Download PDF
J Reconstr Microsurg 2022; 38(05): 343-360
DOI: 10.1055/s-0041-1733922
Original Article

Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database

Jacob Y. Katsnelson 
1   Department of Surgery, Abington-Jefferson Health, Abington, Pennsylvania
,
Richard Tyrell
2   Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
,
Murad J. Karadsheh
3   Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
,
Ely Manstein
2   Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
,
Brian Egleston
4   Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
,
Mengying Deng
4   Biostatistics and Bioinformatics Facility, Temple University Health System, Fox Chase Cancer Center, Philadelphia, Pennsylvania
,
Pablo A. Baltodano
5   Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
,
M. Shuja Shafqat
2   Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
3   Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
5   Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
,
Sameer A. Patel
2   Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
3   Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
5   Division of Plastic and Reconstructive Surgery, Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
› Author Affiliations Funding Statistical work for this project was supported through the National Institutes of Health National Cancer Institute (Grant #P30CA006927).
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years.

Methods Patients undergoing head and neck reconstruction were identified in the 2011–2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay.

Results A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02–6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52–5.71, p = 0.001), and infection (OR = 2.03, CI 1.39–2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50–0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12–0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps.

Conclusion Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

Keywords

head and neck cancer reconstruction - free tissue transfer - pedicled flaps

Prior Presentation

American Society of Plastic Surgeons, Virtual Plastic Surgery The Meeting, October 16th to 18th, 2020.


Robert H. Ivy Society of Plastic Surgery, Annual Virtual Scientific Meeting, November 7th, 2020.


Authors' Contribution

J.Y.K. contributed toward the conception and design, interpretation of data, drafting of the manuscript, and revision of the manuscript; R.T. contributed toward the conception and design, interpretation of data, drafting of the abstract, and revision of the manuscript; M.J.K. did the conception and design, drafting of manuscript, and revision of manuscript; E.M. did the drafting of manuscript and revision of manuscript; B.E. did the statistical analysis, acquisition of data, and revision of manuscript; M.D. contributed toward the acquisition of data, statistical analysis, and revision of manuscript; P.A.B. did the interpretation of data and revision of the manuscript; M.S.S. contributed toward the interpretation of data and revision of the manuscript; S.A.P. did the conception and design, interpretation of data, and revision of the manuscript. All authors have reviewed and approved the final version of this manuscript.


Note

The American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.




