Analysis of first week complications of microvascular free flap reconstructions after oral cavity cancer resection: A Single Institutional Experience of 314 Cases

Nikita Jimmy Chokshi; Sachin Wani; Yogesh Bhatt; Piyush Doshi; Shishir Shah; Ankit Shah; Rajiv Bhatt

doi:10.4103/jhnps.jhnps_18_19

ORIGINAL ARTICLE

Year : 2019 | Volume : 7 | Issue : 1 | Page : 11-15

Analysis of first week complications of microvascular free flap reconstructions after oral cavity cancer resection: A Single Institutional Experience of 314 Cases

Nikita Jimmy Chokshi¹, Sachin Wani¹, Yogesh Bhatt², Piyush Doshi², Shishir Shah¹, Ankit Shah¹, Rajiv Bhatt¹
¹ Department of Surgical Oncology, HCG Cancer Centre, Vadodara, Gujarat, India
² Department of Plastic Surgery, HCG Cancer Centre, Vadodara, Gujarat, India

Date of Web Publication

26-Jul-2019

Correspondence Address:
Nikita Jimmy Chokshi
Department of Surgical Oncology, HCG Cancer Centre, Sunpharma Road, Opposite Satsang Party Plot, Vadodara - 390 012, Gujarat
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_18_19

Abstract

Introduction: There has been an increase in patients seeking treatment for oral cancers. Good and reliable reconstruction methods are needed to provide good cosmesis in early stage cancers and to fulfill large tissue requirement after complex head and neck resections in advanced stage cancers. Microvascular free flaps exactly fit into the needed framework. However, free flaps also have their limitations and complications. Materials and Methods: Data of all patients who had oral cancer resections and reconstructions performed at HCG Cancer Centre, Vadodara from May 1, 2016, to December 31, 2018, were reviewed. Out of them, patients in whom free flaps were done were included in the study. Ethical approval for this study was not needed as it was on a retrospective basis. Postoperative monitoring of the flap was done mainly by clinical observation and pinprick test. Color Doppler ultrasound was done to detect flow in arterial failure cases. Observation and Results: Our complication rate was 6.68% out of which flap salvage rate was 23.8%. Hence, it is very important to pick up early signs of developing complications to increase the flap salvage rate. Discussion: Better wound healing, cosmesis, better functional – social – psychological rehabilitations are the prime advantages of various free flaps. Events occurring in the 1^st week have maximum influence on the free flap viability. During the 1^st postoperative week, vigilant lookout should be there for signs and symptoms to detect early flap-related complications so that timely interventions can be taken to salvage them. No flap complication in the 1^st week is a good prognostic indicator for flap survival and thus preventing any delays in further adjuvant treatment. Conclusion: No flap complication in the 1^st week is a good prognostic indicator for flap survival and thus preventing any delays in further adjuvant treatment.

Keywords: Anterolateral thigh flap, flap salvage, free fibula flap, microvascular anastomosis, radial forearm flap, thrombosis, venous congestion

How to cite this article:
Chokshi NJ, Wani S, Bhatt Y, Doshi P, Shah S, Shah A, Bhatt R. Analysis of first week complications of microvascular free flap reconstructions after oral cavity cancer resection: A Single Institutional Experience of 314 Cases. J Head Neck Physicians Surg 2019;7:11-5

How to cite this URL:
Chokshi NJ, Wani S, Bhatt Y, Doshi P, Shah S, Shah A, Bhatt R. Analysis of first week complications of microvascular free flap reconstructions after oral cavity cancer resection: A Single Institutional Experience of 314 Cases. J Head Neck Physicians Surg [serial online] 2019 [cited 2022 Jun 28];7:11-5. Available from: https://www.jhnps.org/text.asp?2019/7/1/11/263511

Introduction

There has been an increase in patients seeking treatment for oral cancers due to easy widespread techniques of diagnosis, increase in diagnostic centers, recent developments due to continuous research and awareness.^[1] Good and reliable reconstruction methods are needed to provide good cosmesis in early stage cancers and to fulfill large tissue requirement after complex head and neck resections in advanced stage cancers. Reconstructions after salvage surgeries are also challenging.^[2]

Before the era of vascular anastomosis, pedicled flaps and local rotational flaps were into use. However, often the reconstruction was compromised due to less tissue availability and limited reach of flap resulting in contractures and facial scars.^[3] Problem in wound healing delays adjuvant treatment in cancer patients which impacts the long-term prognosis of cancer. Microvascular free flaps exactly fit into the needed framework. They enhance postsurgical wound healing and recovery of function. However, free flaps also have their limitations and complications.

