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Objective: Assess the impact of tracheostomy on postoperative morbidity and mortality and examine factors that predicted tracheostomy in head and neck flap patients. Study Design: Retrospective cohort January 2017 to December 2021. Setting: Single tertiary center. Methods: Adult patients undergoing head and neck flap reconstruction were included, excluding cutaneous reconstruction, laryngectomy, or with tracheostomy present at surgery. Patients were routinely extubated immediately following surgery. Univariate and multivariable analyses examined associations between tracheostomy and postoperative outcomes and identified predictors of tracheostomy. Results: We included 193 patients, 69 (35.8%) with tracheostomy and 124 (64.2%) without. Tracheostomy avoidance was associated with no difference in 30‐day mortality (P =.531) and with decreased likelihood of 30‐day complications (0.019), unplanned return to the operating room (0.021), and discharge to a facility (<0.001) and with 2.2 decrease in length of stay on multivariable analysis (confidence interval [CI]: 0.62‐3.82, P =.007). Four patients (2.1%) required reactive tracheostomy with no resulting mortalities. Significant associations with tracheostomy on multivariable analysis included bilateral neck dissections (odds ratio [OR]: 3.13, CI 1.12‐9.06, P =.030), number of resected mandibular subsites (OR: 2.65, CI: 1.50‐5.67, P =.0023), specimen volume (OR: 1.87, CI: 1.29‐2.71, P =.001), body mass index < 20 (OR: 3.80, CI: 1.24‐11.64, P =.019), mandibulectomy (OR: 0.04, CI: 0.01‐0.22, P <.001), forearm flap (OR: 0.15, CI: 0.05‐0.41, P <.001), oral cavity site (OR: 0.21, CI: 0.06‐0.73, P =.014), and age > 70 (OR: 0.33, CI: 0.14‐0.81, P =.016). Conclusion: Tracheostomy avoidance is safe in properly selected patients undergoing head and neck flap reconstruction. Multiple factors predicted tracheostomy, which may guide patient selection at other centers. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to define a new surgical method using a neurotized platysma free flap to provide dynamic reanimation, enhanced functional recovery, and low morbidity for blepharoptosis repair. Methods: Ten hemifaces and neck halves of five formalin-fixed cadavers were included in the study. The origin of the neurovascular structures of the pedicle was identified at the submandibular triangle. A 5 × 3 cm platysma flap was dissected. For the recipient side, the main donor vascular structures were observed at the frontal part of the temporal region. The diameters of the donor structures were measured with a digital Vernier caliper. The statistical analysis of the study was performed with Jamovi statistical software version 2.3.36. P < 0.05 was accepted as a statistically significant value. Results: At the donor region, the pedicle included branches of the cervical branch of the facial nerve and the facial artery in all specimens. However, the venous graft pedicle origin could be either the facial vein or the lingual vein. At the recipient region, the mean diameters of the most anterior nerves, arteries, and veins were 1, 2.03, and 2.37 mm respectively. In a side comparison of pedicle variables, only pedicle artery diameter and lateral palpebral commissure-anterior superior point of auricula distance had statistically significant differences between hemifaces. Conclusion: A 5 × 3 cm size platysma flap located in the submandibular trigone would be a good choice for functional blepharoptosis surgery. The thin structure and the appropriate neurovascular pedicle structure should enable performing a successful flap transfer. [ABSTRACT FROM AUTHOR]

Introduction: The reconstruction of extensive scalp defects often requires free tissue transfer, offering single-stage and reliable reconstruction. The aim of this study is to evaluate the outcomes of free tissue transfer in scalp reconstruction. Patients and Methods: Thirteen patients were included in the study. Patient age, gender, smoking status, comorbidities, defect etiology, the specific type of flap used, the chosen recipient artery and vein, the need for revision, and flap success were reviewed. Results: The majority of the patients were male (76.9%). Defect reconstruction was performed using the latissimus dorsi musculocutaneous flap in 10 (71.4%) cases, which was followed by anterolateral thigh (ALT) and vertical rectus abdominis flaps. Two patients needed expansion of latissimus dorsi flaps. Superficial temporal vessels were used as recipient vessels in most patients. Three patients required anastomosis revision, all of which resulted in flap success. Conclusion: The high success rate observed in this study may be attributed to close monitoring of patients in the postoperative period and quick, early decision-making for revisions when necessary. The latissimus dorsi flap is the best option when large area coverage is needed, while the ALT flap is preferred when minimizing donor site morbidity is a priority. The vertical rectus abdominis myocutaneous flap offers the advantage of a long pedicle for anastomosis, though it comes with higher donor site morbidity. The superficial temporal artery and vein are reliable recipient vessels for scalp reconstruction. [ABSTRACT FROM AUTHOR]

The article discusses the use of endoscopic neck dissection through a post‐auricular hairline incision, followed by intraoral resection of oral cancer and free flap reconstruction. The study included eight patients with tongue and buccal squamous cell carcinoma, with a focus on minimizing facial and cervical skin scars. The procedures were found to be safe, feasible, minimally invasive, and aesthetically appealing, resulting in high patient satisfaction. Further research with larger sample sizes is recommended to compare these techniques with traditional approaches. [Extracted from the article]

Background: Free flap (FF) reconstruction of traumatic injuries to the head and neck is uncommon. Methods: Multi‐institutional retrospective case series of patients undergoing FF reconstruction for a traumatic injury (n = 103). Results: Majority were gunshot wounds (GSW; 85%, n = 88) and motor vehicle accidents (11%, n = 11). Majority underwent osseous reconstruction (82%, n = 84). FF failures (9%, n = 9/103) occurred in GSW patients (100%, n = 9/9) and when multiple subsites were injured (89%, n = 8/9). Preoperative antibiotics correlated with lower rates of a neck washouts (4% vs. 19%) (p = 0.01) and 30‐day readmissions (4% vs. 17%) (p = 0.02). Conclusions: All FF failures occurred in the setting of a GSW and the majority involved multiple subsites. Preoperative antibiotics correlated with lower rates of postoperative washout procedures and 30‐day readmission. [ABSTRACT FROM AUTHOR]

