Common Flap Research Articles

Tips to Virtually Plan Your Free Scapula Flap

Summary: The use of virtual surgical planning (VSP) and computer-aided design and manufacturing to assist in osseous reconstruction has become the standard of care in head and neck reconstruction. The use of the free fibula flap with VSP remains the most common flap for osseous reconstruction, and as such, it is well described in the published literature. The scapular free flap (SFF) based on the angular branch has not yet garnered the same attention. The popularity of the SFF osseus head and neck reconstruction is increasing due to the flaps’ inherently different properties and indications it can fulfill; the natural curvature of the bone, the reduced incidence of atheroscelerosis in the donor vessels and the earlier postoperative mobilization of the patient. In the preoperative planning process, the SFF presents several unique challenges and considerations that differ from the free fibula flap. It is important for surgeons already using, or considering using the SFF, that VSP is used correctly to achieve optimal outcomes. The authors aim to describe and clarify aspects of VSP use in SFF reconstruction in the head and neck area with a specific focus on: (1) The perforator-like vascular anatomy of the scapula; (2) How to maximize the shape of the scapula to minimize osteotomies; (3) Fine-tuning of scapula osteotomies on side table; (4) How to plan cutting guide placement and fit on the scapula. The authors hope that this article will help reconstructive microsurgeons plan and perform the SFF in conjunction with VSP.

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review.

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes. A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All study designs were included. Non-English articles were excluded. Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula. Free tissue transfer for a palatal fistula repair. Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained. Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies. Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

Analyzing the effect of undermining on suture forces during simulated skin flap surgeries with a three-dimensional finite element method

Skin flaps are common procedures used by surgeons to cover an excised area during the reconstruction of a defect. It is often a challenging task for a surgeon to come up with the most optimal design for a patient. In this paper, we set up a simulation system based on the finite element method for one of the most common flap types — the rhomboid flap. Instead of using the standard 2D planar patch, we constructed a 3D patch with multiple layers. This allowed us to investigate the impact of different undermining areas and depths. We compared the suture forces for each case and identified vertices with the largest suture force. The shape of the final suture line is also visualized for each case, which is an important clue when deciding on the most optimal skin flap orientation according to medical textbooks. We found that under the optimal undermining setup, the maximum suture force is around 0.7 N for top of the undermined layer and 1.0 N for bottom of the undermined layer. When measuring difference in final suture line shape, the maximum normalized Hausdorff distance is 0.099, which suggests that different undermining region can have significant impact on the shape of the suture line, especially in the tail region. After analyzing the suture force plots, we provided recommendations on the most optimal undermining region for rhomboid flaps.

Mandibular revascularization using a humeral periosteal free flap: A technical note

The vascularized periosteal free flap transposes a non-irradiated soft tissue with neoangiogenesis, bone induction, and osteogenesis qualities. A surgical technique using a humeral periosteal free flap is described for the treatment of recurrent osteoradionecrosis of the lower jaw. The humeral periosteal free flap is a technique associated with low morbidity. The procedure described avoids sacrificing major vessels as seen in other common flap procedures. Hence, this revascularization approach is equivalent to a prevention technique that should be considered early in the development of osteoradionecrosis to avoid further damage and challenging reconstruction.

"Flap-in-Flap" Technique: Double V-Y Flap in Fingertip Injury Management.

