Flap Survival Research Articles

The Impact of Preoperative Radiotherapy and Chemotherapy on Autologous Breast Reconstruction Outcomes—A Retrospective Single-Center Study

Background: While radiotherapy (RT) and chemotherapy (CT) significantly improve breast cancer outcomes, they may affect breast reconstruction by causing vascular damage and delayed wound healing. This retrospective study evaluates how preoperative RT, CT, or the combination of both impacts intraoperative and postoperative outcomes in immediate or delayed deep inferior epigastric perforator (DIEP) flap breast reconstructions. Methods: We conducted a single-center review of all patients undergoing autologous DIEP flap reconstruction after mastectomy between 2018 and 2024. Patients were divided into four groups: RT only, CT only, a combination of RT and CT, and a control group with no preoperative therapies. Intraoperative and postoperative outcomes were then compared among these groups, with statistical significance defined as p < 0.05. Results: We included 114 patients representing 141 DIEP-flap breast reconstructions. Flap survival rate was 98.5%. In the univariate analysis, total microvascular recipient site complications were significantly higher in the RT + CT group (14.0%, p = 0.021). Donor-site complication rates differed significantly among the four groups (p = 0.025), with the highest rate observed in the RT + CT group (44.7%). In the logistic regression analysis, ischemia time was found as an independent risk factor for total recipient site complications, but not for microvascular complications (OR = 1.019, 95%-CI = 1.004–1.035, p = 0.014). Conclusions: Combined RT + CT significantly increased microsurgical complications. Ischemia time correlated with higher odds of total recipient site complications. Individualized patient management and diminished ischemia time are likely to improve flap survival.

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.

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.

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

An evaluation of the scapular osseous free flap in maxillary reconstruction using the FACE-Q Head and Neck Cancer Module for patient-reported outcome measures.

Health-related quality of life (HR-QoL) outcomes following maxillary reconstruction with the scapular osseous free flap (SOFF) are lacking. Material and Methods: To determine these outcomes, a study of patients who completed maxillary reconstruction with flap survival of the SOFF between 2016 and 2023 was conducted, using Face-Q Head and Neck Cancer Module (FACE-Q). Eligible patients had at least six months of follow-up. Twenty questionnaires were completed (100% response rate). Median age was 59 years, 80% were male, and 90% were being treated for malignant disease. Overall, best scores were reported in the facial appearance and experience of care domain. Furthermore, the worst scores were reported in the facial function domain. Subgroup analysis focused on the following three specific surgical outcomes; dental rehabilitation, oronasal fistula and eye-related problems. A better score, though non-significant, in facial function was recorded in the dental rehabilitation group, (70±23 vs. 40±34, p = 0.089). A tendency towards worse facial function regarding eating and drinking was noted in the fistula group (49±14 vs. 56±23, p = 0.468). Patients suffering from eye-related problems reported marginally worse facial appearance scores, (79±21 vs. 68±19, p = 0.289). In 20 patients who completed maxillary reconstruction with flap survival of the SOFF, the group reported the best scores in the facial appearance and experience of care domain.

Early Initiation of Dangle Protocol in Lower Extremity Free Flap Microsurgery.

Defects of the lower extremity often require free tissue transfer to provide adequate soft tissue reconstruction. Patients typically undergo a postoperative dangle protocol to condition the flap to withstand the increase in venous pressure. The purpose of this study was to evaluate the safety and postoperative length of stay after early initiation of dangle. A retrospective review of patients undergoing lower extremity free tissue transfer reconstruction at the Grady Memorial Hospital from 2012 to 2022 was conducted. Patient demographics, surgical characteristics, and outcomes were analyzed. Patients were categorized into two groups: early (within 5 days after surgery) and late dangle (day 6 or greater). Univariate and multivariate statistical analyses were performed, with significance determined to be p < 0.05. A total of 83 of 99 available patients met inclusion criteria; 22 patients underwent early and 61 late dangle. Free flap survival was 90.9% in the early and 90.2% in the late group. The mean postoperative length of stay in the early and late groups were 12.3 and 18.8 days, respectively (p = 0.0018). There was no difference in the number of patients who had wound healing complications, flap failure, and a need for amputation in each group. Our results demonstrate that initiation of an early dangle protocol does not affect surgical outcome and leads to a reduction in postoperative length of stay. These results can be used to inform evidence-based recommendations for flap management in lower extremity reconstruction.

