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Zoghi S, Millar K, Thorpe S, Bayne CO. Late lower extremity free flap vascular compromise and salvage in a Pediatric patient diagnosed with monophasic synovial sarcoma. Case Reports Plast Surg Hand Surg 2023; 10:2249092. [PMID: 37622029 PMCID: PMC10446794 DOI: 10.1080/23320885.2023.2249092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023]
Abstract
Free tissue flap transfer can be utilized for reconstruction following tumor resection. While flap failure occurs primarily within 72 h post-operation, late failure after day 7 is rare. We present the case of a 14-year-old with a late lower extremity free flap vascular compromise, along with the successful flap salvage.
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Affiliation(s)
- Shervin Zoghi
- Department of Orthopedic Surgery, UC Davis Health, Sacramento, CA, United States
| | - Kelsey Millar
- Department of Orthopedic Surgery, UC Davis Health, Sacramento, CA, United States
| | - Steven Thorpe
- Department of Orthopedic Surgery, UC Davis Health, Sacramento, CA, United States
| | - Christopher O. Bayne
- Department of Orthopedic Surgery, UC Davis Health, Sacramento, CA, United States
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Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD. Late free flap failure in head and neck reconstruction: A systematic review. EAR, NOSE & THROAT JOURNAL 2018; 97:213-216. [PMID: 30036435 DOI: 10.1177/014556131809700712] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Our objectives were to review all reported cases of late flap failure in head and neck surgery and describe any relevant patterns. We conducted a systematic review of all published cases of free flap failure after postoperative day 7 in head and neck surgery from January 1990 to January 2018. Data were collected with respect to flap type, site of reconstruction, reason for failure, and time to failure. A total of 45 cases of late free flap failure in the head and neck were identified. Among the 34 cases in which the necessary data were available for analysis, 50% of late failures occurred between postoperative day 7 and 14. Common reasons for failure were abscess and vascular compromise. We conclude that most late flap failures occur in the second postoperative week. In patients with risk factors for flap failure, close monitoring for up to 14 days after surgery could detect flap compromise before the flap is lost.
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Affiliation(s)
- David Forner
- ENT Clinic, Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, Dalhousie University, 3rd Floor Dickson Building, 5820 University Ave., Halifax, NS B3H 1V7 Canada
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Demidov V, Zhao X, Demidova O, Pang HYM, Flueraru C, Liu FF, Vitkin IA. Preclinical quantitative in-vivo assessment of skin tissue vascularity in radiation-induced fibrosis with optical coherence tomography. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-9. [PMID: 30315644 DOI: 10.1117/1.jbo.23.10.106003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/19/2018] [Indexed: 05/16/2023]
Abstract
Radiation therapy (RT) is widely and effectively used for cancer treatment but can also cause deleterious side effects, such as a late-toxicity complication called radiation-induced fibrosis (RIF). Accurate diagnosis of RIF requires analysis of histological sections to assess extracellular matrix infiltration. This is invasive, prone to sampling limitations, and thus rarely used; instead, current practice relies on subjective clinical surrogates, including visual observation, palpation, and patient symptomatology questionnaires. This preclinical study demonstrates that functional optical coherence tomography (OCT) is a useful tool for objective noninvasive in-vivo assessment and quantification of fibrosis-associated microvascular changes in tissue. Data were collected from murine hind limbs 6 months after 40-Gy single-dose irradiation and compared with nonirradiated contralateral tissues of the same animals. OCT-derived vascular density and average vessel diameter metrics were compared to quantitative vascular analysis of stained histological slides. Results indicate that RIF manifests significant microvascular changes at this time point posttreatment. Abnormal microvascular changes visualized by OCT in this preclinical setting suggest the potential of this label-free high-resolution noninvasive functional imaging methodology for RIF diagnosis and assessment in the context of clinical RT.
