Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population

BACKGROUND

 In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps.

METHODS

 Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status.

RESULTS

 Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973).

CONCLUSION

 This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.

[Rare case of reconstruction of the anterior thigh compartment after resection of high-grade sarcoma by hybrid technique: Latissimus dorsi free flap associated with a medial gastrocnemius pedicled flap]

INTRODUCTION

The soft tissue sarcomas of the limbs require extensive surgical excision. Reconstructive surgery plays an essential role in its management to preserve the limb, as exposed in a case of thigh sarcoma.

CLINICAL CASE

A 73-year-old patient has a large sarcoma within the quadriceps. Its excision requires resection of the entire anterior thigh compartment. Preservation of the limb is permitted by reconstruction by latissimus dorsi free flap and medial gastrocnemius pedicled flap. The patient resumed walking using an orthosis at 3 months.

CONCLUSION

Surgery to remove a sarcoma of a limb can threaten the integrity of the limb. Plastic surgery, with all the reconstruction techniques, contributes to the preservation of a functional limb.

A 3D Analysis of Plating Strategies in Mandibular Reconstruction: A Randomized Control Pilot Study

OBJECTIVE(S)

The purpose of this study was to compare computer-assisted mandibular plating to conventional plating using quantitative metrics.

METHODS

Patients scheduled to undergo mandibular reconstruction were randomized to three-dimensional modelling for preoperative plate bending or intraoperative freehand bending. Preoperative and postoperative head and neck computed tomography scans were obtained to generate computer models of the reconstruction. The overall plate surface contact area, mean plate-to-bone distance, degree of conformance, and position of the condylar head within the glenoid fossa between pre- and post-operative scans were calculated.

RESULTS

Twenty patients were included with a mean age of 57.8 years (standard deviation [SD] = 13.6). The mean follow-up time was 9.8 months (range = 1.6-22.3). Reconstruction was performed with fibular (25%) or scapular free flaps (75%). The percentage of surface contact between the reconstructive plate and mandible was improved with three-dimensional models compared to freehand bending (93.9 ± 7.7% vs. 78.0 ± 19.9%, p = 0.04). There was improved overall plate-to-bone distance (3D model: 0.7 ± 0.31 mm vs. conventional: 1.3 ± 0.8 mm, p = 0.06). Total intraoperative time was non-significantly decreased with the use of a model (3D model: 726.5 ± 89.1 min vs. conventional: 757.3 ± 84.1 min, p = 0.44). There were no differences in condylar head position or postoperative complications.

CONCLUSION

Computer-assisted mandibular plating can be used to improve the accuracy of plate contouring.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:2182-2186, 2024.

Comparison of condylar position after free fibular flap mandibular reconstruction using computer-assisted and traditional techniques

OBJECTIVES

To compare the changes in condylar position after mandibular reconstruction with free fibular flap(FFF) and the differences between computer-assisted techniques and traditional methods on CT images.

METHODS

Thirty-four patients who underwent mandibular reconstruction with free fibular flap were selected according to the inclusion and exclusion criteria. In the 3D group, virtual surgical planning (VSP) with osteotomy cutting plate and placement guiding plate were used, while the traditional group underwent freehand reconstruction. The CT data of 68 temporomandibular joints (TMJs) were recorded before and immediately after surgery. The condylar position was evaluated by measuring the anterior space (AS), posterior space (PS) and superior space (SS), and the ln (PS/AS) was calculated according to the method proposed by Pullinger and Hollender.

RESULTS

In the patients included in the 3D group, the condyle on the ipsilateral side moved slightly backward; however, in the patients in the traditional group, the ipsilateral side moved considerably anteroinferior. No obvious changes on the contralateral side were noted. In the 3D group, 33% of ipsilateral condyles were in the posterior position postoperatively when compared with the preoperative position (13%). In the traditional group, the number of ipsilateral condyles in the anterior position increased from 4 to 10, accounting for 53% postoperatively. Contrary to the traditional group, the 3D group presented less condylar displacement on the ipsilateral side postoperatively.

CONCLUSIONS

This study showed a decreased percentage of change in condylar position postoperatively when VSP was used. Virtual surgical planning improved the accuracy of FFF mandibular reconstruction and made the condylar position more stable.

[Robot-assisted Microsurgery for Autologous Breast Reconstruction - Robotic Breast Reconstruction]

BACKGROUND

With the introduction of novel surgical robots and surgical microscopes for the special needs of open microsurgery, the concept of robotic-assisted microsurgery is gaining popularity. While initial preclinical studies indicate a steep learning curve, favourable ergonomics and improved precision, albeit with an increased operating time, data on the clinical application of the new systems is still limited. This study describes our first clinical experience with robotic-assisted autologous breast reconstruction and outlines the opportunities and limitations of the approach.

PATIENTS AND METHODS

Our retrospective data analysis included a total of 28 patients who underwent unilateral robotic-assisted autologous breast reconstruction between July 2022 and August 2023. We applied a combined approach using the Symani Surgical System together with the RoboticScope. Descriptive evaluation of patient characteristics, surgical data and complications was performed.

RESULTS

Average patient age was 54.3±11.1 years and average BMI was 26.5±3.5 kg/m2. Twenty-six patients received a DIEP flap and 2 patients received a PAP flap, the flaps being connected to the internal mammary artery in 22 cases, to a perforator of the internal mammary artery in 5 cases, and to a branch of the thoracodorsal artery in one case. The average incision-suture time was 267±89 min, with an average ischaemia time of 86±20 min and duration of the arterial anastomosis of 29±12 min. In two cases, immediate intraoperative anastomosis revision was performed, but no flap loss occurred.

CONCLUSION

The results of this study demonstrate the safe feasibility of robot-assisted autologous breast reconstruction using a combination of Symani and RoboticScope. In the future, special attention should be paid to minimally invasive techniques of flap harvest and connecting vessel preparation.

Robotic-Assisted Anastomosis in Orthoplastic Surgery: Preliminary Data

BACKGROUND

The evolution of microsurgery has relied on advancements in operating microscopes and surgical instruments. Pioneering advancements, however, especially within the domain of "super-microsurgery", challenge the limits of human dexterity by dealing with anastomoses between vessels smaller than 0.8 mm. Based on these premises, the Symani robotic system was designed and developed. This platform utilizes teleoperation and motion-scaled movement to provide surgeons with precision and accuracy in manipulating millimetre and submillimetre-sized anatomical structures. In this study, we present our experience in performing robotic-assisted anastomoses using the Symani Surgical System in free flap reconstruction.

METHODS

We present a comprehensive analysis of all reconstructive procedures involving microsurgical free flaps performed using the Symani robotic platform at the orthoplastic unit of the Rizzoli Orthopaedic Institute from 1 October 2022 to 1 May 2023.

RESULTS

Sixteen microsurgical reconstructions using free flaps were performed, involving a total of 40 anastomoses on vessel calibres ranging from 0.6 mm to 2.5 mm. In each case, the anastomosis was executed with the assistance of the robotic platform, achieving a 100+% success rate in patent anastomoses, and no major complications occurred.Conclusion The Symani system has proven to be safe and reliable in performing microsurgical anastomoses. While this platform demonstrated successful in various vessel calibres, its most promising potential lies in anastomoses below the size of a millimetre. Larger patient cohorts and extended investigation periods will be essential to explore whether robotics in microsurgery offers advantages across all microsurgical procedures or should be reserved for selected cases.