Red and blue LED light increases the survival rate of random skin flaps in rats after MRSA infection.

Skin flap transplantation is a conventional wound repair method in plastic and reconstructive surgery, but infection and ischemia are common complications. Photobiomodulation (PBM) therapy has shown promise for various medical problems, including wound repair processes, due to its capability to accelerate angiogenesis and relieve inflammation. This study investigated the effect of red and blue light on the survival of random skin flaps in methicillin-resistant Staphylococcus aureus (MRSA)-infected Sprague Dawley (SD) rats. Forty male SD rats were divided into control and light-emitting diode-red and blue light-treated (LED-RBL) groups at a ratio of 1:1 and a McFarland flap procedure was performed, which was subsequently infected with MRSA strains. After 7 days, the appearance and survival of the flaps were evaluated. The microvascular density was determined by hematoxylin and eosin (HE) staining. The expression levels of vascular endothelial growth factor (VEGF), hypoxia inducible factor 1α (HIF-1α), phosphatidylinositol 3-kinase (PI3K), and protein kinase B (normally expressed as AKT) were detected by immunohistochemistry. The flap survival rate and microvascular density in the LED-RBL group were significantly higher than those in the control group (P < 0.05). In addition, the VEGF, HIF1-α, PI3K, and AKT levels were significantly higher in the LED-RBL group compared to the control group (P < 0.05). Red and blue light increased the survival area of the infected flap in rats by promoting angiogenesis, relieving oxidative stress, and reducing bacterial loads, indicating that PBM therapy is a convenient, simple, analgesic, and safe treatment intervention in promoting the survival rate of transplanted flaps after wound repair surgery.

Cervico-acromial flap for large defects in face and neck reconstruction: 34-year experience.

Extensive cervicofacial defects often lead to functional and aesthetic impairments. The pre-expanded cervico-acromial flap technique is reliable and cost-effective for addressing such defects. To introduce our 34 years' experience on pre-expanded cervico-acromial flap technique, emphasizing key surgical techniques. The supraclavicular artery and its main branches were evaluated with Doppler ultrasound preoperatively. Pre-expansion was performed in most cases to optimize flap dimensions, with the tissue expander placed at the subfascial level to preserve adequate blood supply. Once fully expanded, the cervico-acromial flap was raised and rotated to cover the cervicofacial defects. The pedicle was divided three weeks postoperatively. A total of 19 patients (5-57 years) were finally included in this retrospective study. They all accepted the above-mentioned technique by the same senior surgeon from October 1990 to October 2024. The expanded flap sizes ranged from 15 × 7 cm to 35 × 15 cm. The follow-up lasted from 6 months to 9 years. All flaps survived without necrosis or infection. Patients expressed high satisfaction with functional and cosmetic outcomes in both donor and recipient areas. The pre-expanded cervico-acromial flap is safe and effective for repairing the extensive cervicofacial defects. Thorough understanding of this flap's blood supply and careful design based on the vascular anatomy help to improve the flap's survival rate.

Research progress on quercetin in improving the survival rate of random skin flap.

Random skin flap transplantation is critical in wound repair, organ reconstruction and cosmetic surgery, yet skin flap necrosis remains a common and challenging issue. Quercetin, a flavonoid abundant in various plants, exhibits anti-inflammatory, antioxidant, and other beneficial pharmacological effects. Recent studies suggest quercetin can improve random skin flap survival by modulating inflammation, reducing oxidative stress, and promoting angiogenesis. This review evaluates quercetin's potential mechanisms and efficacy, proposing a foundation for its clinical use in preventing ischemic necrosis and enhancing flap viability.