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Affiliation(s)
- Valentin Demidov
- University of Toronto, Department of Medical Biophysics, Faculty of Medicine, Toronto, Canada
| | - Xiao Zhao
- University of Toronto, Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, To, Canada
| | - Olga Demidova
- Seneca College, Department of Arts and Science, Toronto, Canada
| | - Hilary Y M Pang
- University of Toronto, Department of Medical Biophysics, Faculty of Medicine, Toronto, Canada
| | - Costel Flueraru
- National Research Council Canada, Information Communication Technology, Ottawa, Canada
| | - Fei-Fei Liu
- University of Toronto, Department of Medical Biophysics, Faculty of Medicine, Toronto, Canada
- University of Toronto, Department of Otolaryngology - Head and Neck Surgery, Faculty of Medicine, To, Canada
- University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
| | - I Alex Vitkin
- University of Toronto, Department of Medical Biophysics, Faculty of Medicine, Toronto, Canada
- University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
- University of Toronto, Department of Radiation Oncology, Faculty of Medicine, Toronto, Canada
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Re-expression of pro-fibrotic, embryonic preserved mediators in irradiated arterial vessels of the head and neck region. Strahlenther Onkol 2017; 193:951-960. [DOI: 10.1007/s00066-017-1192-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 07/28/2017] [Indexed: 01/19/2023]
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Microvascular head and neck reconstruction after (chemo)radiation. Curr Opin Otolaryngol Head Neck Surg 2016; 24:83-90. [DOI: 10.1097/moo.0000000000000243] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kubo T, Matsuda K, Kiya K, Hosokawa K. Behavior of anastomozed vessels and transferred flaps after anastomosed site infection in head and neck microsurgical reconstruction. Microsurgery 2016; 36:658-663. [PMID: 26790991 DOI: 10.1002/micr.30025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 11/23/2015] [Accepted: 12/31/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This report evaluates the behavior of anastomosed vessels and transferred flaps after anastomosed site infection in head and neck reconstruction. PATIENTS AND METHODS Eleven free-flap cases after infection at the vascular pedicle site were included, the patency of which was observed macroscopically after re-exploration and pus drainage. Location was in the tongue (5 cases), oropharynx (3 cases), mouth floor (1 case), mandible (1 case), and hypopharynx (1 case). Transferred flaps originated from rectus abdominis (3 cases), anterolateral thigh (3 cases), radial forearm (3 cases), jejunum (1 case), and latissimus dorsi (1 case). Days for infection found were ranged 3-14 days postoperatively. Causes of infection were the salivary fistula formation in 5 cases, and precise etiology was not defined in the other 6 cases. RESULTS Disruption of the vascular pedicles occurred with high frequency after infection. Disruption of vein occurred most frequently (5 cases), followed by both artery and vein (2 cases) and artery only (1 case). Of the eight flaps, two flaps failed, but the other six flaps survived despite pedicle disruption, indicating overall survival of nine flaps after pedicle site infection. Five of the nine survived cases were healed with simple washing and ointment application. However, the other four patients, whose cause of infection was a salivary fistula, needed second flap transfer to treat those fistulas. CONCLUSION Disruption of anastomosed vessels can occur with high frequency after infection, causing subsequent flap loss. Therefore, surgeons need to deal with pedicle site infection to save the flap. © 2015 Wiley Periodicals, Inc. Microsurgery 36:658-663, 2016.
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Affiliation(s)
- Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ken Matsuda
- Division of Plastic and Reconstructive Surgery, Niigata University Graduate School of Medicine, Niigata, Japan
| | - Koichiro Kiya
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ko Hosokawa
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
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Koerdt S, Rohleder NH, Rommel N, Nobis C, Stoeckelhuber M, Pigorsch S, Duma MN, Wolff KD, Kesting MR. An expression analysis of markers of radiation-induced skin fibrosis and angiogenesis in wound healing disorders of the head and neck. Radiat Oncol 2015; 10:202. [PMID: 26390925 PMCID: PMC4578371 DOI: 10.1186/s13014-015-0508-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 09/11/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Radiation-induced fibrosis (RIF) is one of the severe long-term side effects of radiation therapy (RT) with a crucial impact on the development of postoperative wound healing disorders (WHD). The grades of fibrosis vary between mild to severe depending on individual radiosensitivity. In this study, we have investigated the molecular pathways that influence RIF and have correlated data from immunohistochemistry (IHC) for von -Willebrand Factor (vWF) and from Real-Time Polymerase Chain Reaction (RT-PCR) concerning markers such as Transforming Growth Factor (TGF)-β 1, and vWF, with clinical data concerning the occurrence of WHD during follow-up. METHODS Expression profiles of the genes encoding TGF-β 1, vWF, and α-procollagen (PC) were analyzed, by RT-PCR, in specimens from patients with (n = 20; 25.6 %) and without (n = 58; 74.4 %) a history of previous RT to the head and neck. Moreover, IHC against vWF was performed. Clinical data on the occurrence of cervical WHDs were analyzed and correlated. RESULTS A statistically significant increase in the expression profiles of α-PC and TGF-β 1 was observed in previously irradiated skin samples (occurrence of RT >91 days preoperatively). vWF showed a statistically significant increase in non-irradiated tissue. Moreover, analysis of expression profiles in patients with and without WHDs during follow-up was performed. IHC showed a reduced amount of vessels and structural changes in epidermal tissue post-RT. CONCLUSIONS The expression of markers of fibrosis and angiogenesis was analyzed in order to gain insight into molecular pathways that account for structural changes in irradiated skin and that eventually lead to WHDs. The results are congruent with reports from the literature and are a possible starting point for further research, as anti-TGF-β 1 treatment, for example, could represent new therapeutic opportunities in the management of previously irradiated patients.
