Two Cases of Impaired Wound Healing Among Patients With Major Head and Neck Free-Flap Reconstruction in the Setting of COVID-19 Infection

Abstract

Due to the microvascular effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), head and neck reconstructive surgeries utilizing free tissue transfers may be profoundly affected by SARS-CoV-2 infection in the immediate postoperative period. Our objective is to describe two adult patients who developed SARS-CoV-2 after undergoing relatively uncomplicated segmental mandibulectomies. In both cases, the patients were initially negative for SARS-CoV-2, underwent relatively uncomplicated segmental mandibulectomies with fibula free flap reconstructions, and were later discharged in stable conditions. Both patients subsequently experienced significant infectious sequelae at the donor and recipient sites with neartotal split-thickness skin graft loss in the donor sites in the setting of postoperative SARS-CoV-2 infection. The first patient developed sepsis and gangrenous changes to his fibula donor site requiring four operative debridements and partial amputation with subsequent osteomyelitis of the remaining fibula. The second patient experienced dehiscence of the oral fibula free flap as well as a 22 cm phlegmon at the fibula donor site that required surgical debridement. In consideration of these cases, SARS-CoV-2 infection during the immediate postoperative period of head and neck reconstruction procedures may elevate the risk of major wound complications. Special consideration must be taken when performing free tissue transfers during the COVID-19 pandemic.

Asymptomatic or mildly symptomatic COVID-19 patients with craniomaxillofacial injuries have an increased risk of surgical site infection

“… [18] , [19] The binding of SARS-CoV-2 to ACE2 increases levels of angiotensin II (Ang II), a potent vasoconstrictor and pro-inflammatory molecule which exerts oxidative stress, mitochondrial dysfunction, endothelial cell damage, hypercoagulation and thrombosis (via free radical generation), and jeopardise proper neovascularisation for wound healing. 2 High levels of serum plasminogen activator inhibitor-1 (PAI-1) and D-dimers are consistent with microthrombi observed in COVID-19 patient autopsies. 19 Clinically, Inouye et al 2 reported free flap failure in patients with SARS-CoV-2, and Talmor et al .…”

“… 2 High levels of serum plasminogen activator inhibitor-1 (PAI-1) and D-dimers are consistent with microthrombi observed in COVID-19 patient autopsies. 19 Clinically, Inouye et al 2 reported free flap failure in patients with SARS-CoV-2, and Talmor et al . 20 described pedicled nasoseptal flap necrosis and failure due to SARS-CoV-2 infection.…”

“…PAU is reasonable in the circumstances of AS/MS-COVID patients with SSI. Inouye et al 2 found that SSIs in COVID-19 patients were intensified by secondary bacterial infections, which emerge from Staphylococcus aureus (75%), Escherichia coli (58.3%), Klebsiella pneumonia (41.6%), Pseudomonas aeruginosa (33.3%) as well as Acinetobacter baumannii , Streptococcus pneumonia, and Haemophilus influenza (25%). 25 These populations should, therefore, be recognised as high-risk and are SSI-prone via acquired immune compromise, poor microcirculation, and infected surgical sites (if involve VROs), and may benefit from human recombinant soluble ACE2 ( hrs ACE2).…”

“…Microvascular alterations due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were found to cause SSIs at both donor and recipient sites in free fibular flap reconstruction. 2 Our recent study, nevertheless, demonstrated the absence of nosocomial SARS-CoV-2 infection among hospital personnel in contact with asymptomatic COVID-19 patients undergoing midfacial fracture repair 1 , suggesting that craniomaxillofacial injury (CMFI) care in asymptomatic or mildly symptomatic COVID-19 patients (AS/MS-COVID) could be safe. Moreover, several studies rejected the association between SARS-CoV-2 infection and surgical site infections (SSI) such as after hand surgery 3 , caesarean births 4 , or appendectomy 5 .…”

COVID-19 and rhinological surgery

“… 43 Inouye and colleagues also presented two SARS-CoV-2 associated cases of impaired wound healing in patients undergoing head and neck free flap reconstruction. 44 Benmoussa et. al also noted free flap failure in a SARS-CoV-2 positive patient undergoing gingival mandibular carcinoma resection and reconstruction.…”