Free Flap Reconstruction Research Articles

Complex scalp defects represent a significant reconstructive challenge and frequently require free tissue transfer. Although the latissimus dorsi (LD) and anterolateral thigh (ALT) flaps are widely regarded as preferred options, existing studies are limited by small sample sizes or short follow-up. This study reviews an 8-year institutional experience with scalp free flap reconstruction to inform best practices in managing complex scalp defects. A retrospective review was conducted of a consecutive set of scalp reconstruction cases that required free tissue transfer between 2015 and 2023. Comorbidities, surgical details, and postoperative complications up to 90 days after surgery were noted. Standard descriptive analysis was performed. The LD flap was the most frequently used flap, accounting for 45.2% (n = 14) of reconstructions, followed by the ALT flap in 35.5% (n = 11) of cases. Among LD flaps, hematoma was the most frequent 30-day complication, occurring in 35.7% (n = 5) of patients, and 1 patient (7.1%) experienced complete flap necrosis within 90 days. In the ALT group, wound dehiscence occurred in 27.3% (n = 3) of patients and hematoma in 18.2% (n = 2), representing the most common 30-day complications. No patients in the ALT group developed complete flap necrosis within 90 days. Across the entire cohort, the overall rate of complete flap necrosis at 90 days was 3.2% (n = 1). Free flap reconstruction is an effective method for complex soft tissue scalp defects, although it carries associated morbidities. Understanding the risks and benefits of such procedures is crucial in patient education and shared decision-making.

Fibula free flap reconstruction: improving the accuracy of virtual surgical planning using titanium inserts.

The Importance of the Ilizarov Frame in Free-flap Reconstruction of the Heel as a Protection Tool

This paper presents a systematic review of donor site morbidity in free fibula flap (FFF) reconstruction, one of the fundamental options for mandibular reconstruction and extremity reconstruction, to define novel methods to reduce complications and maximize patient outcomes and quality of life. A systematic literature review with the implementation of PRISMA followed and included the combination of the following keywords: free fibula flap, donor site morbidity, and surgical strategies in PubMed, Embase, Scopus, Cochrane Library, and Web of Science (20002025). Studies that had previously undergone peer review, clinical trials, or cohort studies with a minimum of 10 patients were included in the study. Case reports were excluded, as were studies that were not in English. The extraction of data included morbidity rates (such as wound dehiscence, infection, and chronic pain), surgical methods, and demographics. The quality of the data was evaluated using the Newcastle-Ottawa Scale and the ROBINS-I tool. Qualitative synthesis and, where possible, quantitative meta-analysis were carried out with subgroup analysis based on patient age, site of reconstruction, and method of closure. Available evidence suggests that wound complications (10 to 30 percent), functional disability (e.g., ankle instability, 5 to 20 percent), and chronic pain (5 to 15 percent) are commonly reported morbidities. These novel discoveries, includes perforator-sparing techniques, endoscopic harvesting, and biomaterials (such as collagen matrices), have shown potential in reducing the rates of complications to over 25%. Custom surgical plans and new technologies, such as 3D-printed guides and regenerative medicine, are effective ways to alleviate donor site morbidity, which necessitates their inclusion in practice to maximize FFF outcomes.

Background: Treatment of head and neck cancer with radiation can cause osteoradionecrosis of the mandible (MORN), requiring removal of nonviable bone and free flap reconstruction. Objective: To compare surgical outcomes in patients with MORN treated with free tissue transfer who received hyperbaric oxygen therapy (HBO) to those who did not, measured by flap failure, nonunion, plate exposure, and postoperative infections. Methods: This retrospective cohort study evaluated 311 patients with advanced MORN treated at a single tertiary care academic center with segmental mandibulectomy and free flap reconstruction. One group received HBO preoperatively and postoperatively; the other group did not. Postoperative complications were compared using chi-square test or Fisher's exact test. Results: This study included 311 patients, 131 HBO group (74% male, 26% female, mean age 75.6 years), 180 in the non-HBO group (73% male, 27% female, mean age 76.3 years). Postoperative metrics included; complete flap failure (HBO = 4, non-HBO = 2), partial flap failure (HBO = 2, non-HBO = 3), nonunion (HBO = 10, non-HBO = 14) exposed plate (HBO-7, non-HBO = 8), wound infections treated surgically (HBO = 2, non-HBO = 7), wound infections treated with antibiotics alone (HBO = 5, non-HBO = 12). No differences were identified between groups. Conclusion: We found no difference in rates of postoperative complications between the HBO group and the non-HBO group.

