Fibular free flap necrosis after mandibular reconstruction surgery with osteoradionecrosis: Establishment and verification of an early warning model

OBJECTIVE

Fibular free flap necrosis (FFFN) is the most common complication in patients with osteoradionecrosis (ORN) after mandibular reconstruction surgery. However, there are no effective forecasting tools at present. This research is aimed to establish and verify a nomogram model to predict the risk of FFFN after mandibular reconstruction surgery in ORN patients.

METHODS

A total of 193 ORN patients with mandibular reconstruction using fibular free flap (150 cases in the model group and 43 cases in the validation group) were enrolled in this study. In the model group, the variables were optimized by lasso regression. Then the prediction model was established by binary logistic regression analysis, and the nomogram was drawn. The bootstrap self-sampling method was used for internal verification. Moreover, 43 cases in the validation group were used for external validation.

RESULTS

The results of lasso regression and binary logistic regression analysis showed that the radiotherapy interval (≤2 years), trismus, diabetes, without deep venous anastomoses, and American society of anesthesiologists (ASA) III were the independent risk factors for FFFN after mandibular reconstruction surgery in ORNJ patients (P<0.05). Based on the above-mentioned risk factors, the nomogram model was established. The AUC values of the model group and the validation group were 0.936 and 0.964, respectively. The curve analysis showed that when the probability thresholds of the model group and the validation group were 5.699%∼98.229% and 0.413%∼99.721%, respectively. So the patient's clinical net profit rate was the highest.

CONCLUSION

A nomogram combining the factors of radiotherapy interval (≤2 years), trismus, diabetes, without deep venous anastomoses, and ASA III provided a comparatively effective way to predict the risk of FFFN after mandibular reconstruction surgery in ORN patients, which has distinct applied clinical value.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study

BACKGROUND

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction.

METHODS

We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis.

RESULTS

The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases.

CONCLUSIONS

Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction.

DATA ACCESS STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Is hardware colonization associated with latent hardware complications and removal in maxillomandibular free flap reconstruction?

BACKGROUND

The relationship between hardware colonization, latent hardware complications, and hardware removal remains unclear following osteocutaneous free flap reconstruction of the jaws.

METHODS

Retrospective cohort study of all patients undergoing free flap reconstruction of the maxilla or mandible from 2016 to 2021.

RESULTS

A total of 240 subjects were included. Hardware colonization was associated with latent hardware complication in bivariate (p ≤ 0.001) and multivariate analysis (p ≤ 0.001). Time to latent hardware complication was 6.87 months earlier in colonized subjects (p ≤ 0.001). Of the 35 subjects undergoing hardware removal, 25 initiated but failed conservative therapy, and resolution of symptoms was achieved in 24 subjects after one operative intervention and 33 subjects after repeat intervention if indicated.

CONCLUSIONS

Hardware colonization increases the risk and onset of latent hardware complication. Prompt hardware removal may improve outcomes by leading to faster resolution of symptoms without the burden and cost of conservative therapies.

Incidence and risk factors of postoperative pulmonary complications after oral cancer surgery with free flap reconstruction: A single center study

BACKGROUND

Postoperative pulmonary complications (PPCs) increase the risk of morbidity and mortality in patients who underwent oral cancer surgery with free flap reconstruction. The association between PPC and preoperative risk factors has been investigated; however, reports on intraoperative factors are limited. Therefore, we investigated PPC incidence and its associated preoperative and intraoperative risk factors in these patients.

METHODS

We retrospectively analyzed medical records of patients who underwent free flap reconstruction between 2009 and 2019. PPC was defined as presence of atelectasis, pneumonia, and respiratory failure based on radiological confirmation and clinical symptoms during hospitalization. Mortality, hospital stay, preoperative factors (including age and tumor stages), American Society of Anesthesiologists (ASA) classification, and intraoperative factors (including intraoperative fluids and medications) were recorded.

RESULTS

PPC incidence among the 993 patients included in this study was 25.8% (256 patients). Six patients with PPCs died; death was not observed among patients without PPCs (p < 0.001). Patients with PPCs had longer hospitalization than those without PPCs (30.3 vs 23.3 days; p < 0.001). Tumor stage (stage I: reference; stage II [OR]: 3.3, p = 0.019; stage III: 4.4, p = 0.002; stage IV: 4.8, p = 0.002), age (OR: 1.0; p < 0.001), and ASA grade >2 (OR: 1.4; p = 0.020) were independent risk factors of PPC; using labetalol was a borderline significant factor (OR: 1.4; p = 0.050).

CONCLUSION

The PPC incidence was 25.8% in patients undergoing oral cancer surgery with free flap reconstruction. Tumor stage, age, and ASA >2 were risk factors of developing PPC.

Body Mass Index Is Associated With Myocutaneous Free Flap Reliability: Overcoming the Obesity Obstacle With a Proposed Clinical Algorithm to Identify and Manage High-Risk Patients Undergoing Gracilis Free Flap With Skin Paddle Harvest

INTRODUCTION

The purpose of this study was to evaluate the role of body mass index (BMI) in predicting postoperative complications following myocutaneous free flap transfer. In addition, we sought to identify certain body composition variables that may be used to stratify patients into low- versus high-risk for gracilis myocutaneous free flap with skin paddle failure.

METHODS

Using the National Surgical Quality Improvement Program database, we collected data for all patients who underwent myocutaneous free flap transfer from 2015 to 2021. Demographic data, medical history, surgical characteristics, and postoperative outcomes, including complications, reoperations, and readmissions, were collected. Body mass index was correlated with outcome measures to determine its role in predicting myocutaneous free flap reliability. Subsequently, we retrospectively obtained measurements of perigracilis anatomy in patients who underwent computed tomography angiography bilateral lower extremity scans with intravenous contrast at our institution. We compared body composition data with mathematical equations calculating the potential area along the skin of the thigh within which the gracilis perforator may be found.