Background Fingertip injuries with amputation are one of the common hand injury problems. Several reconstructive options are available for fingertip injury. V-Y advancement flap is one of the common flaps. In some cases, their advancement capacities are not sufficient to cover the whole defect, resulting in flexion deformity of the distal interphalangeal (DIP) joint, loss of finger pulp shape, or hooked deformity. The double V-Y flap consists of harvesting two cutaneous flaps on the same neurovascular digital palmar bundle. The first V-Y flap is raised as a neurovascular flap and the second flap is an advancement V-Y plasty. Objective This article evaluates the outcomes of the double V-Y advancement flap for the fingertip reconstruction. Materials and Methods This is a prospective study on 19 patients with zone II and III fingertip amputation tip defects between December 2021 and June 2023. The majority were workplace injuries. Results There were 16 males and 3 females. The average static two-point discrimination was 6 mm. Average advancement of first flap is 8.5 mm and the average advancement of second flap is 4.3 mm. The average total advancement of a double V-Y flap is 12.94 mm (10-15 mm). All of them had "good" total active motion with movement > 210. One patient had flexion deformity at the DIP joint without causing any functional disturbance. All the flaps settled well except for one patient who had superficial partial necrosis of flap which was managed conservatively. Conclusion This is simple and safe for the reconstruction of zone II and III fingertip amputations with the advantage of like-for-like tissue with near-normal sensation. The second flap increased the advancement of the proximal flap, restoring the pulp shape, and thereby reconstructing a functional and aesthetic fingertip.

Surgical delay in abdominal based flap surgery: a scoping review.

The abdominal donor site is the most common flap used for breast reconstruction, with flap necrosis a feared complication. The technique of surgical 'delay' involves the inducing of relative ischemia to promote neovascularisation, amongst other metabolic adaptations, and has been used to augment flap vascularity and reduce this complication. There is significant variability in the manner in which flap surgery and surgical delay may be performed, such as the vessels ligated, the presence and degree of flap elevation, and the decision to harvest muscle with the flap, amongst other factors. A formal review of techniques, however, has not yet been performed, and there is no consensus as to the optimal technique for surgical delay. A scoping review of the current literature was undertaken to determine the optimal surgical delay technique in abdominal-based flap surgery. A literature search was conducted across PubMed, Embase, Cochrane, and Medline databases. Data regarding the type of flap surgery, delay techniques, and corresponding clinical outcomes was collected and categorised by technique type. Nine studies met the inclusion criteria and were included for review. Levels of evidence and rates of complications were compared. The range of surgical delay techniques reported in the literature was described. Surgical delay was found to reduce overall complication rates, and the available data suggests it may be particularly beneficial in high-risk patients. The current data support delay as a viable method for reducing rates of complications. Further studies and data are required to compare surgical delay techniques and determine the benefit delay may pose to patients with risk factors.

Robotic-assisted free flap harvesting for diverse soft tissue reconstruction: a PRISMA scoping review of clinical outcomes over the last decade.

The aim of our study was to assess the advantages and limitations of robotic technology in diverse reconstructive procedures. A scoping review was conducted in Oct'23, on published studies from 2013 to 2023, focussing on robotic-assisted free flap harvesting. Three databases Ovid-MEDLINE, Scopus, and PubMed were searched. Original research studies reporting robotic-assisted free flap harvest were included. Studies on lesion excision, microvascular anastomosis, local flap harvest, roboticassisted flap inset, review articles, abstract-only studies, non-English documents, and animal studies were excluded from this review. Sixteen studies met the inclusion criteria out of a total of 318, searched initially. These studies included a total of 128 patients, who underwent robotic-assisted free flap harvest for the reconstruction of various defects, with 140 free flaps harvested. The most common flaps harvested by robotic technique were deep inferior epigastric artery perforator (DIEP) flap 120 (85.7%), radial forearm free (RFF) flap 11 (7.9%), latissimus dorsii flap 4 (2.9%), rectus abdominus flap 4 (2.9%), and omental flap 1 (0.7%). Breast reconstruction was the major procedure done i.e. 120 (85.7%) followed by head and neck 11 (7.9%) and limb defects 9 (6.4%) reconstruction procedures. The reported clinical outcomes were acceptable in all the studies with a 99% flap success rate and minimal complications. Variability in operating time was observed depending upon surgical steps undertaken with robotic systems. This scoping review highlights the role of robotic-assisted free flap harvesting in plastic surgery and its potential benefits on clinical outcomes, due to its high precision and minimal invasiveness. However, challenges like cost effectiveness, resource distribution and learning curve are there.