[Robotic-assisted harvesting of a latissimus dorsi muscle flap: a case report]

Having established itself in various other areas of surgery as well as in urology, robotics is increasingly gaining importance in plastic surgery. The case presented in this manuscript describes the first published robotic-assisted harvesting of a latissimus dorsi muscle free flap in the German-speaking world. The aim is to increase the knowledge of robotics in plastic surgery and to support the introduction of robotic-assisted plastic surgery in Germany.

Functional and esthetic outcomes of virtual surgical planning versus the conventional technique in mandibular reconstruction with a free fibula flap: A retrospective study of 24 cases

This study aimed to compare the functional and esthetic results in patients following mandibular reconstruction with a free fibula flap (FFF) by virtual surgical planning (VSP) versus the conventional technique. Patients who had undergone mandibular reconstruction with a FFF by VSP or the conventional technique were retrospectively assessed. The two groups were compared regarding functional and esthetic variables with appropriate scales preoperatively, intraoperatively, and postoperatively. Twenty-four patients were evaluated in two groups: conventional (n = 8) and VSP (n = 16). The mean amount of mandibular asymmetry was 2.62 mm (SD = 1.59) in the conventional group and 1.19 mm (SD = 1.32) in the VSP group. Of the patients who underwent conventional surgery, 12.5% had mandibular asymmetry of <2 mm and 87.5% had asymmetry of 2-5 mm. Of the VSP patients, 61.5% had mandibular asymmetry of <2 mm and 38.5% had mandibular asymmetry of 2-5 mm (p = 0.03). The mean difference in size of mandibular angle on the surgical and control sides was not significantly different between the two groups (p = 0.62). The difference in mean length of the mandibular body on the surgical side relative to the control side was not significant between the two groups (p = 0.75). Differences in functional variables between the two groups were not significant. Within the limitation of the study, it seems that the VSP technique resulted in better facial symmetry and superior esthetic outcomes compared with the conventional technique.

Malignant primary tumors of scalp with cranial extension: multidisciplinary surgical strategies and outcomes

OBJECTIVE

Malignant cancers arising in the scalp may exhibit calvarial invasion, dural extension, and rarely cerebral involvement. Typically, such lesions require a multidisciplinary approach involving both neurosurgery and plastic surgery for optimal resection and reconstruction. The authors present a retrospective analysis of patients with scalp malignancies who underwent resection and reconstruction.

METHODS

Patients presenting with scalp malignancies (1993-2021, n = 84) who required neurosurgical assistance for tumor resection were prospectively entered into a database. These data were retrospectively reviewed for this case series. The extent of neurosurgical resection was classified into four levels of involvement: scalp (level I), calvarial (level II), dural (level III), or intraparenchymal (level IV). Complications and evidence of local, locoregional, or regional recurrence were documented.

RESULTS

Patients underwent level I (n = 2), level II (n = 61), level III (n = 13), and level IV (n = 8) resections. Pathologies consisted of primarily squamous cell carcinoma (n = 50, 59.5%), basal cell carcinoma (n = 11, 13.1%), and melanoma (n = 9, 10.7%), with infrequent lesions including sarcoma, atypical fibroxanthoma, and malignant fibrous histiocytoma. For cases requiring a cranioplasty, 92.2% were done using titanium mesh and 7.8% with methylmethacrylate. At a mean follow-up of 35.5 ± 45.9 months, the overall survival was 48.8% (n = 41) and recurrence-free survival was 31.0% (n = 43). Scalp-based reconstruction involving plastic surgery was performed in 75 (89.3%) patients. The most commonly used free flap was a latissimus dorsi muscle flap (n = 46, 61.3%). One or more postoperative complications occurred in 21.4% of all patients, the most common being wound dehiscence or delayed wound healing in 13% (n = 11).

CONCLUSIONS

A multidisciplinary approach with aggressive neurosurgical resection is associated with good outcomes in patients with primary malignant scalp tumors, despite invasive disease on presentation. This analysis suggests that aggressive resection (level II and higher) is effective at reducing locoregional recurrence and is not associated with a higher risk of complications relative to resection without craniectomy. As most patients require scalp reconstruction to close the postresection defect, usually with vascularized free tissue transfer, involving a plastic surgeon in the surgical planning and execution is essential.

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.

In-house virtual surgical planning and guided mandibular reconstruction is less precise, but more economical and time-efficient than commercial procedures

BACKGROUND

To compare an in-house and a commercially available surgical planning solution for mandibular reconstruction in terms of postoperative reconstruction accuracy and economic benefit.

METHODS

Twenty-nine consecutive patients with advanced oral squamous cell carcinoma (OSCC) requiring segmental mandibular reconstruction were enrolled. Fifteen patients underwent in-house surgical planning and 14 patients underwent a commercially available planning solution. A morphometric comparison of preoperative and postoperative computed tomography (CT) data sets and a cost-benefit comparison were performed.

RESULTS

Volumes of planned and reconstructed bone segments differed significantly for both in-house planning (p = 0.0431) and commercial planning (p < 0.0001). Significant differences in osteotomy angles were demonstrated for in-house planning (p = 0.0391). Commercial planning was superior to in-house planning for total mandibular deviation (p = 0.0217), intersegmental space volumes (p = 0.0035), and lengths (p = 0.0007). No significant difference was found between the two planning solutions in terms of intersegmental ossification and the incidence of wound healing disorders. In-house planning took less time than commercial planning (p < 0.0001). Component manufacturing costs (p < 0.0001) and total cumulative costs (p < 0.0001) were significantly lower for in-house planning.

CONCLUSIONS

In-house surgical planning is less accurate but has a cost advantage and could be performed in less time.

[Robot-assisted Microsurgery in Lower Extremity Reconstruction]

BACKGROUND

In recent years, various robotic systems specifically designed for microsurgical tasks have been developed and approved. There is not much evidence for these systems to date. In our study, we examined the use of robot-assisted microsurgery in the reconstruction of the lower extremity.

PATIENTS/MATERIAL AND METHODS

Data was prospectively collected between February and November 2023. The Symani robotic system was used in 42 robot-assisted microsurgical procedures on the lower extremity, and the results were evaluated and documented.

RESULTS

The average age of the patients was 57±18 years. A total of 39 free flap reconstructions (95%), one lymphatic surgical procedure (3%) and two nerve transfers (5%) were performed. In total, 46 anastomoses and coaptations were carried out. This included six arterial end-to-end anastomoses (11%), seven arterial end-to-side anastomoses (13%), 36 venous end-to-end anastomoses (65%), two lymphovenous anastomoses (4%), and five epineural coaptations in the context of nerve transfers (9%). Arterial end-to-end anastomoses took an average of 26±12 minutes, and arterial end-to-side anastomoses took 42±21 minutes. The venous anastomoses took an average of 33±12 minutes. Epineural coaptations took an average of 24±13 minutes. In no procedure was there a need for a conversion to conventional hand suturing. There were two arterial thromboses (5%), one of which was successfully revised to save the flap. One total flap loss occurred, but there were no partial flap losses.

CONCLUSION

Using the Symani robotic system for microsurgical reconstruction of the lower extremity, we were able to demonstrate results that are comparable to conventional microsurgery.

Complications and Functional Outcomes After Esophageal Reconstruction with an Intact Larynx

BACKGROUND

Esophageal defects can result from primary pathologies such as malignancy or stricture, or secondary ones such as perforation due to trauma or iatrogenic injury. Techniques, management, and outcomes of reconstruction in this setting are poorly understood. Herein, we aim to highlight surgical outcomes in patients undergoing local and free flap reconstruction of esophageal defects in the setting of an intact larynx.