Snail Flap for Scalp Reconstruction: Technique and Outcomes.

Local flaps are widely described for scalp reconstruction, but there is minimal literature surrounding the snail flap. The objective of this study was to describe the surgical technique and outcomes of scalp reconstruction with the snail flap. This case series retrospectively evaluated all consecutive patients undergoing scalp snail flap reconstruction from January 1, 2019 to February 1, 2024. The primary outcome measure was incidence and extent of complications. Demographic and intra-operative variables were assessed. A total of 44 patients were included with a median age (range) of 74 years (27-88) with scalp defects ranging in size from 3 x 3 cm to 8 x 8 cm (median defect size 5 cm). The mean (SD) flap base-to-defect ratio was 1.82 (0.31). Forty (91%) of the cases were performed outpatient or with overnight observation only. Complications included 9 (20%) wound infections, 12 (27%) patients with necrosis (all minimal), and 2 (5%) patients with hematoma, which were all managed outpatient. The flap survival rate was 100%. The snail flap is easy to perform with high reliability and allows for hair preservation. The morbidity and need for hospitalization are minimal, making it an ideal reconstructive option for elderly or frail patients with moderate-sized scalp defects.

Comparison of Functional Outcomes of Superficial Palmar Branch of Radial Artery (SPBRA) and Free Venous Flap (FVF) Techniques for Finger Tissue Defects.

Objectives: This study aimed to compare two surgical techniques-the free flap of the superficial palmar branch of the radial artery (SPBRA) and the free venous flap (FVF)-to evaluate their efficacy and aesthetic outcomes in repairing finger tissue defects. The goal was to determine which procedure offers faster healing curves and better overall patient outcomes, ultimately improving the quality of life for individuals undergoing these surgeries. Materials and Methods: A retrospective study was conducted using the clinical database of Sanliurfa Mehmet Akif Inan Education and Research Hospital, University of Health Sciences, from 1 January 2019 to 1 January 2022. A total of 44 patients with finger tissue defects, excluding thumb defects, were randomly divided into two groups: 21 patients underwent the SPBRA free flap procedure and 23 patients underwent the FVF procedure. Primary endpoints included flap survival rates, sensory recovery rates, aesthetic satisfaction scores, and complication rates. Data were collected during preoperative assessments and postoperative follow-ups at 1, 3, and 6 months. Results: The SPBRA group demonstrated a higher success rate (95% vs. 92%) and greater patient satisfaction in terms of restoring normal appearance and function. The SPBRA technique also showed superior sensory recovery with a lower two-point discrimination score (mean SPBRA = 6 mm vs. mean FVF = 8 mm). Functional outcomes, assessed by the Michigan Hand Outcomes Questionnaire, indicated higher scores for the SPBRA group (85/100) compared to the FVF group (80/100). Additionally, the SPBRA procedure was associated with fewer complications, highlighting its effectiveness and safety. Conclusions: The findings suggest that the SPBRA free flap technique offers better outcomes than the FVF procedure for repairing finger tissue defects. It provides superior functional restoration, enhanced cosmetic satisfaction, and a lower rate of complications. These results support the preference for the SPBRA technique in addressing complex finger tissue defects and improving patient outcomes.

Single-Double-Single Barrel (1-2-1) Fibula Free Flap Design for Functional and Esthetic Brown Class III Mandibular Reconstruction.

This novel hybrid single-double-single barrel (1-2-1) design for fibula free flap reconstruction addresses the unique challenges presented by Brown Class III mandibular defects, which involve long-span defects at both bodies of the mandible and the chin. The importance of this design lies in its ability to overcome the limitations of traditional approaches in terms of mandible height and pedicle length, while optimizing both functional and esthetic outcomes.The technique utilizes a combination of single-double-single barrel fibula segments to achieve ideal esthetics and support for dental prosthesis across different areas of the mandible. At the chin, a double barrel design provides proper chin and lower lip projection and supports dental prosthesis at the alveolus, while single barrel segments are used for the mandibular bodies to allow adequate restorative space for dental rehabilitation and save the pedicle length.Favorable outcomes were demonstrated in terms of flap survival, dental implant osseointegration, bony healing, facial aesthetics, and occlusal rehabilitation. By addressing both functional and aesthetic requirements, this technique represents an important advancement in mandibular reconstruction for complex Brown Class III defects. The approach showcases the potential of computer-assisted surgery and innovative flap designs to improve patient outcomes in challenging reconstructive scenarios.