A BSTRACT Background: Osteoradionecrosis (ORN) is a severe complication of radiation therapy in head and neck cancer patients, characterized by necrotic bone exposure, pain, and secondary infections. The optimal treatment approach remains debated between conservative management and surgical intervention. Methods: A prospective study was conducted on subjects diagnosed with ORN. Participants were divided into two groups: One receiving conservative management (antibiotics, hyperbaric oxygen therapy, pentoxifylline, and tocopherol) and the other undergoing surgical treatment (sequestrectomy, resection, or free flap reconstruction). Outcomes were assessed based on pain relief, radiographic healing, functional recovery, and recurrence rates. Results: A total of 60 subjects were included, with 30 in each group. Pain relief was achieved in 70% of the conservative group versus 90% in the surgical group ( P = .03). Complete resolution of ORN occurred in 50% of the conservative group and 83% of the surgical group ( P = .01). Surgical intervention was associated with longer hospital stays but superior long-term functional recovery. Conclusion: Conservative management is beneficial in early-stage ORN but has a higher recurrence rate. Surgical treatment remains the gold standard for advanced cases. A multidisciplinary approach is crucial for optimizing treatment outcomes.

Background: The gold standard for reconstructive surgery is free flap reconstruction. Nevertheless, in developing nations, the high volume of cases, along with infrastructural and resource limitations, has led to the continued use of pectoralis major musculocutaneous flap (PMMC). This article seeks to share our experiences with the harvesting of PMMC flap and the associated outcomes. Methods: A total of 45 patients were retrospectively assessed for reconstruction over a period of 5 years (January 2019 to February 2024). Of these, 30 patients underwent reconstruction using the PMMC flap following a stream lined protocol. The outcomes of the reconstruction, categorized as either successful or unsuccessful, along with any complications that arose, were thoroughly evaluated. Data was analyzed using SPSS version 26.0.and presented a numbers and percentages. Results: The largest proportion of patients fell within the 41–60 age range, accounting for 63.33%. The buccal mucosa was identified as the most frequent location for primary lesions, affecting 21 patients (70.00%). Among the 30 patients who received PMMC flap reconstruction following a standardized technique making it a streamlined protocol, there were no instances of complete flap loss, resulting in a success rate of 100%. However, one case did report necrosis of the breast mound where standardization was not considered. Conclusions: Based on our experience, PMMC flap remains a practical choice for reconstruction, particularly in settings with limited resources. Present approach was standardized by clearly defining the steps of the flap elevation by making it thin and less bulky, increasing its reach, minimizing the donor site morbidities and reducing the donor site deformities. With this stream lined protocol even a junior most plastic surgeon can perform the surgery confidently without facing significant complexity.

