Free Flap Group Research Articles

"Revolutionizing retrosigmoid surgical precision: AI in free bone flap reconstruction".

Free bone flap reconstruction is essential to the retrosigmoid method of microvascular decompression (MVD) and can completely transform surgical methods worldwide. According to studies like Liao et al. (2023), 92.3% of patients report feeling better after receiving treatment. The study by Shize Li et al. emphasizes the affordability and accessibility of free bone flap reconstruction, demonstrating shorter recovery times, lower expenses, and similar rates of complications to those of conventional fixation techniques. With benefits like fewer headaches and a quicker recovery in the free bone flap group, their retrospective analysis of 189 patients showed no significant differences in hospital stay or complication rates between the fixed and unfixed bone flap groups.Despite these results, larger sample sizes and longer-term studies are needed to confirm these findings and address issues such as leakage of cerebrospinal fluid. Furthermore, adding Artificial Intelligence (AI) to this method may improve accuracy and results. AI has the potential to enhance MVD procedures and patient outcomes through its capacity to create 3D models, direct bone flap placement, and track postoperative progress. Standardizing AI's application in clinical practice still presents difficulties, though. In the end, even though Shize Li et al.'s research significantly advances the body of knowledge already in existence, more creativity and investigation are required to maximize free bone flap reconstruction in MVD.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study.

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction. We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis. The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases. Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Propeller vs. free fasciocutaneous flap in reconstruction of complex lower limb defects–A prospective study

BackgroundOf all body regions, lower extremity wounds have been and remain the greatest challenge. Free flaps have been accepted as a reasonable option to solve this dilemma, but they require the complexity of microsurgery. This study aimed to compare the postoperative and clinical outcomes of propeller flap and fasciocutaneous free flap in the reconstruction of complex lower limb defects. Materials and methodsThis randomized controlled trial was conducted from July 2021 to June 2023. Selected patients were randomized into two groups: the propeller flap group and fasciocutaneous free flap group. Demographic data, preoperative parameters, and postoperative parameter, including esthetic analysis, scar assessment, neurosensory analysis, psychosocial analysis, and lower extremity function, were estimated and statistically significant compared between the two study groups. ResultsRoad traffic accident (73.3%) was the most common etiology for lower limb defects in both groups. The foot and lower third of the leg were the most common site of defect, constituting 79.99%. The duration of surgery was significantly shorter in propeller flap as compared to fasciocutaneous free flaps. Flap size was smaller, with better neurosensory improvements in propeller flap group. Esthetic analysis, scar assessment, psychosocial analysis, and lower extremity functional analysis yielded similar results in both study groups. ConclusionPropeller flap has better outcomes compared to free flap in terms of smaller size of flap, shorter duration of surgery, and reduced length of hospital stay. Comparable results were obtained with respect to esthetic score, scar assessment score, psychosocial analysis, and neurosensory recovery and lower extremity functional score.

A retrospective propensity score-matched analysis of oncological and functional outcomes of submental island flap versus radial forearm free flap for oral cavity cancer reconstruction

BackgroundThis retrospective study aims to compare the oncological and functional outcomes of the submental island flap versus the radial forearm free flap used for oral cavity cancer reconstruction after minimizing differences in baseline characteristics.MethodsPropensity scores for each oral cavity cancer patient who underwent surgical resection and immediate reconstruction with a submental island flap or a radial forearm free flap with a flap size ≤ 60 cm2 between October 2008 and December 2021 were generated based on the likelihood of being selected given their baseline characteristics. Patients were matched using a 1:1 nearest-neighbor approach.ResultsThe final matched-pair analysis included 51 patients in each group. The 5-year overall survival, disease-specific survival, and locoregional control rates were 70.1% and 64.8% (p = 0.612), 77.3% and 83.7% (p = 0.857), and 76.1% and 73.3% (p = 0.664), respectively, for the submental island flap group and the radial forearm free flap group. Speech and swallowing functions were comparable between groups. However, there were significantly lower rates of complication associated with both donor and recipient sites in the submental island flap group, and also the duration of hospital stays and hospital costs were significantly lower in these patients. A subgroup analysis of patients in which the reconstruction was carried out using the submental island flap procedure revealed that in selected cases, the presence of clinically and pathologically positive level I lymph nodes did not affect survival or locoregional control rates.ConclusionsAlthough this study was not randomized, the matched-pair analysis of surgically treated oral cavity cancer patients showed that submental island flap reconstruction is as effective as radial forearm free flap reconstruction with regard to oncological and functional outcomes with lower complication rates, hospital stay, and hospital costs. This flap can be safely and effectively performed in selected cases with a clinical level I lymph node smaller than 1.5 cm and no signs of extranodal extension.

Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population.

In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973). This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.

Comparing donor site morbidity in osteocutaneous radial forearm versus fibula free flap for mandibular reconstruction

PurposeThe osteocutaneous radial forearm free flap has gained popularity as a less morbid option for oromandibular reconstruction compared to the fibular free flap. However, there is a paucity of data regarding direct outcome comparison between these techniques. MethodsRetrospective chart review of 94 patients who underwent maxillomandibular reconstruction intervened from July 2012–October 2020 at the University of Arkansas for Medical Sciences. All other bony free flaps were excluded. Endpoints retrieved encompassed demographics, surgical outcomes, perioperative data, and donor site morbidity. Continuous data points were analyzed using independent sample t-Tests. Qualitative data was analyzed using Chi-Square tests to determine significance. Ordinal variables were tested using the Mann-Whitney U test. ResultsThe cohort was equally male and female, with a mean age of 62.6 years. There were 21 and 73 patients in the osteocutaneous radial forearm free flap and fibular free flap cohorts, respectively. Excluding age, the groups were otherwise comparable, including tobacco use, and ASA classification. Bony defect (OC-RFFF = 7.9 cm, FFF = 9.4 cm, p = 0.021) and skin paddle (OC-RFFF = 54.6 cm2, FFF = 72.21 cm2, p = 0.045) size were larger in the fibular free flap group. However, no significant difference was found between cohorts with respect to skin graft. There was no statistically significant difference between cohorts regarding the rate of donor site infection, tourniquet time, ischemia time, total operative time, blood transfusion, or length of hospital stay. ConclusionsNo significant difference in perioperative donor site morbidity was found between patients undergoing fibular forearm free flap and osteocutaneous radial forearm flap for maxillomandibular reconstruction. Osteocutaneous radial forearm flap performance was associated with significantly older age, which may represent a selection bias.

Comparison of outcomes following pedicled and free flap transfers for the defect after shoulder sarcoma resection

Reconstruction after wide resection of a sarcoma arising in the shoulder girdle is challenging, and little evidence is available to compare short-term outcomes between pedicled-flap and free-flap reconstruction. Thirty-eight patients undergoing immediate reconstruction surgery with only a pedicled-flap (n=18) and with a free-flap (n=20) after sarcoma resection on the shoulder girdle between July 2005 and March 2022 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. Transferred flaps survived completely in 20 cases in the free-flap group. In the all-patient analysis of binary outcomes, the occurrences of total complications, takebacks, total flap complications, and flap dehiscence were higher in the pedicled-flap group than in the free-flap group. The propensity score-matched analysis showed the occurrence of total complications was significantly higher in the pedicled-flap group than the free-flap group (53.8% vs. 7.7%, p=0.03). In the propensity score-matched analysis of continuous outcomes, the pedicled-flap group demonstrated a shorter operation time than the free-flap group (279 vs. 381min, p=0.05). This clinical study demonstrated the feasibility and reliability of a free-flap transfer for the defect after wide resection of a sarcoma arising in the shoulder girdle.

Regulating Microvascular Free Flaps Reconstruction in "Schobinger Stage 4" Arteriovenous Malformations of Face.

