Full-thickness nasolabial facial artery flap: A modified surgical approach for reconstruction of lower lip defects

OBJECTIVES

Reconstruction of large lower lip defects remains challenging in terms of aesthetics, function and safety. The aim of this study is to explore a modified nasolabial flap to repair large lower lip defects.

METHODS

The full-thickness nasolabial facial artery flap was used for reconstruction of defects in lip squamous cell carcinoma (LSCC) patients after tumor ablation. The postoperative recovery of patients was obtained through clinical review and follow-up in the first and sixth month.

RESULTS

There were four LSCC patients who received tumor ablation at the Beijing Stomatological Hospital of Capital Medical University from November 2022 to March 2023, were included in our study. All patients did not suffer from postoperative infection, orocutaneous fistula, flap necrosis, and flap loss. One patient had the trapdoor deformity. These patients achieved better lip closure function. One patient developed cervical lymph node metastasis 2 months after surgery.

CONCLUSIONS

The modified nasolabial flap could achieve good outcomes in terms of aesthetics, function, and safety. It provided a supplementary strategy for the using of nasolabial flap in larger defects of lower lip.

Functional Rehabilitation of Anterior Cruciate Ligament Tear in the Pediatric Population: A Comprehensive Review

Pediatric sports injuries are a growing concern due to increased youth participation in sports. Effective rehabilitation strategies are essential for ensuring optimal recovery, restoring knee function, and preventing long-term consequences. This research aims to explore and evaluate various functional rehabilitation approaches tailored to pediatric anterior cruciate ligament (ACL) tear injuries. Functional rehabilitation of ACL tears in pediatric sports injuries is an important area of research due to the unique considerations and challenges that arise when treating ACL injuries in young athletes. Over the last 20 years, there has been a well-documented uptick in ACL injuries among pediatric populations. This rise can be attributed to the growing involvement of the younger population in competitive sports, as well as heightened awareness regarding sports-linked injuries. This study highlights the importance of early surgical reconstruction in children to enable a quick return to sports and prevent long-term cartilage and meniscal damage resulting from instability. The use of physeal-sparing ACL reconstruction techniques, particularly hamstring autografts, is recommended for favorable clinical outcomes while minimizing growth disturbances. This study offers valuable insights for healthcare professionals and researchers, serving as a reference to guide optimal approaches in managing pediatric ACL injuries and achieving successful results in this field.

Functional Outcomes Following Arthroscopic Anterior Cruciate Ligament (ACL) Reconstruction Using the Sironix Titanium Button and the Polyetheretherketone (PEEK) Button: A Retrospective Observational Study

Background Anterior cruciate ligament (ACL) injury is most common among athletes compared to the general population. ACL reconstruction is a clinical standard for restoring joint mechanical stability and enabling sports return. The purpose of the study is to evaluate the safety and functional outcomes after arthroscopic ACL reconstruction using the Sironix titanium button and the polyetheretherketone (PEEK) button. Methods A total of 31 subjects who have undergone arthroscopic ACL reconstruction using the Sironix titanium button and PEEK button between August 2022 and January 2023 were included in the study. Demographic data, surgery details, and other baseline characteristics of the subjects were collected from the hospital records. The primary objective of the study was to assess the functional outcome using the International Knee Documentation Committee (IKDC) questionnaire. The secondary objectives were to determine the pre- and post-surgery activity levels using the Tegner Activity Score (TAS) and Lysholm score. Quality of life evaluation was done by using the Quality of Life (QoL) subscale from the Knee Injury and Osteoarthritis Outcome Score (KOOS) and Single Assessment Numerical Evaluation (SANE). Device-related adverse effect information was recorded. Results The mean (SD) of the total IKDC score of 31 subjects at baseline and post-surgery was 51.4 (2.84) and 91.8 (2.59) out of 100, respectively. The mean (SD) of TAS pre-injury and post-surgery was 5.3 (1.47) and 5.4 (1.38) out of 10, respectively. The total mean (SD) value of the total Lysholm Score at baseline and post-surgery was 53.9 (3.72) and 91.4 (3.61) out of 100, respectively. The mean (SD) value of the quality of life subscale of the KOOS score was 91.2 (3.91) out of 100. The total mean (SD) value of the SANE score that had affected joint/region of interest today was 97.4 (1.78), while for the opposite side today, it was 99.5 (0.85) out of 100. There were no adverse device effects reported in this study. Conclusion Based on the score assessment, it was observed that the performance of Sironix knee implant devices, Proloop-Titanium adjustable loop button, T-Button A® Closed PEEK button, and Surestitch® All Inside Meniscal Repair Implant (Healthium Medtech Limited, Bengaluru, Karnataka, India) was effective and safe with no adverse effects. Therefore, Sironix knee implants are considered safe and effective in ACL reconstruction and meniscus repair surgery.

