Failure of Free Flaps in Head and Neck Oncology Surgery in COVID-19 Patients

Abstract

Healthcare workers who come in close contact with the upper aerodigestive tract during diagnostic and therapeutic procedures in coronavirus disease 2019 (COVID-19) patients, such as otolaryngologists and head and neck surgeons, are particularly at risk of contracting the disease.1 We report the case of a 56-year-old woman who presented with a gingival mandibular squamous cell carcinoma (T4aN1M0). She was operated on at the beginning of the French epidemic and before home lockdown was mandated. The operative procedure was performed without any COVID-19 safety precautions. A tracheotomy was performed at the beginning of the intervention. A chimeric double skin paddle free fibula flap and a thoracodorsal artery perforator (TDAP) flap were used (Fig. 1, left). The anastomosis was performed on the left side for the TDAP flap and on the right side for the fibula flap. On the seventh postoperative day, the TDAP flap and the septocutaneous fibular skin paddle showed no bleeding on scarification, and the soleus musculocutaneous perforator skin paddle presented a slow capillary refill time. A second operation was performed, and intraoperative findings showed no arterial or venous thrombosis of the TDAP flap (Fig. 1, right). The soleus musculocutaneous perforator skin paddle also presented signs of early necrosis in several zones, and total necrosis of the bone was found. Both the fibula and the TDAP flaps were removed. The salvage procedure was performed using a pedicled musculocutaneous latissimus dorsi flap.Fig. 1.: Case of a 56-year-old female patient with a gingivomandibular squamous cell carcinoma (T4aN1M0) located in the anterior part of the oral cavity. (Left) Final appearance of the two free flaps after the first surgery. (Right) The TDAP failure after the second surgery.After the second operation, guidelines changed in accordance with COVID-19 measures. Our institution suggested screening all ear, nose, and throat patients before any invasive procedures. Therefore, a chest computed tomographic scan and a nasopharyngeal sample polymerase chain reaction assay were performed for this patient to detect severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) before the percutaneous endoscopic gastrostomy. The chest computed tomographic scan showed ground-glass opacification of the left upper lobe; the polymerase chain reaction test was SARS-Cov-2–negative. (The polymerase chain reaction test was performed using a nasopharyngeal swab where it would be more sensitive, on a tracheal aspiration in this case.) At the same time, three physicians who were in the operating room on this day were contaminated by the COVID-19 virus. Several articles have suggested that a disseminated intravascular coagulation can be found in COVID-19 patients.2 The values of D-dimer, fibrin/fibrinogen degradation products, and fibrinogen in all SARS-CoV-2 cases were substantially higher than those in healthy controls.3 In oncologic cases, we suppose that the antithrombin values are certainly higher than those in healthy controls and we cannot use it to predict free flap failure. The sepsis induced coagulopathy with markedly elevated D-dimer greater than six-fold at the upper limit of normal, and the use of heparin was suggested in a publication.4 In case of free flaps, the authors suggest using heparin for at least 15 days. In our opinion, free flap surgeries for oncologic reasons should not be cancelled, but surgeons must screen patients with thoracic computed tomographic scans and swab testing and delay surgery for 15 days if there is suspicion of COVID-19. Because pathologic changes were described,5 pathological analysis should be practiced for all patients with flap failure for up to 6 months. DISCLOSURE The authors have no financial conflict of interest to declare in relation to the content of this article. There were no funding sources for this work.

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