Background: Lymph flow measurements can assist in attaining a better understanding of the lymphatic system's function and its diseases. However, invivo assessment of lymph flow has been challenging. Transit-time ultrasound technique (TTUT) provides direct quantitative lymph flow values and has been used to successfully measure lymph flow in patients with secondary lymphedema. Currently, no measurements using TTUT in healthy subjects have been reported. The aim of this study is to measure lymph flow in healthy subjects using the TTUT. Methods and Results: Twenty consecutive patients who had an indication for a free radial forearm flap (FRFF) reconstruction were included in the study. Patients with scars on their arms, a history of extremity lymphedema, metastatic disease, or axillary node dissection were excluded. The Transonic® Microvascular Flow Probe was used to measure lymph flow during FRFF reconstruction in accordance with the Transonic® protocol for Quantitative Patency Assessment. The subdermal superficial lymphatic collecting vessels had a mean diameter of 0.40 ± 0.10 mm (range: 0.3-0.5 mm) and a mean lymph flow velocity of 0.45 ± 0.48 mL/min (range: 0.08-1.68 mL/min). Neighboring subdermal veins measured had a mean diameter of 0.48 ± 0.11 mm (range: 0.03-0.7 mm) and a mean blood flow velocity of 0.96 ± 1.73 mL/min (range: 0.07-7.40 mL/min). Conclusion: The TTUT is a viable method to measure real-time lymph flow velocities in healthy subjects. Future studies with a larger sample size are required to validate the TTUT measurement accuracy and establish clinical correlations.

Background: Anterolateral thigh free flap (ALTFF) and radial forearm free flap (RFFF) are preferred for oral cavity reconstruction due to reliability, high success, and low donor-site morbidity. The aim of this study was to evaluate the early surgical and functional outcomes of ALTFF and RFFF in the reconstruction of soft tissue defects of the oral cavity. Methods: This prospective observational study was conducted in the department of plastic surgery, NIBPS, Dhaka, from July 2020 to December 2021. A total of 20 patients who required free flap reconstruction following surgical resection of oral cavity lesions, with or without adjacent soft tissue or bone involvement, were included. Results: The mean patient age was 54.8±8.48 years, with a female predominance (60%). All defects were in the cheek, most commonly involving the angle of the mouth (60%). ALTFF was used in 55% and RFFF in 45% of cases. Flap survival was 90.9% for ALTFF and 77.7% for RFFF. Functional outcomes were satisfactory. ALTFF donor sites were closed primarily, while RFFF donor sites required STSG, with 33.3% showing minor graft loss. Donor site morbidity was higher in RFFF cases. Conclusions: Both ALTFF and RFFF are reliable for reconstruction of oral cavity soft tissue defects, providing high flap survival and acceptable functional results.

This study aimed to determine the optimal timing and viscosity of thickened liquid intake for patients undergoing tongue and floor-of-mouth tumour resection with reconstruction, using VFSS to reduce nasogastric tube dependence, improve swallowing function, and the quality of life. This randomised controlled trial was conducted at a dental specialty hospital from September 2023 to November 2024. Forty-three patients who underwent free flap reconstruction for tongue and floor-of-mouth tumours were randomly divided into control (n = 22) and intervention groups (n = 21). Both received swallowing training, but the intervention group followed a structured oral intake protocol with thickened liquids. After tracheostomy removal, patients received 5 mL of medium-viscosity liquid. If no aspiration occurred, VFSS was performed using 5 mL each of medium-, low- and high-viscosity liquids. The liquid with the lowest PAS score was selected for oral intake. Nasogastric tubes were removed upon safe consumption of 200 mL within 20 min. Outcomes included tube duration, swallowing function, weight loss and quality of life. VFSS revealed increasing penetration risk with viscosity: 52.4% for low-viscosity, 23.8% for medium-viscosity and 19.0% for high-viscosity liquids. Low-viscosity liquids exhibited an aspiration rate of 14.3%, whereas no aspiration was observed with medium- or high-viscosity liquids. The intervention group had shorter nasogastric tube duration (9.2 vs. 15.6 days, p < 0.05), better swallowing function, less weight loss and higher quality of life (p < 0.05). A structured thickened liquid diet protocol safely reduces nasogastric tube dependence, enhances swallowing function and quality of life postoperatively.

