Flap Loss Research Articles

Does controlled, gradually increased venous pressure exposure (dangling) of the lower extremity after free flap reconstructions reduce partial flap loss? A multicenter randomized controlled trial.

Controlled, gradually increased venous pressure exposure of lower extremity free flaps (dangling) is common, based on the assumption that this reduces (partial) flap loss. Dangling protocols potentially increase length of hospital stay and resource utilization. We investigated whether: (1) the proportion of partial flap loss 6 weeks after lower extremity free flap reconstruction is non-inferior after uncontrolled exposure compared to gradually increased venous pressure exposure; (2) there is a difference in length of hospital stay and major or minor adverse events 3 months after surgery. For this multicenter randomized controlled trial patients who underwent lower extremity free flap reconstruction were included. Seven days after surgery 39 were randomized to dangling and 36 mobilized without limitations. Partial flap loss was assessed 6 weeks after surgery (primary outcome), length of stay, and major and minor adverse events 3 months after surgery. An absolute increase of 12% partial flap loss was considered inferior. Uncontrolled exposure was non-inferior to controlled, gradually increased venous pressure exposure (absolute risk difference: 2.4%, 95% CI -10%-15%, partial flap loss dangling: 5.1% (n=2) vs. non-dangling: 2.8% (n=1)). There was no difference in length of stay and major or minor complications. Seven days after surgery, dangling the lower extremity after free flap reconstruction seems unnecessary. Surgeons and patients can consider forgoing a formal dangling protocol at that time. Future research is warranted to assess whether forgoing dangling is also safe earlier after free tissue transfer possibly reducing length of hospital stay and resource utilization.

Perioperative Venous Thromboembolism Chemoprophylaxis Does Not Increase Risk of Complications in Free Flap Breast Reconstruction.

Patients undergoing abdominal-based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation. A retrospective review was conducted on patients who underwent abdominal-based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010-2015 patients were pre-ERAS and 2015-2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation. 2317 patients were included: 679 were pre-ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre-ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre-ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre-ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05). A standardized perioperative anticoagulation protocol for abdominal-based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.

Prognostic Factors of Flap Complications After Carbon-ion Radiotherapy for Head and Neck Cancer With Reconstruction.

The incidence of flap complications after carbon-ion (C-ion) radiotherapy (RT) for head and neck cancer with reconstruction is unknown. This study investigated the incidence and risk factors of flap complications following C-ion RT for head and neck cancer with reconstruction. We retrospectively analyzed 24 cases, excluding cases of re-irradiation, treated with C-ion RT at QST Hospital for loco-regional recurrence after reconstructive surgery for head and neck cancers from April 1997 to March 2020. We evaluated flap complications as anastomosis-related (flap loss and necrosis) and flap bed-related (wound dehiscence) complications. Wound dehiscence was assessed using Common Terminology Criteria for Adverse Events version 5.0. The correlation between clinical factors, dosimetric parameters, and flap complication was analyzed retrospectively. The median follow-up period was 42.2 months (range=6.7-155.9 months). None of the 24 enrolled patients experienced flap loss and flap necrosis, and two (8.3%) patients had grade 1 wound dehiscence; grade 2 or greater toxicities were not recorded. The median interval between C-ion RT and wound dehiscence of the flap was 6.8 (6.5 and 7.0) months. Univariate analysis to identify clinical and dose-volume histogram parameters associated with the occurrence of grade 1 wound dehiscence after C-ion RT revealed that the minimum dose (Dmin) ≥5.9 Gy for flap was a statistically significant risk factor (p=0.017). C-ion RT for head and neck cancers after reconstructive surgery is safe, with no serious flap complications. Dmin was an independent risk factor for the development of wound dehiscence.

Unilateral Versus Bilateral Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Systematic Review and Meta-analysis.

