Flap Reconstruction Procedures Research Articles

Readability of Online Spanish Materials for Breast Reconstruction Using Deep Inferior Epigastric Perforator Flaps.

Background The internet has become an increasingly popular tool for patients to find information pertaining to medical procedures. Although the information is easily accessible, data shows that many online educational materials pertaining to surgical subspecialties are far above the average reading level in the United States. The aim of this study was to evaluate the English and Spanish online materials for the deep inferior epigastric perforator (DIEP) flap reconstruction procedure. Methods The first eight institutional or organizational websites that provided information on the DIEP procedure in English and Spanish were included. Each website was evaluated using the Patient Education and Materials Assessment Tool (PEMAT), Cultural Sensitivity Assessment Tool (CSAT), and either Simplified Measure of Gobbledygook (SMOG) for English websites or Spanish Orthographic Length (SOL) for Spanish websites. Results The English websites had a statistically lower CSAT score compared to the Spanish websites (p=0.006). However, Spanish websites had a statistically higher percentage of complex words compared to English sources (p<0.001). An analysis of reading grade levels through SMOG and SOL scores revealed that Spanish websites had statistically lower scores (p<0.001). There were no statistically significant differences in the understandability or actionability scores between the English and Spanish websites. Conclusions Online educational materials on the DIEP flap reconstruction procedure should be readable, understandable, actionable, and culturally sensitive. Our analysis revealed that improvements can be made in understandability and actionability on these websites.Plastic surgeons should be aware of what constitutes a great online educational resource and what online educational materials their patients will have access to.

Variability of anterolateral thigh flap perforator locations - clinical implications.

&lt;b&gt;&lt;br&gt;Introduction:&lt;/b&gt; The anterolateral thigh flap is an example of a free flap widely applied for reconstruction of tissues within various areas of the body.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Aim:&lt;/b&gt; The aim of the study was to determine the most common locations of the ALT flap perforators in men and women as well as to clarify any potential differences in the location of the vessel in male vs. female subjects.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Material and method:&lt;/b&gt; In years 2021-2022, a study was conducted at the Plastic, Reconstructive, and Aesthetic Surgery Clinic in a group of 90 volunteers (45 women and 45 men, a total of 180 lower extremities) to determine the location of the anterolateral thigh flap perforator against the flap surface using a portable Doppler probe.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Results:&lt;/b&gt; Variable locations were revealed for the anterolateral thigh flap perforator within the study. In women, the perforator is located more distally from the anterior superior iliac spine, most frequently within the inferolateral quadrant, while being located closer to the anterior superior iliac spine, and most frequently within the superolateral quadrant, in men. No perforator was found in 3.3% of the examined limbs. No statistically significant differences were observed between the course of the perforators within the left and right lower limbs in individual patients.&lt;/br&gt; &lt;b&gt;&lt;br&gt;Conclusions:&lt;/b&gt; The location of the ALT flap perforator is subject to sexual dimorphism, which facilitates the investigation area being narrowed down to the well-defined locations of its most frequent occurrence when planning anterolateral thigh flap reconstructive procedures.&lt;/br&gt.

Comparison between the high-definition 3D exoscope and the operating microscope in head and neck reconstruction

The purpose of this study was to compare the three-dimensional (3D) operating exoscope (OE) with the conventional operating microscope (OM) in head and neck reconstruction. A retrospective cohort study was performed including 50 consecutive patients with no history of previous surgery or irradiation (32 male, 18 female; mean age 59.2 ± 13.3 years), who underwent free flap head and neck reconstruction using a 3D OE (n = 25; OE group) or conventional OM (n = 25; OM group). The mean total operative time was 8.0 ± 1.53 h in the OE group and 7.6 ± 1.52 h in the OM group (P = 0.86). The median (interquartile range) anastomosis time was 78.0 (63.0–91.5) minutes in the OE group and 90.0 (75.5–115.0) minutes in the OM group (P = 0.06). The final free flap survival rate was 100%. Only seven patients experienced a free flap reconstruction-related complication, and they were similarly distributed between the two groups (four in the OE group, three in the OM group; P = 0.68). Secondary outcomes (length of hospital stay, tracheostomy dependence, feeding tube dependence) were comparable in the two groups (P > 0.05). The 3D OE is a viable alternative to the conventional OM for performing standard head and neck free flap reconstructive procedures.

