Free-flap reconstruction for recurrence of head-and-neck cancer with vessel depletion is a technical challenge, and the literature is sparse. The present technical note describes the key-points of an approach harvesting the internal mammary pedicle. Results are reported in 3 patients, and pros and cons are discussed.

Reconstruction after wide resection of a sarcoma arising in the shoulder girdle is challenging, and little evidence is available to compare short-term outcomes between pedicled-flap and free-flap reconstruction.
Thirty-eight patients undergoing immediate reconstruction surgery with only a pedicled-flap (n = 18) and with a free-flap (n = 20) after sarcoma resection on the shoulder girdle between July 2005 and March 2022 were identified. One-to-one propensity score matching was performed to compare the postoperative complications.
Transferred flaps survived completely in 20 cases in the free-flap group. In the all-patient analysis of binary outcomes, the occurrences of total complications, takebacks, total flap complications, and flap dehiscence were higher in the pedicled-flap group than in the free-flap group. The propensity score-matched analysis showed the occurrence of total complications was significantly higher in the pedicled-flap group than the free-flap group (53.8% vs. 7.7%, p = 0.03). In the propensity score-matched analysis of continuous outcomes, the pedicled-flap group demonstrated a shorter operation time than the free-flap group (279 vs. 381 min, p = 0.05).
This clinical study demonstrated the feasibility and reliability of a free-flap transfer for the defect after wide resection of a sarcoma arising in the shoulder girdle.

The globally increasing incidence of cutaneous malignancies leads, in parallel, to increasing numbers of locally advanced skin cancer resulting in reconstructive surgery. Reasons for locally advanced skin cancer may be a patient\'s neglect or aggressive tumor growth, such as desmoplastic growth or perineural invasion. This study investigates characteristics of cutaneous malignancies requiring microsurgical reconstruction with the aim of identifying possible pitfalls and improving diagnostic and therapeutic processes. A retrospective data analysis from 2015 to 2020 was conducted. Seventeen patients (n = 17) were included. The mean age at reconstructive surgery was 68.5 (±13) years. The majority of patients (14/17, 82%) presented with recurrent skin cancer. The most common histological entity was squamous cell carcinoma (10/17, 59%). All neoplasms showed at least one of the following histopathological characteristics: desmoplastic growth (12/17, 71%), perineural invasion (6/17, 35%), or tumor thickness of at least 6 mm (9/17, 53%). The mean number of surgical resections until cancer-free resection margins (R0) were achieved was 2.4 (±0.7). The local recurrence rate and the rate of distant metastases were 36%. Identified high-risk neoplastic characteristics, such as desmoplastic growth, perineural invasion, and a tumor depth of at least 6 mm, require a more extensive surgical treatment without concerns about defect size.

Patients with recurrent oropharyngeal cancer can achieve survival benefits from surgical salvage, and often require simultaneous free-flap reconstruction. Resection and reconstruction can impact function, leading to tube dependence.
describe rates of tracheostomy and gastrostomy tube dependence after oropharyngeal resection and free flap after prior radiation.
evaluate patient, tumor, and treatment factors associated with tube dependence.
Retrospective, multi-institutional cohort study. Patients treated from 2003 to 2020. Average follow-up 21.4 months.
Five tertiary care centers.
Consecutive cohort of patients undergoing resection and simultaneous free-flap reconstruction for oropharyngeal squamous cell carcinoma after head and neck radiation.
gastrostomy tube dependence and tracheostomy or tracheostoma 1 year after surgery. Univariable and multivariable logistic regression were performed to identify factors associated with dependence.
89 patients underwent oropharyngectomy and free-flap reconstruction; 18 (20%) underwent total laryngectomy as part of tumor extirpation. After surgery, 51 patients (57%) lived 12 months. Among patients alive at 12 months, 22 (43%) were at least partially-dependent on gastrostomy tube, and 15 (29%) had either tracheostomy or tracheostoma. On multivariable analysis, extensive glossectomy (OR 16.6, 95% CI 1.83-389, p = 0.026) and total laryngectomy (OR 11.2, 95% CI 1.71-105, p = 0.018) were associated with long-term gastrostomy tube. No factors were associated with long-term tracheostomy on multivariable analysis.
Even among long-term survivors after salvage resection and free-flap reconstruction, rates of tube dependence are significant. This multi-institutional review is the largest such study to the date and may help inform shared decision-making.
4 Laryngoscope, 133:2141-2147, 2023.