Objectives Arteriovenous malformations (AVMs) are high-flow, aggressive lesions that cause systemic effects and may pose a risk to life. These lesions are difficult to treat as they have a tendency to recur aggressively after excision or embolization. So, it requires a regulating free flap with robust vascular flow averting the postexcisional ischemia-induced collateralization, parasitization, and recruitment of neovessels from the surrounding mesenchyme-a phenomenon precipitating and perpetuating the recurrence of AVM. Materials and Methods Sixteen patients (12 males and 4 females) with AVMs Schobinger type 4 involving face were treated from March 2015 to March 2021 with various free flaps: three free rectus abdominis flaps, one free radial forearm flap, and twelve free anterolateral thigh flaps were used for reconstruction following the wide local excision of Schobinger type 4 facial AVM. The records of these patients were analyzed retrospectively. The average follow-up period was 18.5 months. The functional and aesthetic outcomes were analyzed with institutional assessment scores. Results The average size of the flap harvested was 113.43 cm 2 . Fourteen patients (87.5%) had good-to-excellent score ( p = 0.035) with institutional aesthetic and functional assessment system. The remaining two patients (12.5%) had only fair results. There was no recurrence (0%) in the free flap group versus 64% recurrence in the pedicled flap and skin grafting groups ( p = 0.035). Conclusion Free flaps with their robust and homogenized blood supply provide a good avenue for void filling and an excellent regulating effect in inhibiting any locoregional recurrences of AVMs.

Flaps for lower limb diabetic wound reconstruction: A systematic review and meta-analysis

The treatment of chronic diabetic wounds includes wound dressing, debridement, flap surgery, and amputation. For suitable patients with nonhealing wounds, locoregional flaps or free flaps may be used. This paper aims to review the outcomes of flap surgery and identify the risk factors for flap loss. MEDLINE, Embase, and Cochrane Library were searched. Articles reporting flap loss outcomes for flap surgery in lower limb chronic diabetic wounds were included. Case reports and case series with fewer than five patients were excluded. A subset of articles was used for revascularization subgroup analysis and another subset for meta-analysis of risk factors for flap loss. In the free flap group, the total flap failure rate was 7.14% and partial flap failure rate was 7.54%. The rate of major complications requiring operative takeback was 19.0%. Early mortality was 2.76%. In the locoregional flap group, the total flap failure rate was 3.24% and partial flap failure rate was 5.36%. The rate of major complications requiring operative takeback was 13.3%. There was no early mortality. The rate of free flap loss was 18.2% with revascularization, significantly higher than 6.66% without revascularization. Our findings concur with previously published studies on flap loss and complications in diabetic lower limb wounds. There is an increased risk of flap loss in patients who require free flap and revascularization compared to patients who only require free flap. This could be because of the fragile and fibrotic vessels found in diabetics with comorbid atherosclerosis.

A comparative analysis of fasciocutaneous versus muscle free flaps in peripheral vascular disease patients.

Chronic lower extremity (LE) wounds are common in patients with peripheral vascular disease (PVD). Free tissue transfer (FTT) provides healthy soft tissue for wound coverage and additional blood supply to promote wound healing. Given previous studies demonstrate increased complications in LE fasciocutaneous flaps, it was hypothesized that low vascular resistance in muscle flaps may be more advantageous for wound healing in PVD patients. Therefore, this study compared outcomes in PVD patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. Retrospectively reviewed PVD patients undergoing FTT between 2011 and 2021. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included complications, flap success, post-reconstruction vascular interventions, limb salvage, and ambulatory status. One hundred thirteen patients with PVD were identified, of which 60.2% received fasciocutaneous (n= 68) and 39.8% received muscle flaps (n= 45). Forty-two patients (37.2%) underwent pre-flap endovascular interventions. Flap success rate was 98.2% (n= 111). Overall complication rate was 41.2% following fasciocutaneous flaps compared to 24.4% in muscle flaps (p= 0.067). Fasciocutaneous flaps had higher odds of ulceration requiring repeat angiogram within 1 year of reconstruction compared to muscle flaps (OR 3.4, 95% CI: 1.07-10.95, p= 0.047), and higher odds of requiring repeat angiogram overall (OR 3.4, 95% CI: 1.07-10.95, p= 0.047). No difference in requiring procedures in the operated limb within 1 year was observed (p= 0.155). At mean follow-up, there was no difference in limb salvage, ambulatory, and mortality rate between groups. This study demonstrates that fasciocutaneous flaps had higher postoperative complication rates and more commonly required repeat arteriograms following LE FTT reconstruction due to recurrent ulcerations, suggesting greater utility of muscle flaps for FTT reconstruction in PVD patients.