Anaesthetic Challenges in a Case of Oral Carcinoma With Anticipated Difficult Airway Posted for Tumour Excision and Reconstruction Surgery

Mandibular surgery, edentulous jaw, denture wear, and ageing are all risk factors for persistent mandibular ridge resorption and weakening. The tongue occludes the upper airway due to the mandible's edentulous condition. All of these factors contribute to the difficulties in regulating the airway. An adequate preoperative review assisted in classifying this index patient as having a high risk of difficult airway management, and appropriate actions were made to facilitate effective airway care. A 60-year-old male presented to casualty with a complaint of squamous cell carcinoma of the right buccal mucosa and was posted for wide local excision of the tumour, segmental mandibulectomy, bilateral modified radical neck dissection, and reconstruction with a fibular free flap. He had a restricted mouth opening and a heavy jaw, with Mallampati grade 4 and had an anticipated difficult airway. Hence, awake endotracheal intubation was done by flexible fibreoptic bronchoscope following airway blocks and an 8.0 mm cuffed flexometallic armoured tube was secured at 28 cm at the angle of the nose. Bilateral modified radical neck dissection and wide local excision of the tumour were done followed by mandibulectomy and its reconstruction by fibular free flap and anastomosis was performed. Tracheostomy was performed and the patient was shifted to the intensive care unit and kept knocked out with injection vecuronium and injection midazolam infusion. The patient was gradually weaned off the ventilator the following day and discharged on postoperative day 12 with minimal postoperative complications. A thorough pre-anaesthetic plan, simple and skilled anaesthetic management strategy, and well-organized teamwork aided in the effective anaesthetic care of this challenging airway patient.

A preliminary biomechanical study on trachea reconstruction surgery using the clavicular periosteum

Introduction: The clavicular periosteum is a suitable material for trachea reconstruction. However, because the periosteum is softer and has different mechanical properties than tracheal cartilage, the mechanical loads under physiological conditions after trachea reconstruction may cause collapse or stenosis of the repaired trachea. Methods: In this study, the mechanical properties of the clavicular periosteum were tested, and the 3D trachea geometry was constructed based on CT-scanning images acquired before the surgery. Differing degrees of stenosis (0%, 33%, and 55%) for the repaired trachea sections were predetermined, presenting the different degrees of the tracheal cross-sectional area immediately after clavicular periosteum reconstruction. Then the biomechanical environments of the trachea and the airflow were simulated and analyzed. Results: In the fluid mechanics simulation, the air pressure on the patch area decreased with increasing degrees of stenosis, while the fluid velocity increased as stenosis increased. In solid mechanics simulations, patch area deformation increased as the cross-sectional area of the trachea decreased, and the stress in the patch increased as stenosis increased. Discussion: The solid stress changes may cause tissue remodeling, thickening, and scarring of the patch area. The fluid mechanical changes in the repaired trachea would further aggravate the stenosis. The numerical simulation study would provide references for biomechanical evaluation of trachea reconstruction surgery. The surgical indications may be expanded in the future based on the model prediction results.

Squamous Cell Carcinoma of Skin Cancer Margin Classification From Digital Histopathology Images Using Deep Learning

Objectives

Now a days, squamous cell carcinoma (SCC) margin assessment is done by examining histopathology images and inspection of whole slide images (WSI) using a conventional microscope. This is time-consuming, tedious, and depends on experts’ experience which may lead to misdiagnosis and mistreatment plans. This study aims to develop a system for the automatic diagnosis of skin cancer margin for squamous cell carcinoma from histopathology microscopic images by applying deep learning techniques.

Methods

The system was trained, validated, and tested using histopathology images of SCC cancer locally acquired from Jimma Medical Center Pathology Department from seven different skin sites using an Olympus digital microscope. All images were preprocessed and trained with transfer learning pre-trained models by fine-tuning the hyper-parameter of the selected models.