Ischemic preconditioning in arterialized venous flap: Temperature effects and monitoring.

Arterialized venous flap, like any other flap, will undergo an ischemic reperfusion injury during its transfer process. To overcome this, ischemic preconditioning can be done to provide protection and enhanced flap survival. One of the reliable parameters of flap survival is its temperature. However, there was no recorded data regarding AVF's temperature or its monitoring. This research aimed to demonstrate the temperature effect of ischemic preconditioning on arterialized venous flap. Male Wistar Rats were randomly divided into 4 groups, consisting of 6 negative control groups, 8 positive control group (PS) rats that underwent an anastomosis of the superficial epigastric artery to the superficial epigastric vein, 8 experimental rat group 1 (EX1) that underwent 3 cycles of 5 minutes pre-anastomosis clamping with 3 cycles of 5 minutes each, and 8 experimental rats' group 2 (EX2) with 3 cycles of 10 minutes. Flap's temperature was observed preoperatively and postoperatively from day 1 to day 7, day 14, and day 21 with an android-based thermal camera and recorded in Celsius degrees. All the flaps (N= 26) were vital. The temperature drop was seen in all anastomosed flaps compared to the negative control (30.37 vs. 25.08 vs. 23.77 vs. 25.27, p<0.05). A significant increase in temperature occurred on days 4 to 6 in Ex1 (33.62±1.820, 33.62±1.820, 32.40±1.627; p<0.05). As in the temperature trend, Ex2 is shown to have a stable temperature from day 2 until 21. This study has recorded an increase in temperature in the early days of the creation of the arterialized venous flap at various timings of ischemic preconditioning. The flap's monitoring was easily observed with a thermal camera that can be implemented in humans.

Revisit to Old Friends: Abdominal and Groin Flaps For Upper Extremity Soft Tissue Reconstruction

Introduction: Soft tissue defects of the upper extremity pose significant challenges in hand surgery. While microsurgical advancements have expanded reconstructive options, pedicled groin and random-pattern abdominal flaps remain valuable alternatives, particularly in resource-limited settings or when microsurgical techniques are contraindicated due to patient-specific factors such as comorbidities or previous flap failures. This study revisits these 'old friends' of reconstructive surgery, emphasizing their indications, techniques, and outcomes. Methods: This retrospective study evaluated the clinical outcomes of 16 patients who underwent two-stage abdominal or groin flap surgeries between 2021 and 2023 for traumatic upper extremity injuries. Demographic data, injury characteristics, and surgical details were analyzed. Postoperative outcomes, including functional recovery, complications, and patient satisfaction, were assessed over a mean follow-up period of 13 months. Results: Of the 16 cases, 14 achieved complete flap survival, with one partial and one near-total failure. Complications were observed in 43% of cases, primarily due to infections. Patients who underwent abdominal flaps experienced higher rates of shoulder stiffness, whereas total flap loss was more frequent with groin flaps. Functional recovery varied, with mild to moderate cold intolerance severity scores and limited sensory outcomes. Aesthetic satisfaction remained suboptimal, with only a few patients reporting satisfactory results. Conclusion: Random-pattern abdominal and pedicled groin flaps are effective for upper extremity soft tissue reconstruction, particularly when microsurgical options are unavailable. However, challenges such as complications, sensory recovery, and aesthetic satisfaction necessitate further refinement in surgical techniques and multidisciplinary care.

Impact of Norepinephrine Use on Free Flap Survival in Breast Reconstructive Microsurgery.

