title: Wound healing complications with intraoperative brachytherapy for head and neck cancer: a unique form of radiation injury.
abstract: BACKGROUND
  Intraoperative brachytherapy (IOBT) to the tumor bed coupled with surgery has been shown to increase survival and to improve locoregional disease control after head and neck tumor extirpation. Flap reconstruction attempts to restore patient anatomy, while also covering the radioactive implants. The purpose of this study was to better characterize the wound healing complications experienced by patients undergoing reconstruction in the setting of IOBT after tumor ablation, as well as to identify risk factors predicting complications and the need for reoperation.
  
  
  METHODS
  A retrospective chart review of patients receiving IOBT for head and neck cancer at Yale-New Haven Hospital between 2005 and 2013 was conducted. Patient, tumor, treatment, and reconstructive details were recorded. The number and type of flap complications, as well as instances in which patients had to be taken back to the operating room, were documented. Bivariate and multivariate logistic regressions were performed to identify risk factors associated with the occurrence of 1 or more flap complications, as well as the need for reoperation.
  
  
  RESULTS
  Ninety-three patients aged 31 to 93 years (mean, 64 ± 12 years) who underwent IOBT with flap reconstruction were included in the study. Of these, 94% had a prior history of radiation (external beam or previous IOBT). Overall, 48 (51.6%) patients experienced at least 1 flap complication, the most common of which was flap dehiscence (32% of patients). Thirty-two patients (34% of the cohort) had to be taken back to the operating room at least once for flap debridement or a revision procedure. On multivariate analysis, only the placement of mandibular hardware during flap reconstruction was significantly associated with the risk of developing any type of flap complication (odds ratio, 3.7; P = 0.009) or with subsequent return to the operating room (odds ratio, 3.9; P = 0.012).
  
  
  CONCLUSIONS
  This study, the largest of its kind, demonstrated a very high complication rate for flaps used to cover brachytherapy implants in this patient cohort. However, many of the patient complications could be managed nonoperatively. Avoiding the use of mandibular hardware with IOBT suggests a method of reducing complications with reconstruction.
authors.affiliation: From the Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Erik J
authors.initials: EJ
authors.lastname: Geiger
authors.forename: Bryce A
authors.initials: BA
authors.lastname: Basques
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Chang
authors.forename: Andre W
authors.initials: AW
authors.lastname: Alcon
authors.forename: Deepak
authors.initials: D
authors.lastname: Narayan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001918:Brachytherapy / Q000009:adverse effects*; D002294:Carcinoma, Squamous Cell / Q000532:radiotherapy* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006258:Head and Neck Neoplasms / Q000532:radiotherapy* / Q000601:surgery; D006801:Humans; D007430:Intraoperative Care / Q000009:adverse effects*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology; D018714:Radiotherapy, Adjuvant; D019651:Plastic Surgery Procedures; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013524:Surgical Flaps; D016896:Treatment Outcome; D014945:Wound Healing / Q000528:radiation effects*