all cases were performed in either a revision or compromised setting. There was an 11% incidence of early postoperative complications, but there were no major complications at the donor site and only two major complications at the recipient site., Conclusion: Calvarial bone is a very useful material in the primary, revision, and compromised settings. This series suggests that split calvarial bone grafts is an adaptable, durable, and reliable material. It can be reliably used in the setting of radiation, infection, and inflammation.

Mandible defects are created by trauma as well as ablative surgery for both benign and malignant tumors. Ablative surgery for malignant tumors creates complex defects that impact form and function. This is often further complicated by the use of chemotherapy and radiation. In order to achieve a highly functional reconstruction with an acceptable cosmetic result, patients must be properly evaluated preoperatively. A patient's performance status and expectations for postoperative form and function can impact reconstruction. Once the defect is created, both the bone and soft-tissue loss must be considered. A structured approach to mandible defects will enable the re-establishment of mandible continuity and optimal soft-tissue reconstruction. This will ultimately lead to a patient with oral competence and limited swallowing deficits, as well as the ability to communicate effectively and interact with their community in a meaningful manner. There are ongoing investigations into new techniques and materials, such as distraction osteogenesis and tissue engineering, which will hopefully advance our ability to reconstruct the mandible.