Racial Disparities Following Reconstructive Flap Procedures.

Prior reports have highlighted disparities in healthcare access, environmental conditions, and food insecurity between Black and White populations in the United States. However, limited studies have explored racial disparities in postoperative complications, particularly reconstructive flap surgeries. Cases of flap reconstruction based on named vascular pedicles were identified in the American College of Surgeons National Surgical Quality Improvement Program database and grouped into 3 time periods: 2005 to 2009, 2010 to 2014, and 2015 to 2019. Logistic regression was used to compare rates of postoperative complications between White and Black patients within each time period while controlling for comorbidities. Data for flap failure was only available from 2005 to 2010. A total of 56,116 patients were included in the study, and 6293 (11.2%) were Black. Black patients were significantly younger than White patients and had increased rates of hypertension, smoking, and diabetes across all years ( P <0.01). Black patients had significantly higher rates of sepsis compared to White patients in all time periods. From 2005 to 2009, Black patients had a significantly higher incidence of flap failure (aOR=2.58, P <0.01), return to the operating room (aOR=1.53, P =0.01), and having any complication (aOR=1.48, P <0.01). From 2010 to 2019, White patients had a higher incidence of superficial surgical site infection. Surgical complication rates following flap reconstruction based on a named vascular pedicle were higher for Black patients. Limited data on this topic currently exists, indicating that additional research on the drivers of racial disparities is warranted to improve plastic surgery outcomes in Black patients.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.

Incidence of brachial plexus injury with concurrent subclavian or axillary vascular injury and its influence on reconstruction.

Brachial plexus reconstruction with free functional muscle transfers (FFMT) has become a reliable tool in the armamentarium of brachial plexus surgeon (Potter and Ferris, The Journal of hand surgery, European volume, 2017, 42,693-9). The successful execution of performing FFMT relies on favourable motor nerves for coaptation and appropriate vessels for microvascular anastomoses. Due to shared traumatic aetiology, subclavian and axillary vascular injury (SAVI) can coexist with the brachial plexus palsy and may pose a surgical dilemma with such FFMT execution. We performed a retrospective study of 100 consecutive patients who presented to our hospital with brachial plexus injury over a 10-year period. Patient records were reviewed for concomitant SAVI and subsequent treatment that was required for both vascular (SAVI) and brachial plexus injuries (BPI). Concomitant BPI and SAVI occurred in 27% of patients. Open injuries predicted significantly higher rates of SAVI as well as complete plexus palsy. Complete plexus palsy was associated at a higher rate in the SAVI group compared to the non-SAVI group. Coexistence of SAVI and BPI is frequent. Complete plexus palsy and SAVI are more common in open injuries in this study. Complete plexus palsy is the most common indication for FFMT in BPI. Surgical execution of FFMT is more challenging in the setting of previous SAVI and requires careful consideration of the microsurgical plan. We recommend that all patients with previous SAVI or potential need for FFMT in this setting undergo vascular imaging at the time of acute injury and prior to any free flap reconstructive procedures.

First dorsal metacarpal artery flap with dorsal digital nerve with or without dorsal branch of the proper digital nerve produces comparable short-term sensory outcomes

BackgroundThe first dorsal metacarpal artery flap, including dorsal digital nerves with or without dorsal branches of the proper digital nerves, can be used to reconstruct thumb pulp defects with good results. However, it is still unclear whether there are differences in the sensory outcomes between preserving or not preserving the dorsal branches of the proper digital nerves.MethodsThis retrospective cohort study included 137 thumb pulp defect patients who underwent first dorsal metacarpal artery flap reconstruction procedure from October 2015 to June 2019. Patients were divided into two groups according to whether the dorsal branches of the proper digital nerves were preserved. In the non-preservation group (n = 80), the dorsal digital nerves were included in the flap for sensory reconstruction. In the preservation group (n = 57), the dorsal digital nerves and the dorsal branches of the proper digital nerves of the index finger were included in the flap. The stump of the proper digital nerves in the defect was coaptated to the donor nerves of the flap using the end-to-end fashion. At the last follow-up, static two-point discrimination, Semmes–Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction in both groups were compared.ResultsAll patients were followed up for at least 17 months. No significant differences were found regarding pain of thumb pulp, static two-point discrimination, Semmes–Weinstein monofilament score, cold intolerance in the injured finger, and patient satisfaction. The non-preservation group presented slightly shorter operative times (p < 0.05).ConclusionThere are no differences at 2 years in postoperative clinical outcomes when dorsal digital nerves are used to reconstruct flap sensation regardless of preservation of the dorsal branches of the proper digital nerves in the first dorsal metacarpal artery flap.Level of evidence: Level III, retrospective comparative study.

