Microvascular reconstruction after intra-arterial chemotherapy with concomitant radiation

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

BACKGROUND

Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases.

PATIENTS AND METHODS

Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm.

RESULTS

The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm² (range 12-80 cm² ) for the pedicle flaps and 104 cm² (range 24-200 cm² ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life.

CONCLUSIONS

The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

The impacts of intra-arterial chemotherapy on head and neck microvascular reconstruction

BACKGROUND

For locally advanced head and neck cancers, intra-arterial (IA) chemotherapy is utilized for locoregional control with favorable results. The study aimed to evaluate the surgical outcomes of microsurgical reconstruction in head and neck cancer patients with IA chemotherapy METHODS: This cohort study retrospectively reviewed patients who underwent head and neck microsurgical reconstruction from January 2014 to August 2018. Patients with prior history of chemotherapy were included and categorized into two groups according to history of IA chemotherapy (IA group)/intravenous chemotherapy (IV group). Flap survival was evaluated along with microsurgical revision rates and complications. Recipient vessel specimens were analyzed by histological examination. A 1:1 propensity score matched analysis was performed.

RESULTS

The study cohort included 45 patients with IA chemotherapy and 201 patients with IV chemotherapy. After propensity score matching, the difference in total flap loss and microsurgical revision rates were nonsignificant between two groups. However, the IA group had significantly higher rates of arterial thrombosis (Odds ratio [OR] 4.98; 95%CI, 1.28-19.38; p = 0.021), wound-related complications (OR 3.30; 95%CI, 1.21-9.02; p = 0.02) and revision surgery within one month (OR 3.73; 95%CI, 1.10-12.64; p = 0.035). Based on histology, IA group vessels showed a higher intima/media ratio than the IV group (0.45 ± 0.06 versus 0.23 ± 0.03, p = 0.02) CONCLUSION: Despite treating local advanced head and neck cancers with good results, IA chemotherapy may cause subsequent deleterious effects on local tissue due to the high concentration of cytotoxic chemotherapeutic agents. Surgeons should be cautious in selection of recipient vessels when performing microvascular reconstruction.

Selection of recipient vessels for free flap following intra-arterial chemoradiotherapy

OBJECTIVE

This study aims at selecting recipient vessels for free flap following intra-arterial chemoradiotherapy. At present, many centers combine intra-arterial chemotherapy and concomitant radiotherapy for treating head and neck cancer with favorable results. However, some patients develop recurrent, residual disease/complications after completing treatment protocols and thus require free-flap surgery. The feasibility of microsurgery following intra-arterial chemoradiotherapy remains unclear.

STUDY DESIGN AND METHODS

We retrospectively analyzed 730 patients who underwent free-flap surgery for managing treatment-related complications/defects following head and neck surgery from January 1999 to February 2012. All patients were categorized into two groups according to the presence (group A)/absence (group B) of a history of intra-arterial chemotherapy. Microvascular revision rates were compared between the groups. In group A, the correlation between catheterization sites and recipient vessels used for microsurgery was assessed.

RESULTS

A total of 769 free flaps were created in 730 patients and comprised 36 and 733 flaps in groups A and B, respectively. Microvascular revision rates were 2.8% (1/36) and 4.2% (31/733) in groups A and B, respectively, with no significant difference observed between the groups. No statistically significant difference was observed when only cases of arterial thrombosis were included. Vessels used for recipient anastomoses were not directly exposed to intra-arterially injected agents.

CONCLUSION

Preoperative intra-arterial chemoradiotherapy does not significantly increase the risk of microvascular revisions, particularly artery-related revisions, if vessels selectively catheterized and perfused with chemotherapeutic agents during intra-arterial chemotherapy are avoided as recipient vessels.