Possibilities of intranasal reconstruction in complex nasal defects.

Reconstruction after resection of large tumors of the lower lip requires the use of free flaps in order to restore the shape and the function of the lip, with the free radial forearm flap being the most popular. In this study we describe our experience in using the dorsalis pedis free flap as a salvage option in reconstruction of total lower lip defect in a patient with an extended lower lip carcinoma after failure of the radial forearm free flap, that was initially used. The flap was integrated excellently and on the followup the patient was free of disease and fully satisfied with the aesthetic and functional result.

Background: patients with the lower 3rd leg defects are increasing in number especially among victims of road accidents .Due to anatomical features of this area nearly most cases required flap coverage. Aim of the work: the aim of this study was to help in selection of the appropriate option for coverage among available local perforator flaps and free microvascular flaps. Patients and methods: 30 patients with lower 3rd leg defect were included in this study and they were categorized into 2 groups. 15 patients underwent reconstruction by using local flaps (A) and 15 patients under went reconstruction using free micro-vascular flaps (B). Results: free flaps were more versatile than local flaps, but consumed more operative time and had higher morbidity Conclusion: small and moderately-sized lower 3rd leg soft tissue defects can be covered easily and safely by using locally available perforator flaps. Local flaps do not scarify any of the main arteries, consume less operative time, there was a specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. Free flaps have proven its versatility and reliability in coverage of significantly large and complex defects.

<b>Introduction:</b> The nose is the central and probably the most important organ of the face. In view of the three-dimensional shape and variety of tissues, reconstructive surgery after tumor resection in this anatomical region requires the surgeon's knowledge of anatomy. <br><b>Materials and Method:</b> In the years 2010-2019, 48 patients were treated in the Oncological and Reconstructive Surgery Clinic for extended nasal tumors, which required the use of free microvascular flaps after resection for functional and aesthetic supply of anatomical structures of the nose. <br><b>Results:</b> In 48 patients, a total of 92 free microvascular flaps were used for nasal reconstruction including: radial forearm free flap in 24 patients, radial forearm free flap with radial bone in 14 patients, auricular free flap in 16 patients, radial forearm free flap in combination with auricle free flap in 7 patients, double auricular free flap in 6 patients, radial forearm free flap in combination with double auricular free flap in 4 patients. Total necrosis of the free flap was noted in 4 cases, partial in 6 patients. <br><b>Conclusions:</b> The presented surgical techniques using microvascular free flaps constitute a recognized method of treatment and should be used in everyday surgeon practice. The results demonstrated in this article allow to obtain optimal functional and aesthetic effects.

Poster 12: Venous Anastomoses Coupler With Implantable Doppler in Head and Neck Microvascular Reconstruction: A Preliminary Cohort

Dorsal hand coverage

Background: Coverage of post-traumatic or post-oncosurgical nasal defects is a very challenging procedure. Small nasal defects may be covered by skin grafts or small local flaps while larger nasal defects require more complex flap coverage techniques as using tissue expanders, prefabricated flaps or free flaps. The forehead flap has been used for centuries and remains a workhorse flap for reconstruction of large and complex nasal defects. Aim: evaluate the feasibility and versatility of forehead flap for resurfacing nasal defects. Materials and Methods: 12 patients underwent coverage of nasal defects after trauma or tumor excision using forehead flaps. All flaps needed a second stage for flap separation 3 weeks after the time of operation. The size of the harvested flap, the harvesting time, results of transferred flaps, patient satisfaction and flap-related complications were analyzed. Results: 12 patients (10 males and 2 females) underwent reconstruction of different nasal defects using 12 forehead flaps. The overall complications occurred in 2 patients. The remaining 10 patients showed no complications and passed an uneventful follow-up period. 7 Patients were very satisfied, 4 were satisfied and only one patient was not satisfied as she was 23 years old young female and was subjected to human bite. Follow-up periods ranged from 6 to 12 months. Conclusion: Nasal defects can successfully be managed with the forehead flap. Probably, the flap provides the best result due to the good matching of the skin in terms of color, texture, and thickness. Also, despite the increasing use of free flaps, the forehead flap is still a valid and safe option for nasal defects coverage that allows good aesthetics and functional outcomes.

BACKGROUND: Reconstruction of partial glossectomy defects secondary to tumor excision has always been challenging because of the complexity of tongue function. Small to medium-sized glossal defects are often repaired with primary closure or with bulkier free flaps. However, these methods of reconstruction can lead to tethering and poor tongue mobility. We present use of the using the facial artery myomucosal (FAMM) flap for partial glossectomy defects. We propose the use of the FAMM flap for improved tongue function in the setting where the defect is too large for primary closure, but where free tissue transfer would provide coverage where the volume of the flap would interfere with tongue function. METHODS: We conducted a retrospective chart analysis of nineteen patients who underwent partial glossectomy with FAMM flap reconstruction. We examined tumor type and location, along with post-operative complications, functional outcomes, and need for further procedures. We then emailed all living patients with the MD Anderson Dysphagia Inventory and the University of Michigan Voice-Related Quality of Life Measure to better elucidate their overall functional outcomes with regard to speech and swallowing. RESULTS: Of the 19 patients, all flaps provided adequate coverage and there were no flap failures. Two patients had minor post-operative complications that easily resolved. All patients had intelligible speech and adequate swallowing capabilities. Almost all of the patients rated their quality of voice to be good, very good, or excellent, and they did not feel that their flap interfered with their feeding abilities. CONCLUSION: The FAMM flap provides a good alternative to primary closure and split-thickness skin grafting for patients with small and medium-sized tongue defects after glossectomy. The flap is close in proximity to the defect, is of similar tissue composition, and produces good functional outcome. The FAMM flap provides an excellent alternative to partial glossectomy defects that are less than 50% of the total surface area of the tongue.

