Flap Failure Rate Research Articles

Three-stage limb salvage in tibial fracture related infection with composite bone and soft-tissue defect

IntroductionManaging critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss. The purpose of this study is to describe a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and report the clinical outcomes.Materials and methodsA retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss from 2010 through 2018. Thirty-one patients were included. All cases were treated using a three-stage protocol: (1) infected limb damage control; (2) soft-tissue coverage with a vascularized or local flap; (3) definitive bone reconstruction using distraction osteogenesis principles with external fixation. Primary outcomes: limb salvage rate and infection eradication. Secondary outcomes: patient functional outcomes and satisfaction.ResultsPatients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol. The mean soft-tissue and bone defect sizes were 124 cm2 (6–600) and 5.4 cm (1–23), respectively. A free flap was performed in 67.7% (21/31) of the cases; bone transport was the selected bone-reconstructive option in 51.7% (15/31). Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21). Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs. ASAMI bone score: 100% good/excellent. Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases. Return-to-work rate was 83%; 86% were “very satisfied” with the treatment outcome.ConclusionA three-stage surgical approach to treat chronically infected tibial injuries with combined bone and soft-tissue defects yields high rates of infection eradication and successful limb salvage, with favorable functional outcomes and patient satisfaction.

Moving to a more restrictive transfusion protocol: Outcomes in head and neck free flap surgery

PurposeTo determine if a more restrictive transfusion protocol results in increased rates of adverse flap outcomes in patients undergoing free tissue transfer. Materials and methodsMixed retrospective and prospective cohort study. Patients who underwent surgery before the protocol change were collected retrospectively. Patients who underwent surgery after the protocol change were collected prospectively. ResultsOf the 460 patients who underwent free tissue transfer, 116 patients in the pre-change cohort (N = 211) underwent transfusion (54.98%) and 78 in the post-change cohort(N = 249) (31.33%) (p < 0.001). The mean number of units transfused was 1.55 + 2.00 in the pre-change cohort, and 0.78 + 1.51 in the post-change cohort (p < 0.001). When separated temporally, the pre-change cohort received significantly more blood transfusions than the post-change cohort in the operating room (33.65% vs 18.07%) (p < 0.01), within 72 h of surgery (35.55% vs 15.66%) (p < 0.001), and after 72 h after surgery to discharge (16.59% vs 8.03%) (p = 0.018017). The rate of flap failure was 6.70% in the pre-change cohort, and 5.31% in the post-change cohort (p = 0.67). In a logistic regression model controlling for potential confounders, transfusion protocol was not significantly associated with flap failure (OR = 1.1080, 95% CI: 0.48–2.54). There were no significant differences between cohorts for medical morbidity, ICU transfer, or death. ConclusionOur data support the conclusion that patients undergoing free tissue transfer to the head and neck can be transfused following the same protocols as other patients, without increasing the rate of flap failure or other morbidities.Level of evidence: 3 (mixed retrospective, prospective cohort study).

1106 Timing of Free Flap Reconstruction in Sarcoma Patients

Abstract Aim In 1986 Godina reported that microsurgical reconstruction of traumatic wounds in the extremities undertaken with &amp;gt;72-hour delay caused significant tissue damage, hampering the microsurgical reconstruction and significantly increasing complication rates. It is our opinion that surgical treatment of sarcoma in the extremity is comparable to trauma surgery, given the extent of tissue destruction. The nature of sarcoma management often means that performing definitive reconstruction within 72 hours is not possible. We analyse the outcomes of our ‘delayed’ extremity reconstruction. Method We performed a retrospective analysis of 52 consecutive cases of free flap extremity reconstruction following sarcoma excision. Data was analysed for time from resection to reconstruction, significant patient demographics, details of the flap and post-operative complications. Results Between March 2017 and December 2020, we performed 52 free flaps for sarcoma reconstruction in the extremities. Mean time to reconstruction was 28 days (Median 15 days, Range: 0-316 days), with two reconstructions within 72 hours of excision. 9 patients had neoadjuvant chemo- or radiotherapy. Three patients had significant post-operative complications; two flaps failed intra-operatively (3.8%) and one patient (1.9%) experienced wound infection. Conclusions Godina’s study demonstrated the negative impact of delaying surgical reconstruction in the traumatised extremity, with a 12% failure and 17.5% infection rate in delayed reconstruction (72 hours to 3 weeks). Our results show that with advancements in microsurgical techniques and physiological optimization, it is possible to safely and successfully undertake delayed (&amp;gt;72 hours) microsurgical extremity reconstruction in sarcoma patients and achieve low flap failure and infection rates.

