Comparison between the radial forearm and superficial circumflex iliac artery perforator free flaps for oral soft tissue reconstruction

Head and neck reconstruction with the superficial circumflex iliac artery perforator (SCIP) free flap: Lessons learned after 73 cases

BACKGROUND

Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator-based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP-based reconstruction, making this flap our first choice for head and neck reconstructions.

PATIENTS AND METHODS

Seventy-three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37-89), 51 were males and 22 were females. Fifty-eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases.

RESULTS

All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow-up period was 11 months (range 3-24).

CONCLUSIONS

Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post-anastomosis vessel patency in complex microvascular flap-based reconstructions.

SCIP flap in head and neck reconstruction after oncologic ablative surgery: a systematic review

BACKGROUND

In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap.

METHODS

This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications.

RESULTS

A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data.

CONCLUSIONS

In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

Expanding the Armamentarium of Donor Sites in Microvascular Head and Neck Reconstruction

The field of microsurgical head and neck reconstruction has witnessed tremendous advancements in recent years. While the historic goals of reconstruction were simply to maximize flap survival, optimizing both aesthetic and functional outcomes has now become the priority. With an increased understanding of perforator anatomy, improved technology in instruments and microscopes, and high flap success rates, the reconstructive microsurgeon can push the envelope in harvesting and designing the ideal flap to aid patients following tumor extirpation. Furthermore, with improvements in cancer treatment leading to improved patient survival and prognosis, it becomes increasingly important to have a broader repertoire of donor sites. The present review aims to provide a review of newly emerging soft tissue flap options in head and neck reconstruction. While certainly a number of bony flap options also exist, the present review will focus on soft tissue flaps that can be harvested reliably from a variety of alternate donor sites. From the upper extremity, the ulnar forearm as well as the lateral arm, and from the lower extremity, the profunda artery perforator, medial sural artery perforator, and superficial circumflex iliac perforator flaps will be discussed, and we will provide details to aid reconstructive microsurgeons in incorporating these alternative flaps into their armamentarium.

Trends in free flap reconstruction of the head and neck: a single surgeon series of 1027 free tissue transfers

BACKGROUND

Free tissue transfer has fundamentally changed head and neck surgery, enabling reliable reconstruction of large defects with better function and aesthetics. This study assesses two decades of trends in free flap reconstruction, and how disease incidence, survival, surgeon caseload, team approach, and technology have impacted practice.

METHODS

Retrospective analysis of 1027 head and neck free flaps from 2006 to 2022. Outcomes examined include chronological changes in flap selection, indication, length of stay, incorporation of virtual surgical planning (VSP), annual caseload, survival, and their associations with the single versus multi-team approach.

RESULTS

There were 764 soft-tissue and 263 osseous reconstructions utilizing 21 different flaps. Anterolateral thigh and radial forearm accounted for 76.7% of soft tissue flaps, with recent increase in superficial circumflex iliac perforator flaps in young patients. Osseous flap proportion remained stable, but fibula flaps increased five-fold with more VSP, dental implants, oral cancer, and multi-team surgery. Outcomes such as complication rates, length of stay and disease specific/overall survival have improved over time despite increasing complexity (P = 0.001, P = 0.001, P < 0.001, and P < 0.001, respectively). However, there was no significant difference in operative time, complication rate, or disease specific/overall survival between single team or multi-team approaches (P = 0.45, P = 0.054, P = 0.57, and P = 0.60, respectively).

CONCLUSION

Single and multi-team approaches may have similar fundamental outcomes, but as caseload, complexity, and life-expectancy increases, both patients and surgeons benefit from a collaborative multi-team approach that focuses on improving long-term functional outcomes.

Innovative Strategies in Microvascular Head and Neck Reconstruction

The field of reconstructive microsurgery has witnessed considerable advancements over the years, driven by improvements in technology, imaging, surgical instruments, increased understanding of perforator anatomy, and experience with microsurgery. However, within the subset of microvascular head and neck reconstruction, novel strategies are needed to improve and optimize both patient aesthetics and post-operative function. Given the disfiguring defects that are encountered following trauma or oncologic resections, the reconstructive microsurgeon must always aim to innovate new approaches, reject historic premises, and challenge established paradigms to further achieve improvement in both aesthetic and functional outcomes. The authors aim to provide an up-to-date review of innovations in head and neck reconstruction for oncologic defects.