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Background: Current knowledge about patients’ perceptions of the donor site following abdominal-based breast reconstruction and its effect on health-related quality of life (HRQoL) several years after breast reconstruction is limited. This study aimed to assess the long-term effects of deep inferior epigastric perforator (DIEP) flap breast reconstruction on HRQoL, specifically focusing on the abdomen and donor site aspects. Methods: This retrospective cohort study compared 66 women who underwent DIEP breast reconstruction between 2000 and 2007 with a matched control cohort of 114 women who underwent therapeutic mastectomies without reconstruction in the year 2005. The DIEP cohort of patients completed the BREAST-Q Reconstruction module during an outpatient visit in 2015–2016. The control cohort completed the same questionnaire online in 2016. Results: The follow-up time was at least 8 years (mean 11.4 ± 1.6 years) postreconstruction for the DIEP cohort and 10 years postmastectomy (mean 11.0 ± 0.3 years) for the control cohort. In the DIEP cohort, 93% reported no donor site pain, 89% had no difficulty sitting up, and 91% had no activity limitations 2 weeks before completing the survey. Patients undergoing DIEP were more satisfied with their abdominal appearance than the control group (adjusted OR, 5.7; 95% confidence interval 1.8–17.6). Conclusions: A decade postoperatively, DIEP breast reconstruction yields high abdominal donor site satisfaction, with comparable abdominal physical well-being to nonreconstructed women., Authors and title in the list of papers of Andreas Svee's thesis: Svee, A., Sjökvist, O., Moradi, M., Falk-Delgado, A., Mani, M. The Long-term Effects of DIEP Breast Reconstruction on Abdomen-Related Quality of Life: A Cohort Study with More Than Eight Years Follow-up

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Oncoplastic breast reconstruction has allowed for the optimization of oncologic and reconstructive outcomes after breast-conserving surgery (BCS). Volume replacement procedures in oncoplastic reconstruction most commonly utilize regional pedicled flaps, though several studies have reported benefits to free tissue transfer for oncoplastic partial breast reconstruction in the immediate, delayed-immediate and delayed settings. Microvascular oncoplastic breast reconstruction is a useful technique in the appropriate patients with small-to-medium size breasts and larger tumor-to-breast ratios who desire to preserve breast size, those with a paucity of regional breast tissue and patients that wish to avoid chest wall and back scars. Several free flap options for partial breast reconstruction exist, including superficially-based abdominal flaps, medial thigh-based flaps, deep inferior epigastric artery perforator (DIEP) flaps and thoracodorsal artery-based flaps. However, special consideration should be given to preserving donor sites for potential future total autologous breast reconstruction with any flap choice that should be tailored to individual recurrence risk. Aesthetically placed incisions should take recipient vessel access into consideration which include the internal mammary vessels and perforators medially, and then intercostal, serratus branch and thoracodorsal vessels laterally. The utilization of a thin strip of lower abdominal tissue based on the superficial abdominal circulation allows for a well-concealed donor site with minimal morbidity and preservation of the abdominal donor site if future total autologous breast reconstruction is needed. Optimizing outcomes requires a team-based approach to appropriately design recipient and donor-site considerations while individualizing tumor and patient-specific plans.

Chapter 2 retrospectively investigated postoperative complications (POC) in patients who had undergone primary free flap reconstructions after surgical treatment of oral cancer. Surgical complications occurred in 32% of the patients and systemic complications occurred in 8% of the patients. Prolonged anaesthesia time and red cell transfusion were associated with systemic complications and prolonged hospital stay, respectively. Although both variables are difficult to modify, these may create awareness during the postoperative course and may be informative in the preoperative phase for patient selection and during the informed consent process. Chapter 3 gives an estimation of the occurrence of symptomatic venous thromboembolism (VTE) in 233 surgical oral cancer patients. Despite almost all patients (97%) were classified as having the highest risk for VTE, the occurrence of VTE in surgical oral cancer patients seems to be rare, if thromboprophylaxis is used (overall incidence: 0.4 %). We could not recommend the use of routine thromboprophylaxis as there was no control group without thromboprophylaxis. Therefore, thromboprophylaxis could be advocated in patients with obvious and serious risk factors. Chapter 4 focused on POCs in patients who had undergone reconstruction of segmental mandibular defects with free fibula flaps after surgical ablation of oral cancer. During the first year, POCs occurred in 47 patients (54.7%). Twenty-eight patients (32.6%) had surgical complications, 10 patients (11.6%) had systemic complications and 9 patients (10.5%) had surgical and systemic complications. Active smoking, mandibular reconstruction in the symphyseal region, and TNM anatomic stage group>II were associated with surgical complications. Age>60 years and a Charlson Comorbidity Index (CCI)>2 were identified as predictive factors for systemic complications. With exemption of smoking habits, most variables are relatively unchangeable and its clinical value is mostly inf