Study Design: Prospective and retrospective studies. Objective: The aim of this study was to evaluate the clinical effects and accuracy of three-dimensionally (3D)-printed patient-specific surgical plates used for mandibular defect reconstruction. Methods: This study included patients who underwent mandibular defect reconstruction with vascularized autogenous bone grafts between January 2012 and August 2021. They were divided into experimental (fixation with 3D-printed surgical plates) and control (fixation with conventional surgical plates) groups. Flap survival rate, postoperative complications and patient self-evaluated facial appearance were compared. Mandibular reconstruction accuracy evaluation included postoperative position deviation of the whole mandible, transplanted bone graft, lower mandibular border, mandibular condyle, and mandibular angle on the reconstructed side compared to baseline. Results: This study included 20 patients (14 males, six females; age, 39.45 ± 11.69 years), ten each in the experimental and control groups. The mean follow-up was 16 ± 22.05 (range, 6-99) months. All procedures were successful, no plate-related complications (breakage, loosening, or exposure of the surgical plates) were reported, and all patients were satisfied. The groups were statistically similar in th e position deviation of the whole mandible, transplanted bone graft, mandibular condyle, and mandibular angle, but the position and morphology of the lower mandibular border on the reconstructed side in the experimental group were better than those in the control group (P = 0.016). Conclusions: 3D-printed patient-specific surgical plates could be applied in mandibular reconstruction safely and effectively, simplifying the surgical procedure, shortening the preoperative preparation times, achieving satisfactory outcomes, and improving the clinical effects and accuracy of individualized mandibular reconstruction. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case series. Objective: Cellular bone allografts (CBAs) contain the components of a successful bone graft with no autologous component and have been used extensively outside the head and neck. Descriptions of their utilization for mandible reconstruction are limited. We review our experience utilizing a CBA, with no autologous component, for the reconstruction of mandible defects. Methods: Patients undergoing reconstruction of a composite mandible defect with a CBA, no added autologous component, within a patient-specific graft cage and soft tissue free flap coverage were retrospectively identified. Graft survival and defect management are assessed and results of post-operative imaging reported. Results: Five subjects, aged 23–56 years, underwent reconstruction of mandible defects with the described technique. Defects resulted from gunshot wounds in 4 patients and the composite resection of a low-grade malignancy in one. The defect was definitively managed in 4 subjects, 3 of which had post-operative imaging demonstrating bone formation. The fifth experienced graft failure after developing an orocutaneous fistula and was successful salvaged with an osteocutaneous fibula free flap. Conclusions: Our early experience is promising that a CBA, with no autologous component, and soft tissue free flap coverage can be used for the reconstruction of composite mandible defects in select patients. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the effect of functional status and patient factors on delays in treatment with adjuvant therapy. Methods: Retrospective chart review (2020–2022) was conducted at a single tertiary referral center. Data were collected between January 2020 and October 2022, and 63 patients underwent free flap reconstructive surgery of the head and neck due to the presence of cancer and received adjuvant radiation therapy (RT). The main outcomes measured were Area Deprivation Index (ADI), Beale scores, distance to radiation center, functional status, patient demographics, gender, and length from surgery to initiation of RT. Results: Of the 63 patients who were reviewed, the average age was 65.5 years old and 63.8% were male. The average ADI state score was 5.6 and the national percentile of 77.1. The average Beale score was 3.7. The average distance traveled was 101.1 miles. Thirty‐five patients were living independently, 16 were living in assisted living or received home care, and 15 were dependent or lived in a nursing home. Mann–Whitney U analysis revealed a significant association of increasing levels of dependence to delays in treatment compared to on‐time treatment (p = 0.002). The odds of treatment delay were increased almost 10‐fold for every additional increase in dependency level (OR = 9.87, 95% CI = 1.42–68.83). Conclusions and Relevance: Degree of dependent functional status correlates with delays in postoperative adjuvant RT in patients undergoing free tissue transfer for head and neck cancer. Preoperative risk stratification allows for physicians to address barriers to adjuvant therapy prior to delay. Level of Evidence: 3 Laryngoscope, 134:4979–4984, 2024 [ABSTRACT FROM AUTHOR]

Background and Objectives: The lateral arm flap has been a very useful choice for the reconstruction of small to medium-sized defects, such as in the hands, extremities, and oral head and neck area. Its versatile characteristics and surgical feasibility allow this flap to be widely applied, but its reconstructive potential in the facial subunit after tumor ablation procedures has never been reported. In this study, we aimed to utilize the advantages of this flap to carry out facial temple subunit defect reconstruction. Materials and Methods: Between 2020 and 2023, 12 patients underwent temple reconstruction with lateral arm free flaps after wide malignant tumor excisions. There were seven women and five men, and the mean patient age was 60.6 years. Among the patients with cancer, six had squamous cell carcinoma, five had basal cell carcinoma, and one had myxofibrosarcoma. All flaps were elevated under general anesthesia. Alprostadil (PGE1, Eglandin®, Mitsubishi Tanabe Korea, Seoul, Republic of Korea) was administered postoperatively. Results: All flaps were the fasciocutaneous type, with sizes that varied from 3 cm × 4 cm to 5 cm × 7 cm (average size: 22.7 cm2). The average pedicle length was 6.1 cm. The versatility of the lateral arm flap enabled successful coverage in all cases, with no specific complications. Good functional outcomes and good ranges of motion in the donor arms were observed after surgery. Conclusions: The authors successfully verified the advantages of lateral arm flaps in the treatment of medium-sized facial temple subunit defects. [ABSTRACT FROM AUTHOR]

Copyright of Sultan Qaboos University Medical Journal is the property of Sultan Qaboos University and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Head and neck osteoradionecrosis (ORN) of the midface requiring free flap (FF) reconstruction is uncommon. This multi‐institutional study was designed to review outcomes for this rare patient population. Methods: Retrospective multi‐institutional review of FF reconstruction for midface ORN (2005–2022; n = 54). Results: The FF survival rate was 87% (n = 54). Patients were less likely to be tolerating a regular diet at 3 months postoperative if they had a preoperative history of prior head and surgery (80% vs. 95%; p = 0.02), a pathologic fracture (50% vs. 90%; p = 0.04), exposed bone intraorally (43% vs. 94%; p = 0.002), or a fistula (67% vs. 96%; p = 0.03). Mean albumin was higher in patients whose FF survived (3.6 ± 0.5 vs. 2.7 ± 1.4; p = 0.03). Patients with low prealbumin were more likely to undergo a hematoma evacuation (27% vs. 0%; p = 0.02). Conclusion: In this series of midface ORN requiring FF reconstruction preoperative nutritional status impacted postoperative complications. Preoperative occurrence of a fistula, pathologic fracture, and intraoral bone exposure correlated with decreased tolerance of a regular diet following reconstruction. [ABSTRACT FROM AUTHOR]

Objectives: The popularity of artificial intelligence (AI) in head and neck cancer (HNC) management is increasing, but postoperative complications remain prevalent and are the main factor that impact prognosis after surgery. Hence, recent studies aim to assess new AI models to evaluate their ability to predict free flap complications more effectively than traditional algorithms. This systematic review aims to summarize current evidence on the utilization of AI models to predict complications following reconstructive surgery for HNC. Methods: A combination of MeSH terms and keywords was used to cover the following three subjects: "HNC," "artificial intelligence," and "free flap or reconstructive surgery." The electronic literature search was performed in three relevant databases: Medline (Ovid), Embase (Ovid), and Cochrane. Quality appraisal of the included study was conducted using the TRIPOD Statement. Results: The review included a total of 5 manuscripts (n = 5) for a total of 7524 patients. Across studies, the highest area under the receiver operating characteristic (AUROC) value achieved was 0.824 by the Auto-WEKA model. However, only 20% of reported AUROCs exceeded 0.70. One study concluded that most AI models were comparable or inferior in performance to conventional logistic regression. The highest predictors of complications were flap type, smoking status, tumour location, and age. Discussion: Some models showed promising results. Predictors identified across studies were different than those found in existing literature, showing the added value of AI models. However, the algorithms showed inconsistent results, underlying the need for better-powered studies with larger databases before clinical implementation. [ABSTRACT FROM AUTHOR]

Background Oral cavity cancers requiring excision of the oral commissure and free flap reconstruction often requires commissuroplasty to manage oral incontinence. We aimed to evaluate the implications of primary versus delayed commissuroplasty on drooling, and interincisal distance outcomes in this cohort. Methods A retrospective query of head and neck cancer patients operated by a single surgeon from 2017 to 2020 was performed. Patients were included if they underwent free flap reconstruction of the oral commissure, had an immediate or delayed commissuroplasty, and had 2 years of follow-up data including Thomas-Stonell and Greenberg drooling rating scales and interincisal distance measurements. Results Thirty-five patients were included in the review. Twelve patients received immediate commissuroplasty and 23 patients had delayed commissuroplasty. Interincisal distance was similar at baseline, although significantly varied between immediate and delayed commissuroplasty groups at 1 month and 2 years postoperative. Drooling scores were significantly elevated in the group treated with delayed commissuroplasty, but eventually normalized after staged surgery and follow-up. Patients treated with adjunct radiation therapy had lower interincisal distance than patients who did not have radiation. Conclusion Delayed commissuroplasty increased interincisal distance and normalize drooling in patients who required full-thickness excision of the buccal mucosa and oral commissure and free tissue reconstruction. The presented data can help to educate patients on expected postoperative outcomes and likely advocates for a second-stage procedure after completion of adjunct radiotherapy to achieve optimal commissural placement and oral competence. [ABSTRACT FROM AUTHOR]