This study reviews our experience of 314 patients in whom free flaps were used. We are presenting our data on their 1^st week complications.

Materials and Methods

Data of all patients who had oral cancer resections and reconstructions performed at HCG Cancer Centre, Vadodara, Gujarat, India, from May 1, 2016, to December 31, 2018 were reviewed. Out of them, patients in whom free flaps were done were included in the study. Ethical approval for this study was not needed as it was on a retrospective basis. Gender, age, primary site, any comorbidity present in the patient, type of flap, and any complications of the flap occurring in the first postoperative week were noted. In general, osteocutaneous free fibular flaps, anterolateral septocutaneous or musculocutaneous thigh flaps, radial forearm fasciocutaneous free flaps and rarely medial sural perforator flaps are done at our institution. The decision to do single flap or combination of one or more free flaps with pedicled flaps was made according to the extent of primary cancer resection. However, in any case plan of the whole surgery was made preoperatively based on the clinical and radiological findings.

Preoperatively, contrast-enhanced computed tomography (CT) or magnetic resonance imaging was done, scanning structures from skull base to clavicle, to evaluate the extent of disease and for surgical planning. In recurrent or second primary cases, positron emission tomography CT scan was done for metastatic workup. Color Doppler ultrasonography of lower limb was done preoperatively for those patients in whom free fibular flap harvest was planned to evaluate vessel's and perforator's structure, anatomy, and wall caliber. All patients underwent resection of the tumor, neck dissection to remove fibrofatty – lymphatic structures and simultaneous vessel dissection for microvascular anastomosis followed by immediate free flap reconstruction. Facial artery or superior thyroid artery were mainly used for arterial end to end anastomosis. Common facial vein, internal jugular vein (IJV), or superior thyroid vein was used for deep venous system end to end or end to side anastomosis. External jugular vein (EJV) was used for superficial venous system anastomosis. Donor and recipient vessel selection was based in a way to avoid the use of vein graft.

Postoperative monitoring of the flap was done mainly by clinical observation and pinprick test. Color Doppler ultrasound was done to detect flow in arterial failure cases.

Observation and Results

A total of 314 cases of oral cancers were operated, which were reconstructed using free flaps. There were 273 male and 41 female with sex ratio of 6.66:1. Age of the patients ranged from 24 to 77 years with an average age of 50.86 years. More than 80% of patients were in the age group 31–60 [Table 1].

Table 1: Age groups

Click here to view

Majority of the reconstructions were done after resection of buccal mucosa cancers (about 66%) followed by tongue carcinomas (22%) [Table 2]. Malignancies of buccal mucosa which may extend up to commissure of mouth, lower gingiva – buccal sulcus (GBS), retromolar trigone were grouped together as buccal mucosa diseases. Extensive cancer of lower labial mucosa involving in continuity middle third mandibular bone and floor of mouth were grouped together as lower central arch disease. Bony reconstruction using free fibula was mainly used in such cases for restoring bony continuity which would have an impact on the holding of tongue musculature and floor of mouth muscles, swallowing and early weaning of tracheostomy tubes. the Furthermore, cutaneous portion of free fibular flap was pliable enough for reconstructing labial vestibule and lip.

Table 2: Primary site of oral cancer

Click here to view

Cancer resections of lower lip, maxilla, and floor of mouth were also reconstructed using radial or fibular flaps. Malignancies of upper GBS, maxillary bone, hard, and soft palate were grouped as maxillary diseases.

In one case of recurrent posterior neck sarcoma, the resultant large defect was reconstructed with anterolateral thigh (ALT) flap. Transverse cervical vessels were used for anastomosis.

Radial forearm-free flap (RFFF) was our workhorse for reconstruction with 184 flaps done in about 2.5 years [Table 3]. However, for large tissue availability, ALT flaps were used. Seventy-four of them were done. Fifty-five free fibular flaps were done for lateral or central segmental defects of mandible. In some cases after unilateral disarticulation of mandible, hanging fibula reconstructions were also done.

Table 3: Type of flaps done

Click here to view

All complications which had a direct impact on flap viability occurred in the first 7 days of surgery [Graph 1]. Two patients in whom radial forearm flap was done for buccal mucosa and tongue reconstruction developed cheek and native tongue swelling, respectively, on the 1^st postoperative day with a tensed flap which was supple earlier. On pricking, dark red blood was noticed. Patients were immediately taken up for re-exploration, hematoma was evacuated, and flaps were salvaged [Table 4]a and [Table 4]b.

