Abstract
Objectives
Ablative procedures of the head and neck often result in significant facial and cervical irregularities and cosmetic asymmetry. The deformity resulting from ablative procedures of the head and neck is a significant source of cosmetic morbidity and postoperative dissatisfaction. Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from primary closure to free tissue transfer. The free dermal fat graft (FDFG) is one such option and has been used to repair volume defects of varying sizes after common head and neck procedures such as parotidectomy. However, its use is largely undocumented in the literature. We seek to further illustrate the FDFG as an alternate method of reconstruction of head and neck defects.
Study design
Non-randomized retrospective analysis.
Methods
The medical records of all patients who underwent primary autologous abdominal FDFG reconstruction of head and neck defects by a single surgeon at Vanderbilt University Medical Center from January 1997 to August 2010 were reviewed. All patients were called in order to assess their post-operative cosmetic satisfaction.
Results
Sixty-two patients were analyzed. Only three patients were found to have post-operative complications directly related to the FDFG. No complications were found at the donor site. Based on a telephone survey, the majority of patients were satisfied post-operatively with their cosmetic outcomes in the primary site and donor site.
Conclusions
From our experience the FDFG is a cosmetically and functionally advantageous option for reconstruction of ablative procedures of the head and neck.
1
Introduction
Ablative procedures of the head and neck often result in significant facial and cervical irregularities and asymmetry. Deformities resulting from these ablative procedures are a significant source of cosmetic morbidity and postoperative dissatisfaction . Reconstruction of post-ablative defects in the head and neck can employ a broad range of techniques, ranging from healing by secondary intention to free tissue transfer. Innovations such as microvascular surgery and advances in alloplastic materials and tissue engineering offer great hope for the future of head and neck reconstruction. In order to maximize the ultimate cosmetic and functional outcome for an individual wound, the head and neck surgeon must possess a firm grasp of fundamental techniques, as well as the ability to use a reconstructive modality that meets the unique demands of each defect after a thorough defect analysis. Attention to the depth of the wound and the involved layers, the location, the size, the relationship of the defect to recognized aesthetic units and subunits, the function of local and surrounding tissues, and the properties of the adjacent tissue provides a comprehensive assessment of the requirements for reconstruction . Detailed consideration of these data points allows selection of a technique from the reconstructive ladder .
Free dermal fat grafts (FDFGs) are described extensively in other surgical fields, namely Facial Plastic and Reconstructive Surgery (FPRS). The dermal fat graft has remained a well-established tool for the correction of contour defects in reconstructive surgery for more than seventy years . Its proven uses include the correction of moderate contour deficiencies throughout the head and neck that are the result of aging, trauma, infection, neoplasms, and birth . In the arena of FPRS, the reputation of the dermal fat graft for predictable take is documented in countless reports, in contrast to the erratic reputation of free macrografts of adipose tissue alone . Unfortunately, to date there is minimal literature describing the indications, technique, surgical and cosmetic outcomes of FDFGs in the world of head and neck oncologic surgery and reconstruction.
The purpose of our study is multifaceted. Our first objective is to describe the unique method by which the primary investigator harvests free dermal fat grafts. Our second objective is to describe the short and long term outcomes of FDFG use, including complications. Our third objective is to demonstrate the varying locations that FDFGs can be utilized when reconstructing post-ablative defects of the head and neck. Finally, our fourth objective is to assess patient’s satisfaction with their cosmetic outcomes in the primary and donor site by way of a novel patient based satisfaction survey.