Background and objectives: Although rare, complications like skin dehiscence and necrosis after neurosurgery pose significant challenges by increasing the risk of infections spreading to the epidural, subdural, or intracerebral spaces. This retrospective, single-center study aims to assess the prior clinical courses, neuroplastic repair, and outcomes of patients with skin defects following cranial neurosurgical procedures, and to outline our interdisciplinary reconstructive protocol. Methods: A retrospective analysis was performed on cranial surgeries conducted at the Department of Neurosurgery, spanning from 2017 to 2023. Patients with skin defects requiring the combined expertise of neurosurgery and plastic surgery for effective treatment were included. The sizes of the skin defects were measured using intraoperative photographs analyzed with the freeware ImageJ software, version 2018. All patients provided informed consent for the surgeries. If informed consent was not possible due to neurological deterioration, consent was sought from adult representatives or next of kin except for acute circumstances. All patients admitted to our hospital agree to the pseudonymized use of their medical data and tissue specimens for research purposes in their treatment contract. Results: A cohort of 24 patients experiencing wound healing complications after neurosurgical procedures underwent a total of 29 interdisciplinary surgeries for the reconstruction of skin, dural, and bone defects. After the neuroplastic surgery, 8 out of 24 patients (33.3%) developed surgical complications, with 6 of these requiring revision surgeries due to persistent cranial infection. In all cases, permanent wound closure was successfully achieved following adherence to the proposed treatment algorithm. Conclusions: Our study underscores the necessity of an integrated neurosurgical and plastic surgical approach to effectively manage wound healing complications in a single stage surgery. Key interventions include differentiation between necrosis and gaping lesions, alongside precise management of neurosurgical issues like cerebrospinal fluid fistulas and hydrocephalus. Plastic surgical expertise in assessing the possibilities and limitations of both local and free flap surgeries is essential. [ABSTRACT FROM AUTHOR]

Introduction: The choice of the most adequate surgical technique for upper limb defects remains challenging. The aim of this article is to discuss the main microsurgical (pedicled or free) reconstructive options for the post-oncological reconstruction of different anatomical areas of the upper extremity. Materials and methods: We reviewed different reconstructive methods reported in the literature needing microsurgical expertise and compared them to our clinical experience, in order to provide further guidance in the choice of different flaps for upper limb soft tissue reconstruction. Six clinical cases, one for each anatomical district, are presented as examples of possible solutions. Results: We report the options available in the literature for post-oncologic upper limb reconstruction, dividing them by anatomical area and type of flap: local flaps, regional flaps, free flaps, and distant pedicled flaps. Our examples of the reconstruction of each anatomical area of the upper limb include one reverse ulnar pedicled perforator flap, one free Antero-Lateral Thigh (ALT) flow-through flap, one perforator-based lateral arm flap, two myocutaneous latissimus dorsi pedicled flaps, and one parascapular perforator-plus flap. Conclusions: In oncological cases, it is important to consider reconstructive options that provide stable tissue and allow for the early healing of the donor and recipient site if the patient needs to undergo adjuvant radiotherapy or chemotherapy. A wider range of flap options is essential when choosing the proper technique according to the patient's needs, surgeon's preference, and logistical possibilities. Perforator flaps combine the advantages of other flaps, but they require microsurgical expertise. Free flap reconstruction remains the gold standard to obtain a better overall and cosmetic outcome in complex and wide defects, where no suitable local pedicled flap option exists. The pedicled latissimus dorsi flap should still be included among the reconstructive options for its strong vascularization, size, and arc of transposition. [ABSTRACT FROM AUTHOR]

Objective: To compare free flap outcomes between those who received and did not receive vasopressors (VPs) at the time of free flap reconstruction. Study Design: This retrospective cohort study includes patients from January 2013 to January 2023. Setting: This multicenter cohort study utilized data from the TriNetX Research Network which includes 80 health care organizations. Methods: Head and neck cancer patients older than 18 years who underwent free flap reconstruction were separated into those who received or did not receive VPs on the day of surgery. The primary outcomes were flap failure defined by need for secondary free flap procedures, blood vessel repair, and other flap revision procedures. Results: After propensity score matching, 7446 patients were analyzed. The VP group included 3723 patients (mean age [SD], 62.9 [11.4] years; 2511 males [67.4%]). The non‐VP group included 3723 patients (mean age [SD], 63.0 [11.2] years; 2479 males [66.6%]). Free flap outcomes were not statistically different between groups (secondary free flap: 166 [4.5%] VP vs 155 [4.2%] non‐VP, P =.04; vessel repair: 314 [8.4%] vs 319 [8.6%], P =.06; other flap revision procedures: 416 [11.2%] vs 449 [12.1%], P =.02). Bony flaps were found to have decreased rates of vessel repair in the VP group (47 [6.1%] vs 69 [9.0%], P =.003]. For secondary outcomes, pneumonia (173 [4.6%] vs 231 [6.2%], P =.0002), urinary tract infection (34 [1.0%] vs 59 [1.6%], P =.0007), and deep vein thrombosis (93 [2.5%] vs 122 [3.3%], P =.004) were significantly different. Conclusion: VP use is not significantly associated with free flap complications. These results imply that VP use on the same day as surgery may be safe if clinically necessary. [ABSTRACT FROM AUTHOR]

Background: Complications following head and neck microvascular free tissue transfer (MFTT) are common. Less is known about when they occur. Method: Retrospective study of patients with primary or recurrent head and neck cancer undergoing MFTT reconstruction at a tertiary care institution. MFTT reconstructions with inpatient postoperative complications were included. The Kruskal–Wallis test was used to compare median postoperative day (POD) onset of complication by flap type. Results: Of 1090 patients undergoing MFTT reconstruction, 126 (11.6%) patients experienced inpatient complications including fibula (n = 35), anterolateral thigh (n = 60), or radial forearm (n = 31) MFTTs. POD onset was shortest for surgical site hematoma (median = 1 [IQR 1–5]), and longest for donor site infection (median = 11.5 [IQR 8–15]). There was no significant difference between flap types and POD onset of complications (p > 0.05). Conclusion: Hematoma formation and flap failure occur earliest during hospitalization, while dehiscence, infection, and fistula occur later. There is no difference in complication timing between flap types. [ABSTRACT FROM AUTHOR]