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Affiliation(s)
- Steffen Koerdt
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Nils H Rohleder
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Niklas Rommel
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Christopher Nobis
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Mechthild Stoeckelhuber
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Steffi Pigorsch
- Department of Radiation Oncology, Technische Universität München, Ismaninger Str.22, 81675, Munich, Germany.
| | - Marciana-Nona Duma
- Department of Radiation Oncology, Technische Universität München, Ismaninger Str.22, 81675, Munich, Germany.
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Marco R Kesting
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
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8
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Vascular Complications After Radiotherapy in Head and Neck Free Flap Reconstruction. Ann Plast Surg 2015; 75:309-15. [DOI: 10.1097/sap.0000000000000081] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Mücke T, Borgmann A, Fichter AM, Wagenpfeil S, Mitchell DA, Ritschl LM, Kesting MR, Wolff KD. The influence of different VEGF administration protocols on the perfusion of epigastric flaps in rats. Br J Oral Maxillofac Surg 2013; 51:555-62. [DOI: 10.1016/j.bjoms.2012.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Accepted: 09/12/2012] [Indexed: 11/15/2022]
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Selective Epithelial Ischemia of Transferred Free Jejunum After Late Loss of Its Vascular Pedicle. Ann Plast Surg 2011; 67:612-4. [DOI: 10.1097/sap.0b013e3181fe32cc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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11
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Halle M, Hall P, Tornvall P. Cardiovascular disease associated with radiotherapy: activation of nuclear factor kappa-B. J Intern Med 2011; 269:469-77. [PMID: 21255133 DOI: 10.1111/j.1365-2796.2011.02353.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
There have been several recent reports of an increased risk of cardiovascular disease after radiotherapy. Hence, with an increasing number of cancer survivors, the incidence of cardiovascular disease caused by radiotherapy will increase. The existence of a type of vascular disease, or vasculopathy, induced by radiotherapy has been known for decades. It is important to identify and understand the molecular causes of this vasculopathy to determine preventive strategies. Recently, a chronic inflammation with similarities to atherosclerosis has been observed, with activation of the transcription factor nuclear factor kappa-B (NF-κB) as a possible cause. However, the trigger for NF-κB activation is unclear although it may be that reactive oxygen species or direct DNA damage is involved. To minimize the risk of cardiovascular disease in vulnerable patients, careful selection of patients, radiation dose and fractionation are important, together with the development of new techniques that reduce radiation dose to the blood vessels. In the light of the finding of an interaction between risk factors for cardiovascular disease and radiotherapy, it is reasonable to modify these factors including diabetes mellitus, hyperlipidaemia, hypertension and smoking. We believe that preventive strategies focusing on NF-κB can reduce the risk of future adverse cardiovascular events.
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Affiliation(s)
- M Halle
- Department of Molecular Medicine and Surgery, Section of Reconstructive Plastic Surgery, Karolinska Institutet, Stockholm, Sweden.
