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Objectives/hypothesis: Free flap transfer offers a versatile option for reconstruction in head and neck surgery, with success rates over 95%. There remains a substantial re-exploration rate of roughly 5% to 15%, with early recognition of compromise essential to flap survival. Monitoring techniques are highly desirable, with the gold standard being clinical monitoring. The Cook-Swartz Doppler (CSD) probe utilizes Doppler technology to inform clinicians about real-time flow. We aim to describe our adoption of this technology in 100 consecutive free flaps., Study Design: Prospective case series., Methods: Prospective data were collected from July 2014 to June 2015 on 100 consecutive free flaps performed at a head and neck unit in London, Ontario. All patients had a CSD inserted for arterial and venous monitoring., Results: A total of 100 free flaps were performed on 99 patients. Sensitivity was 87.1% and specificity was 85.7%. Positive predictive value was 98.8% and negative predictive value was 33.3%. False-negative and false-positive rate were 1.0% and 12.0%, respectively. The exploration rate was 12%, with no flap loss and two partial debridements. The CSD was helpful in management in 9% of cases and was clinically unhelpful in 11% of cases, with 10 of 11 abnormal signals ignored. There were three unique CSD complications; one retained wire, one pedicle laceration during extraction, and one clot around the probe interrupting signal., Conclusions: The CSD is a helpful adjunct to clinical monitoring but has unique complications, which were not previously described. Pros and cons must be considered for new centers adopting this technology., Level of Evidence: 4 Laryngoscope, 131:E1854-E1859, 2021., (© 2021 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Purpose of Review: The current article reviews the most recent publications of computer-assisted reconstruction using bony free flaps, emphasizing on comparative reports using these novel techniques., Recent Findings: Computer-aided reconstruction has shown some benefits in comparison with traditional techniques and some of the perceived limitations are currently being addressed in the latest reports. Still, there is a lack of appropriate comparative studies and unblinded measurements to establish solid conclusions., Summary: Despite the application of new technologies showed encouraging results, it is premature to state that the traditional technique should be replaced by the modern approaches.

Objectives: Plate extrusions after free tissue transfer for mandibular reconstruction can be problematic and generally require revision surgery. Our objective was to assess the predictors of plate extrusion and compare outcomes between fibular free flaps (FFF), lateral border scapular flaps (LBSF), and scapular tip free flaps (STFF)., Methods: Retrospective review of consecutive patients who underwent osseous free tissue reconstruction of the mandible (2008-2014) at Victoria Hospital, London, Ontario. Patient demographics and treatment-related information were collected., Results: We identified 134 procedures and 27 (20.2%) plate extrusions (21/61 FFF, 3/49 STFF, and 3/24 LBSF). Freedom from extrusion after 2 years was significantly associated with the use of FFF (P = .003, HR 6.09 1.82-20.44), performing 1 osteotomy (P = .03, HR 2.61 1.08-6.31), and anterior mandibular defects (P = .01, HR 2.66 1.25-5.66) in the univariate model. FFF's were employed more frequently in younger patients, with 2.4 mm plates, more anterior defects, and with a greater number of osteotomies (P < .001). However, after controlling for these variables in multivariate analyses the use of a FFF was the only significant predictor of extrusion at 2 years (P = .006, HR 3.68 1.46-9.28)., Conclusions: At our institution, use of the STFF predicts mandibular defects that are less prone to developing plate extrusion and FFF tended to be used more frequently in anterior defects with osteotomies. However, after controlling for these factors use of the FFF appeared to have higher rates of extrusion than scapular flaps. Further prospective studies controlling for defect variables are needed to elucidate the risk factors for plate extrusion., (© 2018 Wiley Periodicals, Inc.)