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Introduction: Intraoperative fluid management is one of the most important factors affecting optimal perfusion in the microcirculatory area in patients that undergo flap surgery. While insufficient fluid administration in the intraoperative period leads to flap complications and organ dysfunction, volume load can cause complications such as edema in the denervated flap tissue, the opening of the sutures, or fat necrosis. The Infrared Fluorescent Angiography Perfusion Evaluation Device (SPY) is one of the many noninvasive techniques that evaluate the well-being of microcirculation at the tissue level. This device monitors and scores the perfusion distribution in the flap area. This retrospective study aimed to investigate the effect of fluid resuscitation in head and neck free flap transfer surgery on flap quality and patient outcomes according to the change in SPY scores. Material and Method: This study included 39 ASA I–II patients who were aged 18–60 years and underwent simultaneous free flap reconstruction of the head and neck between 2015 and 2021. Patients' blood pressure, body temperature, hemoglobin, pH, and lactate values were recorded at both baseline and end of the operation. Also, the SPY "Infrared Fluorescent Angiography Perfusion Evaluation Device" scores, the amount of intraoperative fluid and transfusion, bleeding and urine output, and the duration of mechanical ventilation, anesthesia and surgery, and the duration and amount of drainage, the length of stay in hospital and intensive care unit, and the presence of flap infection, detachment, necrosis and loss, and re-exploration rate were recorded for the patients. Results: The difference between the first and last measured SPY values was observed to be positively correlated with the length of stay in the hospital and intensive care unit and the duration of drainage. There was a positive correlation between the length of stay in the hospital and intensive care unit and the duration of drainage, the amount of drainage, as well as the duration of anesthesia and the duration of surgery (p < 0.001). A positive correlation was found between the amount of drainage and the amount of crystalloid solution administered (r = 0.36, p < 0.05). In patients with flap infection, the difference between SPYfirst and SPYlast, the duration of anesthesia, and the duration of surgery were significantly higher. The amount of crystalloid solution given and bleeding and the duration of anesthesia and surgery were found to be significantly higher in mechanically ventilated patients (p < 0.05). Conclusions: It has been concluded that SPY-guided fluid management can be beneficial in preventing morbidities, such as extended hospital and intensive care stay, by reducing flap infection, mechanical ventilation duration, and drainage, with early diagnosis of insufficient perfusion. [ABSTRACT FROM AUTHOR]

Objective: Recent literature studying the impact of blood transfusion on outcomes in patients with head and neck cancer (HNC) have shown that blood transfusions are associated with increased risk of death and higher wound infection rates. The purpose of this study was to implement a lower transfusion threshold while comparing outcomes of free flap patients following initiation of a new transfusion guideline. Methods: A retrospective study of all patients at a tertiary care academic center who underwent free tissue transfer after HNC resection between July 17, 2007 and June 7, 2021. Transfusion criteria were adjusted in 2014; the hematocrit threshold to transfuse was incrementally reduced from 30% in 2007 to 21% in 2017. The main outcomes of interest were overall survival (OS) and recurrence free survival (RFS). Results: A total of 346 patients met the criteria for inclusion in the study. Groups 1 (less strict protocol – 30%) and 2 (stricter protocol – 21%) consisted of 171 and 175 patients, respectively. Fewer units of packed red cells were transfused per patient in group 2 (0.26 vs. 2.87 in group 1, p <.001). Group 1 was associated with worse OS (p =.01; hazard ratio [HR] = 1.7) and RFS (p <.001; HR = 2.5). Comparing only patients with SCC between the two groups also demonstrated poorer OS (p =.01; HR = 1.8) and RFS (p =.006; HR = 2.1) in group 1. Conclusion: In HNC patients undergoing free tissue transfer, stricter transfusion criteria with threshold hematocrit of 21% was associated with improved OS, RFS, and complication rates with no negative impact on free flap survival. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Introduction: Free tissue transfer is now done routinely for Head & neck reconstruction. A suction drain is needed for efficient drainage of the neck post-dissection & with it arises a new dilemma, challenge or obsession amidst the practicing surgeons about the safe and efficient placement of suction drain in an anatomical location so that it does not injure or impair the anastomosis but will still be able to carry out its role efficiently. No prior studies are available regarding the safe practice. Hence the aim of our study was to explore & establish a reliable manoeuvre where the drain could be introduced in a safe and efficient way. From April of 2017-February of 2024 a prospective study was carried out in which cases of 517 patients were taken into account who underwent head and neck reconstruction using a free tissue transfer procedure where the suction drain tube was placed in the dependent part of the neck (i.e. the posterior triangle region) & the margin of sternocleidomastoid muscle was fixed with the pre-vertebral layer of the cervical fascia. The drain was secured externally with a percutaneous non- absorbable suture. Study Design: A prospective Study. Study Period: April 2017- February 2024. Observation: A thorough observation was carried out & no evidence of drain induced anastomotic complications were reported. Conclusion: Hence it can be assumed that this particular method of drain placement is both safe & efficient and it can act as a beacon among the surgeons who suffer a from a dilemma & challenge about where to place the drain safely & efficiently. [ABSTRACT FROM AUTHOR]

Objective: To compare the postoperative complications of the fibular free flap (FFF), scapula free flap (SFF), and osteocutaneous radial forearm free flap (OCRFFF) following osseous reconstruction in the head and neck. Data Sources: PUBMED, EMBASE, Cochrane. Review Methods: A literature search and systematic review were performed using the Preferred Reporting Items for Systematic Reviews and Meta‐analysis guidelines. A meta‐analysis of proportions was conducted using a random effects model to compare operative time and postoperative complications. Results: The systematic review identified 26 studies comparing at least 1 variable of interest. The odds ratio estimates favored reduced rates of flap failure with the OCRFFF when compared to FFF (0.7, confidence interval [CI]: 0.29‐1.11, P <.001), while FFF and SFF were similar. The mean difference estimates for operative time significantly favored FFF over SFF (−51.04 minutes, CI: −92.73 to −9.35, P =.016) and OCRFFF over FFF (66.77 minutes, CI: 52.74‐80.8, P <.001). The FFF was more prone to hardware exposure, longer hospital stays, and donor site complications. Recipient wound complications and fistula rates were similar for all flap types. Conclusion: Depending on the clinical context, the OCRFFF, FFF, and SFF are all robust options for reconstruction in the head and neck. The OCRFFF is associated with a reduced rate of flap failure and shorter operative times. The SFF requires longer operative times, although significant variation was observed between institutions. The FFF has broad reconstructive indications but is associated with more perioperative and long‐term complications. [ABSTRACT FROM AUTHOR]

Background: Perforator mapping is a mandatory tool for the preoperative planning of a microsurgical free flap, especially in breast reconstruction. Numerous methods for mapping have been described. In this study, we investigate the combined use of Dynamic Infrared Thermography (DIRT) and Colour Doppler Ultrasonography (CDUS) only to see whether it can eliminate the need for Computed Tomography Angiography (CTA). Methods: A prospective study was conducted on 33 patients with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. DIRT, followed by CDUS and CTA, was performed preoperatively and perforators were confirmed intraoperatively. Results: From 135 hot spots found on DIRT, 123 perforators were confirmed by CDUS (91.11%). A total of 86.66% of the perforator vessels detected on CTA have their correspondent on DIRT, while 95.12% have their correspondent on CDUS. No statistically significant difference (p > 0.05) was found comparing DIRT vs. CTA and CDU vs. CTA. The average DIRT time was 121.54 s and CDUS 232.09 s. The mean sensitivity for DIRT was 95.72% and 93.16% for CDUS. Conclusion: DIRT combined with CDUS can precisely and efficiently identify suitable perforators without the need for CTA in DIEP breast reconstruction. [ABSTRACT FROM AUTHOR]

Circular pharyngolaryngectomy for oncologic resection requires a tubular reconstruction. Different options can be proposed to the patient: digestive free flap, fasciocutaneous flap, or musculocutaneous flap. The jejunum free flap is a tubular flap commonly used in esophageal and pharyngeal reconstruction with good functional outcomes and an acceptable rate of complications. Reconstruction with a jejunum free flap is an ideal choice. Patients at Gustave Roussy Institute (Villejuif, France) were offered a jejunum flap free flap for all circular pharyngolaryngectomies. The surgical technique is explained with a step‐by‐step video. The jejunum flap free flap has many advantages in circular pharyngolaryngectomy. This video article explains surgical steps for other teams. [ABSTRACT FROM AUTHOR]

