Microsurgical reconstruction of the heel: evaluation and decision-making recommendations based on a case series

Free tissue transfers can successfully address a wide range of reconstructive requirements. While the negative influence of cigarette smoking is well documented, its effects in the setting of microsurgical free flap reconstruction remain debated. This study evaluates the impact of cigarette smoking on microsurgical reconstructions. Over a 7-year period, 897 patients underwent 969 microvascular free flap reconstructions at a single surgical center. The cases were divided into "smoker" (S) and "nonsmoker" (NS) groups according to their cigarette smoking status. The data were retrospectively screened for patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and overall outcomes. Both groups were comparable regarding comorbidities including hypertension, peripheral artery disease, diabetes, American Society of Anesthesiologists scores, types of performed free flaps, and recipient sites. While patients in the NS group were significantly older and had a higher prevalence of obesity (p < 0.05), there were no significant differences regarding the rate of major or minor complications during our 3-month follow-up period (p > 0.05). While minor and major complications were increased regarding virtually all examined parameters, cigarette smoking did not have significant effects on the overall outcomes of microsurgical free flap reconstructions.

Malignant Immature Teratoma of the Larynx and Trachea with Functional Osteocutaneous Free Flap Reconstruction

The relative survival of composite free flaps in head and neck reconstruction

BackgroundThe free flap surgical method is useful for the reconstruction of head and neck defects. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 30 years.MethodsBetween 1989 and 2018, a total of 866 free flap procedures were performed on 859 patients with head and neck defects, including 7 double free flaps. The causes of vascular crisis and salvage rate were analyzed, and the total flap survival rate calculated among these patients. Additionally, the survival and complication rates for each flap type were compared.ResultsThe 866 cases included 557 radial forearm flaps, 200 anterolateral thigh flaps, 39 fibular osteocutaneous flaps, and 70 of various other flaps. The incidence of the vascular crisis was 5.1%; its most common cause was venous thrombosis (52.3%). Salvage surgery was successful in 52.3% of patients, and the total flap survival rate was 97.6%. The success rate of the radial forearm flap was higher than of the anterolateral flap (p<0.01), and the primary sites of malignancy were the tongue, tonsils, and hypopharynx, respectively.ConclusionThe free flap technique is the most reliable method for head and neck reconstruction; however, the radial forearm free flap showed the highest success rate (98.9%). In patients with malignancy, flap failure was more common in the anterolateral thigh (5.5%) and fibular (5.1%) flaps.

Introduction and importance: Ablative surgery for oral cancer, irrespective of the histological subtype, causes large tissue defects, functional and aesthetic damage. Microsurgical free flaps have been widely used in reconstruction after resection, with satisfactory success rates in conjunction with adjuvant radiotherapy (RT). This study aims to describe our clinical institutional experience based on the multimodal treatment performed in four cases diagnosed with oral squamous cell carcinoma with the use of different microvascular free flaps and RT. Case series presentation: Four patients underwent reconstructive microsurgery after surgical resection of oral cancer, using three types of free flap: radial forearm fasciocutaneous, osteomyocutaneous fibular, and anterolateral thigh musculocutaneous flaps; RT was performed in Case 2 and Case 3. In the period of 3 years after microsurgical reconstruction and RT, flaps remain clinically stable without failure signs in full patients submitted to multimodal treatment. Clinical discussion: After resection of oral carcinomas, extensive tissue defects can be successfully treated with reconstructive microsurgery using different types of microvascular free flaps. RT for locoregional control is a feasible option and did not seem to interfere with the survival of flaps. Conclusion: An enhance long-term follow-up to assess overall and disease-free survival rates and quality of life must be carried out; however, cohort studies would be necessary for better understanding of the role of each treatment in the multimodal scheme.

Seventeen free flaps were used to reconstruct severe injuries to the foot over the last 36 months at the University of Cincinnati College of Medicine. The type of free flaps used included six fasciocutaneous free flaps and eleven free muscle flaps with split-thickness skin grafts. The fasciocutaneous flaps were either radial forearm or scapular flaps. The muscle flaps used were gracilis, rectus, or latissimus dorsi muscle flaps. Each type, with their specific advantages, disadvantages, and indications for use as they apply to the anatomical areas of the foot, are described. Regardless of the type of free flap used, careful preoperative planning, attention to the size and location of the anatomical defect, and correct contouring and insetting should allow for maximal functional result and minimize postoperative morbidity.