Background: The indications for microsurgical breast reconstruction remain debated, particularly concerning the safety of deep inferior epigastric perforator (DIEP) flaps in elderly women. Free tissue transfer still carries a risk of perioperative morbidity and mortality in elderly patients. We conducted this comparative study to clarify this issue. Methods: This retrospective cohort study included all unilateral DIEP breast reconstructions performed at a single institution. Patients were divided into two groups based on age: an elderly (60 years or older) and a non-elderly cohort (younger than 60 years). Demographic and comorbidity data were secondary predictor variables. The primary outcomes were complete flap loss, partial flap loss, and the need for flap re-exploration. The secondary outcomes included surgical site occurrences, such as wound healing-related complications, seroma, and others. Results: We included 214 flaps, 177 in the non-elderly and 37 in the elderly cohort. Elderly women had slightly higher comorbidity rates than those of non-elderly women, although these differences were not statistically significant. BMI was significantly lower in elderly women than in non-elderly women. The incidence of total or partial flap loss did not differ significantly between the two cohorts (2.7% vs 1.1%, p = 0.459% and 0.0% vs 5.1%, p = 0.161), nor did the flap re-exploration (8.1% vs 10.1%, p = 0.937). Similarly, postoperative complication rates did not differ significantly between the two groups (45.9% vs 61.8%, p = 0.074). On logistic regression, being elderly was not a risk factor for complete flap loss, nor for any complications. The overall success rate for the non-elderly cohort was 98.7%, whereas that for the elderly cohort was 97.3%. Conclusions: Microsurgical breast reconstruction using DIEP is safe in elderly patients, as it achieves outcomes and complications rates comparable to those observed in a younger population. Patients should not be denied DIE

Introduction : During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure.Patients and methods : In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications.Results : In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion : Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery., Einleitung : Während der letzten Dekaden erhielt die freie Lappenplastik eine Hauptrolle in der rekonstruktiven Chirurgie. Insbesondere an den Extremitäten, mit begrenzt verfügbarem Gewebe, haben freie Lappenplastiken eine besonders wichtige Funktion. Das Ziel unserer Studie war, die Risikofaktoren für einen partiellen oder kompletten Lappenverlust zu evaluieren.Patienten und Methoden : In einer retrospektiven Kohortenstudie wurden die Daten von allen Patienten gesammelt, welche eine freie Lappenplastik innerhalb der ersten fünf Jahre seit der Gründung unserer Abteilung erhielten. Patienten- und Chirurgie-bezogene Risikofaktoren wurden bezüglich der postoperativen Komplikationen untersucht.Ergebnisse : Insgesamt wurden 182 freie Lappenplastiken in diese Studie eingeschlossen. Ein partieller Lappenverlust trat bei 21,42%, ein kompletter bei 17,03% auf. Die Zeitspanne von Débridement bis zum Tag der Deckung mittels freier Lappenplastik stellte einen statistisch signifikanten Risikofaktor für den Lappenverlust dar (p=0.022). Die Lappenplastiken, die zwischen Tag 4 und 14 operiert wurden, zeigten die geringste Verlustquote. Geschlecht, Alter, arterielle Hypertonie, Nikotinabusus, Diabetes mellitus, periphere arterielle Verschlusskrankheit sowie die Anzahl der anastomosierten Venen waren nicht signifikant mit dem Lappenverlust assoziiert. Schlussfolgerung : Unsere Studie zeigt, dass freie Lappenplastiken sicher und mit einer akzeptablen Lappenverlustratte sowohl bei Gesunden als auch bei Risikopatienten durchgeführt werden können. Randomisiert kontrollierte Studien sind zukünftig notwendig, um die genaue Rolle jedes Risikofaktors festzustellen.

Purpose: The availability of reliable and suitably sized veins is limited for creating free flaps to treat severe trauma and infection, and it is important to manage vessel size discrepancy between the recipient and flap veins. We evaluated the clinical outcomes of free flaps with large-to-small venous end-to-side (ETS) anastomoses using the microscopic parachute end-to-side (MPETS) anastomosis in soft tissue defects in the extremities. This procedure comprises mainly a wide-slit venotomy and parachute procedure at the heel. Methods: We examined 24 free flaps in 23 patients given a largeto-small venous anastomosis using the MPETS technique. Patient demographics, details of vessel anastomoses, and flap outcomes and complications were obtained from medical records. Results: Two veins were anastomosed in six flaps. Thirty anastomosed veins were assessed, and 24 deep veins, all of which accompanied main arteries, were chosen as recipient veins. The mean diameters were 1.5 mm in the recipient veins and 2.7 mm in the flap veins, and the mean vessel size discrepancy was 1.8-fold (range 1.3-3.3 fold). Because of the presence of venous valves at the anastomotic site, trimming of venous cusps was performed in six veins. All flaps survived, though one venous thrombosis occurred because of pedicle kinking in a case with a short pedicle. Conclusions: The MPETS technique is simple, reliable, and useful for performing various types of venous anastomoses regardless of a vessel size discrepancy and the presence of a venous valve. This may be a good option for large-to-small venous anastomosis in free flaps. (c) 2022 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.

BACKGROUND: Frontal sinus cranialization with closure via bifrontal pericranial flaps is the gold standard for separating the nasofrontal recess from the intracranial cavity for posterior table defects. Despite the high success rate, cerebrospinal fluid (CSF) leak may persist and is particularly challenging when vascularized reconstructive options from the bicoronal incision are exhausted. OBJECTIVE: To assess a novel endonasal technique using an adipofascial radial forearm free flap delivered to the frontal recess through a Draf sinusotomy to repair complex CSF leaks from the frontal sinus. METHODS: A retrospective review of 3 patients (all male; ages 42, 43, and 69 yr) with persistent CSF leak despite frontal sinus cranialization and repair with bifrontal pericranium was performed. Etiology of injury was traumatic in 2 patients and iatrogenic in 1 patient after anaplastic meningioma treatment. To create space for the flap and repair the nasofrontal ducts, endoscopic Draf III (Case 1, 3) or Draf IIb left frontal sinusotomy (Case 2) was performed. The forearm flap was harvested, passed through a Caldwell-Luc exposure, and placed within the Draf frontal sinustomy. The flap vessels were tunneled to the left neck and anastomosed to the facial vessels by the mandibular notch. RESULTS: Intraoperatively, the flaps were well-seated and provided a watertight seal. Postoperative hospital courses were uncomplicated. There were no new CSF leaks or flap necrosis at 12, 14, and 16 mo. CONCLUSION: Endoscopic endonasal free flap reconstruction through a Draf procedure is a novel viable option for persistent CSF leak after failed frontal sinus cranialization.

