Free Flap Research Articles

Prognostic Factors for Free Flap Failure in Head and Neck Reconstruction.

The failure rate of free flaps varies from 0.8% to 10.6% in the literature in head and neck reconstruction. The primary objective was to identify prognostic factors for free flap failure. We prospectively included all consecutive free flaps performed between August 2021 and January 2024, and used a multivariate Cox proportional hazard model. We included 307 free flaps, performed on 274 patients. Age, cardiovascular risk, radiotherapy history, type of flap, type of arterial anastomosis, and ischemia duration were not statistically linked to the risk of flap failure. In multivariate analysis, a venous anastomosis to the anterior jugular vein or to the superior thyroid vein were associated with an increased risk of flap failure, such as per- or postoperative revision of the anastomoses. The choice of venous anastomosis, appear to have a greater influence on the success or failure of a microvascularized transfer than patient characteristics.

Intraoral perfusion assessment using endoscopic hyperspectral imaging (EHSI)- first description of a novel approach.

This study aimed to establish a method to detect and quantify mucosal malperfusion intraorally using state-of-the-art Endoscopic Hyperspectral Imaging (EHSI). For this purpose, mucosal ischemia was selectively induced by intraligamentary anesthesia (ILA) with and without + epinephrine using a standardized protocol. EHSI was performed using a novel endoscopic hyperspectral imaging system. Parameters assessed were Tissue Oxygen Saturation (StO2 [%]), Tissue Hemoglobin Index (THI), Near Infrared Perfusion Index (NPI) and Tissue Water Index (TWI). Fifty-seven healthy subjects received ILA using Articaine 4% with (ILA+) and without (ILA-) epinephrine at a dosage of 1:200,000 administered mesially and distally to the target tooth 42 (Universal No. 26). Mucosal perfusion was assessed using EHSI for 45min post-injection. After ILA+, a distinct ischemia of the mucosa was already clinically apparent after 30s with significant reduction of THI and StO2 by an average of 57% (p < 0.001) and 7% (p < 0.040) compared to baseline values. Persistent hypoperfusion of the oral mucosa was observed throughout the monitoring period, exhibiting a gradual resolution at the 30-minute mark, and nearing baseline perfusion approximately 45min post-injection. There was no papillary necrosis after ILA + injection. EHSI is suitable to adequately detect and visualize actual perfusion of the intraoral mucosa. The study revealed that LA with epinephrine (1:200,000) induce temporary hypoxia in the dental papilla but without causing severe ischemia. EHSI will enable promising applications in the future, i.a. success monitoring of periodontal therapies, intraoral free flap monitoring and the assessment of cancer margins.

Pectoralis fascia patch for the management of intraoperative pleural injury in free flap breast reconstruction

Pectoralis fascia patch for the management of intraoperative pleural injury in free flap breast reconstruction

Exosomes in Skin Flap Survival: Unlocking Their Role in Angiogenesis and Tissue Regeneration

This review explores the critical role of exosomes in promoting angiogenesis, a key factor in skin flap survival. Skin flaps are widely used in reconstructive surgery, and their survival depends heavily on the formation of new blood vessels. Exosomes, small extracellular vesicles secreted by various cells, have emerged as important mediators of intercellular communication and play a crucial role in biological processes such as angiogenesis. Compared to traditional methods of promoting angiogenesis, exosomes show more selective and targeted therapeutic potential as they naturally carry angiogenic factors and can precisely regulate the angiogenesis process. The review will delve into the molecular mechanisms by which exosomes facilitate angiogenesis, discuss their potential therapeutic applications in enhancing skin flap survival, and explore future research directions, particularly the challenges and prospects of exosomes in clinical translation. By highlighting the unique advantages of exosomes in skin flap survival, this review provides a new perspective in this field and opens up new research directions for future therapeutic strategies.