RESULTS

Across the United States, 1549 patients underwent myocutaneous free flap transfer over the 7-year study period. Being in obesity class III (BMI ≥40 kg/m2) was associated with a 4-times greater risk of flap complications necessitating a return to the operating room compared with being within the normal BMI range. In our computed tomography angiography analysis, average perigracilis adipose thickness was 18.3 ± 8.0 mm. Adipose thickness had a strong, positive exponential relationship with the area of skin within which the perforator may be found.

CONCLUSIONS

In our study, higher BMI was associated with decreased myocutaneous free flap reliability. Specifically, inner thigh adipose thickness can be used to estimate the area along the skin within which the gracilis perforator may be found. This variable, along with BMI, can be used to identify patients who are considered high-risk for flap failure and who may benefit from additional postoperative monitoring, such as the use of a color flow Doppler probe and more frequent and prolonged skin paddle monitoring.

The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis

BACKGROUND

The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures.

METHODS

Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05.

RESULTS

When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic.

CONCLUSION

Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.

The contribution of microvascular free flaps and pedicled flaps to successful chest wall surgery

OBJECTIVE

Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects.

METHODS

We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days.

RESULTS

In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P = .004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P = .5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P = .3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P = .6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P = .033).

CONCLUSIONS

Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions.

Risk-Stratified Anticoagulation Protocol Increases Success of Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia

BACKGROUND

Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and achieve high rates of microsurgical success. At the authors' institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. The authors present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for nontraumatic lower extremity (LE) wounds.

METHODS

The authors retrospectively reviewed patients who underwent FTT to an LE from 2012 to 2021. Their risk-stratification AC protocol was implemented in July of 2015. Low-risk and moderate-risk patients received subcutaneous heparin. High-risk patients received heparin infusion titrated to a goal partial thromboplastin time of 50 to 70 seconds. Before July of 2015, nonstratified patients were treated with either subcutaneous heparin or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (nonstratified and risk-stratified) based on date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success.

RESULTS

Two hundred nineteen hypercoagulable patients who underwent FTT to an LE were treated with nonstratified ( n = 26) or risk-stratified ( n = 193) thromboprophylaxis. The overall flap success rate was 96.8% ( n = 212). Flap loss was lower among risk-stratified patients (1.6% versus 15.4%; P = 0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% versus 15.4%; P = 0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% versus 0%; P = 0.048). Intraoperative anastomotic revision (OR, 6.10; P = 0.035) and nonrisk stratification (OR, 9.50; P = 0.006) were independently associated with flap failure.

CONCLUSIONS

Hypercoagulability can significantly affect microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The Use of Machine Learning for Predicting Complications of Free-Flap Head and Neck Reconstruction

BACKGROUND

Machine learning has been increasingly used for surgical outcome prediction, yet applications in head and neck reconstruction are not well-described. In this study, we developed and evaluated the performance of ML algorithms in predicting postoperative complications in head and neck free-flap reconstruction.

METHODS

We conducted a comprehensive review of patients who underwent microvascular head and neck reconstruction between January 2005 and December 2018. Data were used to develop and evaluate nine supervised ML algorithms in predicting overall complications, major recipient-site complication, and total flap loss.

RESULTS

We identified 4000 patients who met inclusion criteria. Overall, 33.7% of patients experienced a complication, 26.5% experienced a major recipient-site complication, and 1.7% suffered total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = 0.61, sensitivity = 0.60). Regularized regression had the best performance for predicting major recipient-site complications (AUROC = 0.68, sensitivity = 0.66), and decision trees were the best predictors of total flap loss (AUROC = 0.66, sensitivity = 0.50).

CONCLUSIONS

ML accurately identified patients at risk of experiencing postsurgical complications, including total flap loss. Predictions from ML models may provide insight in the perioperative setting and facilitate shared decision making.

Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction: What Are the Roles of Procedure Indication and Defect Etiology?

BACKGROUND

Advancements in lower extremity (LE) microsurgery have allowed for the expansion of indications for LE reconstructions. This project aims to better understand the temporal pattern and risk factors associated with LE free flap failure based on the clinical indication.

MATERIALS AND METHODS

We analyzed all patients undergoing LE free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 prospectively collected data to determine rates and timing of reoperation. Free flaps were stratified by indication, type, and timing of reoperation. Weibull survival models were used to compare rates of takebacks among time intervals. Multivariable logistic regression was used to identify independent predictors for unplanned reoperation.

RESULTS

Four hundred seven of LE free flaps were analyzed. There was a 14.5% rate (59/407) of unplanned reoperation within the first 30 postoperative days (PODs) after surgery. When stratified by the indication necessitating reoperation, patients with an underlying vascular indication had the highest rate of reoperation (40.9%). The reoperation rates were significantly different between indications (P < 0.05) The mean daily proportion of patients experiencing reoperation was highest during POD 0 to 2 (1.47% reoperations per day), which dropped significantly during POD 3 to 10 (0.55% per day) and again during POD 11 to 30 (0.28% per day, P < 0.05). African American race as well as malignant, prosthetic/implant, and wound/infectious indications were significant independent predictors for unplanned reoperation.

CONCLUSIONS

Lower extremity reconstruction is an important reconstructive option for the coverage of a myriad of defects. Understanding the differences between postoperative reoperation timelines among indication subtypes is important for updated flap monitoring protocols, optimizing ERAS pathways, and beginning dangle protocols.

An Analysis of the Modified Five-Item Frailty Index for Predicting Complications following Free Flap Breast Reconstruction

BACKGROUND

The modified five-item frailty index is a validated and effective tool for assessing risk in surgical candidates. The authors sought to compare the predictive ability of the modified five-item frailty index to established risk factors for complications in free flap breast reconstruction.

METHODS

The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for free flap breast reconstructive procedures. Univariate and multivariate regression analysis models were used to assess how modified five-item frailty index and factors commonly used to risk stratify (age, body mass index, American Society of Anesthesiologists classification, and history of smoking) were associated with complications.