Previous studies have shown a higher complication rate in bilateral (BL) compared to unilateral (UL) deep inferior epigastric perforator (DIEP) flap breast reconstructions. This systematic review and meta-analysis aimed to offer an update by including recent studies to thoroughly assess the complication rates in UL versus BL DIEP flap reconstructions and provide clear guidance for clinicians and their patients. A systematic review of the literature and comparative meta-analysis were performed to assess the differences in complication rates between UL and BL procedures. Only comparative studies that reported on postoperative complications after UL and BL DIEP flap breast reconstructions were included. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Five studies representing 5120 patients who underwent either UL or BL DIEP flap breast reconstructions were included. BL DIEP flap reconstructions were associated with a higher risk of total flap loss, with an OR of 1.48 (95% CI, 1.02-2.14) and a P value of 0.04. Conversely, the risk of reexploration surgery was reduced, with an OR of 0.68 (95% CI, 0.55- 0.84) and a P value of 0.0002. BL DIEP flap breast reconstruction carries a higher risk of complete flap loss compared with UL reconstructions, with a moderate risk increase. Despite this increased risk, the significant benefits of BL reconstruction make it a viable and recommended option for women requiring this type of surgery.

Antithrombotic Agents after Free Tissue Transfer in the Pediatric and Adolescent Population.

Even for the experienced microsurgeon, free tissue transfer in pediatric patients is challenging, and large patient series remain scarce in the literature. Moreover, the added value of antithrombotic agents in pediatric free tissue transfer remains unclear. We conducted a retrospective outcome analysis of pediatric free tissue transfer with respect to postoperative antithrombotic treatment at our tertiary academic center. All patients aged 0 to 18 years who underwent free tissue transfer from 1998 to 2022 were included in the study. Seventy patients received 73 free tissue transfers. The most common indications were facial paralysis, trauma, and tumor (49.3, 21.9, and 20.5%, respectively). The most common recipient sites were the head and neck (56.1%) and lower extremity (32.8%). We observed a flap revision rate of 12.5% of the cases and one flap loss (1.4%). A total of 58.9% of the population received postoperative antithrombotic agents. The rate of flap revision surgery was similar (11.6 and 10.0%, respectively), with and without antithrombotic treatment (p > 0.05). There were no major bleeding complications or deep vein thrombosis. The antithrombotic treatment did not seem to affect the flap revision rate or the bleeding complications in our cohort. Hence, the data do not support the routine administration of antithrombotic treatment in pediatric free flap reconstruction. However, these findings should be solidified in prospective randomized trials.

Dynamic Facial Reanimation for Facial Palsy: The Oman experience.

The goal of facial reanimation for facial palsy is to restore resting facial symmetry and dynamic facial motion that mirrors the opposite side as closely as possible. This study aimed to evaluate the restoration of oral commissure symmetry at rest and during excursion among patients with facial paralysis treated with free gracilis muscle transfer. This study included 9 patients who underwent facial reanimation with free gracilis muscle transfer at Khoula Hospital, Muscat, Oman, from 2019 to 2022. Children under 14 underwent a 2-stage surgery, while those above 14 underwent single-stage reconstruction. The average age among the cohorts was 24 years. Overall, 5 cases underwent a 2-stage facial animation, 4 underwent single-stage reconstruction and 1 patient had free flap loss following the free gracilis muscle transfer. The mean time for noticing recovery was 3 months postoperatively. Early recovery was noted in patients who underwent single-stage free gracilis muscle transfer with motor innervation from the ipsilateral nerve to the masseter compared to the cross-facial nerve transfer. Good patient satisfaction (88.9%) was observed following the procedure. This study observed earlier recovery in patients who had undergone single-stage free gracilis muscle transfer with motor innervation from the ipsilateral nerve to the masseter compared to the cross-facial nerve transfer. The oral commissure symmetry at rest and during excursion among patients with facial paralysis treated with free gracilis muscle transfer in Oman was found to be near normal.

Perioperative Blood Transfusion in Traumatic Limb Salvage.

Background Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction. Methods A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007-October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis. Results In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf-) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf+). Overall flap survival rates were similar across both cohorts (Tf+: 92.9% vs Tf-: 96.6%, p=0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9% vs. 2.0.%, p<0.001), amputation (6.0% vs 0.7%, p=0.015), and postoperative hardware infection (10.6% vs 2.7%, p=0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis (p=0.033). Conclusion Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.

DIEP flap with implant placement has a favorable complication profile compared to implant-only or flap-only reconstruction.