2
Materials and methods
2.1
Patient selection
The records of all patients who underwent primary free dermal fat graft reconstruction of post-ablative defects of the head and neck between January 1997 and August 2010 at Vanderbilt University Medical Center were obtained. All data collection and reporting was in compliance with regulations set forth by the Vanderbilt University Medical Center Institutional Review Board and the Health Insurance Portability and Accountability Act. Institutional Review Board approval was obtained prior to data extraction. This initial search yielded 205 total patients who underwent procedures by several different surgeons during the time period of interest. Of this initial search, 95 patients were identified who underwent primary FDFG reconstruction by the primary investigator and these patients were selected for further review. Medical records were manually reviewed and requisite data was compiled by the authors and entered into a computerized database. Data recorded included the age, sex, presence of vascular co-morbidities, smoking status, incidence of diabetes, date of procedure, type of ablative procedure performed, associated complications, final pathologic classification of the resected neoplasm, location of the neoplasm, incidence of chemotherapy/radiation before and after the procedure, incidence of recurrence, and treatment for recurrences. Pre-operative and post-operative photographic, MRI, and CT imaging was also reviewed and stored for analysis if available. For the purposes of this study, complications were defined as any outcome that required procedural intervention for resolution. Of the 95 patients selected for further review, 33 patients were excluded from further analysis because operative reports, pathology reports, and/or other documents necessary to assess the post-operative course were unavailable in the electronic medical record. A total of 62 patients met study inclusion criteria and had adequate post-operative follow-up documentation (> 6 months) to allow for further analysis. A time period of six months was chosen to ensure adequate incorporation of the FDFG as well as post-operative healing. Cosmesis was assessed by the primary investigator and a second head and neck surgeon not associated with the patient’s care using a modified analog scale after reviewing pre and post-operative photographic images. A rating of 4–5 out of 5 was deemed a favorable cosmetic outcome.
2.2
Patient cosmesis outcomes
In order to assess our 62 patients’ satisfaction with their fat graft reconstruction, a telephone survey was conducted. Patients were asked to rate the success of their operations across four dimensions using a novel grading scale, similar to others used in the literature, to assess post-operative facial cosmesis . Patients were asked the four questions and were asked to give their response as a number between 1 and 5 ( Table 1 ). The results of the patient survey were collected, tabulated, and reported in the study.
| Question 1 | How satisfied are you with the cosmetic appearance of your head/neck reconstruction with respect to symmetry? (1 – Very Unsatisfied to 5 – Very Satisfied) |
|---|---|
| Question 2 | Do you feel like the contour of your reconstruction has changed over time? If so, please rate the amount of change that has taken place. (1 – Unchanged to 5 – Changed Significantly) |
| Question 3 | How satisfied are you with the overall aesthetic result of your head and neck reconstruction? (1 – Very Unsatisfied to 5 – Very Satisfied) |
| Question 4 | How satisfied are you with the cosmetic appearance of your abdominal scar/defect? (1 – Very Unsatisfied to 5 – Very Satisfied) |
2.3
Surgical technique
After the initiation of general endotracheal anesthesia, the patients underwent resection of both benign and malignant head and neck neoplasms representing a diversity of sites and pathologies. As described previously, each of the patients subsequently underwent primary transplantation of an abdominal FDFG to fill the post-ablative defect. The FDFG was harvested through a suprapubic elliptical incision using a sharp, steel blade with incisional dimensions that varied depending on the size of the defect to be filled. Sharp dissection was carried through the skin, subcutaneous tissue, fat, and Scarpa’s fascia until the anterior rectus fascia was identified. The tissue was then elevated off the rectus fascia. Harvest of the fat graft was accomplished using a sharp steel blade, without significant use of bipolar cautery. The use of bipolar cautery was limited to control bleeding in the peripheral subcutaneous tissue and was not used for the purpose of dissection to prevent thermal damage to the fat. Monopolar cautery was never used during FDFG harvesting. The resulting fat graft was then trimmed to match the dimensions of the recipient site and de-epithelialized, again using a sharp steel blade. The resultant grafts were comprised of fat and dermis only, with the epidermis carefully denuded in preparation for placement. The dermal fat grafts were then placed in the facial defects and sutured in place with the dermal side up ( Fig. 1 ). In some cases, a piece of AlloDerm was used to help anchor the fat graft in place but did not serve as a substantial part of the reconstruction. After harvesting the graft, the abdominal donor wound was irrigated, followed by the introduction of a small closed suction drain. The abdominal defects were closed primarily in multiple layers using 3-0 Vicryl in the fat layer, 4-0 Vicryl for the subcuticular tissue, and finally a Monocryl fast-absorbing suture or Steri-Strips for the most superficial layer. The closure of the head and neck recipient sites varied from patient to patient depending on the site and size of the defect.