Buried Autologous Breast Reconstruction: Outcomes and Technical Considerations.

The purpose of this study is to compare outcomes in patients undergoing buried and non-buried free flaps for breast reconstruction, in addition to evaluating the safety and reliability of venous flow couplers. A retrospective review was performed of all patients undergoing free flap breast reconstruction between 2013 and 2023. The primary outcomes were free flap failure, complications and the number of procedures required to complete the reconstructive journey. A total of 322 flaps were performed in 254 consecutive patients, with 47.5% (n = 153) being buried and 52.0% (n = 169) being non-buried reconstructions. The most common flap of choice being deep inferior epigastric artery perforator flaps (81.9%) followed by profunda artery perforator flaps (14.3%). There was no significant difference between the two groups in complications, including flap failure (buried 2.0% vs. non-buried 1.8% p = 0.902). There was a significant reduction in the number of procedures required to complete the reconstructive journey, with 52.2% (n = 59) of patients undergoing single-stage breast reconstruction in the buried group compared with only 25.5% (n = 36) in the non-buried group (p < 0.001). Two (0.6%) patients experienced a false negative in which the signal of the flow coupler was lost but the flap was perfused during re-exploration. No flap losses occurred without being identified in advance by a loss of audible venous flow signal. Buried free flap breast reconstruction is safe and requires fewer operations to complete patients' reconstructive journey. Flow couplers are a safe and effective method of monitoring buried free flaps in breast reconstruction.

Use of Flow-through Free Flaps in Head and Neck Reconstruction.

Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.

The role of digital mammographic surveillance for detection of asymptomatic recurrence in autologous flap reconstructions

ObjectiveTo evaluate the utility of digital mammography in detecting asymptomatic malignancy in autologous flap reconstructions after mastectomy. MethodsA retrospective database review identified all mammograms performed on asymptomatic patients with flap reconstructions over a 9-year period (1/1/2009 to 12/31/2017). A negative examination was defined as BI-RADS 1 or 2 and a positive examination was defined as BI-RADS 0, 4, or 5 assigned to the mastectomy side. Malignant outcomes were determined by pathology results. Interval cancers, or false negatives, were defined as locoregional malignant diagnosis within one year of a negative mammogram. Sensitivity, specificity, predictive values, abnormal interpretation rate, and cancer detection rate were calculated. Results626 mammograms of asymptomatic flap reconstructions were performed in 183 patients. The most common flap type was TRAM (83.5 %, 523/626) and DIEP (13.4 %, 84/626). Most exams (98.2 %, 615/626) were negative, assessed as BI-RADS 1 or 2, with no interval cancers at follow-up. Eleven exams (1.8 %, 11/626) were positive, assessed as BI-RADS 0, 4, or 5. After diagnostic work-up of all BI-RADS 0 exams, 9 cases had a final recommendation for biopsy of which 3 were malignant. Mammography yielded a cancer detection rate of 0.5 % (3/626), abnormal interpretation rate of 1.8 % (11/626), NPV of 100 % (615/615), overall PPV of 27.3 % (3/11), PPV2 (positive predictive value of a biopsy recommendation) of 33.3 % (3/9), sensitivity of 100 % (3/3), and specificity of 98.7 % (615/623). ConclusionDigital mammography of asymptomatic autologous flap reconstructions after mastectomy demonstrated high sensitivity and low abnormal interpretation rate. Cancer detection rate was comparable to current national benchmarks for mammographic screening in the general U.S. population without mastectomy.

Novel single-centre experience - evaluation of outcomes post-implementation of a coordinated combined breast reconstruction service.