RESULTS

Of the total 10,550 cases, 24.1 percent experienced complications. A high modified five-item frailty index score is associated with a higher overall rate of postoperative complications (p < 0.001). This significant trend was demonstrated in both surgical (p < 0.001) and medical (p < 0.001) complications. When controlling for other risk factors commonly used for risk stratification such as age, body mass index, American Society of Anesthesiologists classification, and history of smoking, the modified five-item frailty index was significantly associated with medical (OR, 1.75; 95 percent CI, 1.37 to 2.22; p = 0.001) and any complications (OR, 1.58; 95 percent CI, 1.29 to 1.93; p < 0.001) and had the largest effect size. Assessing for specific complications, the modified five-item frailty index is the strongest independent predictor of reoperation (OR, 1.41; 95 percent CI, 1.08 to 1.81; p = 0.009).

CONCLUSION

The modified five-item frailty index is a useful predictor of postoperative outcomes in patients undergoing free flap breast reconstruction when compared to other historically considered risk factors for surgical complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis

BACKGROUND

Metabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction.

METHODS

Review of the 2015-2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge.

RESULTS

The MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group.

CONCLUSION

Patients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.

Cost and clinical outcomes of postoperative intensive care unit versus general floor management in head and neck free flap reconstructive surgery patients

PURPOSE

To compare clinical, surgical, and cost outcomes in patients undergoing head and neck free-flap reconstructive surgery in the setting of postoperative intensive care unit (ICU) against general floor management.

METHODS

Retrospective analysis of head and neck free-flap reconstructive surgery patients at a single tertiary academic medical center. Clinical data was obtained from medical records. Cost data was obtained via the Mayo Clinic Rochester Cost Data Warehouse, which assigns Medicare reimbursement rates to all professional billed services.

RESULTS

A total of 502 patients were included, with 82 managed postoperatively in the ICU and 420 on the general floor. Major postoperative outcomes did not differ significantly between groups (Odds Ratio[OR] 1.54; p = 0.41). After covariate adjustments, patients managed in the ICU had a 3.29 day increased average length of hospital stay (Standard Error 0.71; p < 0.0001) and increased need for take-back surgery (OR 2.35; p = 0.02) when compared to the general floor. No significant differences were noted between groups in terms of early free-flap complications (OR 1.38;p = 0.35) or late free-flap complications (Hazard Ratio 0.81; p = 0.61). Short-term cost was $8772 higher in the ICU (range = $5640-$11,903; p < 0.01). Long-term cost did not differ significantly.

CONCLUSION

Postoperative management of head and neck oncologic free-flap patients in the ICU does not significantly improve major postoperative outcomes or free-flap complications when compared to general floor care, but does increase short-term costs. General floor management may be appropriate when cardiopulmonary compromise is not present.

Cost-Effectiveness of Vioptix versus Clinical Examination for Flap Monitoring of Autologous Free Tissue Breast Reconstruction

BACKGROUND

Vioptix is a near-infrared spectroscopy tissue oximetry technology that allows for noninvasive monitoring of flap perfusion. Despite the reported benefits of Vioptix, the cost-effectiveness of this flap monitoring technology has not been compared to clinical examination alone.

METHODS

A cost-effectiveness model, from the patient perspective, was constructed with two treatment arms: clinical examination versus clinical examination combined with Vioptix for flap monitoring after autologous, free flap breast reconstruction. Costs, utilities, and other model inputs were identified from the literature. One-way and probabilistic sensitivity analyses were performed. Gamma distributions were created for cost variables, and beta distributions were created for probability variables. An incremental cost-effectiveness ratio under $50,000 per quality-adjusted life-year (QALY) was considered cost-effective. All analyses were performed using TreeAge Pro (Williamstown, Mass.).

RESULTS

Mean cost of autologous free tissue transfer breast reconstruction with clinical examination-based flap monitoring was found to be $37,561 with an effectiveness of 0.79, whereas the mean cost of clinical examination with Vioptix for flap monitoring was $39,361 with effectiveness of 0.82. This yielded an incremental cost-effectiveness ratio of $60,507 for clinical examination combined with Vioptix for flap monitoring. One-way sensitivity analysis revealed that clinical examination with Vioptix became cost-effective when the cost of Vioptix was less than $1487. Probabilistic sensitivity analysis found that clinical examination was cost-effective in 86.5 percent of cases.

CONCLUSION

Although clinical examination combined with Vioptix is minimally more effective for flap monitoring after autologous, free flap breast reconstruction, clinical examination alone is the more cost-effective flap monitoring option.

The use of the posterior interosseous artery flap and anterolateral thigh flap for post-traumatic soft tissue reconstruction of the hand

The purpose of this study was to examine the differences between the use of a posterior interosseous artery (PIA) flap and an anterolateral thigh (ALT) flap for post-traumatic, medium-sized soft tissue reconstruction of the hand based on flap characteristics, postoperative complications, and aesthetic outcomes.From October, 2010 to March, 2016, 62 patients undergoing soft tissue reconstruction of the hand with 30 PIA flaps and 32 ALT flaps were included in this study. The 62 patients were divided into the PIA flap group and the ALT flap group. The differences between the 2 groups were analyzed.The 62 patients included 52 males and 10 females, and the mean age at the time of surgery was 41 years. The flap failure rate was 13.3% (4/30) in the PIA flap group and 9.4% (3/32) in the ALT flap group. No significant differences in flap failure rate, recipient site complication rate, or donor site complication rate were observed between the 2 groups. However, the operative time (136 min vs 229 min) and aesthetic outcomes (flap bulk swelling, 0 cases vs 31 cases) were statistically significantly different.Both the pedicled PIA flap and the free ALT flap were comparable for the reconstruction of post-traumatic, medium-sized soft tissue defects of the hand according to the evaluated outcomes of postoperative complications. Based on the surgical characteristics of the flap and the evaluation of aesthetic outcomes, the pedicled PIA flap was significantly superior to the free ALT flap.