Publication History

Received: 27 February 2021

Accepted: 22 June 2021

Article published online:
17 August 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67 (01) 7-30
    Google Scholar
  • 2 Gurtner GC, Evans GR. Advances in head and neck reconstruction. Plast Reconstr Surg 2000; 106 (03) 672-682 , quiz 683
    CrossrefPubMedGoogle Scholar
  • 3 Chim H, Salgado CJ, Seselgyte R, Wei FC, Mardini S. Principles of head and neck reconstruction: an algorithm to guide flap selection. Semin Plast Surg 2010; 24 (02) 148-154
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Patel SA, Chang EI. Principles and practice of reconstructive surgery for head and neck cancer. Surg Oncol Clin N Am 2015; 24 (03) 473-489
    CrossrefPubMedGoogle Scholar
  • 5 Hurvitz KA, Kobayashi M, Evans GRD. Current options in head and neck reconstruction. Plast Reconstr Surg 2006; 118 (05) 122e-133e
    CrossrefPubMedGoogle Scholar
  • 6 Abouyared M, Katz AP, Ein L. et al. Controversies in free tissue transfer for head and neck cancer: a review of the literature. Head Neck 2019; 41 (09) 3457-3463
    CrossrefPubMedGoogle Scholar
  • 7 Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck 2010; 32 (09) 1236-1245
    CrossrefPubMedGoogle Scholar
  • 8 Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg 2006; 35 (03) 199-207
    CrossrefPubMedGoogle Scholar
  • 9 Kim EK, Evangelista M, Evans GR. Use of free tissue transfers in head and neck reconstruction. J Craniofac Surg 2008; 19 (06) 1577-1582
    CrossrefPubMedGoogle Scholar
  • 10 McCarthy CM, Cordeiro PG. Microvascular reconstruction of oncologic defects of the midface. Plast Reconstr Surg 2010; 126 (06) 1947-1959
    CrossrefPubMedGoogle Scholar
  • 11 Rosenthal E, Carroll W, Dobbs M, Scott Magnuson J, Wax M, Peters G. Simplifying head and neck microvascular reconstruction. Head Neck 2004; 26 (11) 930-936
    CrossrefPubMedGoogle Scholar
  • 12 Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T. Free versus pedicled flaps for reconstruction of head and neck cancer defects: a systematic review. J Otolaryngol Head Neck Surg 2019; 48 (01) 13
    CrossrefPubMedGoogle Scholar
  • 13 American College of Surgeons Quality Improvement Program Participant Data Use File. Accessed January 22nd, 2020 at: www.facs.org/quality-programs/acsnsqip
    PubMed
  • 14 Brady JS, Desai SV, Crippen MM. et al. Association of anesthesia duration with complications after microvascular reconstruction of the head and neck. JAMA Facial Plast Surg 2018; 20 (03) 188-195
    CrossrefPubMedGoogle Scholar
  • 15 Brady JS, Govindan A, Crippen MM. et al. Impact of diabetes on free flap surgery of the head and neck: a NSQIP analysis. Microsurgery 2018; 38 (05) 504-511
    CrossrefPubMedGoogle Scholar
  • 16 Raval MV, Pawlik TM. Practical guide to surgical data sets: National Surgical Quality Improvement Program (NSQIP) and Pediatric NSQIP. JAMA Surg 2018; 153 (08) 764-765
    CrossrefPubMedGoogle Scholar
  • 17 Thomas LE, Li F, Pencina MJ. Overlap weighting: a propensity score method that mimics attributes of a randomized clinical trial. JAMA 2020; 323 (23) 2417-2418
    CrossrefPubMedGoogle Scholar
  • 18 Li F, Thomas LE, Li F. Addressing extreme propensity scores via the overlap weights. Am J Epidemiol 2019; 188 (01) 250-257
    PubMedGoogle Scholar
  • 19 McCarthy JG, Galiano RD, Boutros SG. Current Therapy in Plastic Surgery. 1st ed.. Saunders/Elsevier; 2006: 710
    Google Scholar
  • 20 Jose B, Banis J, Flynn M. et al. Irradiation and free tissue transfer in head and neck cancer. Head Neck 1991; 13 (03) 213-216
    CrossrefPubMedGoogle Scholar
  • 21 Liu M, Liu W, Yang X, Guo H, Peng H. Pectoralis major myocutaneous flap for head and neck defects in the era of free flaps: harvesting technique and indications. Sci Rep 2017; 7: 46256
    CrossrefPubMedGoogle Scholar
  • 22 Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg 2000; 105 (07) 2331-2346 , discussion 2347–2348
    CrossrefPubMedGoogle Scholar
  • 23 Paydarfar JA, Patel UA. Submental island pedicled flap vs radial forearm free flap for oral reconstruction: comparison of outcomes. Arch Otolaryngol Head Neck Surg 2011; 137 (01) 82-87
    CrossrefPubMedGoogle Scholar
  • 24 Anand AG, Tran EJ, Hasney CP, Friedlander PL, Chiu ES. Oropharyngeal reconstruction using the supraclavicular artery island flap: a new flap alternative. Plast Reconstr Surg 2012; 129 (02) 438-441
