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Page 8 of 15 Gidumal et al. Plast Aesthet Res 2021;8:42 https://dx.doi.org/10.20517/2347-9264.2021.27

in the general surgery field has shown benefits of early oral feeding compared to enteral therapy. These
benefits include a decreased length of stay and improved quality of life [72,73] . Furthermore, weak evidence
[74]
supports early oral intake as a mechanism to preserve muscle memory associated with swallowing .
Historically, however, head and neck services have hesitated to start an oral diet on the first postoperative
day (POD-1) out of concern that overuse of the tongue and pharynx could increase the risk of wound
dehiscence and fistula formation in the aerodigestive tract. Until recently, head and neck surgery data on
the benefits of early oral regimens had been sparse and inconclusive [60,71] . It has led to the continued
[8]
avoidance of standardized oral diet initiation for head and neck patients .
However, recent work in the field of head and neck surgery has demonstrated convincing evidence that
initiation of oral diet on POD-1 reduces the length of stay without an increase in perioperative
[75]
complications . More compelling evidence now supports older studies that had occasionally shown that
rates of fistula formation were not increased by early oral feeding [76-79] . Together with the aforementioned
promising data seen in the general surgery populations, these findings suggest that oral feeding as early as
postoperative day one is likely to improve dysphagia outcomes, quality of life, and length of stay in patients
after head and neck oncologic surgery. We are currently exploring clinical trials in order to compare
outcomes of early oral feeding vs. traditional approaches.

Tracheostomy management
For patients who require tracheostomy, early tracheostomy tube cuff deflation, 24 h capping trials to judge
readiness for decannulation, and subsequent early decannulation are all practices that have improved
outcomes in tracheostomized patients [8,12] . Additionally, recent data have supported the implementation of
two new strategies for managing tracheostomies in the postoperative setting: immediate use of an uncuffed
tracheostomy tube and the use of high flow oxygen therapy (HFOT).

Immediate placement of an uncuffed tracheostomy tube, rather than placement of a cuffed tube with
subsequent deflation, has recently been shown to reduce time to decannulation as well as the length of
stay . Uncuffed tracheostomy tubes both reduce resistance to airflow around the tube, allowing for earlier
[80]
assessment of readiness for decannulation, and reducing pressure on the esophagus, diminishing the risk of
dysphagia in the postoperative setting. While it has been proposed that the lack of a cuff to prevent tracheal
secretions from entering the lower airway may lead to increased rates of lower respiratory infection,
equivalent rates of respiratory complications have been found in cuffed and uncuffed populations .
[80]
High flow oxygen therapy through a tracheostomy tube has reduced rates of postoperative pulmonary
[81]
complications in preliminary work . Oxygen provided at a rate of 60 L/min from the cessation of
mechanical ventilation to decannulation reduces anatomical dead space and improves airway
humidification, thus decreasing the risk of mucous plugging and retention of respiratory secretions [82,83] .
Patients undergoing HFOT did not suffer from adverse events often associated with positive-pressure
oxygenation such as pneumothorax. Furthermore, these patients benefited from reduced time to
mobilization, reduced physiotherapy needs and decreased overall length of stay . Further work in larger
[81]
study populations will be required to establish HFOT as common practice in patients after tracheotomy.

Wound care
While postoperative wound care after head and neck surgery must be individualized, the use of specific
dressing types for skin grafts and specific drainage mechanisms after neck dissection facilitate faster
recovery, reduced pain, and lower infection rates. The management of the donor sites for split-thickness
skin grafts (STSG) has garnered attention because patients often report more pain from the skin graft donor