Artery Flap Research Articles

Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic

BackgroundMost of the head and neck cancers are time-critical and need urgent surgical treatment. Our unit is one of the departments in the region, at the forefront in treating head and neck cancers in Pakistan. We have continued treating these patients in the COVID-19 pandemic with certain modified protocols. The objective of this study is to share our experience and approach towards head and neck reconstruction during the COVID-19 pandemic.ResultsThere were a total of 31 patients, 20 (64.5%) were males and 11 (35.4%) patients were females. The mean age of patients was 52 years. Patients presented with different pathologies, i.e. Squamous cell carcinoma n = 26 (83.8%), mucoepidermoid carcinoma n = 2 (6.4%), adenoid cystic carcinoma n = 2 (6.4%) and mucormycosis n = 1 (3%). The reconstruction was done with loco-regional flaps like temporalis muscle flap n = 12 (38.7%), Pectoralis major myocutaneous flap n = 8 (25.8%), supraclavicular artery flap n = 10 (32.2%) and combination of fore-head, temporalis major and cheek rotation flaps n = 1 (3%). Defects involved different regions like maxilla n = 11 (35.4%), buccal mucosa n = 6 (19.3%), tongue with floor of mouth n = 6 (19.3%), mandible n = 4 (12.9%), parotid gland, mastoid n = 3 (9.6%) and combination of defects n = 1 (3%). Metal reconstruction plate was used in 3 (9.6%) patients with mandibular defects. All flaps survived, with the maximum follow-up of 8 months and minimum follow-up of 6 months.ConclusionPedicled flaps are proving as the workhorse for head and neck reconstruction in unique global health crisis. Vigilant use of proper PPE and adherence to the ethical principles proves to be the only shield that will benefit patients, HCW and health system.

Innovative Surgical Techniques for Nasal Septal Perforations: Management and Treatment.

The aim of this study was to review and describe the main innovative surgical techniques for nasal septal perforation (NSP) repair that have been published in recent years. Several techniques for NSP repair have been developed recently. The anterior ethmoidal artery (AEA) flap is a versatile technique for middle-size perforations in different locations. The greater palatine artery (GPA) flap is an excellent option for anterior-most NSPs. The lateral nasal wall flap and the pericranial flap are the most appropriate techniques for large perforations. The advent of these techniques has changed the management and has expanded the therapeutic arsenal to treat all types of NSPs according to the size, location, and osteo-cartilaginous support. However, no technique has been accepted as the gold standard. Extensive knowledge of different techniques is important to individualize the treatment, selecting the most appropriate in each case.

A Modification to Enhance the Survival of the Island FDMA Flap by Adding a Skin Bridge.

Background:Distal thumb injuries are common in high construction load regions, and it is a challenging task for the plastic surgeon to find the optimum choice that preserves thumb length and provides a sensory substitute to the lost tissue. Introducing first dorsal metacarpal artery flap has solved the dilemma. One drawback is that the flap is susceptible to distal necrosis, which can happen because of tight tunneling or insufficient venous drainage. We combined Foucher and Holevich characteristics to design a flap that promises to solve the problem.Methods:This is a case series that includes 9 patients where we describe a technique that has the potential to enhance the survival of the first dorsal metacarpal artery (FDMA) flap and decreases the rate of distal necrosis via addition of a 5-mm skin bridge to the pedicle and by avoiding tunneling. Distal necrosis of the patients in this study patients was compared with that in a control of 10 patients in whom we did the conventional FDMA flap. Patients were followed for 6 weeks to trace early postoperative complications (infection, dehiscence, and necrosis) and the establishment of protective sensation (pain and temperature).Results:None of our patients had distal necrosis, infection, or dehiscence, and all had protective sensation in the flap. In comparison, 4 patients in the control group developed distal necrosis.Conclusion:FDMA is one of the best choices when it comes to distal thumb reconstruction, but it has the disadvantage of distal necrosis, which might be avoided when using the technique mentioned in this study.