Direct-to-Implant versus Immediate Free Flap Reconstruction after Nipple-Sparing Mastectomy: A Propensity Score-Matched Analysis.

Both direct-to-implant (DTI) and immediate free flap (FF) breast reconstruction following nipple-sparing mastectomy (NSM) have been described in the literature. However, there is a paucity of comparative studies between these two techniques. Furthermore, existing studies do not control for factors influencing ischemic complications. A retrospective review of all NSMs performed at a single institution between January of 2014 and January of 2020 was performed. Immediate FF reconstructions were propensity score matched using probit regression to identify a comparable DTI cohort based on mastectomy weight, smoking, age, and history of radiotherapy. Primary outcomes of interest were 30-day ischemic complications. One hundred eight NSMs performed in 79 patients were included. Average age was 45.7 ± 10.5 years and mean body mass index was 27.1 ± 4.8 kg/m 2 . There were 54 breasts in both the DTI group and the immediate FF group. Median mastectomy weight in the DTI group was 508 g (interquartile range, 264 g) as compared with 473 g (interquartile range, 303 g) in the FF group ( P = 0.792). There was no significant difference in the rate of partial nipple-areola complex necrosis in the DTI and FF groups (5.6% versus 3.7%, respectively; P = 0.500) or mastectomy flap necrosis (5.6% versus 11.1%; P = 0.297). Both the DTI and FF groups had a total nipple-areola complex necrosis rate of 1.9% ( P = 0.752). Both DTI and immediate FF reconstruction can be safely offered to patients undergoing NSM while providing the benefit of a single reconstructive procedure. Therapeutic, III.

Surgical outcomes of split-thickness skin grafts versus free flaps of the lateral thoracic region for incurable chronic venous ulcers

Purpose: This study conducted a comparative analysis of the effectiveness of split-thickness skin grafts (STSGs) and free flaps of the lateral thoracic region performed for coverage after extensive debridement in patients with difficult-to-treat chronic venous ulcers (CVUs) with severe symptoms.Methods: This retrospective, single-center study included 20 patients (28 cases) with CVUs. Patients who received an STSG or free-flap procedure were included in the study. Data comparing these two groups were analyzed.Results: The STSG and free-flap groups showed no significant differences in patient demographics. There was no significant difference in wound size before and after debridement between the two groups (before, 52.25±58.03 cm2 vs. 37.69±32.83 cm2, p=0.407; after, 210.92±202.80 cm2 vs. 142.63±84.01 cm2, p=0.291). Wound disruption was not significantly different between the groups (p=0.231). However, a significant difference was found in recurrence between the STSG group (n=7, 58.3%) and the free-flap group (n=1, 6.3%) (p=0.004).Conclusion: Free-flap surgery may be a good option for difficult-to-treat, recurrent CVU. Because venous ulcers require extensive debridement, a lateral thoracic region free flap, which enables the harvest of large and various forms of flaps, could be the best choice for microsurgery.

PMMC flaps for reconstruction of oral defects in the age of microvascular flaps: A developing nation perspective.

PurposeThe purpose of this study was to compare Pectoralis major myocutaneous flap (PMMC) and Free flaps for reconstruction of post ablative defects in patients undergoing treatment for oral squamous cell carcinoma and to understand the reasons for choosing each from a developing nation perspective.Material and methodsIn the present study, a retrospective study was conducted of the patients treated by either free flaps or PMMC flaps for reconstructive procedures over a five year period in the Department of Oral and Maxillofacial Surgery, Shri Guru Ram Das Institute of Dental Sciences and Research.ResultsOut of 90 PMMC flaps, 44 patients (48.8%) had reconstruction due to lack of micro vascular facility at the center, in 39 patients (43.3%) due to financial constraints and in 7 patients (7%) due to associated comorbities. The overall complication rate in PMMC group was 30% as compared to 28% in Free Flap group. Total flap loss was seen in 3 flaps (2 microvascular and 1 PMMC) while marginal necrosis of skin paddle was seen in 12 patients (13%) in the PMMC group.ConclusionThough, the selection of PMMC flap over free flap was influenced by many factors, results of this study suggest that PMMC flap still has a major role in post-ablative defect reconstruction even in this era of free flaps, especially in developing countries like India.