Both early and advanced stage laryngeal cancers are treated with organ-preserving strategies including radiation alone or concurrent chemoradiotherapy. While organ-preserving modalities have proven effective in eradicating cancer while also preserving laryngeal function, there remains a proportion of cases where residual or recurrent cancer prevails, or conversely, where radiotherapy renders a larynx dysfunctional. In these circumstances, salvage total laryngectomy is often the surgical treatment. The effects of radiotherapy to the neck, amplified by chemotherapy, can create an inhospitable surgical environment, making the salvage laryngectomy an operation fraught with the potential for major complications such as the dreaded pharyngocutaneous fistula. The introduction of vascularized tissue from outside the irradiated field decreases the risk of major wound complications. Free tissue transfer, with a variety of donor sites available, is commonly employed to reconstruct either a patch or a circumferential segment of the pharynx. When there is enough pharyngeal mucosa for primary closure, a vascularized onlay graft or a pharyngeal interposition graft can be used to reinforce the closure. This has been demonstrated to both reduce the severity of pharyngocutaneous fistula and decrease the risk of developing a pharyngocutaneous fistula compared to primary closure alone. Beyond mitigating the risk for perioperative complications, flap selection may have implications on the long-term outcomes after salvage total laryngectomy and these must be considered preoperatively. The purpose of this review is to examine the various options for reconstruction after salvage total laryngectomy and to examine some of their advantages and disadvantages in the short and long-term., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The pedicled adipofascial infraclavicular flap (ICF) is based on the anterior perforator of the supraclavicular artery and supplies the fasciocutaneous tissue of the upper chest. This flap may be used to address neck contour defects and vessel coverage after radical and modified radical neck dissections (MRNDs)., Methods: We described the pedicled adipofascial ICF elevation technique and its use immediately after neck dissections in order to maintain soft tissue volume and vessel coverage. A video of the operation is provided., Results: Our results demonstrated satisfactory neck contours with adequate volume replacement, great vessel coverage, and little donor-site morbidity., Conclusion: The pedicled adipofascial ICF is a technically straightforward operation with broad possible applications in head and neck surgery. It may be useful to provide vascularized soft-tissue coverage and maintain neck contour after neck dissections. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1582, 2016., (© 2016 Wiley Periodicals, Inc.)

Background: The purpose of this study was to review our experience with the scapular tip free flap for mandibular reconstruction, describe the surgical approach, and highlight specific clinical applications., Methods: A retrospective review of all patients undergoing oromandibular reconstruction using a scapular tip free flap at the London Health Sciences Centre was undertaken. Patient demographics, surgical data, and early outcomes were collated., Results: Twenty patients were identified. The majority involved mandibular angle and short segment defects (16 of 20). Average length of the segmental defect was 6.2 cm with the longest measuring 8 cm. A single patient required an osteotomy. Six were revision cases. No vein grafts were required. One complete flap failure occurred., Conclusions: The natural scapular angle makes the scapular tip flap ideal for mandibular angle reconstruction. Short bone segments can be harvested with little donor-site morbidity. The long pedicle length may obviate vein grafts., (Copyright © 2012 Wiley Periodicals, Inc.)

Importance: Provides an approach to osseous free flap selection for reconstruction of segmental mandible defects that takes into consideration general medical status of the patient and reconstruction requirements; demonstrates the complementary qualities of fibular and subscapular system free flaps; and describes the different surgical indications for lateral border scapular and scapular tip free flaps., Objectives: To review our experience with osseous mandible reconstruction comparing the fibular and subscapular system free flaps, determine reconstruction-specific and general health variables that may differ between these patient groups, and present our approach to oromandibular reconstruction., Design: Retrospective study., Setting: Academic tertiary care medical center., Participants: A total of 110 patients (68 male, 42 female) undergoing single-stage oromandibular reconstructions with free-tissue transfers between May 1, 2006, and May 30, 2012., Intervention: Single-stage oromandibular reconstruction with free-tissue transfer., Main Outcome Measures: Differences in patient demographics, bone and soft-tissue aspects of the reconstruction, operative time, flap outcomes, and major postoperative complications between fibular, lateral scapular border, and scapular tip free flaps., Results: A total of 110 patients underwent 113 reconstructions, including 58 fibular free flaps (FFFs) (51.3%) and 55 subscapular system flaps (48.7%). Of the subscapular system free flaps, 27 flaps (49%) were scapular tip free flaps (STFFs) based on the angular artery branch of the thoracodorsal pedicle; the remaining 28 cases were lateral scapular border flaps (LSBFs). Patients undergoing reconstruction with FFFs were significantly younger than their subscapular system flap counterparts (56 vs 70 years, P < .001). Mean mandible defect lengths were similar for patients undergoing FFF and LSBF reconstruction (7.8 and 7.7 cm, respectively); STFFs were used to reconstruct significantly shorter defects (mean, 6.0 cm, P < .001). The FFFs were more commonly used for anterior mandible defects in which multiple osteotomies and limited soft tissue were required, while subscapular flaps were more commonly used for linear mandible defects with complex soft-tissue requirements. A single complete flap loss occurred in a patient who underwent reconstruction with an STFF; other complication rates were similar between groups., Conclusions and Relevance: The FFFs and subscapular flaps are complementary options for oromandibular reconstruction. The FFF is ideal for younger patients, extended defects, multiple osteotomies, and limited soft-tissue requirements. The subscapular system free flaps (LSBF and STFF) are excellent options for (1) elderly patients; (2) those with significant comorbidities, such as peripheral vascular disease; and (3) mandible defects associated with complex soft-tissue requirements. Furthermore, the STFF offers a reliable option to reconstruct short-segment defects, in particular, defects involving the angle of the mandible.