Training of Oral and Maxillofacial Surgery Residents in Virtual Surgical Planning: A Feasibility Study Comparing Open-Source Freeware and Commercially Available Software for Mandibular Reconstruction with Fibula Free Flap

Study Design: This is an experimental feasibility study. Objective: The objective was to analyze the potential of open-source freeware (OSF) to train residents in virtual surgical planning (VSP) and compare this workflow with commercially available software (CAS). Methods: A workflow for mandibular reconstruction with a fibular free flap (FFF) was developed in 3D-Slicer® and Blender® and compared to our clinical workflow in Materialise Mimics Innovation Suite version 25 (Materialise InPrint®, ProPlan CMF® and 3-Matic®). Five CMF residents, inexperienced in VSP, were trained to use both the OSF and CAS workflows and then performed four planning sessions on OSF and CAS. The duration (minutes) and the amount of mouse clicks (MCs) of every step in the workflow were recorded. Afterwards, the experience with VSP was investigated with the System Usability Scale (SUS) and a self-developed questionnaire. Results: The total VSP time with CAS took 91 ± 15 min and needed 2325 ± 86 MCs compared to 111 ± 26 min and 1876 ± 632 MCs for OSF, respectively. The questionnaire had an 80% response rate. The SUS for CAS was 67.5 compared to 50 for OSF. The participants believe it is extremely valuable to learn VSP during their training and to be able to perform VSP as a surgeon. Conclusion: We believe OSF can be a cost-effective alternative compared to CAS for the training of surgical residents to gain insight in complex surgeries and to better understand CAD limitations and possibilities.

Advanced Reconstructive Techniques Following Orbital Exenteration: The Role of LCFA Free Flaps

BackgroundOrbital exenteration is a severe and disabling surgical procedure that involves the removal of all orbital contents. Effective reconstruction is crucial to managing the resulting defects. This study aims to propose a reconstructive algorithm utilizing free flaps derived from the lateral circumflex femoral artery (LCFA) system for orbital exenteration defects, based on our clinical experience. Patients and MethodsBetween January 2013 and January 2022, patients who underwent orbital exenteration and subsequent reconstruction using LCFA-based free flaps were included in this study. ResultsA total of 44 patients underwent orbital exenteration followed by LCFA free flap reconstruction. The choice of reconstructive technique varied according to defect type and dura mater exposure, adhering to the proposed algorithm. The procedures included 20 standard ALT flaps, 13 chimeric ALT flaps, 1 SALT chimeric flap with skin grafting, 7 SALT flaps with skin grafting, and 3 buried SALT flaps. Complications were recorded in 10 cases at the recipient site and in 2 cases at the donor site. ConclusionOrbital exenteration presents significant challenges both surgically and reconstructively, with a high risk of local recurrence and postoperative mortality. The reconstruction algorithm using LCFA-based free flaps, as proposed in this study, may guide surgeons in selecting the most appropriate technique, tailored to the specific defect and considering postoperative treatments such as adjuvant radiotherapy.

Smartphone Thermal Imaging as an Adjunct to Identify Free Flap Perforators and Assisting Flap Design: A Pilot Study.

The main technique for identification of free flap perforator vessels is Doppler sonography, which is not always accurate, user dependent and affected by the patient's body habitus. Adult patients undergoing head and neck resection and free flap reconstruction at two academic institutions were enrolled. Doppler sonography was used to identify perforators, and were marked using a skin marker. The donor site was cooled down for 3 min using a sterile iced saline bag. FLIR-ONE (FLIR Systems Inc., Wilsonville, OR) camera was used to assess for "hot spots" during a 3-5 min period of re-warming as a surrogate for cutaneous blood flow. The distance between the Doppler signal location, and the "hot spot" was recorded. The position of the perforator was then identified intraoperatively and the distances between the surgical position, the Doppler and "hot spot" were recorded. A total of 28 patients were included. For all flap types, FLIR thermal imaging measurements consistently tended to be closer to the surgical site compared to Doppler ultrasound. In anterolateral thigh flaps (n = 20), thoracodorsal artery perforator flaps (n = 5), and fibula osteocutaneous flaps (n = 3), absolute mean differences ranged from 0.62 to 1.33 cm, with trends favoring FLIR. While paired t-tests did not reach statistical significance, both methods correlated with intraoperatively identified skin perforators, and distances generally ranged between 0 and 2 cm. We demonstrate that a smartphone-based thermal imaging system has the potential to serve as an adjunct for identifying flap perforators, with the possibility of reducing operative times and minimizing patient morbidity. Level 3.