Post-operative healing and long-term stability after mastoid cavity reconstruction using the middle temporal artery and inferior musculoperiosteal flaps.

This study aims to evaluate the surgical outcomes with the use of a combination of the middle temporal artery (MTA) flap and the inferior musculoperiosteal (IMP) flap for mastoid obliteration after canal wall down mastoidectomy. Seventy-five patients who have undergone canal wall down mastoidectomy and mastoid obliteration with the MTA and the IMP flaps at a single tertiary hospital were included. Surgical outcomes measured included the creation of a dry mastoid cavity as measured by a previously developed semi-quantitative scale, mastoid cavity epithelization time, rate of revision surgery needed, and rate of recurrent cholesteatoma. Patients were followed up for a median of 29months. The median time to epithelization of the mastoid cavity was 2 months. At 1 and 3 months, 36.0% and 76.0% of patients had grade 0 and grade 1 cavities, respectively, with either a dry cavity or one or less episodes of mild otorrhea or sensation of wetness. Hundred percent of the patients achieved a grade 2 (more than one episode of otorrhea or the presence of granulation tissue that promptly resolved with simple treatment) or better cavity at 3 months. One patient re-presented with a grade 3 cavity with uncontrolled infection and daily otorrhea secondary to an attic perforation that manifested at 6 months, requiring revision surgery. There were no recurrent cholesteatomas during the follow-up period. The use of the MTA and the IMP flaps for mastoid obliteration may be considered as an adjunct to achieving a safe, dry ear after canal wall down mastoidectomy.

Sensory Disturbance of the Lower Extremity after Sural Artery Flap Elevation.

Purpose Elevation of the sural artery flap with the sural nerve is associated with donor-site morbidities, such as postoperative sensory disturbance of the lower extremity. We evaluated the sensory disturbance of the lower extremity after elevation of the sural artery flap. Methods This study included 7 patients who underwent surgery using the sural artery flap. The sensory disturbances immediately after surgery and at present were evaluated on a 10-point scale. The influences of surgery on activities of daily living and patient satisfaction were also evaluated. Results The sensory disturbance was 4.48 immediately after surgery and 2.24 presently, and the difference between the timepoints was not statistically significant. The influence of surgery on activities of daily living was 2.30, and the patient satisfaction was 7.90. Conclusion It may be necessary to consider the sural artery flap, which does not include the sural nerve, to avoid unnecessary complications. When it is unavoidable to use the sural artery flap, including the sural nerve, it is important to thoroughly inform patients beforehand about the postsurgery sensory disturbance in the lower extremities.

Repair of Defects in the Scalp and Face With Expanded Superficial Temporal Artery Flaps: A Single-Center Retrospective Study.

Defects resulted from the removal of large scars, benign tumors, severe pigmentation abnormalities, and vascular malformations, etc., in the scalp and face need to be repaired to restore the appearance. Here, the authors introduced the application of various expanded superficial temporal artery (STA) flaps in the repair of above defects. From Jan. 2015 to Dec. 2018, 19 patients with craniofacial secondary defects received the repair with expanded STA flaps in our clinic. The defects were resulted from the removal of scalp scar (n = 6), neurofibroma (n = 4), sebaceous nevus (n = 3), arteriovenous malformation (n = 2), facial scar (n = 2), and port-wine stain (n = 2). The expanded STA flaps included 14 cases of flaps pedicled by parietal branch of STA, 2 cases of flaps pedicled by parietal branch of STA combined with laser hair removal, 1 case of flaps pedicled by frontal branch of STA, and 2 cases of prefabricated expanded skin flap with the superficial temporal fascia in the neck. The two-stage operation and water-filling expansion were accomplished in all patients. All flaps survived well, except one flap with venous congestion, which resolved after blood-letting and application of drugs promoting venous draining. In the three to six months follow-up, the flaps' color, texture, and thickness were satisfying. Individual application of different types of expanded STA flaps could achieve ideal results in repairing craniofacial secondary defects.