BACKGROUND: Perforator flaps yield the best results for the patient with the least morbidity, and they should be considered the gold standard in head and neck reconstruction. Although deep inferior epigastric perforator (DIEP) flap is considered as the gold standard in breast reconstruction, its use in head and neck reconstructive surgery does not seem so widespread. The objective of this study is to conduct a systematic review of the use, applications and results of the DIEP flap in the head and neck area. METHODS: Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through meta-searcher Trip Database with deep inferior epigastric perforator flap AND head neck keywords. Studies on animal and human experiments published in peer-reviewed journals, where investigators assessed the use of DIEP flap, according to the Koshima criteria, in the head and neck area were considered. RESULTS: A total of 31 articles and 185 flaps with 95% of survival were found. Thrombosis or venous stasis is the most frequent cause of flap loss and 16.1% presented some type of complication, the most frequent being the dehiscence. The most use was in the reconstruction of glossectomy defect secondary to squamous cell carcinoma (30.51%), being able potentially to re-establish sensory innervation in oral cavity. The assessment of risk bias (National Institutes of Health) highlights the lack of uniformity, with no standardisation of the outcome variable collection and monitoring. DISCUSSION: By virtue of its versatility, reliable vascular supply and high flap survival rate, the DIEP flap reconstruction could be an option in complicated 3-dimensional head and neck defects while maintaining the standard of low donor site morbidity.

Introduction: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. Methods: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. Results: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. Conclusions: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.

Purpose: The aim of the present of study was to examine nutrition deficit during the immediate postoperative in-hospital period following free flap surgery for cancer of the head and neck (HNC). Underfeeding and malnutrition are known to be associated with impaired short- and long-time recovery after major surgery. Methods: This single-center retrospective cohort study included 218 HNC patients who underwent free flap surgery in Oulu University Hospital, Finland between the years 2008 and 2018. Nutrition delivery methods, the adequacy of nutrition and complication rates were evaluated during the first 10 postoperative days. Results: A total of 131 (60.1%) patients reached nutritional adequacy of 60% of calculated individual demand during the follow-up period. According to multivariate analysis, nutrition inadequacy was associated with higher ideal body weight (OR 1.11 [1.04–1.20]), whereas adequate nutrition was associated with higher number of days with oral food intake (OR 0.79 [0.67–0.93]). Conclusion: Inadequate nutrition is common after HNC free flap surgery. The present results suggest that more adequate nutrition delivery might be obtained by the early initiation of oral food intake and close monitoring of nutrition support.

Background The European Leadership Forum (ELF) of the European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) previously identified the need for harmonisation of breast reconstruction standards in Europe, in order to strengthen the role of plastic surgeons. This study aims to survey the status, current trends and potential regional differences in the practice of breast reconstruction in Europe, with emphasis on equity and access. Materials and Methods A largescale web-based questionnaire was sent to consultant plastic and reconstructive surgeons, who are experienced in breast reconstruction and with understanding of the national situation in their country. Suitable participants were identified via the Executive Committee (ExCo) of ESPRAS and national delegates of ESPRAS. The results were evaluated and related to evidence-based literature. Results A total of 33 participants from 29 European countries participated in this study. Overall, the incidence of breast reconstruction was reported to be relatively low across Europe, comparable to other large geographic regions, such as North America. Equity of provision and access to breast reconstruction was distributed evenly within Europe, with geographic regions potentially affecting the type of reconstruction offered. Standard practices with regard to radiotherapy differed between countries and a clear demand for European guidelines on breast reconstruction was reported. Conclusion This study identified distinct lack of consistency in international practice patterns across European countries and a strong demand for consistent European guidance. Large-scale and multi-centre European clinical trials are required to further elucidate the presented areas of interest and to define European standard operating procedures.

Background: Treatment of chronic osteomyelitis (OM) usually comprises surgical excision of infected bone and soft tissue, dead space management, and soft tissue closure. When soft tissue revision results in defects too large for direct closure, assistance from plastic surgeons is needed. This study reports outcomes for patients with OM treated by plastic and orthopedic surgeons in a one-stage operation with an antibiotic-loaded biocomposite (ALB) and a local or free flap. Methods: We report a series of 11 consecutive patients with OM treated from February 2017 to September 2019. The treatment protocol included surgical debridement, tissue sampling, dead space management using ALB, stabilization as needed, and soft tissue closure with a local or free flap. Results: Mean age at surgery was 62 years (39–79), mean BMI 28 kg/m2 (23–39). Multiple comorbidities were present. Local flaps were used in six patients, one reverse lateral arm flap, one soleus flap, two gastrocnemius flaps, one latissimus dorsi flap, and one fascia plantaris flap. Free flaps were used in five patients, three gracilis muscle flaps and two antero-lateral thigh (ALT) flaps. Mean follow-up was 28 months (15–42). Nine patients (81.8%) healed uneventfully after the one-stage surgical intervention, while two patients (18.2%) experienced partial or complete flap necrosis and required additional surgery. No patients required amputation, and no mortalities were reported. Conclusions: One-stage treatment of OM using ALB, performed by a multidisciplinary team, led to zero amputations in a highly comorbid population, where amputation would otherwise have been unavoidable. Level of evidence: Level IV, therapeutic study.