Objective assessment of the effect of surgery on limb function after medial femoral condyle free flap harvest: biomechanical parameters

The aim of this study was to evaluate the influence of medial femoral condyle (MFC) free flap harvest on donor site muscle strength and kinematic parameters of gait. The study included 30 patients treated for head and neck squamous cell carcinoma who underwent reconstruction with an MFC free flap. In each case, the donor site was the left thigh. A dynamometer was used to measure muscle strength, in isokinetic bilateral mode and with concentric contraction for the extension/flexion knee pattern, at 18 months postoperative. In addition, kinematic data were obtained and evaluated. On statistical analysis, no significant difference in muscle strength of the quadriceps muscle was found between the left involved and right uninvolved lower extremities (P = 0.124). Also, when comparing hamstring strength, no statistically significant difference was found between the left involved and right uninvolved sides (P = 0.210). Moreover, spatiotemporal gait parameters did not differ significantly between the involved and uninvolved legs (all P > 0.05), and no differences in kinematic or kinetic parameters were observed. This study reports the effects of MFC free flap harvest on the knee muscle strength and locomotion of patients. For most biomechanical parameters investigated, there was no effect (positive or negative).

Microsurgical Reconstruction of Complex Scalp Defects With Vastus Lateralis Free Flap.

Scalp reconstruction is a challenging field for plastic surgeons. In case of large or complex defects, microsurgical-free flaps are usually required. Reconstructive failure can result in high morbidity and in some cases be life-threatening. In this article, we present our experience in the reconstruction of complex scalp defects with the use of a vastus lateralis (VL) free flap. From July 2013 to July 2023, we retrospectively analyzed patients who underwent soft tissue reconstruction of the scalp with a VL-free flap at the authors' institution. The patient's demographic, clinical and surgical characteristics, and postoperative complications were recorded and analyzed. Thirty patients were included. The mean age was 67.3 years. Seventeen patients were male, while 13 were female. In 56.7% of patients, defects resulted from cancer resection. In four patients, the defect was limited to the soft tissues while a multi-layer defect with bone and/or dura involvement was present in 26 patients. Soft tissue reconstruction was always achieved with a VL-free flap (n = 30). In 28 cases, a skin-grafted muscular flap was used. The most used recipient vessels were the superior thyroid vessels (n = 18). Complications occurred in six patients (20%): two cases of total flap loss and two cases of infection of the cranioplasty materials requiring their removal. In two cases patients died within 48 h. All patients were satisfied with the aesthetic and functional results at 6 months. In the case of complex scalp defects, the gold standard is reconstruction through microsurgical flaps that provide well-vascularized tissue and allow to cover large defects, reducing the incidence of infections and ensuring good brain protection even without cranioplasty. In our experience, VL-free flap represents a valid option, providing a low donor site morbidity, the possibility of a two-team approach, and a low complication rate.

National Survey on Implantation Practices for Free Bone Flaps: Key Findings and Insights

National Survey on Implantation Practices for Free Bone Flaps: Key Findings and Insights

Neuropathic Pain at the Donor-site Following Free Fibula Flap Harvest: A Multicenter Study

Neuropathic Pain at the Donor-site Following Free Fibula Flap Harvest: A Multicenter Study

“Use of the Radial Forearm Free Flap in Eyelid and Orbit Defect Reconstruction: A Systematic Review and Meta-Analysis”

“Use of the Radial Forearm Free Flap in Eyelid and Orbit Defect Reconstruction: A Systematic Review and Meta-Analysis”

Enhanced hydrogel loading of quercetin-loaded hollow mesoporous cerium dioxide nanoparticles for skin flap survival

Enhanced hydrogel loading of quercetin-loaded hollow mesoporous cerium dioxide nanoparticles for skin flap survival

Danshensu enhances autophagy and reduces inflammation by downregulating TNF-α to inhibit the NF-κB signaling pathway in ischemic flaps.

The significant distal necrosis of the random-pattern skin flaps greatly restricts their clinical applications in flap transplantation. Previous studies have demonstrated the potential of danshensu (DSS) to alleviate ischemic tissue injury. However, no research to date has confirmed whether DSS can improve the survival of ischemic flaps. This study employed DSS to examine its role and the mechanisms underlying its impact on flap survival. RNA sequencing was conducted to identify potential targets of DSS in ischemic flaps. The viability of random-pattern skin flaps was assessed by analyzing the survival area, tissue edema, laser Doppler blood flow, and histological examination. Western blot and immunofluorescence were used to determine the protein levels related to angiogenesis, pyroptosis, macrophage polarization, autophagy, and the TNF-α-mediated NF-κB signaling pathway. Through RNA sequencing analysis, we observed differences in gene expression related to inflammation and cell death before and after flap injury. Based on the above, DSS, which possesses anti-inflammatory and antioxidant properties, came into our view and was confirmed to enhance the viability of ischemic flaps. The results showed that DSS promoted angiogenesis, induced macrophage polarization toward the M2 type, and reduced pyroptosis. We also demonstrated that enhancing autophagic flux promoted angiogenesis and reduced inflammation. In addition, DSS enhanced autophagy by suppressing the NF-κB signaling pathway through the downregulation of TNF-α. Overexpression of TNF-α activated the NF-κB signaling pathway, reduced autophagic flux, and eliminated the protective effect of DSS. DSS promoted autophagy and reduced inflammation by downregulating TNF-α to suppress the NF-κB signaling pathway, thereby improving the vitality of ischemic flaps and providing strong support for its clinical application.