Reconstruction after ablative oral cancer surgery is challenging mission. Soft tissue and hard tissue could be resected in case of advanced oral cancer. The final goal of oral reconstruction is to gain normal swallowing, chewing and speech. Nowadays, free flap reconstruction after oral cancer resection is more popular than pedicled flap. Microsurgical reconstruction with free flap could be used effectively in complicated cases of oral cavity defect. However, complications could be happened. So not only meticulous preoperative study about the extent of defects but also the donor site dressing after surgery were performed to prevent postoperative complication. The most favorite free flap for soft tissue reconstruction is radial forearm flap. It has a lot of advantages such as pliable, hairless, reliable vessels, appropriate diameter of radial artery and diverse flap design. And the most popular free flap for jaw reconstruction is free fibular flap. In this article, we report the classification of flap for reconstruction and reveal the pits and falls of radial forearm free flap and free fibular flap.

Introduction: Reconstruction with a free flap is routinely done at site especially head and neck and oral because of better surgical and functional outcomes, improved esthetics results, and overall higher success rates. Aim &amp; Objective: To evaluate the clinical outcomes in patients undergoing different microvascular free flap reconstructions and tudy various demographic and pre-operative factors associated with it. Methods: This was a retrospective study of 45 patients undergoing reconstructions with free flaps from January 2020 to December 2022. Different types of free flap were performed like Anterolateral thigh, Free fibula osteocutaneous flap (FFOCF), free functioning muscle transfer (FFMT), Free radial artery forearm flap (FRAF), The medial sural artery perforator (MSAP), latissimus dorsi (LD), myocutaneous flap, superficial circumflex iliac artery perforator (SCIP). Results: The patients included total 45 participants, with 35 men and 10 women, with a mean age of 45.56 years. Oral malignancy was the most common cause. Squamous cell carcinoma represented the majority of the diagnosed tumors (31.1%) followed by ameloblastoma. The most common recipient vessels were the internal jugular vein (91.4%), the facial artery (77.4%) followed by superior thyroid artery. The overall flap success rate was 93.33%. Venous thrombosis was the most common cause for re-exploration. The majority of patients had satisfactory cosmetic and functional results of both donor site and recipient site on 1 month follow up. Conclusion: Microsurgical free flap seems to be a valuable and successful method in head and neck surgery. The reconstruction can be done by skilled surgeons with post-op monitoring.

Background:Ballistic facial injuries are rare, with most trauma centers reporting 1–20 cases annually. These patients present significant management challenges to reconstructive surgeons, not only due to their rarity but also due to the complex decision-making process that is involved. The aim of this study was to review our experience with the application of craniofacial microsurgery in management of facial gunshot wounds.Methods:A retrospective review of a single-surgeon experience at a level I trauma center from 2011 to 2020 for patients sustaining self-inflicted gunshot wounds to the face requiring microsurgical reconstruction was performed. Outcomes included reconstructive techniques, free flap type and indication, airway evolution, feeding modality, respective timing of interventions, and complications.Results:Between 2012 and 2021, 13 patients presented for microsurgical reconstruction at our institution for gunshot wounds to the face. The majority (90%) of patients were men, and the average age at time of injury was 26. The median from the time of injury to first free flap was 93 days. Thirteen patients represented 23 free flaps. On average, patients underwent a total of two free flaps. The most common microsurgical flap was the fibula flap (14) followed by the radial forearm flap (6).Conclusions:Based on our findings, we describe a novel algorithm for function restoration and aesthetic revisions based on injury location. Underlying principles include avoiding early use of reconstruction plates, establishing occlusion early, and aligning bony segments using external fixation. An algorithmic approach to these injuries can improve outcomes.

Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.

Surgical Management of Ameloblastoma in the Mandible: Segmental Mandibulectomy and Immediate Reconstruction With Free Fibula or Deep Circumflex Iliac Artery Flap (Evaluation of the Long-Term Esthetic and Functional Results)

The timing of microsurgical free flap reconstruction for traumatic lower limb injury has been described as being optimal if conducted within the early period following injury, as higher rates of infection and flap loss were reported in the subsequent time period. However, for various reasons, reconstruction of these defects may be delayed. The aim of this article is to show that adequate debridement, negative pressure wound dressing, and sound reconstructive principles has led to increased free flap success rates regardless of the period between injury and reconstruction. A 10-year retrospective single-center analysis of 50 traumatic lower limb cases from 2002 to 2012 was conducted. All patients had microsurgical free flap reconstruction after a period of negative pressure wound therapy (NPWT). Patient factors and reconstructive methods were analyzed and outcomes were compared. Mean interval between admission and free flap coverage was 17.5 days, and patients underwent NPWT for an average of 12 days (range, 1-35). Approximately 8% of patients had postoperative infections. Overall free flap success rate was 96%. Approximately 90% of patients were able to return to their premorbid footwear, with 96% able to mobilize independently approaching the end of their follow-up period. Our study shows that traumatic lower limb reconstruction in the delayed period is no longer associated with high rates of flap failure. Improvements in microsurgery and the advent of NPWT have made timing no longer crucial in free flap coverage of traumatic lower limb injuries.

