Preoperative Near-Infrared (NIR) Vein Visualization in Zygomatic Implant Perforated (ZIP) Flap.

Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate. A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates. Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality. The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Comparison between Fasciocutaneous and Jejunum Flaps in Pharyngolaryngoesophageal Reconstruction

Muscle (M) and fasciocutaneous (FC) free flaps are frequently used options in the reconstruction of traumatic lower limb injuries. The use of one flap over another has remained the topic of controversy in the literature. With a large experience, we sought to evaluate key outcomes of M versus FC free flap reconstructions in lower limb trauma in a single trauma center. A consecutive 7- year review of all free flap reconstructions for lower limb trauma performed at the Royal Melbourne Hospital was conducted. Patient data were prospectively entered into a unit database and retrospectively reviewed. One hundred three patients underwent 105 free flap reconstructions (M = 48 and FC = 57) in lower limb trauma. We experienced a rate of 2.9% total flap failures and 11.4% partial flap losses. Total flap failures represented 6.3% M and 0% FC flaps. The partial flap failures included 15.8% of M and 5.3% of FC flaps. Latissimus dorsi (40% of M group) and radial forearm free flaps (67% of FC group) were most commonly used in each group. There was a statistically significant difference between groups in rates of reoperation (M = 44% versus FC = 16%), postoperative infection (M = 38% versus FC = 12%), fracture nonunion (M = 40% versus FC = 21%), and donor site morbidity (M = 25% versus FC = 4%). Nonstatistically significant differences were encountered with higher rates of osteomyelitis (M = 14.6% versus FC = 10.5%), unplanned bone graft (M = 14.6 versus FC = 10.5%), and inability to bear full weight at 1 year (M = 30.2% versus FC = 17.0%) found in the M group. In our cohort, M flaps used for metal coverage resulted in higher rates of reoperation, postoperative infections, and flap loss than FC flaps (M = 61% versus FC = 25%, p < 0.05). Statistically higher complication rates in key reliability markers were found in the M free flap group. This study found FC free flaps to be more reliable for reconstruction of lower limb injuries in a major trauma center.

Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes. A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes. A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity. Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs. Therapeutic, III.

Propeller vs. free fasciocutaneous flap in reconstruction of complex lower limb defects–A prospective study

Free flaps for lower limb soft tissue reconstruction – A systematic review of complications in ‘Silver Trauma’ patients

Plastic surgeons are often asked to assist with the reconstruction of lower extremity wounds. These patients many times require free tissue transfer for coverage given paucity of soft tissue. Anecdotally, many orthopedic surgeons prefer muscle coverage--particularly in the setting of potentially infected bone. Today's surgeons now easily harvest and transfer fasciocutaneous flaps--a versatile option with less donor-site morbidity. We hypothesized that there would be no difference in outcomes between these 2 types of reconstruction. We performed a single-institution retrospective review of lower extremity free flap reconstructions in the last 10 years. Demographics, preoperative and postoperative course, and the documented time to weight-bearing and bony union were collected. Major cohorts compared were muscle free flaps and fasciocutaneous free flaps, further divided into subgroups including acute trauma, tumor resection, osteomyelitis, and nonunion. Data comparisons were made using paired t test and Fischer exact tests. There were 121 patients who met inclusion criteria--86 in the muscle flap group, and 35 in the fasciocutaneous group and demographics were equal. Total complication rates were higher in smokers than nonsmokers (P < 0.03). There was no significant difference in major or minor complication rates between muscle and fasciocutaneous flaps in any subgroup. In both the acute fracture group and the infected nonunion group, there was a significantly faster return to weight bearing in the fasciocutaneous group (P < 0.03) although there was no difference in documented time to bony union. Patients who underwent fasciocutaneous reconstruction were more likely to require revisionary surgery for improved aesthetics (P < 0.001). Our data suggest that in essentially all clinical parameters, there is no difference between free flap type used for soft tissue coverage of the lower extremity. Patients undergoing reconstruction with a fasciocutaneous flap may return to weight bearing earlier--although they are more likely to require elective flap revisions. These results imply essentially equivalent outcomes regardless of flap type or operative indication, in contrast with some of the biases in the orthopedic community. The particular flap chosen for any reconstruction should remain solely at the discretion of the plastic surgeon.

