Local Anesthesia in Superficial Circumflex Iliac Artery Free Flap Transfer.

The mechanical integrity of a deep circumflex iliac artery (DCIA) free flap connected to the remaining mandible after a segmental mandibulectomy directly influences the reconstructive surgery prognosis. This study aimed to assess the biomechanical integrity of fixation systems on the reconstruction site. The mechanical properties of mini-plate and screw fixations in two different materials, namely titanium (Ti) and hydroxyapatite/poly-L-lactide (HA-PLLA), were simulated using finite element analysis. Each end of the free flap was fixed with three mini-plates, a total of six mini-plates at the midline and the anterior to the coronoid process with 35 screws. The masticatory loading increment effect on peak von Mises stress (PVMS) distribution, size of fixation deformation, principal stresses on bones, and a gap opening size were taken into account for each material's pros and cons evaluation. Based on the comprehensive evaluation, the Ti fixation system presented superior performance immediately after surgery. However, the Ti fixation system's superiority was diminishing over time, and eventually, the differences became marginal at 12-months postop. This study's results imply the clinical indications of the HA-PLLA fixation system with the DCIA free flap during mandibular reconstructive surgery.

Modifications of the deep circumflex iliac artery free flap for reconstruction of the maxilla

A patient was diagnosed with squamous cell carcinoma of the maxillary sinus and consequently underwent a unilateral total maxillectomy and reconstruction using an anterolateral thigh (ALT) free flap. Soft tissue transplantation without a bone graft at the large maxillary defect site caused a midfacial collapse, which worsened, especially after radiotherapy. The 3-dimensional positioning of the composite flap for wide maxillary reconstruction is aesthetically important. To achieve ideal symmetry and aesthetics, a mirror image was created using the normal contralateral side. Through computer simulation, the function and symmetry of the virtually reconstructed maxilla was evaluated, and the surgical guide was made using a 3D printing system. Based on the prepared surgical guide, a deep circumflex iliac artery (DCIA) free flap was harvested, and its implementation in the reconstruction ultimately led to satisfactory results. Utilization of mirror image based virtual surgical planning and a 3D printing guide is a significantly effective method for maxilla reconstruction with DCIA flaps.

Repair of the deep circumflex iliac artery free flap donor site with Protack (titanium spiral tacks) and Prolene (polypropylene) mesh

Open de-gloving hand injuries with exposed tendons and bones require coverage by a flap.Conventionally used groin or abdominal flaps are cumbersome to patients due to extensive dressing and prolonged passive positioning of the hand until pedicle division. Superficial circumflex iliac artery (SCIA) flap is evolved from a traditional groin flap, and because of its thinness, pliability, and concealed donor site, it is an ideal option for single-stage reconstruction of traumatic hand defects avoiding discomforting passive hand position, joint stiffness, and unexpected flap avulsion which were associated with traditional groin flap.All patients with exposed bones or tendons due to traumatic hand injuries who opted for free flap coverage during the year 2018 to 2020 were enrolled in our study. After initial debridement, the wound was covered with a free SCIA flap. Duration of hospital stay, days out of work, the number of dressings required, postoperative complications, and any secondary procedures for flap readjustment were noted till six months postoperatively. A total of eight patients were included in the study. The mechanism of injury was road traffic accidents in a single patient and occupational injury in eight patients. The average duration of hospital stay was six days after reconstructive surgery. The average number of dressings a patient had was 18, and only two patients required flap thinning. Only one patient had a postoperative infection which was managed with dressings and antibiotics. One patient had peripheral flap necrosis. We had zero flap re-exploration. Therefore, we conclude that hand defects coverage with SCIA flap leads to a smaller number of working days lost and rarely requires secondary procedures.