Management of pedicle ossification following free flap reconstruction: A case report

INTRODUCTION

Heterotopic ossification of a vascular pedicle is an uncommon, but established, phenomenon occasionally seen incidentally on post-operative imaging after fibular free flap reconstruction. Symptomatic cases of pedicle ossification, however, are much rarer, with very few cases requiring operative intervention. We present the largest case of pedicle ossification recorded to date, review the literature on symptomatic pedicle ossification, and describe our experience with the surgical management and outcomes of this complication in symptomatic patients.

PRESENTATION OF CASE

A 60-year-old man with a 7 cm neck mass and neck pain presents six months after fibular free flap reconstruction of an osteonecrotic mandible. CT demonstrates heterotopic ossification of the free flap vascular pedicle. The patient underwent surgical resection of the ossification with preservation of the pedicle and had an uncomplicated post-operative course with resolution of symptoms.

DISCUSSION

While pedicle ossification following fibula free flap surgery appears to be a somewhat common occurrence in the literature, clinically significant and symptomatic cases are rare. Symptomatic pedicle ossification may require secondary surgical intervention if large, painful, or disfiguring. Although there are surgical techniques described which may decrease the incidence of postoperative ossification, the rarity of symptomatic cases may not justify the additional surgical risks created by subperiosteal dissection.

CONCLUSION

Here, we present what appears to be the largest case of pedicle ossification in the literature. We believe this case may aid in the understanding of pedicle ossification and contribute towards a standard treatment protocol in the prevention and treatment of clinically relevant pedicle ossification.

Ameliorating Effects of β-Glucan on Epigastric Artery Island Flap Ischemia-Reperfusion Injury

BACKGROUND

Ischemia-reperfusion injury has been one of the culprits of tissue injury and flap loss after island flap transpositions. Thus, significant research has been undertaken to study how to prevent or decrease the spread of ischemia-reperfusion injury. Preventive effects of β-glucan on ischemia-reperfusion injury in the kidney, lung, and small intestine have previously been reported. In this study, we present the ameliorating effects of β-glucan on ischemia-reperfusion injury using the epigastric artery island-flap in rats.

MATERIALS AND METHODS

Thirty Wistar-Albino rats were equally divided into three groups: sham, experimental model, and treatment groups. In the sham group, an island flap was elevated and sutured back to the original position without any ischemia. In the experimental model group, the same-sized flap was elevated and sutured back with 8 h of ischemia and consequent 12 h of reperfusion. In the treatment group, 50 mg per kilogram β-glucan was administered to the rats using an orogastric tube for 10 d before the experiment. The same-sized flap is elevated and sutured back to its original position with 8 h of ischemia and 12 h of consequent reperfusion in the treatment group. Tissue biopsies were taken on the first day of the experimental surgery. Tissue neutrophil aggregation and vascular responses were evaluated by histological examinations. Tissue oxidant and antioxidant enzyme levels are evaluated biochemically after tissue homogenization. Topographic follow-up and evaluation of the flaps were maintained, and photographs were taken on the first and seventh day of the experimental surgery.

RESULTS

Topographic flap survival was significantly better in the β-glucan administered group. The neutrophil number, malondialdehyde, and myeloperoxidase levels were significantly lower while glutathione peroxidase and superoxide dismutase levels were significantly higher in the β-glucan administered group respective to the experimental model group.

CONCLUSIONS

Based on the results of our study, we can conclude that β-glucan is protective against ischemia-reperfusion injury. Our study presents the first experimental evidence of such an effect on skin island flaps.

Short-Term Outcomes following Virtual Surgery-Assisted Immediate Dental Implant Placement in Free Fibula Flaps for Oncologic Mandibular Reconstruction

BACKGROUND

Despite reports demonstrating feasibility of immediate dental implant placement in mandibular reconstruction with free fibula flaps for benign disease, this practice is not routinely used in the oncologic setting. The authors aim to demonstrate the safety of immediate dental implant placement for oncologic mandible reconstruction.

METHODS

In 2017, the authors' center began immediate dental implant placement in free fibula flaps for oncologic patients undergoing mandibulectomy reconstruction. Immediate dental implant placement patients were compared to a historical cohort also reconstructed with computer-aided design and manufacturing technology beginning in 2011 (n = 34) as a noninferiority study design. Primary outcomes of interest included 90-day complications, time to radiotherapy, and time to and number of patients achieving dental restoration.

RESULTS

Sixty-one patients underwent free fibula flaps following mandibulectomy using computer-aided design and manufacturing. Seventy-two dental implants were placed in the immediate dental implant placement cohort (n = 27). No differences were noted in major or minor 90-day complications between groups (p > 0.05). Radiotherapy was required in 55 percent in the immediate dental implant placement cohort versus 62 percent in the historical cohort, with no significant difference in time to radiotherapy (67.6 days versus 62.2 days, respectively). One dental implant was removed for nonosseointegration noted during vestibuloplasty. Fourteen (51.8 percent) immediate dental implant patients had complete dental restoration at 90 days compared with none in the historical cohort (p < 0.05).

CONCLUSIONS

Immediate dental implant placement is a safe procedure with an unchanged short-term complication profile and no delay in radiotherapy initiation. Patients undergoing immediate dental implant placement are more likely to complete full dental rehabilitation. Long-term and health-related quality-of-life outcomes remain to be determined.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Does postoperative non-sedation improve outcomes for patients after head and neck cancer reconstruction?: A STROBE compliant study

Whether a strategy of postoperative non-sedation produces better outcomes compared with sedation in patients after head and neck reconstruction remains controversial. Therefore, we retrospectively investigated outcomes in 150 of these patients in our institution.Patients with head and neck cancer that received free anterolateral thigh flap were studied retrospectively, and were categorized in terms of their postoperative care into "sedation" and "non-sedation" groups. The related parameters of each patient were collected for analysis.Overall, 150 patients were included (sedation protocol (N = 56) and non-sedation strategy (N = 94)). No significant differences were observed between groups in patient demographics or postoperative outcomes. Significantly shorter durations of mean and median intensive care unit (ICU) length of stay, mechanical ventilation, hospitalization, and operative time were observed in the non-sedation group than in the sedation group. Among all patients, the sedation and flap reopen were the common variables related to prolonged ICU stay, mechanical ventilator duration, and hospitalization.The current study suggested the strategy of postoperative non-sedation is associated with a significant decrease in the duration of mechanical ventilation, ICU length of stay, hospitalization. Regardless of hospital stay, there were no differences in postoperative outcome between 2 groups.