Click here to view

Venous congestion developed in nine patients. All were taken up for re-exploration. Two flaps were salvaged by reanastomosis. One had developed a block in EJV (superficial system) and other in common facial vein (deep venous system). In the third patient, EJV was blocked so reanastomosis was done but even after that flap got necrosed and could not be salvaged. Hence, in seven patients, flap debridement and Pectoralis Major Myocutaneous Flaps (PMMC) was done.

Flap necrosis developed in seven patients. Clinically, the flaps were pale. On pricking the flap, there was delayed bleeding in the beginning and then no bleeding. Along with paleness, some had pus discharge from beneath the flap. One had frank arterial thrombus which was evident on color Doppler of the vessel. The reason of flap necrosis in the remaining six patients was problems in microcirculation attributed to pedicle compression, obesity with a large amount of fat in subdermal layer and diabetes. In one free fibular flap, half of the skin paddle got necrosed due to lack of perforator [Figure 1]. It was partly debrided and reconstructed with deltopectoral flap. The remaining part of the flap survived. Hence, our complication rate was 6.68% out of which flap salvage rate was 23.8%. Hence, it is very important to pick up early signs of developing complications to increase the flap salvage rate.

Figure 1: Part necrosis of extraoral paddle of cutaneous portion of osteocutaneous free fibular flap

Click here to view

Of 314 patients, 99 (31.52%) had one or more medical comorbidities. Nine (42.85%) patients, out of 21, who have had complications, had one or more medical comorbidities [Table 5].

Table 5: Medical comorbidities

Click here to view

Discussion

Oral cancer resection sacrifices considerable soft and hard tissues causing disfiguring orofacial defects.^[4] Primary reconstruction of such defects comes in the core planning of oral cancer surgery.^[5],[6] Better wound healing, cosmesis, better functional – social – psychological rehabilitations are the prime advantages of various free flaps.^[7] However, these are complex reconstructions which need proper preoperative planning. Such surgeries need advanced well-equipped operation theatres with microsurgical facilities and intensive care units with proper postop monitoring facilities.^[8] However, even such time-consuming surgeries have their own complications. Events occurring in the 1^st week have maximum influence on the free flap viability. Hence, in this retrospective cohort of patients, we are evaluating immediate 1^st week complications.

Out of 314 patients in whom free flaps were done postcancer resections, 6.68% developed complications in the first 7 days of surgery which would have had major impact of flap viability. All were surgical complications. None of them developed after 7 days of surgery which would have a direct impact on flap viability. This would mean aggressive flap vascularity monitoring is needed for the 1^st postoperative week. Delayed complications occurred a minimum of after 15 days after surgery. They were mainly functional such as oral incompetence and microstomia, problems associated with implants and bone healing in free fibular flaps, swallowing dysfunctions and aspirations due to bulky ALT flaps, implant exposures in free fibula cases after radiotherapy, implant fractures, and nonunions.

Majority high volume centers have flap success rate more than 95%. Kroll et al. studied 990 patients out of which 50 cases (5.1%) developed pedicle thrombosis.^[8]

Hidalgo et al.^[9] reviewed 716 cases of free flaps used for reconstruction of defects after cancer resections. He reported that common etiology of flap failure were venous issues (35%) than arterial problems (28%). In his case series, hematoma rate was 26%. Flap complications after 48 h were mostly due to mechanical compression around the anastomosis or infection.^[10],[11]

Chalian^[12]et al. studied 156 free flaps and concluded that anastomosis to EJV was associated with higher venous congestion rate as compared to the anastomosis performed with IJV. Hence, when single vein was available for anastomosis, it was anastomosed with deep venous system, especially IJV. In RFFFs, radial artery venae comitantes were anastomosed with deep venous system and cephalic vein with EJV.