Pectoralis major myocutaneous flaps vs. revascularised free tissue flaps following salvage surgery for recurrent head and neck cancer

To assess the efficacy of two reconstructive methods: pectoralis major myocutaneous flap and revascularised free flap in salvage surgery for recurrent head and neck cancer. We retrospectively analysed 100 cases of patients who had recurrent head and neck cancer and were treated in the Department of Head and Neck Surgery between 2011 and 2021. The study participants were divided into two groups depending on the method of reconstruction: 62 patients who underwent revascularised free flap reconstruction and 38 patients with pectoralis major myocutaneous flap. In total, flap necrosis was observed in 20 cases, 18 of which were in the group who received revascularised free flaps (29.03%) and 2 in the pectoralis major myocutaneous flap group (5.26%). The OR of flap failure in the free flap group vs. pectoralis major flap group was 7.36 (95% CI 0.85-63.75; p=0.067) In the group who underwent revascularised free flap reconstruction the total surgery time was significantly longer than in the other group (p < 0.0001). We suggest the advantages of using pectoralis major myocutaneous flaps for recurrent head and cancers, which is of the utmost importance for malnourished patients in poor general health and whose primary treatment comprised of a combination therapy.

Comparison of short-term outcomes between pedicled- and free-flap autologous breast reconstruction: a nationwide inpatient database study in Japan.

Despite the increasing popularity of autologous breast reconstruction, limited evidence is available. The aim of the present study was to compare the short-term outcomes of pedicled- and free-flap breast reconstructions. Using a nationwide Japanese inpatient database, we identified 13,838 patients who underwent breast reconstruction for breast cancer (July 2010-March 2020) using a pedicled or free-flap (pedicled- and free-flap groups, n = 8279 and 5559, respectively). One-to-one propensity score matching was performed to compare the occurrence of postoperative complications, duration of anesthesia, length of stay, and total costs between the two groups. We also performed subgroup analyses stratified by hospital volume. The propensity score-matched analysis involving 3524 pairs showed that the pedicled-flap group had significantly lower proportions of takeback (2.1% vs. 3.2%, p < 0.001), thrombosis (0.6% vs. 1.7%, p < 0.001), and postoperative bleeding (2.1% vs. 5.7%, p < 0.001) than the free-flap group. No significant differences were found in wound dehiscence or tissue necrosis. Compared to the free-flap group, the pedicled-flap group had a short duration of anesthesia (412 vs. 647min, p < 0.001) and low total hospitalization costs (12 662 vs. 17 247 US dollars, p < 0.001) but a prolonged postoperative length of stay (13 vs. 12days, p < 0.001). The subgroup analyses showed results compatible with those of the main analysis. In this large nationwide cohort of patients who underwent breast reconstruction, pedicled-flap reconstruction was associated with fewer postoperative complications (excluding necrosis and wound dehiscence) and lower hospitalization costs but a longer postoperative length of stay than free-flap reconstruction.

Pedicled Flaps versus Free Flaps for Oral Cavity Cancer Reconstruction: A Comparison of Complications, Hospital Costs, and Functional Outcomes.