Correlation between Venous Thromboembolism Risk and Venous Congestion in Microvascular Reconstruction of the Lower Extremity

BACKGROUND

Risk for venous thromboembolism formation and the relationship to postoperative free flap venous congestion and flap failure have not been adequately evaluated in a trauma population. The authors aim to use the Caprini Risk Assessment Model to evaluate the association between venous thromboembolism risk and postoperative flap venous congestion following lower extremity free tissue transfer.

METHODS

A retrospective analysis was conducted of all patients who underwent lower extremity free flap reconstruction of traumatic defects at a single institution between 2007 and 2016. A Wilcoxon rank sum test was used for nonparametric analysis of aggregate Caprini Risk Assessment Model scores and flap outcomes. Flap venous congestion and failure rates as associated with the categorical variables underlying the Caprini Risk Assessment Model were further studied. Logistic regression was used to evaluate each of these outcomes and other flap-related covariates relative to the Caprini Risk Assessment Model categorical variables that had the greatest effect on our patient sample.

RESULTS

One hundred twelve patients underwent lower extremity free flap reconstruction. One hundred eight free flaps were analyzed. Eight patients were excluded. The majority of patients were male (75.9 percent) and required reconstruction because of acute trauma (68.1 percent versus 31.9 percent for chronic wounds). There was no statistically significant association found between age, body mass index, or timing of trauma versus venous congestion, flap failure, or other flap-related covariates.

CONCLUSION

In patients with significantly elevated Caprini Risk Assessment Model scores, there was no significant association between venous thromboembolism risk and flap failure following free tissue reconstruction of lower extremities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers

BACKGROUND

Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications.

METHODS

Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index.

RESULTS

A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001).

CONCLUSION

If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.

Comparison of patients satisfaction with aesthetic outcomes following lower extremity reconstruction: Muscle vs. fasciocutaneous free flaps

BACKGROUND

The microsurgical reconstruction of complex lower limb defects has become a routine procedure with high success rates. The emphasis has changed from ensuring flap 'success' to providing a reconstruction, which is also aesthetically pleasing. The aim of this study was to compare patients' satisfaction with aesthetic outcomes, following muscle or fasciocutaneous free flap reconstruction to the lower limb.

METHODS

Data were collected retrospectively between July, 2013 and May, 2018 at a single institution. The inclusion criteria were adult patients who had successful free tissue transfers to the lower limb following any aetiology. A Likert Scale questionnaire was sent to all patients who met these criteria. The questionnaire included questions related to the reconstruction and donor site.

RESULTS

Questionnaires were sent to 83 patients who met the inclusion criteria. Forty-seven (57%) patients responded, of which 22 (47%) underwent reconstruction with muscular flap and 25 (53%) with fasciocutaneous flap. A statistically significant difference between the two groups was found in relation to flap texture (p = 0.003). Patients with fasciocutaneous flap reconstruction being more satisfied. No significant difference was observed for contour, similarity to the contralateral side, bulkiness of flap, colour match, scar, or overall appearance. The comparison of donor site results revealed no significant difference between the two groups CONCLUSIONS: Despite increase in success in lower extremity reconstruction, many patients still find aesthetic results suboptimal and this affects an individual's global sense of well-being. Aesthetic restoration should be viewed as an integral part of lower limb reconstruction.

LEVEL OF EVIDENCE

Therapeutic, III.

Prospective Comparison of Donor-Site Morbidity following Radial Forearm and Ulnar Artery Perforator Flap Harvest

BACKGROUND

The forearm is a common donor site, providing thin, pliable workhorse flaps for head and neck reconstruction. There are no prospective studies comparing the donor-site morbidity of the radial forearm flap to the ulnar artery perforator flap.

METHODS

All patients undergoing forearm free flaps were included for analysis and followed for a minimum of 1 year. Grip strength, sensation to light touch, temperature sensation, and wound healing were assessed.

RESULTS

A total of 98 patients were enrolled (radial forearm flap, n = 50; ulnar artery perforator flap, n = 48). There were three osteocutaneous radial forearm flaps performed. The donor site was closed primarily in one radial forearm flap patient and four ulnar artery perforator flap patients. The majority of donor sites were resurfaced with full-thickness skin grafts (radial forearm flap, n = 40; ulnar artery perforator flap, n = 44), and the remaining were closed with split-thickness skin grafts. Average grip strength compared to baseline measured at 1, 3, 6, and 12 months after surgery demonstrated no significant differences. All patients returned to baseline sensation to light touch with no long-term sensory deficits at 1 year. No patients suffered significant changes in temperature sensation or cold intolerance. Seven patients suffered partial skin graft loss (radial forearm flap, n = 5; ulnar artery perforator flap, n = 2); all of them healed secondarily with local wound care. There were no flap losses in the study.

CONCLUSIONS

The radial forearm and ulnar artery perforator flaps are equivalent in terms of success and donor-site morbidity. Selection of flap should be based on need for pedicle length, flap bulk, concerns with radial or ulnar dominance, and surgeon comfort.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population

BACKGROUND

Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates.

METHODS

A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.).

RESULTS

One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years.

CONCLUSIONS

This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction

The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm³), with a PNI <40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p <0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 ± 55.5 days vs. 28.3 ± 24.4 days, p <0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.

