Free perforator flap transfer for reconstruction of skull base defects after resection of advanced recurrent tumor

The Role of Deep Inferior Epigastric Perforator and Thoracodorsal Artery Perforator Flaps in Head and Neck Reconstruction

Head and neck reconstruction has evolved to a more accurate replacement of the missing tissues for aesthetic and functional benefits, besides a concern with the morbidity caused in the donor site. This has led us to the use of perforator flaps. Deep inferior epigastric perforator flap allows the harvest of a large well-vascularized skin paddle with adequate bulk for large and voluminous defects reconstruction. Its main uses described in the literature are: tongue reconstruction, orbitomaxillary reconstruction, and scalp reconstruction. Thoracodorsal artery perforator flap is derived from the subscapular system and allows the harvest of a large array of chimeric flaps.

The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis

The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.

Free Flap Transfer, a Safe and Efficient Method for Reconstruction of Composite Skull Base Defects After Salvage Resection of Advanced Intracranial and Extracranial Communicating Tumors

OBJECTIVE

Surgical treatment of advanced intracranial and extracranial communicating skull base tumors is challenging, especially for the reconstruction of the large composite defect left by tumor resection. The aim of the study is to evaluate the utility of the free flap reconstruction of the defects resulting from radical resection of these tumors in a single institution.

METHODS

The clinical data of 17 consecutive patients who underwent free flap reconstruction for defect left by salvage resection of advanced intracranial and extracranial communicating tumors from 2013 to 2019 were retrospectively collected and analyzed.

RESULTS

There were 5 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 basal cell carcinomas, 2 meningiomas, 1 anaplastic hemangiopericytoma, 1 pleomorphic adenoma, 1 osteosarcoma, and 1 chondrosarcoma. All patients had recurrent neoplasms, 2 of whom had pulmonary metastasis. A modified radical cervical dissection was performed in 6 patients. The anterolateral thigh myocutaneous flap and rectus abdominis myocutaneous flap were used in 15 patients (88.2%) and 2 patients (11.8%), respectively. Complications were seen in 3 of 17 patients (17.6%) with 1 total flap loss. The median progression-free survival duration was 31 months. The 3- and 5-year progression-free survival rates were 0.47 and 0.24, respectively. The mean overall survival duration was 66 months. The 3- and 5-year overall survival rates were 0.85 and 0.68, respectively.

CONCLUSIONS

Free flap transfer is a safe and effective method with acceptable complications, useful for reconstruction of large composite skull base defects after salvage resection of advanced intracranial and extracranial communicating tumors. The functional and cosmetic results are satisfying.

Deep inferior epigastric artery perforator free flap in head and neck reconstruction: A systematic review

BACKGROUND

Perforator flaps yield the best results for the patient with the least morbidity, and they should be considered the gold standard in head and neck reconstruction. Although deep inferior epigastric perforator (DIEP) flap is considered as the gold standard in breast reconstruction, its use in head and neck reconstructive surgery does not seem so widespread. The objective of this study is to conduct a systematic review of the use, applications and results of the DIEP flap in the head and neck area.

METHODS

Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through meta-searcher Trip Database with deep inferior epigastric perforator flap AND head neck keywords. Studies on animal and human experiments published in peer-reviewed journals, where investigators assessed the use of DIEP flap, according to the Koshima criteria, in the head and neck area were considered.

RESULTS

A total of 31 articles and 185 flaps with 95% of survival were found. Thrombosis or venous stasis is the most frequent cause of flap loss and 16.1% presented some type of complication, the most frequent being the dehiscence. The most use was in the reconstruction of glossectomy defect secondary to squamous cell carcinoma (30.51%), being able potentially to re-establish sensory innervation in oral cavity. The assessment of risk bias (National Institutes of Health) highlights the lack of uniformity, with no standardisation of the outcome variable collection and monitoring.

DISCUSSION

By virtue of its versatility, reliable vascular supply and high flap survival rate, the DIEP flap reconstruction could be an option in complicated 3-dimensional head and neck defects while maintaining the standard of low donor site morbidity.

Toe resurfacing with a thin thoracodorsal artery perforator flap

BACKGROUND

In toe reconstruction, amputation procedures are much more common than salvage procedures. However, toe resurfacing, rather than amputation, provides superior functional and aesthetic results. In this study, we report the clinical outcomes of toe resurfacing using a thin thoracodorsal artery perforator flap.

PATIENTS AND METHODS

Between January 2004 and June 2013, a total of 15 patients underwent toe resurfacing using thoracodorsal artery perforator flaps. Thin flaps were harvested by discarding the deep adipose layer. Twelve cases involved a great toe defect, three, a second toe defect, three, a third toe defect, and one, a fourth toe defect. Patient ages ranged from 19 to 82 years (mean, 42.9 years). The mechanism of injury varied, including crushing injury, degloving injury, and diabetic foot infection.

RESULTS

The size of thoracodorsal artery perforator flap ranged from 4 × 3 to 20 × 8 cm² and the thickness of the flap ranged from 4 to 9 mm (mean, 6.5 mm). All flap survived completely without complications. The mean follow-up period was 18.8 months (range, 12-60 months). Only one patient with rheumatoid arthritis had mild gait disturbance. All patients were satisfied with the aesthetic and functional results.

CONCLUSION

Toe resurfacing with thin thoracodorsal artery perforator flaps appears to be a safer and more reliable option than amputation for preserving their function. © 2015 Wiley Periodicals, Inc. Microsurgery 37:312-318, 2017.

Reliability of eccentric position of the pedicle instead of central position in a thoracodorsal artery perforator flap

INTRODUCTION

To obtain longer vascular pedicle in perforator flaps, surgeons often use eccentrically rather than centrally located perforators. The aim of this study was to compare the safety and reliability of thoracodorsal artery perforator (TDAP) flaps harvested with centrally or eccentrically located perforators.