Hybrid deep inferior epigastric perforator (DIEP) flap and simultaneous silicone implant breast reconstruction procedures ("DIEP+I") have many conceptual advantages compared to either reconstruction method alone, but the outcomes of DIEP+I reconstruction have not yet been well studied. Therefore, the purpose of this study was to compare the outcomes of DIEP+I with implant-only and DIEP-only reconstruction. A retrospective review was conducted of patients undergoing DIEP+I, implant-only, and DIEP-only breast reconstruction from 2019-2023 at a single institution. Demographics and complication rates were compared between groups. A total of 145 patients were included in the DIEP+I (N = 26), implant-only (N = 59), and DIEP-only (N = 60) groups. The DIEP+I group had a lower overall complication rate than implant-only reconstruction (18.4% vs 41.1%, P = 0.014), which was primarily due to the lower incidence of infections in the DIEP+I group (2.6% vs 22.2%, P = 0.006). Accordingly, DIEP+I reconstruction decreased the odds of infection by 90% (OR = 0.095, P = 0.024) compared to implant-only reconstruction. The DIEP+I group had similar rates of wound healing and implant-related complications compared to the implant-only and DIEP-only groups, and no patients in the DIEP+I group experienced flap loss. DIEP+I breast reconstruction had a lower rate of infectious complications than implant-only reconstruction, and no higher rate of flap compromise or wound healing complications. This technique could be considered as a means of minimizing infection risk in patients with other risk factors who are seeking implant-based reconstruction, and of enhancing breast projection in patients who are seeking DIEP flap reconstruction.

The Effect of Medial Circumflex Artery Variation on the Success Rate of Gracilis Flap Procedures: A Systematic Review.

This systematic review examines the impact of anatomical variations in the medial circumflex artery (MCA) on the outcomes of gracilis flap procedures in reconstructive surgery. Incorporating 16 studies, this review analyzes how different MCA variants influence the success rates of these procedures. Findings highlight critical MCA variations, including cases of split and double pedicles and differences in pedicle length and branching patterns, which can complicate flap harvesting and vascular anastomosis. The studies consistently underscore the need for precise preoperative imaging and intraoperative adaptability to manage these anatomical differences effectively. Notably, variants with shorter or branched pedicles present higher risks of partial flap loss and complications, particularly in autologous breast reconstruction and lower extremity repairs. The findings support the adoption of advanced imaging protocols, such as high-resolution Doppler and CT angiography, to enable detailed vascular mapping. Interdisciplinary collaboration among anatomists, radiologists, and surgeons is essential for developing comprehensive strategies tailored to individual anatomical landscapes, optimizing both the success and viability of gracilis flaps. The review emphasizes that understanding MCA variability is crucial for enhancing surgical precision and improving patient outcomes. Standardizing preoperative assessment protocols and exploring alternative flap techniques may mitigate risks associated with MCA variations, advancing the field of reconstructive surgery.

Lumbosacral rotation flap: a simple method for covering sacral pressure injuries.

Pressure injuries (PIs) are among the most common skin and soft tissue wounds occurring in patients who are bedbound and/or immobile. PI management hinges on their prevention; however, reoccurrence poses a challenge to their management and requires a multidisciplinary approach. Here, the authors describe a lumbosacral rotation flap (LSRF) for the coverage of sacral PIs. A single-centre, retrospective analysis of prospectively collected data was carried out. All patients undergoing LSRF for sacral PIs were included. Patients with active systemic sepsis, immune compromise, hepatic or renal dysfunction were excluded. All patients underwent preoperative optimisation and wound cultures to direct antibiotic therapy after surgery. A total of nine patients underwent the procedure (seven male and two female). Mean age was 47.6 years with a mean ulcer size of 92.9 cm2. Bone biopsy indicated the presence of osteomyelitis in three patients. Of the LSRFs, two flaps showed minimal local complications in the form of marginal flap necrosis which was managed conservatively. All flaps healed well with no cases of flap loss or the need for secondary procedures. The results of this analysis showed that LSRF can be considered a first line of treatment of sacral PIs. They can be used to cover large defects. Due to their large base and flap size, readvancement in cases of recurrence is also possible.