Introduction Free flaps have been the preferred method for reconstruction after resection of oral cavity cancer. However, pedicled flaps remain valuable alternatives in appropriate settings. Objective The main objective of the present study was to compare surgical complications, hospital costs, and functional outcomes of oral cavity cancer patients who underwent soft tissue reconstruction with pedicled flaps or free flaps. Methods A total of 171 patients were included in the study. Ninety-eight underwent reconstruction with a pectoralis major, submental, temporalis, or supraclavicular pedicled flap, and in 73 patients, a radial forearm or anterolateral thigh free flap had been used. The cases were retrospectively reviewed, and a comparative analysis was carried out between the two groups. Results Recipient site and flap complications, speech, and swallowing functions did not differ between groups, but donor site complications, operative time, hospital stay, and costs were significantly reduced in the pedicled flap group compared with the free flap group. However, the pectoralis major flap reconstruction resulted in a more inferior swallowing function than the free flap reconstruction. Conclusions With comparable complications and functional outcomes, while decreasing in costs, pedicled flaps are a useful alternative to free flaps in oral cavity cancer reconstruction. However, in an extensive defect (> 70 cm 2 ), free flaps are the reconstruction of choice for the preservation of swallowing function.

Peri-Operative Pain and Opioid Use in Opioid-Naïve Patients Following Inpatient Head and Neck Surgery.

Pain management is an important consideration for Head and Neck Cancer (HNC) patients as they are at an increased risk of developing chronic opioid use, which can negatively impact both quality of life and survival outcomes. This retrospective cohort study aimed to evaluate pain, opioid use and opioid prescriptions following HNC surgery. Participants included patients undergoing resection of a head and neck tumor from 2019–2020 at a single academic center with a length of admission (LOA) of at least 24 h. Exclusion criteria were a history of chronic pain, substance-use disorder, inability to tolerate multimodal analgesia or a significant post-operative complication. Subjects were compared by primary surgical site: Neck (neck dissection, thyroidectomy or parotidectomy), Mucosal (resection of tumor of upper aerodigestive tract, excluding oropharynx), Oropharyngeal (OP) and Free flap (FF). Average daily pain and total daily opioid consumption (as morphine milligram equivalents, MME) and quantity of opioids prescribed at discharge were compared. A total of 216 patients met criteria. Pain severity and daily opioid consumption were comparable across groups on post-operative day 1, but both metrics were significantly greater in the OP group on the day prior to discharge (DpDC) (5.6 (1.9–8.6), p < 0.05; 49 ± 44 MME/day, p < 0.01). The quantity of opioids prescribed at discharge was associated with opioid consumption on the DpDC only in the Mucosal and FF groups, which had longer LOA (6–7 days) than the Neck and OP groups (1 day, p < 0.001). Overall, 65% of patients required at least one dose of an opioid on the DpDC, yet 76% of patients received a prescription for an opioid medication at discharge. A longer LOA (aOR = 0.82, 95% CI: 0.63–0.98) and higher Charlson Comorbidity Index (aOR = 0.08, 95% CI: 0.01–0.48) were negatively associated with receiving an opioid prescription at the time of discharge despite no opioid use on the DpDC, respectively. HNC patients, particularly those with shorter LOA, may be prescribed opioids in excess of their post-operative needs, highlighting the need the for improved pain management algorithms in this patient population. Future work aims to use prospective surveys to better define post-operative and outpatient pain and opioid requirements following HNC surgery.

An Anatomical Study of Posterior Trunk Recipient Vessels, and Comparisons of Outcome following Pedicled- and Free-Flap Transfers for Treatment of Sarcoma in the Posterior Trunk.

Reconstruction after wide resection of a large sarcoma arising in the posterior trunk may require free-flap transfer to reduce the postoperative complications. Here, we describe the recipient vessels on the whole posterior trunk. Moreover, to show the reliability of these vessels, we describe an institutional series of free-flap reconstruction. In the cadaveric study, 20 posterior trunk regions from 10 fixed cadavers were dissected. The location and the diameter of the perforating artery and vein on the posterior were documented. In the clinical study, 54 patients undergoing immediate reconstruction surgery with only a pedicled flap (n = 45) and with a free flap (n = 9) after sarcoma resection on the posterior trunk between July 2005 and September 2021 were identified. One-to-one propensity score matching was performed to compare the postoperative complications. In the cadaveric study, a total of 178 perforators were identified. The average diameter of the superficial cervical artery (SCA) and vein, dorsal scapular artery (DSA) and vein, medial branch of dorsal intercostal artery perforator (m-DICAP) and vein, lateral branch of dorsal intercostal artery perforator (l-DICAP) and vein, and dorsolateral intercostal artery perforator (DLICAP) and vein were 1.03, 1.67, 1.38, 1.84, 1.28, 1.84, 1.01, 1.60, 1.11, and 1.70 mm. In the clinical study, the propensity score-matched analysis involving eight pairs showed a significantly higher occurrence of total complications in the pedicled-flap group than the free-flap group (62.5 vs. 0%, p = 0.03). The cadaveric study showed that the perforators from the SCA, DSA, and posterior intercostal artery are constantly present. The clinical study demonstrated the feasibility and reliability of a free-flap transfer.