METHODS

Between January 2008 and March 2012, 100 TDAP flaps were used to reconstruct the lower extremity defects. Flaps longer than 10 cm, with a single musculocutaneous perforator, and one artery-one vein anastomoses were included. The cases were divided into two groups according to perforator location; Central perforators in 60 cases (group 1), and peripheral perforators in 40 cases (group 2). Total pedicle length was between the points where the perforator enters the flap to the end of the pedicle. Real pedicle length was from flap margin to the end of the pedicle. The flap dimension, total pedicle length, real pedicle length, and flap related complications were measured.

RESULTS

The flaps were smaller in group 1 than in group 2 (159.6 ± 94.08 vs.189.95 ± 134.30 cm² , P = 0.455). Total pedicle length was almost the same (12.12 ± 1.57 vs.12.88 ± 2.10 cm, P = 0.420), but the mean real pedicle length was longer in group 2 (6.13 ± 1.33 vs.11.65 ± 2.08 cm, P < 0.05). There were 4 cases of partial loss of flap in group 1 and 3 partial loss and one total flap loss in group 2 without significant difference (P = 0.547).

CONCLUSIONS

Using eccentrically located perforators is simple method of extending real pedicle length, but there have been concerns regarding flap perfusion and distal vascularity. Our findings suggest that, in TDAP flaps, both eccentric and central perforator are safe options. © 2014 Wiley Periodicals, Inc. Microsurgery 37:44-48, 2017.

Reconstructing facial contour deformities using stereoscopic thoracodorsal artery perforator adipofascial flaps

PURPOSE

Correcting facial contour deformities is a challenge, as it demands thoughtful planning on design, composition of flap, and secondary procedures. The thoracodorsal artery perforator (TDAP) flap has become a workhorse flap for various reconstructions. In this report, we present our experience of reconstructing facial contour deformities using the free TDAP adipofascial flap, focusing on its customized design.

PATIENTS AND METHOD

Sixteen patients underwent correction of a facial contour deformity with free TDAP adipofascial flaps from 2002 to 2012. The causes of defects were Romberg disease (n = 7), oncological defects (n = 5), craniofacial microsomia (n = 3), and trauma (n = 1). The flaps were three-dimensionally designed in a contour map fashion to have different thickness according to the defects by adjusting the height of adipose tissue and varying tissue composition. Customized dimension of flaps having reliable perfusion were harvested with minimized sacrifice of overlying skin.

RESULTS

Flap size ranged from 6 × 3 cm to 25 × 25 cm. Six flaps were based on two perforators and the other 10 on one. Five flaps were harvested in a chimeric fashion. All flaps survived completely. No donor morbidity developed in any case. Seven patients underwent secondary corrections including fat injection or liposuction. Improved contour and symmetry were achieved in all patients and was confirmed by a photographic evaluation. Mean follow-up period was 37.8months.

CONCLUSIONS

Our results suggest that the stereoscopic TDAP adipofascial flaps with diligent secondary approaches may be a reliable alternative for aesthetic reconstruction of facial contour deformities. © 2015 Wiley Periodicals, Inc. Microsurgery 37:300-306, 2017.

Reconstruction of the lateral malleolus and calcaneus region using free thoracodorsal artery perforator flaps

Reconstruction of the lateral malleolus or calcaneus region is challenging because of poor vascularity, minimal presence of soft tissue, and difficulties with flap positioning during and after the operation. In many cases, local flaps are limited in terms of size, durability, and vascularity. Free tissue transfer can be useful for complicated wounds. We report here on the results of the reconstruction in this region using free thoracodorsal artery perforator flaps. Between October 2010 and October 2013, 16 cases of lateral malleolus or calcaneus defects were reconstructed using free thoracodorsal artery perforator flaps. The defects varied from 2 × 5 cm(2) to 12 × 16 cm(2), and the flaps from 3 × 5 cm(2) to 10 × 15 cm(2). Two cases were reconstructed using chimeric-pattern flaps. Only the superficial adipose layers were harvested for all the flaps, without further thinning or debulking process. Five cases with complications occurred, including three cases of partial necrosis of the flap and two cases of venous congestion caused by thrombosis and compression of the venous pedicle, and one flap was totally lost. The mean follow-up duration was 11.8 months. All the patients were able to wear shoes. All but one were able to walk. The thoracodorsal artery perforator flap can be made super-thin, allowing patients to wear shoes, and it can be harvested in a chimeric-pattern for complex defects. Therefore, it may represent a viable alternative choice for the reconstruction of the lateral malleolus and calcaneus region.

Reliable harvest of a dorsal scapular artery perforator flap by augmenting its perfusion

Despite confirmation of a reliable perforasome in the dorsal scapular artery in an anatomic study, a true perforator flap has not been recommended in previous clinical studies because of concerns regarding insufficient perfusion in the distal region. In this report, we present two cases of reconstruction for occipital defects caused by tumor extirpation using pedicled dorsal scapular artery perforator flaps without a muscle component. To secure the perfusion of the dorsal scapular artery perforator flap, inclusion of an additional perforator was attempted for perfusion augmentation. The second dorsal scapular artery perforator was harvested in one case. In an additional case, the sixth dorsal intercostal artery perforator with a branch that directly connected with the dorsal scapular artery within the trapezius muscle was additionally harvested. The flaps survived without any perfusion-related complications, including tip necrosis, and no donor site morbidities were observed. We suggest that a perfusion augmented dorsal scapular artery perforator flap by harvesting multiple perforators could be a safe and useful alternative for reconstructive surgery of head and neck defects.