No consensus exists regarding the utilization of the lower extremity superficial venous system compared with the deep veins in free flap procedures for limb salvage. This study analyzed the risks of venous complications associated with superficial and deep venous anastomoses for lower extremity reconstruction.A retrospective review was performed on patients who required free flap reconstruction of the lower extremity between 2016 and 2024. The recipient veins were characterized as deep (venae comitantes) or superficial (saphenous veins). Flaps with two venous anastomoses were further classified as deep, superficial, or combined venous drainage. The primary study outcome was composite venous complications, which included venous congestion, flap hematoma, and partial and total flap necrosis during index hospitalization.A total of 333 patients underwent free flap reconstruction of the lower extremity. Of these patients, 31 (9.3%) experienced the primary outcome. Free flaps with superficial-only drainage had a significantly higher rate of venous complications (27.8%) than those with deep (8.6%) or combined (4.3%) drainage systems. Multivariate analysis showed that flaps anastomosed to superficial veins had significantly higher odds of venous complications (OR = 4.11, CI: 1.24-11.9, p = 0.049) than those utilizing a deep drainage system.This study showed higher rates of venous complications with the use of superficial venous drainage in lower-extremity free flaps. Although efforts should be made to incorporate a deep venous recipient, superficial veins may be used as an adjunct in certain situations with good reconstructive outcomes.

Multiple simultaneous free flap reconstructions for extensive head and neck defects in vessel-depleted necks are extremely challenging. The "Orochi" flap, described by Koshima, in which one or more secondary free flaps are anastomosed to the main pedicle of a primary free flap resulting in a fabricated chimeric flap may be a useful option when recipient vessels are scarce. Orochi free flap reconstructions for head and neck defects from 2005 to 2024 were reviewed. Postoperative outcomes for Orochi flaps were compared to outcomes for traditional free flaps and vein grafted free flaps using multivariable regression and propensity score matching. Seventy-two Orochi flaps were compared to 385 traditional flaps, and 47 vein grafted flaps. The flap loss rate was 0% for primary Orochi flaps and 4% for secondary Orochi flaps. Only vein grafted flaps (OR= 68.7 (95% CI: 2.6-1788.6)) and history of prior free flaps (OR = 44.2 (95% CI:2.2-879.4)) were found to be independent predictors of total flap loss on multiple regression analysis. In propensity score matched analysis, Orochi flaps had shorter median hospital stays (8 vs. 10 days, p <0.05), and vein-grafted flaps had higher rates of overall complications (21% vs. 8.3%, p = 0.037) and total flap loss (7.1% vs. 0%, p = 0.035) compared to traditional flaps. Orochi flaps are a reliable option for head and neck reconstruction requiring multiple simultaneous free flaps in patients with vessel-depleted necks, possibly offering an advantage over vein grafting to reach recipient vessels at distant sites.

Dysphagia is common in patients with oral cancer undergoing flap reconstruction surgery. Surgical resection and reconstruction can affect the sensory and motor functions associated with swallowing. Studies on dysphagia have not investigated patients with oral cancer undergoing flap reconstruction surgery. In this hospital-based retrospective study, we examined the occurrence rates, risk factors, and clinical outcomes of dysphagia in patients with oral cancer undergoing flap reconstruction surgery. Data were collected from the Chang Gung Research Database, which includes structured and unstructured electronic medical records. These data covered the period from January 1 to November 30, 2022. A total of 892 patients were included in the study. Dysphagia was identified on the basis of NANDA International Nursing Diagnoses criteria. Univariate and multivariable logistic regression models were used for data analysis. Of a total of 892 patients, 679 (76.1%) experienced dysphagia. Body mass index, smoking status, alcohol consumption, betel nut chewing, pain score, neck lymph node dissection, radiotherapy, and chemotherapy were identified as significant risk factors for dysphagia. Compared with those without dysphagia, patients with dysphagia had significantly higher rates of nasogastric tube placement and tracheostomy at discharge, longer hospital stays, and higher readmission rates. Dysphagia is common in patients with oral cancer undergoing flap reconstruction surgery and is associated with certain risk factors and clinical outcomes. Enhancing postoperative care and implementing targeted interventions can facilitate the development of precise treatment plans aimed at reducing the incidence of dysphagia and improving the overall quality of care for patients undergoing flap reconstruction surgery.

