Survival of pedicled pectoralis major flap after secondary myectomy of muscle pedicle including transection of thoracoacromial vessels: Does the flap remain dependent on its dominant pedicle?

The Forgotten Flap: The Pedicled Trapezius Flap's Utility in Pediatric Head and Neck Reconstruction-A Systematic Review

BACKGROUND

 When free tissue transfer is precluded or undesired, the pedicled trapezius flap is a viable alternative for adults requiring complex head and neck (H&N) defect reconstruction. However, the application of this flap in pediatric reconstruction is underexplored. This systematic review aimed to describe the use of the pedicled trapezius flap and investigate its efficacy in pediatric H&N reconstruction.

METHODS

 A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles describing the trapezius flap for H&N reconstruction in pediatric patients were included. Patient demographics, surgical indications, wound characteristics, flap characteristics, complications, and functional outcomes were abstracted.

RESULTS

 A systematic review identified 22 articles for inclusion. Studies mainly consisted of case reports (n = 11) and case series (n = 8). In total, 67 pedicled trapezius flaps were successfully performed for H&N reconstruction in 63 patients. The most common surgical indications included burn scar contractures (n = 46, 73.0%) and chronic wounds secondary to H&N masses (n = 9, 14.3%). Defects were most commonly located in the neck (n = 28, 41.8%). The mean flap area and arc of rotation were 326.4 ± 241.7 cm2 and 157.6 ± 33.2 degrees, respectively. Most flaps were myocutaneous (n = 48, 71.6%) and based on the dorsal scapular artery (n = 32, 47.8%). Complications occurred in 10 (14.9%) flaps. The flap's survival rate was 100% (n = 67). No instances of functional donor site morbidity were reported. The mean follow-up was 2.2 ± 1.8 years.

CONCLUSION

 This systematic review demonstrated the reliability of the pedicled trapezius flap in pediatric H&N reconstruction, with a low complication rate, no reports of functional donor site morbidity, and a 100% flap survival rate. The flap's substantial surface area, bulk, and arc of rotation contribute to its efficacy in covering soft tissue defects ranging from the proximal neck to the vertex of the scalp. The pedicled trapezius flap is a viable option for pediatric H&N reconstruction.

Long-term patient-reported outcomes after reconstructive surgery for head and neck cancer: A systematic review

Current literature on reconstruction after head and neck cancer (HNC) focusses on short-term patient-reported outcomes (PROs), while there is a need for knowledge on long-term consequences. Embase, Medline, Web of Science, and Cochrane were searched for studies on health-related quality of life (HRQoL) after HNC reconstruction, using validated PROMs in at least 50 patients, and a follow-up of more than 1 year. Thirty studies were included, comprising 2358 patients with a follow-up between one and 10 years. The most used questionnaire was the UW-QoL v4. Reconstructive surgery was generally followed by diminished oral function, worsened by radiotherapy. Patients experienced anxiety and fear of cancer recurrence. However, there was a progressive decrease in pain over time with some flaps having more favorable HRQoL outcomes. Age and bony tumor involvement were not related to postoperative HRQoL. These results may lead to better patient counseling and expectation management of HNC patients.

In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation

BACKGROUND

The vessel-depleted, irradiated, and frozen neck, as well as severe atherosclerosis of recipient vessels represent challenging problems in free flap transfer. Extracorporeal free flap perfusion theoretically allows free flap reconstructions in the absence of local donor vessels, but is associated with a number of technical issues. In this study, a novel technique is presented using a commercially available system for extracorporeal membrane oxygenation (ECMO), modified for small blood volumes.

METHODS

After preclinical testing, an ECMO system certified for lung support was used to establish blood flow through the flap's artery with oxygenation, decarboxylation and warming of diluted packed blood cells. Venous blood was allowed to flow passively into a separate container. Perfusion was performed for 15 min at intervals of 4 h over 4-6 days.

RESULTS

Five patients with soft tissue defects requiring free flap reconstruction were included. Either primarily thinned anterolateral thigh (ALT) flaps (n = 3) or radial forearm flaps (n = 2) were used. We observed infection of the perfusate, with consequent subtotal flap loss, in one patient, complete epithelial loss in two patients, venous congestion in one case, and almost uneventful healing in the fifth patient. With conservative wound care and a split thickness skin graft in one case, stable wound coverage was achieved in all patients except one, who had secondary healing. None of the patients required a second flap for sufficient coverage.

CONCLUSIONS

The technique described is associated with the risks of infection, flap congestion, nutritive hypoperfusion, and consequent tissue loss. Nevertheless, stable defect closure seems to be achievable even in patients with depleted recipient vessels.

Chest wall tumors: Diagnosis, treatment and reconstruction

The aim of the present study was to determine a suitable procedure for the treatment of chest wall neoplasms with less potential risk and an increased rate of survival. Fifty patients with suspected chest wall malignancies were analyzed using various preliminary investigation tools. Whole-chest scanning was performed in all the patients. The patients were subsequently subjected to biopsies for further confirmation of the neoplasm. All such patients were then treated with a surgical approach and radiation therapy, with a follow-up period lasting up to six years. The majority of the patients showed improved survival rates relative to conventional therapies. The survival rates of patients suffering from osteosarcoma (78%) were higher those of patients with rhabdomyosarcoma (73%) and malignant small round cell tumors (64%). The survival and the mortality rates of the patients with synovial sarcoma and fibrosarcoma were the same. This study, which was conducted on a small group of patients, has provided guidance for further studies on tumors of the chest wall, which may, in turn, increase the longevity of affected patients.

The myocutaneous trapezius flap revisited: a treatment algorithm for optimal surgical outcomes based on 43 flap reconstructions

BACKGROUND

Because the vascular anatomy of the trapezius flap is highly variable, choosing the most appropriate flap type and design is essential to optimize outcomes and minimize postoperative complications. The aim of this study was to develop a surgical treatment algorithm for trapezius flap transfers.

METHODS

The medical files of all consecutive patients with a myocutaneous trapezius flap reconstruction of the head, neck, and upper back area treated at three different university medical centers between July 2001 and November 2012 were reviewed.

RESULTS

There were 43 consecutive flaps performed in 38 patients with a mean follow-up time of 15 months (range, 1-48 months). Eleven patients had a mentosternal burn scar contracture (12 flaps), 12 patients (13 flaps) presented with cancer, and 15 patients (18 flaps) were suffering from chronic wounds due to failed previous reconstruction (n = 6), osteoradionecrosis (n = 1), chronic infection (n = 3), bronchopleural fistula (n = 3), and pressure sores (n = 2). The mean defect size was 152 cm(2). Sixteen flaps were based on the superficial cervical artery (SCA; type 2), 16 were based on the dorsal scapular artery (DSA; type 3), one was based on the intercostal arteries (type 4), and 10 flaps were based on both the DSA and SCA. Recipient-site complications requiring reoperation occurred in 16.3%, including one total flap failure (2.6%).

CONCLUSIONS

The trapezius myocutaneous flap is a valuable option to reconstruct various head and neck and upper back defects. Based on our data, a surgical treatment algorithm was developed in an attempt to reduce variation in care and improve clinical outcomes.