Unplanned Reoperations in Oral and

Maxillofacial Surgery
Zhifang Zhao, MM,* Jing Hao, MM,y Qian He, MM,z and Runzhi Deng, PhDx
Purpose: The purpose of this study was to determine the incidence of and reasons for unplanned reop-
erations in oral and maxillofacial surgery.
Materials and Methods: During a 4-year period, a total of 169 patients undergoing reoperations were
encountered. The clinical characteristics and causes were reviewed.
Results: There were 11,151 patients who underwent surgery, and the incidence of unplanned reopera-
tions was 1.52%. The male-to-female ratio was 2.45:1. The average age in this cohort was 51.5 years. Among
the common causes of an unplanned return to the operating room, the most common were reoperations
performed for postoperative bleeding, diagnostic issues, and vascular crisis (32.54%, 28.40%, and 29.59%,
respectively).
Conclusions: The unplanned reoperation rate was 1.52%. The main causes were postoperative
bleeding, diagnostic issues, and vascular crisis. Patients with malignant tumors or microvascular flaps
were more likely to undergo unplanned reoperations. Improving perioperative management and diag-
nostic capability might reduce the incidence of unplanned reoperations.
Ó 2018 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 77:135.e1-135.e5, 2019

No operation is without risk.1 A variety of risks always
exist in oral and maxillofacial surgery (OMS), including
infection, thrombosis, deformity, and bleeding. The
overall incidence of surgical complications is usually
not more than 4%.2-4 Various indicators of medical
quality have been designed to improve medical
security. ‘‘Unplanned reoperation’’ is a well-accepted
choice for surgical quality assessment in OMS, which
is associated with adverse events and surgical compli-
cations. Reoperations almost always indicate surgical
complications. Debate continues regarding the corre-
lation between postoperative death and the rate of
unplanned reoperations. A reoperation could be
indicated as a life-saving measure. However, higher
reoperation rates do not always correspond to lower
postoperative mortality rates. A reoperation also could
indicate poor operation quality.5,6 According to
different definitions, the unplanned reoperation rate
ranges widely from 0.6 to 10.1%. Other factors also
may affect the unplanned reoperation rate, including
age, operation difficulty, detection means, patient
heterogeneity, and differences in clinical
practice.1,2,5,7 The aim of this research study was to
determine the incidence of and reasons for
unplanned reoperations in elective OMS.
Materials and Methods
Because of the retrospective nature of this study,
it was granted an exemption by the Nanjing

Received from Nanjing Stomatological Hospital, Medical School of
Nanjing University, Nanjing, China.
*Resident.
yResident.
zResident.
xDepartment Head.
Z.Z., J.H., and Q.H. contributed equally to this work.
Financial support was received from Jiangsu Provincial Medical
Youth Talent (QNRC2016122), Six Talent Peaks Project in Jiangsu
Province (WSW-082), Nanjing Medical Science and Technique
Development Foundation (YKK15114), and Nanjing Foundation
for Development of Science and Technology (201715041).
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Deng: Nanj-
ing Stomatological Hospital, Medical School of Nanjing University,
No. 30 Zhongyang Rd, Nanjing, Jiangsu Province, China, Postal
Code 210008; e-mail: papersci@yeah.net
Received June 15 2018
Accepted August 18 2018
Ó 2018 American Association of Oral and Maxillofacial Surgeons
0278-2391/18/30982-0
https://doi.org/10.1016/j.joms.2018.08.017

135.e1
135.e2 UNPLANNED REOPERATIONS

Stomatological Hospital Institutional Review Board. were more at risk of encountering unplanned
The data were derived from a stomatologic hospital reoperations. The 169 cases involved 120 male and
that specialized in OMS. During the 4-year period from 49 female patients, with a male predominance.