Effects of Preoperative Hemoglobin on Microsurgical Reconstruction and Perioperative Blood Transfusion Requirement: A Meta‐Analysis and Systematic Review of the Literature

ABSTRACTPurposeAlthough blood loss in microsurgical reconstruction is rarely large enough to be life‐threatening, preoperative anemia can be a particular issue in terms of postoperative morbidity, impaired wound healing, and compromised tissue viability. We seek to review the effect of preoperative hemoglobin (Hgb) levels on perioperative blood transfusion (PBT) requirements and complications to guide management of patients with preexisting anemia undergoing reconstruction.MethodsPubMed, Embase, and Scopus were queried for relevant articles. Inclusion criteria were as follows: original studies investigating outcomes and PBT requirements in flap‐based reconstruction based on preoperative Hgb levels. Patient and study characteristics were analyzed using descriptive statistics. A meta‐analysis was conducted to assess transfusion requirements across the included studies using Stata (version 18.0 Stata Corp, College Station, Texas, USA). The Fisher method was used to aggregate individual study p values into a single combined value to statistically assess the combined findings, where a p value of &lt; 0.05 was set as statistically significant.ResultsOne thousand three hundred and eighty‐nine studies were screened for title and abstract relevance, 14 of which met the inclusion criteria, including a total of 61,116 patients. Meta‐analysis of the studies revealed a PBT requirement of 36.2% for anemic individuals, significantly higher than the 20.0% for those with normal preoperative Hgb levels (p &lt; 0.001), with an average 4.9 versus 2.4 units of packed red blood cells being transfused (p &lt; 0.001). The majority of studies concluded that preoperative anemia was associated with medical complications, such as myocardial infarction, stroke, and infection (p &lt; 0.001). While six studies reported a significant relationship between low preoperative Hgb and flap morbidity (flap loss and partial flap necrosis), two studies found no correlation. The overall postoperative complication rate across the studies was 42.2% among patients with low preoperative Hgb levels, whereas the nonanemic group demonstrated a markedly lower rate of 13.9% (p &lt; 0.001).ConclusionThe existing evidence is strongly suggestive of increased PBT requirement in patients with anemia, highlighting the necessity for preoperative optimization of Hgb levels and intraoperative monitoring. While preliminary evidence demonstrates a relationship between anemia and medical complications, more research is warranted to characterize the specific association between preoperative Hgb levels and flap morbidity.

Comparing Safety Profiles of Skin-Sparing and Nipple-Sparing Mastectomy With Deep Inferior Epigastric Perforator Flap Breast Reconstruction: A Retrospective Analysis.

Mastectomy is performed prior to or concurrently with deep inferior epigastric perforator (DIEP) flap breast reconstruction. However, the complication rates of nipple-sparing mastectomy (NSM) versus skin-sparing mastectomy (SSM) with DIEP are not well-characterized. This retrospective study included patients who underwent SSM or NSM with DIEP reconstruction between January 2019 and July 2022 at an academic institution. The primary outcome was 30-day postoperative complication rate. Variables were compared using Student's t-tests/Wilcoxon rank-sum and Chi-square/Fisher's exact tests. Of 535 patients, 195 (36%) underwent NSM and 340 (64%) underwent SSM. The 30-day postoperative complication rates did not differ between cohorts (16.4% in NSM vs. 16.8% in SSM, p > 0.9). The NSM cohort had a higher rate of any flap necrosis (9.2% vs. 3.5%, p = 0.01) compared to the SSM cohort, though rates of total DIEP flap loss rate did not differ (4.1% vs. 1.5% respectively). Site-wide total DIEP flap loss was 2.4%. The NSM cohort had smaller preoperative sternal notch-to-nipple distances (25.0 vs. 26.5 cm, p < 0.001) and had lower rates of preoperative radiation therapy (28.2% vs. 42.9%, p < 0.002) compared to the SSM cohort. The cohorts did not differ in demographic or operative variables including reconstruction timing (delayed vs. immediate interval), readmission, and reoperation. Individuals who received an NSM prior to DIEP reconstruction had more flap complications compared to the SSM cohort. Both cohorts had comparable overall 30-day postoperative complication rates and demographic variables, and rate of total DIEP flap loss was 2.4%. Patient preference can further guide surgical decision-making.