The optimal method for maintaining intraoperative blood pressure during microsurgical procedures remains controversial. While intravenous fluid administration is essential, overfilling can lead to complications. Vasopressor agents are used cautiously due to their vasoconstrictive effects, which could potentially lead to flap failure. Numerous studies have explored the possible link between amine administration and free flap failure, yielding inconsistent results. This study aims to determine whether intraoperative norepinephrine administration increases the flap failure rate in microsurgical breast reconstructions. All women (n = 335) who underwent breast reconstruction using DIEP or PAP flaps (n = 400) in 2018 and 2022 in the Plastic Surgery Department of Georges-Pompidou European Hospital (Paris, France) were included in the study. These patients were classified into two groups based on the intraoperative administration of norepinephrine: the N+ group (50 patients) and the N- group (285 patients). Norepinephrine was administered when systolic blood pressure fell below 90 mmHg or mean arterial pressure (MAP) dropped below 65 mmHg, following fluid resuscitation in 2018, or without prior fluid loading in 2022. The primary endpoint was total flap loss. Secondary endpoints included arterial and venous thrombosis and the need for revision surgeries. Norepinephrine administration significantly increased the risk of total flap loss in DIEP and PAP flap surgeries (p < 0.001). It also heightened the risk of arterial thrombosis (p = 0.002) and venous thrombosis (p = 0.04), and led to a greater number of revision surgeries (p < 0.001). Subgroup analysis indicated that PAP flaps are more sensitive to norepinephrine compared to DIEP flaps. Our study suggests that the intraoperative administration of any dose of norepinephrine is associated with an increased risk of flap failure in breast reconstructive microsurgery using DIEP and PAP flaps.

Application of Reverse Sural Flaps in Pediatric Patients: A Systematic Review.

The reverse sural flap (RSF) is a random-type, pedicled flap based on sural artery perforators indicated for traumatic lower-extremity wounds. The RSF has demonstrated comparable results to free flap placement in the adult population for reconstruction of distal third defects, but few reports describe its application and outcomes in the pediatric population. We investigated RSF application in pediatric patients (<18 years of age) through systematic review and meta-analysis. PubMed, Scopus, CINAHL, and ProQuest databases were utilized. Inclusion criteria included case series and chart studies reporting on pediatric RSF patients. Primary outcomes included overall flap survival rate, venous congestion, and necrosis. Screening of 244 initial articles yielded 16 studies for further review and statistical analysis. There were 207 patients treated with a mean age of 9.51 ± 2.27 years and follow-up of 20.07 months. The majority of studies focus on the distal third as the primary site for RSF reconstruction, with fasciocutaneous being the most commonly used flap type. Trauma was the predominant etiology of soft-tissue defect (91.0%). Analysis of outcomes shows a 91.0% survival rate for reverse sural flaps. Approximately 13.0% of patients experienced venous congestion. Flap necrosis rate was 15.0%, although most cases were subtotal (93.1%) and successfully managed through additional skin grafting. With comparable efficacy to free flaps for distal third defects in the pediatric population as well as similar success rates to adult RSF patients, the RSF should be considered a first-line therapy for lower-extremity soft-tissue reconstruction in pediatric patients.

“C-shaped” anterolateral thigh flap for stomal repair due to recurrence in patients with total laryngectomy

Background: Stomal recurrence after total laryngectomy is one of the most challenging problems in head and neck surgery due to the complexity of its management. The tracheal opening remains deep and caudal after resection, creating a neo stoma that presenting a significant challenge for reconstructive surgery. With this study, we aimed to describe the design of the C-shaped ALT flap to show that it is the ideal design in such a difficult reconstruction. Methods: Five patients who underwent a free ALT flap for defects in the anterior neck wall and airway after resection due to tumor recurrence adjacent to a permanent stoma between 2018-2020 were included in the study. Tumor resection was performed by the Otolaryngology team in all cases. Age, gender, cause of defect, ALT flap size, donor site closure method, number of perforators, ischemia time, flap survival, early complications, and postoperative tracheostomy use and postoperative quality of life assessment were reviewed. Results: 5 male patients were included in the study and the mean age was 63.8. The mean duration between admission and recurrence after laryngectomy was 11.2 months. Flap survival was noted in all patients. The patients did not encounter complications such as tracheostomy-related dehiscence, discharge, fistula, cannulation difficulties due to flap collapse, and mediastinitis during their lifetime. In the follow-ups, one still alive, the mean survival time of the other three patients was four months. We found an average high score in our patients regarding functional scales in QLQ-H&amp;N35 module. Conclusions: The C-shaped ALT flap design provides ease of insertion into a tension-free tracheal-skin suture line and helps to reduce the rates of stoma-related complications and increase the quality of life of the patients.