D-shape asymmetric excision with primary closure versus limberg flap surgery for sacrococcygeal pilonidal sinus

Background: Treatment of sacrococcygeal pilonidal disease with off-midline closure after excision has been suggested to improve surgical outcomes. The aim of this study was to compare the short-term outcomes in patients with sacrococcygeal pilonidal disease, who underwent D shaped asymmetrical excision with flap reconstruction and Limberg flap reconstruction.Methods: An analysis of 50 patients was done; 25 were treated with D shaped asymmetrical excision with flap reconstruction and 25 with Limberg flap reconstruction procedure from September 2015 to Feb 2017 and were followed up for six months to 1 year.Results: There were significant difference between group 1 and group 2 with respect to operation time (mean: 40.20±3.19 min and 49.24±3.76 min, p&lt;0.001), blood loss (mean: 45.64±2.93 mland 61.04±3.34 ml, p&lt;0.001). Visual analog scale score was evaluated on postoperative day 15 and 30. On postoperative day 15, VAS score was 2.52±0.77 in group 1 and 3.12±0.97 in group 2. On day 30, VAS score was 1.56±0.77 in group 1 and 2.16±0.94 in group 2, and the differences were statistically significant. The complications were lesser I patients with D shaped asymmetric excision when compared to Limberg flap.Conclusions: The D-shape procedure is an easier and safer treatment option when compared to Limberg flap for the surgical treatment of sacrococcygeal pilonidal sinus disease owing to the associated low complication rate, short duration to return to normal activity, faster healing, and a high patient satisfaction rate and an easier learning curve.

The 5-Factor Modified Frailty Index as a Predictor of 30-day Complications in Pressure Ulcer Repair

The 5-item modified frailty index (mFI-5) is a validated tool to assess postoperative risks in older surgical candidates. We sought to compare the predictive ability of mFI-5 to its individual components and other established risk factors for complications in flap reconstruction of late-stage pressure ulcer repair. The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for pressure ulcer diagnosis and reconstructive flap repair procedures. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status before surgery, diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, and history of hypertension requiring medicine), and other factors commonly used to risk-stratify (age, obesity, ASA classification, and history of smoking) were associated with complications. 35.1% of the total 1254 flap reconstructive procedures for pressure ulcer repair experienced complications. Most cases had at least one of the five mFI-5 factors in both the complication (42.7%) and no complication (45.7%) cohorts. Compared with the factors making up the mFI-5 score and other common variables used to risk-stratify, mFI-5 was significantly associated with complications in the univariate (OR 1.17, CI 1.03 - 1.33; P=0.02) and multivariate analysis (OR 1.16, CI 1.02 - 1.34; P=0.043). The mFI-5 is a useful predictor of postoperative outcomes in patients undergoing reconstructive flap surgery for pressure ulcer injuries compared to other historically considered risk factors for surgical complications.

