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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]

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]

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: This retrospective study aimed to assess whether delaying flap coverage in open midshaft tibia fractures leads to higher infection rates. Methods: Patients were recruited retrospectively from a tertiary trauma database between 2012 and 2020. Patients included were over 18-years old and had an open tibia fracture that required flap coverage with at least 6 months follow-up. The collected complications were deep infections, aseptic non-union, flap failure and revision surgery. Results: Group-A (n = 18) and Group-B (n = 37) were analysed. Deep infections rate was 6% in Group-A and 38% in Group-B which was significantly different, χ2(1, N = 55) = 6.4, p = 0.01. The rate of revision surgery was 17% in Group-A and 54% in Group-B and was significant, χ2(1, N = 55) = 7, p = 0.008. Binary logistic regression showed that Group-B were 10 times more likely to develop a deep infection (95% confidence interval 1.2–83, p = 0.034). Conclusion: Delaying soft tissue coverage of open tibia fractures for over a week increases the risk of deep infection and revision surgery. [ABSTRACT FROM AUTHOR]

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]

Objectives: The goal of facial reanimation for facial palsy is to restore resting facial symmetry and dynamic facial motion that mirrors the opposite side as closely as possible. This study aimed to evaluate the restoration of oral commissure symmetry at rest and during excursion among patients with facial paralysis treated with free gracilis muscle transfer. Methods: This study included 9 patients who underwent facial reanimation with free gracilis muscle transfer at Khoula Hospital, Muscat, Oman, from 2019 to 2022. Children under 14 underwent a 2-stage surgery, while those above 14 underwent single-stage reconstruction. Results: The average age among the cohorts was 24 years. Overall, 5 cases underwent a 2-stage facial animation, 4 underwent singlestage reconstruction and 1 patient had free flap loss following the free gracilis muscle transfer. The mean time for noticing recovery was 3 months postoperatively. Early recovery was noted in patients who underwent singlestage free gracilis muscle transfer with motor innervation from the ipsilateral nerve to the masseter compared to the cross-facial nerve transfer. Good patient satisfaction (88.9%) was observed following the procedure. Conclusion: This study observed earlier recovery in patients who had undergone single-stage free gracilis muscle transfer with motor innervation from the ipsilateral nerve to the masseter compared to the cross-facial nerve transfer. The oral commissure symmetry at rest and during excursion among patients with facial paralysis treated with free gracilis muscle transfer in Oman was found to be near normal. [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]

Preoperative planning with CT-angiography (CTA) in deep inferior epigastric perforator (DIEP) flap reconstruction is an essential preoperative tool. The aim of this study was to describe the management of the incidental findings following the introduction and further modification of a combined CTA and CT-staging preoperative protocol which includes chest, abdomen, pelvis, and musculoskeletal system. A retrospective case series of 292 patients (Group 1) with breast cancer who underwent DIEP flap between 2015 and 2019. This was followed by a re-assessment between 2019 and 2021 of 101 patients (Group 2) following modification of the staging-CT protocol to include only those patients who received chemotherapy. Group 1 included immediate and delayed reconstruction; whereas Group 2 included only the high-risk delayed reconstruction cases. Both groups had CT staging. Overall, 30% of Group 1, most likely those who had the delayed reconstruction, had findings which were recommended for further follow-up. This led to a change in staging of the high-risk patients only at the end of 2019 to those who underwent chemotherapy and had delayed reconstruction. Briefly, 56.4% of Group 2 demonstrated incidental findings, 42.1% of them required repeat scanning, 7% were referred to other specialties, and 47.4% did not require further action. There were no cases of occult metastatic breast cancer in either series; however, 1% were diagnosed with de novo primary cancers at non breast sites only in the first series. The screening of patients with asymptomatic breast cancer as part of CTA scanning prior to autologous reconstruction is not universally practiced and not supported by the NICE guidelines. This unit changed the practice to stop preoperative staging for low-risk patients by the end of 2019, and reserved it for the high-risk patient groups to reduce cost. [ABSTRACT FROM AUTHOR]

