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Enhancing composite graft survival with hyperbaric oxygen
OtolaryngologyHead and Neck Surgery Volume 121 Number 2
Methods: A series of 116 consecutive patients who underwent microvascular reconstruction of the head and neck during a 42-month period was analyzed to determine those factors that affected cost of treatment. Results: The mean cost of hospitalization was $31,972. The 2 predominant factors that contributed to the cost of therapy were operating room charges and room and nursing care charges. The median cost of therapy was $74,418 in those patients who had major medical or reconstructive complications, compared with a median cost of $23,900 in patients who had no major complications. Medical complications frequently resulted in a high cost of therapy, with cardiovascular and pulmonary complications being most common. Reconstructive complications that contributed to a high cost of therapy were rare, occurring in only 2 patients. Conclusions: Perioperative medical complications most commonly contribute to a high cost of therapy in patients who undergo microvascular head and neck reconstruction. Careful preoperative evaluation of cardiovascular and pulmonary comorbidity may be useful to identify those patients who are at increased risk of experience medical complications, and selection of suitable alternative methods of reconstruction that do not require prolonged surgery may be indicated when significant comorbidities are identified. As operating room expenses represent a major contribution to cost of therapy, a 2-team approach to simultaneous cancer resection and free flap reconstruction is desirable to decrease the length and cost of surgery. Reconstructive complications are rare in patients who undergo microvascular head and neck surgery, and this may contribute to an overall cost savings when compared with less reliable methods of head and neck reconstruction. 10:38 AM
Osteocutaneous Radial Forearm Flap Use without Donor Site Morbidity ANDREAS WERLE MD (presenter); EDWARD BRUCE TOBY MD; TERANCE TTSUEMD; DOUGLAS A GIROD MD; Shawnee Mission KS; Kansas City KS; Kansas City KS; Kansas City KS
Objectives: Fasciocutaneous radial forearm free flap (FC RFFF) has become the "workhorse flap" of the 1990s in head and neck reconstruction, whereas the osteocutaneous radial forearm free flap (OC RFFF) has been condemned because of the high rate of radius bone fracture. We have previously demonstrated increased strength in partially resected cadaveric radius bones after dynamic compression plating (DCP). The objective of this study is to assess the clinical performance of this method in patients undergoing OC RFFF reconstruction. Methods: This is a retrospective review of 43 patients from the University of Kansas Medical Center undergoing OC RFFF reconstruction between 1994 and 1998. In most cases, the donor site radius was plated with a low-contact DCP. Most cases involved reconstruction of oral cavity defects; 2 airway reconstructions are also included. Patient ages range was 16 to
Scientific Sessions--Monday
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89 years. Postoperative follow-up was more than 1 year in 27 patients (range 1 to 48 months). Results: Complete OC RFFF loss occurred in only 1 patient (success rate 98%). The most common donor site complication was tendon exposure, all but one of which healed simultaneously. One case of radius bone fracture has occurred in DCP-plated patients. One patient suffered a fall on postoperative day 7 and sustained a humeral fracture but no injury to the plated radius. Average donor side pinch/grip strength is approximately 90% of the average contralateral side strength. There have been no cases of median or ulnar neuropathy or ischemic symptoms. Sequential x-rays have shown remodeling and some reconstitution of the radii with no evidence of osteopenia. Conclusion: OC RFFF provides excellent oral cavity/oftpharyngeal reconstruction characteristics and allows reconstruction of bony defects up to 10 cm. Donor site complications have been minimal when internal fixation of the radius bone has been performed, and these have been similar to those experienced with the widely used FC RFFF.