Comparison between an Operating Surgical Microscope and High Magnification Surgical Loupes in Microvascular Reconstruction of Head and Neck Defects in a Tertiary Healthcare Centre.

Microvascular free tissue transfers have become an important method of reconstruction following head & neck oncological resection. The objective of this study was to evaluate the efficacy of surgical loupes against surgical operating microscope, which is the gold standard for microvascular anastomosis and also to explore the possibility of surgical loupes as an essential cost-effective armamentarium in head and neck reconstruction. This prospective randomized study included 40 patients diagnosed with head and neck malignancies, requiring microvascular free flap reconstruction. A total of 20 patients who underwent free flap reconstruction following oncologic/maxillofacial defects using high magnification surgical loupes & the other 20 patients were subjected to reconstruction under an operating surgical microscope. The efficacy was assessed based on the following parameters. 1. Total operating time taken for completing anastomosis. 2. Overall fatigue. 3. Free flap failure rate. The microscope group took an overall mean time of 34.26min considering its limited degree of freedom in adjusting intraoperatively whereas the loupes group had a shorter mean anastomosis time 33.29min considering its ease of operator adjustability. Overall, fatigue was compared using Mann-Whitney Test and found to be statistically significant with P value of 0.17, the loupe group was found to be better with mean score of 6.90 in 21 patients than microscope with mean score of 6.21in 19 patients. Flap survival rate in the loupe group had two cases of venous obstruction at 24h follow-up and microscope group had 1 case of venous.obstruction. The success with loupe only free tissue transfer can be attributable considering expertise with the microscope and the loupes can be a cost-effective alternative to microscope.

Head and Neck Free Flap Reconstruction in an Academic versus a Community Setting.

Head and neck free flap reconstructions are complex procedures requiring extensive resources, and have the potential to be highly morbid. As such, it is imperative that they should be performed in an appropriate setting, optimizing outcomes while limiting morbidity. The aim of this study is to identify any disparities in the treatment outcomes of patients undergoing head and neck free flap reconstruction by a single surgeon in an academic versus a community hospital setting. A retrospective review of all patients who underwent head and neck free flap reconstruction for any indication by a single surgeon from 2009 to 2019 was conducted. All surgeries were performed at one of two hospitals: one academic medical center and one community hospital. Demographics and rates of partial or complete flap failure, medical complications, surgical complications, mortality, and other secondary outcomes were compared between the two settings. Ninety-two patients who underwent head and neck free flap reconstruction were included. Fifty-seven (62%) of free flap reconstructions were performed in the academic medical center, while 35 (38%) were performed in the community hospital. There were no significant differences in complete flap loss, either intraoperative or postoperative (p = 0.5060), partial flap loss (p = 0.5827), postoperative surgical complications (p = 0.2930), or medical complications (p = 0.7960) between groups. The in-hospital mortality rate was 0% (n = 0) at the university hospital as compared with 5.7% at the community hospital (p = 0.0681). The mean operative time was 702.3 minutes at the university hospital and 606.3 minutes at the community hospital (p = 0.0080). Head and neck free flap surgery can be performed safely in either an academic or a community setting, with no difference in primary outcomes of surgery. Preferential selection of either treatment setting should be based on consideration of patient needs and availability of auxiliary specialty services.

Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries

BackgroundIn many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services.MethodsA PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.DiscussionTo-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes.Systematic review registrationPROSPERO 225613

The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis.

Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction. A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap. A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1-8%). No significant heterogeneity was present across studies (Q statistic 22.12, p = 0.14; I 2 = 27.68%, p = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm2, respectively. The area of the skin paddles was 117 cm2. The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.

Hepatitis C as a Potential Risk Factor for Adverse Surgical Outcomes in Head and Neck Free Tissue Transfer Reconstruction.

Background: Infection with hepatitis C virus (HCV) is associated with an increased risk of developing head and neck cancer (HNC), and negatively impacts cancer-specific survival. Objective: To measure the impact of HCV status on free tissue transfer failure, flap takeback, and length of stay in HNC patients undergoing reconstruction. Methods: We retrospectively reviewed patients who underwent head and neck free tissue transfer reconstruction at a single academic institution between August 2011 and June 2020. Results: In the HCV-infected group, total flap failure rate was 2.9% versus 1.3% in the control group and the takeback rate was 11.1% versus 9.6%. On multivariate analysis, HCV status was not associated with flap failure, flap takeback, or total length of hospital stay >7 days. Conclusion: In this study, HCV status was not associated with differences in postoperative complications or length of stay. Future research with greater numbers of HCV-positive study subjects is required to elucidate the effect of HCV infection in this patient population.

Technical Considerations in Pedicle Management in Upper and Midfacial Free Flap Reconstruction.

Mid and upper face free flaps frequently are associated with challenges due to pedicle length. We sought to evaluate the frequency at which alternative pedicle maneuvers were required for these reconstructions and determine if there was any association with flap survival or postoperative complications. Retrospective review at three tertiary care institutions. Database review. Free flap reconstruction of the upper and midface was performed in 295 patients (108 bony, 187 soft tissue). In 82% of cases, the vessels reached the ipsilateral neck for anastomosis to traditional target vessels. Arterial grafts were required in 2% of reconstructions (4% bony and 1% soft tissue). Venous grafting was required in 7% of reconstructions (21% fibula, 16% scapula, and 3% soft tissue) and was associated with an increase in flap failure rate (19% vs 3%, P=.003). The most common recipient artery for revascularization was the cervical facial artery (78%). Alternate recipient vessels were selected in 13% of cases, including the superficial temporal vessels (7%), distal facial branches through a separate facial incision (4%), and angular vessels (2%). Vein grafting was associated with a higher flap failure rate. Alternative maneuvers did not affect need for intraoperative pedicle revision or complications. In upper and midface reconstruction, vascular grafting, targeting more distal branches of the facial system, or additional maneuvers to optimize pedicle orientation is often required to secure revascularization. Vein grafting is associated with a higher free flap failure rate. Scapular border flaps often require vascular grafting or atypical anastomotic locations. 3-Non randomized cohort study 4 Laryngoscope, 131:2465-2470, 2021.

The use of the posterior interosseous artery flap and anterolateral thigh flap for post-traumatic soft tissue reconstruction of the hand.

The purpose of this study was to examine the differences between the use of a posterior interosseous artery (PIA) flap and an anterolateral thigh (ALT) flap for post-traumatic, medium-sized soft tissue reconstruction of the hand based on flap characteristics, postoperative complications, and aesthetic outcomes.From October, 2010 to March, 2016, 62 patients undergoing soft tissue reconstruction of the hand with 30 PIA flaps and 32 ALT flaps were included in this study. The 62 patients were divided into the PIA flap group and the ALT flap group. The differences between the 2 groups were analyzed.The 62 patients included 52 males and 10 females, and the mean age at the time of surgery was 41 years. The flap failure rate was 13.3% (4/30) in the PIA flap group and 9.4% (3/32) in the ALT flap group. No significant differences in flap failure rate, recipient site complication rate, or donor site complication rate were observed between the 2 groups. However, the operative time (136 min vs 229 min) and aesthetic outcomes (flap bulk swelling, 0 cases vs 31 cases) were statistically significantly different.Both the pedicled PIA flap and the free ALT flap were comparable for the reconstruction of post-traumatic, medium-sized soft tissue defects of the hand according to the evaluated outcomes of postoperative complications. Based on the surgical characteristics of the flap and the evaluation of aesthetic outcomes, the pedicled PIA flap was significantly superior to the free ALT flap.