Background:The area of nasal reconstruction can be challenging for the microsurgeon, as the nose is a complex structure. A 3-dimensional understanding of the organ is a prerequisite for a successful outcome. A combination of procedures is usually necessary to completely repair subtotal or total nasal defects. Contouring and secondary revisions may ensue to enhance the postoperative functional and aesthetic outcome of the reconstruction. This study aimed to present a review of the various methods of microvascular reconstruction for complex nasal defects based on the radial forearm flap (RFF).Methods:Two independent reviewers screened the literature on PubMed according to the inclusion criteria. The keywords for the search were “microvascular,” “nasal reconstruction,” and “free flaps in nasal reconstruction.” Articles on locoregional flap reconstruction, experimental animal studies, letters to the editors, non-English literature, and articles without full text were excluded from the study. The protocol is registered at the International Prospective Register of Systematic Reviews (CRD42019146447) under the umbrella of the National Institute for Health Research, and it is reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.Results:Eighteen eligible studies were included in our articles. The infolding RFF, multiple skin paddles RFF, and prelaminated RFF were described. The results have been more than encouraging so far. Also, 3 clinical cases where the RFF provided intranasal lining and a forehead flap resurfaced the nose were presented.Conclusion:The RFF is a reliable technique for nasal reconstruction in expert hands.

Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessary for coverage of large defects. From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 11 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up was 33.3 months. The defect size ranged from 8 x 8 to 25 x 28 cm. Six parascapular flaps (three with a vascularized scapular fascial extension), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achilles tendon. Thirteen flaps survived. In one case a parascapular flap had to be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptable for most patients after flap harvesting in the subscapular region and also satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 degrees for extension/flexion. All patients were satisfied with the functional and aesthetic result. Soft tissue coverage over the exposed Achilles tendon requires an optimal solution for each patient to achieve an aesthetically pleasing result and acceptable function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The complication rate of microvascular flaps is comparable with that of local flaps.

Contact high-tension electrical burn to the penis: Reconstruction of the defect with free radial forearm fasciocutaneous flap and silicon rod, a case report

After years of development, microvascular free tissue transfer has been firmly established as the primary method for reconstrutive surgery. The concept of using a reconstructive ladder to repair complex defects has been revolutionized and the tradition of using free flap surgery as the last resort has been challenged. In a developing country like ours, surgeons are still contending with the basic problems of microvascular free tissue transplantation. An 18-year old student presented to our hospital with a diagnosis of osteomyelitis of the frontal bone. A radical debridement of osteomyelitic bone was done and the defect created was repaired with a microvascular free lattisimus dorsi musculocutaneous flap. The procedure lasted about 16 hours with a long duration of warm ischaemic time, but the flap survived. Institutional support is highly necessary for making available appropriate microvascular instruments, operating microscope, pharmacologic agents, allocation of operative time and post operative care, if we must make progress in the field of microvascular surgery in the West African sub-region. KEY WORDS: Microvascular Free Flap, Challenges, Developing Country Sahel Medical Journal Vol.7(2) 2004: 73-75

Free flap surgery is routine today, yet little is known of its pathophysiology. In this study, the authors evaluated the hemodynamics in different types of free microvascular flaps, by measuring intraoperative transit-time flow. Eighty-six free transplants--21 free TRAM flaps for breast reconstruction, 18 radial forearm flaps for head and neck reconstructions, and 47 muscle flaps for head and neck, trunk and lower extremity reconstructions--were studied. Donor artery flow was highest in the radial artery (mean: 57.5 +/- 50 (SD) ml/min) but dropped (p < 0.001) to one tenth (6.1 +/- 2 ml/min) after anastomosis. The flow was lowest (4.9 +/- 3 ml/min) in the recipient artery of the TRAM flap but, after anastomosis, increased significantly (13.7 +/- 5 ml/min) to the level of the flow in the donor artery. The donor-artery flow in muscle flaps had a mean of 15.9 +/- 11 ml/min, and it significantly increased after anastomosing (23.9 +/- 12 ml/min). Weight-related intake of blood was highest in the radial forearm flap (18.5 +/- 6 ml/ min/100g) and lowest in the TRAM flap (2.5 +/- 1 ml/min/100g). The study showed that blood flow through a free microvascular flap does not depend on recipient artery flow. Even low-flow arteries can be used as recipients, because the flow increases according to free-flap requirements. The blood flow through a free microvascular flap depends on the specific tissue components of the flap.