THE OUTCOME OF LIMBERG FLAP RECONSTRUCTION PROCEDURE FOR PRIMARY NATAL CLEFT PILONIDAL SINUS DISEASE: FOUR YEARS’ EXPERIENCE AT A TEACHING HOSPITAL IN PAKISTAN

Background: Natal cleft pilonidal sinus disease is known for its high recurrence rate after surgery. Different surgical procedures are being used for its treatment and these vary from wide excision followed by healing with secondary intention to excision followed by reconstruction with a flap. Limberg flap reconstruction procedure has been used by many surgeons as their primary choice owing to its low recurrence rate and less postoperative complications.&#x0D; Objective: The objective of this study was to assess the outcome of Limberg flap reconstruction procedure in patients with primary natal cleft pilonidal sinus disease. &#x0D; Methods: This descriptive case series was conducted at Ghurki trust teaching hospital, Lahore, Pakistan, between January 2015 to December 2018. 110 consecutive patients with primary natal cleft pilonidal sinus disease were included in this study. Informed consent was taken from these patients and all patients underwent Limberg flap reconstruction procedure. The evaluated outcomes of this procedure included duration of hospital stay, postoperative pain, primary healing, surgical site Infection, seroma formation, flap necrosis and, recurrence. &#x0D; Results: The patients age ranged between 18 years to 60 years. The mean age was 26.6 ±8.6 years. 73 patients (66.36 %) were males and 23 patients (33.63%) were females. The duration of disease ranged between 1 month to 6 months with a mean of 3.7±1.7 months. The mean operating time was 47.50±5.14 minutes. The mean duration of hospital stay was 1.87±0.80 days. The mean postoperative pain score calculated by the visual analogue scale (VAS) twenty-four hours after the surgery was 3.45. 95 patients (86.36%) had complete primary healing without any complication. 9 patients (8.18%) had a surgical site infection and 6 patients (5.45 %) had seroma formation. No patient suffered from flap necrosis. 2 patients (1.81%) who had complete primary healing presented with recurrence of the disease within six months of the procedure with a period of one year of follow-up designated for every patient.&#x0D; Conclusion: Limberg flap reconstruction procedure is a safe and efficacious treatment option for primary natal cleft pilonidal sinus disease because it provides early complete primary healing in most patients, and shortens the duration of hospital stay thus reducing the cost of treatment. The pain scores fall in the moderate post-operative pain score category and the complication rates and the recurrence rates are very low.

The Role of Cadaver-Based Flap Course in Microsurgical Education and Practice Patterns of Attendees: A Survey Study.

In 2017, our institution initiated a cadaver laboratory-based course dedicated to teaching reconstructive microsurgery indications, preoperative planning, and flap dissection. The goals of this study are to describe the demographics and experience of participants/instructors and to evaluate the learning objectives and effectiveness of the course. Penn Flap Course (PFC) participants were sent an anonymous survey at the inaugural PFC 2017. Then, in 2019, both instructors and participants were sent a more comprehensive survey. Surveys included questions regarding demographics, training background, experiences in practice and/or training, and course evaluation. At PFC 2017, participant response rate was 25% (12/44), and the primary reason for attending the course was to observe and learn from instructor dissections (66.7%). At PFC 2019, the response rate was 77.3% (17/22) for faculty and 73.0% (35/48) for participants. Both in 2017 and 2019, the vast majority of participants reported perceived improvement in understanding of flap dissection principles across all anatomic domains (94.3%-100%). In 2019, when asked about their background experience, the majority of participants reported comfort performing arterial and venous anastomosis without supervision (71%-77%) and being least comfortable with head and neck (H&N) microsurgery (mean comfort level: 5.2/10). Half of the participants (e.g., residents) find the presence of a microsurgery fellow at their institution useful to their educational experience. Instructors with additional fellowship training in microsurgery reported performing a higher volume of free flaps per week (7 vs. 2.3) and per year (94.2 vs. 27.8; p < 0.05 for both) and trend toward performing more H&N reconstruction (p = 0.057). Participants feel least comfortable with H&N microsurgical reconstruction. Surgical faculty with microsurgical fellowship training performs greater volume of microsurgical cases with a trend toward more H&N reconstruction. A cadaver/lecture-based flap course is an effective way to improve participants' perceived confidence and understanding of complex flap and microsurgical reconstructive procedures.

Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction

Inefficiency in the operating room (OR) is detrimental to the patient, the hospital, and the surgeon. Head and neck procedures requiring microvascular reconstruction are complex, lengthy operations in which prolonged operative time is associated with higher complication rates and increased costs. To use Lean methodology to identify potential OR efficiency improvement opportunities for head and neck surgical cases involving free tissue transfer, to implement an intervention, the free flap plan of the day, and to evaluate OR times after implementation. Phase 1: In 2015, with the assistance of the Lean Promotion Office at our institution, a tertiary academic medical center, we identified efficiency-improvement opportunities for 10 patients undergoing free flap reconstruction. Phase 2: A single intervention, the free flap plan of the day, was implemented on February 1, 2016. A retrospective medical record review of head and neck free flap reconstructions beginning 2 years before the implementation of the intervention and ending 2 years after the intervention was performed from February 1, 2014 until February 1, 2018 to analyze OR times, cost, and complications. Mean OR times were compared using the t test. In-room-to-incision time and total OR time. Phase 1: The surgical procedures of 10 patients undergoing free flap reconstruction were observed by Lean specialists, and a time study with a process map was completed. Using this framework, major opportunities for decreasing intraoperative time waste were identified. Multiple communication breakdowns were seen to drive intraoperative time waste; therefore, a free flap plan of the day was created to improve communication between team members. Phase 2: 200 patients were included in the study and were categorized into 2 groups, no plan group (n = 104) and plan group (n = 96), based on whether the plan of the day was used or not. The age and sex distributions of the study participants were not collected. Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group (difference, 7.1 minutes; 95% CI, 3.8-10.4 minutes). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group (difference, 56.7 minutes; 95% CI, 23.6-89.6 minutes). Lean methodology was used to identify efficiency-improvement opportunities for head and neck free flap reconstruction procedures and to design a focused intervention. A free flap plan of the day was used in this study to improve communication between the OR team and was found to improve efficiency and be associated with reduced OR times.

Intraoperative SPY Reduces Post-mastectomy Skin Flap Complications: A Systematic Review and Meta-Analysis.

Indocyanine-green and laser-assisted fluorescence angiography, known as the SPY system, is a recently developed tool that has shown promise in assessing tissue perfusion. Its intraoperative use is becoming more common particularly in breast surgery. This systematic review aims to determine whether SPY technology can reduce postoperative complications related to tissue ischemia, specifically skin necrosis of the mastectomy native breast skin flaps. A systematic review of the literature was performed based on the PRISMA guideline. All studies that involved use of the SPY system to assess perfusion of postmastectomy skin flaps from January 1, 1960, to March 1, 2018 were included. Postoperative complications, including mastectomy skin flap necrosis were extracted from the selected studies. The perfusion-related complication rates and unexpected reoperation rates across multiple studies were then reviewed. Five relevant articles were identified including 902 patients undergoing mastectomy and native breast flap reconstructive procedures. Groups that used indocyanine-green angiography had statistically less incidence of native breast skin flap necrosis and unexpected reoperations due to perfusion-related complications compared with groups that monitored flaps with only clinical observation (odds ratio 0.54 for skin necrosis, and 0.36 for reoperation). In this systematic review, the incidence of native breast skin flap necrosis and unexpected reoperations were found to be statistically lower in cases where SPY was used. However, more prospective studies are required to establish SPY angiography as an accurate and cost-effective tool for assessment of tissue perfusion.

Secondary free tissue transfer in head and neck reconstruction

The incidence of head and neck cancer (H&N) continues to increase together with the need for reconstructive surgery. Head and Neck microsurgeons are likely to encounter challenging secondary free flap surgery on the background of failed primary flaps, radiotherapy treatment or recurrence. The aim of this study was to review our experience of treating such cases in a tertiary referral centre in the United Kingdom. We performed a retrospective analysis of all patients undergoing sequential free flap surgery for head and neck defects in our unit during 2010-2017. Parameters recorded included indication for surgery, type and sequence of reconstruction, recipient vessel use and post-operative complications. We identified 17 patients who underwent 39 free tissue transfers for the reconstruction of head and neck defects (five transfers were performed at other units). The radial forearm and anterolateral thigh flaps were most commonly used. Almost a quarter of patients underwent three or more free flap reconstructive procedures. In over a third, the same vein and artery were used for subsequent anastomoses, and we used five vein grafts over 68 anastomoses. There were no flap failures recorded. Secondary free flaps in the head and neck are required for a variety of aetiologies and can have success rates similar to those for primary free tissue transfers with minimal morbidity and mortality. Free tissue transfer is the best reconstructive option in H&N patients and should still be considered the first choice option in salvage cases until the patient's donor sites have been depleted.