Zhou et al. analyzed various risk factors for flap failure in their retrospective study of 881 free flaps for head and neck reconstruction.^[13] They did not find a significant association of age and diabetes with free flap outcome. Kantar et al. in 2019 concluded in their largest national cohort of 6030 free flap procedures that diabetes is not increasing the rates of flap failure. However, they do increase the chances of surgical site infection and longer length of hospital stay.^[14]

Schrey et al. studied the factor oxygen partial pressure in tissue and concluded that its continuous recording is a reliable method for monitoring of free flaps. Furthermore, blood pressure should be optimal to achieve adequate blood flow in free tissue transfer.^[15]

Also, quality of flap plays a major role in deciding its prognosis. Bulky flaps with large amount of subcutaneous fat are difficult to suture and inset in the defect. They are difficult to fold for complex reconstructions and give better functional outcome. Fatty flaps, especially in diabetic patients, may develop discrepancies in microcirculation in subcutaneous plane resulting in superficial necrosis of skin of flap. Such problems were frequently noticed in bulky ALT flaps. Whenever the longer length of pedicle is needed, RFFF proves to be a boon to microvascular surgeon. It is mainly used for reconstructions of palate, tongue, lip or buccal mucosa. Whenever there is a need for bulky flaps, such as in composite resections, recurrences, through and through large intraoral and extraoral defects, ALT provides the required tissue bulk. In addition, the lie of pedicle is very important. Often folding and suturing of the flap twists and compresses the pedicle which is one of the reasons for intravascular thrombus formation and flap congestion.^[16],[17] In case of free fibular flaps, turning and suturing of cutaneous part is difficult and often provide inadequate soft tissue. In such cases, the chimeric flap can be used.

Conclusion

Flaps are a good technique for reconstruction following oral cancer resection. During the 1^st postoperative week, vigilant lookout should be there for signs and symptoms to detect early flap-related complications so that timely interventions can be taken to salvage them. No flap complication in the 1^st week is a good prognostic indicator for flap survival and thus preventing any delays in further adjuvant treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

1.	Abadeh A, Ali AA, Bradley G, Magalhaes MA. Increase in detection of oral cancer and precursor lesions by dentists: Evidence from an oral and maxillofacial pathology service. J Am Dent Assoc 2019;150:531-9.
2.	Yadav P. Recent advances in head and neck cancer reconstruction. Indian J Plast Surg 2014;47:185-90. [PUBMED] [Full text]
3.	Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990;160:352-5.
4.	Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck 2010;32:1236-45.
5.	González-García R, Naval-Gías L, Rodríguez-Campo FJ, Muñoz-Guerra MF, Sastre-Pérez J. Vascularized free fibular flap for the reconstruction of mandibular defects: Clinical experience in 42 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;106:191-202.
6.	Haughey BH, Wilson E, Kluwe L, Piccirillo J, Fredrickson J, Sessions D, et al. Free flap reconstruction of the head and neck: Analysis of 241 cases. Otolaryngol Head Neck Surg 2001;125:10-7.
7.	Alvi SA, Hamill CS, Lepse JP, Ayala M, Girod DA, Tsue TT, et al. Outcomes after free tissue transfer for composite oral cavity resections involving skin. Head Neck 2018;40:973-84.
8.	Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg 1996;98:459-63.
9.	Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free flaps for oncologic surgical defects: Refinement in donor-site selection and technique. Plast Reconstr Surg 1998;102:722-32.
10.	Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED, et al. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 2003;41:16-20.
11.	Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer. Head Neck 2001;23:475-8.
12.	Chalian AA, Anderson TD, Weinstein GS, Weber RS. Internal jugular vein versus external jugular vein anastamosis: Implications for successful free tissue transfer. Head Neck 2001;23:475-8.
13.	Zhou W, Zhang WB, Yu Y, Wang Y, Mao C, Guo CB, et al. Risk factors for free flap failure: A retrospective analysis of 881 free flaps for head and neck defect reconstruction. Int J Oral Maxillofac Surg 2017;46:941-5.
14.	Kantar RS, Rifkin WJ, David JA, Cammarata MJ, Diaz-Siso JR, Levine JP, et al. Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database. Microsurgery 2019;39:14-23.
15.	Schrey A, Kinnunen I, Vahlberg T, Minn H, Grénman R, Taittonen M, et al. Blood pressure and free flap oxygenation in head and neck cancer patients. Acta Otolaryngol 2011;131:757-63.
16.	Maldonado AA, Silva AK, Humphries LS, Gottlieb LJ. Complex orofacial reconstruction with the intrinsic chimeric flap. J Reconstr Microsurg 2017;33:233-43.
17.	Cummins DM, Kim B, Kaleem A, Zaid W. Pedicle orientation in free-flap microvascular maxillofacial reconstruction. J Oral Maxillofac Surg 2017;75:875.e1-875.e4.