Choice Of Free Flap Research Articles

40. Use of an arteriovenous loop to overcome unfavourable fibula free flap donor site anatomy

The choice of free flap for optimum reconstruction of the mandible can be influenced by the characteristics of the surgical defect and also by the characteristics of the flap donor site such as anatomical variation and patient body habitus. Occasionally, the characteristics of the resection site and the characteristics of potential donor sites result in a situation where the options for free flap reconstruction are limited or compromised.

Extensive Microsurgical Reconstruction of Chest Wall Defects for Locally Advanced Breast Cancer: A 10-Year Single-Unit Experience.

Despite improvements in the early detection of breast cancer, locally advanced breast cancer (LABC) involving the chest wall exists in developing countries. Surgical resection remains a controversial management option. This study aims to demonstrate the value of chest wall reconstructive techniques for large LABC defects and report long-term outcomes. We report a 10-years single-unit experience in the reconstruction of large defects (>300 cm). From 2007 to 2017, all LABC cases managed with large surgical resection with immediate microsurgical chest wall reconstruction were included in this study. Herein, we present the demographics, comorbidities, clinicopathological LABC characteristics, surgical techniques (free flap choice, recipient vessels), and outcomes (survival, complication, cosmesis, and patient satisfaction). Of the 104 LABC cases, free deep inferior epigastric artery perforator flap was performed in 41 (39.4%) cases, free anterolateral thigh flap in 5 (4.8%), free deep inferior epigastric artery perforator combined with pedicled transverse rectus abdominis myocutaneous (TRAM) flap in 23 (22.1%), free muscle-sparing transverse rectus abdominis muscle flap in 30 (28.9%), and free transverse upper gracilis flap in 5 (4.8%). Complications were low. Over a median follow-up of 49.5 months, the 3-year local recurrence rate and distant metastasis-free survival were 13.9% and 84.9%, respectively. In addition, the 3-year disease-free survival and overall survival were 84.2% and 92.0%, respectively. The rate of excellent and good ratings by the esthetic assessment panel was 83.0%, and the patient satisfaction rate was 90.0%. Wide resection and microvascular free tissue transfer is oncologically safe in LABC with huge tumors and provides versatile solutions for the reconstruction of extensive chest wall defects. With favorable long-term survival and cosmetic outcomes, surgical resection of LABC combined with flap reconstruction may offer a practical approach in difficult and complicated cases. In this retrospective review, it was demonstrated that wide resection followed by distinct chest wall reconstructive free flaps transfer is oncologically safe in LABC with huge tumors and provides useful solutions for the reconstruction of extensive chest wall defects.

Effects of Tissue Component Volumes on Vascular Resistance in Free Flaps.

Background A successful free flap transfer is achieved, in part, by having a thorough understanding of vascular anatomy and blood flow dynamics. We previously reported that vascular resistance differs by type of free flap. To test the hypothesis that the difference reflects the proportion of tissue components within free flaps, we calculated blood flow and vascular resistance for free flaps in which we determined the volume of each tissue component. Methods Measurements and calculations were made for 40 free flap transfers performed at our hospital: 7 radial forearm flaps, 14 anterolateral thigh flaps, and 19 rectus abdominis myocutaneous flaps. Results The vascular resistance of free flaps was inversely related to the volume of each tissue component. Univariate regression analysis revealed that muscle volume correlated most closely with resistance (r = 0.881), followed by skin (r = 0.622), and fat (r = 0.577). Multiple regression analysis confirmed the relationship between combined muscle and fat volume and resistance (R2 = 0.865). Conclusions A strong inverse correlation exists between vascular resistance and combined muscle and fat tissue volume in flaps. It may be helpful to consider these relationships when making decisions regarding choice of free flap and recipient vessels.

Flap decisions and options in soft tissue coverage of the upper limb.

Soft tissue deficiency in the upper limb is a common presentation following trauma, burns infection and tumour removal. Soft tissue coverage of the upper limb is a challenging problem for reconstructive surgeons to manage. The ultimate choice of soft tissue coverage will depend on the size and site of the wound, complexity of the injury, status of surrounding tissue, exposure of the vital structures and health status of the patient. There are several local cutaneous flaps that provide adequate soft tissue coverage for small sized defects of the hand, forearm and arm. When these flaps are limited in their mobility regional flaps and free flaps can be utilised. Free tissue transfer provides vascularised soft tissue coverage in addition to the transfer of bone, nerve and tendons. Careful consideration of free flap choice, meticulous intraoperative dissection and elevation accompanied by post-operative physiotherapy are required for successful outcomes for the patient. Several free flaps are available for reconstruction in the upper limb including the groin flap, anterolateral flap, radial forearm flap, lateral arm flap and scapular flap. In this review we will provide local, regional and free flap choice options for upper limb reconstruction, highlighting the benefits and challenges of different approaches.