Reverse digital artery cross-finger flap for reconstruction of failed finger replantation.

This study aimed to describe the reverse digital artery cross-finger flap (RDAC flap) in the treatment of failed finger replantation. This study retrospectively reviewed the records of patients who underwent modified RDAC flap reconstructions for failed finger replantation and assessed their outcomes. Of the patients who underwent soft tissue reconstructions for finger injuries between March 2011 and February 2015, we enrolled 11 patients in whom RDAC flap reconstruction procedures were performed to treat the failed replantations. The flaps survived in all cases, with a mean static, two-point discrimination value of 5.3 mm (range, 4-7 mm) in the healed flaps. The sizes of the flaps ranged from 2 × 1 cm2 to 2.3 × 1.5 cm2. The RDAC flap was introduced by Lai et al., and it is a mixed form with the advantages of both cross-finger flap and heterodigital island flap. Our results suggest that it could provide reliable coverage of the sensate soft tissue of fingers with failed replantation.

Eyelash hair transplantation with strip composite eyebrow graft: an enhancing technique in tarsoconjunctival flap eyelid reconstruction procedure

ABSTRACTPurpose: To describe and evaluate the eyelash transplantation with strip composite eyebrow graft to improve eyelid anatomy in tarsoconjunctival flap eyelid reconstruction procedure.Methods: Twenty two patients with eyelid tumors managed by local excision and reconstruction using tarsoconjunctival flap reconstruction procedure were included. Eyelash graft was performed during flap division by harvesting a graft from the eyebrow and creating a recipient pocket in the receptor eyelid. Patients had a 1-year follow up. Eyelash orientation and follicle survival rate were recorded. Demographic variables were analyzed with descriptive statistics. For eyelash follicles survival rate assessment, we evaluated the number of follicles found in the first postoperative day with the follicles found at the end of the study using the Wilcoxon signed rank test. P < 0.05 was considered statistically significant.Results: All eyelash grafts showed a good follicle orientation and no cases of eyelashes misdirection toward the eyeball were reported. No statistical differences (p > 0.05) were found in Wilcoxon signed rank test when comparing the number of follicles present at the first postoperative day and the number of follicles present at the 12th postoperative month, meaning that the vast majority of follicles survived at the end of the study. Graft ischemia, necrosis or infection were not observed.Conclusions: Tarsoconjunctival flap is an outstanding option for eyelid reconstruction and eyelash transplantation with an eyebrow composite graft is an excellent procedure to enhance and recreate a normal eyelid.

Secondary contouring of flaps.

Perforator flaps are becoming increasingly common, and as primary thinning techniques are being developed, the need for secondary contouring of flaps is decreasing. However, many reconstructive flap procedures still incorporate secondary debulking to improve the functional and aesthetic outcomes. Direct excision, liposuction, tissue shaving with an arthroscopic cartilage shaver, and skin grafting are the four major methods used for secondary debulking. Direct excision is primarily applied in flaps where the skin is redundant, even though the volume is not excessive. However, due to the limited range of excision, performing a staged excision is recommended. Liposuction can reduce the amount of subcutaneous tissue of the flap and protect the vascular pedicles. However, the main drawback of this method is its limited ability to remove fibrotic tissues, for which the use of a shaver may be more convenient. The main drawback of using a shaver is that it is difficult to simultaneously remove excess skin. Skin grafting enables the removal of sufficient excess tissue to recover the contour of the normal limb and to improve the color match, facilitating excellent aesthetic results.

Predictors of Complications in Patients Receiving Head and Neck Free Flap Reconstructive Procedures.