Protocol for a systematic review of venous coupler devices versus hand-sewn anastomosis for microsurgical free flap reconstruction

BACKGROUND

A patent microvascular anastomosis is of paramount importance in free tissue transfer. Anastomotic coupler devices provide an alternative to technically demanding hand-sewn venous anastomosis. Various advantages of these devices have been discussed but previous systematic reviews had methodological flaws or did not perform a meta-analysis. This review aims to evaluate the quality of the evidence and quantify the efficacy and safety of venous couplers compared to hand-sewn anastomosis.

METHODS

A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive search strategy has been developed and will be applied to the databases MEDLINE and Embase from inception to October 2018. All clinical studies using anastomotic coupler devices for venous anastomoses in free tissue transfer will be eligible for inclusion. Screening of studies and data extraction will be performed independently by two authors. Our primary outcome is anastomotic venous thrombosis. Secondary outcomes will include time to complete the venous anastomosis, tearing of veins, anastomotic leakage, flap loss/failure and fiscal outcomes. The risk of bias for included studies will be assessed by using the ROBINS-I tool, and recommendations based on the evidence will be made using the GRADE approach. Descriptive statistical analyses will be used and if two or more studies report the same outcome, data will be pooled for comparative analysis. A direct comparison meta-analysis will be performed if possible.

DISCUSSION

There has been no comparison of coupled and hand-sewn venous anastomoses using a robust and validated methodology preceded by a protocol and performing meta-analysis. Included studies are expected to be mainly observational and prone to bias; however, there is value in summarising the evidence, assessing its risk of bias and performing meta-analysis to guide clinicians. By using a broad approach including all types of flaps, we foresee inherent differences regarding the unit of analysis and different anatomic sites. This will limit the validity of our conclusions but is unavoidable. We will seek unpublished data from authors and perform subgroup analysis where appropriate. Limitations and areas of uncertainty will be discussed to guide future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110111.

Preoperative radiation and complication rates after double free flap reconstruction of head and neck cancer

INTRODUCTION

In this study, we explore whether preoperative external beam radiation affects complication rates in patients that have undergone double simultaneous free tissue transfer for head and neck defects.

STUDY DESIGN, SETTING, SUBJECTS AND METHODS

Approval was obtained from the JPS Institutional Review Board. We performed a retrospective analysis of patients who underwent double free flap reconstruction of head and neck defects between August 1997 and April 2017. Minimum follow up was 6 months. Patients were grouped according to preoperative radiation status (XRT vs non-XRT). The chi-squared test was used for all comparisons. P-values and 95% confidence intervals (CI) were reported as (P, 95% CI).

RESULTS

90 flaps were performed on 45 patients. The most common flap combination utilized was fibula plus radial forearm free flap (RFF) in 17 out of 45 patients. There were no statistically significant differences in frequency of flap failure (0.35, -15.9-20.1), wound infection (0.75, -22.1-19.3), hematoma (0.16, -5.3-36.7), or fistula formation (0.69, -22.5-24.6). There were also no statistically significant differences in cardiac complications (0.57, -10.3-28.2) and DVT (0.22, -12.4-25.3).

CONCLUSION

Our findings suggest that double free flap patients who had preoperative radiation are not more likely to have complications compared to non- radiated patients. Simultaneous double free flaps should be reserved for the most complex cases. Extensive discussion should be had with the patient about possible morbidity and mortality.

Automatic Early-Onset Free Flap Failure Detection for Implantable Biomedical Devices

OBJECTIVE

Up to 10% of free flap cases are compromised, and without prompt intervention, amputation and even death can occur. Hourly monitoring improves salvage rates, but the gold standard for monitoring requires experienced personnel to operate and suffers from high false-positive rates as high as 31% that result in costly and unnecessary surgeries. In this paper, we investigate free flap patency monitoring using automatic hardware-only classification systems that eliminate the need for experienced personnel. The expected flow ranges of the antegrade and retrograde veins for breast reconstruction are studied using a syringe pump to create the laminar flow seen in veins.

METHODS

Feature data extracted from the Doppler blood flow signals are analyzed for sensitivity, specificity, and false-positive rates. Hardware is built to perform the classification automatically in real-time and output a decision at the end of the observation period.

RESULTS

Experimental results using the hardware-only classifier for a 50 ms window size show high sensitivity (96.75%), specificity (90.20%), and low false-positive rate (9.803%). The experimental and theoretical classification results show close agreement.

CONCLUSION

This work indicates that automatic hardware-only classifiers can eliminate the need for experienced personnel to monitor free flap patency.

SIGNIFICANCE

The hardware-only classification is amenable to a monolithic implementation and future studies should study a totally implantable wirelessly-powered blood flow classifier. The high classifier performance in a short window period indicates that duty-cycled powering can be used to extend the safe operational depth of an implant. This is particularly relevant for the difficult buried free flap applications.

Strategies for free flap transfer and revascularisation with long-term outcome in the treatment of large diabetic foot lesions

OBJECTIVE/BACKGROUND

To analyse the impact of ischaemia and revascularisation strategies on the long-term outcome of patients undergoing free flap transfer (FFT) for large diabetic foot lesions penetrating to the tendon, bone, or joint.

METHODS

Foot lesions of 63 patients with diabetes (median age 56 years; 70% male) were covered with a FTT in 1991-2003. Three groups were formed and followed until 2009: patients with a native in line artery to the ulcer area (n = 19; group A), patients with correctable ischaemia requiring vascular bypass (n = 32; group B), and patients with uncorrectable ischaemia lacking a recipient vessel in the ulcer area (n = 12; group C).

RESULTS

The respective 1, 5, and 10 year amputation free survival rates were 90%, 79%, and 63% in group A; 66%, 25%, and 18% in group B; and 50%, 42%, and 17%, in group C. The respective 1, 5, and 10 year leg salvage rates were 94%, 94%, and 87% in group A; 71%, 65%, and 65% in group B; and 50%, 50%, and 50% in group C. In 1 year, 43%, 45%, and 18% of the patients in groups A, B, and C, respectively, achieved stable epithelisation for at least 6 months. The overall amputation rate was associated with smoking (relative risk [RR] 3.09, 95% confidence interval [CI] 1.8-5.3), heel ulceration (RR 2.25, 95% CI 1.1-4.7), nephropathy (RR 2.24, 95% CI 1.04-4.82), and an ulcer diameter of >10 cm (RR 2.08, 95% CI 1.03-4.48).