2012 to 2015, all surgical patients were evaluated. In Regarding the operation grades (except for diagnostic
total, 11,151 cases were eligible for this study. In this issues), 2 cases were grade I, 6 cases were grade II, 13
study, reoperations were defined as unplanned reopera- cases were grade III, and 100 cases were grade IV. Ac-
tions in the operating room after the primary operation cording to the major categories of surgical disease, the
during the same admission. No patient died after a reop- 2 most common elements were malignant tumors
eration. Therefore, the postoperative mortality rate was (n = 91, or 53.85%) and microvascular flaps (n = 50,
not analyzed. Unplanned reoperations occurred in a or 29.59%) (Table 2).
total of 169 cases. Clinicopathologic parameters were Among the common causes of an unplanned return
reviewed, including age, gender, operation grade, and to the operating room, most reoperations were per-
causes of unplanned reoperations. The operation grade formed for postoperative bleeding, vascular crisis,
was divided into 4 levels according to the complexity of and diagnostic issues (32.54%, 29.59%, and 28.40%,
the operation. The first level represented the most respectively) (Table 3). Other rarer causes included
straightforward operations, such as resection of small
superficial tumors or extraction. The fourth level repre- Table 2. CHARACTERISTICS OF 169 PATIENTS
sented the most complex surgical procedures, such as UNDERGOING UNPLANNED REOPERATIONS
resection of malignant tumors and neck dissection. Sta-
tistical analysis was performed using IBM SPSS Statistics Characteristic n % Statistical Significance
software (version 19.0; IBM, Armonk, NY). The c2 test
was performed for categorical data. P < .05 was consid- Age, yr P < .001 for #20,
21-30, and 31-40 yr
ered statistically significant.
vs 41-50, 51-60,
61-70, and $71 yr
Results #20 7 4.14
21-30 10 5.92
A total of 11,151 surgical cases were included in the
31-40 20 11.83
cohort. The clinical characteristics of these patients
41-50 30 17.75
are listed in Table 1. Unplanned reoperations were 51-60 49 28.99
required in a total of 169 cases. The overall unplanned 61-70 43 25.44
reoperation rate was 1.52%. The average age in this $71 10 5.92
study was 51.5 years, with an age range of 1 to 81 years. Gender P < .001
Compared with young patients, elderly patients Male 120 71.01
Female 49 28.99
Operation grade
Table 1. CHARACTERISTICS OF 11,151 PATIENTS (except for
diagnostic
Characteristic n % issue)
I 2 1.65
Age, yr II 6 4.96
#20 2,417 21.68 III 13 10.74
21-30 1,669 14.97 IV 100 82.64
31-40 1,263 11.33 Elective vs
41-50 1,805 16.19 emergency
51-60 1,843 16.53 Elective 65 38.46
61-70 1,409 12.64 Emergency 104 61.54
$71 745 6.68 Category P < .001 for
Gender malignant tumor
Male 6,280 56.32 and P < .001 for
Female 4,871 43.68 microvascular
Category Malignant tumor 90 53.25
Malignant tumor 984 8.82 Microvascular 50 29.59
Microvascular 685 6.14 Benign tumor 16 9.47
Benign tumor and cyst 4,225 37.89 and cyst
Orthographic 218 1.95 Orthographic 5 2.96
Trauma 849 7.61 Trauma 3 1.78
Other 4,190 37.58 Other 5 2.96
Zhao et al. Unplanned Reoperations. J Oral Maxillofac Surg 2019. Zhao et al. Unplanned Reoperations. J Oral Maxillofac Surg 2019.
ZHAO ET AL 135.e3

Table 3. REASONS FOR UNPLANNED REOPERATIONS

1.52%. As our study documented, there were no
deaths after these unplanned reoperations.
Reason n % Unplanned reoperations were often associated with
improper perioperative management, a patient’s indi-
Bleeding 55 32.54 vidual constitution, or an error in surgical technique.
Flap compromise 50 29.59 Our results showed that the major reasons for
Diagnostic issue 48 28.40 unplanned reoperations included postoperative
Chylous fistula 4 2.37 bleeding, diagnostic issues, vascular crisis, chylous
Wound infection 4 2.37 fistula, wound infection, surgical failure, airway
Surgical failure 3 1.78
obstruction, judgment issues, salivary fistula, drainage
Airway obstruction 2 1.18
Salivary fistula 1 0.59
breakage, flap swelling, and operative incision split.