Microvascular free tissue transfer has in many cases replaced classic flap techniques and is now an established workhorse for head and neck reconstructions. In this retrospective study the over 300 patients, who had microvascular free flap reconstructions in head and neck cancer surgery in Finland during a 10-year period (1986–1995) were reviewed. The operations were performed in the University Hospitals by plastic surgeons, ENT specialists or maxillofacial surgeons. The cases consisted of defects resulting from resection of oral cavity tumors (63%), mid- or upper-face and skullbase tumors (20%) and hypopharyngo-esophageal tumors (17%). The series includes a wide range of flap types and analyses flap outcome and complications. A total of 313 cases was reconstructed by 317 flaps (forearm flaps 47%, latissimus dorsi flaps 19%, free jejunum or colon transfers 15%, free iliaca crest flaps 8% and other flaps 11%). Thrombosis of one of the vessels and haematoma were the most frequent causes of failure in microvascular free tissue transfer. A total flap necrosis occurred in 27 (8.5%) and a partial necrosis in 12 (4%) patients. The most reliable flap in terms of survival was the radial forearm flap. The ever-improving success of microvascular free tissue transfer has made it a useful procedure for head and neck reconstructions. There is also a growing need for microvascular team surgery in the field of head and neck cancer therapy.

e18065 Background: Reconstruction of complex orofacial defects following tumour resection has always posed as a challenge for clinicians for providing functional and morphological outcomes. Though microvascular free flaps revolutionized reconstruction, local flaps provide a viable alternative in resource constraint settings. Oncological safety of harvesting local flaps has always been a matter of debate in oral squamous cell carcinoma due to proximity of nodal stations. Available literature on oncological safety is limited to clinically node negative patients. The purpose of this study was to evaluate the oncologic safety of local flaps in clinically node positive patients. Methods: Retrospective analysis of data available of all patients diagnosed with clinically node positive oral squamous cell carcinoma who underwent modified radical neck dissection at Malabar Cancer Centre during the period January 2012 to December 2017 was done. Demographic profile, tumour characteristics and pathological outcomes were compiled. The factors included were pathological tumour, nodal stage, levels of nodes involved, extranodal extension, choice of flap and site of recurrence. Fisher's exact test was used to compare recurrence patterns between local and regional flaps. Results: A total of 309 clinically node positive patients were analyzed with a median follow up of 4 years. Overall incidence of pathologically proven nodal metastases to ipsilateral levels Ia Ib, II, III, IV and V were 8.1%, 35.3%, 39.5%,15.5%, 2.9% and 1.3% respectively. Level Ia was most commonly involved in buccal mucosa and tongue cancers. Levels Ib, II, III were most commonly involved in tongue and buccal mucosa cancers. Level IV was commonly involved in tongue cancers while level V in cancer of retromolar trigone. Local flaps analyzed were submental flap (2.6%), supraclavicular flap (2.6%), infrahyoid flap (2.6%), sternocleidomastoid muscle flap (4.5%), nasolabial flap (1.3%), facial artery myomucosal flap (1.6%). Pathological nodal positivity was 60% and 52% in local and regional flaps respectively. Amongst the patients who had reconstruction with submental flap there were no nodal recurrences at level Ia, only 1 patient had recurrence at flap site. Amongst the patients who had reconstruction with supraclavicular flap there was 1 patient with pathological involvement of level V as per histopathological report but no nodal recurrences at level V. There was no difference in pattern of nodal recurrence between local and regional flaps (p = 0.436). Conclusions: This retrospective analysis is the first of its kind analysing the oncological safety of harvesting local flaps in clinically node positive oral squamous cell carcinoma. Thus, with appropriate management of the levels Ia and V nodal compartment, oncologic outcomes are not compromised, thereby making it oncologically sound to harvest local flaps in N+ neck.

Breach in the palatal vault leading to an abnormal communication between oral and nasal cavity is known as oro-nasal communication. It is an uncommon presentation in day-to-day clinical practice except in some patients of cleft lip and palate.Etiology may be congenital or acquired. Alveolar and palatal cleft defects are the most common etiological factor. The acquired causes may be trauma, periapical pathology, infections, neoplasms, postsurgical complications, and radio and chemo necrosis.Clinical features like nasal regurgitation of food, defective speech, fetid odor, bad taste, and upper respiratory tract and ear infection are associated with oro-nasal communication.Management depends upon the size and site of defect, age of patient, and associated comorbidity. The definitive management is always surgical. Two layered closure provides greater support and stability and reduces the risk of failure. Palatal rotational flaps are suitable for smaller defects. The other local flaps are buccal mucosal flap, tongue flap, and facial artery myomucosal flap. Temporoparietal galeal flap, turbinate flap, free radial forearm flap, and scapular flap have also been successfully used for closure of oronasal communication. Newer procedures like the use of bone morphogenic protein, acellular dermal matrices, human amniotic membrane, and distraction osteogenesis have been tried successfully. The rate of recurrence is high.Unsuccessful surgical attempts and larger defects associated with compromised medical conditions are better managed nonsurgically with obturator incorporating the missing teeth.