The impact of preoperative radiotherapy on microvascular reconstructive surgery outcome has been a subject of debate. However, data are conflicting and often dependent on local treatment protocols. We have studied the effects of radiotherapy in a unique, single-center setting where a treatment protocol change was undertaken from pre- to postoperative radiotherapy administration for microsurgical head and neck reconstructions.
A cohort study was conducted for 200 consecutive head and neck free flap cases, where 100 were operated on before and 100 after the treatment protocol adjustment in 2006. Only direct cancer reconstructions were included. Complication rates of anastomosis-related (flap necrosis) and flap bed–related (infection, fistula, and wound dehiscence) complications were compared between irradiated and nonirradiated patients. A multivariate analysis was performed to correct for treatment period.
One hundred twenty-six patients had received radiotherapy before reconstruction due to cases of cancer recurrence. There were no significant differences in demographic data or risk factors between irradiated and nonirradiated cases. Irradiated cases had a higher rate of both flap loss (9.5% versus 1.4%; P = 0.034) and flap bed–related complications (29% versus 13%; P = 0.014). However, after multivariate analysis, there was only a significant relationship between preoperative irradiation and infection (odds ratio = 2.51; P = 0.033) and fistula formation (odds ratio = 3.13; P = 0.034).
The current single-center study clearly indicates that preoperative radiotherapy is a risk factor for both infection and fistula formation, most likely related to an impaired flap bed. We suggest postoperative radiotherapy administration whenever possible for oncological reasons, otherwise proper antibiotic cover and meticulous flap insetting to prevent radiation-related infection and fistula formation.
From the *Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, Stockholm, Sweden; †Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden, Stockholm, Sweden; ‡Department of Clinical Sciences Intervention and Technology, Karolinska Institute, Stockholm, Sweden; and §Department of ENT Head & Neck Surgery, Karolinska University Hospital, Stockholm, Sweden.
Received for publication November 26, 2016; accepted January 10, 2017.
M.H. is supported by the Cancer Research Funds of Radiumhemmet (Grant number 161072), the Swedish Society of Medicine (Grant number SLS-248851), and together with C.G. by the Stockholm County Council (Grant number 20140458).
Presented in part at the 26th Annual Meeting of European Association of Plastic Surgeons, EURAPS, May 28, 2015, Edinburgh, UK.
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by M.H., supported by Funds of Radiumhemmet (Grant 161072).
Martin Halle, MD, PhD, Department of Plastic and Reconstructive Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden, E-mail: firstname.lastname@example.org
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