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12
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Mueller C, Schultze-Mosgau S. Histomorphometric analysis of the phenotypical differentiation of recruited macrophages following subcutaneous implantation of an allogenous acellular dermal matrix. Int J Oral Maxillofac Surg 2011; 40:401-7. [DOI: 10.1016/j.ijom.2010.10.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 08/16/2010] [Accepted: 10/27/2010] [Indexed: 12/12/2022]
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13
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Analysis of inflammatory periimplant lesions during a 12-week period of undisturbed plaque accumulation—a comparison between flapless and flap surgery in the mini-pig. Clin Oral Investig 2011; 16:379-85. [DOI: 10.1007/s00784-011-0546-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
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14
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Microvascular free tissue transfer after prior radiotherapy in head and neck reconstruction – A review. Surg Oncol 2010; 19:227-34. [DOI: 10.1016/j.suronc.2009.06.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Revised: 04/29/2009] [Accepted: 06/01/2009] [Indexed: 11/17/2022]
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15
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Lee S, Thiele C. Factors associated with free flap complications after head and neck reconstruction and the molecular basis of fibrotic tissue rearrangement in preirradiated soft tissue. J Oral Maxillofac Surg 2010; 68:2169-78. [PMID: 20605307 DOI: 10.1016/j.joms.2009.08.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2009] [Accepted: 08/24/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Several factors are associated with free flap complications in head and neck reconstruction after radiotherapy. The present study aimed to identify the correlation between irradiation and the healing of wounds after microvascular free flap transfer and to clarify the molecular mechanisms for the differences in healing between irradiated and nonirradiated patients. PATIENTS AND METHODS A retrospective study of 81 cases of microvascular free flap transfer was conducted. Tissue samples were obtained from 3 different regions of the patients (nonirradiated oral mucosa, irradiated skin, and nonirradiated skin). Expression of transforming growth factor-beta(1) was monitored by immunohistochemistry and immunoblot analysis. The levels of matrix metalloproteinase-1 and tissue inhibitor of matrix metalloproteinase-1 were investigated qualitatively and quantitatively. RESULTS Multivariate analysis revealed that only preoperative irradiation was a significant predictor of free flap complications (P = .006), with a 4 times greater risk (odds ratio 4.141). It was also shown that patients with an advanced tumor stage and those who had received chemotherapy after radiotherapy were twice as likely to develop free flap complications. Transforming growth factor-beta(1) was overexpressed in free flaps for as long as 6 months after radiotherapy. It was remarkably observed in the granulation tissue in the preirradiated skin. Moreover, extracellular matrix remodeling regulated by transforming growth factor-beta(1) was detected with decreased matrix metalloproteinase-1 and increased TIMP-1 expression in the irradiated skin. CONCLUSION The healing of surgical wounds created by microvascular free flap transfer correlated negatively with preoperative radiotherapy. Extracellular matrix remodeling was also detectable in the free flap for up to 6 months after radiotherapy completion.
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Affiliation(s)
- Sooyeon Lee
- Department of Oral and Craniomaxillofacial Surgery/Plastic Surgery, University of Jena, Jena, Thueringen, Germany.
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Transgenic Overexpression of VEGF164 Enhances Topical Neoangiogenesis Without Detectable Local or Systemic Side Effects. Ann Plast Surg 2010; 65:85-90. [DOI: 10.1097/sap.0b013e3181b0baea] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Mueller CK, Thorwarth MW, Schultze-Mosgau S. Angiogenic Gene-Modified Fibroblasts for Induction of Localized Angiogenesis. J Surg Res 2010; 160:340-8. [DOI: 10.1016/j.jss.2008.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Revised: 11/23/2008] [Accepted: 12/03/2008] [Indexed: 11/17/2022]
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18
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Mueller C, Lee SY, Schultze-Mosgau S. Characterization of interfacial reactions between connective tissue and allogenous implants used for subdermal soft tissue augmentation. Int J Oral Maxillofac Surg 2009; 38:1194-200. [DOI: 10.1016/j.ijom.2009.07.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 06/06/2009] [Accepted: 07/21/2009] [Indexed: 01/30/2023]
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Kadota H, Sakuraba M, Kimata Y, Yano T, Hayashi R. Analysis of thrombosis on postoperative day 5 or later after microvascular reconstruction for head and neck cancers. Head Neck 2009; 31:635-41. [DOI: 10.1002/hed.21021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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20