Microsurgical autologous breast reconstruction (MABR) remains the gold standard technique of breast reconstruction, providing a durable, natural, and aesthetically pleasing result. However, some patients may not be candidates for a traditional deep inferior epigastric perforator (DIEP) flap, either due to abdominal tissue paucity, the need for higher-volume reconstruction, or prior surgical procedures. In these patients, alternative flaps must be considered to achieve the optimal result. Such configurations include the conjoined (or double pedicle) DIEP flap, and alternative flaps such as the lumbar artery perforator (LAP) and profunda artery perforator (PAP) flaps, which can be combined in a stacked fashion. By combining multiple flaps in a conjoined or stacked fashion, breast reconstruction can be optimized to fulfill the three critical components of breast reconstruction in restoring the skin envelope, breast footprint, and conus shape. When harvesting multiple flaps, the surgical sequence of events must be meticulously planned to ensure an efficient and successful operation. Preoperative imaging can aid the surgeon in identifying the ideal perforator, assess for side branches for possible intra-flap anastomoses, expedite the operative time, and decrease intraoperative complications. Reconstructive surgeons should be familiar with the variety of configurations with conjoined and/or stacked flaps to address patient-specific reconstructive needs. [ABSTRACT FROM AUTHOR]

Background: Free muscle flaps can develop significant postoperative edema and wound exudation, thereby increasing interstitial pressure and potentially compromising microcirculation. While concerns exist regarding negative pressure wound therapy (NPWT) to compress free flaps and hinder monitoring, recent studies have indicated a reduction in edema and an increase in blood flow. Objective: To compare microcirculation in free latissimus dorsi muscle (LDM) flaps dressed with and without NPWT. Methods: This retrospective cohort study analyzed prospectively collected data of patients who received free LDM flap reconstruction. Patients were separated into two groups according to management with or without NPWT. Microcirculation was evaluated continuously for up to 72 h utilizing laser doppler flowmetry and tissue spectrometry. Results: In total, n = 61 patients (26 females, 35 males) with an average age of 56.90 (17.4) years were included. NPWT was applied in 12 patients, while a regular cotton dressing was used in 49 patients. Overall, no significant differences in the number of minor and major complications were observed between groups. Both groups showed an increase in microvascular flow over the investigated time period. The flow showed higher absolute values in the NPWT group, reaching statistical significance at 12 h post-anastomosis, p = 0.038. There was a tendency for lower rHb values in the NPWT group, without reaching statistical significance. Conclusions: The presented study confirms the increase in microvascular flow after NPWT application. Whilst ensuring continuous free flap monitoring utilizing laser doppler flowmetry and spectrometry, the data further support the safety of NPWT application without risking vascular compromise due to external compression. [ABSTRACT FROM AUTHOR]

We report the application and results of skin defect coverage using the free lateral great toe flap in revision surgery for residual postoperative deformities in Wassel-Flatt type IV-D thumb duplications. This retrospective study included five patients treated between June 2020 and September 2021 to correct angular deformity and repair the secondary skin defect. All the flaps survived. The patients were followed up for 8–12 months and all the reconstructed thumbs had a satisfactory appearance. The results of the Japanese Society for Surgery of the Hand scoring system were excellent in one patient, good in three patients and fair in one patient. The results of the Alignment, Ulnar and Radial stability, Range of motion and Aesthetical aspects (ALURRA) scoring system were good in four patients and moderate in one patient. Level of evidence: IV [ABSTRACT FROM AUTHOR]

This report describes two similar cases in which the distal forearm was compressed between the rib cage and floor for a prolonged period owing to immobility, resulting in severe compartment syndrome and extensive penetrating necrosis in the forearm. The cases were a 59-year-old man with cervical spondylolisthesis and a 65-year-old man suspected of having Parkinson's disease. A distinctive necrotic pattern characterized by necrosis in the volar and dorsal compartments, preservation of the lateral compartment, and retention of the radial artery was commonly observed in both cases. Despite the anticipated nonfunctional outcome of the salvaged limb, a two-lobed free latissimus dorsi musculocutaneous flap transfer with interposition of the thoracodorsal nerve in the median nerve defect was performed in both cases. Although the salvaged limbs were nonfunctional, the patients were able to use it for activities such as getting up and other daily tasks. [ABSTRACT FROM AUTHOR]

Background and Objectives: Cutaneous squamous cell carcinoma is the second most common skin cancer. There are many methods for the reconstruction of facial subunit defects after skin cancer excision. The face is vital to a person's life and should be reconstructed considering functional and aesthetic aspects. Despite a variety of flap types and techniques, it is still challenging to meet the various demands. The aim of this study was to compare free flaps for facial reconstruction after resection of cutaneous squamous cell carcinoma. Materials and Methods: This study included 14 patients from January 2021 to June 2023. Patients who underwent facial SCC resection and subsequent reconstruction using free flaps were analyzed retrospectively. Age, sex, and localization were recorded. Follow-ups ranged from 5 to 21 months, with an average of 13 months. Results: All free flaps survived well except one case of partial flap necrosis. In most patients, good to excellent functional and aesthetic results were obtained. The donor site healed uneventfully in all patients. Conclusions: Free flap reconstruction is an excellent choice in wide skin oncologic defects. In terms of texture, it also could be a good surgical method. The use of a fraxel laser can progressively facilitate improved color matching with the surrounding skin. [ABSTRACT FROM AUTHOR]

Anterior mandible defects result in loss of support for the tongue, floor of the mouth and lower lip, resulting in impairment of airway, feeding, and speech. We treated four patients with these "Andy Gump" deformities. Reconstruction was performed with two free flaps: a fibula osteocutaneous flap for the anterior mandible and floor of the mouth, and a soft tissue free flap for the lip, chin, and anterior neck. The lower lip was suspended cranially with fascia or tendon grafts ± mini-temporalis turndown flaps. All flaps survived completely. All patients were tube feed-dependent before surgery; they all resumed an oral diet. All tracheostomies were decannulated. Lip competence was restored as evidenced by cessation of drooling. Speech improved from unintelligible to intelligible with frequent repetitions. Objective assessment was performed with the functional intraoral Glasgow scale; the mean FIGS score improved from 3.25 (range 3–4) to 11 (range 9–13). We conclude that composite anterior mandible and tongue defects have large tissue requirements that require multiple free flaps. Reconstruction leads to significant improvement in function. [ABSTRACT FROM AUTHOR]

Objective: To evaluate postoperative hematoma and takeback rates in a large series of microvascular reconstructions. We sought to determine whether the use of ultrasonic shears reduced these rates. Study Design: Retrospective cohort study. Setting: Tertiary referral hospital. Methods: A total of 2288 patients undergoing free flap reconstruction for head and neck defects between 1995 and 2022 were reviewed. Patients undergoing dissection with and without ultrasonic shears were compared to determine postoperative hematoma and takeback rates. Results: The overall hematoma rate was 1.3% (29/2288) for the entire cohort. The postoperative hematoma rates with and without ultrasonic shears were 0.63% (9/1418) and 2.3% (20/870), relative risk = 0.28, P =.0015. Of 870 patients undergoing surgery without ultrasonic shears, 14 (1.61%) were taken back to the operating room for control of bleeding compared to 8 of 1418 (0.56%) in the ultrasonic shears cohort. Conclusion: Our large series of patients undergoing microvascular reconstruction shows a decrease in postoperative hematoma rate and takeback for bleeding with the adoption of ultrasonic shears. Ultrasonic shears are an effective tool that can help decrease perioperative morbidity secondary to hematoma after head and neck tumor resection and microvascular reconstruction. [ABSTRACT FROM AUTHOR]