Abstract Background Microvascular anastomotic coupling devices (MACDs) help to improve the patency and reproducibility of venous anastomosis. However, owing to the high cost of MACDs in Taiwan, surgeons seldom use them. We compared the efficacy, surgical outcomes, and benefits of using MACDs versus traditional hand-sewn sutures for anastomosis. Methods This retrospective clinical study was conducted in the Plastic Surgery Division at the Tri-Service General hospital between December 2020 and October 2022. We compared the clinical characteristics and outcomes of two groups of patients who underwent free tissue transfer and venous anastomosis using traditional hand-sewn sutures or MACDs. The Synovis venous coupler (Synovis Micro Companies Alliance Inc, Birmingham, AL) was used in all coupled venous anastomoses. Results Overall, 81 patients were included in the study. Of these, traditional hand-sewn sutures were utilized in 46 patients and MACDs were used in 35 patients (43 venous anastomoses in total, all of which were end-to-end anastomoses). The success rates for the hand-sewn and MACD groups were 97.8% and 97.1%, respectively. The mean time taken for venous and arterial anastomosis in the MACD group was 93.26 min, compared with 102.48 min in the hand-sewn group ( p = 0.12). Additionally, the lengths of stay in the intensive care unit were 12.91 days for the hand-sewn group and 7.29 days for the MACD group ( p = 0.11). No thrombosis or leakage incidents occurred when using MACDs. Conclusions In resident-performed microvascular reconstruction, MACDs offer comparable success rates to hand-sewn techniques, with potential benefits in operative efficiency and postoperative recovery. These findings support the use of MACDs as a safe and effective tool in microsurgical training and practice. Not only in surgical outcomes but also in efficiency. Collectively, our results underscore the benefits of MACD use. Level of Evidence: Level III, risk / prognostic study.

Osseous non-union following free flap reconstruction of segmental mandibular defects can prolong patients’ dental rehabilitation. Various plating systems have been developed to optimize biomechanical fixation, but healing may be retarded. Quantifying intersegmental micromovements could help monitor healing but remains challenging. This study investigates a novel method to visualize segmental movements during healing using a fluoroscopy-based approach. To track segment movements, tantalum beads were implanted intraoperatively in the osseous flap and native mandibular segments. Additionally, single-plane fluoroscopic imaging was performed to assess bead position at maximum mouth opening and intercuspation. Bead positions were merged as three-dimensional objects. Intersegmental movements were quantified using model-based roentgen stereophotogrammetry (mbRSA). Exemplarily, preliminary images were collected from one patient. Fluoroscopic imaging with mbRSA effectively displayed movements and allowed quantification. Translation and rotation were assessed between the native mandible and the flap during maximum mouth opening and intercuspation. For the first time, our analyses demonstrate the feasibility of quantifying segment mobility during healing. This first in men study illustrates the feasibility of the method to monitor intersegmental movements in cases of maxillofacial reconstructions. Further research involving larger patient cohorts is necessary to identify relevant thresholds and differentiate from those that result in lack of healing.

Posterior Urethral Reconstruction With Ileal Chimeric Free Flap: A Novel Approach for Management of Radiation-Induced Devastated Bladder Outlet.

Complex distal extremity trauma often involves both extensive soft tissue loss and vascular injury. While the anterolateral thigh (ALT) free flap is a mainstay for limb salvage, large defects may exceed the capacity of a single flap and are associated with higher complication rates. We report a one-stage bilateral ALT free-flap reconstruction strategy designed to provide stable wound coverage and improve functional outcomes. In six patients with severe distal extremity trauma (affecting upper or lower limbs) treated from 2018 to 2020, one-stage reconstruction was performed using bilateral ALT free flaps. Flaps were inset via tandem or parallel vascular configurations based on recipient vessel status. Functional outcomes were assessed by DASH scores (upper limbs) or LEFS (lower limbs) with 5years of follow-up. Four patients had postoperative photon-counting CT (PCCT) angiography to assess anastomotic patency. All flaps survived without major complications. By final follow-up, all patients had achieved stable soft-tissue coverage and satisfactory functional recovery. Functional outcome scores improved in every case, and notably the pediatric patient attained normal gait and limb development after reconstruction. The four patients underwent PCCT angiography were confirmed patent anastomoses and robust perfusion. One-stage bilateral ALT free-flap reconstruction is a safe and feasible approach for complex distal extremity trauma. It provides reliable wound coverage and facilitates timely functional recovery while avoiding the morbidity of staged procedures. Long-term outcomes demonstrate sustained flap viability and functional gains, supporting this approach to avoid staged procedures and improve limb salvage.