Results

The overall best training accuracy of the models become 95.3%, 97.1%, 89.8%, and 89.9% on EffecientNetB0, MobileNetv2, ResNet50, VGG16 respectively. In addition to this, the best validation accuracy of the models was 94.7%, 91.8%, 87.8%, and 86.7% respectively. The best testing accuracy of the models at the same epoch was 95.2%, 91.5%, 87%, and 85.5% respectively. From these models, EfficientNetB0 showed the best average training and testing accuracy than the other models.

Conclusions

The system assists the pathologist during the margin assessment of SCC by decreasing the diagnosis time from an average of 25 minutes to less than a minute.

Association Between Early Postoperative Graft Signal Intensity and Residual Knee Laxity After Anterior Cruciate Ligament Reconstruction

Background:

Magnetic resonance imaging (MRI) graft signal intensity is associated with graft damage after anterior cruciate ligament reconstruction (ACLR). However, little is known about the relationship between graft signal intensity and residual laxity of the reconstructed knee based on patient age.

Purpose/Hypothesis:

To evaluate the relationship between graft signal intensity and residual laxity in younger and older patients who underwent ACLR. We hypothesized that higher graft signal intensity would be associated with reduced postoperative knee stability.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A total of 192 patients who underwent double-bundle ACLR were recruited. Proton density–weighted and T2-weighted MRI was performed at 3, 6, and 12 months after surgery, and the signal intensity ratio (SIR) of the anteromedial and posterolateral bundles was measured as the graft signal intensity reference values. At 12 months after surgery, if the KT-1000 arthrometer measurement exhibited a side-to-side difference of ≥2 mm, the patient was determined as having anterior knee laxity. Rotatory knee laxity was defined as a positive pivot shift with International Knee Documentation Committee grade ≥1. The Mann-Whitney U test was used to compare the SIR in patients with and without residual laxity. The Spearman correlation coefficient was used to evaluate the relationship between demographic parameters and the SIR. Based on receiver operating characteristic curves, the optimal SIR cutoff values to predict residual laxity were calculated, and logistic regression analysis was conducted.

Results:

Of 192 patients, 26 (13.5%) had anterior knee laxity, and 20 (10.4%) had rotatory knee laxity. The SIR was negatively correlated with age. In younger patients (<30 years; n = 135), those with residual laxity had a significantly higher SIR than those without laxity; this relationship was not significant in older patients (≥30 years; n = 57). Based on receiver operating characteristic curves and logistic regression analysis, the cutoff values that were determined for the SIR were significantly associated with a higher odds ratio of residual laxity.

Conclusion:

Graft signal intensity decreased with patient age. Patients with higher graft signal intensity in the early postoperative phase after ACLR exhibited a higher prevalence of residual laxity, particularly in younger patients.

Three-Dimension-Printed Custom-Made Prosthetic Reconstructions in Bone Tumors: A Single Center Experience

Bone can be affected by different neoplastic conditions. Limb salvage surgery has become the preferred treatment strategy for most malignant tumors of the extremities. Advanced 3D printing technology has transformed the conventional view of oncological surgery. These types of implants are produced by electron beam melting (EBM) technology by sintering titanium powder in a scaffold shape designed following a project designed from HRCT and MRI. The aim of our study was to evaluate the outcomes and the mid-term follow-up of a population treated with 3D-printed custom-made prosthesis implantation in major oncological bone resection or after failure of primary implants. The primary outcome was the general patient satisfaction one year after surgery. The secondary outcomes were: mortality rate, treatment related complication rate, functional and clinical outcomes (KPS, ADL and IADL). Eight patients were included, five females and two males, with a mean age of 50.3 (±23.72) years at the surgery. The enrolled patients reported a mean satisfaction rate after surgery of 7.38 (±2) where 10 was the maximum value. There were no changes between pre- and postoperative mean KPS (81.43 +/−10.69). Mean preoperative ADL and IADL score was in both cases 4.86 (±1.07), while postoperative was 5 (±0.82), with a delta of 0.13 (p > 0.05). Custom-made prosthesis permits reconstructing bone defects caused by large tumor resection, especially in anatomically complex areas, restoring articular function.