Background Microsurgical reconstruction of upper extremity injuries is often challenging, and the resulting impact on the quality of life (QoL) may be significant. However, there is a lack of knowledge on long-term patient-reported QoL. Methods In a retrospective long-term follow-up study, all consecutive patients with an upper extremity injury who had undergone a free flap reconstruction were identified and categorized into three groups based on the type of injury. Patient-reported upper extremity function and QoL were assessed using three validated questionnaires: the 36-item Short Form Health Survey (SF-36), the Disabilities of the Arm, Shoulder, and Han

Better cancer treatment has led to a steadily growing population of cancer survivors suffering from late adverse effects after cancer treatment. The aim of this study was to investigate whether there has been an increase in free flap reconstruction due to osteoradionecrosis (ORN). A retrospective review was conducted to identify all consecutive head and neck free flap reconstructions performed over an 18-year period (1995-2012) at Karolinska University Hospital. A total of 235 free flaps were identified. Cases were divided into two groups: head and neck cancer reconstructions and ORN reconstructions. A comparison between the two groups showed longer survival (P < 0.001) and higher rates of late complications (P < 0.001) among ORN cases. ORN as an indication for reconstruction increased over time, from 7.0% of the total number of free flaps performed in 1995-2000, to 15.2% during the period 2001-2006, and to 27.3% in 2007-2012 (P < 0.001). This, in accordance with the results of other studies, highlights the importance of the appropriate allocation of resources within the healthcare system to treat this patient group within the steadily increasing population of cancer survivors.

The chronic complications of bone free-flap revascularization surgery are mainly characterized by skin fistulization of the osteosynthesis material, which sometimes leads to reactivation of the osteoradionecrotic phenomenon. The objective of the study is to evaluate the benefit of mandibular basilar edge preservation in bone reconstructive surgery in irradiated areas performed for the treatment of advanced mandibular osteoradionecrosis. A retrospective monocentric study conducted between 2003 and 2018 including all patients undergoing revascularization surgery for the treatment of advanced osteoradionecrotic lesion with respect to the basilar margin was conducted. Eight patients (7 males and 1 female, aged 50 to 63 years) who had a marginal mandibulectomy with reconstruction by bone free flap or composite free flap were included. The stability of the reconstruction (junction native mandible/bone free flap) was achieved on average by using 1.75 [range 0-4] mini plates (Medartis® Modus 2.0, Medartis AG, Basel, Switzerland). During the follow-up (30±13 months) no chronic complication related to a dissociation of the osteosynthesis material or a reactivation of the osteoradionecrotic phenomenon were identified. Despite the limited number of patients, it seems that the increase in the friction surface between the free flap and the native mandibular bone, linked to the preservation of the basilar edge, improves the primary stability of the reconstruction. This reduction in mechanical stress on osteosynthesis materials limits its use and reduces the rate of chronic complications of bone flap revascularization surgery in irradiated areas.

Mandibular osteoradionecrosis (mORN) is a severe complication of head and neck irradiation. International consensus on the management of mORN is currently lacking. The present study sought to evaluate the effectiveness and benefits of early reconstructive surgery (resection of the diseased bone and immediate reconstruction with a free flap) in treatment-refractory mORN. A single-center retrospective study was carried out of operations performed in a French university medical center between 2003 and 2013 inclusive. For each patient, the surgical modalities and postoperative outcomes were recorded. A total of 55 operations (19 marginal resections and 36 segmental resections) were performed, and the overall success rate was 92.3%. Relative to marginal resections, segmental resections were associated with longer operating times (440±62min vs. 531±72min, respectively; P<0.05 in Student's t-test), a longer length of hospital stay (16.5±6.5 days vs. 25.6±11.3 days, respectively; P<0.05), and a higher complication rate (26.3% vs. 63.9%, respectively; P<0.05 in Fisher's test). Given the unpredictable progression of treatment-refractory mORN and the risk-benefit ratio observed here, the value of early reconstructive surgery with curative intent should be reassessed.

Mandibular osteoradionecrosis (ORN) is one of the most serious complications of radiotherapy of the head and neck, and is characterised by hypoxia, hypovascularisation, and hypocellularity. Periosteal free flaps have intrinsic osteogenic, and extrinsic neoangiogenic, properties that are related to the periosteum. Our objective was to present our experience with the use of periosteal free flaps in the treatment of ORN (Notani class I or II) that are refractory to conservative management or have a large area of bone (≥2 cm) exposed. We organised a single-centre, retrospective study between 2003 and 2013 and describe the management of 11 patients (4 women and 7 men) who were being treated for refractory mandibular ORN. Thirteen periosteal free flaps were used: inner femoral condylar periosteum (n = 4), iliac crest (n = 1), external brachial with humeral periosteum (n = 1), and forearm with radial periosteum (n = 7). During follow-up we found three acute complications (haematoma, partial necrosis, and total vascular necrosis) that required immediate construction of a second periosteal free flap. There were also two chronic complications (fistula and post-traumatic fracture). With only one progressive lesion identified, the ORN was stopped in 11/12 patients. Two examples of osteoconduction were identified on postoperative images at six months and two years. Because of its osteoconductive and neoangiogenic capacities, the periosteal free flap seems to offer a real biological dimension to the treatment of ORN, and its efficiency favours its early revascularisation.