Background: A co-surgeon model is known to be favorable in microvascular breast reconstruction, but simultaneous co-surgeon deep inferior epigastric perforator (DIEP) flap cases have not been well-studied. The authors hypothesize that performing two simultaneous co-surgeon bilateral DIEP flap reconstructions results in non-inferior clinical outcomes and may improve patient access to care. Methods: A single-institution, retrospective cohort study was performed utilizing record review to identify all cases of co-surgeon free-flap breast reconstructions over a 38-month period. Patients who underwent simultaneous bilateral DIEP flap breast reconstructions with the same two co-surgeons were identified. The control group consisted of subjects who underwent non-simultaneous reconstruction by the same co-surgeons within the same, preceding, or following month of those in the study group. Primary outcome variables were 90-day postoperative complications, while secondary outcomes were operating time, ischemia time, and length of stay. Descriptive statistics, univariate and multivariable regression analyses were performed. Results: Overall, 137 subjects were identified and 64 met the inclusion criteria (n = 28 study, n = 36 control). There were no statistically significant differences between groups in body mass index, radiation, trainee experience, flap perforator number, immediate/delayed reconstruction, or length of stay. There were also no statistically significant differences in complications, including flap loss, anastomosis revision, take-back to the operating room, or re-admission. Operative time was longer in the simultaneous DIEP group (540.5 vs. 443.5 min, p < 0.01), but ischemia time was shorter in the simultaneous group (64.0 vs. 80.5 min, p < 0.01). Conclusions: A simultaneous co-surgeon approach to bilateral DIEP flap reconstruction may improve access to care and does not result in a higher complication rate compared with non-simultaneous bilateral DIEP flaps. [ABSTRACT FROM AUTHOR]

Background: Limb-sparing resections of thigh soft tissue sarcomas (STSs) can result in adverse outcomes. Identifying preoperative predictors for wound healing complications, tumor recurrence, and mortality is crucial for informed reconstructive decision-making. We hypothesized that preoperative measurements of thigh and tumor dimensions could serve as reliable indicators for postoperative complications, recurrence, and death. Patients and Methods: In this retrospective cohort study conducted from March 2016 to December 2021, we analyzed patients undergoing thigh STS excisions followed by reconstruction. Preoperative magnetic resonance imaging or computed tomography scans provided necessary thigh and tumor dimensions. Univariate and multivariate regression assessed relationships between these dimensions and postoperative outcomes, including complications, recurrence, and death. Results: Upon the analysis of 123 thighs, we found thigh width to be highly predictive of postoperative complications, even surpassing body mass index (BMI) and retaining significance in multivariate regression [odds ratio (OR) 1.19; 95% CI 1.03–1.39; p = 0.03]. Sarcoma-to-thigh width and thickness ratios predicted STS recurrence, with the thickness ratio retaining significance in multivariate regression (OR 1.03; 95% CI 1.001–1.05; p = 0.041). Notably, greater thigh thickness was independently protective against mortality in multivariate analysis (OR 0.80; 95% CI 0.65–0.98; p = 0.030). Conclusions: Thigh width outperformed BMI in association with postoperative complications. This may create an opportunity for intervention, where weight loss can play a role during the neoadjuvant therapy period to potentially reduce complications. Sarcoma-to-thigh width and thickness ratios, particularly the latter, hold substantial predictive value in terms of STS recurrence. Moreover, thigh thickness is an independent predictor of survival. [ABSTRACT FROM AUTHOR]

Background: Medication related osteonecrosis of the jaw (MRONJ) requiring free flap (FF) reconstruction is uncommon with limited reported findings. Methods: Multicenter, retrospective case series of 49 consecutive adult patients presenting with advanced MRONJ requiring FF reconstruction from 2010 to 2022. Perioperative complications and outcomes were analyzed. Results: Eighty‐two percent (n = 40) of cases were of the mandible and 18% (n = 9) were of the maxilla. The mean follow‐up was 15 months (±19.6). The majority of FF survived (96%, n = 47). FF reconstructions of the maxilla were more likely to require postoperative debridement (56%, 95% CI [27, 81%] vs. 15%, 95% CI [7, 25%], p = 0.008) or develop intraoral bone exposure (56%, 95% CI [27, 81%] vs. 18%, 95% CI [9, 27%], p = 0.02). Most patients (71%, n = 35) received preoperative antibiotics which was associated with a higher rate of FF survival (100% vs. 86%, 95% CI [60, 96%], p = 0.02) and fewer complications. Conclusions: Patients undergoing FF reconstruction for MRONJ do well with high rates of FF success. MRONJ of the maxilla have a higher rate of some complications. Preoperative antibiotics correlated with higher FF survival and fewer postoperative complications. [ABSTRACT FROM AUTHOR]

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow‐up was 12.6 (IQR: 6–18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications. [ABSTRACT FROM AUTHOR]

Topical application of 3 vasodilators has been used in 19 patients and 20 free flaps to facilitate microvascular anastomosis. The author by hit and trial struck with a formula of one ampule of heparin, two ampules of papaverine, and five ampules of lidocaine for topical application just before microvascular anastomosis. This solution was tested both subjectively as an intragroup operating team for the ease of anastomosis, and objectively the outcome of microvascular flap survival was assessed. A sample of 20 consecutive free flaps was included on accrual and assessed for ease of operating under aided vision and flap survival. The solution was poured on recipient and donor site until the vessels were flooded for at least 15 min for its full vasodilatory effect. Vessels' diameters were measured before and after using the solution by a caliper and a micrometer. A total of 40 arteries and 46 veins were measured at recipient and donor sites. Mean diameter of artery increased from 3.07 to 3.77 mm, a 22.80% increase (p value < 0.001). Mean diameter of vein increased from 3.45 to 3.93 mm, a 13.62% increase (p value < 0.001). HM125 is an effective vasodilatory solution—HM is the initials of senior author's name, and 125 stand for one ampule heparin, two papaverine, and five ampules of lidocaine, respectively. This is a pilot study of this innovative concoction for vasodilatation for microvascular anastomosis which needs to be externally verified by other users both in case series analyses and trials. [ABSTRACT FROM AUTHOR]

Background: Soft tissue defects of the lower limbs pose significant challenges in reconstructive surgery, accounting for approximately 10% of all reconstructive free flaps performed. These reconstructions often encounter higher complication rates due to various factors such as inflammation, infection, impaired blood flow, and nerve injuries. Methods: A systematic review was conducted following PRISMA guidelines, reviewing literature from 2017 to 2024. Eligible studies included those on free flap reconstruction of lower limb defects in living human subjects, with more than three cases and reported rates of flap failure and return to the operating room. Systematic reviews and metanalysis were excluded. Results: A total of 17 studies comprising 5061 patients and 5133 free flap reconstructions were included. The most common defects were in the lower leg (52.19%) due to trauma (79.40%). The total flap necrosis rate was 7.78%, the partial necrosis rate was 9.15%, and the rate of return to the operating room for suspected vascular compromise was 13.79%. Discussion: Lower limb reconstruction presents challenges due to diverse etiologies and variable tissue requirements. Factors such as recipient vessel availability, flap selection, and multidisciplinary approaches influence outcomes. Muscle and fasciocutaneous flaps remain common choices, each with advantages and limitations. This systematic review underscores the importance of individualized treatment planning. Conclusions: Microsurgical reconstruction of lower limb defects demonstrates safety and reliability, with overall favorable outcomes. Flap selection should be tailored to specific patient needs and defect characteristics, emphasizing meticulous surgical techniques and multidisciplinary collaboration. This systematic review provides valuable insights into current standards and encourages adherence to best practices in lower limb reconstruction. [ABSTRACT FROM AUTHOR]