Objectives: The temporoparietal fascia flap (TPFF) is a versatile tool in head and neck reconstruction. This article aims to describe the spectrum of TPFF applications through a series of case studies and related review of the literature., Methods: Medical records were reviewed to identify cases that represent major TPFF application categories. A literature review was performed to support the presentation and discussion of each case category., Results: Seven cases were identified each representing a distinct application category. These included auricular reconstruction, hair-bearing tissue transfer, facial soft tissue augmentation, cutaneous and mucosal oncologic defect repair, reconstruction after salvage laryngectomy, skull base reconstruction, and orbital reconstruction., Conclusion: The TPFF is a uniquely versatile tool in head and neck reconstructive surgery. Outstanding in its pliable, ultra-thin yet hardy and highly vascular form, the temporoparietal fascia flap is a workhorse for the creative head and neck reconstructive surgeon., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose of Review: This article reviews the buccinator flap, its relevant surgical anatomy, surgical technique, and applications in head and neck reconstruction., Recent Findings: Reconstruction of defects after extirpation of head and neck neoplasms can be challenging and complex. Various reconstructive techniques, including skin grafts, regional flaps, and free tissue transfer, can be employed in restoration of form and function after ablative surgery. Although a wide array of reconstructive options is available, the technique employed will largely depend on the surgeon preference and experience. Commonly used pedicled flaps and free tissue transfer techniques can share several disadvantages, including prolonged operative time, poor cosmesis, donor site morbidity, functional limitations, and excessive tissue bulk for intraoral reconstruction. The ideal reconstructive method would adhere to the plastic surgery principle of replacement of 'like with like'. The ease of dissection and useful application makes the buccinator flap an excellent additional reconstructive option for the head and neck surgeon., Summary: The buccinator myomucosal flap is a versatile and dependable flap for head and neck reconstruction. Its minimal donor site morbidity, pliability, ease of elevation, and flexible usage while offering optimal functional and cosmetic results make it a viable option for select defects.

Objective: To review the experience with scapular free tissue transfer at the University of Western Ontario and to describe the various applications of both the fasciocutaneous and osteocutaneous versions., Design: Retrospective review., Setting: Tertiary care centre., Methods: A retrospective review was conducted of patients who underwent a scapular free flap reconstruction between 1997 and 2007. Osteocutaneous and fasciocutaneous flaps were included. Demographic data including gender and age were collected. Defect analysis and complications were also reviewed., Main Outcome Measures: Defect analysis, flap-related complications, and non-flap-related complications., Results: Sixty procedures, including 31 osteocutaneous and 29 fasciocutaneous flaps, were performed. Most fasciocutaneous flaps were used for large lateral skull base and facial defects (70%). The skin paddle dimensions ranged from 4 × 3 to 15 × 10 cm. All osteocutaneous flaps were used for mandibular reconstruction. The length of the bony defect ranged between 4 and 12 cm. Eleven patients required osteotomies. In most cases, the facial or external carotid arteries and internal jugular or facial veins were selected as recipient vessels. A vein graft was required in four cases. The total flap failure rate was 5%. Seven patients who had osteocutaneous flaps suffered medical complications, including one mortality., Conclusions: Scapular free flaps are reliable options. Fasciocutaneous applications are suitable for defects requiring facial contouring or complex skull base defects. Osteocutaneous flaps are acceptable options for patients with comorbidities requiring bony reconstructions. The flap complication rates were acceptable even in medically higher-risk patients.