Autologous breast reconstruction services are logistically complex and challenging to implement but have better outcomes than implants. This study aimed to evaluate the effect of implementing a coordinated, low-cost combined breast reconstruction service (0.8 FTE nurse liaison, 0.25 FTE plastic surgeon, two dedicated breast surgeons 0.05 FTE each and protected weekly all-day oncoplastic theatre) on unit productivity and efficiency in reducing wait times for immediate autologous breast reconstruction. A retrospective cohort study was conducted on all patients who underwent immediate autologous breast reconstruction at Fiona Stanley Hospital between two study periods, pre-intervention - February 2016 to June 2019 and post-intervention - November 2022. Data were analysed using SPSS v.27. One hundred twenty-seven participants were included, with 49% (n = 62) in the post-intervention group. Most procedures performed were therapeutic (n = 108, 85%). DIEP was the most common flap (84%), and the mean BMI was 26.9 (SD ± 4.2). There was a statistically significant increase in the number of high-risk gene carriers' prophylactic cases and bilateral cases performed post-intervention (5% to 26%, P = 0.001) and (29% to 55%, P = 0.003), respectively. Time to surgery on the waitlist did not significantly change after the intervention (therapeutic group: 3.1 to 3.5 weeks, P = 0.821; prophylactic group: 55.0 to 61.1 weeks, P = 1.000). Overall, there was a marked increase in the overall productivity of the breast service unit in terms of mastectomies, total reconstructions, and autologous reconstructions performed. This single-centre experience showed that implementing a coordinated service significantly increased the unit's productivity. This low-cost intervention can be applied to other healthcare settings.

Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

(199) Anterolateral Thigh Flap Phalloplasty for Micropenis

Abstract Introduction Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps. Objective The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. Methods A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder. Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. Results The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. Conclusions Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further esthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Disclosure No

Through a New Lens: Skin-Grafted Free Flaps and Objective Facial Skin Color Matching.

Background: Head and neck ablative surgery can impose aesthetic disfigurement, particularly when severe color mismatch exists between native and reconstructed facial skin. To date, the accuracy, objectivity, and modifiability of facial skin color matching remains poorly understood. Objective: To measure skin color match outcomes after head and neck reconstruction using handheld colorimetry. Methods: Patients undergoing complex head and neck reconstruction involving facial skin were included. A variety of skin paddle donor sites were studied, including split-thickness skin graft (STSG) placement over myocutaneous or adipofasciocutaneous free flaps after de-epithelization. Skin color match (deltaE) was measured during follow-up using a handheld colorimeter. Results: Forty-seven patients were included, with median age 69. The most common flap type was the anterolateral thigh (n = 31, 66%). Twenty patients underwent STSG to the skin paddle. DeltaE measurements among the patients with STSGs demonstrated better color match (lowest deltaE), compared with patients with unaltered skin paddles (3.4 ± 1.0 vs. 6.5 ± 2.5, p < 0.0001). Conclusion: We found the use of STSGs over de-epithelialized myogenous or adipofasciocutaneous flaps improves color match, as measured by handheld colorimetry.

V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP

You have accessJournal of UrologyCME1 Apr 2023V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP Aurélie Schirmann, Nim Christopher, David Ralph, and Wai Gin Lee Aurélie SchirmannAurélie Schirmann More articles by this author , Nim ChristopherNim Christopher More articles by this author , David RalphDavid Ralph More articles by this author , and Wai Gin LeeWai Gin Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps.The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. METHODS: A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder.Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. RESULTS: The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. CONCLUSIONS: Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further aesthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Source of Funding: None declared © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aurélie Schirmann More articles by this author Nim Christopher More articles by this author David Ralph More articles by this author Wai Gin Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

Venous Thromboembolism Rates After Free Flap Reconstruction of the Head and Neck Region.