METHODS

Retrospective review of patients who underwent esophageal reconstruction with an intact larynx between 2009 and 2022 at our institution was performed.

RESULTS

Ten patients met inclusion criteria. Esophageal reconstruction was performed for extruded spinal hardware (n = 8), and esophageal stricture (n = 2). Four patients underwent reconstruction with free tissue transfer, and six with local pedicled flaps. There were no cases of flap failure, esophageal fistula, hematoma, or wound dehiscence. One patient had post-operative bleeding requiring return to the operating room. Three patients had a postoperative wound infection, two of whom required washout. There were no unplanned 30-day readmissions. At three months after operation, all patients who were not tube feed-dependent prior to surgery returned to oral intake. Of the four patients who were tube feed-dependent preoperatively, three were tolerating oral intake at nine months postoperatively. Nine patients (90%) had stable flexible laryngoscopy exams pre- and postoperatively with no voice changes.

CONCLUSIONS

Reconstruction of esophageal defects in the setting of an intact larynx can be challenging. In this series, surgical intervention with free tissue transfer and local pedicled flaps was effective in returning patients to oral intake with low long-term morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1227-1233, 2024.

A preliminary analysis of patient reported outcomes following posterolateral mandible reconstruction: The role of flap type

BACKGROUND

The choice of tissue type for free flap reconstruction of posterolateral mandible resections is dependent on patient and defect characteristics. We compared clinical and patient-reported outcomes following reconstruction of these defects with a soft tissue or bony free flap.

METHODS

A retrospective review was performed on patients who underwent posterolateral segmental mandibulectomy with immediate free flap reconstruction at MSKCC from 2006 to 2021. Outcomes of interest were patient-reported outcome measures (PROMs) assessed by FACE-Q surveys and complications at the flap recipient site.

RESULTS

Ninety patients received a bony flap and 24 patients received a soft tissue flap. Patients reconstructed with soft tissue flaps had greater rates of composite soft tissue defects (p < 0.0001), condyle resection (p = 0.001), and peripheral vascular disease (p = 0.035). Complication rates were similar between the cohorts (p > 0.05). Bony flaps scored higher on multiple FACE-Q scales: Facial Appearance (p = 0.023) Eating/Drinking (p = 0.029), Smiling (p = 0.012), Speaking (p < 0.001), Swallowing (p = 0.012), Smiling Distress (p = 0.037), and Speaking Distress (p = 0.001).

CONCLUSION

Reconstruction of posterolateral mandibular defects has a similar complication profile when utilizing a bony or soft tissue free flap. Bony flaps may perform better with respect to PROMs. Reconstructive surgeons should consider using bony flap reconstruction to achieve higher patient satisfaction and quality of life.

Quality of life and subjective donor-site morbidity in patients after a free fibula flap

INTRODUCTION

We evaluated the subjective donor-site morbidity and quality of life in patients with a free fibula flap (FFF) reconstruction in terms of self-reported symptoms, function and quality of life, and we compared inclusion vs. exclusion of the flexor hallucis longus (FHL) muscle in the graft, primary wound closure vs. skin graft and the occurrence vs. absence of donor-site complications.

METHODS

In this cross-sectional study, patients who underwent a mandibula or maxilla reconstruction with a FFF between 2011 and 2021, were included. Symptoms and function were measured with the Foot and Ankle Outcome Score (FAOS) and quality of life with both FAOS and a Visual Analogue Scale (VAS).

RESULTS

Thirty-four patients were included in the analyses (mean age 59 years, 59% males). Most patients underwent a mandibular reconstruction for a malignancy. The median FAOS domain scores ranged between 92.9 (interquartile range (IQR) 77.7-100.0) and 100.0 (IQR 88.2-100.0) points, and the median VAS score was 86.5 points. No statistically significant differences were found between inclusion vs. exclusion of the FHL, primary wound closure vs. graft and occurrence vs. absence of donor-site complications. An unfavorable trend was seen for inclusion of the FHL in the flap on recreational functioning, and quality of life.

CONCLUSION

Patients who underwent a FFF experience little donor-site morbidity and high quality of life, as measured by FAOS and VAS.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Comparison of swallowing disorder in patients with tongue cancer undergoing reconstruction with either a radial forearm free flap or a submental island flap

PURPOSE

In this study, the swallowing status of patients with tongue cancer undergone tongue reconstruction using radial forearm free flaps (RFFF) and submental flaps were compared.

METHODS

A total of 26 patients with tongue cancer undergone tongue resection were randomly treated by tongue reconstruction with either submental flap or RFFF approach. Swallowing status of the patients was investigated using fiberoptic endoscopic evaluation of swallowing (FEES) by measurement of pharyngeal residue and penetration scales.

RESULTS

The pharyngeal residue scale in vallecula and pyriform sinus and the average of vallecula and pyriform sinus on days 10 and 30 post-operation as well as penetration scale at the same time showed no significant difference between two groups. However, the time to start oral feeding was significantly reduced in the submental group compared to the free flap group (P = 0.031). A positive Pearson correlation was found between the size of oral tongue and base of tongue resection and some of swallowing parameters.

CONCLUSION

Since there was no significant difference between submental and free flap respected to swallowing disorder, the submental flap is prior to free flap due to lower cost and hospitalization and less complication after tongue reconstruction.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee

BACKGROUND

The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively.

METHODS

Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality.

RESULTS

In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups.

CONCLUSION

The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Operative technique: Pectoralis major flap with rib

The osteomyocutaneous pectoralis major flap was first described in 1980 and provides a single stage reconstructive option for poor free flap or pectoralis major flap with reconstruction plate candidates requiring bony reconstruction. The flap provides good functional and cosmetic outcomes in appropriately selected patients. We describe the indications and operative techinique for harvesting this flap in written and video format.

Comparison of the microvascular anastomotic Coupler™ system with hand-sewn suture for end to end veno-venous anastomosis for head and neck reconstruction with free flap transfer: Medico-economic retrospective case-control study

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon.

Comparison of complications and functional outcomes following total or subtotal glossectomy with laryngeal preservation using a deep inferior epigastric artery perforator free flap versus a rectus abdominis musculocutaneous free flap

OBJECTIVE

Wide defects resulting from subtotal or total glossectomy are commonly reconstructed using a bulk flap to maintain oral and speech functions. The flap, including muscle tissue, diminishes with time. This study aimed to compare the surgical outcomes of deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions after glossectomy with laryngeal preservation.

METHODS

Medical records of 13 and 26 patients who underwent deep inferior epigastric artery perforator and rectus abdominis musculocutaneous free flap reconstructions, respectively, from 2014 to 2022 at our institution were reviewed. Patients who underwent middle pharynx resection except for the base of the tongue, mandibular bone resection, and sensory reinnervation were excluded.

RESULTS

The rectus abdominis musculocutaneous groups showed a higher number of lymph node dissection and shorter operative time than the deep inferior epigastric artery perforator groups. No significant differences in postoperative complications or functional oral intake scale scores at 6 months were observed. Volumetric changes on computed tomography images at 6 and 12 months were significantly lower in the deep inferior epigastric artery perforator group. Cancer recurrence was significantly associated with reduced oral function.

CONCLUSIONS

Oral function in patients with cancer is influenced by various other factors. However, the deep inferior epigastric artery perforator flap may be suitable for tongue reconstruction because of the minimal postoperative changes in flap volume, easy adjustment of flap thickness, elevation of multiple flaps, and minimal complications at the donor site.

[Clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury]

Objective: To investigate the clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury. Methods: The study was a retrospective observational study. From May 2019 to January 2022, 11 patients with upper limb complex tissue defects combined with main artery injury who met the inclusion criteria were admitted to the Department of Hand, Foot and Ankle Surgery of General Hospital of Ningxia Medical University, including 7 males and 4 females, aged from 18 to 56 years. After debridement, the area of skin and soft tissue defects was from 20 cm×6 cm to 32 cm×10 cm, and the exposed area of dead cavity or deep tissue was from 7 cm×4 cm to 10 cm×7 cm. Three patients had radial artery defects with a length of 4 to 7 cm; two patients had ulnar artery defects with a length of 5 to 8 cm; 4 patients had defects in both ulnar and radial arteries with a length of 3 to 7 cm; and in two patients, the ulnar, radial and brachial arteries were all defective with a length of 4 to 8 cm. The anterolateral thigh flow-through chimeric perforator flap was designed and cut. The skin flap area was from 22 cm×7 cm to 32 cm×11 cm, the chimeric muscle flap area was from 7 cm×4 cm to 10 cm×7 cm, and the length of the flow-through vessel in the "T" shaped vessel pedicle was from 4 to 8 cm. When transplanting the skin flap, the proximal end of the vascular pedicle was anastomosed with the proximal end of the recipient site, and the distal end of the vascular pedicle was anastomosed with the more normal blood vessel at the distal end of the forearm; the invalid cavity was filled with the muscle flap. The donor site wounds of tissue flap were closed directly or treated with skin grafting. After operation, the blood supply and survival of the flap, the survival of the distal limb, and the survival of the skin graft at the flap donor site were observed. Computed tomography angiography (CTA) was performed to observe the patency of the proximal and distal anastomotic arteries from 2 to 4 weeks after surgery. During follow-up, the texture of the flap, the survival of the grafted skin and the healing of the donor area were observed. Results: One patient (complete forearm disconnection) developed distal limb blood disorder on 5 days after surgery. CTA examination suggested embolization of the distal anastomosis of the flow-through artery. more muscle and skin and soft tissue necrosis of the distal limb showed in emergency exploration. So, amputation was performed ultimately. No vascular crisis occurred in the skin flaps of the remaining 10 patients, and all skin flaps, distal limbs and the skin grafts in flap donor sites survived well. Two to 4 weeks after surgery, the proximal and distal ends of the anastomosed arteries were good in the patency. Follow-up for 11-37 months, the flap texture was good, and all donor site wounds healed well. Conclusions: The use of anterolateral thigh flow-through chimeric perforator flap to repair upper limb complex tissue defects accompanied by main artery injury can improve the success rate of limb salvage, which can be promoted in clinical practice.

[Clinical analysis of denture rehabilitation after mandibular fibula free-flap reconstruction]

OBJECTIVE

To evaluate the postoperative denture restoration and denture function in patients with mandibular defect reconstructed with vascularized free fibula flap.

METHODS

In the study, 154 patients who underwent mandibular segment resection and used vascularized free fibula flap to repair mandibular defects due to inflammation, trauma and tumor from January 2015 to December 2020 were collected. These patients had common inclusion criteria which were stable occlusal relationship before operation, segmental defects of mandibular bone caused by lesions of mandible and adjacent parts (such as floor of mouth, tongue, cheek), free fibula flap used for repair and surviving after operation. Relevant data were reviewed and situation of denture restoration was followed up. A questionnaire related to denture functional evaluation had been proposed for those who had completed the denture rehabilitation. The evaluation index of denture restoration function was assigned by expert authority to obtain the denture function score. SPSS 18.0 software was used for statistical analysis of the basic information of the patients included in the study and the denture restoration of the patients.

RESULTS

The rate of postoperative denture restoration in the patients with mandibular defects repaired by free fibula flap was 17.5%, and the rate of postoperative denture restoration in the patients with benign mandibular tumors was 25.0% (18/72), which was significantly greater than that in the patients with malignant tumors 11.0% (9/82, P < 0.05). There was no significant difference in denture function score between the patients with condylar defect and those without condylar defect in denture repair rate and denture function score (P>0.05). The functional score of implant denture was significantly greater than that of removable denture (P < 0.05). According to Brown classification, the denture function score of the patients with the defect invo-lving the anterior mandibular region was significantly greater than that of the patients without the anterior mandibular region involved (P < 0.05). The poor oral conditions, such as less amount of remaining teeth, insufficient retention strength, large mobility of soft tissue in the surgical area, poor oral vestibular groove condition became the main reason of not receiving denture restoration (37.86%).

CONCLUSION

The denture rehabilitation of mandibular defect reconstructed with vascularized free fibula flap is closely rela-ted to pathological properties and oral conditions. The clinical outcome of implant denture has been confirmed effectively and it is a better choice for future denture restoration after mandibular reconstruction.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft

OBJECTIVE

Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof.

METHODS

Retrospective chart review and description of surgical technique.

RESULTS

Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up.

CONCLUSION

We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:654-658, 2024.

Orbital floor reconstruction via autologous radial forearm free flap with palmaris longus tendon

We describe reconstruction of the orbital floor following suprastructure maxillectomy for resection of maxillary squamous cell carcinoma utilizing an osteocutaneous radial forearm free flap and palmaris longus tendon.

Peri-implant health after microvascular head and neck reconstruction-A retrospective analysis

INTRODUCTION

Prosthodontic rehabilitation after reconstruction with microvascular revascularized free flaps following ablative tumor surgery is challenging due to the altered anatomical and functional conditions. The aim of this retrospective study was to determine whether the type of graft and the type of peri-implant tissue have an effect on peri-implant inflammatory parameters and implant survival.

MATERIALS AND METHODS

Patients who received a free flap reconstruction with subsequent implant-prosthetic rehabilitation between 2010 and 2022 were retrospectively included. The primary outcome variable was the probing depth (PPD) at a minimum of 1 year after completion of prosthetic restoration. Predictive variables were type of free flap, emergence profile, and history of radiation.

RESULTS

Seventy-one patients after free flap reconstruction were included in the analysis. At a minimum of 24 months after implant insertion the primary outcome, PPD showed no clinically relevant differences between the types of free flaps used. The emergence profile through a skin island resulted in an increase in BOP compared to native mucosa in the descriptive analysis (p-value > .05). The analysis showed a 5-year implant survival of 96.2% (95% CI: 0.929-0.996) in cases without irradiation and 87.6% (95% CI: 0.810-0.948) with irradiation of the region evaluated (p-value .034).

CONCLUSION

Flap and associated soft tissue type had no significant effect on 5-year implant survival or peri-implant inflammatory parameters. However, the large heterogeneity of the patient population indicates that further prolonged studies are required for a more differentiated assessment of the long-term success.

Serial assessment and long-term radiographic evaluation of the maxillary sinus after inferior maxillectomy and soft tissue free flap reconstruction in patients with oral cancer

PURPOSE

This study evaluates serial radiographic changes in the maxillary sinus of patients with oral cancer after an inferior maxillectomy and a soft tissue free flap reconstruction.

METHODS

Fifty-six patients were evaluated between Oct 2005 and Mar 2017 from an institutional database. Preoperative and surveillance imaging was reviewed at set time-points. Maxillary sinus scores were allotted based on a modification of the Lund-MacKay staging system. Patients were evaluated for change in sinus score. A univariate (UV) and multivariate (MV) analysis was performed.