Does age at aortic coarctation repair have an impact on left ventricle size and function?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Adults with repaired aortic coarctation (CoA) require lifelong follow-up due to late complications, including left ventricular (LV) myocardial dysfunction. Age at the time of CoA repair is an important prognostic factor in these patients (pts). Purpose To evaluate LV size, ejection fraction (EF) and global longitudinal strain (GLS) values using 2D speckle tracking echocardiography (STE) in a population of adult pts with repaired CoA and to assess the relationship between these echocardiographic parameters and age at the time of CoA repair. Methods Retrospective analysis of adult pts with repaired CoA, followed in a Grown Up Congenital Heart Disease Centre. Pts with hemodynamically significant concomitant cardiac lesions were ruled out. Epidemiologic and clinical data were obtained from clinical records. Transthoracic echocardiograms were reviewed in order to assess GLS using 2DSTE (Echopac Software, GE). Results The study population consisted of 63 pts (61.9% male), with a mean age of 35.3 years at the time of the echocardiographic evaluation. The mean age at the time of the CoA repair was 117 months (95% CI 89.8-144.1 months). Surgical repair was performed in 46 pts (73%): resection with subclavian artery flap aortoplasty (n = 21); patch aortoplasty (n = 15) and head-to-head anastomosis (n = 10). In 10 pts there was no data regarding the type of surgical repair. Seven pts (11.1%) were submitted to percutaneous intervention (6 with aortic stent implantation and 1 with balloon aortic angioplasty). Mean LVEF was 63.4% (CI 95% 55.6 – 71.2%) and mean LV end-diastolic diameter (LVEDD) was 50mm (CI 95% 43-57mm). Mean GLS was - 17.3 (CI 95% 14.8- 19.8), which is inferior to the mean normal values reported for the software used. Age at the time of CoA repair had a statistically significant positive linear relationship with LVEDD (r= 0.282; p= 0.026) and a linear negative relationship with both GLS (r= -0,29; p= 0.022) and LVEF (r= -0.33; p= 0.05). Conclusion Older age at the time of CoA repair was associated with increased LVEDD and decreased GLS and LVEF. Also, GLS may be an important tool for the identification of subclinical LV dysfunction in adult pts with repaired CoA.

SUPRACLAVICULAR ARTERY FLAP: A SAFE, VERSATILE AND A RELIABLE FLAP A NEW WORKHORSE IN HEAD AND NECK RECONSTRUCTION OUR CLINICAL EXPERIENCE

Background: Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Material and Methods: This study was carried out in the Plastic Surgery Department of GMC Srinagar between November 2015 and October 2019. It involved 50 patients (40 females and 10 males), in whom supraclavicular artery flap was done to reconstruct head and neck. Follow-up period ranged from 2-27 months (average 12.3). Results: The study involved 50 patients. Mean age was 26.5 years (range 57-12 years). Thirty five patients had post-burn neck contractures, five patients had portwine stain face, three had marjolin ulcer, four patients had post traumatic and three had post bear maul defect. We harvested unilateral flaps in all of patients. In thirty five patients the flap was pedicled, three had adipofascial pedicle and twelve were islanded. The size of the reconstructed defect ranged from 23x10 to 14x6, and the size of the flap varied from 16x7cm to 25x11. Mean length was 21.7 cm. We used a partial thickness skin graft for donor site closure in 41 cases and closed primarily in 9 cases. Flap was used to resurface neck in 35 patients, face resurfacing in 10 patients, as intraoral lining in 3 patients. The following complications occurred: hematoma in 3 cases, partial distal necrosis in 2 cases, and donor site graft loss in 3 cases. Follow-up period ranged from 2-27 months Conclusion: The supraclavicular artery island flap is a thin, malleable fasciocutaneous flap that is easily and rapidly harvested, with a reliable pedicle and minimal donor site morbidity. It constitutes an alternative to local flaps, while providing equivalent functional results, and must be an integral part of the head and neck reconstructive surgeons therapeutic armamentarium.