Iatrogenic tracheoesophageal fistulae management and repair are difficult to manage with few resourced describing management and repair. Two cases are presented describing the approach to and repair of a tracheoesophagea fistula; one with a free flap and one with local flap reconstruction. Both cases utilized allograft material to maintain separation between the alimentary and repiratory tracts. Laryngoscope, 134:3761–3764, 2024 [ABSTRACT FROM AUTHOR]

Background: Electrical burns are potentially devastating injuries. Scalp defects following electrical burns present as a reconstructive challenge. The factors influencing decision-making in the repair of scalp defects are their size, depth and location, and integrity of surroundings. A successful reconstruction must result in less morbidity, decreased hospitalization time, and good aesthetic appearance preserving the hairline. The rationale for the study is to study the epidemiology of post-electrical burns scalp defects and to propose an algorithm for their reconstruction. Methods: This retrospective study includes 95 patients with post-electrical burns scalp defects from Jan 2013 to Dec 2022. Patients admitted with scalp defects resulting from electrical injuries were initially resuscitated. Once deemed fit for surgery, they underwent wound debridement. Due to the progressive tissue necrosis associated with electrical burns, multiple debridements were necessary. Various methods were employed to reconstruct the scalp defects based on the specific nature of the defect, including primary closure, skin grafting, and the use of flaps. Follow-up visits were scheduled weekly for the first month and then monthly for the subsequent six months. Results: 52 patients had pericranium intact for which SSG was performed. 43 cases had loss of pericranium for which local flaps were given in 36 cases. In 2 patients skin traction by stainless steel wires was done. Sequestrectomy + Tensor fascia lata Graft with Bipedicle Advancement Flap cover was done for a patient with osteomyelitis of bone. Regional Vertically placed Trapezius Myocutaneous flap was done in 3 cases and for one case Free Anterolateral thigh flap was given. Conclusion: Reconstruction of post-electrical burn scalp defects should follow the reconstructive ladder. Reconstructive strategies are to be adapted based on defect size, depth, presence or absence of pericranium. If pericranium is intact - split-thickness skin grafting can be done. If pericranium is lost - a flap cover is to be given. Local flaps are the ideal choice for the reconstruction of scalp defects due to their easy availability, and minimal complications. [ABSTRACT FROM AUTHOR]

Introduction: The tongue plays a crucial role in speech, swallow and sleep. It is the most common site of primary intraoral cancer. A fasciocutaneous free flap is the first reconstructive option after surgery. Materials and Methods: The aim of this study was to investigate the functional outcomes in patients treated with hemiglossectomy. We evaluated the objective tests and subjective assessments of swallowing, speech and sleep at 30 days after the surgery (T0) and at least 6 months after the end of the treatment (T1). We have implemented a battery of validated tools that comprehensively evaluate functional outcomes after resection of oral cancer, including speech, swallowing and head-and-neck-specific quality of life: MD Anderson Dysphagia Inventory (MDADI), Performance Status Scale-Head and Neck (PSS-HN) and Lazarus Tongue Range of Motion (ROM) Scale. Patients underwent objective tests such as videonasal endoscopic evaluation and magnetic resonance imaging. All patients were subjectively assessed with the Epworth Sleepiness Scale and underwent nocturnal polygraphy. Results: We treated six patients with advanced squamous cell carcinoma of the tongue; three received radial forearm flap and three received anterolateral thigh flap. Our study found that ROM, flap volume and defect volume are the most important characteristics for better MDADI, PSS-HN, Epworth score and respiratory disturbance index (RDI) on polygraphy. Discussion: Reconstruction of tongue cancer defects is challenging as the surgeon must consider adequate control of the tumour while also optimising residual functional capacity. The volume of the flap and ROM would seem to be the most important characteristics for improving the functional outcome. [ABSTRACT FROM AUTHOR]

Case: A 51-year-old woman, who had previously undergone C5-C7 anterior cervical discectomy and fusion, presented with symptomatic hardware failure and subsequently underwent instrumentation removal. Her postoperative course was complicated by an esophageal perforation. Despite initial repair using a rotational flap, the leak persisted, prompting esophageal reconstruction with a radial forearm free flap (RFFF). Conclusion: Persistent esophageal perforation is exceedingly rare and difficult to treat. This report discusses the surgical technique for RFFF, an excellent option for revising failed sternocleidomastoid rotational flaps. The decision between rotational repair and free flap reconstruction depends on factors such as defect size, vascularization, wound condition, and donor site morbidity. [ABSTRACT FROM AUTHOR]

Background: Obesity remains a high-level risk factor for various cancers. Yet, some research has shown that higher BMIs may improve survival outcomes, particularly for head and neck squamous cell carcinoma (HNSCC). While this is a clear deviation from the norm, it raises the question of what other effects obesity may have on head and neck cancer patients, including surgical outcomes. Choosing the most appropriate flap for patients can be difficult for even experienced surgeons. Head and neck reconstructive surgeries are no exception to this rule and can be especially challenging. To produce the most favorable outcomes, a physician must be able to combine all flap attributes including donor and recipient site location, flap thickness, as well as each patient's individual risk factors such as prior radiation. Purpose: The purpose of this study was to compare the outcomes of vertical rectus femoris myocutaneous (VRAM) and anterolateral thigh (ALT) flaps in overweight and obese individuals with varying head and neck cancers leaving large-sized defects to the outcomes in normal and underweight patients. Methods: A retrospective chart review was conducted of VRAM and ALT flaps performed over a period of 12 months at our university hospital for large head and neck reconstruction. Results: Of the 17 ALT patients, 80% (4/5) of the underweight patients, 57% (4/7) of the normal weight patients, 50% (1/2) of the overweight patients, and 33% (1/3) of the obese patients experienced complications. Of the 15 VRAM patients, 40% (2/5) of the underweight patients, 83% (5/6) of the overweight patients, and 50% (1/2) of the obese patients experienced complications. Conclusions: In our small sample size, a smaller percentage of obese patients with head and neck cancer who underwent flap reconstruction surgery had complications when undergoing ALT flaps than VRAM flaps, which contrasts with the normal and underweight patients, who had less complications with VRAM flaps than ALT flaps. [ABSTRACT FROM AUTHOR]

Background: The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free flap, the reserve flow principle has been primarily described to either augment or "supercharge" a large ALT to optimize skin perforator supply or lengthen the vascular pedicle. Methods: We report a case of a 77‐year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed. Results: We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction. Conclusion: This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle. [ABSTRACT FROM AUTHOR]

Background: Transoral robotic surgery (TORS) for oropharyngeal malignancy optimizes oncologic outcomes while preserving functionality. This study identifies patterns of functional recovery after TORS with free flap reconstruction (FFR). Methods: Retrospective cohort study at a tertiary care center of patients with primary oropharyngeal tumors treated with TORS with FFR between 2010 and 2022. Patients were categorized into: adjuvant chemoradiation or radiation, or no adjuvant therapy (NAT). Functional outcomes were measured by functional oral intake scale (FOIS). Results: 241 patients were included. FOIS declined at first postoperative appointment (median = 7.0 to 2.0, IQR = [7.0, 7.0], [2.0, 4.0]), and progressively improved to 6.0 (5.0, 6.0) after 1 year, with NAT having the highest FOIS (7.0, p < 0.05). Predictors of poor long‐term FOIS included RT and hypoglossal nerve (CN XII) involvement (p < 0.05). Conclusions: TORS with FFR leads to good long‐term function with minimal intake restrictions. Radiation therapy and CN XII involvement increase risk of worse functional outcomes. [ABSTRACT FROM AUTHOR]