RESULTS

There were 53.5% T3/T4 category tumors and 68% received adjuvant treatment. Median follow-up was 24.4 months. Preoperative mean sinus score was 0.27 ± 0.44 and postoperative mean sinus score at 24 months was 1.2 ± 1.3 (p = <0.001). On UV analysis advanced T-stage at 12 months (OR 6.7, 95% CI 1.2-50.3, p = 0.01) and 24 months (OR 5.2, 95% CI 1.03-36.8, p = 0.04) was associated with significantly higher sinus score. On MV analysis, advanced T-stage continued to be associated with increased odds for higher sinus score (OR 4.9, 95% CI 1.1-26.8, p = 0.039).

CONCLUSION

A mild increase in postoperative sinus score is seen in this cohort of patients. Advanced T-stage is associated with increased odds for higher sinus scores.

The Effect of Body Mass Index on Free Flap Breast Reconstruction

BACKGROUND

 Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class.

METHODS

 Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time.

RESULTS

 Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001).

CONCLUSION

 This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

Anatomical features of a crossing vein connecting left and right internal mammary veins: A preliminary study with computerized tomography or magnetic resonance imaging

BACKGROUND

In breast reconstruction with free flaps, retrograde venous anastomosis into the internal mammary vein (IMV) is often unavoidable. Utility of a crossing vein between the right and left IMV, one of the anatomical foundations which make retrograde flow possible, has been reported but only with a few detailed features. This study evaluated the presence, actual location, and diameter of the crossing veins using preoperative imaging such as contrast-enhanced computed tomography (CECT), or contrast-enhanced magnetic resonance imaging (CEMRI). Moreover, this is a preliminary non-invasive study to clarify these processes on a larger scale.

METHODS

We included 29 cases of unilateral breast reconstruction performed between July 2018 and September 2023 at our institution using unipedicled or bipedicled free deep inferior epigastric artery perforator (DIEP) flaps with retrograde venous anastomosis to only one IMV at the level of anastomosis. No congestion or necrosis was observed. In the final 24 cases with sufficient imaging coverage of preoperative contrast-enhanced images (15 CECT and 9 CEMRI), the crossing veins of IMVs were detected and the number, localization, and diameter were measured.

RESULTS

In 20 cases of 24 images, the crossing veins between IMVs were completely identified (83%). In 18 of the cases, only one crossing vein was established immediately ventral to the xiphoid process, averaging 19.3 ± 7.18 mm caudal to the fibrous junction between the sternal body and xiphoid process. The average diameter of the veins was 1.57 ± 0.42 mm. In two other cases, the second crossing vein originated on the dorsal surface of the sternum, but it was a very thin vein of about 0.4 mm. Three images indicated incomplete identification of the crossing vein at the xiphoid process, and in one case, no crossing vein was observed between bilateral IMVs.

CONCLUSION

The contrast-enhanced imaging study revealed an anatomic feature that the crossing veins (about 1.5 mm in diameter) connecting the right and left IMVs are located just ventral to the xiphoid process. Furthermore, the crossing veins can be identified on contrast-enhanced images, and refinement of this method is expected to lead to future non-invasive anatomical investigations in an even larger number of cases.

How I do it: single-staged emergency neurosurgical management of frontal penetrating craniocerebral injury with depressed skull fracture

CONTEXT

Penetrating craniocerebral injury associated with depressed skull fracture is an infrequent yet timely neurosurgical emergency. Such injury frequently occurs in the frontal region during traffic accident or stone throw in the civilian setting. As military neurosurgeons, we present our experience in the surgical debridement and reconstruction of this peculiar type of traumatic brain injury.

METHODS

The patient lies supine, the head in neutral position heal by a Mayfield head clamp. The first step is the debridement of the frontal wound. Then, the depressed skull fracture is operated on using a tailored coronal approach through Merkel dissection plane, in order to keep a free pericranial flap. The bone flap is cut around the depressed skull fracture. Neuronavigation allows to locate the frontal sinus depending on whether it has been breached and thus requires cranialization. Brain and dura mater debridement and plasty are performed. Cranioplasty is performed using either native bone fragments fixed with bone plates or tailored titanium plate if they are too damaged.

CONCLUSION

Performing wounded skin closure first and then a tailored coronal approach with free pericranial flap and a craniotomy encompassing the depressed skull fracture allows to treat frontal penetrating craniocerebral injury in an easy-to-reproduce manner.

Biomechanical evaluation of CAD/CAM magnesium miniplates as a fixation strategy for the treatment of segmental mandibular reconstruction with a fibula free flap

Titanium patient-specific (CAD/CAM) plates are frequently used in mandibular reconstruction. However, titanium is a very stiff, non-degradable material which also induces artifacts in the imaging. Although magnesium has been proposed as a potential material alternative, the biomechanical conditions in the reconstructed mandible under magnesium CAD/CAM plate fixation are unknown. This study aimed to evaluate the primary fixation stability and potential of magnesium CAD/CAM miniplates. The biomechanical environment in a one segmental mandibular reconstruction with fibula free flap induced by a combination of a short posterior titanium CAD/CAM reconstruction plate and two anterior CAD/CAM miniplates of titanium and/or magnesium was evaluated, using computer modeling approaches. Output parameters were the strains in the healing regions and the stresses in the plates. Mechanical strains increased locally under magnesium fixation. Two plate-protective constellations for magnesium plates were identified: (1) pairing one magnesium miniplate with a parallel titanium miniplate and (2) pairing anterior magnesium miniplates with a posterior titanium reconstruction plate. Due to their degradability and reduced stiffness in comparison to titanium, magnesium plates could be beneficial for bone healing. Magnesium miniplates can be paired with titanium plates to ensure a non-occurrence of plate failure.

Robot-assisted augmented reality surgical navigation based on optical tracking for mandibular reconstruction surgery

PURPOSE

This work proposes a robot-assisted augmented reality (AR) surgical navigation system for mandibular reconstruction. The system accurately superimposes the preoperative osteotomy plan of the mandible and fibula into a real scene. It assists the doctor in osteotomy quickly and safely under the guidance of the robotic arm.

METHODS

The proposed system mainly consists of two modules: the AR guidance module of the mandible and fibula and the robot navigation module. In the AR guidance module, we propose an AR calibration method based on the spatial registration of the image tracking marker to superimpose the virtual models of the mandible and fibula into the real scene. In the robot navigation module, the posture of the robotic arm is first calibrated under the tracking of the optical tracking system. The robotic arm can then be positioned at the planned osteotomy after the registration of the computed tomography image and the patient position. The combined guidance of AR and robotic arm can enhance the safety and precision of the surgery.

RESULTS

The effectiveness of the proposed system was quantitatively assessed on cadavers. In the AR guidance module, osteotomies of the mandible and fibula achieved mean errors of 1.61 ± 0.62 and 1.08 ± 0.28 mm, respectively. The mean reconstruction error of the mandible was 1.36 ± 0.22 mm. In the AR-robot guidance module, the mean osteotomy errors of the mandible and fibula were 1.47 ± 0.46 and 0.98 ± 0.24 mm, respectively. The mean reconstruction error of the mandible was 1.20 ± 0.36 mm.

CONCLUSIONS

The cadaveric experiments of 12 fibulas and six mandibles demonstrate the proposed system's effectiveness and potential clinical value in reconstructing the mandibular defect with a free fibular flap.