Anterior Neck Resurfacing Using Multiple Free Flaps in Patients With Burn Sequelae of the Anterior Neck and Chest.

It has been established that patients with burn sequelae of the anterior neck and chest have a significant degree of flap descent and deficit in neck extension when resurfaced with a single free flap. A protocol was developed to avoid flap descent in these patients by resurfacing the neck with multiple free flaps. The purpose of this article is to present our protocol for treatment and long-term results of this technique. Twenty-five 25 patients with burn sequelae of the anterior neck and anterior thorax were retrospectively identified. Ten patients were treated with a single free flap (group 1), and 15 patients were treated with multiple free flaps (group 2). Patients were followed up for an average of 7 years after their definitive reconstructive procedure at which time measurements including flap descent from sternal notch, deficit of neck extension, and subjective reports of discomfort were obtained. Patients in group 1 demonstrated 8 cm (interquartile range [IQR], 1.75 cm) of flap descent, whereas patients in group 2 demonstrated 0.5 cm (IQR, 0 cm) of flap descent. Patients in group 1 demonstrated 12.5 degrees (IQR, 10 degrees) of deficit in neck extension, whereas patients in group 2 demonstrated 0 degrees (IQR, 0 degrees) of deficit in neck extension. Analysis demonstrated significantly greater descent and deficit in neck extension in group 1 compared with group 2. Patients with burn sequelae of the neck and anterior chest experience less flap descent and deficits in neck extension when resurfaced with multiple free flaps.

Three-dimensional navigation in maxillofacial surgery - the way to minimize surgical stress and improve accuracy in fibula free flap and Eagles syndrome surgical procedures.

Surgical navigation with three-dimensional (3D) printing techniques presents two major advantages: First, from atechnical aspect, it facilitates orientation in target anatomical structures resulting in improvement of the accuracy of surgery. Moreover, it shortens the time of complex surgical interventions by preparing the exact position of customized autologous grafts with fixation devices. Second, from aclinical point of view, it also lessens the impact of surgical stress to adjacent tissues by decreasing the duration of surgery. Two maxillofacial procedures were evaluated in this study using 3D navigation and planning approach - resection of the styloid process due to Eaglessyndrome and microvascular mandibular reconstruction with the fibula free flap. All patients who underwent these procedures were divided into two groups (with or without 3D navigation). In the Eaglessyndrome group procedure independent t-test showed significant difference in the operating time between group 1 (M = 148; SD = 0) and group 2 (M = 78; SD = 4.24) t (1) = 13.472; P = 0.047. There was no significant difference in the duration of postoperative hospitalization (2 days), which was equal in all patient groups. Regarding the fibula free flap procedure, the independent t-test revealed significant difference in operating time with (M = 8: 40 : 25; SD = 0 : 58 : 07) and without 3D printing guides (M = 10 : 43 : 15; SD = 3 : 04 : 32) t (14)=2.133, P = 0.051. Similarly, there was no significant difference between groups (group 1 M = 15.5; SD = 0,71; group 2 M = 13; SD = 1,63) in the duration of postoperative hospitalization time t (4) =1,98; P = 0.119. In summary, reduction in operation time in Eaglessyndrome and in microvascular mandibular reconstruction with the fibula free flap group mitigates the surgical stress on target tissues enabling faster tissue healing and quicker recovery.