l 0:46 AM Enhancing Composite Graft Survival with Hyperbaric Oxygen STACIE DAWN MCCLANE MD (presenter); GREGORY J RENNER MD; Columbia MO
Objectives: The traumatically amputated auricle has long presented a challenge to the facial plastic and reconstructive surgery team. Reattachment of the amputated part often fails. Several surgical techniques and pharmaceutical agents have been used in an attempt to improve the survival of this composite tissue. This investigation is a prospective, randomized, "blinded," study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of the reattached auriculm composite graft in the New Zealand White rabbit. Methods: Twenty New Zealand White rabbits were prospectively randomized to control (10) and treatment (t0) groups. Following partial amputation and reattachment of the auricle, the treatment group received 14 hyperbaric oxygen (HBO) treatments over 10 days. The control group received only standard postoperative care. The ears were examined grossly and microscopically on postoperative day 18. Results: The surviving composite graft was measured, recorded, and statistically analyzed. The mean percentage of graft survival for the control group was 0.3 l%(range 0%2.5%) while the mean for the control group was 15.94% (range 0%-38%). A median test was used to evaluate this difference, which was found to be statistically significant (P = 0.0057). ANOVA demonstrated that variables such as operative time, length of the rabbit's ear, and operative sequence did not affect the outcome variable measured. Conclusion: Our study demonstrates that hyperbaric oxygen therapy did enhance survival of reattached auricular composite
OtolaryngologyHead and Neck Surgery P132
August 1999
Scientific Sessions--Monday
graft tissue in the New Zealand White rabbit. Hyperbaric oxygen therapy may play a useful role in enhancing healing in the traumatically amputated ear; however, this role is still not clear and will need to be defined with further scientific investigation. 11:00 AM
Calvarial Bone Graft Harvest: A New Technique E BRADLEYSTRONG MD (presenter); THOMAS H M MOULTHROP MD; Sacramento CA
Objectives: The ideal instrument for harvesting outer table calvarial bone grafts (CBGs) does not currently exist. This study evaluates the use of a new calvarial bone graft harvesting device (BHD) to more safely and efficiently harvest outer table CBGs. The BHD is a U-shaped instrument, which holds a wire Gigli saw blade spanning the distal aspect of the tips. The BHD is attached to an oscillating drill and is used in a fashion analogous to a wire cheese cutter. The oscillating arms accurately follow the skull contour and reduce or eliminate the risk of intracranial injury. Methods: Eleven outer tables CBGs were harvested from the parietal region of 6 cadaveric skulls. An outer table bone island was fashioned using a 0.5-cm cutting burr. The island was formed by drilling a 1-cm-wide circumferential trough into the diploic space and beveling the trough on the periphery. The Gigli saw blade of the oscillating BHD was then passed through the diploic space, freeing the outer table bone island. The recorded parameters include drilling time, graft harvest time, graft size (area), graft integrity, and violation of the calvarial inner table. Results: Eleven bone grafts were harvested. Graft dimensions ranged as follows: width, 1.25 to 2.5 cm; length, 3.75 to 16.0 cm; area, 4.75 to 32 cm2; and thickness, 1.5 to 2.0 ram. There were no fractured grafts, no violations of the calvarial inner table with the BHD, and all grafts were of adequate thickness to retain their preharvest shape. The inner table was violated twice while the cutting burr was being used. The time necessary for drilling the bone island ranged from 4:15 to 13:30 minutes (mean 7:54 minutes). Bone graft harvesting time ranged from 1:40 to 12:00 minutes (mean 5:13 minutes). Conclusion: The BHD is extremely rapid, efficient, and safe. Average total harvest time was approximately 13 minutes. The graft length and width are limited only by the surgical exposure, cranial anatomy, and width of the particular BHD being used. Suture lines do not affect the harvest. While caution must be used with all CBGs, the BHD appears to significantly reduce or eliminate the risk of intracranial injury when compared with osteotomes or oscillating saws. 11:08 AM
Facial Translocation Approach to Skull Base and Paranasal Sinuses SHENG-PO HAO MD (presenter); Taipei Taiwan (Republic of China)