Risk of Microvascular Anastomosis Performed in Previous Treated Neck

Background and Objectives This study aimed to determine if a microvascular anastomosis on the neck, which had previously been treated, increases the risk of early complications, such as flap failure or hemorrhage and venous congestion that necessitates re-exploration.Subjects and Method A retrospective review was conducted on 274 cases of tumor resection with simultaneous free flap reconstruction from 2005 to 2019. Flap failure and re-exploration rate was evaluated according to the clinical variables including treatment history of recipient vessels.Results Twenty-one (7.7%) cases of flap failure were identified and re-exploration was conducted in 51 (18.6%) cases. Although the failure rate appeared to be high when micro-anastomosis was performed in the neck, where neck dissection with radiotherapy was previously performed (22.7%), there was no statistical significance compared with no previous treatment group. Previous neck dissection with irradiation was found to influence re-exploration {odds ratio (OR)=3.674 [95% confidence interval (CI) 1.348–10.014, &lt;i&gt;p&lt;/i&gt;=0.011]} compared to no treatment. However, previous radiotherapy or surgery only did not show any significant difference compared to the untreated group. Venous congestion was the most common cause of re-exploration (50.1%), followed by hematoma (33.3%), and previous neck dissection with radiotherapy increased the risk of both [OR for venous congestion=3.056 (95% CI 1.009–9.255)], &lt;i&gt;p&lt;/i&gt;=0.048, OR for hematoma=6.286 (95% CI 1.679–23.526), &lt;i&gt;p&lt;/i&gt;=0.006] compared with no previous treatment. Radiotherapy alone did not change the risk of early complication.Conclusion Micro-anastomosis in a previously treated neck is feasible in terms of flap failure. However, micro-anastomosis in a neck, where neck dissection with radiotherapy were performed, may be more likely to cause complications such as venous congestion and hematoma that necessitate re-exploration.

635 Free Versus Pedicled Flaps for Primary Reconstruction of Electrical Injuries: A Systematic Review and Observational Meta-Analysis

Abstract Introduction Both high-voltage (&amp;gt;1000 V) and low-voltage (&amp;lt; 1000 V) electrical burns can cause serious injuries due to dissipation of heat as electric current passes through deep tissues. Because of tissue loss and vital structure exposure, flap-based reconstruction is frequently performed in patients with these injuries. Depending on clinical presentation, both free and pedicled flaps may be indicated. We wondered if reported reconstructive outcomes after electrical injury differ between free and pedicled flaps when implemented in the immediate post-injury period. Methods A systematic literature review following PRISMA guidelines was conducted using PubMed and Ovid MEDLINE databases. Articles that were included described patients with electrical burn injuries who underwent reconstruction with either free or pedicled flaps within 90 days of injury. Technique articles or articles lacking outcomes analysis were excluded. Data was extracted from articles that met inclusion and exclusion criteria, including flap type, timing of reconstruction, complications, and patient demographics. Statistical analysis was performed with chi-square tests. Results Of 536 articles obtained from the literature search, 37 met criteria. To date, no randomized control trials comparing these modalities have been performed. In total, these studies reported on 364 total patients who experienced high- and low-voltage electrical burn injuries. Pooled reported outcomes of 374 flap reconstructions were analyzed, including 145 free flaps and 229 pedicled flaps. Reported complication rates did not differ significantly between free flaps (30/145, 20.7%) and pedicled flaps (46/229, 20.1%; p = .89). However, free flaps experienced significantly higher failure rates than pedicled flaps (13/145, 9.0% vs. 0/229, 0%; p = &amp;lt; .05). Conclusions Electrical burn injuries present a unique indication for flap-based reconstruction in the immediate post-burn phase of care. However, substantial variation exists amongst physicians regarding whether to proceed with a free flap or pedicled flap surgery when indicated. Our data identified an overall significant difference between free versus pedicled flap failure rate but did not identify a significant difference between overall complication rates.

