Unplanned return to theater (URTT) following head and neck cancer reconstruction presents significant clinical and economic challenges. Identifying risk factors for URTT can aid in surgical planning and patient risk stratification. This study evaluates preoperative and intraoperative factors associated with URTT in patients undergoing free flap reconstruction after head and neck tumor resection. A retrospective cohort study was conducted on patients undergoing head and neck tumor resection with free flap reconstruction between July 2015 and January 2024. Demographic, clinical, and operative data were analyzed using univariable and multivariable logistic regression. Of 609 patients included, 199 (32.7%) experienced URTT within 90 days postoperatively. Common indications for URTT included infected collections (33.7%), hematoma (24.6%), and flap dehiscence (16.1%). On univariable analysis, preoperative PEG tube use (unadjusted odds ratio (OR) 1.78 [95% confidence interval (CI) 1.03-3.07], p = 0.04), higher frailty index scores (1.27 [1.03-1.58], p = 0.03), longer operative duration (1.15 [1.06-1.24], p < 0.001), use of bony free flaps (2.08 [1.44-3.01], p < 0.001), and tracheostomy (2.09 [1.22-3.56], p = 0.01) were associated with URTT. Yet, on multivariable analysis, only higher frailty index score (adjusted OR 1.32, 95% CI 1.03-1.70, p = 0.03) and use of bony free flaps (adjusted OR 1.92, 95% CI 1.19-3.11, p < 0.01) retained statistical significance. The findings of this study suggest that frailty and the use of bony free flaps are key risk factors for URTT among reconstructive head and neck cancer patients. These findings support patient risk stratification preoperatively and targeted interventions to reduce the risk of URTT and improve resource utilization in head and neck cancer surgery.

We performed a systematic review and meta-analysis to evaluate the outcomes of end-to-side (ETS) anastomosis to the internal jugular vein (IJV) in head and neck free flap reconstruction. Postoperative outcomes of ETS were compared to the conventional end-to-end (ETE) technique. A comprehensive electronic search was performed on PubMed/MEDLINE, Scopus, and Google Scholar databases. Odds ratios (ORs) were calculated with their 95% confidence intervals (CIs) for each study comparing the two groups (ETS vs. ETE). A total of 9645 patients undergoing 9663 head and neck free flap reconstructions (ETS, N = 2618; ETE, N = 7045) were included from 45 studies. The ETS technique showed an overall free flap failure rate of 2.5% (95% CI: 1.9-3.2). The pooled venous thrombosis rate was 3.8% (95% CI: 2.5-5.8), while the reoperation rate was 5.6% (95% CI: 2.7-11.5). No significant difference was found for the free flap failure rate (OR = 1.35, 95% CI: 0.77-2.36), venous thrombosis rate (OR = 0.93, 95% CI: 0.48-1.82) and reoperation rate (OR = 0.83, 95% CI: 0.42-1.63) when comparing the two groups. This study demonstrates that ETS venous anastomoses offer excellent outcomes, with safety and efficacy comparable to ETE anastomoses. Both techniques can be successfully employed depending on individual patient anatomy and surgeon experience.

In severe lower leg trauma requiring soft tissue transfer, a limited number of run-off vessels is a risk factor for reoperation and flap necrosis. We hypothesized that early reconstruction of injured major arteries (the anterior tibial artery (ATA) or posterior tibial artery (PTA)) to prepare two recipient arterial systems could reduce anastomotic complications. This study aimed to evaluate the effectiveness of arterial reconstruction in patients with severe lower extremity trauma. This study included patients with Gustilo-Anderson type IIIB open lower leg fractures and arterial injuries who underwent free flap surgery. The patients were divided into two groups: group 1 comprised patients with ATA or PTA run-off at free-flap surgery, and group 2 comprised patients with both ATA and PTA run-off after early revascularization. Patient demographics, injury characteristics, and treatment details were recorded. Primary outcome was occurrence of flap necrosis, and secondary outcomes were occurrence of intraoperative anastomosis revision and unplanned return to operating room. Outcomes were statistically compared between the two groups. Groups 1 and 2 comprised 12 patients. Group 1 had a mean age of 38.7 years (nine males and three females), including nine ATA injuries and three PTA injuries: 11 latissimus dorsi (LD) and one anterolateral thigh (ALT) flaps were used. Group 2 had a mean age of 50.8 years (all males), with 2 ATA and 10 PTA injuries; 10 LD and 2 ALT flaps were used. Intraoperative revision and unplanned return were significantly more frequent in group 1 than in group 2 (both p = 0.029). Complete flap loss occurred in two patients in group 1 and none in group 2 (p = 0.333). Early reconstruction of injured arteries to prepare two recipient systems significantly reduced vascular complications and may improve free-flap outcomes in patients with severe open lower leg fractures.