BACKGROUND: Within the field of plastic surgery, free tissue transfer is common practice for knee and lower leg defects. Usually, after such free flap reconstruction, patients undergo a dangling protocol in the postoperative phase. A dangling protocol is designed to gradually subject the free flap to increased venous pressure resulting from gravitational forces. Worldwide there are multiple variations of dangling protocols. However, there is no evidence available in the literature that supports the use of a dangling protocol. METHODS: This is a multicenter randomized controlled trial that includes patients with a free flap lower leg reconstruction. The primary outcome is to assess whether a no-dangling protocol is not inferior to a dangling protocol, in terms of proportion of partial flap loss, 6 months after surgery. Secondary objectives are to identify differences in major and minor complications, length of stay, and costs, and to objectify blood gaseous changes during dangling. Furthermore, at 2 years we will assess difference in physical function, infection rates, and osseous union rates. DISCUSSION: The primary outcome of this study will give a more decisive answer to the question of whether a dangling protocol is necessary after a free flap reconstruction of the lower leg. The secondary outcomes of this study will provide a better insight into the physical functions, infection rates, and union rates in these patients. TRIAL REGISTRATION: Central Committee on Research Involving Human Subjects (CCMO), NL63146.041.17. Registered on 11 July 2018. Netherlands Trial Register, NTR7545 . Registered on 10 October 2018.

Vascular grafts for free flap transfers should be of very small diameter and remain patent for approximately three weeks to supply blood until the revascularization from the surrounding tissue is established, with the autologous vein grafts acting as the gold standard. Artificial submillimeter-diameter vascular grafts with clinically useful size of 0.6 mm inner diameter and 5 cm length were prepared and evaluated by replacing the axial artery of free flap in rats. The rat tail artery, selected as a novel bioscaffold material, was decellularized using ultrahigh-hydrostatic pressure (UHP) method and compared with the detergent-based conventional method. To induce rapid endothelialization, the graft lumen was modified with synthesized peptides, having high affinity to the endothelial progenitor cells. The UHP method and peptide modification at 37 °C were found to preserve the extracellular matrix structure well, leading to the stable immobilization of the peptide at the luminal surface. These grafts showed the neointima formation, even at the center position far from the native vessels, remained patent for three weeks, and resulted in the flap survival in the rat free-flap model. The tissue-engineered vascular grafts with functionalized lumen have great future potential as an alternative to autologous vein grafts in free flap transfers.

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Uvod: Poglavinu (eng. scalp) čine meka tkiva koja pokrivaju kalvariju odnosno krov lobanje. Značaj poglavine i kostiju lobanje proističe iz činjenice da formiraju štit oko mozga. Ove strukture su povezane kako fizički, tako i brojnim dinamičkim fiziološkim procesima. Njihova oštećenja stoga mogu dovesti do brojnih i ozbiljnih komplikacija. S obzirom da poglavina posle lica predstavlja jedan od najupadljivijih delova ljudske figure, estetska razmatranja su vrlo značajna pri planiranju rekonstrukcije. Izbor optimalne metode za rekonstrukciju poglavine zasniva se na analizi većeg broja ulaznih varijabli. Cilj: Ova doktorska teza ima za cilj evaluaciju rezultata rekonstrukcije skalpa različitim hirurškim tehnikama, kao i: 1. Utvrditi distribuciju stečenih defekata poglavine po starosnim grupama i prema polu ispitanika. 2. Utvrditi distribuciju stečenih defekata poglavine prema veličini, dubini i lokalizaciji i ispitati uticaj ovih parametara na izbor rekonstruktivne procedure. 3. Utvrditi značaj pušenja, zračenja, kvaliteta okolne kože i komorbiditeta za odabir metode rekonstrukcije i utvrditi njihov uticaj na učestalost komplikacija. 4. Utvrditi najčešće komplikacije i njihovu učestalost u zavisnosti od veličine, dubine defekta i primenjene operativne tehnike. 5. Uporediti prednosti i nedostatke primene fasciokutanih režnjeva sa drugim operativnim tehnikama primenjenim za zatvaranje defekata iste veličine i dubine poglavine, sa posebnim osvrtom na regije. 6. Utvrditi i uporediti zadovoljstvo pacijenata postignutim rezultatima zatvaranja defekata u zavisnosti od primenjene metode rekonstrukcije. 7. Na osnovu rezultata istraživanja i dostupne literature napraviti algoritam za izbor optimalne hirurške procedure za zatvaranje stečenih defekta poglavine različite etiologije, veličine i dubine. Materijal i metode: Studijom je obuhvaćeno 135 ispitanika, pacijenata sa stečenim defektima poglavine lečenih na Klinici za opekotine, plastičnu i rekonstruktivnu hirurgiju i Klinici