Lower limb salvage in patients older than 75 years old affected of soft tissue sarcoma: beyond the limits

Microsurgical procedures were initially believed to be feasible only in younger patients. On the one hand, operative times may be prolonged, and on the other, older patients usually present with other comorbidities. However, without the option of microsurgical reconstructive procedures, the only curative treatment for patients with bone and soft tissue sarcomas in the lower extremity is limb amputation. This was a retrospective observational study of two cohorts of patients (group A, > 75 years old, n = 20; and group B, < 75 years old, n = 21) to compare their outcomes after lower limb salvage surgery. Selection criteria included all patients who underwent free flap reconstruction after sarcoma resection in the lower limb between 2017 and 2019. Exclusion criteria included smoking, severe comorbidities, inability to ambulate, or inadequate vessels in the preoperative image studies. Length of stay, complications, and rates of flap failure, recurrence, and amputations were compared. Average age, BMI, and presence of other comorbidities for groups A and B were 80 and 61 years old, 26 and 24 kg/m2, and 50 and 45%, respectively. Most patients (53%) had leg defects and were reconstructed with an ALT flap (60%) anastomosed to the anterior tibial artery (60%). Flap failure was observed in one group A patient. The average surgical time was 9 h. The patients followed 10 days of total bed rest and a dangling protocol was started on day 11. The mean hospital stay was 16 days and patients underwent physical therapy afterward. Postoperative surgical and medical complications in groups A and B occurred in 7/20 and 2/21, and 5/20 and 5/21 patients (25%), respectively. Age or ASA status had no effect on the incidence of complications. Radiotherapy was given postoperatively in all patients. At 1-year follow-up, all patients were alive; 27% had a recurrence or metastatic disease. The amputation rate was 25% and 0% in groups A and B, and was the only variable that reached statistical significance (p = 0.021). Based on our findings, limb salvage surgery can be performed successfully in selected old patients with lower limb sarcomas. It should be considered as a treatment option in this group of patients as it offers a safe alternative to amputation with an acceptable risk of complications, good flap success rates, and functional outcomes. Level of evidence: Level III, therapeutic; risk/prognostic study.

Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies.

Background:Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.Methods:Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient’s reconstructive journey.Results:Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.Conclusion:The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

Free tissue transfer with supermicrosurgical perforator-to-perforator (P-to-P) technique for tissue defect reconstruction around the body: Technical pearls and clinical experience

BackgroundResorting to perforators as recipient vessels is a valid alternative that might offer a series of advantages in many situations. They allow the use of a shorter pedicle, reduce the time of dissection, and are a good solution when deep vessels are difficult to reach. The aim of this study is to investigate the efficacy of P-to-P tissue transfer for reconstructing defects in different areas of the body. Patients and MethodsBetween April 2018 and February 2020, 40 patients presenting soft tissue defects were reconstructed by using P-to-P-anastomosed free flap transfer. The cause of the defect was trauma in 16 cases and surgically excised tumor in 24. Five defects were located in the upper extremities, 1 in the neck, 1 in the thorax, and 21 in the lower limb, and 13 cases were breast reconstructions, 2 of which bilateral (43 total flaps). ResultsOf all 43 flaps, 22 were abdominal flaps, 17 flaps were harvested from the upper thigh, and 4 were harvested from the lower leg. At the 9 month follow-up, 42 flaps were successfully healed, 36 without complications, 3 after wound dehiscence, and 3 after wound infection, and only 1 flap was lost requiring further surgery. Flap failure rate was 2.3%. ConclusionsFree flaps anastomosed in perforator-to-perforator fashion can be safely used in different settings throughout the body. Even if they are technically more demanding, they may allow a quicker operation time and lower morbidity. With the developments in microsurgical instruments, we believe that this technique may become the gold standard for tissue-defect reconstruction.