Primary Repair for Treating Acute Proximal Anterior Cruciate Ligament Tears: A Histological Analysis and Prospective Clinical Trial

Reconstruction surgery for acute proximal anterior cruciate ligament (ACL) tears remains controversial. Recently, ACL primary repair has received increasing attention in ACL treatment. This study aimed to explore the histological characteristics of ACL healing in primary repair and compare its therapeutic and prognostic results with the reconstruction of acute proximal ACL tears. Histological experiments using rabbits and a prospective clinical trial were conducted. We established a rabbit model of ACL primary repair, and histological changes were observed using haematoxylin and eosin (HE) and toluidine blue staining. We performed immunohistochemical analysis of CD34 and S-100 and measured the expression of collagen I and II using qRT-PCR, Western blotting, and immunohistochemistry. The prospective clinical trial involved performing ACL primary repair and reconstruction in patients with acute proximal ACL tears to detect proprioception and evaluate the function of joints. We discovered that primary repair promoted cell proliferation in the tendon-bone transition and ligament portions, reduced osteoarthritis-like pathological changes, and maintained blood vessels and proprioceptors within the ACL. In the clinical trial, primary repair achieved similar therapeutic outcomes, including recovery of knee function and proprioception, in the follow-up period as ACL reconstruction. However, the primary repair had a significantly shorter operative time and lower cost than reconstruction. Therefore, doctors should consider the benefit of primary repair in treating acute proximal ACL tears.

Comparison between Aquacel and Aquacel Foam dressing on split-thickness skin graft donor site

OBJECTIVE

To compare the effectiveness of two commonly used moist dressings, Aquacel and Aquacel Foam (both ConvaTec Ltd., UK), in managing split-thickness skin graft (STSG) donor site wounds.

METHOD

Patients undergoing STSG harvesting for reconstruction were eligible for this quasi-experimental study. After reconstruction surgery, the Aquacel (A) or Aquacel Foam (AF) dressings were applied on the donor site wound. The STSG donor site was assessed by two trained research nurses daily. Clinical outcomes including pain on dressing removal, use of intravenous analgesics, signs and symptoms of wound infection, incidence of exudate leakage and percentage healed were recorded in a standardised form. Cost of the dressing change was retrieved from the hospital billing system.

RESULTS

Of 50 patients recruited, 25 received dressing A and 25 received the AF dressing for their STSG donor site wound. The average pain score on dressing removal was significantly lower in the AF dressing group compared with the A dressing group (0.8±0.8 versus 3.1±1.5, respectively (p=0.04)). Regression analysis demonstrated that compared with dressing A, the AF dressing was associated with a lower average pain score (beta: -2.27, standard error: 0.33; p<0.001), lower likelihood of pro re nata (PRN) intravenous analgesic use (odds ratio (OR)=0.21, 95% confidence interval: 0.06-0.71; p=0.01) and lower likelihood of exudate leakage (OR=0.11, p=0.01). The differences in time to wound healing, infection and cost were not statistically significant between the two groups.

CONCLUSION

In this study, the AF dressing demonstrated superior performance in pain response on dressing removal for STSG donor site wounds compared with dressing A. Large-scale randomised controlled trials should be conducted to confirm the findings.

Development of a patient-reported outcome measure in limb reconstruction : a pilot study assessing face validity

Aims

Patients undergoing limb reconstruction surgery often face a challenging and lengthy process to complete their treatment journey. The majority of existing outcome measures do not adequately capture the patient-reported outcomes relevant to this patient group in a single measure. Following a previous systematic review, the Stanmore Limb Reconstruction Score (SLRS) was designed with the intent to address this need for an effective instrument to measure patient-reported outcomes in limb reconstruction patients. We aim to assess the face validity of this score in a pilot study.

Methods

The SLRS was designed following structured interviews with several groups including patients who have undergone limb reconstruction surgery, limb reconstruction surgeons, specialist nurses, and physiotherapists. This has subsequently undergone further adjustment for language and clarity. The score was then trialled on ten patients who had undergone limb reconstruction surgery, with subsequent structured questioning to understand the perceived suitability of the score.

Results

Ten patients completed the score and the subsequent structured interview. Considering the tool as a whole, 100% of respondents felt the score to be comprehensible, relevant, and comprehensive regarding the areas that were important to a patient undergoing limb reconstruction surgery. For individual questions, on a five-point Likert scale, importance/relevance was reported as a mean of 4.78 (4.3 to 5.0), with ability to understand rated as 4.92 (4.7 to 5.0) suggesting high levels of relevance and comprehension. Flesch-Kincaid reading grade level was calculated as 5.2 (10 to 11 years old).

Conclusion

The current SLRS has been shown to have acceptable scores from a patient sample regarding relevance, comprehensibility, and comprehensiveness. This suggests face validity, however further testing required and is ongoing in a larger cohort of patients to determine the reliability, responsiveness, precision, and criterion validity of the score in this patient group.