Assessing postoperative morbidity and mortality after soft tissue and bony free flap reconstruction of maxillectomy defects using the TriNetX database

To determine the association between Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) scores and flap-related complications. The hypothesis was that higher OTA-OFC cumulative and subcomponent scores would be associated with increased flap-related complications. Design: Retrospective cohort. 20 US trauma centers. The study population included patients ages 18-64 who underwent flap reconstruction after a severe open tibial fracture (OTA/AO 41, 42, or 43). The primary outcome was hospitalization or reoperation for a flap-related complication within 1 year of study enrollment. Logistic regression and omnibus tests were used to determine associations between OTA-OFC cumulative and subcomponent scores with complications stratified by local or free flap reconstruction. Of the 258 included patients, 71 patients [male 58 (82%); median age 33 (IQR 23-51)] underwent local flap and 187 patients [male 160 (86%); median age was 37 (IQR 26-47)] underwent free flap reconstruction. The mean cumulative OTA-OFC was 9 points (range 5-14) for both cohorts. Within patients treated with free flaps, a 1-point increase in the cumulative OTA-OFC was associated with a 35% increase in the odds of a flap-related complication (95% CI, 1.14-1.63; P = 0.001). Among patients treated with local flaps, a 1-point increase was not associated with flap-related complications (OR, 1.30; 95% CI, 0.92-1.73; P = 0.15). The odds of a flap complication varied significantly based on the wound contamination subcomponent score within the free flap group (omnibus P = 0.01) and the arterial subcomponent within the local flap group (omnibus P = 0.03). The OTA-OFC provided data that helped risk-stratify flap-related complications in patients undergoing flap reconstruction for severe open tibial fractures. The arterial and contamination subcomponent scores might provide particularly valuable information when predicting the odds of flap-related complications. Prognostic, Level III.

Diabetic foot disease is a significant global health, often leading to poor wound healing and a higher risk of lower-extremity amputation. These challenges are exacerbated in diabetic patients with end-stage renal disease (ESRD). Currently there is limited evidence on the long-term efficacy of combined angioplasty and free flap reconstruction for limb preservation in the diabetic-ESRD population. We report the long-term outcomes of this limb preservation approach. A retrospective cohort study of diabetic patients on hemodialysis with peripheral arterial occlusive disease and soft tissue defects in the foot was conducted. Patients who underwent endovascular revascularization followed by free flap reconstruction for lower limb preservation at Dalin Tzu Chi General Hospital, Taiwan, from January 2010 to January 2022 were included. The primary objective was to report outcomes of this cohort. The secondary objective was to identify risk factors for flap loss, lower limb amputation, and mortality. We analyzed 40 legs in 35 patients who underwent the combined procedure. The median follow-up was 559.5 days. Flap success rate was 92.5%. The one-, two-, and five-year limb preservation rates were 97%, 91.9%, and 83.5%, respectively. Patient survival rates at one, two, and five years were 65%, 46%, and 21.6%. Age (p=0.043), smoking history (p=0.026), and cerebrovascular accident history (p=0.0003) were associated with higher risks of major limb amputation. Free flap reconstruction for diabetic foot in ESRD patients is reliable with a high limb preservation rate. However, this may not translate to improved patient survival over a 5-year period.