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Richter GT, Bowen T, Boerma M, Fan CY, Hauer-Jensen M, Vural E. Impact of Vascular Endothelial Growth Factor on Skin Graft Survival in Irradiated Rats. ACTA ACUST UNITED AC 2009. [DOI: 10.1001/archfaci.2008.526] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gresham T. Richter
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
| | - Travis Bowen
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
| | - Marjan Boerma
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
| | - Chun-Yang Fan
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
| | - Martin Hauer-Jensen
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
| | - Emre Vural
- Departments of Otolaryngology–Head and Neck Surgery (Drs Richter and Vural and Mr Bowen) and Surgery (Drs Boerma and Hauer-Jensen), University of Arkansas for Medical Sciences, Little Rock; and Departments of Surgery (Drs Boerma and Hauer-Jensen) and Pathology (Dr Fan) and Division of Otolaryngology–Head and Neck Surgery (Dr Vural), John McClellan Veterans Affairs Hospital, Central Arkansas Veterans Healthcare System, Little Rock. Dr Richter is now with the Department of Pediatric Otolaryngology,
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21
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Senchenkov A, Petty PM, Knoetgen J, Moran SL, Johnson CH, Clay RP. Outcomes of skin graft reconstructions with the use of Vacuum Assisted Closure (VAC(R)) dressing for irradiated extremity sarcoma defects. World J Surg Oncol 2007; 5:138. [PMID: 18047659 PMCID: PMC2219960 DOI: 10.1186/1477-7819-5-138] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2007] [Accepted: 11/29/2007] [Indexed: 01/04/2023] Open
Abstract
Background Flaps are currently the predominant method of reconstruction for irradiated wounds. The usefulness of split-thickness skin grafts (STSG) in this setting remains controversial. The purpose of this study is to examine the outcomes of STSGs in conjunction with VAC therapy used in the treatment of irradiated extremity wounds. Methods The records of 17 preoperatively radiated patients with extremity sarcomas reconstructed with STSGs in conjunction with VAC® therapy were reviewed regarding details of radiation treatment, wound closure, and outcomes. Results STSGs healed without complications (>95% of the graft take) in 12 (71%). Minor loss (6% – 20% surface) was noted in 3 patients (17.6%) and complete loss in 2 (11.7%). Two patients (11.7%) required flap reconstructions and 12 (88%) healed without further operative procedures. Conclusion Although flap coverage is an established treatment for radiated wounds, STSG in conjunction with liberal utilization of VAC therapy is an alternative for selected patients where acceptable soft tissue bed is preserved. Healing of the preoperatively radiated wounds can be achieved in the vast majority of such patients with minimal need for additional reconstructive operations.
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Affiliation(s)
- Alex Senchenkov
- Head and Neck Oncology Section, University of Cincinnati, 231 Albert B, Sabin Way, Cincinnati, OH, USA .
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22
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Ozbek N, Guneren E, Yildiz L, Meydan D, Cakir S, Coskun M. The effect of pre-operative conventional and hyperfractionated radiotherapy schedules on wound healing and tensile strength in rats: an experimental study. Int J Oral Maxillofac Surg 2005; 34:185-92. [PMID: 15695049 DOI: 10.1016/j.ijom.2004.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2004] [Indexed: 11/27/2022]
Abstract
We examined the effects of pre-operative conventional and hyperfractionated radiotherapy schedules on wound healing and tensile strength in 90 female Wistar rats weighing between 182 and 240 g. The animals were randomized into three groups (n = 30 each). Group I was sham-irradiated. Group II (conventional) received 20 daily fractions of 200 cGy, to a total dose of 4000 cGy. Group III (hyperfractionated) received 40 fractions of 120 cGy, twice daily, to a total dose of 4800 cGy. Four weeks after radiotherapy, incision and primary repair with simple suturing was performed on one side of the neck. Twenty-one days after wounding, all the rats were sacrificed. Non-parametric Kruskal-Wallis and Mann-Whitney U-tests were used for the statistical analysis of wound tensile strength. The chi-squared test was used for the statistical analysis of the histopathologic findings. The hyperfractionated group had a significantly lower tensile strength than that of the control group (P = 0.03, z = -2.18). According to the histopathologic findings, fibrosis was increased significantly in the hyperfractionated group as compared to the other groups (P = 0.038, chi2 = 6.52). Hyperfractionated radiotherapy significantly reduced the wound tensile strength in the early evaluation period as compared to the control group.
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Affiliation(s)
- N Ozbek
- Department of Radiation Oncology, Samsun, Turkey.
