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

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

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