Objective To (1) determine the overall complication rate, wound healing, and wound infection complications and (2) identify preoperative, intraoperative, and postoperative predictors of these complications. Study Design Case series with chart review. Setting Tertiary academic cancer hospital. Subjects and Methods All head and neck free flap patients at The Ohio State University (2006-2012) were assessed. Multivariable logistic regression assessed the impact of patient factors, flap and wound factors, and intraoperative factors on the aforementioned quality metric outcomes. Results Of the 515 patients identified, 54% had a complication predicted by longer operating room (OR) time, higher comorbidity index, and oral cavity and pharyngeal tumor sites. Predictors of wound-healing complications (15%) were longer OR time, volume of crystalloid given intraoperatively, and oral cavity and pharyngeal tumor sites. Predictors of wound infection (12%) were younger age, diabetes mellitus, and malnutrition. Conclusions Wound healing and infectious complications account for most complications in patients with head and neck cancer undergoing free flap reconstruction. Clean contaminated wounds are a significant predictor of wound complications. Advanced OR time, advanced age, and comorbidity status, including diabetes mellitus and malnutrition, are other important predictors. Crystalloid administration is also an important predictor of wound-healing complications, and this warrants further study.

Therapeutic options and postoperative wound complications after extremity soft tissue sarcoma resection and postoperative external beam radiotherapy.

Soft tissue sarcomas occur most commonly in the lower and upper extremities. The standard treatment is limb salvage surgery combined with radiotherapy. Postoperative radiotherapy is associated with wound complications. This systematic review aims to summarise the available evidence and review the literature of the last 10 years regarding postoperative wound complications in patients who had limb salvage surgical excision followed by direct closure vs flap coverage together with postoperative radiotherapy and to define the optimal timeframe for adjuvant radiotherapy after soft tissue sarcomas resection and flap reconstruction. A literature search was performed using PubMed. The following keywords were searched: limb salvage, limb-sparing, flaps, radiation therapy, radiation, irradiation, adjuvant radiotherapy, postoperative radiotherapy, radiation effects, wound healing, surgical wound infection, surgical wound dehiscence, wound healing, soft tissue sarcoma and neoplasms. In total, 1045 papers were retrieved. Thirty-seven articles were finally selected after screening of abstracts and applying dates and language filters and inclusion and exclusion criteria. Plastic surgery provides a vast number of reconstructive flap procedures that are directly linked to decreasing wound complications, especially with the expectant postoperative radiotherapy. This adjuvant radiotherapy is better administered in the first 3-6 weeks after reconstruction to allow timely wound healing and avoid local recurrence.

Reconstruction of extensive thoracic wall defect using the external oblique myocutaneous flap: An analysis on 20 Chinese patients with locally advanced soft tissue sarcoma.

Soft tissue sarcomas are rare neoplasms that can occur in the thoracic wall, abdominal wall, extremities, and inguinal region. Wide local resection, with precise histological margin control, results in large skin defects that are challenging to close. Various repair procedures, such as vertical rectus abdominis flaps (VRAM), latissimus dorsi flaps, and tensor fascia lata (TFL) flaps are used to cover broad thoracic wall defects. Although the cosmetic reconstruction results of using these flaps are often excellent, each has significant drawbacks. The external oblique musculocutaneous flap is a simple and safe surgical procedure for covering thoracic wall defects. This study aimed to retrospectively assess the safety and technique of using the external oblique musculocutaneous flap to cover large thoracic wall defects after radical excision of locally advanced sarcomas in 20 patients at a single institution. From January 2006 to December 2016, 20 Chinese patients with large advanced sarcomas on their trunks received wide local resection, with precise histological negative margins. The external oblique musculocutaneous flap, mobilized from the ipsilateral abdominal wall, was harvested to cover broad thoracic wall defects. Among the 20 sarcoma patients (12 females and 8 males, ranging in age from 25 to 73 years), there were five patients with primary tumors and 15 patients with recurrent tumors. The median tumor diameter was approximately 15.3 cm. After excising the lesion, the median time to cover the defect with the external oblique myocutaneous flap was 66 min. The average blood loss when harvesting the flap was approximately 48 mL. For the 20 patients in our cohort, the external oblique flap achieved closure of defects measuring an average area of 256 cm2 . No other flaps or reconstruction techniques were used to cover the large defects in this study. There were no deaths directly related to the flap reconstruction procedures. The external oblique musculocutaneous flap was a safe and reliable method of covering broad thoracic wall defects after radical tumor excision.