Background: Microvascular tissue transfer has become a safe and reliable tool in the reconstructive armamentarium, yielding high success rates. However, little is known about the changes in coagulation after free tissue transfer and their potential impact on morbidity.Methods: Fibrinogen concentration and platelet count among other values were available and assessed in 139 undergoing free tissue transfer before, immediately after, and 1-3 as well as 8-11 days after surgery. In patients undergoing urgent revision for either bleeding or microvascular thrombosis, blood samples were drawn directly before re-exploration. Results: In the patients without any surgical revision and in those with thrombosis of the microvascular pedicle, both fibrinogen concentration and platelet count increased significantly during the early and late post-operative window. Patients that developed bleeding necessitating re-exploration showed an inadequate increase in fibrinogen levels, resulting in significantly lower concentrations compared to the other two groups. There were no significant differences in platelet count or PTT between these groups.Conclusion: Free flap surgery induces acute and subacute changes in coagulation, comparable to other major surgeries and severe injuries. This leads to an increase in platelet count and fibrinogen over the post-operative course. Patients that developed bleeding requiring surgical re-exploration showed an insufficient increase in fibrinogen, resulting in significantly lower fibrinogen levels. Therefore, monitoring and correction of fibrinogen levels might aid in preventing or treating bleeding complications following free flap surgery., Hintergrund: Mikrovaskulärer Gewebetransfer stellt ein sicheres und zuverlässiges Werkzeug im rekonstruktiven Armamentarium dar. Bezüglich der postoperativen Veränderungen der Gerinnung nach freiem Gewebetransfer und dessen potentieller Morbidität gibt es jedoch nahezu keine Daten.Methoden: Plasma-Fibrinogenkonzentration und Thrombozytenzahl, zusammen mit anderen Parametern, wurden bei 139 Patienten, welche einen freien Gewebetransfer erhielten, vor dem Eingriff, unmittelbar danach und am 1.-3. und 8.-11. postoperativen Tag bestimmt. Im Falle einer Revision wurden die Werte unmittelbar vor dem Revisionseingriff abgenommen.Ergebnisse: Bei Patienten ohne chirurgische Revisionen und bei denen mit Revision wegen Thrombosen des Gefäßstiels stiegen Fibrinogenkonzentration und Thrombozytenzahl während beider postoperativer Zeitpunkte signifikant an. Bei Patienten mit Revision wegen Blutung war kein signifikanter Fibrinogenanstieg zu verzeichnen, so dass deren Wert deutlich niedriger war. Bezüglich der Thrombozytenzahl und der PTT ergaben sich keine Unterschiede zwischen den Gruppen.Schlussfolgerung: Mikrovaskulärer Gewebetransfer führt zu akuten und subakuten Veränderungen der Blutgerinnung, vergleichbar mit anderen ausgedehnten Operationen oder Traumata. Diese führen zu einem Anstieg von Fibrinogen und Thrombozyten. Bei Patienten mit revisionspflichtigen Blutungen zeigte sich ein unzureichender Fibrinogenanstieg. Ein Monitoring und gegebenenfalls die Korrektur der Fibrinogenwerte könnte daher potentiell helfen, Blutungskomplikationen nach freien Lappenplastiken vorzubeugen oder diese zu behandeln.

Background Anecdotally, problems with venous outflow in deep inferior epigastric perforator (DIEP) flaps remain an unsolved problem. A comprehensive review of the entire DIEP literature as well as meta-analysis of the pooled data revealed that although venous complications were relatively common, these complications were poorly categorized and documented, and sporadically reported. Furthermore, an understanding of the relevant anatomical aetiology of these problems was not available, as hampered by the lack of high quality studies of venous anatomy of the anterior abdominal wall. I therefore set out to define the problems in DIEP flaps by performing an extensive literature review and meta-analysis, and thereby reclassify venous complications in DIEP flaps, as well as provide an anatomical explanation of the observations from the literature review and meta-analysis, by introducing a novel technique of studying the venous architecture of the torso in fresh and embalmed human cadavers. Previously, there have been few studies of the venous anatomy – due largely to the technical challenges involved, but also partly because the arterial anatomy was more immediately important to the survival of skin flaps used in reconstructive surgery. With maturing understanding of flap arterial anatomy, venous complications have now become one of the most common problems still remaining when raising flaps. There was therefore a need for greater anatomical understanding of venous architecture in order to explain the aetiology of these problems, and to refine flap design to reduce their occurrence. Materials and Methods 47 hemiabdomens and 24 hemi-chests from 26 separate cadavers were used in this study. All were preserved by freezing, but unembalmed. All veins in the borders of the specimens were cannulated, and veins were then initially primed with 6% hydrogen peroxide, and then injected with a lead oxide mixture and serially radiographed before and during dissection. Results The above

Aim: Fibrin glue becomes a more and more routinely used tool for stabilization of microanastomoses and nerve repair. This paper summarizes the technical properties and advantages of its use in a wide variety of microsurgical contexts, and includes an exemplary limb reconstructive case.Patients and methods: A total of 131 patients who had undergone elective and emergency microsurgery mainly of the limbs were retrospectively analyzed, as was the use of free flaps.Results: The use of fibrin glue allows for proper positioning of anastomoses and repaired nerves. No torsion of the pedicle could be seen. The flap survival rated >94%. The fibrin glue could stay in place in >99%. In the rare case of revision, the fibrin glue could easily be removed without damaging the region of the microanastomosis.Conclusion: Fibrin glue should not be used to repair insufficient, i.e., leaking anastomoses, but it does protect the site of anastomosis from tissue and fluid pressure. It prevents the pedickle from torsion and its use facilitates relocation of the microanastomoses in cases of revision surgery., Einleitung: Fibrinkleber ist ein immer häufiger in der klinischen Routine eingesetztes Tool zur Stabilisierung von Mikroanastomosen und Nervenreparatur.Dieser Artikel fasst die technischen Eigenschaften und Vorteile im Gebrauch sowie die variable Anwendungsmöglichkeit von Fibrinkleber im mikrochirurgischen Kontext zusammen und illustriert dies an einem extremitätenrekonstruierenden Fallbeispiel.Patienten und Methoden: 131 Patienten, an welchen sowohl elektiv als auch in einer Notfallsituation eine mikrochirurgische Intervention durchgeführt wurde, hauptsächlich in der Extremitäten erhaltenden Chirurgie, wurden retrospektiv untersucht; ebenso die Patienten, welche eine freie Lappenplastik erhalten hatten.Ergebnisse: Die Verwendung von Fibrinkleber in der Mikrochirurgie erlaubt ein exaktes Positionieren der Anastomose von Gefäßen und Nerven. Ein Verdrehen oder Kinking des Pedickels konnte in keinem Fall festgestellt werden. Die Überlebensrate der Lappen betrug >94%. In 99% der Fälle konnte der Fibrinkleber belassen werden. In dem seltenen Fall der Revision konnte der Fibrinkleber leicht entfernt werden ohne Schaden an der Anastomose zu hinterlassen. Zusammenfassung: Fibrinkleber ist nicht geeignet Anastomoseninsuffizienzen oder leckende Anastomosen zu behandeln, allerdings schützt er die Anastomose vor schadendem Druck ausgelöst durch Gewebe oder Flüssigkeit. Er bewahrt den Gefäßstiel vor Verdrehung und hilft dem Operateur beim Wiederauffinden der Anastomose im Fall einer Revision.