Management of Through-and-Through Oromandibular Defects after Segmental Mandibulectomy with Fibula Osteocutaneous Flap

BACKGROUND

 Oromandibular defects involving the external skin are a reconstructive challenge. This study aimed to evaluate the use of the fibula osteocutaneous free flap (FOCFF) for through-and-through oromandibular defects by comparing the surgical outcomes and complications of different techniques to close the external skin defect.

METHODS

 A retrospective analysis was conducted of patients who underwent reconstruction of through-and-through oromandibular defects after oncologic segmental mandibulectomy between January 2011 and December 2014. Five groups were analyzed according to the method of external skin coverage: primary closure, locoregional flaps, deepithelialized double-skin paddle FOCFF (deEpi-FOCFF), division of the skin paddle for double-skin paddle FOCFF (div-FOCFF), and a simultaneous second free flap. Intraoperative and postoperative outcomes along with complications were analyzed between groups.

RESULTS

 A total of 323 patients were included. The mean total defect area requiring a simultaneous second free flap was larger in comparison to other groups (p < 0.001). Reconstructions performed with div-FOCFF had a higher number of perforators per flap when compared with deEpi-FOCFF (p < 0.001). External defects closed with another free flap exhibited higher intraoperative time for the reconstructive segment in comparison to other groups (p < 0.05). The overall rate of complications was comparable between groups (24%, p = 0.129).

CONCLUSION

 The FFOCF is a reliable alternative to harvesting multiple simultaneous free flaps for through-and-through oromandibular defects. The authors recommend appropriate curation of the surgical plan based on individual patient characteristics and reconstructive requirements.

Supermicrosurgery with perforator-to-perforator anastomoses for lower limb reconstructions - A systematic review and meta-analysis

BACKGROUND

Supermicrosurgical flaps based on perforator-to-perforator microanastomoses have been described for lower limb reconstruction. This approach offers the benefit of raising short pedicles while sparing axial vessels, which effectively enables complex reconstructive techniques in comorbid patients at high risk of reconstructive failure. The aim of our study is to assess the surgical outcomes of perforator-to-perforator based flaps in comparison to conventional free flaps for reconstructions of the lower limb district, through a systematic review of literature and meta-analysis.

METHODS

A search on PubMed, Embase, Cohrane, and Web of Science was performed between March-July 2022. No restrictions were placed on study date. Only English manuscripts were assessed. Reviews, short communications, letters, correspondence were excluded after reviewing their references for potentially relevant studies. A Bayesian approach was used to conduct the meta-analysis comparing flap-related outcomes.

RESULTS

From 483 starting citations, 16 manuscripts were included for full-text analysis in the review, and three were included in the meta-analysis. Out of 1556 patients, 1047 received a perforator-to-perforator flap. Complications were reported in 119 flaps (11.4%), which included total flap failure in 71 cases (6.8%), partial flap failure in 47 cases (4.5%). Overall flap complications had a HR of 1.41 (0.94-2.11; 95% C.I.). Supermicrosurgical and conventional microsurgical reconstructions were not associated with statistically significant differences (p = .89).

CONCLUSION

Our evidence supports the safety of surgical outcomes, with acceptable flap complication rates. Nevertheless, these findings are limited by poor overall quality which must be addressed and used to encourage higher-level evidence in the field.

Usefulness of Free Tissue Transfer for the Reconstruction of Extensive Thigh Defects

BACKGROUND

 Despite the increasing popularity of free tissue transfer, thigh defects have been alienated from their potential indication, owing to the abundance of regional reconstruction options. However, some challenging situations where locoregional modalities may lead to suboptimal outcomes often require free flap. Due to lacking studies regarding microvascular reconstruction of thigh defects, this study aimed to investigate the versatility of free tissue transfer for reconstruction of thigh defects.

METHODS

 A retrospective review was performed for patients who underwent microvascular reconstruction of thigh defects between 2003 and 2021. Their demographics and operation-related data were summarized and postoperative outcomes were evaluated.

RESULTS

 Sixty-five patients were analyzed, with a median follow-up period of 15.5 months. Most common situations requiring free tissue transfer were extensive defects, followed by large dead space with exposure of major neurovascular bundle and chronic wounds surrounded by unhealthy regional tissue. Defects were most frequently located in the anterior compartment horizontally and in the distal thigh vertically. The median surface area of the defects was 180.0 cm2. The latissimus dorsi musculocutaneous and thoracodorsal artery perforator flaps were the two most commonly used flaps. Reliable recipient vessels could generally be easily found in the vicinity of defects. Overall complications developed in 12 cases (18.5%), including two of partial flap necrosis. No total flap loss was encountered.

CONCLUSION

 Free tissue transfer could provide reliable outcomes and facilitate rapid recovery, and could be actively considered for reconstruction of thigh defects in situations unfavorable to the locoregional option.

The evolution of pediatric soft-tissue free flap reconstruction of the lower extremity after oncologic resection: A 30 year experience

INTRODUCTION

Limb salvage has become the standard of care for lower extremity tumors because of improvements in adjuvant treatments and reconstructive techniques. While there is literature assessing pediatric lower extremity free flap reconstruction in the setting of trauma, there is a paucity of literature that analyzes oncologic free flap reconstruction in this patient population. We report our long-term experience and evolution of care for lower extremity oncologic free flap reconstruction in pediatric patients.

METHODS

This is a retrospective case series of all patients ≤18 years of age who underwent oncologic soft-tissue microvascular reconstruction of the lower extremity, from 1992 to 2021. Data were collected for patient demographics, oncologic treatment, operative details, and post-operative outcomes. Functional outcomes were assessed by weight bearing status, ambulation, and participation in activities-of-daily-living (ADLs), and musculoskeletal tumor society (MSTS) scores.

RESULTS

Over the 30-year study period, inclusion criteria were met by 19 patients (11 males, 8 females) with a mean age of 13.8 years and a mean follow-up of 5.3 years. At last follow-up, 13 patients (68.5%) were alive. The most common pathology was osteogenic sarcoma (13 patients, 68.5%). Sites of reconstruction were the hip (n = 1), thigh (n = 5), knee (n = 4), leg (n = 7), and the foot (n = 2). The most commonly used flaps were latissimus dorsi (n = 8), gracilis (n = 4), and anterolateral thigh ± vastus (n = 4). Postoperative complications occurred in nine patients (43%). Overall flap success rate was 95%. At latest follow-up, ambulation without assistive device was obtained in 11 patients (58%), full weight bearing was achieved by 13 patients (68.5%), and ADLs could be performed independently by 13 patients (68.5%). Mean MSTS score was 23.1/30.

CONCLUSION

Microvascular reconstruction for oncological lower extremity defects in the pediatric population has high limb salvage rates and good functional outcomes.

How Is a Cutting Guide With Additional Anatomical References Better in Fibular-Free Flap Mandibular Reconstruction? A Technical Strategy

BACKGROUND

Computer-assisted surgery is used to design and manufacture cutting guides in mandibular reconstructions with fibula-free flaps. To improve the outcomes of the procedure, the aim of this research was to investigate and compare the accuracy of mandibular reconstruction following the use of 2 versus 3 anatomical reference cutting guides.

METHODS

Eighteen sets of prototype bone models retrieved from an ameloblastoma patient were used for mock operations. The mandibular segmental osteotomies and fibular reconstructions were performed using 2 and 3 anatomical reference cutting guides in vivo surgeries. After reconstruction, the accuracy of the placed reference points was measured by superimposition of computed tomography images.