Treatment of volar defects of the finger using dorsal digital\u2013metacarpal flap versus free medial plantar artery flap: a comparative study

BackgroundThe treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital–metacarpal flap (DDMF) in finger reconstruction.MethodsThis retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment.ResultsAfter more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005).ConclusionMPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Reconstruction of a Mangled Hand with a Thoracodorsal Artery Perforator Free Flap: A Report of Two Cases

Mangled hands are a severely injured condition that is a rare and challenging problem for reconstructive surgeons. Surgical flaps such as anterolateral thigh, radial forearm, or thoracodorsal artery flaps have been used for multiple-digit resurfacing. In this report, we describe two cases of complex defects that included multiple digits in patients who underwent reconstruction with thoracodorsal artery perforator (TDAP) free flaps. All massive soft tissue defects were completely covered with a TDAP free flap. The thinner perforator flap could be harvested, and the patients regained the ability to pinch and grasp. Therefore, the authors present two cases of mangled hands successfully treated with TDAP free flap.

Improved procedure for Brown’s Class III maxillary reconstruction with composite deep circumflex iliac artery flap using computer-assisted technique

Reconstruction of Brown’s Class III maxillary defect can be challenging due to the complex geometry of maxilla. We aimed to introduce an improved method for maxillary reconstruction with a composite deep circumflex iliac artery (DCIA) flap aided by virtual surgical planning and intraoperative navigation. A 27-year-old woman diagnosed with left maxillary fibromyxoma was admitted to our institution in December 2018. Pre-operative facial and iliac computed tomography data were obtained for virtual surgical planning. Personalized cutting template, tooth-supported surgical guide, and rapid prototype model with reconstructed orbital floor were printed for pre-operative preparation. Surgery was completely guided by the intraoperative navigation system. The root mean square estimate of the reconstructed area was 3.68 mm. The average errors measured on the lateral and medial DCIA segments were 0.61 and 0.85 mm, respectively. Application of virtual surgical planning and intraoperative navigation could potentially enhance the reconstruction outcomes.

Thoracodorsal artery flaps for breast reconstruction-the variants and its approach.

Thoracodorsal artery (TDA) flaps, ranging from the vascular-pedicled thoracodorsal artery perforator (TDAP) flap, the propeller TDAP flap, and the muscle-sparing latissimus dorsi (MSLD) flap to the conventional latissimus dorsi (LD) flap and the extended LD flap, can all be used for breast reconstruction. The aim of this paper and review is to share our experiences and recommendations for procedure selection when applying TDA-based flaps for breast reconstruction. We describe the different surgical techniques and our thoughts and experience regarding indications and selection between these procedures for individual patients who opt for breast reconstruction. We have performed 574 TDA flaps in 491 patients: 60 extended LD flaps, 122 conventional LD flaps, two MSLD flaps, 233 propeller TDAP flaps, 122 TDAP flaps, and 35 free contralateral TDAP flaps for stacked TDAP breast reconstruction. All the TDA flaps are important flaps for reconstruction of the breast. The LD flap is still an option, although we prefer flaps without muscle when possible. The vascular-pedicled TDAP flap is an option for experienced surgeons, and the propeller TDAP flap can be used in most reconstructive cases of the breast, although a secondary procedure is often necessary for correction of the pedicle bulk. The extended LD flap is an option for women with a substantial body mass index, although it is associated with the highest morbidity of all the TDA flaps. The MSLD flap can be used if the perforators are small or if dissection of the perforators is assessed to be hazardous.

Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?

Abstract Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed. Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed. Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good. Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.

