Flap Reconstructive Options Research Articles

Various flap reconstruction options for tongue defect in oral squamous cell carcinoma

Various flap reconstruction options for tongue defect in oral squamous cell carcinoma

Lip Reconstruction After Mohs Micrographic Surgery: A Guide on Flaps

The lips are commonly affected by skin cancer because of increased sun exposure over time. Even with early detection, many of these skin cancers require surgical removal with subsequent reconstruction. Mohs micrographic surgery is the preferred method of treatment for nonmelanoma skin cancers of the lip, as it has the lowest recurrence rates and allows for the maximum preservation of healthy tissue. After surgery, the remaining lip defect often requires reconstruction with skin grafts or a local cutaneous or myocutaneous flap. There are several local flap reconstruction options available, and some may be used in combination for more complex defects. We provide a succinct review of commonly utilized flaps and outline their indications, risks, and benefits.

A Systematic Review and Overview of Flap Reconstructive Techniques for Nasal Skin Defects.

Background: Reconstruction of nasal skin defects can be challenging due to limited skin laxity and underlying cartilage and, therefore, often require a complex repair. The aim of this review is to systematically analyze the literature on nasal skin reconstructions with specific detail to flap reconstructions. Methods: A systematic literature review of nasal skin reconstruction was performed and focused on flap reconstructions. Flap reconstructions were stratified based on defect size, nasal subunit, and reconstruction type. Complication rates (CRs) and patient outcomes were also assessed. Results: A total of 176 articles (11,370 patients) met the inclusion criteria. Of these, 59 articles showed various flap techniques. For defects ≤1.5 cm, every subunit had four to six options except the alar rim, which showed one option. Rotation-advancement flaps were mostly used for the nasal tip and sidewall, whereas bilobed flaps were used more for the ala and dorsum. Defects >1.5 cm were most commonly reconstructed with the forehead flap. The mean CR of flap reconstructions was 13.8%. Only 8 of the 176 articles (4.5%) reported patient satisfaction using a standardized questionnaire. Conclusion: This review shows various flap reconstruction options with their corresponding CR that will help guide the surgeon in choosing reconstructive options for different nasal skin defects.

Pectoralis major muscle flap use in a modern head and neck free flap practice.

Pectoralis major muscle flaps (PMMF) are a commonly used reconstructive modality to repair head and neck defects. As the use of free flap reconstruction is increasingly practiced in the head and neck, the role of the PMMF may be changing as well. This study sought to analyze indications and outcomes for PMMF following head and neck resections from one surgeon's experience. Retrospective review from December 1, 2013 through September 30, 2017 at a tertiary care academic medical center. Indications for the PMMF were examined as well as surgical outcomes. Basic demographic data, patient head and neck cancer history, history of radiation and/or chemotherapy, and history of previous reconstructive procedures were obtained and compared across all subjects. Forty patients underwent a PMMF within the designated time frame. The majority of patients were male (83%) and the average age was 65years (range 55.4-74.6years). Of the 40 cases, 9 of the PMMFs were performed as primary reconstruction of the defect. In the remaining 31 cases, these flaps were utilized as a secondary reconstructive option following fistula formation (13), dehiscence (6), need for an additional flap for recurrent disease (6) infection (4), or major bleeding (2). In every case that it was utilized, the PMMF was the definitive reconstruction. Within the same time frame, 429 free flaps were performed by the same surgeon, with an average of 125 free flaps performed yearly. The rate of total flap failure overall was 3.9%. The other failed free flap reconstructive options used besides a PMMF were secondary free flaps (11), local wound care (4), or obturator placement (2). The secondary pectoralis flaps occurred following 7.2% of free flaps with total or partial failure that were performed within the same time range. The indications for the PMMF did not change or evolve during the time frame of the study. Although free flaps were performed with far greater frequency than PMMFs at our institution, the PMMF demonstrated continued utility as a secondary reconstructive option. For a surgeon who performs a high volume of free flaps, preservation of the pectoralis muscle and associated vasculature for possible later secondary reconstruction should be considered due to its strong efficacy.

Soft Tissue Reconstruction After Total Ankle Arthroplasty.