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Lehner B, Bauer J, Rödel F, Grabenbauer G, Neukam FW, Schultze-Mosgau S. Radiation-induced impairment of osseous healing with vascularized bone transfer: experimental model using a pedicled tibia flap in rat. Int J Oral Maxillofac Surg 2004; 33:486-92. [PMID: 15183413 DOI: 10.1016/j.ijom.2003.10.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2003] [Indexed: 11/19/2022]
Abstract
Aim of this study was to establish an appropriate animal model for investigating the healing of vascularized osseous transplants to irradiated recipient sites applying metabolic, vascular and immunologic experimental studies. In 20 Wistar rats (male, weight 300-500 g), a pedicled osseous tibia flap was raised and transferred to a subcutaneous pocket in the ipsilateral groin. The remaining tibia was stabilized with a monocortical titanium miniplate. To create a pre-irradiated transplant bed, the donor-area including the adjacent bone of the tibia was irradiated with a total dose of 50Gy (5 x 10 Gy) in 10 animals. The interval between irradiation and retransfer of the non-irradiated pedicled tibia flap was 4 weeks. Ten animals received no radiation. Evaluation of osseous healing and the success of the transferred flap were based on a clinical and quantitative histomorphometric assessment. Testing for significant differences was performed using the non-parametric Mann-Whitney U-test. The rate of complete osseous healing in the non-irradiated animals was 90%. In contrast there was no significant bone union observed in the group of the pedicled flaps grafted to the pre-irradiated (50Gy) recipient site (P = 0.001). Similarly bone formation in the transitional zone between bone graft and recipient bone was significantly lower in the preirradiated group (P < 0.001) (16.9 +/- 3%) in contrast to the non-irradiated transplant bed (47.9 +/- 6%).
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Affiliation(s)
- B Lehner
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Schultze-Mosgau S, Wehrhan F, Rödel F, Amann K, Radespiel-Tröger M, Grabenbauer GG. Transforming growth factor-beta receptor-II up-regulation during wound healing in previously irradiated graft beds in vivo. Wound Repair Regen 2003; 11:297-305. [PMID: 12846918 DOI: 10.1046/j.1524-475x.2003.11410.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Wound healing disorders may often present in patients with head and neck cancer after surgical interventions, particularly in preirradiated tissue. Inflammatory changes and the expression of cytokines can lead to induction of fibrosis. The isoforms of the transforming growth factor beta (TGFbeta1-3) play a key role for this process. It has been shown that radiation treatment associated fibrosis is induced by TGFbeta1 and TGFbeta2, although the influence of radiation on the expression of the TGFbeta receptor-II (TGFbetaR-II) involved in the signal transduction of TGFbeta remains elusive. The objective of this in vivo study was to analyze the expression profile of TGFbetaR-II in the graft bed and in the transition area between graft and graft bed after surgery with and without prior radiation treatment to compare with the expression profiles of activated TGFbeta1 and latency-associated peptide. A total of 48 Wistar rats (male, weight 300-500 g) were used in the study. Eighteen rats were irradiated in the neck region (3 x 10 Gy) without transplantation. A free myocutaneous gracilis flap was transplanted in 30 rats, of which 16 animals were preirradiated in the neck region (3 x 10 Gy) and 14 animals were not irradiated at all. Tissue samples were taken postoperatively from the transition area between the graft and the graft bed and from the graft bed itself after 3, 7, 14, and 28 days. Tissue samples were taken from the irradiated neck region and the non-irradiated groin region 0, 4, 7, 11, 14, and 28 days after the end of the exposure. The expression of TGFbetaR-II, activated TGFbeta1 and latency-associated peptide was analyzed immunohistochemically both qualitatively and quantitatively (labeling index). The success rate for graft healing was 75% in the previously irradiated group with 30 Gy, and 86% in the non-irradiated group. Following radiation alone a significantly (p = 0.04) increased TGFbetaR-II expression in the neck was revealed 2-4 weeks following irradiation compared to non-irradiated skin. Whereas only minor differences in TGFbetaR-II expression were observed following surgery between the groups with and without prior radiation in the transition area between the graft and the graft bed, the group undergoing prior radiation and subsequent grafting showed significantly increased expression in the bed compared to the non-preirradiated group with a maximum on postoperative day 7 (week 1, p = 0.003; week 2-4, p < 0.001). In irradiated tissues the up-regulation of TGFbetaR-II expression correlated with an increase of activated TGFbeta1 and latency-associated peptide expression compared to non-irradiated tissues. After irradiation, a significantly increased TGFbetaR-II expression was identified in the irradiated graft bed, which may be the reason for delayed reepithelialization and fibrosis. Exogenous blocking or TGFbetaR-II inhibitors could therefore represent a new therapeutic approach for improving wound healing after preoperative radiotherapy.