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The free flap surgical technique is used to cover extensive skin loss areas and situations where no flap is available, or in axial zones. The great breackthrough in the field of reconstructive surgical techniques and the creation of new units where these complex techniques are used, means that the nursing staff who work in these hospital units are adquiring greater protagonism in caring for, and the subsequent success of this type of surgery in which the problems of collaboration in all the perioperative phases depend entirely on the nursing team. The collaborative nursing problems could be defined as real or potential health problems, where users need nursing staff to follow the treatment and control procedures prescribed by other professional, generally doctors, who control and are responsible for the final outcome. While planning collaborative objectives and activities it should be taken into account that the function of the nursing staff is twofold: on the one hand, the patient must be taken care of as prescribed by other professionals and, on the other hand, it should bring into play cognitive elements (knowledge and know-how) and clinical judgment when executing these in controlling the patients evolution. In this article our intention is to give an interesting and comprehensive description of the free flap surgical technique, its pros and cons, and identify the principal collaborative problems which nursing will have to deal with in each one of the perioperative phases, the number and specific nature of such oblige nursing on many occasions, to update and/or acquire new skills., La utilización de la técnica quirúrgica del colgajo libre se realiza para dar cobertura tanto a extensas pérdidas de piel como en aquellas situaciones en las que no se dispone de un colgajo al azar o axial. El gran avance en el campo de la cirugía reconstructiva y la creación de nuevas unidades que utilizan estas complejas técnicas, provoca que la enfermería que trabaja en las unidades de hospitalización de nuestros hospitales, adquiera cada vez más un protagonismo mayor en el cuidado y posterior éxito de este tipo de cirugía, y en el que los problemas de colaboración en todas las fases del perioperatorio dependen totalmente del equipo de enfermería. Los problemas de colaboración de enfermería pueden definirse como problemas de salud reales o potenciales en los que el usuario requiere que la enfermería realice por él las actividades de tratamiento y control prescritas por otro profesional, generalmente el médico, que es quien tiene el control y la autoridad, siendo el responsable del resultado final. Al planificar objetivos y actividades para los problemas de colaboración debe de tenerse en cuenta que el papel de la enfermería es doble: por una parte debe llevar a cabo actividades hacia el enfermo que ha prescrito otro profesional y, por otra, debe aportar elementos cognoscitivos (saber y saber hacer) y aplicar su juicio clínico a la hora de ejecutar esas actividades y de controlar la evolución del enfermo. Con el presente artículo pretendemos, tras realizar una exhaustiva descripción del procedimiento quirúrgico del colgajo libre, indicaciones y contraindicaciones, identificar los principales problemas de colaboración que va a tener que desarrollar la enfermería en cada una de las fases del perioperatorio y que por su número y especificad va a requerir de la enfermería en muchas ocasiones una actualización y/o una adquisición de nuevas competencias.

Free and pedicled flaps are frequently used in reconstruction of the lower two-thirds of the face. For these reconstructions, the submandibular facial vessels are extensively used as a receptor site. In this anatomic study, we investigate if the facial vessels in the nasolabial fold can be used as a receptor site as well. In 13 human cadavers, the facial artery and vein were dissected in the nasolabial fold in the same way as would be done during surgery. The case of dissection and length, diameter, and location of the vessels were analyzed. The average length of the dissected artery was 28 mm (+/- 11 standard deviations [SD]) and of the dissected vein, 19 mm (+/- 6 SD). The mean diameter of the artery was 1.5 mm (+/- 0.4 SD) and 2.5 mm (+/- 0.8 SD) for the vein. In 85% of the sides, both vessels were suitable to use as a microsurgical receptor site. The easy access and the measured diameter of the facial vessels in the nasolabial fold make it a potential site for microsurgical anastomosis.

Introduction: Accurate post operative assessment of free tissue transfers is challenging despite all the subjective and objective techniques available today. In our continual search to optimise patient outcomes, we introduced the Cook-Swartz probe into our clinical practice in May 2006. Methods: We present our single centre experience in 103 patients undergoing 121 microvascular breast reconstructions and monitored using implantable Cook-Swartz venous dopplers between May 2006 and January 2008. Results: In total, we used 145 probes on 121 microvascular breast reconstructions (DIEP = 102, SIEP = 15, SGAP = 4) in 103 female patients. The mean operative time was 4 h and 55 min (mu = 295; range 117-630; o' +/- 101 min) and we suffered 2 complete flap losses. A problem with the audible signal was noted in 15 patients (4 intra-operatively). We revised 14 of the 15. All fourteen had compromised anastomoses. In the remaining case, the patient was not returned to theatre as the primary surgeon was confident there were no other signs of vascular compromise. Overall, when using the venous doppler probe we found a false positive rate of 6.7% and 0% false negatives. Discussion: We advocate the use of a Cook-Swartz probe which has been well received by both surgeons, nursing staff and patients, as an adjunct to traditional clinical monitoring techniques. We also include a comprehensive experience based technical discussion concerning its application, attachment, use and post-operative removal.