RESULTS

The error in cutting guides when using 2 or 3 anatomical references showed no significant difference. The fibular and condylar errors of the cutting guide between 2 and 3 anatomical references showed no significant difference in every plate type. The difference in screw hole position errors between 2 and 3 anatomical reference cutting guides was not statistically significant.

CONCLUSIONS

Two anatomical reference cutting guides are sufficient and reasonable enough for mandible resection. However, there were some limitations and errors in our study.

Nipple-areola-complex preservation and obesity-Successful in stages

BACKGROUND

The superiority of nipple-sparing mastectomy (NSM) on breast aesthetics and patient-reported outcomes has previously been demonstrated. Despite 42.4% of adults in the United States being considered obese, obesity has been considered a contraindication to NSM due to concerns for nipple areolar complex (NAC) malposition or ischemic complications. This report investigates the feasibility and safety of a staged surgical approach to NSM with immediate microsurgical breast reconstruction in the high-risk obese population.

METHODS

Only patients with a body mass index (BMI) of >30 kg/m2 who underwent bilateral mastopexy or breast reduction for correction of ptosis or macromastia (stage 1), respectively, followed by bilateral prophylactic NSM with immediate microsurgical breast reconstruction with free abdominal flaps (stage 2) were included in the analysis. Patient demographics and surgical outcomes were analyzed.

RESULTS

Fifteen patients with high-risk genetic mutations for breast cancer with a mean age and BMI of 41.3 years and 35.0 kg/m2 , respectively, underwent bilateral staged NSM with immediate microsurgical breast reconstruction (30 breast reconstructions). At a mean follow-up of 15.7 months, complications were encountered following stage 2 only and included mastectomy skin necrosis (5 breasts [16.7%]), NAC necrosis (2 breasts [6.7%]), and abdominal seroma (1 patient [6.7%]) all of which were considered minor and neither required surgical intervention nor admission.

CONCLUSIONS

Implementation of a staged approach permits NAC preservation in obese patients who present for prophylactic mastectomy and immediate microsurgical reconstruction.

Reconstruction of circumferential fingertip defect using free superficial palmar branch of the radial artery flap: Report of two cases

Wide local excision of noninvasive malignant melanomas has been increasingly performed instead of digit amputation, which often results in extensive fingertip defects. Owing to the unique anatomical characteristics of the fingertips, achieving favorable outcomes in both function and cosmesis is challenging during reconstruction. The free superficial palmar branch of the radial artery (SPBRA) flap is advantageous for finger reconstruction. However, its application in circumferential fingertip defects has rarely been reported. In this report, we describe two cases of circumferential fingertip defect reconstruction using a free SPBRA flap after wide local excision of subungual melanoma. The patients were women aged 74 and 63 years at the time of surgery. They presented with subungual melanoma on the right fourth finger and left thumb, in which both biopsies confirmed malignant melanoma in situ (Tis N0 M0), Breslow thickness of 0 mm (noninvasive). After wide local excision, circumferential defects, sized 2.5 × 6 and 2.7 × 7 cm, were formed on their fingertips. A vertically designed free SPBRA flap measuring 2.7 × 6 and 3 × 6 cm was elevated from the unaffected palm in each patient. After performing microvascular anastomosis, the flap was inserted transversely, wrapping the exposed phalangeal bone in a conical shape. The donor site was primarily closed. All flaps survived, and postoperative complications did not develop. Neither local recurrence nor distant metastasis was detected at the latest follow-up in either patient at 24 or 28 months postoperatively. The patients were satisfied with the natural contour of the reconstructed fingertip and recovered functions. In the evaluation of subjective sensory recovery using four scales (excellent, good, fair, and poor), they responded "fair" and "good," respectively. We suggest that the free SPBRA flap could be a reliable reconstructive method for circumferential fingertip defects.

Introduction and preliminary application report for a novel 3D printed perforator navigator for fibular flap surgery

The aim of this study was to introduce and report on a 3D-printed perforator navigator and its clinical application. Integrated imaging and 3D printing techniques were employed for the design and manufacture of a perforator navigator. Key techniques included establishing a digital image coordinate system, localizing perforator fascia piercing points, creating a reference plane for the perforator course, and projecting the perforator course onto the body surface. All cases of maxillofacial defect repaired with free fibular myocutaneous flaps, from January 2019 to January 2022, were reinvestigated. Patients treated using traditional perforator localization methods were assigned into group Ⅰ, while those who had a navigator used during treatment were allocated to group Ⅱ. Outcome measurements included perforator positioning accuracy, perforator preparation time (PT), and flap growth score. Capillary refilling time and degree of flap swelling were recorded on the 1st, 3rd, and 7th days after surgery. On the 10th day after surgery, the flap survival situation was graded. In total, 25 patients were included in the study. Perforator preparation time for group Ⅱ was significantly less (p ＝ 0.04) than for group Ⅰ (1038.6 ± 195.4 s versus 1271.4 ± 295.1 s. In group Ⅱ, the mean positioning deviation for the perforator navigator was 2.12 cm less than that for the high-frequency color Doppler (p ＝ 0.001). Group Ⅱ also had a higher score than group Ⅰ for overall flap growth evaluation (nonparametric rank sum test, p ＝ 0.04). Within the scale of the study, it seems that perforator localization and navigation using a 3D-printed navigator is technically feasible, and helps to improve the clinical outcome of free fibular flaps. The perforator navigator will play a useful role in displaying the perforator course, improving the accuracy of perforator localization, reducing surgical injury, and ultimately enhancing flap success rate.

Supra-arcuate free fascial MS-TRAM, a modified technique to reduce donor site morbidity in obese population-comparative study

BACKGROUND

Abdomen-based free flaps represent the gold standard option in the armamentarium of breast reconstruction. The natural evolution to more preservation with less invasive forms of these flaps has been driven by both patient and surgeon satisfaction. Nevertheless, obese patients are challenging due to the increased risk of compromised flap perfusion and donor site morbidity. This challenge is compounded by the prevalence of obesity worldwide, resulting in more free abdominal flaps being performed for breast reconstruction in obese patients. The authors present the outcomes of a modified supra-arcuate fascial muscle-sparing transverse rectus abdominus myocutaneous (FMS-TRAM) technique compared to standard muscle-sparing transverse rectus abdominus myocutaneous (MS-TRAM) technique to reduce the donor site morbidity while providing a well-vascularized large volume of autologous tissue.

METHODS

A retrospective comparative data analysis was conducted at two centers: Cairo University Hospitals, Egypt, and University Hospitals Birmingham, United Kingdom. Standard MS-TRAM was performed in 65 patients between 2008 and 2011 (Group 1) versus 275 patients between 2011 and 2020 (Group 2) who underwent FMS-TRAM. The modified technique involved limiting the fascial incision to above or at the level of the arcuate line to preserve the integrity of the anterior rectus sheath caudally. All patients included were of the obese population (BMI≥30 kg/m2 ) and underwent unilateral post-mastectomy reconstruction. Patient demographics, comorbidities, operative details, and outcomes focusing on donor site morbidity and flap complications were recorded and compared between the two groups.