Venous congestion is a significant complication in microsurgical reconstruction and may persist despite surgical revision attempts, as demonstrated in our clinical experience. In cases where repeated surgical interventions are either not feasible or unsuccessful, alternative methods like bloodletting therapy using subcutaneous heparin injection may be beneficial. This descriptive, retrospective report evaluated six patients who underwent microsurgical tissue transfers between 2019 and 2025 and developed refractory venous congestion. Patients were managed with a standardized protocol involving a single subcutaneous injection of 10 IU heparin administered into the congested flap zone at initiation. Dermal windows measuring approximately 2 × 5 mm were created and during follow-up, heparin-soaked gauze pads (1000 IU heparin in sterile saline) were applied over the dermal windows to sustain bleeding. If bleeding diminished, windows were gently enlarged or new sites were created. The mean age of the six patients was 30.8 years (range 12-63). Total flap survival was achieved in three patients (50%), partial loss in two patients (33%), and marginal loss in one patient (17%). Treatment duration ranged from 3 to 10 days, with a mean transfusion requirement of 1.8 units per patient (Range 0-6 units). Subcutaneous heparin combined with controlled scarification represents a safe, practical, and potentially effective method to manage persistent venous congestion when surgical revision is unsuccessful or contraindicated. Future prospective studies are warranted to better define its role and optimize outcomes.

The tongue is the most common site of oral malignancy, and surgical treatment may result in impaired feeding, swallowing, and speech. Free tissue transfer is the preferred method for reconstructing complex defects. Evidence remains unclear on whether sensory reinnervation improves function. The objective of this review is to evaluate the outcome of patients undergoing innervated versus noninnervated free flap reconstruction following tongue cancer surgery. A systematic review was performed to determine the role of sensory neurotization in lingual reconstruction. Only studies with comparative designs were eligible for inclusion. Primary outcome measures included static two-point discrimination (S2PD), pinprick sensation, swallowing, and speech. A meta-analysis was performed using key data analysis to calculate weighted effect sizes for reconstruction with or without neurotization using random-effects models. The statistical heterogeneity was determined using the Higgins' method. Nine studies were included which produced 107 reinnervated flaps and 117 non-innervated flaps for pooled analysis. Objective measures of sensation were significant, favoring the reinnervation group for pinprick sensation and S2PD (p < 0.05), with the pooled difference in proportions being 0.25 and -13.88 (0.06-0.45, 95% CI, -26.66 mm to -1.11, 95% CI), respectively. Functional outcome measures revealed significantly improved speech in the reinnervated group (p < 0.05, non-weighted means 74.8 vs. 62.5%). This study found a strong association favoring the sensory neurotization for tongue reconstruction. Higher quality studies are required to further define the role of reinnervation for the restoration of swallow, relative differences between type of free flap selected, and measure changes in patients' quality of life.

Recently, the immunomodulatory effects of mesenchymal stem cells have been reported in several studies. The purpose of this study was to evaluate the effect of the administration of human amnion-derived mesenchymal stem cells (hAm-MSCs) in a rat vascularized composite allotransplantation model. A total of 18 Lewis (LEW) rats and 6 Brown-Norway (BN) rats were used. Sixteen LEW rats as recipients were divided randomly into four groups: Isograft (Iso), Untreated (UT), FK, and MSC groups (n = 4, each group). Hind limb transplantation was performed. In the Iso group, 2 LEW rats were used as donors. In the other groups, 6 BN rats were used as donors. In the UT group, no immunosuppressant was used. In the FK group, 0.2 mg/kg/day of FK506 (tacrolimus) was administered from day 0 to day 6. In the MSC group, 2 × 106 hAm-MSCs were administered on day 7 after tacrolimus administration (day 0-6). Graft survival was assessed by daily inspection, histology, and immunohistology with the TUNEL (terminal deoxynucleotidyl transferase dUTP nick-end labeling) assay. Cytokine mRNA expression analysis using real-time, reverse transcription PCR (RT-PCR) of the grafts was analyzed. Graft survival in the MSC group (14.8 days) was significantly prolonged compared with that of the FK group (13 days; p < 0.05). Histology and immunohistology with the TUNEL assay showed a significant reduction of mononuclear cell infiltration and apoptotic cells in the MSC group compared with the FK group (p < 0.05). RT-PCR analysis of cytokine mRNA expression showed a significant decrease of IL-2 and an increase of TGFβ in graft muscle (p < 0.05). hAm-MSCs prolonged graft survival in the rat vascularized composite allotransplantation model. hAm-MSCs could be an alternative immunomodulatory agent to avoid the side effects of conventional immunosuppressant.