Objectives/hypothesis: To conduct a comprehensive assessment of shoulder and neck function following the pectoralis major pedicled flap (PMPF) for head and neck reconstruction., Design: Case-control study., Methods: The study group consisted of laryngectomized patients who underwent PMPF and a control group of those who underwent standard laryngectomy. Bilateral quantitative measurements of shoulder strength and range of motion (ROM) and neck ROM by a blinded physiotherapist and subjective quality-of-life assessment using the Shoulder Pain and Disability Index (SPADI) and Neck Disability Index (NDI) questionnaires were collected. Lateral cervical radiographs in the neutral, flexion, and extension positions were evaluated by a blinded neuroradiologist. The main outcome measures were shoulder ROM, strength, and SPADI scores; physical and radiologic measurements of neck ROM; and NDI Score., Results: Shoulder analysis showed a significantly reduced flexion angle (P = .043) and combined internal/external rotation angle on the operated side (P = .027) and a significant strength reduction for the flexion, external rotation, and adduction domains (P < .05). SPADI score analysis showed a significantly higher disability score (P = .017) and total score (P = .009) on the PMPF side. Neck physical analysis showed significant differences in extension (P = .013) and total ROM distances (P = .002) but not flexion (P = .184). The total flexion/extension angular ROM was reduced in the PMPF population (P = .05) due to a reduced neck extension excursion angle from a neutral position (P = .04)., Conclusions: The PMPF for head and neck reconstruction is associated with a limitation in neck ROM attributed to a loss in extension and reduced shoulder strength and ROM.

Background: Dermal fat grafts are used to reconstruct facial contour defects but may undergo variable resorption. Application of autologous platelet adhesive may improve outcomes. The primary objective was to compare resorption of dermal fat grafts for parotidectomy defects, between patients receiving autologous platelet adhesive versus controls., Methods: This was a double-blinded prospective cohort at a tertiary care center. Volumetric analyses of dermal fat graft measured by MRI scans. Resorption was determined by comparing 1- and 6-month MRIs in each patient. Complications, Frey's Syndrome, and patient satisfaction were also assessed., Results: Twelve patients completed the study. A significant reduction in graft resorption was seen in the treatment group (57% vs. 31%, p = .01). Three patients in the control group developed fat liquefaction. Patient perceived significant differences in scar and contour., Conclusion: Application of autologous platelet adhesives improved graft viability and patient satisfaction at 6 months.

Background: A quasi-experimental retrospective study was undertaken to evaluate a new concept of free tissue volume restoration combined with bridging reconstruction plate (compartment approach) to reduce plate-related complication rates., Methods: We evaluated 40 patients with large lateral mandible defects and associated complex soft tissue defects reconstructed with a revascularized soft tissue flap and titanium hollow screw reconstruction plates. A case-control comparison was performed based on reconstruction type: restoration of soft tissue defect (conventional approach-group 1) versus over-reconstruction of soft tissue defect (compartment approach-group 2)., Results: Plate exposure rate was 6 of 16 (38%) in group 1 versus 2 of 24 (8%) in group 2, and the difference was statistically significant (p = .04). The mean time to exposure was 10 months. Plate fracture rate was 6 of 23 (26.1%) in dentulous patients versus 1 of 17 (5.9%) in edentulous patients. Gastrostomy tube dependence was 6 of 16 (38%) in group 1 versus 6 of 24 (25%) in group 2., Conclusion: The "compartment approach" reduces plate exposure rate and gastrostomy tube dependence. Revascularized osseocutaneous reconstruction is still required in dentulous patients.