Background This study aimed to quantify the blood flow of free flaps and compare the blood flow of small vessel (<0.8 mm) and larger vessel (>0.8 mm) anastomosed free flaps. Methods This retrospective study included patients treated successfully with a perforator free flap in the lower extremity between June 2015 and March 2017. A color duplex ultrasound system measured the flow volume through the pedicle by analyzing the mean flow peak velocity, flow volume, and flow volume per 100 g of the flap. Results A total of 69 patients were enrolled in this study. There was no statistical difference in peak velocity between the small vessel anastomosed free flap (25.2 ± 5.6) and larger vessel anastomosed free flap (26.5 ± 5.4). Flow volume (6.8 ± 4.2 vs. 6.3 ± 3.6) and flow volume/100 g (3.6 ± 3.9 vs. 6.2 ± 6.9) also did not show significant differences. Conclusion Small vessel (<0.8 mm) free flaps showed similar flow velocity and flow volume to larger vessel (>0.8 mm) anastomosed free flaps. Blood flow to the small vessel anastomosed free flap was sufficient despite its small vessel size. [ABSTRACT FROM AUTHOR]

Background Superficial inferior epigastric artery (SIEA) flap offers a significant advantage of lower donor site morbidity over other abdominal-based flaps for breast reconstruction. However, the inconsistent anatomy and territory across the midline remains a major issue. This study aimed to investigate the SIEA and determine its pattern and territory across the midline. Methods Twenty cadavers were studied. Ipsilateral dye was injected to the dominant SIEA. Dissection was performed to evaluate the SIEA origin, artery and vein pattern, vessel diameter, and dye diffusion territory. Results Overall, three SIEA patterns were identified: bilateral presence (45%), ipsilateral presence (30%), and bilateral absence (25%). The territory depended on the vessel course and dominant SIEA diameter, not on its common origin from the femoral artery, at the pubic tubercle level. Regarding the midline territory (pubic tubercle level to umbilicus), SIEA (type 1a) with a diameter of ≥1.4 mm on either side supplied at least half the distance, whereas SIEA with a diameter of <1 mm was limited to the suprapubic area. Conclusion Designing a SIEA flap island across the midline is feasible when contralateral SIEA is present to augment the contralateral territory (e.g., type 1a SIEA) or in SIEA with a common/superficial external pudendal artery origin. Preoperative imaging studies are important for confirming the SIEA system. When the diameter at the origin of the SIEA flap is larger than 1.4 mm, the blood supply to the ipsilateral and contralateral sides is sufficient to enable safe flap elevation. [ABSTRACT FROM AUTHOR]

Hyperspectral imaging (HSI) is a new emerging modality useful for the noncontact assessment of free flap perfusion. This measurement technique relies on the optical properties within the tissue. Since the optical properties of hemoglobin (Hb) and melanin overlap, the results of the perfusion assessment and other tissue-specific parameters are likely to be distorted by the melanin, especially at higher melanin concentrations. Many spectroscopic devices have been shown to struggle with a melanin related bias, which results in a clinical need to improve non-invasive perfusion assessment, especially for a more pigmented population. This study investigated the influence of skin tones on tissue indices measurements using HSI. In addition, other factors that might affect HSI, such as age, body mass index (BMI), sex or smoking habits, were also considered. Therefore, a prospective feasibility study was conducted, including 101 volunteers from whom tissue indices measurements were performed on 16 different body sites. Skin tone classification was performed using the Fitzpatrick skin type classification questionnaire, and the individual typology angle (ITA) acquired from the RGB images was calculated simultaneously with the measurements. Tissue indices provided by the used HSI-device were correlated to the possible influencing factors. The results show that a dark skin tone and, therefore, higher levels of pigmentation influence the HSI-derived tissue indices. In addition, possible physiological factors influencing the HSI-measurements were found. In conclusion, the HSI-based tissue indices can be used for perfusion assessment for people with lighter skin tone levels but show limitations in people with darker skin tones. Furthermore, it could be used for a more individual perfusion assessment if different physiological influencing factors are respected. [ABSTRACT FROM AUTHOR]

Background: Knowledge about factors associated with long-term outcomes, after severe traumatic injury to the lower extremity, can aid with the difficult decision whether to salvage or amputate the leg and improve outcome. We therefore studied factors independently associated with capability at a minimum of 1 year after amputation or free flap limb salvage. Methods: We included 135 subjects with a free flap lower extremity reconstruction and 41 subjects with amputation, between 1991 and 2021 at two urban-level 1 trauma centers with a mean follow-up of 11 ± 7 years. Long-term physical functioning was assessed using the Physical Component Score (PCS) of the Short-Form 36 (SF36) and the Lower Extremity Functional Scale (LEFS) questionnaires. Independent variables included demographics, injury characteristics, and the Mental Component Score (MCS) of the SF36. Results: Greater mental health was independently and strongly associated with greater capability, independent of amputation or limb reconstruction. Mental health explained 33% of the variation in PCS and 57% of the variation in LEFS. Injury location at the knee or leg was associated with greater capability, compared to the foot or ankle. Amputation or limb reconstruction was not associated with capability. Discussion: This study adds to the growing body of knowledge that physical health is best regarded through the lens of the bio-psycho-social model in which mental health is a strong determinant. This study supports making mental health an important aspect of rehabilitation after major lower extremity injury, regardless of amputation or limb salvage. [ABSTRACT FROM AUTHOR]

Background: Head and neck tissue defects after ablative surgery often require complex and composite reconstructions. The superficial circumflex iliac artery perforator (SCIP) flap is an extremely versatile perforator‐based flap with minimal donor site morbidity, which may represent the optimal procedure in this setting. Over the last 5 years, we collected a large base of experience, including both simple and chimeric SCIP‐based reconstruction, making this flap our first choice for head and neck reconstructions. Patients and Methods: Seventy‐three patients undergoing ablative head and neck surgery for oncologic pathologies were treated by means of a SCIP flap reconstruction. Patients' mean age was 67 years old (range 37–89), 51 were males and 22 were females. Fifty‐eight flaps were simple and 15 were chimeric reconstruction patterns. Indocyanine green perfusion imaging was performed in all cases. Results: All the patients were successfully treated with no flap losses were encountered. Twelve patients encountered postoperative complications: in four cases revision surgery was required for venous congestion, while the remaining cases were managed conservatively (four wound dehiscence and three infections). No patients showed donor site complications. The mean follow‐up period was 11 months (range 3–24). Conclusions: Our case series demonstrates the reliability and versatility of the SCIP flap for different kinds of head and neck reconstructions. The chimeric options combined with bone, double skin paddle, and muscle offer a broad variety of functional reconstructive solutions for complex head and neck surgeries. Intraoperative indocyanine green perfusion examination provides a valuable tool to assess and ascertain proper vascularization and post‐anastomosis vessel patency in complex microvascular flap‐based reconstructions. [ABSTRACT FROM AUTHOR]

The osteocutaneous radial forearm free flap (OCRFFF) is a versatile flap with the ability to reconstruct complex defects. We detail the techniques necessary to harvest an OCRFFF, including an outline on making 90‐degree osteotomies to maximize bone harvest. In this pictorial essay, we provide illustrations of the anatomy and surgical techniques necessary for OCRFFF harvest. Detailed discussion is provided on how to protect the perforators to the bone and the approach to making osteotomies in a 90‐degree fashion. The approach for prophylactic plating of the radius to prevent radius fractures is outlined. A case presentation on the real‐life utilization of this flap is included. The OCRFFF is an excellent head and neck reconstructive option. While there are limitations to its use for patients requiring dental rehabilitation or long/anterior mandibular defects, for the right patient and indication it has shown great success in reconstructive efforts. [ABSTRACT FROM AUTHOR]