Comparative Study of Free Flap Reconstruction after Total Laryngopharyngectomy for Hypopharyngeal Cancer

Received May 13, 2013 Revised July 18, 2013 Accepted July 18, 2013 Address for correspondence Kyung Tae, MD Department of OtolaryngologyHead and Neck Surgery, College of Medicine, Hanyang University, 222 Wangsimni-ro, Seongdong-gu, Seoul 133-792, Korea Tel +82-2-2290-8585 Fax +82-2-2293-3335 E-mail kytae@hanyang.ac.kr Background and ObjectivesZZRecently, both jejunal and fasciocutaneous free flap reconstruction are widely used after total laryngopharyngetomy for the treatment of hypopharyngeal cancer. The aim of this study is to evaluate and compare the functional outcomes between jejunal and fasciocutaneous free flap in the reconstruction of hypopharynx after total laryngopharyngectomy. Subjects and MethodZZThe medical records of 27 patients with hypopharyngeal cancer who underwent total laryngopharyngectomy and free flap reconstruction were reviewed retrospectively. Of 27 patients, 18 (66.7%) were reconstructed with jejunal free flap and 9 (33.3%) with fasciocutaneous free flap. We compared complications, flap success rates, functional outcomes such as swallowing, respiration and quality of life (QOL) between two reconstruction groups. The swallowing function was evaluated by Functional Outcome of Swallowing Scale (FOSS), and QOL was evaluated by EORTC QOL-C30, HN35. ResultsZZTwenty-seven patients consisted of 26 males and 1 female. The mean age of 69±9.1. There were 4, 13, and 10 cases for T2, T3, and T4, respectively. Also, there were 8, 5, 7, and 7 for N0, N1, N2 and N3 cases. The success rate of free flap was 96.3%. The complication rate, operative time, the period of hospital stay did not differ between the two groups. The average score of FOSS was 0.92 in the jejunal group and 1.00 in the fasciocutaneous group. Quality of life was satisfactory in both groups. ConclusionZZBoth jejunal and fasciocutaneous free flap are very effective reconstructive methods after total laryngopharyngectomy for hypopharyngeal cancer. The choice of free flap can be determined based on the individual status of patient and preference of surgeon. Korean J Otorhinolaryngol-Head Neck Surg 2013;56:569-73

Free Groin Flap Applications in the Pediatric Population

The popularity of the groin flap has gradually decreased because of the disadvantages related to its short pedicle and technically demanding harvesting. We have summarized our experience with free groin flap applications in the pediatric population, which were performed by the same surgeon between 2004 and 2007. A total of 10 free groin flap transfers were performed in patients aged 3 to 13 years. Nine of the patients were operated on because of contractures of the extremities (six lower, three upper), and one patient was operated on for facial contour augmentation. The total duration of the operation was estimated to be between 2.6 and 6.1 hours (mean: 4.1 hours). A revision of the anastomosis was performed in two patients (20%), and in one of these patients (50%) partial flap failure was seen. Flap defatting via liposuction was performed in four patients (40%) in the late postoperative period. In our opinion, donor site morbidity comes into prominence particularly in the pediatric population, and we think that free groin flap should be the first choice of free flap for suitable cases in this group of patients.

Anterolateral thigh free flap for tracheal reconstruction after parastomal recurrence

Stomal recurrence after total laryngectomy is 1 of the most serious issues in head and neck surgery, both because of the complexity of its management and because of its morbidity. Prior to the introduction of free-tissue transfer, mediastinal tracheostomy has been the standard reconstructive procedure with high rate of complications. The ideal reconstructive solution to these problems must provide well-vascularized soft tissues that can cover the defect after resection and also allow suturing of the tracheal remnant to skin edges without tension. We describe a case of a 56-year-old man with stomal recurrence after total laryngectomy treated by the use of a tubed anterolateral thigh (ALT) flap to elongate the shortened trachea and simultaneously cover the cervical skin defect. The ALT can be accepted as an ideal free-flap choice for stomal recurrence, because it has maximal reconstructive capacity and produces minimal donor-site morbidity.