CONCLUSION

Despite diabetic comorbidities, complicated foot defects may be covered by means of an FFT with excellent long-term amputation free survival, provided that a patent native artery feeds the ulcer area. Ischaemic limbs may also be salvaged with combined FFT and vascular reconstruction in non-smokers and in the absence of very extensive heel ulcers. Occasionally, amputation is avoidable with FFT, even without the possibility of direct revascularisation.

Ossification of the vascular pedicle in microsurgical fibular free flap reconstruction of the head and neck

BACKGROUND AND PURPOSE

The fibular free flap, often used for osseous reconstruction following extirpation of head and neck malignancies, has been associated with heterotopic periosteal ossification. We aimed to determine the frequency and radiologic characteristics of this process and describe its clinical correlates.

MATERIALS AND METHODS

Surgical records for 2 years and neck imaging reports for 10 years were evaluated to identify patients with fibular free flap reconstruction and CT and/or PET/CT imaging available for review. The images were evaluated for the quality, type, and contour of ossification, and the reports were reviewed for associated clinical findings and radiologic impressions.

RESULTS

Of 32 patients with posttreatment CT or PET/CT imaging, ossification was evident in 16 patients (50%) as early as 1 month following fibular free flap reconstruction. In 8 patients, it mimicked a new bone; in 5, it appeared as linear attenuation; in 2, as multiple short segments; and in 1 patient, a mixed appearance was found. No associated FDG uptake was seen on PET/CT. On MR imaging, these findings were extremely subtle or not appreciable. In only 1 patient was new bone associated with symptoms.

CONCLUSIONS

Periosteal ossification of the vascular pedicle is commonly evident on CT following fibular free flap, even as early as 1 month after reconstruction, though the finding is not typically noted on imaging. While symptoms related to new bone are uncommon, they may mimic recurrent tumor. The location and pattern of ossification and the absence of a soft-tissue mass or FDG uptake are useful distinguishing imaging features.

Microsurgical free flaps at Kathmandu Model Hospital

BACKGROUND

Microsurgery is an emerging subspecialty in Nepal. Microsurgery was started at Kathmandu Model Hospital in 2007 with the support from Interplast Australia and New Zealand. This study will be useful for establishing a baseline for future comparisons of outcome variables and for defining the challenges of performing microsurgical free flaps in Nepal.

METHODS

A retrospective cross sectional study was conducted using the clinical records of all the microsurgical free flaps performed at Kathmandu Model Hospital from April 2007 to April 2014.

RESULTS

Fifty-six free flaps were performed. The commonest indication was neoplasm followed by post-burn contracture, infection and trauma. Radial artery forearm flap was the commonest flap followed by fibula, antero-lateral thigh, rectus, tensor facia lata, lattisimus dorsi, deep inferior epigastric artery perforator, and deep circumflex iliac artery flap. Radial artery forearm flaps and anterolateral thigh flaps were mostly used for burn contracture reconstructions. Twelve of the 13 (92%) fibulae were used for mandibular reconstruction for oral cancer and ameloblastoma. Rectus flaps were used mainly for covering defects over tibia. Hospital stay ranged from six to 67 days with an average of fourteen. Fifteen patients (26%) developed complications. The duration of operation ranged from six hours to 10.5 hours with an average of nine hours. The longest follow up was for four years.

CONCLUSIONS

Microsurgery can be started even in very resource-poor center if there is support from advanced centers and if there is commitment of the institution and surgical team.

A case of nonisland pedicled foot fillet flap for below-knee amputation stump wound: treatment option for compartment syndrome after fibular free flap surgery

Despite the frequent use of the fibular free flap, there have been no reports of severe compartment syndrome of the donor leg that necessitated limb amputation. A 66-yr-old man had a fibular osseous free flap transfer from the left leg to the mandible that was complicated by postoperative compartment syndrome. An extensive chronic leg wound resulted, which was treated with multiple debridements and finally with below-knee amputation. Successful coverage of the below-knee amputation stump was accomplished with a nonisland pedicled foot fillet flap. Various foot fillet flaps may be used acutely as a free or an island pedicled flap, but dissection of the vascular pedicle may be difficult in a chronically inflamed wound because of inflammation and adhesions to surrounding tissue. The nonisland pedicled foot fillet flap may be considered as a useful option for treatment of a chronically inflamed stump wound after below-knee amputation.

Analysis of free flap complications and utilization of intensive care unit monitoring

We aimed to determine the optimal time for intensive care unit (ICU) monitoring after free flap reconstruction based on the timing of surgical complications. We reviewed retrospectively 179 free flaps in 170 subjects during an 8-year period at University Hospital. Thirty-seven flaps were reoperated due to vascular (n = 16, 8.9%) and nonvascular complications (n = 21, 11.7%). Vascular complications presented earlier relative to nonvascular complications (10.8 versus 99.3 hours). The flap survival rate was 93.2% with a mean ICU length of stay of 6.2 days. The lack of standardized monitoring protocols can lead to overutilization of ICU. Sometimes, flap monitoring is not the limiting factor, as patients with other comorbidities necessitate longer ICU stays. However, our study suggests that close monitoring of flaps seems most critical during the first 24 to 48 hours, when most thrombotic complications occur and prompt identification and re-exploration is critical. Some thrombosis and most hematomas present within 72 hours, and thus close monitoring is still warranted. We suggest close monitoring of free flaps in the ICU or dedicated flap monitoring unit where nursing can check the flap on an every-1-to-2-hour basis for the first 72 hours postoperatively to assure optimal surveillance of any potential problems.

Evaluation and management of complications or functional problems at the recipient site after esophageal and voice reconstruction with free ileocolon flap

BACKGROUND

The free ileocolon flap has been considered a safe method of simultaneous restoration of swallowing and voice production; however, the management of complications at the recipient site and its impact on functional outcomes are lacking in the literature.