The optimal sequence of microvascular clamping during free flap transfer is yet to be established. Many surgeons are reluctant to perform temporary declamping and subsequent reclamping during microvascular anastomosis; however, we generally anastomose the artery first and temporarily declamp it before performing venous anastomosis to confirm arterial patency and ensure proper alignment of the flap veins. Herein, we aimed to retrospectively investigate the efficacy and safety of this temporary revascularization method in 126 patients who underwent microvascular head and neck reconstruction. A total of 127 free flaps were transferred, with the anterolateral thigh flap (49 flaps) being the most frequently used. The internal jugular vein was the most frequently used recipient vein and end-to-side anastomoses to it were performed in 112 patients. Intraoperative reanastomosis was required because of arterial thrombosis in 5 cases (4.0%), arterial and venous thrombosis in 1 case (0.8%), injury to the flap artery distal to the anastomotic site in 1 case (0.8%), and venous twisting in 1 case (0.8%). Postoperatively, all the flaps survived without microvascular compromise. Vascular kinking or twisting of the vascular pedicle is a major cause of free flap failure. However, it is difficult to place empty vessels accurately during clamping. Nonetheless, temporary revascularization engorges the flap vein before venous anastomosis and minimizes the risk of venous kinking and twisting. According to our results, reclamping did not increase the risk of arterial thrombosis. [ABSTRACT FROM AUTHOR]

Microsurgical free tissue transfer is the gold standard for reconstructing major bone or soft tissue defects but requires complex training, and specific resources. Therefore, some authors have stated that microsurgery is impossible in low- and middle-income countries. Patients from Khmer underwent free flap surgery at the Children's Surgical Centre in Phnom Penh between 2004 and 2023. Two non-governmental organizations facilitated the program: Rose Charities Cambodia provided the facilities, patients and local staff, and Doctors of the World provided the surgeons, and anesthetists. At least one Khmer surgeon was trained during these operations. Digital data were collected retrospectively, and analyzed in June 2023. Fifty-six free flaps in 54 patients have been performed since 2004. The most frequent sites requiring reconstruction were the head and neck (35.7%), lower limbs (30.4%), and upper limbs (21.4%). The most frequent free flaps were free fibula (44.6%), gracilis (19.6%), and anterolateral thigh (16.1%). Among the 56 flaps, 41 (= 73.2%) were viable long-term and 15 (26.7%) were microsurgical failures. Sixteen flaps underwent revision in the operating room. Twenty-three flap-related complications were reported in 21 patients with mostly vascular thrombosis (n = 12), hematoma (n = 3) and infections (3). However, 83.3% had improved or were cured of their initial pathology after final surgical management. Free flaps performed in our series as part of international surgical collaborations in a low-income country are feasible, but we experienced higher failure rates, and later revisions compared to the results in high-income countries. We identified several solutions to improve the microsurgery outcomes in low-income settings. [ABSTRACT FROM AUTHOR]

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]

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.

Introduction: Management of patients with head and neck squamous cell carcinoma mainly consists of controlling the primary tumour and regional cervical nodal metastases if any. Surgical complications lead to increased hospital stay, further surgical interventions and sometimes a fatal outcome. Postoperative neck hematoma is one such potential and dreaded complication of head and neck surgeries leading to infection, airway obstruction, compression of the surrounding structures causing free flap failure or sometimes may even lead to death. Haematoma might arise from any of the unaddressed neck vessels or some major vessels in the primary site which were inadvertently injured. Aims and Objectives: Development of a checklist to minimise the incidence of haematoma. Results: Between August 2017 to March 2019 out of 548 patients operated and reconstructed with free flap, 24 patients (4.38%) had developed a post-operative haematoma. However, after following our protocol, the incidence of haematoma drastically decreased and out of 1234 patients operated between April 2019 to December 2022 only 14 patients (1.13%) developed haematoma of the neck. Conclusion: Though ours is a pilot study, we feel that our protocol is easy to follow, and we have applied it successfully in surgical practice and decreased the incidence of post-operative hematoma. We believe if the same protocol is followed and applied in surgical practice it will be of great help to all head-and-neck surgeons.

