A National Multi-institutional Analysis of Predictors of Surgical Site Complications and Unplanned Reoperation after Paramedian Forehead Flap Reconstruction
Rohan Brebion1, Garrett Ni2, Pablo Baltodano3, Theresa Webster1, Nicholas Elmer4, Michael Coronado1, Brianna Kaplunov1, Karen Massada5, Huaqing Zhao1, Xiaoning Lu1, Sameer Patel3
1Lewis-Katz School of Medicine at Temple University, Philadelphia, PA, 2TUH-Otolaryngology, Philadelphia, PA, 3Fox Chase Cancer Center, Philadelphia, PA, 4Jefferson 5Mercy Catholic Medical Center, Yeadon, PA
Background: The paramedian forehead flap remains a work horse for nasal reconstruction following excision of cutaneous and non-cutaneous malignancies. Despite this, patients who undergo this procedure may experience considerably high rates of complications and unplanned reoperation. Recent literature suggests infection to be the most common complication following paramedian forehead flap reconstruction. In light of this, we sought to determine the patient and operative factors associated with surgical site wound complications and unplanned reoperation at a national level.
Methods: Patients who underwent paramedian forehead flap reconstruction from the ACS-NSQIP 2007-2019 database were analyzed to determine composite surgical site morbidity and unplanned return to the operating room. We defined surgical site morbidity as a composite outcome of post-operative wound disruption and superficial, deep, or organ space infection. Patient and operative factors were also analyzed via multivariable logistic regression to assess for independent risk factors for surgical site morbidity and unplanned reoperation in the first 30 post-operative days.
Results: 1,592 paramedian forehead flaps were analyzed between 2007 and 2019. The mean age (SD) among patients in the cohort was 66.3 (14.1) years. 2.7% (43/1592) developed a composite surgical site complication in the first 30 post-operative days. Independent risk factors for composite surgical site complication based on multivariate analysis included weight loss greater than 10% in the previous 6 months (p<0.05), disseminated cancer (p<0.01), class 4 wounds (dirty/infected) (p<0.01), and operative time greater than the cohort median, or 123 minutes (p<0.01). Additionally, 2.5% (40/1592) of patients underwent unplanned reoperation related to initial forehead flap reconstruction in the first post-operative month. Multivariate analysis demonstrated that higher ASA class (p<0.05) and class 4 wounds (p<0.05) were associated with unplanned return to the operating room.
Conclusion:: Given the utility of the paramedian forehead flap and its relevance in complex nasal reconstruction, it is critical to analyze the patient and operative factors associated with complications as well as unplanned return to the operating room. This is the first study to assess these factors using a nationally validated database. Given the data presented, optimal preoperative planning of these procedures and measures to optimize nutritional indices (a surrogate to weight loss) preoperatively are critical. Appropriate antibiotic use in the perioperative and postoperative period and other steps to reduce infection for those at increased risk should be employed.
Back to 2021 Abstracts