Drainage breakage 1 0.59 Bleeding (32.54%), flap compromise (29.59%), and
Operative incision split 1 0.59 diagnostic issues (28.40%) accounted for more than
90% of unplanned reoperations in this series. Un-
Zhao et al. Unplanned Reoperations. J Oral Maxillofac Surg 2019.
planned reoperations provided surgeons with the
opportunity to modify conventional practices and
chylous fistula (n = 4, or 2.37%), wound infection improve health care. The most common reasons for
(n = 4, or 2.37%), surgical failure (n = 3, or 1.78%), unplanned reoperations should be borne in mind
airway obstruction (n = 2, or 1.18%), salivary fistula and avoided when possible. Surgeons should aim to
(n = 1, or 0.59%), drainage breakage (n = 1, or improve management during the perioperative
0.59%), and operative incision split (n = 1, or 0.59%). period, which would subsequently result in reduced
All unplanned reoperation cases were resolved, and bleeding, flap compromise, and inaccurate diagnoses.
the patients were discharged home. No patients died In this cohort, postoperative bleeding was the main
after reoperations. cause of unplanned reoperations. There were 55 cases
The main cause of vascular crisis was vein drainage of postoperative bleeding, representing 32.54% of all
disturbance, with a rate of 58% (n = 29). Other causes patients. Postoperative bleeding was a potential
included flap necrosis (n = 9, or 18%), judgment issues complication of every operation. Bleeding may result
(n = 7, or 14%), improper flap location (n = 3, or 6%), from a failure to achieve hemostasis or coagulation de-
and arterial occlusion (n = 2, or 4%) (Table 4). Diag- fects. Blood vessel rupture may not be appropriately
nostic issues were a major contributor to unplanned controlled by ligature or electrocoagulation. Aspirin
reoperations. In this study, 48 unplanned reoperations and other nonsteroidal anti-inflammatory drugs could
were caused by diagnostic issues. elicit acquired coagulation deficits and cause postoper-
ative bleeding.11 Preoperatively, coagulopathy should
be treated and hypertension should be controlled
effectively. Intraoperatively, a meticulous surgical tech-
Discussion nique, reliable hemostasis, and blood pressure control
This study focused on the characteristics of and rea- during anesthesia are crucial.12 In this study, most de-
sons for unplanned reoperations in OMS. Most litera- layed hemorrhages occurred in muscle or connective
ture reports have stated that the rate of unplanned tissue at the operation site. An electrical knife has
reoperations is usually no greater than 10%.2,8-10 been widely used for incisions and hemostasis during
There are no reports regarding unplanned operations. We considered that the improper use of
reoperations in OMS. During a 4-year period in a the electrical knife was responsible for postoperative
busy institution, 169 unplanned reoperation cases hemorrhage. High-frequency electrical knives should
occurred in the OMS department, yielding a rate of provide enough heating time to achieve coagulation
of blood vessels; however, if an electrical knife moves
too quickly, it will not achieve hemostasis. Increased
Table 4. REASONS FOR VASCULAR CRISIS blood pressure, dysphoria, and pain after general anes-
thesia also may result in wound errhysis or small blood
Reason n % vessel hemorrhage. Therefore, clinicians should oper-
ate with strictly refined manipulation. Ligation was
Vein drainage disturbance 29 58 more reliable than electrocoagulation for larger blood
Flap necrosis 9 18 vessels and muscle remnants. Appropriate postopera-
Judgment issue 7 14
tive analgesia also contributed to the elimination of
Improper flap location 3 6
Arterial occlusion 2 4
postoperative restlessness and reduced the risk of
bleeding. Only then could postoperative hemorrhage
Zhao et al. Unplanned Reoperations. J Oral Maxillofac Surg 2019. be reduced.