Objectives: Facial translocation approach, with temporary removal of facial bone and reinsertion at the end of the procedure, provides an excellent surgical exposure to facilitate extensive resection and delicate reconstruction of the tumors from skull base and paranasal sinuses. However, the viability of the reinserted bone graft is seldom evaluated. A retrospective review of the patients who underwent the facial translocation approach was undertaken to evaluate the viability of the reinserted bone graft. Methods: Sixty patients underwent the facial translocation approach. Among them, 56 were evaluated for viability of the translocated bone graft. Eleven patients underwent preoperative irradiation, while 26 had postoperative irradiation. The translocated bone graft was attached to the cheek soft tissue in 14 patients, while 42 patients had free bone grafts. A vascularized flap was used to obliterate the paranasal defect in 9 patients. Results: There were 19 benign and 41 malignant lesions. Forty,three (71.7%) patients survived with a mean survival of 26.8 months. Twelve (21.4%) patients had necrotic bone graft (NBG) and needed sequestrectomies. Statistical analysis revealed that the NBG rate increased by postoperative irradiation (P = 0.04) and decreased by soft tissue reconstruction of the paranasal defect (P = 0.006). Although the results were not statistically significant, the patients with free bone graft had a higher incidence of NBG than the patients with attached bone grafts. Conclusion: Facial translocation is an excellent surgical approach to skull base and paranasal sinuses. To prevent NBG, the translocated bone graft should be attached to the cheek soft tissue, or the paranasal defect should be reconstructed with soft tissue flap. However, soft tissue obliteration of the paranasal defect might obscure the detection of local recurrence. ll:16AM
Outcomes and Trends in 241 Free Flap Head and Neck Reconstructions BRUCE H HAUGHEY MBCHB MS FRACS (presenter); EWAIN P WILSON MD; LUCIA KLUWE MD; JAY F PICCiRiLLO MD; MELISSA WEBER BA; Saint Louis MO; Wilmington NC; Porte Alegre Brazil; Saint Louis MO; Saint Louis MO
Objectives: (1) To stratify 241 head and neck free flap procedures in 236 patients at a tertiary institution; (2) to measure flap and patient outcomes, including complications and trends in flap use; and (3) to detect factors predictive for complications. Methods: An outcome database was kept of all patients undergoing 241 free flap reconstructions by the senior author's team over l0 years. A complications database was created between 1992 and 1997, recording 48 preoperative and intraoperative variables and adverse outcomes (mortality, surgical and medical complications, and prolonged length of stay). Analysis by ~2 tests (bivariate) and logistic regression modeling (multivariate) were run.
Methods: A series of 116 consecutive patients who underwent microvascular reconstruction of the head and neck during a 42-month period was analyzed to determine those factors that affected cost of treatment. Results: The mean cost of hospitalization was $31,972. The 2 predominant factors that contributed to the cost of therapy were operating room charges and room and nursing care charges. The median cost of therapy was $74,418 in those patients who had major medical or reconstructive complications, compared with a median cost of $23,900 in patients who had no major complications. Medical complications frequently resulted in a high cost of therapy, with cardiovascular and pulmonary complications being most common. Reconstructive complications that contributed to a high cost of therapy were rare, occurring in only 2 patients. Conclusions: Perioperative medical complications most commonly contribute to a high cost of therapy in patients who undergo microvascular head and neck reconstruction. Careful preoperative evaluation of cardiovascular and pulmonary comorbidity may be useful to identify those patients who are at increased risk of experience medical complications, and selection of suitable alternative methods of reconstruction that do not require prolonged surgery may be indicated when significant comorbidities are identified. As operating room expenses represent a major contribution to cost of therapy, a 2-team approach to simultaneous cancer resection and free flap reconstruction is desirable to decrease the length and cost of surgery. Reconstructive complications are rare in patients who undergo microvascular head and neck surgery, and this may contribute to an overall cost savings when compared with less reliable methods of head and neck reconstruction. 10:38 AM
Osteocutaneous Radial Forearm Flap Use without Donor Site Morbidity ANDREAS WERLE MD (presenter); EDWARD BRUCE TOBY MD; TERANCE TTSUEMD; DOUGLAS A GIROD MD; Shawnee Mission KS; Kansas City KS; Kansas City KS; Kansas City KS