A New Surgical Technique for the Correction of Severe Cryptotia Using Retroauricular Z-shaped Skin Flap Combined with Auricular Cartilage Stretching Surgery

A New Surgical Technique for the Correction of Severe Cryptotia Using Retroauricular Z-shaped Skin Flap Combined with Auricular Cartilage Stretching Surgery

Paradigm Shift from Conventional to Virtual Surgery Using Three-dimensional Model of Fibula as Preoperative Planning and Guide Technique in Mandibular Reconstruction in Oral Carcinoma: A Prospective Multicentric Comparative Study

Abstract Background: Mandibular reconstruction using a free fibula osseocutaneous flap is a commonly performed and well-established technique accepted worldwide, as the postoperative restoration of form and function of the oral cavity and facial features is superior compared to pedicled flaps. However, this requires precise preoperative planning, followed by execution to correctly restore the loss caused by the complex defect created after the surgical extirpation. With the incorporation of virtual surgical planning (VSP) and computer-assisted design and manufacturing (CAD/CAM) techniques in medical science, their incorporation as preoperative tools holds a lot of promise for a better surgical outcome. Aim: The aim of study was to assess the utility and benefits of VSP using CAD/CAM techniques over preexisting preoperative planning methods for mandibular reconstruction using a free fibular flap. Materials and Methods: A multicentric prospective comparative study was carried out at two tertiary care hospitals of the Armed Forces. Two-year data were collected from October 2020 to October 2022. A total of 39 consecutive cases of oral carcinoma requiring mandibular reconstruction using a free fibular flap were included in the study. Nineteen cases underwent free fibula flap reconstruction using already established preoperative planning in one center, whereas 20 cases underwent VSP as a preoperative tool in another center. The primary objectives assessed were the operative time and intraoperative blood loss in each arm. The secondary objectives assessed were the incidence of flap loss, the presence of oral incompetence postsurgery, the total hospital stay, and the presence of facial symmetry. Results: The total flap harvest time in the VSP group (68 min ± 13 standard deviation [SD]) was lower than that in the control group (88 min ± 14 SD), which was statistically significant (P &lt; 0.001). There was no statistical difference in total operative time (P = 0.06), although in the VSP group, the mean was 10.6 h ± 1.5 SD as opposed to 11.5 h ± 1.6 SD in the control group. Nearly 26.3% of cases in the control group, as compared to 10.5% in the VSP group, had flap-related complications. In the early postoperative period, oral competence was achieved in 94.7% of cases (18/20) in the VSP group as opposed to 68.4% (13/19) in the conventional arm, which was statistically significant (P = 0.04). The mean overall hospital stay was higher in the VSP group (7.1 weeks ± SD) compared to the conventional group (4.4 weeks ± 0.9 SD), which was statistically significant (P &lt; 0.001). Nearly 73.7% (14/20) of cases in the VSP group were satisfied with their facial symmetry, compared to 63.2% (12/19) in the conventional group in the postoperative rehabilitation phase. However, this was not statistically significant (P &lt; 0.48). Conclusions: This index multicentric study carried out in two tertiary care hospitals of the Armed Forces Medical Services, where this emerging technology was adopted as its test arm to prove a better postoperative outcome, may have exhibited equivocal results so far, but it is encouraging results, although not proven statistically significant, hold lots of promises for the future.

Sociodemographic and Clinical Determinants of 12-Month Decision Regret for Head and Neck Cancer Patients.