135.e4
Flap failure was another important cause of
unplanned reoperations. However, several studies
have indicated that factors such as smoking, diabetes,
body mass index, older age, and increased operative
time may be associated with a higher incidence of
flap failure.13-19 The main cause of flap failure was
found to be vessel occlusion due to thrombus
formation.20,21 Vein drainage disturbance was the
main cause of flap failure in 29 cases. In our
institution, a single vein was generally used unless
the drainage of the recipient vessel was considered
unreliable and showed remarkable venous stenosis
or a thick endomembrane. Some studies have
suggested that a secondary vein for the drainage of a
free flap may reduce venous congestion.20,22 In
theory, 2 venous anastomoses could provide more
reliable flap venous drainage systems. However,
studies have shown that 1 venous anastomosis can
provide adequate drainage with a similar flap survival
rate and a reduced operative time.21 In 3 cases, pres-
sure on the drainage vein may have caused drainage-
induced venous thrombosis. Therefore, drainage tubes
should be placed away from the anastomosis site.
In this study, diagnostic issues also were found to be
a major contributor to unplanned reoperations. A total
of 48 unplanned reoperation cases were related to
diagnostic issues. Clinical misdiagnosis (19 cases) re-
sulted in incorrect index surgery methods, accounting
for 42.5% of cases. The most common misdiagnosis
was oral cancer misdiagnosed as oral leukoplakia pre-
operatively. Oral cancer requires extensive resection
to ensure operative thoroughness in the initial opera-
tion. However, extensive resection is not suitable for
oral leukoplakia. When malignancy was confirmed,
an unplanned reoperation was inevitably performed.
In addition, histopathologic diagnostic uncertainty
led to reoperations, accounting for 52.5% of cases
(27 cases). The intraoperative diagnosis of salivary
neoplasm was often very difficult to establish. Surgical
treatment of the parotid gland was a common event in
unplanned reoperations. Frozen section findings from
parotid gland ablation were frequently benign or un-
certain, reflecting an indication for classic superficial
parotidectomy as the index operation. However, post-
operative hematoxylin and eosin and immunohisto-
chemical staining can confirm malignant tumors,
leading to complete ablation of the parotid
glands. Some cases could not be confirmed by frozen
section analysis, such as acinic cell carcinoma, salivary
duct carcinoma, mucoepidermoid carcinoma, and car-
cinoma ex pleomorphic adenoma. Another diagnostic
issue was that ameloblastoma could be misdiagnosed
as cystic lesions of the jaw. Cystic curettage is not suit-
able for ameloblastoma. Therefore, broader resection
would be performed. Unplanned reoperations are an
additional burden for patients in terms of medical
UNPLANNED REOPERATIONS
expenses and psychological issues. Clinicians should
perform careful preoperative evaluations to correctly
determine the preoperative diagnosis. It is also impor-
tant that pathologists improve the accuracy of intrao-
perative frozen section procedures.
Other rare cases included chylous fistula, salivary fis-
tula, wound infection, and airway obstruction. We
encountered a case with postoperative drainage tube
rupture, in which a second surgical procedure had
to be performed to remove the stump of the tube.
Therefore, perioperative management should always
be performed carefully.
Unplanned reoperations can result in adverse
events. However, unplanned reoperations may
reflect the severity of illness or complexity of the
surgical procedure and do not always indicate that
the first operation is defective. In our study, grade
IV operations were the most common (compared
with the other complexity grades), accounting for
82.64% of cases. Patients with malignant tumors or
microvascular flaps were more likely to undergo
unplanned reoperations. Unplanned reoperations
were more common than death in OMS, which
was easy to track and compare. In our institution,
the unplanned reoperation rate is suggested as an
important reference index for medical quality,2,4
showing opportunities for medical quality
improvement. Surgeons can learn from this
experience and benefit from the lessons provided
by unplanned reoperations performed by other
surgeons, including us. However, some limitations
might have caused bias in our findings. First, this
study was a retrospective analysis over a period of
4 years with a limited number of cases. Second,
this study was a single-institution study. Therefore,
in the future, a prospective multicenter study would
provide more reliable conclusions.