Free flap transfer is an essential technique for head and neck reconstruction after oncological ablative resection. Selection of recipient vessels can be challenging in patients with a history of neck dissection and/or radiotherapy. We analyzed outcomes with regard to recipient vessel selection and flap failure, referring to patients' histories of radiotherapy and/or neck dissection. Records of 671 patients who had undergone head and neck reconstruction in our institution from April 2018 to March 2024 were retrospectively reviewed. We divided patients into four groups based on their treatment history: radiotherapy alone (RT, n = 82), neck dissection alone (ND, n = 43), both radiotherapy and neck dissection (NDRT, n = 39), and intact neck with no history of radiotherapy or neck dissection (IN, n = 488). We collected data on flap types, defect areas, selected recipient vessels, and the occurrence of flap failure. We also assessed the risk factors for flap failure. In Group RT, 66 of 84 (79%) recipient vessels were located within irradiated areas. In contrast, in Group ND, 37 of 45 (82%) recipient vessels were outside the dissected areas. No significant association was observed between overall flap failure and variables we assessed. However, our additional flap failure analysis by arterial or venous factors showed an association with the patients' history of radiation treatment (p < 0.05) and in cases where anastomosed vessels were actually located within irradiated areas (p < 0.05). In patients with previous radiotherapy history, recipient vessels even within irradiated areas can often be successfully used as recipient vessels. However, after undergoing irradiation treatment, the risk of venous-related flap failure may be higher compared with the non-irradiated area; thus, it necessitates careful consideration during reconstruction.

ABSTRACTBackgroundImmediate lymphatic reconstruction (ILR) is a technique in which lymphatics are visualized and lymphovenous bypass is done at the time of axillary lymph node dissection (ALND) to prevent breast cancer‐related lymphedema (BCRL). This meta‐analysis estimates the benefit of ILR in preventing lymphedema by incorporating double‐ and single‐arm studies and stratifying by length of follow‐up time.MethodsThree databases were queried for studies with primary data on ILR. Both double‐ and single‐armed studies were included, and papers with small sample sizes, overlapping samples, and unreported data were excluded. Treatment effects were calculated with risk ratios and converted to a logarithmic scale. A meta‐analysis was performed using the inverse variance method and a random‐effects model, with further analysis done by study design and length of follow‐up time.ResultsA total of 17 studies were included (9 double‐arm and 8 single‐arm; n = 2607). The pooled treatment effect of ILR, expressed as log risk ratio (95% CI), was −0.89 (−1.18, −0.60; p < 0.0001). This corresponds to a relative risk of 0.41 (0.31, 0.55) and a number needed to treat of 9. Double‐ and single‐arm studies showed no significant differences in effect sizes. Studies with < 1‐year follow‐up demonstrated a larger effect size than those with longer follow‐up, and the benefits of ILR were no longer significant past 3 years.ConclusionPatients receiving ILR were significantly less likely to develop BCRL than those receiving ALND alone. Further work is needed to examine whether benefits can truly be sustained long‐term.

Augmented reality (AR) is an emerging technology in microsurgery for free flap reconstruction. AR allows surgeons to superimpose preoperative CT images onto the patient, providing real-time insight into the underlying anatomy and aiding in the decision-making process; however, there is limited empirical evidence supporting the effectiveness of this modality. We conducted a systematic review to investigate whether the use of AR devices in free flap reconstruction correlates with improved outcomes. A comprehensive search of PubMed, Embase, and Scopus was performed on February 19, 2025. Our search included retrospective and prospective articles that demonstrated the use of AR technology intraoperatively and reported surgical outcomes in any type of free flap reconstruction. The initial search yielded 158 articles, with 8 ultimately included in the study. Articles were reviewed for technical accuracy, surgeon ease of use, operative time, complications, and operative costs. AR can guide surgeons, particularly those with less experience. As surgeons gain a better understanding of perforator locations, they operate with increased confidence and efficiency. AR outperformed Doppler ultrasound in perforator identification, demonstrating higher accuracy during flap planning and dissection. The time required to harvest flaps was significantly shorter when AR was used compared to traditional flap dissection techniques. Compared to computer-aided design and computer-aided manufacturing (CAD/CAM) navigation systems, AR surgical guidance exhibited greater accuracy and required significantly less time for flap design. AR devices surpassed cutting guides in various aspects, including cost savings, reduced preparation time, increased flexibility in surgical plan modification, intraoperative tissue drift, and a more favorable effect on hand-eye coordination. No conclusive postoperative complications were reported. The majority of the literature about AR in free flap surgery comes from small clinical studies. Widescale, multi-center studies are necessary to determine the true clinical impact of AR technology in microsurgery.