Episode 69: Head and neck surgery with Alexandra Kejner

We discuss head and neck surgery with Dr. Alexandra Kejner, otolaryngologist at the Medical University of South Carolina specializing in transoral robotic surgery, reconstructive surgery including microvascular free tissue transfer, salivary neoplasms, and sialoendoscopic procedures.

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Takeaway lessons

  1. Robotics has enabled much less invasive approaches to many head and neck procedures.
  2. Major airway procedures create edema, and there is always risk for bleeding, so patients often remain intubated overnight.
  3. The other common ICU indication is a free flap, a portion of tissue (potentially including skin, subcutaneous tissue, muscle, even bone) removed from a remote site and transplanted into the head and neck area, with vessels anastomosed. These are at risk of failure and require close monitoring.
  4. Most of these procedures will involve placing a tracheostomy, and potentially a PEG (or NG). This facilitates both surgical access and early recovery.
  5. Tumors are superficially resected with adequate margins, then reconstruction begins. Meanwhile, exposure of deeper structures and deeper resection occur, which may involve a jig to guide the removal (prepared in advance from imaging), and a matching cut to prepare the flap tissue. Lymph nodes are removed en bloc. Then the flap is transplanted and vessels anastomosed (at least one robust artery and vein), using microsurgery and teeny sutures (often 8-0 nylon).
  6. As a supplement to the clinical exam, an implantable Doppler monitor is occasionally left in place to augment post-op monitoring of perfusion, as well as sometimes a Vioptix near-infrared spectroscopy device which performs real-time tissue oximetry.
  7. On POD 0-1, hourly nursing monitoring of the flap is usually needed, with periodic provider checks. Changes in the exam (swelling, turgor, cap refill, color), signal, or bleeding may require return to the OR for revision. A single ICU night is the norm, although comorbidities are common and may require a longer stay if the stress of surgery unmasks other problems.
  8. Laryngectomy may be performed, involving removal of the larynx (voice box), leaving a blind pouch; the lungs no longer connect to the upper airway in this case, and the entire team should be aware of this anatomy, as the patient cannot be intubated or their airway otherwise managed from above.
  9. Most flaps will be on a baby aspirin and enoxaparin, but occasionally may use a heparin drip.
  10. Most will receive three doses of dexamethasone, both to reduce edema and to treat any adrenal insufficiency.
  11. Chlorhexadine or salt water oral rinses are performed to keep the operative site clean.
  12. Multimodal pain management is needed for both the oral site and the donor flap site.
  13. A drop in the Vioptix signal from the initial post-op reader, neck swelling, or difficulty breathing (dyspnea, hypoxia, etc) all warrant immediate involvement of the surgical team for danger to the airway or the flap. Flaps might also turn purple from venous congestion, sometimes a little later, also a surgical emergency.
  14. A questioned flap might be scratched to see if it bleeds (which is good).
  15. A patient in shock might need vasopressors, fluid, or to be hypotensive, none of which are great for a flap. A balanced approach is probably best. A low-dose phenylephrine drip may be the most appealing pressor, and vasopressin might be the riskiest. MAP >65 is a minimum, some prefer higher (>80).
  16. Intro-operative feeding has been used in some centers due to the prolonged procedure times.
  17. Flap failure historically was most often from a venous clot, but this has reduced over time; nowadays it’s often late failures due to a salivary fistula contaminating the area and creating a region of digestion, clot, and breakdown.
  18. Surgeons will occasionally request deeper sedation (or even forcing the patient to maintain a specific neck position) to avoid dislodging monitors, disrupting a very delicate anastomosis, etc.
  19. A swollen or firm anterior tongue, ooziness in the mouth, or a difficult airway on the initial intubation may lead a surgeon to request delaying extubation.
  20. The immediate post-op appearance usually heals into a better eventual aesthetic result. Occasionally measures like prosthetics can be used.


  1. Vasopressors improve outcomes in autologous free tissue transfer: A systematic review and meta-analysis
  2. Postoperative Use of Vasopressors in Head and Neck Microvascular Reconstruction

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