References
1. Kroon HM, Breslau PJ, Lardenoye JW: Can the incidence of
unplanned reoperations be used as an indicator of quality of
care in surgery? Am J Med Qual 22:198, 2007
2. McLaughlin N, Jin P, Martin NA: Assessing early unplanned
reoperations in neurosurgery: Opportunities for quality
improvement. J Neurosurg 123:198, 2015
3. de Vries EN, Ramrattan MA, Smorenburg SM, et al: The incidence
and nature of in-hospital adverse events: A systematic review.
Qual Saf Health Care 17:216, 2008
4. Halfon P, Eggli Y, Matter M, et al: Risk-adjusted rates for poten-
tially avoidable reoperations were computed from routine
hospital data. J Clin Epidemiol 60:56, 2007
5. Henneman D, Dekker JW, Wouters MW, et al: Benchmarking
clinical outcomes in elective colorectal cancer surgery: The
interplay between institutional reoperation- and mortality rates.
Eur J Surg Oncol 40:1429, 2014
6. Almoudaris AM, Mamidanna R, Bottle A, et al: Failure to rescue
patients after reintervention in gastroesophageal cancer surgery
in England. JAMA Surg 148:272, 2013
7. Kazaure HS, Chandra V, Mell MW: Unplanned reoperations after
vascular surgery. J Vasc Surg 63:730, 2016
ZHAO ET AL
8. Birkmeyer JD, Hamby LS, Birkmeyer CM, et al: Is unplanned re-
turn to the operating room a useful quality indicator in general
surgery? Arch Surg 136:405, 2001
9. Dierks MM, Huang ZS, Siracuse JJ, et al: Diagnostic, surgical judg-
ment, and systems issues leading to reoperation: Mining admin-
istrative databases. Am J Surg 199:324, 2010
10. Merkow RP, Bilimoria KY, Cohen ME, et al: Variability in reoper-
ation rates at 182 hospitals: A potential target for quality
improvement. J Am Coll Surg 209:557, 2009
11. Scher KS: Unplanned reoperation for bleeding. Am Surg 62:52,
1996
12. Algattas H, Kimmell KT, Vates GE: Risk of reoperation for hem-
orrhage in patients after craniotomy. World Neurosurg 87:531,
2016
13. Wong AK, Joanna NT, Peric M, et al: Analysis of risk factors asso-
ciated with microvascular free flap failure using a multi-
institutional database. Microsurgery 35:6, 2015
14. Bozikov K, Arnez ZM: Factors predicting free flap complications
in head and neck reconstruction. J Plast Reconstr Aesthet Surg
59:737, 2006
15. Miller RB, Reece G, Kroll SS, et al: Microvascular breast
reconstruction in the diabetic patient. Plast Reconstr Surg
119:38, 2007
135.e5
16. Valentini V, Cassoni A, Marianetti TM, et al: Diabetes as main risk
factor in head and neck reconstructive surgery with free flaps. J
Craniofac Surg 19:1080, 2008
17. Serletti JM, Higgins JP, Moran S, Orlando GS: Factors affecting
outcome in free-tissue transfer in the elderly. Plast Reconstr
Surg 106:66, 2000
18. Ishimaru M, Ono S, Suzuki S, et al: Risk factors for free flap
failure in 2,846 patients with head and neck cancer: A
national database study in Japan. J Oral Maxillofac Surg 74:
1265, 2016
19. Sanati-Mehrizy P, Massenburg BB, Rosa JH, Taub PJ: Risk factors
associated with free flap failure—An analysis of 2103 patients.
Plast Reconstr Surg 136(Suppl):18, 2015
20. Ahmadi I, Herle P, Rozen WM, Leong J: One versus two venous
anastomoses in microsurgical free flaps: A meta-analysis. J Re-
constr Microsurg 30:413, 2014
21. Futran ND, Stack BJ: Single versus dual venous drainage of the
radial forearm free flap. Am J Otolaryngol 17:112, 1996
22. Enajat M, Rozen WM, Whitaker IS, et al: A single center
comparison of one versus two venous anastomoses in
564 consecutive DIEP flaps: Investigating the effect on
venous congestion and flap survival. Microsurgery 30:185,
2010