Reduce Flap Necrosis After Autologous Breast Reconstruction: A Systematic Review.

Autologous breast reconstruction provides substantial benefits in terms of aesthetics and longevity. However, the risk of flap necrosis poses potential challenges to patients' appearance and psychological well-being, while also escalating health care costs. Consequently, examining the risk factors, assessment techniques, and therapeutic approaches for flap necrosis is critically important. The authors conducted a comprehensive search for relevant studies from January 2010 to August 2024 using PubMed, Web of Science, and the Cochrane Library. The search terms included "autologous breast reconstruction", "flap necrosis", "risk factor", "assessment", and "treatment". The authors initially screened titles and abstracts, followed by a detailed review by 3 investigators to determine the studies that met the inclusion criteria. A total of 68 studies were ultimately selected for analysis. Identified risk factors for flap necrosis include smoking, advanced age, obesity, diabetes, large breast volume, previous radiotherapy, and abdominal surgery. Various assessment methods (e.g., preoperative imaging, intraoperative blood flow monitoring, and postoperative evaluations) can enhance flap survival. The review also covered surgical treatment strategies and non-surgical interventions, including local wound care, hyperbaric oxygen therapy, and pharmacological treatments. This review highlights the critical role of thorough planning and management in minimizing the risk of flap necrosis after autologous breast reconstruction. Effective preoperative assessments, perioperative monitoring, and specific postoperative interventions can significantly lower the incidence of flap necrosis.

The Impact of Perioperative Blood Transfusion on Flap Survival: A Single-Center Review of Limb Salvage in the Trauma Setting.

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. A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007 and 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. 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). 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.

Fibula flap reconstruction for maxillary stage 3 medication-related osteonecrosis of the jaw from recipient and donor site perspectives: a preliminary single-center study

BackgroundWhile the surgical treatment of mandibular stage 3 medication-related osteonecrosis of the jaw (MRONJ) is well-documented, research on maxillary stage 3 MRONJ is limited. Antiresorptive medications can induce MRONJ and atypical femoral fracture (AFF), but their impact on the feasibility of using fibula flaps for reconstruction remains controversial. This study aimed to assess the surgical outcomes and functional recovery of fibula flap reconstruction for maxillary stage 3 MRONJ, considering both recipient and donor site outcomes.MethodsThis retrospective study included patients with maxillary stage 3 MRONJ who underwent fibula flap reconstruction. Demographic and clinical features, postoperative complications, long-term outcomes and functional recovery of both recipient and donor sites were analyzed. Long-term outcomes included the survival of fibula flaps, the incidence of fibula graft or tibia fractures, recurrence of MRONJ, and patient survival status. Function assessments focused on speech, swallowing, and ankle joint.ResultsSeven patients (two with multiple myeloma, five with bone metastases) were included. Two patients experienced delayed healing at the donor site, both of whom recovered within two months postoperatively. All fibula flaps survived with primary healing. There were no recurrences of MRONJ or fractures of fibula graft or tibia. The mean speech function score was 28.00 ± 12.03, the mean swallowing function score was 2.86 ± 2.79, the mean pain score of donor site was 2.71 ± 2.29, and the mean ankle function score was 94.43 ± 4.35.ConclusionFibula flap reconstruction is feasible for maxillary stage 3 MRONJ, yielding satisfactory surgical outcomes and functional recovery.