Microvascular free-flap reconstruction of the head and neck is a common technique utilized across many ages. The purpose of this study was to identify if advanced age or comorbidity was associated with worse post-operative outcomes in patients undergoing free-flap reconstruction.
A retrospective analysis was performed on 344 consecutive patients undergoing free-flap surgery of the head and neck. Demographic, clinical and pathological factors were considered along with Charlson Comorbidity Index (CCI) scores and American Society of Anesthesiologists (ASA) status. Logistic regression analysis was used to investigate the association of age, CCI or ASA with post-operative complications.
Elderly patients (≥75 years) had a higher overall complication rate (odds ratio (OR) 1.7, P = 0.04) that was restricted to medical complications (OR 2.1, P = 0.05) and not surgical complications (OR 1.4, P = 0.14). Reconstructions of defects from cutaneous malignancy predominated in the elderly cohort (48% versus 29%, P < 0.01), but there was no difference in complication rate when cutaneous or mucosal subgroups were separated by age. ASA IV status was weakly associated with surgical complications (OR 3.89, P = 0.053), but CCI and elderly age were not associated with any outcome. Median length of stay was similar between age groups.
Free-flap reconstruction in older patients was associated with increased medical complications, and surgical complications were weakly associated with ASA status. Advanced age or comorbidity should not preclude microvascular reconstruction, but comorbid status should be optimized pre-operatively and factors predisposing to medical complications minimized where possible.

Head and neck surgeons are moving away from routine tracheostomy in free-flap reconstruction. We reviewed prophylactic tracheostomy use in patients undergoing oral cavity or oropharynx free-flap reconstruction to identify patient groups who avoided tracheostomy. Secondary aims were to describe complications associated with and without tracheostomy.
A retrospective cohort study was undertaken, using a prospectively maintained database. Inclusion criteria was free-flap reconstruction for an oral cavity or oropharyngeal defect, excluding partial or total laryngectomy. Variables collected included demographics, comorbidity, American Society of Anesthesiologists grade, Charlson Comorbidity Index, tumour site and subsite, extent of resection, surgery duration, tracheostomy, complications, return to theatre and re-intubation.
A total of 344 head and neck free-flap reconstructions were performed between January 2017 and July 2019. A total of 164 (87.7%) oral cavity and 23 (12.3%) oropharyngeal reconstructions were included totalling 187 free flaps. A total of 107 (57.2%) were males and 80 (42.8%) females, mean age 62.4 years (range 21-89). Of 187 patients, 100 (53.5%) underwent prophylactic tracheostomy at time of reconstruction. Longer operative time (P < 0.001), resection site (P < 0.001), number of subsites resected (P = 0.007), segmental mandibulectomy (P = 0.04), lip-split (P = 0.05), floor of mouth resection (P < 0.001), lingual release (P = 0.007), glossectomy (P < 0.001), extent of tongue resection (P < 0.001), extent of hard palate resection (P = 0.04), soft palate resection (P < 0.001) and double free-flap reconstruction (P = 0.04) were associated with tracheostomy use.
A personalized approach to postoperative airway management allowed almost half of our cohort to avoid tracheostomy. In high-volume institutions with the necessary expertise and support, appropriately selected patients may be safely managed without routine tracheostomy.

BACKGROUND: De-escalating treatments have been focused on for HPV-associated oropharyngeal squamous cell carcinoma (OPSCC). We assessed the efficacy of a triplet induction chemotherapy (ICT) followed by surgery with or without neck dissection (ND) for locally advanced OPSCC, aiming at less invasive surgery without free-flap reconstruction and avoiding postoperative irradiation.
METHODS: This was a retrospective study of 41 patients with advanced resectable HPV-positive OPSCC who underwent ICT followed by surgery of primary resection with or without ND. Patients underwent triplet ICT, including docetaxel, cisplatin, and 5-fluorouracil, or carboplatin, paclitaxel, and cetuximab.
RESULTS: Twenty-nine patients had tonsillar cancer, 15 patients were current smokers, and 18 and 12 patients had T2N1M0 and T1N1M0 status (UICC 8th), respectively. After ICT, a surgical procedure without free-flap reconstruction and tracheostomy was possible in 90.2%. Pathological complete response at both the primary site and lymph nodes was achieved in 73.2%. Of the patients who underwent surgery, no adjuvant radiotherapy was required in 85.0%. Two patients (4.9%) experienced recurrence at regional lymph nodes, but were cured by salvage ND followed by adjuvant radiotherapy.
CONCLUSIONS: Upfront ICT using highly responsive triplet chemotherapeutic regimens may enable us to perform less invasive surgery without free-flap reconstruction and to avoid postoperative irradiation to the locoregional field through excellent postoperative pathological features.