This study aims to identify factors associated with increased decision regret (DR) 12 months following treatment among head and neck cancer (HNC) patients. A retrospective observational cohort study. Patients with newly diagnosed HNC at an academic tertiary care center from 2018 to 2023. Data from a patient registry assessing quality of life (QOL), DR, social support, and anxiety at initial diagnosis and 12 months post-treatment were analyzed. Only patients who completed the decision regret questionnaire at 12 months were included. Among 225 participants, 60% experienced mild DR and 28% reported moderate to severe regret. Stronger regret was associated with advanced disease presentation, free flap reconstructive surgery, chemoradiation, and disease recurrence. Patients with more severe regret had lower QOL at baseline and 12 months, higher anxiety at 12 months, and lower social support at 12 months. Multivariable analysis identified multimodal treatment including radiation (adjusted odds ratio [aOR] 3.67, 95% confidence interval [CI] [1.25-10.78], P = .018), lower 12-month social support (aOR 1.03, 95% CI [1.00-1.05], P = .039), and decreases in QOL (aOR 1.03, 95% CI [1.00-1.06], P = .024) as independent predictors of increased DR. Treatment involving radiation, lower concurrent social support, and diminished QOL are associated with DR 12 months after treatment. This highlights the potential of interventions aimed at enhancing social support, addressing treatment-related sequelae, and strengthening shared decision-making to prevent regret. Further studies are needed to elucidate factors driving regret in HNC patient subgroups and assess the efficacy of proposed mitigative interventions.

SCIP/SIEA and PAP: The New Workhorse Flaps in Soft Tissue Reconstruction for All Body Regions

Background: In reconstructive microsurgery, the aesthetic outcome has gained increasing importance, and new applications of flaps have been explored, focusing on improved donor site concealment. This paper presents our experience with flaps gaining popularity in reconstructive microsurgery, specifically the SCIP/SIEA and PAP flaps. Methods: Since August 2022, SCIP/SIEA and PAP flaps have been offered for soft tissue reconstruction across all body regions. These flaps were added to the other traditionally offered free flaps, such as RFF, mSAP, ALT, DIEP, and LD. Where the defect could be equally reconstructed using flaps from various donor sites, the choice of donor site was left to the patient. In all other cases, the donor site was selected by the surgeon according to clinical needs. This retrospective study analyzes the first author’s experience with the SCIP/SIEA and PAP flaps, providing an overview of their applications, outcomes, advantages, and disadvantages. Results: A total of 79 patients were reconstructed with 86 free flaps during the study period. The SCIP/SIEA flap was used in 54 patients, and the PAP flap in 18 patients. Flaps other than SCIP/SIEA were used in the remaining seven. Among the 27 patients who were given the option to choose their donor site, 8 selected either the abdomen or inner thigh (5 and 3 cases, respectively). The remaining 19 patients expressed no preference and left the choice to the surgeon. Defects involved the head and neck in 30 patients (38.0%), extremities in 25 (31.7%), the breast in 23 (29.1%), and the trunk in 1 patient (1.3%). Major complications occurred in 12 patients (15.2%) while minor complications managed conservatively occurred in 18 patients (22.8%). Four flaps (4.7% of all flaps) were lost. Conclusions: In our clinical practice, the SCIP/SIEA and PAP flaps have proven reliable as workhorse flaps for small to large soft tissue defects. For very large defects, the latissimus dorsi flap remains the most reliable solution.

Brief Ectopic Banking and Immediate Plate Fixation With Free Omental Flap Addresses Multiple Fundamental Problems for Single-Stage Replant of Transhumeral Amputation.

High-velocity traumatic amputations of the proximal upper extremity are devastating to the patient and represent an extreme surgical challenge to the treatment team. The hand surgeon must simultaneously battle devascularization with timely microvascular anastomosis, gross contamination with meticulous debridement, and amputation with stable fixation. In restoring a functional extremity, many of these goals are in contention with each other. This case describes a novel management strategy for a left transhumeral amputation sustained by a 23-year-old man in a motorcycle accident. The amputated arm was temporized by ectopic banking via the lateral circumflex femoral artery to allow for thorough debridement and immediate open reduction internal plate fixation with coverage provided by a free omental flap and subsequent split-thickness skin graft. This strategy allows for a single-stage treatment of upper arm amputations with immediate microvascular anastomosis, stable internal fixation, and soft tissue coverage by the omentum providing immunogenic and lymphangiogenic properties to combat infection, lymphedema, and swelling. Functional reconstruction was then performed in a staged fashion with a free functional muscle transfer using the contralateral gracilis.

Osteoradionecrosis in osseous free flaps after maxillofacial reconstruction: a single-center experience

Osteoradionecrosis in osseous free flaps after maxillofacial reconstruction: a single-center experience