Considerable controversy persists regarding the optimal technique for hypopharyngeal reconstruction. The ideal procedure should provide low mortality and morbidity, short hospitalization, a high success rate, few complications, and the greatest potential for neopharyngeal speech and deglutition. In this study, a variety of fasciocutaneous free flaps were used for reconstruction of the hypopharynx. Over a two-year period, fasciocutaneous flaps were used for reconstruction of pharyngoesophageal segments following total laryngopharyngectomies in 16 patients at The National Cancer Institute, Cairo University, Cairo, Egypt. Flap survival, recipient vessels used, and complications were examined. The ultimate functional and cosmetic outcomes of free flaps were compared. Of the 16 patients included in this study, nine were males, and seven were females. Free flaps used for reconstruction included the radial forearm (8), lateral arm (2), anterolateral thigh (3), and posterolateral thigh (3) flaps. Free flaps were successful in 15 patients. One patient had total flap loss. Salvage surgery was successful for one flap that developed venous congestion. Eleven patients received adjuvant radiation therapy. The commonly used recipient vessels were the small arteries of the neck and the external jugular vein. Five patients developed minor pharyngocutaneous fistulas that healed spontaneously. Six patients developed anastomotic line stricture. Donor-site morbidity was more significant with the radial forearm flap, compared to other flaps. Fasciocutaneous free flaps have a definite place in pharyngoesophageal reconstruction. The flap should be selected with reference to the type of the defect and patient obesity; however, donor-site morbidity should also be considered.

Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes. A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I2 < 50%) was identified. Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p=0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p=0.98), complete flap necrosis (6.2% vs. 4.7%; p=0.30), infection (19.4% vs. 14.7%; p=0.18), non-union (18.9% vs. 14.8%; p=0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p=0.69). This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.

Fasciocutaneous free flaps in pharyngolaryngo-oesophageal reconstruction: a critical review of the literature

Free flap reconstruction in acute burns is high risk but often required for limb salvage and coverage of vital structures. Prior studies have shown a flap loss rate up to 44%. This study aimed to compare the complications associated with muscle and fasciocutaneous free flaps in acute burn reconstruction. A systematic review and meta-analysis was conducted according to PRISMA guidelines and registered on the PROSPERO database (CDR42023471088). The databases accessed were Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was free flap failure rate based on flap type. Secondary outcomes included venous congestion, arterial thrombosis, amputation, and need for reintervention. Twelve studies with 181 free flaps were included: 87 muscle flaps and 94 fasciocutaneous flaps. Muscle flaps had a higher risk ratio (RR) for total flap loss [RR: 2.32, 95% confidence interval (CI): 1.01-5.32, P = 0.04], arterial thrombosis (RR: 3.13, 95% CI: 1.17-8.42, P = 0.02), and amputations (RR: 8.89, 95% CI: 1.27-70.13, P = 0.03) compared with fasciocutaneous flaps. No significant differences were found in venous thrombosis (RR: 1.33, 95% CI: 0.37-4.78, P = 0.65) or need for reinterventions (RR: 1.34, 95% CI: 0.77-2.32, P = 0.29). Muscle flaps in burn injuries are associated with higher risks of flap failure, arterial thrombosis, and amputations. Fasciocutaneous free flaps in acute burns seem to be safer with better outcomes, though further research is needed to confirm these findings.