Venous thromboembolism (VTE) is a major concern for the postoperative hospitalized patient, especially after long and complex procedures. Cancer itself also contributes to the hypercoagulable state, further complicating the management of patients. Despite prophylaxis, breakthrough events can occur. We aimed to assess our institutional VTE and bleeding rates after free flap reconstruction of the head and neck (H&N) region and the factors associated with VTE events. A retrospective review of the patients who underwent H&N free flap reconstruction at an academic center from 2012 to 2021 was performed from a prospectively maintained database. Data regarding patient demographics, medical history, surgical details, and overall outcomes were collected. Outcomes studied included postoperative 30-day VTE rates and major bleeding events. Patients who had a VTE event were compared with the rest of the cohort to identify factors associated with VTE. Free flap reconstruction of the H&N region was performed in 949 patients. Reconstruction after cancer extirpation for squamous cell carcinoma was the most common etiology (79%). The most common flap was thigh based (50%), followed by the fibula (29%). The most common postoperative VTE chemoprophylaxis regimen was enoxaparin 30 mg twice daily (83%). The VTE and bleeding rates over the 10-year period were 4.6% (n = 44) and 8.7% (n = 83), respectively. Body mass index (28.7 ± 5.8 vs 26.2 ± 6.6, P = 0.013) and pulmonary comorbidities were found to be significantly higher in patients who had a VTE event (43% vs 27%, P = 0.017). Patients with a VTE event had a prolonged hospital stay of 8 more days (19.2 ± 17.4 vs 11 ± 7, P = 0.003) and a higher incidence of bleeding events (27% vs 8%, P < 0.001). Postoperative VTE is a significant complication associated with increased length of hospitalization in patients undergoing free flap reconstruction of the H&N region. Institutional measures should be implemented on an individualized basis based on patient comorbidities to improve the postoperative VTE rates, while balancing the bleeding events.

Flap management of groin wounds following vascular procedures: A review of 270 flaps for vascular salvage

Groin dehiscence following vascular procedures results in morbidity for patients with peripheral vascular disease. Controversy exists around the indications for flap coverage. We present an institutional experience with flap reconstruction of groin wounds after vascular procedures to identify predictors of beneficial outcomes. A retrospective review of patients who had flap coverage for infected/nonhealing groin wounds following a vascular procedure between 1998 and 2021 was performed. Demographics and clinical characteristics, including flap and vascular graft type, were collected along with major complications. Univariate and multivariable logistic regression analyses were performed to assess the associations between procedures and major complications. A total of 270 flaps were transferred to 237 patients. Thirty-three patients had bilateral wounds. The mean age and BMI were 67±11 years and 27.9±6.3kg/m2, respectively. Flaps included rectus femoris (n=142), sartorius (n=118), rectus abdominis (n=7), and gracilis (n=3). Covered vascular grafts included prosthetic materials (n=200) and autografts (n=70). The median length of hospital stay after surgery was 10 days (interquartile range=12), and the mean follow-up was 29.1±39.2 months. The major complication rate was 38.5% with wound infection being the most common. Flaps successfully prevented the infection-related removal of the grafts in 98.9% of cases. Multivariable analysis revealed no significant associations between variables and having a major complication. Flap coverage of the inguinal vessels can be performed safely with favorable limb salvage. Wound complications were high, but graft salvage was excellent. Rectus femoris and sartorius muscle flaps were the most common flaps, yielding comparable outcomes.

Soft tissue reconstruction of the thumb: Classification of defects and standardisation of treatment

The aim of this article is to share our experience of thumb defects based on the defect irrespective of the etiology of the defect and to work towards standardizing the treatment for thumb defects. This study was conducted at the Burns and plastic surgery center at Hayatabad Medical complex from 2018 to 2021. Thumb defects were divided into small (&lt; 3 cm), medium (4-8cm) and large defects (&gt; 9cm). Post-operatively, patients were evaluated for complications. The type of flaps were stratified for size and site of the soft tissue defects to generate a standardized algorithm for thumb soft tissue reconstruction. After scrutinizing the data, 35 patients qualified for the study, including 71.4% (25) males and 28.6% (10) females. The mean age was 31.17+15.8SD. Right thumb was affected in majority of the study population (57.1%). Majority of the study population was affected by machine injury and post-traumatic contractures, affecting 25.7% (n=9) and 22.9% (n=8) respectively. First web-space and injuries distal to IPJ of thumb were the most common areas affected, accounting for 28.6% (n=10) each. First dorsal metacarpal artery flap was the most common flap followed by retrograde posterior interosseous artery flap, observed in 11 (31.4%) and 6 (17.1%) cases. The most common complication observed in the study population was flap congestion (n=2, 5.7%) with a complete flap loss in 1 patient (2.9%) cases. Based on the cross tabulation of flaps against the size and location of defects, an algorithm was developed to help standardize reconstruction of thumb defects. Thumb reconstruction is critical in restoring hand function of the patient. The structured approach towards these defects make their assessment and reconstruction easy especially for novice surgeons. This algorithm can further be extended to include defects of the hand irrespective of etiology. Most of these defects can be covered with local easy to do flaps without the need for a microvascular reconstruction.