Central giant cell tumour (CGCT) accounts for < 7% of all benign tumours of the jaws with various non-surgical and surgical treatment modalities. In this study, the authors perform one of the largest retrospective analysis on central giant cell tumour over a ten-year period. A total of 157 cases of CGCT treated in service hospitals by a single operator were retrospectively analysed in terms of basic demographic data, clinical and radiographic features, surgical intervention protocols, reconstruction modalities and complications. Out of the 157 patients, 70 were male and 87 were female with 97 cases (62%) localised to the maxilla and 60 cases (38%) localised to the mandible. Sixty-three patients presented with facial asymmetry whilst paraesthesia was noted in 20 patients. Radiographically, 105 lesions were multilocular (66%), whereas 52 were unilocular (33%). Out of the 97 maxillary CGCT, subtotal maxillectomy was performed in 60 cases and total maxillectomy without orbital exenteration in 37 cases. Radial forearm free flap reconstruction was done in 65 cases, fibula free flap was done in 15 cases, deep circumflex iliac artery free flap was done in 7 cases and patient-specific implant reconstruction was done in 10 cases. Out of the 60 mandibular CGCT, en block marginal resection was done in 37 cases, segmental resection was done in 13 cases and hemimandibulectomy was done in 10 cases. Fibula free flap was used as the reconstructive option in 20 cases, reconstruction plate was used in 25 cases and patient-specific implant reconstruction was done in 15 cases. Partial flap necrosis was noted in 5 patients (3%) and wound dehiscence in 8 patients (5%) and was managed conservatively. Proper diagnosis and treatment planning is paramount for successful management of central giant cell tumour of the maxillofacial skeleton. In the present study, aggressive resection keeping a 5-mm safety margin was the preferred treatment modality with the reconstruction options ranging from autogenous options like radial forearm, fibula free flap and deep circumflex iliac artery free flap to alloplastic options like reconstruction plates and more recently patient-specific implants (PSIs). Though PSIs with their immediate functional and dental rehabilitation along with decreased patient morbidity mark an exciting and accessible alternate treatment modality with can revolutionise how we treat CGCT, long-term randomised controlled trials comparing autogenous reconstruction and patient-specific implants are needed before PSIs can be considered the primary reconstructive option.

Summary:Vascularized free flaps have become the gold standard in reconstructing large segmental mandibular defects; however, even when bony union and soft-tissue coverage is achieved, insufficient bone stock and altered facial contour can create functional and cosmetic problems for the patient. There have been limited case reports on the use of secondary distraction osteogenesis to address these issues. The authors report a case of bilateral mandibular distraction of deep circumflex iliac artery free flaps, used for mandibular reconstruction after total mandibulectomy for treatment of osteosarcoma. Performed for reasons of retrognathia and facilitation of dental prosthetic rehabilitation, this is the first case of bilateral horizontal distraction osteogenesis of deep circumflex iliac artery free flaps reported in the literature.

Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries

Purpose:The reconstruction of mandibular defects poses many difficulties due to the unique, complex shape of the mandible and the temporomandibular joints. With development of microvascular anastomosis, free tissue transplantation techniques, such as deep circumflex iliac artery (DCIA) flap and fibular free flap (FFF), were developed. The DCIA offers good quality and quantity of bone tissue for mandibular segmental defect and implant for dental rehabilitation. Virtual surgical planning (VSP) and stereolithography-guided osteotomy are currently successfully applied in three-dimensional mandibular reconstruction, but most use FFF. There are only a few articles on reconstruction with the DCIA that assess the postoperative results.Methods:Three patients admitted during a five month period (April of 2013 to August of 2013) underwent resection of mandible and DCIA musculo-osseous reconstruction using a VSP and stereolithographic modeling and assessment of outcomes included technical accuracy, esthetic contour, and functional outcomes.Results:This technique yielded iliac bone segment with excellent apposition and duplication of the preoperative plan. Flap survival was 100 percent and all patients maintained preoperative occlusion and contour.Conclusion:Based on our experience, we offer considerations and logically consistent protocols by classification of mandibular defects, and demonstrate the benefits in VSP and stereolithographic modeling of mandibular reconstructive surgery with DCIA flap.

The aim of our study was to determine the factors influencing the evolution of the total volume and bone volume of free flaps commonly used in head and neck surgery, with a 30-month prospective study, to establish volume change predictions and thus propose a degree of overcorrection to be expected before reconstruction. We prospectively included all consecutive free flap. Our maxillofacial surgery department between August 2021 and January 2024. We collected information on preoperative, per-operative, and postoperative factors, on patients, surgical techniques, and adjuvant treatments. We measured on each postoperative imaging the overall flap volume and bone volume if applicable. Multivariate mixed models were then used to select clinical parameters associated with volume loss. We included 166 flaps, performed on 155 patients. The mean age was 60.1 ± 15.1 years. A total of 634 imagings were segmented (487 computed tomography [CT] scans, 77%; 147 magnetic resonance imagings [MRIs], 23%). The use of the superior thyroid or lingual veins for venous anastomosis, such as the use of small couplers, resulted in negative volume changes. Predicted bone volumes decreased by 23% at 30 months for deep circumflex iliac artery (DCIA) free flaps, 19% for fibula free flap (FFF), and 38% for scapular system free flap (SFF). These findings allow us to envisage a volume overcorrection of around 60% for fasciocutaneous or osteocutaneous flaps, and 75% for muscle or osteomuscular flaps. The choice of vein and microsurgical technique seems to have more impact on the evolution of free flap volume than patient characteristics or adjuvant treatments.

