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.