RESULTS

The median age and BMI for Group 1 were 43 and 32, respectively. While for Group 2, they were 47 and 33, respectively. Flap weight ranged from 560 to 1470 g (Mean 705) for Group 1, while Group 2 ranged from 510 to 1560 (mean 715). The majority (280/340 [82%]) of the patients in both groups received radiotherapy. 7.7% of Group 1 were smokers, while in Group 2 it was 4.7%. The percentage of delayed versus immediate reconstruction in Group 1 was 60%/40%, while in Group 2, it was 43%/56%. The incidence of fat necrosis, partial necrosis, and total necrosis was 7.6%.1.5%, and 3%, respectively, for Group 1 and 8%, 1.4%, and 2.6%, respectively, for Group 2. The two-tailed p-value demonstrated a significant statistical difference (p < 0.00001) in donor site morbidity between both groups, with more bulge 20% (13/65) and hernia 1.5% (2/65) occurrence in Group 1 versus 1.9% (5/275) and 0.7% (2/275) in Group 2 respectively, over a follow-up period ranging from 24 to 60 months (mean 32).

CONCLUSION

FMS-TRAM flaps are safe, robust, and reliable with less donor site morbidity while maintaining optimal flap perfusion for large volume flaps in obese patients with excellent, durable outcomes. It should be considered a valuable tool in the reconstructive armamentarium of breast reconstruction.

Applying unsupervised machine learning approaches to characterize autologous breast reconstruction patient subgroups: an NSQIP analysis of 14,274 patients

BACKGROUND

Autologous breast reconstruction is composed of diverse techniques and results in a variety of outcome trajectories. We propose employing an unsupervised machine learning method to characterize such heterogeneous patterns in large-scale datasets.

METHODS

A retrospective cohort study of autologous breast reconstruction patients was conducted through the National Surgical Quality Improvement Program database. Patient characteristics, intraoperative variables, and occurrences of acute postoperative complications were collected. The cohort was classified into patient subgroups via the K-means clustering algorithm, a similarity-based unsupervised learning approach. The characteristics of each cluster were compared for differences from the complementary sample (p < 2 ×10-4) and validated with a test set.

RESULTS

A total of 14,274 female patients were included in the final study cohort. Clustering identified seven optimal subgroups, ordered by increasing rate of postoperative complication. Cluster 1 (2027 patients) featured breast reconstruction with free flaps (50%) and latissimus dorsi flaps (40%). In addition to its low rate of complications (14%, p < 2 ×10-4), its patient population was younger and with lower comorbidities when compared with the whole cohort. In the other extreme, cluster 7 (1112 patients) almost exclusively featured breast reconstruction with free flaps (94%) and possessed the highest rates of unplanned reoperations, readmissions, and dehiscence (p < 2 ×10-4). The reoperation profile of cluster 3 was also significantly different from the general cohort and featured lower proportions of vascular repair procedures (p < 8 ×10-4).

CONCLUSIONS

This study presents a novel, generalizable application of an unsupervised learning model to organize patient subgroups with associations between comorbidities, modality of breast reconstruction, and postoperative outcomes.

The niche of dermal graft to reconstruct a complex pressure injury wound in sacral region: A case report

RATIONALE

Pressure ulcers are a common health issue, particularly among elderly and bedridden patients who are vulnerable to pressure injuries in the sacral region. Currently, free flap and local flap surgeries are the gold standard procedures for the reconstruction of such injuries. However, the recurrence rate of flap surgery appears to be high. In this context, we presented a case involving a sacral pressure ulcer reconstructed with dermal grafting.

PATIENT CONCERNS

A 59-year-old male with a medical history of hepatitis C, brain hemorrhage, hydrocephalus, and multiple fractures presented with a sacral ulcer. Owing to the patient's history of recurrent pressure injuries and the challenges associated with postoperative wound care, the patient and his family were hesitant to proceed with flap surgery.

DIAGNOSES

The patient was diagnosed with a stage IV pressure ulcer measuring 4 cm × 4 cm in size in the sacral region, according to the National Pressure Ulcer Advisory Panel staging system.

INTERVENTIONS

Before surgery, the patient received standard wound care with dressing for 4 months, along with short-term oral antibiotics due to a positive wound culture for Pseudomonas aeruginosa. During the surgery, a dermal graft with a size of 35 cm2 and a thickness of 0.014 inches was harvested from the patient's left thigh. The graft was then secured to the wound bed.

OUTCOMES

Although the dermal graft failed with sloughing after 1 week, the wound bed showed improvement with granulation. After 1.5 months, the wound area had decreased to half of its original size, and the wound eventually healed after 3.5 months.

LESSONS

Dermal grafts have a niche in reconstructing pressure injury wounds in the sacral region, because of the relative ease of wound care and additional benefits even in cases where the graft fails.

Various soft tissue defect reconstructions using anterolateral thigh and vascularized fascia lata composite free flap

The anterolateral thigh flap (ALT) is versatile for soft-tissue reconstruction of various body defects because of its thick and vascularized fascia component. We present our clinical experience with the functional one-stage reconstruction of complicated soft-tissue defects using ALTs with vascularized fascia lata (FL). Between April 2018 and February 2022, we transferred ALTs with FL components for various soft-tissue defects in 15 patients. The FL component was used for reconstruction of hand & forearm tendon, medial and lateral patellar synovial membrane, plantar aponeurosis, abdominal wall, dura and Achilles tendon. Functional outcomes were evaluated in each patient. Partial flap necrosis occurred in 2 patients and were treated successfully with minimal surgical debridement and dressing. The vascularized fascia could replace a tendon and fascial component and all the patients achieved satisfactory results without major postoperative complications. Anterolateral thigh flaps with vascularized FL provide reliable fascial and tendon components for single-stage reconstruction of complex soft tissue defects.

"Y" anastomosis, a solution in doubtful venous anastomosis: a case report and review of the literature

BACKGROUND

Lower lip squamous cell carcinoma is a significant subtype of head and neck cancer, constituting about 25-30% of cases. Traditional surgical methods, like primary closure, have limitations in managing large resections of lip tumors. Recent advancements in surgical techniques, particularly free flaps, have shown promising results in addressing these challenges. The Y-shaped anastomosis is an innovative approach aimed at enhancing the efficiency of microvascular free flap surgeries for improved lip cancer reconstruction outcomes.

CASE PRESENTATION

A 77-year-old Persian male with lower lip squamous cell carcinoma underwent tumor resection with a 2 cm safety margin, bilateral neck dissection, and lip reconstruction using the right radial forearm free flap. The surgery incorporated a Y-shaped anastomosis to improve venous pedicle outcomes.

CONCLUSION

In this case, it was decided not to open the first anastomosis but to add the second end to the side one to provide two vascular supports for the venous anastomosis. Y anastomosis makes the surgery easier and decreases complications resulting from vascular size mismatch.

Utility of preoperative colour flow Doppler assessment of perforator anatomy in medial sural artery perforator (MSAP) free flaps

PURPOSE

It is known that the vascular perforators upon which the medial sural artery perforator (MSAP) flap is based are subject to considerable variation. This study seeks to evaluate the use of colour flow Doppler (CFD) as an imaging technique to establish the presence of suitable vessels, the discriminatory findings from that imaging, the rate of flap abandonment and flap complications.

METHODS

All patients undergoing MSAP in our institution since 2015 had a pre-operative CFD using a standardised technique. A prior group of 22 patients not having CFD acted as a control group. Data were  collected prospectively.

RESULTS

Fourteen patients had CFD. In one patient, no suitable vessels were found. In 13 patients, vessels of suitable size and position were identified, which then correlated precisely with operative findings. Three had suitable vessels in one leg only. No flaps in the CFD group were abandoned. One flap in the CFD group was partially lost. One flap in the prior control group was abandoned.

CONCLUSIONS

CFD provided reliable discriminatory information to decide on flap suitability/which leg and correlated precisely with operative findings, with no flap abandonment. Flap survival rate was very high.