METHODS

We reviewed retrospectively all consecutive patients with combined defects of the cervical esophagus and larynx reconstructed with free ileocolon flap between July 2005 and December 2009 (follow-up of ≥18 months). Patients were evaluated during the follow-up period to judge the impact of revision surgery on functional outcomes. Complications were reviewed, and the appropriate management was reported.

RESULTS

Swallowing function was restored in 69% of patient; functional speech function was achieved in 59%. Fourteen of the 29 patients underwent revision surgery because of complications or to improve functions at the recipient site. The mean functional improvement after revision surgery was 1.0 point on the 5-point Likert scale for speech and 1.1 point on the 7-point Likert scale for swallowing (P < .01 each).

CONCLUSION

Continuous research over the last 10 years has allowed us to refine the technique and to make the outcome more predictable.

[Use of vascularized free flaps for reconstruction of oncological defects in the head and neck]

The aim of the study is to assess our results with free flap transfer. Since October, 2005 till December, 2011 51 operations were performed. Mucosa of upper digestive tract was reconstructed in 40 cases, soft tissues and skin of the head and neck region-in 11 cases. Reconstruction was primary in all but 2 cases. 18 first cases were performed with 2,5x and 4x binocular loupes magnification. Operating microscope was used in another 33 cases. 37 radial forearm fasciocutaneous flaps, 5 latissimus dorsi musculocutaneous flaps, 7 anterolateral thigh flaps, 1 scapular osteocutaneous were used with the single case of visceral flap--jejunal free flap. Death in early postoperative period occurred once. Complete flap loss occurred six times. Five radial and one latissimus dorsi free flaps were lost. Arterial thrombosis is considered as a primary cause of failure in one case, venous thrombosis-in two cases. Severe postoperative infection was considered as a primary cause of failure in one case. In remaining 2 cases the cause of flap loss could not be determined exactly. There were three cases of revision surgery with attempts to reperform venous anastomosis, one of them was successful. Overall success rate in this series is 86,3 %. The main cause of such a low rate of success is a lack of experience.

[Comparative assessment of the reparative process of wounds of the liver and kidneys depending on the kind of plastic material in experiment]

In 52 rabbits a morphological assessment was made of regeneration of wounds of the liver and kidneys after their plasty with a seromuscle flap of the stomach on the vascular pedicle (26 rabbits), of hepatorhaphy and omentonephroplasty (26 rabbits) within the period from 1 to 360 days and was compared with literature data concerning reparation of the liver and kidney of the rabbit with the application of bio- and polymer materials for covering their wounds. The influence of plastic properties of the materials used on the productivity of the inflammatory-reparative process was established. In suturing the wounds of parenchymatous organs it is necessary to use plastic materials stimulating regeneration. The application of seromuscle flap of the stomach for these purposes improves the inflammatory-reparative process making it more productive as compared with bio- and polymer materials.

[Clinical study of safflower injection in treating and preventing the vascular crisis after free flap transplantation]

OBJECTIVE

To observe the clinical efficacy of Safflower Injection (Al) in treating and preventing the vascular crisis after free flap transplantation.

METHODS

Sixty patients undergoing free flap transplantation were randomly assigned to the treatment group and control group according to the visiting sequence, thirty in each. Free flap transplantation was performed on all patients, and medication was given 0. 5 h before flap vascular anastomosis, 1-7 days after surgery. Twenty mL Al was intravenously dripped to patients in the treatment group after adding in 250 mL 5% glucose injection, while Dextran-40 was intravenously dripped to patients in the control group. The medication was conducted once per day. The hemorheology and four indices of blood coagulation [prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (APTT), fibrinogen (FIB)] were compared between the two groups before operation (TO), during operation (T1), 24 h after operation (T2), three days after operation (T3), and seven days after operation (T4). Meanwhile, flaps were observed and adverse reaction recorded. The clinical efficacy and safety were compared.

RESULTS

Better result was obtained in the treatment group when compared their clinical efficacy (86. 67% vs 60. 00%, P<0.05). The whole blood high and low viscosity, plasma viscosity, red blood cell (RBC) volume, RBC aggregation index all decreased, and RBC deformed index increased in the two groups at T4, showing statistical difference when compared with those at T3 (P<0.05, P<0.01). There was no statistical significance in the four indices of blood coagulation when compared with any time point in the same group (P>0.05). There was no statistical significance in hemorheology and the four indices of blood coagulation between the two groups at the same time point (P>0.05). The adverse reaction rate in the treatment group was lower than that in the control group, showing statistical difference (13.33% vs 30.00%, P<0.05).

CONCLUSIONS

AI could effectively prevent and treat the vascular crisis after free flap transplantation. It had less adverse reaction and good safety. It was better than Dextran-40. It was a safe and effective drug to prevent the vascular crisis.

[Postoperative vessel thrombosis and its management after free flap transfers in head and neck region]

OBJECTIVE

To analyze the rate of postoperative vessel thrombosis and its management after free tissue transfers in head and neck region.

METHODS

Eight hundred and forty-nine consecutive free flap transfers were performed from May 1999 to September 2004. Among them, the flaps with postoperative vessel thrombosis were selected and reviewed. Data concerning each case included time of vessel thrombosis, kind of thrombosis, time of emergent exploration, and salvage of free flaps.

RESULTS

Among the 849 free flaps, postoperative vessel thrombosis occurred in 28 free flaps, between 8 to 120 hours after operation. There were 5 arterial thrombosis, and 23 venous thrombosis. Thirteen flaps were salvaged after emergent exploration, and 15 flaps were lost. The rate of postoperative vessel thrombosis was 3.3% in this group, the salvage rate of flap was 46.4%, and the overall successful rate was 98.2%.

CONCLUSION

Clinical monitoring after free flap transfer in head and neck region is very important and effective. In case of vessel thrombosis, emergent exploration is the only effective way to salvage the flap.