Objectives: Fasciocutaneous radial forearm free flap (FC RFFF) has become the "workhorse flap" of the 1990s in head and neck reconstruction, whereas the osteocutaneous radial forearm free flap (OC RFFF) has been condemned because of the high rate of radius bone fracture. We have previously demonstrated increased strength in partially resected cadaveric radius bones after dynamic compression plating (DCP). The objective of this study is to assess the clinical performance of this method in patients undergoing OC RFFF reconstruction. Methods: This is a retrospective review of 43 patients from the University of Kansas Medical Center undergoing OC RFFF reconstruction between 1994 and 1998. In most cases, the donor site radius was plated with a low-contact DCP. Most cases involved reconstruction of oral cavity defects; 2 airway reconstructions are also included. Patient ages range was 16 to
Scientific Sessions--Monday
P131
89 years. Postoperative follow-up was more than 1 year in 27 patients (range 1 to 48 months). Results: Complete OC RFFF loss occurred in only 1 patient (success rate 98%). The most common donor site complication was tendon exposure, all but one of which healed simultaneously. One case of radius bone fracture has occurred in DCP-plated patients. One patient suffered a fall on postoperative day 7 and sustained a humeral fracture but no injury to the plated radius. Average donor side pinch/grip strength is approximately 90% of the average contralateral side strength. There have been no cases of median or ulnar neuropathy or ischemic symptoms. Sequential x-rays have shown remodeling and some reconstitution of the radii with no evidence of osteopenia. Conclusion: OC RFFF provides excellent oral cavity/oftpharyngeal reconstruction characteristics and allows reconstruction of bony defects up to 10 cm. Donor site complications have been minimal when internal fixation of the radius bone has been performed, and these have been similar to those experienced with the widely used FC RFFF.
l 0:46 AM Enhancing Composite Graft Survival with Hyperbaric Oxygen STACIE DAWN MCCLANE MD (presenter); GREGORY J RENNER MD; Columbia MO
Objectives: The traumatically amputated auricle has long presented a challenge to the facial plastic and reconstructive surgery team. Reattachment of the amputated part often fails. Several surgical techniques and pharmaceutical agents have been used in an attempt to improve the survival of this composite tissue. This investigation is a prospective, randomized, "blinded," study to evaluate the efficacy of hyperbaric oxygen therapy in improving the survival of the reattached auriculm composite graft in the New Zealand White rabbit. Methods: Twenty New Zealand White rabbits were prospectively randomized to control (10) and treatment (t0) groups. Following partial amputation and reattachment of the auricle, the treatment group received 14 hyperbaric oxygen (HBO) treatments over 10 days. The control group received only standard postoperative care. The ears were examined grossly and microscopically on postoperative day 18. Results: The surviving composite graft was measured, recorded, and statistically analyzed. The mean percentage of graft survival for the control group was 0.3 l%(range 0%2.5%) while the mean for the control group was 15.94% (range 0%-38%). A median test was used to evaluate this difference, which was found to be statistically significant (P = 0.0057). ANOVA demonstrated that variables such as operative time, length of the rabbit's ear, and operative sequence did not affect the outcome variable measured. Conclusion: Our study demonstrates that hyperbaric oxygen therapy did enhance survival of reattached auricular composite
OtolaryngologyHead and Neck Surgery P132
August 1999
Scientific Sessions--Monday
graft tissue in the New Zealand White rabbit. Hyperbaric oxygen therapy may play a useful role in enhancing healing in the traumatically amputated ear; however, this role is still not clear and will need to be defined with further scientific investigation. 11:00 AM
Calvarial Bone Graft Harvest: A New Technique E BRADLEYSTRONG MD (presenter); THOMAS H M MOULTHROP MD; Sacramento CA