Purpose: Reconstructing soft tissue defects around the knee with free flaps presents challenges in recipient vessel selection. Although the superficial femoral artery (SFA) offers exposure ease and anatomical stability, concerns arise regarding its distance from the defect site, difficulty in performing anastomosis and potential peripheral ischaemia. This study aimed to reassess the suitability of SFA as a recipient vessel for knee reconstructions by examining our cases and those from previous reports. Methods: We reviewed four cases of knee soft tissue defects reconstructed with free flaps using the SFA, detailing surgical techniques and outcomes. Additionally, a comprehensive literature search was conducted for articles on using SFA as a recipient vessel for knee free flaps, using PubMed, Web of Science and EBSCOhost databases. Results: In all four cases, latissimus dorsi (LD) flaps were used, with end-to-side anastomosis performed using a large slit-shaped arteriotomy. All flaps demonstrated successful survival without complications. Our analysis included 85 cases, comprising four of our cases and 81 cases from 16 articles. Sarcoma resection was the most common aetiology, followed by total knee prosthesis-related defects, trauma and osteomyelitis. Complete flap necrosis occurred in 5% of cases. The LD flap was the predominant choice, alongside other long-pedicle flaps. The SFA provided coverage for all knee areas except the distal lateral patellar region. Conclusion: Despite the limited evidence, the SFA appears to be a reliable recipient vessel for knee soft tissue reconstruction. Comprehensive understanding of the characteristics of the SFA and flaps used enhances the safety and efficacy of soft tissue defect reconstruction around the knee.

Breast revision surgery is often necessary in patients following postmastectomy breast reconstruction with free autologous flaps for aesthetic improvement. Indications for nipple-sparing mastectomy continue to be expanded oncologically. However, revision techniques for aesthetic concerns following breast reconstruction are underreported in the literature. Therefore, we describe a mastopexy technique following deep inferior epigastric perforator (DIEP) flap breast reconstruction after nipple-sparing mastectomy to correct ptosis and reshape the breast. The blood supply of the nipple-areolar-complex is through the microvasculature of the DIEP flap and subdermal plexus. We report three patients who underwent nipple preserving Wise-pattern mastopexy following DIEP flap breast reconstruction.

Introduction: Extensive scalp defects present a significant reconstructive challenge due to the complex needs of patients that are often beyond the scope of conventional therapies, which makes free flaps the most reliable solution. Despite the variety of free flaps available for such cases, there is a lack of clear criteria for selecting the most suitable option. The primary objective of this study was to provide a simplified guide for the selection of donor sites for free flaps for achieving optimal reconstruction outcomes. Materials and Methods: A retrospective study was conducted on 15 patients who underwent scalp reconstruction with free flaps between 2017 and 2022: 4 latissimus dorsi (LD), 4 omental (OM), 5 anterolateral thigh (ALT), and 2 radial forearm free (RFF) flaps. Reconstructive and postoperative data for all patients were collected, evaluated, and compared. Results: The mean defect size to be restored was 110.60 ± 14.55 cm² (LD 162.23 ± 23.1 cm2, OM 141.68 ± 11.80 cm2, ALT 73.83 ± 14.69 cm2, and RFF 37.13 ± 4.88 cm2). Seven complications were reported, with partial flap loss being the most common: LD n = 2 and OM = 3. Mean healing time of the donor and recipient sites was 2.53 ± 0.27 and 1.8 ± 0.31 months, respectively, with OM having the longest average period for recipient site healing (3.65 ± 0.24 months). Conclusion: Reconstructing extensive scalp defects requires careful consideration of critical factors such as defect size, donor tissue availability, need for adjuvant therapies, and patient comorbidities when selecting a flap. This underscores the importance of tailored approaches to enhance clinical outcomes. We propose a simplified algorithm for free flap selection to streamline the decision-making process in complex cases.

The eyebrow plays a crucial role in facial aesthetics and expression. Reconstructing an eyebrow defect remains a challenge due to the unique characteristics of eyebrow hair. While various advanced methods exist, we report the first documented use of a free superficial temporal artery flap for total eyebrow reconstruction. This case study describes a successful eyebrow reconstruction in a patient with a total eyebrow defect. The free superficial temporal artery flap provided excellent vascularity, texture, and hair growth, mimicking the natural eyebrow. Our findings suggest that the free superficial temporal artery flap offers a promising new option for reconstructing large eyebrow defects. This technique warrants further investigation in larger patient populations.