Cite this article: Bone Jt Open 2021;2(9):705–709.

Reconstruction of Extensive Chest Wall Defects Using Light-Weight Condensed Polytetrafl uoroethylene Mesh - Case Reports

Tumors of the chest wall require extensive surgical intervention, which includes radical resection of the tumor mass followed by reconstruction of the defect. The depth of the defects may vary from a shallow one to a deep defect with exposure of the internal organs. In reconstruction of the chest wall, it is important to ensure the stability of the chest. Advanced synthetic biomaterials in combination with flap surgery are nowadays used as a treatment method of choice. The main advantage of biomaterials is easy manipulation, good fixation and a porous membrane. They are generally well tolerated by the patient. Flap surgery including regional flaps, pedicled flaps and free flap transfer are used for final closure of a deep defect. Shallow defects may be covered by autologous split-thickness skin graft transplantation. We present a series of case reports where we used light-weight condensed polytetrafluoroethylene (cPTFE) Omyra® Mesh TX B. Braun in combination with flap surgery for reconstruction of the chest wall. Different flaps for closure of the defects were used. In all cases the reconstruction of the chest wall was sufficient. One of the keys to success is a good cooperation between the oncosurgeon and the plastic surgeon.

Accuracy of Fibula Reconstruction Using Patient-Specific Cad/Cam Plates: A Multicenter Study on 47 Patients

OBJECTIVES

This prospective study evaluated the accuracy of mandibular reconstruction using free fibular flaps (by comparing virtual plans to the three-dimensional postoperative results), and the extent of bone-to-bone contact after computer-assisted surgery.

METHODS

We included 65 patients who underwent partial-continuity mandibular resections from February 2013 to January 2017, and evaluated virtual planning, surgical techniques, and accuracy.

RESULTS

Forty-seven patients were analysed. A total of 112 fibular segments received 54 implants. We measured 227 distances between landmarks to assess the accuracy of reconstruction. Postoperative reconstruction accuracy ranged from 0.5 to 3 mm.

CONCLUSION

Virtual surgical planning very accurately translated simulation into reality, particularly in patients requiring large, complex mandibular reconstructions using multiple fibular segments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2169-E2175, 2021.

RECONSTRUCTION OF DEEP HEAD BURN WITH A FREE FLAP - A CASE REPORT

Third degree burn trauma of the head and neck requires an interdisciplinary approach. After emergency care and hemodynamic stabilization of the patient the focus lies on the reconstruction of the damaged tissue. The options of reconstruction are influenced by the general condition of the patient and by the condition of the surrounding tissues. The deep defects of the head are dangerous for a high risk of wound infection and possible fatal complications. In particular cases the first methods of choice for closure of the defect may be ineffective and a free flap transfer should be considered. We present a case report of a 62-year-old woman who suffered third degree burn trauma of the head and neck leading to a deep defect of the forehead reaching behind the hairline. On the bottom there was an exposed bone with no healing tendency. Due to surrounding fragile scarred tissue we chose a free flap transfer using serratus anterior muscle as a method of closure. The flap was fully healed and provided good aesthetic and functional outcome.

Second Free Flap Surgery for Skull Base Tumors: Case Report and Literature Review

Tumors of the skull base, such as meningiomas, tend to recur. With progress in free vascularized flap surgery, an increasing number of studies are investigating skull base reconstruction with free flaps after tumor removal. In this report, we discuss the results of second free flap surgery after skull base reconstructive surgery. We retrospectively analyzed data from patients treated at our center during the period from 2013 through 2017. All four patients identified had skull base anaplastic meningioma and had undergone radiotherapy. In all cases, the flap and donor blood vessel were sourced from sites that differed from those used in the previous surgeries. No complications developed, such as cerebrospinal fluid leakage, meningitis, wound infection, wound hemorrhage, or flap necrosis. Because the first flap was found to be unviable, it was difficult to preserve and was removed. Essential points in preventing complications are anchoring at the appropriate site, pinprick testing of the created flap, and use of multilayered countermeasures to prevent cerebrospinal fluid leakage.

Localized lymphedema after treatment for soft tissue sarcoma in the lower limbs: Comparison of improvement according to duration before lymphaticovenular anastomosis

Surgically invasive procedures involving the medial knee and inguinal regions can cause lymphedema. Lymphaticovenular anastomosis (LVA) could improve volume reduction and decrease the risk of cellulitis. However, it may be preferable to performed LVA as early as possible to achieve optimal results.