Microvascular head and neck reconstruction in patients with liver cirrhosis

The aim of this retrospective case series was to review the safety, complications, and outcomes of free-tissue transfer in head and neck cancer reconstruction in patients with liver cirrhosis. A retrospective review of all microvascular head and neck reconstruction cases with concomitant liver cirrhosis treated in our institution from 1994 to 2005 was performed. Data collected included patient demographics, etiology, and severity of liver cirrhosis, defect site, choice of free flap, complications, and clinical follow-up. Seven patients were identified. They were all males and underwent microvascular head and neck reconstruction due to ablative cancer surgery. Their Child-Pugh classification of liver cirrhosis was graded as follows: Child A (n = 3); Child B (n = 3); and Child C (n = 1). Eight free flaps were transferred (1 patient received 2), including anterolateral thigh (n = 4); radial forearm (n = 3); and fibula (n = 1). All flaps survived without the need for any microvascular revision procedures. Two patients died within postoperative 30 days due to hepatic decompensation. Other complications included neck hematoma (n = 1), neck wound infection (n = 2), and donor site dehiscence (n = 1). Only 2 patients with Child A cirrhosis remained free from complications and survived more than 1 year after the surgery. Microvascular head and neck reconstruction may be performed in patients with liver cirrhosis with a certain degree of technical success. However, the procedure is associated with significant mortality and morbidity in Child class B and C patients. Therefore, we recommend avoiding free-tissue transfer in patients with head and neck cancer with advanced liver cirrhosis.

Free Flap Choice for Soft Tissue Reconstruction of the Severely Damaged Upper Extremity

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.

Microvascular free flap reconstruction after craniofacial trauma

Treatment approaches to injuries of the craniofacial skeleton and soft tissues have seen significant advances over the last 20 years. The techniques of open reduction and internal fixation with modern plate and screw fixation systems replaced interosseous wiring of facial fractures. Nevertheless, severe trauma with tissue loss continues to pose a significant challenge to the reconstructive head and neck surgeon. Facial gunshot wounds, for instance, self-inflicted in suicide attempts, cause the most destructive injuries. In the past, conservative treatment of these craniofacial defects included packing and repeated debridement, which commonly resulted in multiple surgical procedures, prolonged hospitalization, and soft tissue contracture. Delayed reconstruction of the resulting tissue voids of the mid- and lower face was difficult and sometimes impossible. The introduction of free, vascularized soft tissue transfer in the reconstructive armamentarium revolutionized the approach to these major injuries. Today, aggressive debridement and early free flap reconstruction can result in improved functional and cosmetic outcome for the trauma patient. A large number of different free flaps are available, ranging from soft tissue (ie fascidcutaneous) or osseous to osteocutaneous and composite flaps. Decisions on the choice of free flap are primarily governed by the specific requirements of the defect, although potential donor site morbidity, the patient's preference, and the personal experience of the surgeon play a role. We review the modern management of severely destructive craniofacial injuries with a special emphasis on the role of free flaps for the reconstructive effort. Treatment approaches to injuries of the craniofacial skeleton and soft tissues have seen significant advances over the last 20 years. The techniques of open reduction and internal fixation with modern plate and screw fixation systems replaced interosseous wiring of facial fractures. Nevertheless, severe trauma with tissue loss continues to pose a significant challenge to the reconstructive head and neck surgeon. Facial gunshot wounds, for instance, self-inflicted in suicide attempts, cause the most destructive injuries. In the past, conservative treatment of these craniofacial defects included packing and repeated debridement, which commonly resulted in multiple surgical procedures, prolonged hospitalization, and soft tissue contracture. Delayed reconstruction of the resulting tissue voids of the mid- and lower face was difficult and sometimes impossible. The introduction of free, vascularized soft tissue transfer in the reconstructive armamentarium revolutionized the approach to these major injuries. Today, aggressive debridement and early free flap reconstruction can result in improved functional and cosmetic outcome for the trauma patient. A large number of different free flaps are available, ranging from soft tissue (ie fascidcutaneous) or osseous to osteocutaneous and composite flaps. Decisions on the choice of free flap are primarily governed by the specific requirements of the defect, although potential donor site morbidity, the patient's preference, and the personal experience of the surgeon play a role. We review the modern management of severely destructive craniofacial injuries with a special emphasis on the role of free flaps for the reconstructive effort.

Microvascular Free Flap Reconstruction for Head and Neck Defects

In a three-year period, 53 microvascular free-tissue grafts were performed on 51 patients to repair defects following major head and neck ablative surgery or trauma. The vast majority were done at the time of tumor resection. The remainder were done as secondary operations after resection or injury. The choice of free flap was dictated by the reconstructive needs of the patient and donor site availability. Fifty-two (98%) of 53 free-tissue transfers were successful with one failure resulting from venous thrombosis. Complications were noted in 16 of 53 flaps. The majority of these complications were in flaps used to replace bony defects or oropharyngeal resections. Although free flaps may appear to be more risky than traditional forms of reconstruction, they offer the surgeon a greater spectrum of reconstructive options. Limitations of the use of free flaps result only from lack of technical skills and specialized equipment.