Abdominal Wall Closure in Autologous Breast Reconstruction: Optimizing Aesthetics

Background: In contrast to cosmetic abdominoplasty, abdominal flap harvest can result a high degree of morbidity to the abdominal wall. Poor abdominal wall aesthetics that can result following free flap harvest including a high abdominal incision and post-operative hernia or bulge. We report our experience in optimizing cosmesis of the abdominal donor site with the use of a low incision, fascial plication and routine mesh reinforcement. Methods: A retrospective chart review of patients who underwent breast reconstruction with free abdominal tissue transfer from 2013-2017. Pedicled flaps and superior inferior epigastric artery flaps were excluded. Patient demographics, oncologic history, ablative and reconstructive surgery details focusing on abdominal closure techniques, and postoperative complications were evaluated. Results: 135 patients were identified who underwent 223 abdominal free flaps. 59 (26.5%) DIEP flaps were harvested, while 160 (71.7%) msTRAM and 4 (1.8%) fTRAM flaps were harvested (p<0.0001). 160 (71.7%) donor sites closures utilized polypropylene mesh, 9 (4.0%) were closed with biologic mesh and 3 (1.3%) closures used no mesh (p<0.0001). No hernias were observed (0%), while 6 abdominal bulges were identified (2.7%). There were no differences in the rates of abdominal bulge after donor site closure in the DIEP compared with msTRAM and fTRAM groups (3.4% vs 2.4%, p=0.7). No patients required mesh explantation during the study follow up period. Conclusion: To parallel cosmetic abdominoplasty, our authors advocate for a low incision, fascial plication and routine mesh reinforcement of the abdominal wall following free flap harvest.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis.

Background:There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.Objectives:“Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?”Data Sources:PubMed, Cochrane Library, clinicaltrials.gov and hand searches.Participants and Interventions:Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.Study Appraisal and Synthesis Methods:Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.Results:There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412–0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5–7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.Limitations:Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.Conclusions and Implications of Key Findings:Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

Commentary: Thoracodorsal Artery Flaps for Breast Reconstruction—The Variants and its Approach

Commentary: Thoracodorsal Artery Flaps for Breast Reconstruction—The Variants and its Approach

Supraclavicular Artery Flap versus Skin Graft: Which Is a Better Reconstructive Tool for Managing Post-Burn Contractures in the Neck.

BACKGROUNDBurn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures.METHODSIn National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient’s satisfaction with color-texture-match and recurrent contracture formation rate were assessed.RESULTSAmong patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient’s satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group. CONCLUSIONSupraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.

Availability of the “kickstand” to prevent to the pressure of the distally based superficial sural artery flap for the skin defect around Achilles tendon

Availability of the “kickstand” to prevent to the pressure of the distally based superficial sural artery flap for the skin defect around Achilles tendon

A case of reconstruction with a superficial cervical artery flap for dermatofibrosarcoma protuberans occurring on the acromion

A case of reconstruction with a superficial cervical artery flap for dermatofibrosarcoma protuberans occurring on the acromion

Reverse Sural Artery Flap for Dorsum of Foot Reconstruction

Loss of skin over the dorsum of foot is a common clinical entity. Infection, trauma, and vascular disease represent the most common etiological factors. Salvage of foot in these cases has a bearing upon the quality of life of the patient. The reconstruction process is often complex and varied as per exigencies. Reverse sural artery flap is an easy and reliable option for reconstruction of dorsum of foot defect. Reverse sural artery draws its vascularity from the communication of the peroneal artery and the median sural artery. The flow of the flap is from the distal to the proximal and represents an elegant option for dorsum of foot. We have described the peninsular variant of the reverse sural artery. The coverage of the defects of the dorsum of foot in trauma can be performed either immediately if the wound conditions are favorable or we may have to delay the procedure of definitive cover by a few days till the wound conditions improve by use of vacuum-assisted closure (VAC) application. Split thickness graft, reverse sural artery flap, and free flaps provide safe and viable options for dorsum of foot defects. Reverse sural artery is reliable option in the armamentarium of the reconstructive surgeon. Gaba S, Sharma RK, John JR, et al. Reverse Sural Artery Flap for Dorsum of Foot Reconstruction. J Foot Ankle Surg (Asia Pacific) 2021;8(1):28–32.