Early recovery of neuronal functioning in the sensory cortex after nerve reconstruction surgery

BACKGROUND

Nerve reconstructive surgery induces a transient loss and a prolonged and a gradual return of sensory inputs to the brain. It is unknown whether, following this massive peripheral denervation, the brain will experience a prolonged period of severe, intrinsic dysfunction.

OBJECTIVE

We aim to investigate the mechanisms of return of processing function in cortical neurons.

METHODS

We used the whisker model in rats to evaluate the functional recovery in the somatosensory cortex after a nerve reconstruction surgery. Multi-unit recording in the barrel cortex was performed in lightly anesthetized rats while their whiskers were stimulated by a whisker stimulator.

RESULTS

We observed a loss of neuronal responses to whisker stimulation 1 week after surgery, which started to recover 2 weeks after surgery. Following the surgery, only 11.8% of units had principle whiskers (PWs) returned to their original status while 17.7% had PWs different from their original status, indicating the effect of aberrant reinnervation on the whisker response map.

CONCLUSIONS

Robust neuronal responses to sensory stimulation even when only sparse sensory inputs are available in the early recovery phase. During this phase, aberrant reinnervation induces disorganized whisker tuning, a finding that might be account for the hypoesthesia and paresthesia during early recovery after nerve reconstruction.

Osteosynthesis Using the Uncalcined and Unsintered Hydroxyapatite / Poly-L-Lactic Acid System

The poly-L-lactic acid mini-plate system accomplished rapid development. However, the system still has a variety of problems. One such problem is the breakage of screws. In this technical report, we develop the temporary fixing screws made from stainless with hexagon steel that exhibit a hexagonal head and thread part that also features a tapping function.

Effect of femoral tunnel positions on graft stress in outside-in ACL reconstruction surgery during continuous knee motion: A simulation study

BACKGROUND

Previous studies regarding the optimal femoral tunnel location for an anterior cruciate ligament (ACL) reconstruction were based on static experiments at specific angles, and did not consider continuous motion of the knee.

METHODS

Twenty-four surgical sites were set and continuous kinematic data, obtained from motion analysis, was used to describe knee movement. The bending angle and stress of the ACL graft as well as the length of the femoral tunnel was calculated through multi-flexible body dynamics analysis.

RESULTS

The lowest stress was found at both 5 mm and 10 mm radius at a proximal posterior of 45°, and the highest stress was also found at a distal 15 mm radius. Relatively high stresses were also identified between the distal and anterior regions as well as the distal and posterior regions at 15 mm radius.

CONCLUSION

Considering the availability of surgery, it was identified that the optimum femoral tunnel location is at 10 mm radius locations at a proximal posterior of 45°.

Treatment and functional result of desmoplastic fibroma with repeated recurrences in the forearm: A case report

Desmoplastic fibroma, alternatively known as aggressive fibromatosis or desmoid tumors, occurs in the form of benign locally aggressive tumors that possess a high rate of recurrence. The forearm bones are rarely involved. The current study presents a case of desmoplastic fibroma in the distal forearm of a 23-year-old man. The tumor was widely resected, and the bone defect was reconstructed using an autologous vascularized fibular graft during the resection procedure. The patient experienced recurrence three times and underwent four resections during the subsequent 3 years following the initial resection. After 10 years of follow-up, the patient's functional recovery remains positive. Despite the implication that surgical resection may be involved in the development of aggressive fibromatosis, surgical wide local excision and functional reconstruction were recommended for the treatment of the present patient.

External monitor for buried free flaps in head and neck reconstructions

Head and neck defects following oncological surgery must often be repaired with soft tissue and/or bone from other areas of the body. Significant loss of soft tissue requires flaps of sufficient bulk to adequately reconstruct the defect. Microvascular free tissue transfer is a good method for reconstructing even large defects following oncological surgery for head and neck cancer. Continuous post-operative monitoring of the perfusion of a free flap is vitally important to achieve not only a favourable outcome but also to decrease morbidity. Microvascular thrombosis occurs in 4% of the flaps and the best chance for flap salvage is offered by the earliest possible revision of the microanastomosis. Use of buried flaps in head and neck reconstruction makes monitoring particularly difficult and exteriorization of a segment of the flap permits a direct visualization. An original technique is presented for harvesting forearm free flaps with a secondary monitor skin paddle to externally check the status of the paddle and, when modified, can also be used for fibula and rectus abdominis flap.