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Affiliation(s)
- Stefan Schultze-Mosgau
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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Kessler P, Schultze-Mosgau S, Neukam FW, Wiltfang J. Lengthening of the reconstructed mandible using extraoral distraction devices: report of five cases. Plast Reconstr Surg 2003; 111:1400-4; discussion 1405-6. [PMID: 12618598 DOI: 10.1097/01.prs.0000049115.87004.92] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Fibular and scapular osteocutaneous free-tissue transfer represents the workhorse procedure in the reconstruction of large oromandibular defects. However, transplanted bone segments for mandibular reconstruction may be too short for a correct interarch alignment, which is a prerequisite for further functional rehabilitation. Extraoral distraction osteogenesis was performed in the neomandible of five patients after tumor resection following neoadjuvant radiotherapy-chemotherapy. The neomandible was distracted bilaterally in two patients and unilaterally in three patients. Gradual distraction was applied at a rate of 0.5 mm twice a day after osteotomy in the region of vascularized fibular and scapular reconstruction. An average sagittal bone gain of 11 mm was achieved following active distraction. In three patients, the distraction procedure rendered good results with full compensation of the deficit; in one patient, the sagittal bone gain did not compensate for a lateral deviation of the mandible; and in another patient, the fixation pins loosened and had to be reaffixed. Osteodistraction is a treatment option in patients in whom vascularized bone grafts have been used for mandibular reconstruction, but due to contractures or lack of hard and soft tissues, no satisfactory interarch alignment could be achieved. Distraction procedures in irradiated and reconstructed neomandibles bear a higher risk of failure and complications than those in nonirradiated tissues. A correct and stable intermaxillary relation always has to be attempted in the first surgical approach, as osteodistraction cannot be suggested as a routine procedure in this special group of patients.
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Affiliation(s)
- Peter Kessler
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nürnberg, Erlangen, Germany.
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Schultze-Mosgau S, Wiltfang J, Birklein F, Neukam FW. Micro-lightguide spectrophotometry as an intraoral monitoring method in free vascular soft tissue flaps. J Oral Maxillofac Surg 2003; 61:292-7; discussion 297. [PMID: 12618966 DOI: 10.1053/joms.2003.50059] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The aim of this prospective study was to measure the hemoglobin oxygen saturation (HbO(2)%) and relative Hb concentration of free vascular soft tissue flaps using micro-lightguide spectrophotometry. The objective was to measure the normal range and topographic differences in HbO(2)% and rel. Hb conc. in tissue transfers before establishing this as a clinical method for monitoring perfusion and vitality. PATIENTS AND METHODS In 39 patients who had received free vascular soft tissue flaps (34 radial forearm flaps; 8 latissimus flaps) to cover defects after tumor surgery, the capillary HbO(2)% in transferred tissue was measured spectrophotometrically preoperatively at the donor site and postoperatively up to the third postoperative day. On average about 500 hemoglobin spectra (200 to 800 spectra) were measured over each 24-hour period. Additionally, the relative Hb concentration was determined for the individual measuring times. The measurements were carried out topographically on the flap base, flap center, and flap periphery. RESULTS The preoperative HbO(2) values at the donor site of free soft tissue flaps were between 20% and 40% in all topographic regions. In the case of clinically successful flaps, a normal distribution of the HbO(2) values of 20% to 80% was obtained in the immediate postoperative period, and from the second day on, a normal distribution of 45% to 60%. In the case of 2 flaps with partial necrosis, HbO(2) values of less than 10% to 15% were measured from the second postoperative day on. The relative Hb concentration had no influence on the amount of HbO(2)% measured in the transferred capillaries. In the postoperative phase, here was no topographic difference between the individual flap regions. CONCLUSIONS As a noninvasive method, micro-lightguide spectrophotometry permits quantitative determination of HbO(2)% and relative Hb concentration over the entire surface of soft tissue flaps. In the case of partially unsuccessful flaps, HbO(2) values of less than 10% to 15% were measured beforehand, thus indicating that these HbO(2) values are not sufficient to support the vitality of the free tissue transfer. When combined with clinical observation, application can be recommended for the vitality measurement of free soft tissue flaps and permits more information to be obtained on topographic capillary perfusion conditions.
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Affiliation(s)
- Stefan Schultze-Mosgau
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nuremberg, Erlangen, Germany.
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