    CrossrefPubMedGoogle Scholar
  • 25 Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for head and neck oncologic reconstruction: indications, complications, and outcomes. Plast Reconstr Surg 2009; 124 (01) 115-123
    CrossrefPubMedGoogle Scholar
  • 26 Deganello A, Gitti G, Parrinello G. et al. Infrahyoid flap reconstruction of oral cavity and oropharyngeal defects in elderly patients with severe general comorbidities. Head Neck 2012; 34 (09) 1299-1305
    CrossrefPubMedGoogle Scholar
  • 27 Mahieu R, Colletti G, Bonomo P. et al. Head and neck reconstruction with pedicled flaps in the free flap era. Acta Otorhinolaryngol Ital 2016; 36 (06) 459-468
    CrossrefPubMedGoogle Scholar
  • 28 Geiger EJ, Basques BA, Chang CC. et al. Pedicle versus free flap reconstruction in patients receiving intraoperative brachytherapy. J Plast Surg Hand Surg 2016; 50 (04) 227-232
    CrossrefPubMedGoogle Scholar
  • 29 Zhang S, Chen W, Cao G, Dong Z. Pedicled supraclavicular artery island flap versus free radial forearm flap for tongue reconstruction following hemiglossectomy. J Craniofac Surg 2015; 26 (06) e527-e530
    CrossrefPubMedGoogle Scholar
  • 30 Kroll SS, Reece GP, Miller MJ, Schusterman MA. Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck. Am J Surg 1992; 164 (06) 615-618
    CrossrefPubMedGoogle Scholar
  • 31 Mallet Y, El Bedoui S, Penel N, Ton Van J, Fournier C, Lefebvre JL. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol 2009; 45 (12) 1028-1031
    CrossrefPubMedGoogle Scholar
  • 32 Howard BE, Nagel TH, Barrs DM, Donald CB, Hayden RE. Reconstruction of lateral skull base defects: a comparison of the submental flap to free and regional flaps. Otolaryngol Head Neck Surg 2016; 154 (06) 1014-1018
    CrossrefPubMedGoogle Scholar
  • 33 Kim K, Ibrahim AM, Koolen PG, Frankenthaler RA, Lin SJ. Analysis of the NSQIP database in 676 patients undergoing laryngopharyngectomy: the impact of flap reconstruction. Otolaryngol Head Neck Surg 2014; 150 (01) 87-94
    CrossrefPubMedGoogle Scholar
  • 34 Bertino G, Spasiano R, Mazzola I, Benazzo M. The use of pedicled and free flaps in laryngeal cancer recurrences: postoperative considerations and functional results. Ann Plast Surg 2005; 55 (04) 384-388
    CrossrefPubMedGoogle Scholar
  • 35 Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope 2006; 116 (02) 173-181
    CrossrefPubMedGoogle Scholar
  • 36 Teknos TN, Myers LL, Bradford CR, Chepeha DB. Free tissue reconstruction of the hypopharynx after organ preservation therapy: analysis of wound complications. Laryngoscope 2001; 111 (07) 1192-1196
    CrossrefPubMedGoogle Scholar
  • 37 Cannady SB, Hatten KM, Bur AM. et al. Use of free tissue transfer in head and neck cancer surgery and risk of overall and serious complication(s): an American College of Surgeons-National Surgical Quality Improvement Project analysis of free tissue transfer to the head and neck. Head Neck 2017; 39 (04) 702-707
    CrossrefPubMedGoogle Scholar
  • 38 Offodile II AC, Aherrera A, Wenger J, Rajab TK, Guo L. Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? A risk factor analysis of 2,008 patients from the ACS-NSQIP database. Microsurgery 2017; 37 (01) 12-20
    CrossrefPubMedGoogle Scholar
  • 39 Drinane JJ, Drinane J, Nair L, Patel A. Head and neck reconstruction: does surgical specialty affect complication rates?. J Reconstr Microsurg 2019; 35 (07) 516-521
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Zhang JX, Wan M, Ding Y. et al. Do microsurgical outcomes differ based on which specialty does the operation? A NSQIP analysis. Plast Reconstr Surg Glob Open 2020; 8 (04) e2769
    CrossrefPubMedGoogle Scholar
  • 41 Chattha AS, Baltodano PA, Chen AD, Ata A, Patel A. Analysis of post-operative reoperation timing and risk factors for post-operative free flap compromise in head and neck reconstruction: a national retrospective cohort. Plast Reconstr Surg Glob Open 2017; 5 (Suppl. 09) 9-10 DOI: 10.1097/01.GOX.0000526173.91294.2e.
    CrossrefPubMedGoogle Scholar
  • 42 van der Putten L, Spasiano R, de Bree R, Bertino G, Leemans CR, Benazzo M. Flap reconstruction of the hypopharynx: a defect orientated approach. Acta Otorhinolaryngol Ital 2012; 32 (05) 288-296
    PubMedGoogle Scholar