Objective:To determine flap success rate and complications in patients who underwent microvascular free tissue reconstruction after major head and neck ablative surgery and to report the improvement in the results.Methods:Medical records of 124 patients who were operated on in 2012 to 2019 were retrospectively reviewed. Indications for different free flap types, success rates and re-exploration rates, donor site morbidities, and reasons for flap loss were analyzed. Patients were divided into two groups to identify the effects of the anticoagulant and the antiaggregant treatments on postoperative results.Results:There were 127 flaps in 124 patients, including two different free flaps each in three patients that were harvested and used in the same surgical session. Of the total 127 flaps, 82 (64.6%) were radial forearm flaps, 39 (30.7%) were fibula flaps, and 6 (4.7) were rectus abdominis flaps. Four patients were re-explored for flap perfusion problems, and 18 patients were re-explored for hematoma drainage (n=22/124, %17.3). The rate of hematoma and re-exploration was higher in patients who received anticoagulant and antiaggregant treatments synchronously (p=0.02). Three flaps were lost, and the overall success rate was 97.6%. Two patients died from perioperative complications. No major complications were observed at the donor site; minor complications were observed in 30 patients.Conclusion:The success rate for the 127 flaps in 124 patients were found comparable to those reported in the literature. These results show that successful outcomes can be achieved with experience and a head and neck team dedicated to improving the results in microsurgical reconstruction, and flap failure rarely occurs if perioperative care of the patients is given meticulously.

SummaryThe aim of this review was to identify studies that used thromboelastography (TEG) or rotational thromboelastometry (ROTEM) in microsurgical free flap reconstruction and analyse whether it is a useful adjunct at predicting and identifying thrombotic complications.A search was conducted using the MEDLINE database using the keywords “thromboelastogram”, “TEG”, “thromboelastography”, “free flaps” and “free tissue transfer” using a two-component search with the Boolean operators “OR” and “AND”.Eight studies were retrieved using the search criteria. Seven studies met the inclusion criteria, and a further study was found citing several articles from the initial search. Combined, there were 528 patients who underwent 600 free flaps. A total of 10.3% (62) arterial and venous thromboses were reported in the studies, and the combined flap failure rate was 5.2% (26).A total of 67% (4/6) of the studies supported the use of TEG as a predictive tool to detect thromboses, including three retrospective case series and one prospective cohort, which were all statistically significant.There is low-quality evidence (level IV) that a pre-operative TEG and functional fibrinogen to platelet ratio of ≥42 can identify patients at risk of adverse post-operative thrombotic events following free flap surgery; however, further validation is required. Higher quality, standardised prospective or randomised control trials are required to further evaluate the predictive value of TEG. As a pre-operative screening tool, TEG can help to detect pathological changes in coagulation, aid in the transfusion of blood products, target anticoagulation therapy and predict possible adverse events aiding to further reduce patient morbidity.

With significant improvements in success rates for free flap reconstruction of the head and neck, attention has turned to donor site morbidity associated with osteocutaneous free flaps. In this review, we address the morbidity associated with harvest of the four most commonly used osteocutaneous flaps; the free fibula flap, the scapula flap, the iliac crest flap and the radial forearm flap. A comprehensive literature search was performed to identify articles relevant to donor site morbidity for these flaps. We assessed morbidity in terms of incidence of delayed healing, chronic pain, aesthetic outcomes, site specific complications and patient satisfaction/quality of life. Weighted means were calculated when sufficient studies were available for review. The radial forearm and free fibula flaps are associated with high rates of delayed healing of approximately 20% compared to the scapular (<10%) and iliac flaps (5%). The radial forearm flap has higher rates of chronic pain (16.7%) and dissatisfaction with scar appearance (33%). For the majority of these patients harvest of one of these four osteocutaneous does not limit daily function at long-term follow-up. The scapular osteocutaneous flap is associated with the lowest relative morbidity and should be strongly considered when the recipient defect allows. The radial forearm is associated with higher morbidity in terms of scarring, fractures, chronic pain and wrist function and should not be considered as first choice when other flap options are available.