手の外傷を扱う以上，マイクロサージャリーの技術は必須である.切断指の再接着を行う際はこの技術がフルに必要となる.切断指の患者が運ばれたならば，まず通常の開放創と同様な処置を行い，骨固定，腱縫合の後に顕微鏡下に動脈，神経，静脈と縫合していく.またマイクロサージャリーを用いて種々の皮弁移植が行われている.広範囲の軟部組織欠損に対しては広背筋皮弁が，中等度の欠損に対しては肩甲皮弁や腓骨皮弁が用いられる.手や指の軟部組織欠損に対しては，前腕皮弁，後骨間皮弁などの逆行性島状皮弁が適応される.切断指再接着術において血管の欠損を伴う皮膚欠損がある場合，静脈皮弁が有用である.

マイクロサージャリーとは顕微鏡を用いて細い血管の吻合を行うことによって, 外傷や疾病を治療する手術のことである。1965年にここ奈良医大において初めての切断指再接 着術が成功して以来,整形外科領域においては必須の手術手技の一つとなった。その技術は切 断指再接着から足指の移植術へと応用され,その後皮膚,骨,関節,筋肉,神経,腱などのい ろいろな組織の移植へと広がっていった。そして最近では同種手の移植がマイクロサージャリ ーの手技を用いて行われ始めている。今後はロボット技術が導入され,さらに細い血管の吻合 が可能となり,全く新しい手術方法が導入される可能性がある。

Extensive soft tissue defects of different origins and in different regions of the body can be reconstructed with a multitude of flaps in the framework of a general therapy regime. The surgeon should be capable of a wide variety of different techniques to be able to chose the correct indication in each individual case., Weichteildefekte unterschiedlichster Genese und Größe an den unterschiedlichsten Körperstellen können mit vielfältigen Lappenplastiken im Rahmen eines allgemeinen Behandlungsplans gedeckt werden. Man benötigt ein weites Repertoire, um die korrekte Indikation im Einzelfall zu stellen.

Despite low donor-site ]morbidity and a straightforward dissection, the gracilis muscle flap is still for many surgeons a second choice in microsurgical reconstruction of the lower extremity in cases of osteomyelitis. They underscore the difficulty of the procedure, and the problems of insufficient muscle volume and a small sized vascular pedicle. The aim of this study was to assess the reliability of the gracilis muscle free flap in the treatment of osteomyelitis of the foot and ankle. Between 1992 and 1999, 12 consecutive cases (age 9 to 71 years) of osteomyelitis of the foot and ankle were treated using a skin-grafted gracilis free muscle flap. Criteria for osteomyelitis were the presence of exposed bone, positive cultures and bone scans. The wound defect surface ranged from 9 to 90 cm2 (mean 50.5 cm2). Six flaps were applied on the weight bearing area of the foot. Flap harvesting time never exceeded 30 minutes. The mean follow-up is 15 months (range 2 to 60 months). All flaps survived completely. Secondary skin grafts were needed in two cases. One hematoma was noted at the flap donor site. Two patients (18%) had persistent osteomyelitis due to insufficient debridement in the presence of what appeared to be extensive bone involvement. Attempt to salvage the extremity was first performed but ultimately led to amputation. No patients complained of any donor site morbidity. Failure to cure the osteomyelitis was never caused by inadequate flap coverage. Gracilis muscle flap reliability in terms of vascular supply and ease of dissection made it our first choice in osteomyelitis of the foot and ankle. In the presence of extensive bone involvement, complex bone reconstruction is necessary to avoid amputation., SCOPUS: ar.j, info:eu-repo/semantics/published

Background: The radial forearm flap is probably the most frequently used among free flaps for intraoral soft tissue reconstruction. However, this flap is not always available. The other fasciocutaneous flaps may be too bulky or less pliable or may have a short vascular pedicle; their use is therefore less than ideal. We present a variant of the lateral arm flap located distally to the lateral epicondyle and having the same advantages as the radial forearm flap. Methods: Vascular study (dissection and radiography) was previously undertaken to determine the vascular anastomotic network in the epicondylar area, between the posterior radial collateral artery and recurrent arteries running in front of the lateral epicondyle. This demonstrated the possibility of taking a skin paddle on and below the lateral epicondyle, based on the proximal pedicle. Results: We used this flap on three patients for intraoral soft tissue reconstruction (tonsil, floor of the mouth, and piriform sinus). No complication with the flap itself was encountered. In all cases, direct closure of the donor site was possible, with no local complication. Conclusion: The distal lateral arm flap (LAF) represents an interesting and reliable alternative to the fasciocutaneous radial forearm flap. The positioning of the skin paddle over the lateral epicondyle and the proximal third of the lateral aspect of the forearm increases pedicle length, thus avoiding the use of vein grafts. Dissection is straightforward with a reliable vascular anatomy. Moreover, in this area, the limited amount of subcutaneous fatty tissue ensures easier placement and more pliability when compared with the standard LAF., SCOPUS: ar.j, info:eu-repo/semantics/published