Peroneal flap: How to harvest and clinical appraisal for head and neck reconstruction

A peroneal flap, the boneless version of fibula flap, is considered as the equivalent of radial forearm flap of the lower leg. Because it is thinner than an anterolateral thigh (ALT) flap, the use of a peroneal flap is a viable option for the repair of soft tissue defects when a thin flap could bring about better functional and cosmetic outcomes. In this article, we describe the details of peroneal flap harvest and present our experience with the use of peroneal flaps for head and neck reconstruction. Between 1996 and 2017, a total of 265 peroneal flaps were used to reconstruct a variety of head and neck defects. With the same vascular anatomy and slight modifications to the harvesting technique of a fibula flap, a peroneal flap can be harvested within 1-2 h. All medical records were retrospectively reviewed. A peroneal flap can be harvested as different types of chimeric flaps to fit a variety of head and neck defects. The peroneal flap failure rate was 3.4% and the postoperative complication rate was 12.8%. A peroneal flap might be an alternative option for the reconstruction of head and neck defects.

Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36–3.86, P=0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75–38.3, P=0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04–2.48, P=0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis.

The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction. The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables. Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate. Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Consideration in Microvascular Reconstruction during Times of Social Crises: Perspectives on Resource Utilization.

Reconstruction of head and neck surgical defects can be a complicated, costly process. While the era of cost-effective medicine has begun to broadly question the necessity of high-cost care, times of extraordinary sociomedical demand bring increased scrutiny to even routine costs and resource utilization. Within this context, we reviewed the advantages, drawbacks, and financial costs of both regional and free flap reconstructions, namely the decreased costs and hospital resource utilization that may be associated with reconstruction using regional flaps. Although beset by reports of partial necrosis in certain regional flaps-particularly the submental island, cervicofacial advancement, and supraclavicular artery island flaps-many reports have demonstrated complication and flap failure rates equivalent to those of free flaps. Additionally, regional flaps have been associated with decreased costs for hospital stay, most notably in cases of postoperative complications. In cases necessitating free flap reconstruction, cost-savings strategies such as bypassing postoperative intensive care unit admissions have been shown to provide satisfactory, safe outcomes. As the head and neck surgeon continues to adapt to the medical pressures of a global pandemic, resource-sparing approaches to oncologic care will persist in their newfound importance.

Pedicled Myocutaneous Flap Breast Reconstruction in the Community Hospital Setting: An Analysis of Cost and Complications

BackgroundFree tissue transfer breast reconstruction is an option for breast cancer patients that is precluded by a number of factors. The authors’ objective was to assess the use of pedicled myocutaneous breast reconstruction in the community hospital setting, with more limited resources, as a viable option with comparable rates of complications, cost, and outcomes.MethodsThe authors performed a retrospective cohort review of pedicled myocutaneous breast reconstructions of a single surgeon at a community-based institution from 2015 to 2019. Rates of complications, including partial and total flap failure, infection, seroma/hematoma, and reoperation were evaluated, as well as initial hospital cost, readmission cost, and subjective patient satisfaction. Statistical analysis was performed on the data and compared to published data on free flap breast reconstruction with regards to similar data points.ResultsThere were ten patients included in the analysis. This data demonstrated an immediate reoperation rate of 0%, with no incidence of partial or total flap loss, infection, seroma, hematoma, or medical complication. Delayed complications included delayed wound healing of the donor site (10%), abdominal wall bulge (10%), and umbilical partial necrosis (10%). The average length of initial stay was 5.7 days and the average initial hospital costs were $94,717.ConclusionsAs demonstrated at St. Barnabas Hospital, this type of breast reconstruction does not require the presence of a microsurgery fellowship program, high volumes, significant ancillary staff training, or other costly resources to monitor the patient, yet yields comparable or favorable rates of complications when compared to free tissue reconstruction. This allows more reconstructive options to be available to patients who may not have access to large tertiary centers for free flap reconstruction.