Wound complications following total ankle replacement (TAR) may potentially lead to devastating consequences. Soft tissue coverage of the prosthesis and tendons with a flap potentially prevent a catastrophic cascade leading to infection and implant failure. The aim of this study was to investigate the success and complications of flaps following soft tissue defects as a result of total ankle arthroplasty. We retrospectively identified a consecutive series of 1001 primary TARs performed between January 1998 and December 2014 whose data were prospectively collected. We then identified patients who required a secondary surgery to treat soft tissue defects that were not amenable to split-thickness skin grafting. Clinical outcomes including secondary procedures, wound healing failure, complications, and implant failure rate were recorded. Nineteen patients had a total of 44 operative procedures to treat wound issues (1.9% of all prostheses). The follow-up time from the flap procedure is 24.1 months. More than two-thirds (13/19) of patients had 1 or more previous surgeries on the ankle, for an average of 1.2 procedures. The mean time to the flap procedure was 13.1 weeks after the index TAR. The most common reason for flap coverage was a non-healing anterior wound. Thirteen of 19 patients (68.4%) underwent formal operative wound exploration and debridement prior to their definitive flap coverage. The average size of the wound was 5.4 × 3.8 cm with an average area of 24.9 cm(2). The most common type of flap performed was a sural pedicle flap followed by a propeller flap. There were 4 flap failures (21.1%), with 2 subsequent below-the-knee amputations. No TAR patients developed a deep infection following a flap unless they had a preexisting infection. In patients who had a successful flap, there were significant improvements in their American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, visual analog scale (VAS), and Short Musculoskeletal Function Assessment bother index, but not their Short Form-36 scores. Ankle wounds that occur after TAR can result in a devastating outcome, but management with a coordinated effort with surgeons with microvascular experience can help achieve salvage of the prosthesis. A variety of flap reconstruction options are available and should be employed to improve the rate of implant survival and retention. Level IV, case series.

Reconstructive Options in Patients With Late Complications After Surgery and Radiotherapy for Head and Neck Cancer

During the past 40 years, free vascularized flaps have become the golden standard in the reconstruction of postoncologic head and neck defects. When there is a need for an osteofasciocutaneous free flap, the free fibula flap is the first choice because of the advantages of its long bone structure, high reliability, and minimal donor-site morbidity. However, most of these patients receive adjuvant radiation therapy, which sometimes causes symptomatic fibrosis, contractures, and (osteo)radionecrosis. In case of these late complications, locoregional reconstructive options are often limited, and complex secondary free flap procedures are not always feasible or preferred by the patient. The present paper discusses regional and free flap reconstructive options and demonstrates with 3 cases that the delayed deltopectoral flap remains a very safe, reliable, and easy flap, which still has a place in the management of these complex reconstructive challenges.

The role of dermal regeneration template “Integra®” in reconstructive skin cancer surgery

Dermal regeneration templates (DRT) use, like “Integra®”, has spread over the past years since its introduction a few decades ago beyond its initial role in burn reconstruction. There is now evidence that it can be used as a biological template in post-cancer excision surgery as a method of reconstructing challenging defects We identified the patients that have undergone reconstruction following cutaneous cancer surgery within our institute by reviewing our records. The case notes of the patients were retrieved and the information extracted from the case notes. This is a retrospective analysis of the case studies. Over the time period of the study, we performed reconstruction using DRT on five individual cases. All the patients did not have any significant post operative complications and the reconstruction seemed durable and reliable. We discuss its benefits as part of the reconstructive ladder post cancer resection reconstructive surgery. DRT can now play a role in post cancer excision reconstruction in selected patient groups, especially the elderly or in those in which flap reconstruction options have been exhausted or deemed unsuitable. Level of Evidence: Level V, therapeutic study.

Treatment of Ischial Pressure Sores With Double Adipofascial Turnover Flaps

Despite a variety of flap reconstruction options, the ischium remains the most difficult pressure sore site to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using double adipofascial turnover flaps.After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the 2 flaps. The skin is then closed with sutures in 2 layers. A total of 15 patients with ischial sores were treated using this surgical procedure.The follow-up period ranged from 11 to 159 months, with a mean of 93.6 months. Overall, 86.7% of the flaps (13 of 15) healed primarily. One patient had a recurrent grade II ischial pressure sore again 11 months after the operation. The other 14 patients did not have a recurrence.Treatment of ischial pressure sores with adipofascial turnover flaps provides an easy, minimally invasive procedure, with preservation of future flap options, and a soft-tissue supply sufficient for covering the bony prominence and filling dead space. This technique is a reliable and safe reconstructive modality for the management of minor ischial pressure sores.

Treatment of Ischial Pressure Sores Using a Modified Gracilis Myofasciocutaneous Flap

Despite the availability of a variety of flap reconstruction options, ischial pressure sores continue to be the most difficult pressure sores to treat. This article describes a successful surgical procedure for the coverage of ischial ulcers using a modified gracilis myofasciocutaneous flap. From August 2000 to April 2004, 12 patients with ischial sores were enrolled in the study. All patients underwent early aggressive surgical debridement followed by surgical reconstruction with a modified gracilis myofasciocutaneous flap. The follow-up period ranged from 13 to 86 months, with a mean of 44 months. Overall, 91.7% of the flaps (11 of 12) survived primarily. Partial flap necrosis occurred in one patient. Primary wound healing occurred without complications at both the donor and recipient sites in all cases. In one patient, grade II ischial pressure sores recurred 13 months after the operation. There was no recurrence in other 11 patients. A modified gracilis myofasciocutaneous flap provides a good cover for ischial pressure sores. Because it is easy to use and has favorable results, it can be used in the primary treatment for large and deep ischial pressure sores.

