Case and Flap Selection

There has been much written in the last several weeks regarding the appropriate timing and prioritization of oncologic procedures. Our head and neck oncology team has developed a tiered structure to classify cases based on urgency (Table 1). At the present moment, only tier 3 cases are moving forward with scheduling. Largely, this includes squamous cell carcinoma and other high grade malignancies. Free flap reconstructions for nononcologic indications (osteoradionecrosis, post-traumatic, wounds) have been postponed.
With respect to flap selection and planning, it should be noted that at our institution we have a weekly reconstructive surgery conference. This was in place prior to the current pandemic. Similar to a multidisciplinary tumor board, this hour long conference includes members of the otolaryngology team, plastic surgery team, and nursing staff. During this conference, the weeks cases are presented in a systematic fashion and the reconstructive plan is discussed in detail. From this conference, a planning document is sent out to all providers involved in these cases (nursing staff, anesthesia, general surgery, oral surgery, otolaryngology, plastic surgery) summarizing key elements.
This conference has transitioned to a virtual, video conference using the Zoom (Zoom Video Communications, Inc) platform. Our multidisciplinary tumor board has also transitioned to this format and satisfaction has been high. In a survey performed of our tumor board, 78% of providers felt that the new video format should be continued indefinitely.
Decision algorithms for our patients have changed. Given that these are highly aerosolizing mucosal cases, a major focus has been on simplifying reconstruction and reducing surgical duration when possible. This includes staging reconstruction when acceptable and substituting locoregional flap reconstruction when feasible. We are limiting cases of microvascular reconstruction to those in which is it felt by consensus to be absolutely necessary. Often, these decisions are complex and controversial.
Simplifying reconstructive techniques may have functional consequences and may increase the incidence of local wound complications (dehiscence, fistula, etc). As such, these decisions much balance concerns regarding surgical expediency, creation of a safe wound, and functional restoration. In an effort to standardize this thought process, we have prioritized our reconstructive cases in a tiered fashion similar to our oncology team (Table 2).
Even within the subset of cases that are thought to require free flap reconstruction, the decision regarding performing composite soft tissue with bone reconstruction versus soft tissue reconstruction alone should be carefully considered. For most defects, the addition of bone reconstruction adds operative time and complexity and in the current pandemic, may not be indicated. A good example is the soft tissue reconstruction of lateral mandibular defects which has been shown in some studies to have comparable functional outcomes5,6. When soft tissue reconstruction alone can be done without a large functional consequence, this should be considered.
Our use of virtual surgical planning (VSP) for complex oromandibular reconstructions has not changed but this is likely biased by our institution’s experience with this pandemic which has been characterized by a generally low incidence of viral infection. In the setting of large surgical delays, one might consider forgoing VSP planning due to a concern regarding tumor progression and potential intraoperative plan changes. We have found at our institution (unpublished data) that the duration from diagnosis to surgical date is predictive of deviations from VSP planning. Given that our tier 3 oncologic cases have general been able to proceed without delay, our utilization of VSP technology has not changed. Additionally, evidence that VSP generally reduces surgical duration further supports this process7.