2
Materials and methods
2.1
Patient selection
The records of all patients who underwent primary free dermal fat graft reconstruction of post-ablative defects of the head and neck between January 1997 and August 2010 at Vanderbilt University Medical Center were obtained. All data collection and reporting was in compliance with regulations set forth by the Vanderbilt University Medical Center Institutional Review Board and the Health Insurance Portability and Accountability Act. Institutional Review Board approval was obtained prior to data extraction. This initial search yielded 205 total patients who underwent procedures by several different surgeons during the time period of interest. Of this initial search, 95 patients were identified who underwent primary FDFG reconstruction by the primary investigator and these patients were selected for further review. Medical records were manually reviewed and requisite data was compiled by the authors and entered into a computerized database. Data recorded included the age, sex, presence of vascular co-morbidities, smoking status, incidence of diabetes, date of procedure, type of ablative procedure performed, associated complications, final pathologic classification of the resected neoplasm, location of the neoplasm, incidence of chemotherapy/radiation before and after the procedure, incidence of recurrence, and treatment for recurrences. Pre-operative and post-operative photographic, MRI, and CT imaging was also reviewed and stored for analysis if available. For the purposes of this study, complications were defined as any outcome that required procedural intervention for resolution. Of the 95 patients selected for further review, 33 patients were excluded from further analysis because operative reports, pathology reports, and/or other documents necessary to assess the post-operative course were unavailable in the electronic medical record. A total of 62 patients met study inclusion criteria and had adequate post-operative follow-up documentation (> 6 months) to allow for further analysis. A time period of six months was chosen to ensure adequate incorporation of the FDFG as well as post-operative healing. Cosmesis was assessed by the primary investigator and a second head and neck surgeon not associated with the patient’s care using a modified analog scale after reviewing pre and post-operative photographic images. A rating of 4–5 out of 5 was deemed a favorable cosmetic outcome.
2.2
Patient cosmesis outcomes
In order to assess our 62 patients’ satisfaction with their fat graft reconstruction, a telephone survey was conducted. Patients were asked to rate the success of their operations across four dimensions using a novel grading scale, similar to others used in the literature, to assess post-operative facial cosmesis . Patients were asked the four questions and were asked to give their response as a number between 1 and 5 ( Table 1 ). The results of the patient survey were collected, tabulated, and reported in the study.
| Question 1 | How satisfied are you with the cosmetic appearance of your head/neck reconstruction with respect to symmetry? (1 – Very Unsatisfied to 5 – Very Satisfied) |
|---|---|
| Question 2 | Do you feel like the contour of your reconstruction has changed over time? If so, please rate the amount of change that has taken place. (1 – Unchanged to 5 – Changed Significantly) |
| Question 3 | How satisfied are you with the overall aesthetic result of your head and neck reconstruction? (1 – Very Unsatisfied to 5 – Very Satisfied) |
| Question 4 | How satisfied are you with the cosmetic appearance of your abdominal scar/defect? (1 – Very Unsatisfied to 5 – Very Satisfied) |
2.3
Surgical technique
After the initiation of general endotracheal anesthesia, the patients underwent resection of both benign and malignant head and neck neoplasms representing a diversity of sites and pathologies. As described previously, each of the patients subsequently underwent primary transplantation of an abdominal FDFG to fill the post-ablative defect. The FDFG was harvested through a suprapubic elliptical incision using a sharp, steel blade with incisional dimensions that varied depending on the size of the defect to be filled. Sharp dissection was carried through the skin, subcutaneous tissue, fat, and Scarpa’s fascia until the anterior rectus fascia was identified. The tissue was then elevated off the rectus fascia. Harvest of the fat graft was accomplished using a sharp steel blade, without significant use of bipolar cautery. The use of bipolar cautery was limited to control bleeding in the peripheral subcutaneous tissue and was not used for the purpose of dissection to prevent thermal damage to the fat. Monopolar cautery was never used during FDFG harvesting. The resulting fat graft was then trimmed to match the dimensions of the recipient site and de-epithelialized, again using a sharp steel blade. The resultant grafts were comprised of fat and dermis only, with the epidermis carefully denuded in preparation for placement. The dermal fat grafts were then placed in the facial defects and sutured in place with the dermal side up ( Fig. 1 ). In some cases, a piece of AlloDerm was used to help anchor the fat graft in place but did not serve as a substantial part of the reconstruction. After harvesting the graft, the abdominal donor wound was irrigated, followed by the introduction of a small closed suction drain. The abdominal defects were closed primarily in multiple layers using 3-0 Vicryl in the fat layer, 4-0 Vicryl for the subcuticular tissue, and finally a Monocryl fast-absorbing suture or Steri-Strips for the most superficial layer. The closure of the head and neck recipient sites varied from patient to patient depending on the site and size of the defect.