Objective: This study evaluated the effectiveness of laser Doppler flowmetry (LDF) in detecting perfusion disturbances during microvascular free tissue transfer. Methods: Conducted at a single centre from December 2020 to September 2022, this prospective study involved 71 patients mainly undergoing head and neck free flap reconstructions, using the Pocket LDF™ for continuous perfusion monitoring. Results: Out of the 71 cases, data from 69 cases were analysed after excluding those with significant noise or sensor detachment. Blood flow disturbances were observed in 9 cases (13.0 %), with 5 of these cases with a history of surgery or radiation in the same area. There were 5 cases of ischaemia, 4 of which occurred during monitoring. There were 4 cases of venous congestion, with 1 occurring during monitoring. Re-operation was necessary in 8 cases (11.6 %), involving flap replacements, vascular re-anastomoses and hematoma evacuation. Complete flap necrosis occurred in 5 cases (7.2 %) and partial necrosis occurred in 3 cases (4.3 %). The LDF device demonstrated the ability to identify perfusion issues hours before the clinical symptoms manifested, suggesting its potential for early intervention. However, challenges included maintaining continuous monitoring immediately post-surgery and during patient transfers. Conclusion: LDF is a valuable, non-invasive tool for early detection of perfusion disturbances in free flap procedures. It provides continuous, real-time feedback on microcirculation, facilitating timely interventions. Despite its benefits, enhancements in sensor adhesion and wireless technology are needed to improve monitoring reliability. Further studies are recommended to refine LDF usage and validate its efficacy in various clinical settings.

Intraoperative use of vasopressors in free flap surgeries is controversially debated. The predominant concern is that pedicle blood supply will decrease leading to post-operative complications. This study examined the role of intraoperative vasopressors, specifically norepinephrine, in free flap partial necrosis based on the patients’ comorbidities. We retrospectively analyzed 192 patients who received free flap treatment between 2006 and 2021 and were stratified based on vascular comorbidities. We assessed the role of intraoperative vasopressors using multivariate analysis. Patients who were administered vasopressors did not have a significantly higher risk of partial flap necrosis compared to patients who were not administered vasopressors (OR: 1.439, 95% CI: 0.618-3.348, p=0.399). Upon stratifying by vascular comorbidities, we found that patients with two or more vascular comorbidities who were administered vasopressors had a significantly higher risk of developing flap necrosis (OR: 3.882, 95% CI: 1.266-14.752, p=0.046), indicating that vasopressor use in patients with multiple vascular comorbidities is a risk factor for partial flap necrosis. To minimize the risk of flap marginal necrosis in patients with vascular comorbidities, we recommend limited use of vasopressors or minimizing the flap area to preserve vascularization.

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.

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: 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]

Over the last decade, microsurgical soft-tissue transfer became the gold standard for various reconstructions throughout the body. Continuous improvement of instruments and surgical techniques, such as intraoperative indocyanine green angiography (ICG-A), allowed for a very high success rate. This study aimed to assess and validate the role of a standard intraoperative ICG-A in free and pedicled flap surgery to improve overall outcomes. From April 2018 to April 2023, 400 consecutive patients who underwent reconstruction using free and pedicled flaps were enrolled. ICG-A was always performed in a free flap after flap elevation, after microsurgical anastomosis, immediately after the flap inset, and after wound closure. In the pedicled flap, the sequential procedure was performed after flap elevation, flap inset, and wound closure. All 400 patients who underwent flap reconstruction using intraoperative ICG-A had an extremely low incidence of necrosis (0.75% partial necrosis among free and pedicled flaps) and reoperation for perfusion-related complications (0.75% due to acute ischemia and 0.50% due to flap congestion). Minor complications, such as hematoma, seroma, wound dehiscence, and wound infections, were managed with a second operation. No flaps were lost, and all patients were successfully treated. This study showed how systematic multistep ICG-A for intraoperative assessment of free and pedicled flap perfusion can significantly reduce the complication rate, including flap loss and re-exploration surgeries, in a time- and cost-effective manner. [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]