Soft tissue defects of the lower extremity that expose underlying bones, joints, and tendons pose challenging problems and generally require free tissue transfer for a successful reconstruction. Historically, muscle flaps were the gold standard choice for lower limb reconstruction. To obviate the unpredictable appearance and high donor-site morbidity of muscle flaps, fasciocutaneous flaps were introduced. Recently, perforator flaps, such as the anterolateral thigh flap, gained a leading role in the reconstructive scenario. There is growing evidence in the literature supporting that fasciocutaneous and perforator flaps are comparable to muscle flaps in terms of flap survival, postoperative infection, osteomyelitis, bone union, and ambulation. With the advances of knowledge in perforator anatomy and their mapping, a new era of lower limb reconstruction has begun. Propeller flap could be raised on any suitable perforator vessel and, without the aid of microsurgical anastomosis, used to restore small- to middle-sized soft tissue defects. In this review, we intend to analyze pros and cons of muscle and fasciocutaneous free flaps and the applicability of the propeller flaps in lower limb reconstruction.

Most of the patients with hypopharyngeal cancer are still diagnosed with advanced stage, and total or partial pharyngectomy with free flap reconstruction is the mainstay of treatment. The aim of this study was to find out the possible risk factors related to surgical complications after free fasciocutaneous flap reconstruction for partial pharyngeal defect and its sequelae in the follow-up. We retrospectively reviewed the charts of patients with advanced hypopharyngeal cancer who received free fasciocutaneous flaps for partial pharyngeal defects reconstruction. From 2005 to 2015, 79 free fasciocutaneous flaps (59 free fasciocutaneous flaps and 20 anterolateral thigh flaps) were performed in our department. The risk factors for free flap outcome and complications were evaluated with multivariant linear regression model. The mean age of patients was 60.8 years with male predominance. The mean follow-up duration was 39.6 months. Most of the cases (97.5%) were in stage III or IV. Patients with comorbidities showed significant correlation to flap failure (95% confidence interval [CI] = 0.038 to 0.264, P = 0.10). Anastomosis style (end-to-side vs end-to-end) was the only operation-related factors significantly related to flap failure rate (18.8% vs 3.2%, 95% CI = 0.031 to 0.32, P = 0.18). Flap size was significantly associated with fistula formation (95% CI = -0.005 to 0.000, P = 0.38). In our experience, patients with comorbidities and end-to-side anastomosis illustrate significantly higher flap failure rate in free fasciocutaneous flap reconstruction of partial hypopharyngeal defect. Reconstruction with smaller flap size had higher possibility of fistula formation.

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.

Large defects of the lower lip often require free tissue coverage. Fasciocutaneous free flaps have been traditionally used, but innervated muscular free flaps may fundamentally address orbicularis oris deficiency and improve dynamic competence. This review aimed to determine if innervated muscular free flaps provided benefit over fasciocutaneous free flaps for reconstruction of defects of more than 50% of the lower lip. Outcomes of interest included functional oral outcomes including oral competence, aesthetic outcomes, and patient-reported outcome measures. Five databases (PubMed, Embase, Web of Science, CINAHL, and CENTRAL) were searched for variations of "lip" and "free flap." Two authors screened articles and included primary research of free flap reconstruction of more than 50% of the lower lip from any etiology in living humans with an English full-text available. Composite bony flaps were excluded. Oral competence and aesthetic satisfaction, reconstruction details, and complications were extracted. Proportional meta-analyses were used to synthesize results for fasciocutaneous free flaps, which were compared with those for muscular free flaps. Fifty-nine articles describing 242 patients were included. Muscular free flaps reported significantly higher proportional oral competence than fasciocutaneous free flaps (98 vs. 83%, p = 0.01). Aesthetic outcomes (98 vs. 97%, p = 0.22) and complications (17 vs. 18%, p = 0.79) were equivalent between fasciocutaneous and muscular free flaps. Muscular free flaps may address the fundamental orbicularis oris defect that causes oral incompetence and seem to provide better functional results. Aesthetic outcomes and complications seem to be equivalent.