S140 –The Fibula Flap for Through and Through Oral Cavity Defects

Objectives 1) Understand the complexity of through and through osteocutaneous defects of the oral cavity and face. 2) Appreciate that extensive bone requirements preclude the use of other single flap reconstructive options such as scapula or iliac crest. 3) Understand the use of the fibula osteocutaneous flap in these circumstances. Methods A retrospective review was performed of patients undergoing fibula osteocutaneous flap reconstruction of through and through oral cavity defects between August 2006 and December 2007 at a tertiary care referral center. Size and type of defects as well as success rates were examined. Results 7 patients underwent reconstruction of composite through and through mandibular defects of the oral cavity. There were 4 patients with complications of prior reconstructions, 2 with primary oral cancer, and 1 gunshot wound to the face. All patients had successful restoration of mandibular continuity. Soft tissue defects were successfully closed using the perforator-based skin paddle with a de-epithelialized segment to create a double skin paddle. 1 skin paddle from an otherwise viable flap was found to be unusable and was replaced with a pectoralis major(PM) flap. A second flap succumbed to delayed venous congestion but had healed uneventfully prior to postop day 8, and was closed post-debridement with a PM flap. Conclusions While the usual foibles of the fibula osteocutaneous flap still apply, its versatility in the setting of through and through defects of the oral cavity is underestimated. In the setting of extensive bony defects, it is appropriate to reserve second flaps for salvage reconstruction.

Management of recurrent ischial pressure sore with gracilis muscle flap and V-Y profunda femoris artery perforator-based flap

Inappropriate seating has been implicated as a major contributing factor in ischial pressure-sore recurrence. During their lifetime, paraplegic patients may require several flaps for closure of the same or some other adjacent pressure sore. Despite a wide variety of flap reconstruction options being described, the ischium remains the most difficult pressure-sore site to treat. From June 1998 to July 2006, there were 253 pressure-sore patients operated upon at Kaohsiung Medical University Hospital. Ten patients (eight men and two women) suffered from recurrent ischial pressure sores, and all of them received more than one flap reconstruction for the ischial defect. For the treatment of the recurrent ischial pressure sore, gracilis muscle flap and readvancement of the V-Y profunda femoris artery perforator-based flap were used to fill the dead space as well as cover the defect. Among these 10 recurrent ischial pressure-sore patients, six of them had suffered bilateral ischial ulcers. Eight of them had previous sacral pressure sores. In all, 32 flap reconstruction procedures were performed on these 10 patients. Unfortunately, one patient had recurrent grade II bilateral ischial pressure sores after 11 months of ulcer-free period. The other nine patients had no recurrence noted, and enjoyed their lives with an average 27.2 months ulcer-free period (range 9-53 months). The fasciocutaneous flap provides a higher mechanical resistance than the detached and transposed muscle. However, for the recurrent ischial ulcer patients, readvancement of the perforator-based fasciocutaneous flap alone cannot provide adequate bulk to obliterate the 'dead space' after debridement of the bursa and the surrounding necrotic tissue. By combining the readvancement of V-Y profunda femoris artery perforator-based fasciocutaneous flap and gracilis muscle flap, these recurrent ischial ulcers will heal without complication. Recurrence of ulceration often develops despite successful flap closure. Patients and their relatives have to be educated regarding pressure relief, personal skin, and self-care. Surgeons must collaborate with the rehabilitation department, nursing staffs, and social workers to improve long-term results.

Microvascular free flap reconstructive options in patients with partial and total maxillectomy defects.

To evaluate and discuss the free flap reconstructive options for patients with partial and total maxillectomy defects. Retrospective review of cases. Two tertiary referral centers. Fifty-one patients had partial or total maxillectomy defects resulting from oncologic surgical resection, and 7 had partial maxillectomy defects resulting from trauma. Inferior or partial maxillectomy defects included 10 anterior arch and hemipalate defects and 12 subtotal or total palate defects. Total maxillectomy defects with and without orbital exenteration included 36 maxilla defects with hemipalate and malar eminence. There were 11 fibula, 14 rectus abdominis, 9 scapular, 10 radial forearm, 5 latissimus dorsi, and 13 combination latissimus dorsi and scapular flaps. Separation of the oral cavity from the sinonasal cavities, diet, type of dental restoration, type of orbital restoration, speech intelligibility, and complications. Only 1 flap failure was reported. There was loss of bone in 2 flaps and loss of the skin paddle in 1 flap. All palatal defects were sealed by the separation of the oral and sinonasal cavities. Thirty-eight patients were able to eat a regular diet while the remaining patients maintained a soft diet. All patients conversed on the telephone without difficulty in intelligibility. Eight patients had an implant-borne dental prosthetic, and 30 patients had a conventional partial prosthetic. Orbit restoration was achieved in 2 patients with an implant-borne prosthetic, and 6 patients retained a standard orbit prosthetic. Free flap reconstruction of the maxilla creates reproducible permanent separation of the oral and sinonasal cavities in a single-stage procedure. In addition, there exists the potential for dental rehabilitation with restoration of masticatory and phonatory function. Free flap reconstruction also provides a good cosmetic result, which improves patients' outlook and contributes to their overall well-being. Reconstructive flaps are designed to fit specific maxillary defects and patient needs to provide optimally functional and cosmetic results.