Comparison of the Surgical Outcomes of Free Flap Reconstruction in Head and Neck Cancer Patients

Objective: The goals of this research were to (1) assess the efficacy of free flap reconstruction in patients with early and recurrent head and neck cancers, and (2) investigate the variables associated with these surgeries that increase the risk of problems. Study Design: Retrospective Study Place and Duration: Frontier Medical College, Abbottabad, from March, 2022 to August, 2022. Methods: Total 200 patients of head and neck cancer were included in this study. Patients were both males and females with primary and recurrent cancer types were underwent for free flap reconstruction. After receiving informed written consent, in-depth demographic information about the cases that were enrolled was recorded. Patients were divided in two groups. Hundred patients of recurrent cancers were included in group I and 100 patients of primary cancers were included in group II. Surgical outcomes among both groups were assessed and compared. SPSS 24.0 was used to analyze all data. Results: We found that 87 (87%) patients in group I and 81 (81%) patients in group II were males. Mean age of the patients in group I was 49.8±11.37 years and in group II mean age was 51.4±7.42 years. Majority of the patients had tumor stage 5. Smoking, betel nut and alcohol were the most common causes found in all cases. Anterior lateral thigh (ALT) and anterior medial thigh (AMT) were the most common flap types among both groups. We found that free flap reconstruction had higher success rate in primary cancers found in 96 (96%) as compared to recurrent cancers group in 92 (92%). There was no any significant difference found among both groups in terms of post-surgery complications. Conclusion: This study's findings suggest a greater failure rate for free flap reconstruction in the recurrent group compared to the primary group, however this finding may be attributable to the varied patient characteristics between the two groups.

Evaluating the effectiveness of using negative pressure wound therapy in the preservation of the infected prosthetic aortic graft

BackgroundInfected deep sternal infection due to an associated infection of the prosthetic aortic graft is a devastating condition. Standard management requires the removal of the graft and substituting it with a new one. Often, removal of the prosthetic graft is close to impossible. Negative pressure wound therapy is currently the treatment of choice for patients with deep sternal infection. However, its use in deep sternal infection with exposed infected prosthetic aortic graft has not been well described. MethodsEight patients were included in this study. All had type A aortic dissection of the ascending aorta and/or aortic arch. ResultsThere were 7 men and 1 woman. The median age was 53 years old (range 33–81 years old). The median number of days from the initial aortic operation to the diagnosis of infection was 20 days (range 14–52). The median length of stay in the intensive care unit was 17 days (range 6–338 days). The median time interval from the initial debridement to reconstruction was 20 days (range 6–43 days). The median number of times negative pressure wound therapy was changed was 4 (range 2–9). The most common flap used for reconstruction was the pectoralis major musculocutaneous flap in 7 patients, a free antero-lateral thigh flap in 1 patient, and pedicled omental flap in combination with pectoralis major musculocutaneous flap in 1 patient. One patient had persistent recurrent infection of the graft despite negative pressure wound therapy and flap reconstruction. The median length of follow-up was 38.5 months (range 4–120 months). ConclusionThis small study suggests that negative pressure wound therapy could be used successfully for the management of deep sternal infection due to infected prosthetic aortic grafts. In most cases, it eliminated the need to replace the infected prosthetic aortic graft in high-risk patients.