The incidence of skin cancer appearing on the head and neck areas is higher in elderly patients. Although free flap reconstruction is the mainstay after tumor excision, it is challenging to complete in elderly patients, owing to the high risk of complications and/or mortality rates associated with the use of general anesthesia. In this study, we used only local anesthesia in free tissue reconstruction of the head and neck in five elderly patients. From 2013 to 2016, 5 elderly patients with high risk of general anesthesia underwent reconstruction with either anterolateral thigh free flaps or groin free flap under local anesthesia, after wide excision of malignant tumors at head and neck. For each patient, the following information was collected: age, gender, body weight, anesthesia agents, intravenous fluid, blood loss, site of lesion, flap size, operation time, complications, and follow-up time. All flaps survived completely. The mean age of 5 patients (3 male patients and 2 female patients) was 84 years (range, 68-100 years), and mean flap size was 199.6 cm (range, 120-330 cm). The mean follow-up period was 26.6 months (range, 5-38 months). No complications were found. With proper local anesthesia, successful head and neck reconstruction with free flap was possible, and patient prognosis was positive. There are numerous advantages, including: (1) a safer and inexpensive operation; (2) no complications from general anesthesia; (3) the fact that free flap transfer can be performed in elderly patients, even if they cannot tolerate general anesthesia; and (4) allowance of the performance of free tissue transferring in countries without adequate medical resources.

Bowel obstruction following deep circumflex iliac artery free flap harvesting

Free flap transfers can be used to reconstruct the complex tissue deficit resulting from a deep burn that exposes bones, tendons, or neurovascular structures which are unable to support a skin graft. Benefits of free flap transfers in the acute stage are early wound closure, early mobility, decreased hospital stay, and possible limb salvage. The purpose of this retrospective study is to describe a single center's experience in free flap transfers for acute burn hand injuries. Between March 1996 and February 2004, twenty-five patients with acute burn hand injuries, who were treated at the burn unit of Linkou Chang Gung Memorial Medical Hospital, were reviewed for free flap transfers. The following data was collected: age, gender, the etiology of burn injury, the percentage of the burned extent, flap type, operations before free flap coverage, timing of free flap coverage, operation time, length of hospital stay, complications and flap outcome. All twenty-five free flaps were fasciocutaneous flaps and all survived. Two flaps among them with partial necrosis required debridement and skin graft coverage because of wound infection. There was neither vascular compromise to the flap nor donor-site morbidity in any case. Free fasciocutaneous flap transfer in acute burn hand injury provides a safe, efficacious and one-stage functional reconstruction. Flap survival and complication rate are not influenced by the etiology of burn injury and the timing of free flap coverage. This approach may minimize donor-site morbidity, postoperative complications and length of hospital stay.

Application of lateral thoracic flap in maxillofacial defect reconstruction: Experience with 28 cases

The aim of the present study was to perform a comparative analysis of the utility, outcomes, and complications of DCIA (deep circumflex iliac artery) flap for the reconstruction of maxillofacial defects between two institutions that continue to use the DCIA flap as a reconstructive resource. This retrospective analysis included a total of 68 patients (mean age 51.1 years) at the University Hospital of Parma, Parma, Italy, and the University of Maryland, Baltimore, USA, between January 2010 and April 2019. No statistical differences were found in relation to the site of reconstruction (p = 0.09), bone graft quantity (p = 0.93), rehabilitation with dental implants (p = 0.464), length of hospitalization (p = 0.086), BMI (0.677), swallow function (p = 0.419), medical comorbidities (p = 0.933), pre-existing radiation (p = 0.691), adjuvant treatment (p = 0.298), ECOG-PS pre-and post-surgery (p = 0.329; p = 0.545), and flap failure: one partial failure observed (p = 0.412) and donor site morbidities (p = 0.742). A noted trend to increased risk of hernia without the use of a primary mesh repair was observed (p = 0.059). The DCIA free flap represents a useful and reliable reconstructive flap for maxillofacial reconstruction. Reconstructive microvascular surgeons should be proficiently trained in this flap technique for its consideration as a first-line option in maxillofacial reconstruction.