Closure of the Osteocutaneous Fibula Flap Donor Site with a Tonearm (Propeller) Flap: Anatomic Considerations and Surgical Indications

BackgroundSkin graft is frequently used for donor site closure after osteocutaneous fibula free flap (OCFFF) harvest when primary closure is not possible. Partial skin graft loss requiring wound care is a common complication. The purposes of this prospective study were to investigate the perforator anatomy for local propeller/tonearm flap closure and compare outcomes to skin graft closure. MethodsAll patients undergoing OCFFF for head and neck reconstruction from February 2022 to October 2023 were considered for the tonearm flap. Intraoperative perforator anatomy was prospectively recorded. Surgical techniques and criteria for tonearm flap reconstruction were described. A minimum 6-month follow-up was required. Outcome measures included the rate of flap success and wound complications. Results40 consecutive patients were included. The tonearm flap was not possible in 16 patients (40%) due to unfavorable perforator anatomy and 2 patients underwent primary closure. All successful tonearm flaps were eccentrically designed on a proximal lower leg perforator, located 13.5±1.99cm from the fibular head. Most proximal perforators were musculocutaneous through the soleus muscle (n=20, 90.9%), while the rest were septocutaneous (n=2, 9.1%) originating from the peroneal artery. Three patients experienced distal partial flap loss; one required an additional skin graft. Only half of the skin graft cohort (n=99, 50.8%) achieved complete skin graft take. The average skin graft loss was 34.3% and wound care was required for an average 51.6±52.8 days. ConclusionsThe study findings demonstrate that local tonearm flaps, when anatomically feasible, can be successfully performed with superior outcomes compared to skin graft closures.

Nationwide clinical practice variation for reconstructive surgery following oral cavity cancer from the Dutch Head and Neck Audit: Are we all doing the same?

IntroductionQuality registries provide real-world data that can drive quality improvement which often starts with reducing interhospital variation. We explored outcomes and the extent of nationwide interhospital variation for patients undergoing reconstructive surgery after oral cavity cancer (OCC) using the Dutch Head and Neck Audit (DHNA). Material and MethodsWithin the DHNA, we selected all OCC patients between 2018 and 2022 who underwent curative reconstructive surgery. Patient, tumour, and treatment characteristics were compared, including reconstruction strategies (skin grafting, local transposition, pedicled and free flaps). Of those treated with free flap reconstruction, postoperative complications were scored according to the Clavien-Dindo (CD) classification and labelled minor (CD 1-2) or major (CD ≥3). ResultsA total of 1,383 patients were included in the analysis. Especially for patients with stage I tumours (10%), a wide variation in reconstructive surgeries was observed between centres, with a preference for local transposition (42.6%). Free flaps were used most for patients with a more extensive tumour load (65.4% - 89.2%), with the radial forearm flap as the preferred technique (54.7%, range 33.7% - 80.8%). Thirty-four percent of patients treated with a free flap had postoperative complications, with 38 cases of total flap loss (overall 3.9% complications). ConclusionStrategies and percentages varied strongly across centres, showing high interhospital variation in applied techniques and outcomes, and the need for national data improvement.

The Use of Pedicular Arteriovenous Fistula (PAVF) in Microvascular Reconstruction to Enhance Flow Across the Microvascular Anastomoses.

Free flap success rates have improved dramatically over the past three decades, setting a high standard for microvascular reconstruction. However, rates of arterial or venous thrombosis, and subsequent failure, remain high in burn and trauma reconstruction when compared to autologous breast reconstruction and other elective flaps. To address the higher failure rate, we use a novel vascular approach. We create a pedicular arteriovenous fistula (PAVF), allowing the flow to be enhanced across the microvascular anastomoses. We performed a retrospective review of 13 consecutive patients with 14 free flaps who underwent PAVF creation by the first author, AO. All patients who required free tissue transfer for trauma and burn reconstruction were indicated for PAVF during this study period. The flaps in this study included ALT, fibula, parascapular, and partial latissimus. The perforator and pedicle for the flaps were dissected in the usual manner. Distal to the takeoff of the perforator to the flap, the pedicular artery and the larger of the accompanying veins were anastomosed to create the PAVF. Patients were followed for a mean of 171 days Thrombosis was a rare complication in the group with one venous thrombosis (n = 1, 7.14%) and no arterial thrombosis. The most common complication was return to the operating room n = 4 (28.57%), two of which secondary to hematomas (14.29%), one wound dehiscence and one venous thrombosis. This latter patient eventually had partial flap loss. We did not observe flap ischemia due to vascular steal, nor any venous congestion from pressurizing the venous outflow. As opposed to anticoagulation, flow enhancement aims to decrease the risk of thrombosis by reducing stasis. While further data is needed to compare the outcomes of venous enhanced flaps when compared to flaps treated prophylactically with anticoagulation, our initial data suggests that PAVF is a safe procedure and does not result in vascular steal or flap congestion.