Objectives: The ideal instrument for harvesting outer table calvarial bone grafts (CBGs) does not currently exist. This study evaluates the use of a new calvarial bone graft harvesting device (BHD) to more safely and efficiently harvest outer table CBGs. The BHD is a U-shaped instrument, which holds a wire Gigli saw blade spanning the distal aspect of the tips. The BHD is attached to an oscillating drill and is used in a fashion analogous to a wire cheese cutter. The oscillating arms accurately follow the skull contour and reduce or eliminate the risk of intracranial injury. Methods: Eleven outer tables CBGs were harvested from the parietal region of 6 cadaveric skulls. An outer table bone island was fashioned using a 0.5-cm cutting burr. The island was formed by drilling a 1-cm-wide circumferential trough into the diploic space and beveling the trough on the periphery. The Gigli saw blade of the oscillating BHD was then passed through the diploic space, freeing the outer table bone island. The recorded parameters include drilling time, graft harvest time, graft size (area), graft integrity, and violation of the calvarial inner table. Results: Eleven bone grafts were harvested. Graft dimensions ranged as follows: width, 1.25 to 2.5 cm; length, 3.75 to 16.0 cm; area, 4.75 to 32 cm2; and thickness, 1.5 to 2.0 ram. There were no fractured grafts, no violations of the calvarial inner table with the BHD, and all grafts were of adequate thickness to retain their preharvest shape. The inner table was violated twice while the cutting burr was being used. The time necessary for drilling the bone island ranged from 4:15 to 13:30 minutes (mean 7:54 minutes). Bone graft harvesting time ranged from 1:40 to 12:00 minutes (mean 5:13 minutes). Conclusion: The BHD is extremely rapid, efficient, and safe. Average total harvest time was approximately 13 minutes. The graft length and width are limited only by the surgical exposure, cranial anatomy, and width of the particular BHD being used. Suture lines do not affect the harvest. While caution must be used with all CBGs, the BHD appears to significantly reduce or eliminate the risk of intracranial injury when compared with osteotomes or oscillating saws. 11:08 AM
Facial Translocation Approach to Skull Base and Paranasal Sinuses SHENG-PO HAO MD (presenter); Taipei Taiwan (Republic of China)
Objectives: Facial translocation approach, with temporary removal of facial bone and reinsertion at the end of the procedure, provides an excellent surgical exposure to facilitate extensive resection and delicate reconstruction of the tumors from skull base and paranasal sinuses. However, the viability of the reinserted bone graft is seldom evaluated. A retrospective review of the patients who underwent the facial translocation approach was undertaken to evaluate the viability of the reinserted bone graft. Methods: Sixty patients underwent the facial translocation approach. Among them, 56 were evaluated for viability of the translocated bone graft. Eleven patients underwent preoperative irradiation, while 26 had postoperative irradiation. The translocated bone graft was attached to the cheek soft tissue in 14 patients, while 42 patients had free bone grafts. A vascularized flap was used to obliterate the paranasal defect in 9 patients. Results: There were 19 benign and 41 malignant lesions. Forty,three (71.7%) patients survived with a mean survival of 26.8 months. Twelve (21.4%) patients had necrotic bone graft (NBG) and needed sequestrectomies. Statistical analysis revealed that the NBG rate increased by postoperative irradiation (P = 0.04) and decreased by soft tissue reconstruction of the paranasal defect (P = 0.006). Although the results were not statistically significant, the patients with free bone graft had a higher incidence of NBG than the patients with attached bone grafts. Conclusion: Facial translocation is an excellent surgical approach to skull base and paranasal sinuses. To prevent NBG, the translocated bone graft should be attached to the cheek soft tissue, or the paranasal defect should be reconstructed with soft tissue flap. However, soft tissue obliteration of the paranasal defect might obscure the detection of local recurrence. ll:16AM
Outcomes and Trends in 241 Free Flap Head and Neck Reconstructions BRUCE H HAUGHEY MBCHB MS FRACS (presenter); EWAIN P WILSON MD; LUCIA KLUWE MD; JAY F PICCiRiLLO MD; MELISSA WEBER BA; Saint Louis MO; Wilmington NC; Porte Alegre Brazil; Saint Louis MO; Saint Louis MO
Objectives: (1) To stratify 241 head and neck free flap procedures in 236 patients at a tertiary institution; (2) to measure flap and patient outcomes, including complications and trends in flap use; and (3) to detect factors predictive for complications. Methods: An outcome database was kept of all patients undergoing 241 free flap reconstructions by the senior author's team over l0 years. A complications database was created between 1992 and 1997, recording 48 preoperative and intraoperative variables and adverse outcomes (mortality, surgical and medical complications, and prolonged length of stay). Analysis by ~2 tests (bivariate) and logistic regression modeling (multivariate) were run.