OBJECTIVE: To assess the factors associated with long-term quality of life (QoL) and patient concerns in elderly oral or oropharyngeal cancer (OOPC) patients after oncologic surgery and free-flap reconstruction.
METHODS: Patients aged over 70 years who were still alive and disease-free at least 1 year after surgery were enrolled in this cross-sectional multicentric study. Patients completed the EORTC QLQ-C30, -H&N35 and -ELD14 QoL questionnaires, and the Hospital Anxiety and Depression Scale (HADS). Patient needs were evaluated using the Patient Concerns Inventory (PCI). Factors associated with these clinical outcomes were determined in univariate and multivariate analysis.
RESULTS: Sixty-four patients were included in this study. Long-term QoL, functioning scales and patient autonomy were well-preserved. Main persistent symptoms were fatigue, constipation and oral function-related disorders. Salivary and mastication/swallowing problems were the main patient concerns. The mean number of patient concerns increased with the deterioration of their QoL. Psychological distress (HADS score ≥ 15) and patient frailty (G8 score < 15) were significantly associated with poor QoL outcomes.
CONCLUSIONS: We found a negative correlation between the number of patient concerns and QoL. Dental rehabilitation and psychological and nutritional supportive measures are of critical importance in the multidisciplinary management of elderly OOPC patients.

OBJECTIVE: Free flap reconstruction is a valuable technique to preserve function in oncological head and neck surgery. Postoperative graft thrombosis is a dreaded risk. This study aims to compare low-dose unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) in perioperative thrombosis prophylaxis.
METHODS: This is a retrospective analysis of 266 free flaps performed at our academic center. A comparison was made between 2 patient groups, based on their respective postoperative prophylaxis protocols either with UFH (n = 87) or LMWH (n = 179). Primary endpoints were the frequency of transplant thrombosis and the number of flap failures. Secondary endpoints were the occurrence of peri- and postoperative complications.
RESULTS: The flap survival rate was 96.6% and 93.3% for the groups UFH and LMWH, respectively (P = 0.280). The rate of postoperative bleeding requiring revision was 4.6% and 6.7% for each group, respectively (P = 0.498). We found a hematoma formation in 4.6% and 3.9% (P = 0.792).
CONCLUSIONS: The free-flap survival rate using low-dose UFH seems to be equivalent to LMWH regimens without compromising the postoperative outcome. Consequently, for risk-adapted thrombosis prophylaxis, either LMWH or UFH can be administrated.

Implant born prosthetic rehabilitation of tumour patients can be difficult to perform. Challenges in treating such patients include disrupted anatomy with limited mouth opening due to previous ablative surgery as well as free-flaps or simple bone grafts, adjuvant therapy such as radiotherapy and, in general, poorer general health. Combining classical knowledge of ideal prosthesis placement and current virtual planning possibilities the positioning and in consequence the survival of dental implants can be optimised. Since prosthetic rehabilitation has a positive effect on the patients\' quality of life and general health, we propose performing such surgeries as early as possible. All patients at our institution receiving pre-planned guided implant reconstruction and postoperative evaluation with Cone Beam Computed Tomography (CBCT) between 2015 and 2018 were evaluated for inclusion. Eight patients with a total of 30 implants met the inclusion criteria. The planned implant position was compared to the outcome position by fusing the two and deviations in entry-point position, apex-position, angular deviation and depth error were recorded. The mean (SD) discrepancy at entry-point was 2.28 (1.45) mm and 2.89 (1.53) mm at the apex, respectively. Mean (SD) angulation discrepancy was 9.5˚ (4.13˚) and the mean (SD) depth deviation was 1.52 (0.86) mm. Our results demonstrate the feasibility of pre-planned implant placement in challenging clinical situations and that only few concessions have to be made for precision.