Clinical Outcomes Following Profunda Artery Perforator Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

There is a lack of reliable evidence on the surgical outcomes of profunda artery perforator (PAP) flap breast reconstruction. We conducted a meta-analysis to evaluate its safety and compare it with deep inferior epigastric perforator (DIEP) flap, aiming to offer more information on whether the PAP flap was an ideal alternative for autologous breast reconstruction. PubMed, EMBASE, Web of Science and Cochrane Library were searched to retrieve relevant articles. The postoperative complication rates following PAP reconstruction were pooled. Mean differences of patients' age, BMI, mastectomy weight and flap weight between PAP and DIEP group were calculated, and relative risk was estimated to compare their incidence of complications. Twenty-four articles reporting 1612 PAP flap breast reconstructions were included. The surgical success rate was 99.6%; the incidence of total and partial flap loss was 0.4% and 0.0%; the incidence of infection, hematoma, seroma, fat necrosis and wound dehiscence in recipient sites was 0.3%, 1.4%, 1.0%, 3.3% and 0.3%, respectively; the incidence of infection, hematoma, seroma, wound dehiscence and sensory disturbance in donor sites was 2.0%, 0.9%, 3.5%, 9.2% and 0.6%, respectively. Compared to the DIEP group, the average age, BMI, mastectomy weight and final flap weight were significantly lower in the PAP group. No significant difference was observed in terms of flap failure, breast fat necrosis and donor site wound dehiscence. This systematic review demonstrates similar levels of postoperative morbidities for the PAP and DIEP flaps with some subtle differences and verifies the PAP flap as a second-line treatment for patients when the DIEP is unavailable or undesirable. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Intraoperative Complications as Predictors of Flap Failure in Autologous Breast Reconstruction.

Intraoperative microvascular complications in autologous breast reconstruction significantly increase the risk of postoperative complications. No study has identified which specific intraoperative complications contribute to partial or total flap loss. A retrospective chart review of microsurgical breast reconstructions by five surgeons between 2009 and 2020 analyzed operative variables and patient outcomes, with complications determined from the operative report. Flap loss rates were compared between cases with and without intraoperative complications. Statistical analysis was performed using Fisher's exact and t-tests for discrete and continuous variables, respectively. Intraoperative complications were analyzed for 1,465 autologous breast flaps performed in 916 patients. Early partial flap loss was predicted by arterial anastomosis revision (2.90 vs. 0.44%, p = 0.03) and alternate venous outflow (14.29 vs. 0.41%, p = 0.002), with no association with intraoperative thrombosis, venous revision, or difficult recipient or flap dissection. In comparison, early total flap loss was predicted by intraoperative arterial revision (5.80 vs. 0.51%, p = 0.001), venous revision (5.45 vs. 0.57%, p = 0.007), intraoperative thrombosis (12.12 vs. 0.49%, p < 0.001), and difficult flap dissection (2.91 vs. 0.59%, p = 0.04). Difficult flap dissection was the only intraoperative variable associated with late partial flap loss (6.80 vs. 1.69%, p = 0.004). Late total flap loss only occurred in 6/1,465 flaps, the sole association being difficult recipient vessel dissection (2.78 vs. 0.29%, p = 0.03). Postoperative arterial and venous compromise occurred in 1.10% (13/1,187) and 2.53% (30/1,187) of cases with no intraoperative complications, respectively, compared with 3.2% (9/278, p = 0.02) and 6.12% (17/278, p = 0.002) in cases with an intraoperative complication. Alternate venous outflow predicts early partial flap loss, while intraoperative thrombosis and arterial and venous revision predict early total loss. Difficult flap dissection was associated with early total and late partial flap loss, while difficult recipient vessel dissection was associated with late total flap loss.

Clinical and Cost-Effectiveness of Intraoperative Flap Perfusion Assessment With Indocyanine Green Fluorescence Angiography in Breast and Head and Neck Reconstructions: A Systematic Review and Meta-Analysis.

Indocyanine green fluorescence angiography (ICGFA) is gaining popularity for the assessment of reconstructive flap perfusion intraoperatively. This study analyses the literature with a focus on its clinical efficacy and cost-effectiveness across various plastic and reconstructive surgery procedures. A systematic review was conducted in accordance with PRISMA guidelines on published studies in English comparing ICGFA with standard clinical assessment for flap perfusion. Meta-analysis concerned perfusion-related complications and cost data. Twenty-five studies met the inclusion criteria, of which two were randomized controlled trials (RCTs) and four were prospective cohort studies. Twenty-one studies were AHRQ Standard 'Good'; however, the overall level of evidence remains low. ICGFA was predominantly performed in breast surgeries (n = 3310) and head and neck reconstruction (n = 701) albeit with inconsistency in protocols and predominantly subjective interpretations (only five studies utilized objective thresholds). In breast surgery, meta-analysis demonstrated significant reductions in mastectomy skin flap necrosis (odds ratio (OR) 0.58, p < 0.0001), fat necrosis (OR 0.31, p < 0.001), infection (OR 0.66, p = 0.02), and re-operation (OR 0.40, p < 0.0001), but no significant decrease in total or partial flap loss (OR 0.78, p = 0.57/OR 0.87, p = 0.56, respectively) or increase in dehiscence (OR 1.55, p = 0.11). In head and neck surgery, ICGFA significantly decreased total flap loss (OR 0.47, p = 0.04), although not partial flap loss (OR 0.37, p = 0.13) and reoperation (OR 0.92, p = 0.73). Lower limb (n = 104) and abdominal wall (n = 95) reconstructive surgeries were much less studied with no significant ICGFA impact. Seven studies reported cost savings with flap surgeries and breast reconstructions, although study heterogeneity precluded meta-analysis. ICGFA appears to be a useful, cost-effective tool to identify otherwise unsuspected hypoperfusion in breast and head and neck reconstruction. There is a clear need for standardization, however, to avoid bias. Further RCTs are necessary to solidify these promising clinical findings.

Novel Challenges and Opportunities for Anesthesia and Perioperative Care in Microvascular Flap Surgery: A Narrative Review.

Complex microvascular techniques and in-depth knowledge of blood rheology and microanastomosis function are required for success in microvascular flap surgery. Substantial progress has been achieved in preventing complications, but the rate of flap loss is still significant and can have significant adverse effects on the patient. Flap thrombosis, flap hematoma, and flap loss are the most frequent and severe major surgical complications. Advances in understanding the pathophysiology of different flap complications, the use of preoperative risk assessment and new treatment concepts could improve the perioperative care of microvascular flap surgery patients. Our aim was to outline novel avenues for best practice and provide an outlook for further research of anesthesia and perioperative care concepts in microvascular flap surgery.

Computer-Aided Design and Manufacturing in Free Fibula Reconstruction of the Mandible: Comparison of Long-Term Outcomes with the Conventional Technique.

Pre-operative computer-aided design and manufacturing (CAD/CAM) revolutionized head and neck reconstruction after extirpative surgery. However, studies performing head-to-head comparison to the conventional technique have limited long-term follow-up. We aimed to compare short and long-term outcomes between conventional and CAD/CAM approaches for mandibular reconstruction with free fibula flaps. Patients undergoing free flap reconstruction from 2012 to 2021 were included. Data regarding patient demographics, past medical history, surgical details, complications, and reconstructive outcomes were collected. Patients who had CAD/CAM were compared with the patients who underwent reconstruction with the conventional technique. The cumulative incidence of hardware maintenance was displayed using the Kaplan-Meier method. A total of 215 patients (n=79 conventional, n=136 CAD/CAM) were included. Both cohorts had similar demographics except the CAD/CAM cohort was younger (p=0.043). The mean operative duration was 54 minutes shorter with the use of CAD/CAM (p=0.014). Total and partial flap loss rates were similar. Patients with CAD/CAM had significantly lower rates of early wound dehiscence (p=0.037). Median [interquartile range] follow-up duration was similar (931 [1854] days in conventional vs 728 [841] days in CAD/CAM, p=0.084). After excluding patients with major surgical complications in the first 30-days, CAD/CAM cohort had a lower hardware removal rate (28.8% vs 13.9%, p=0.011). The significance persisted after including only the patients with more than 2 years of follow-up. The use of preoperative CAD/CAM may reduce operative duration, while allowing for longer maintenance of hardware with reduced removal rates due to complications.