Free Flap Surgery Research Articles

What about the donor site morbidity - how invasive is the free latissimus dorsi flap?

The free latissimus dorsi muscle (LDM) flap represents a workhorse procedure in the field of trauma and plastic surgery. However, only a small number of studies have examined this large group of patients with regard to the morbidity of flap harvest. The aim of this prospective study was therefore to objectively investigate the morbidity of a free LDM flap. A control group (n = 100) without surgery was recruited to assess the differences in strength and range of motion (ROM) in the shoulder joint with regard to handedness of patients. Additionally, in 40 patients with free LDM flap surgery, these parameters were assessed in an identical manner. We measured higher values for all parameters assessing force in the shoulder joint on the dominant side of patients in the control group. Moreover, LDM flap harvest caused a significant reduction in strength in the glenohumeral joint in all functions of the LDM that were assessed, ranging from 9.0% to 13.8%. Equally, we found a significantly reduced ROM in the shoulder at the side of the flap harvest. For both parameters, this effect was diminished, when the flap harvest took place on the dominant side of the patient. LDM flap surgery leads to a significant impairment of the strength and ROM in the shoulder joint. Moreover, the donor morbidity must be differentiated with regard to handedness: harvest on the non-dominant side potentiates the already existing difference in strength and ROM. Conversely, if the harvest takes place on the dominant side of the patient, this difference is diminished.

Management of Delayed Vascular Occlusion in Free Flap Breast Reconstruction: A Systematic Review of Literature and Case Report.

Free flap surgery is a reliable and safe procedure for breast reconstruction. The survival of free flaps depends on their vascular pedicle initially, but neovascularization can sustain their blood supply after a while. Management of late pedicle occlusion in free flap breast reconstruction and potential implications of late pedicle occlusion on the transferred tissue are controversial. We systematically reviewed current literature focusing on articles that reported on late pedicle occlusion in free flaps for breast reconstruction. We aimed to analyze incidences of late pedicle occlusion, the existing evidence for the most appropriate management strategy for late pedicle occlusion, and its implications on overall outcomes. In support of the review, we present a clinical case of a salvage of a deep inferior epigastric artery perforator flap following late arterial thrombosis 12 days postoperatively. The literature is limited to a few case reports on pedicle occlusion in free flap breast reconstruction and a few heterogeneous retrospective reviews reporting on late pedicle occlusion in general. Despite the heterogeneity of articles and approaches to salvage flaps with late pedicle occlusion, we found no convincing evidence that surgery is the best choice to salvage flaps in breast reconstruction that appear to have late pedicle occlusion. Our case demonstrates that a conservative approach may be justified more than initially deemed necessary. Late pedicle occlusion is a rare but serious event in free flap breast reconstruction. Surgery does not seem to be the most appropriate approach in every case. Decisions should be based on clinical dynamics and imaging findings such as indocyanine-green angiography. A carefully carried out conservative approach may lead to flap salvage.

Treatment of exposed tibial bone by old school burr holes – a case report

Background: We report a successful wound treatment of a chronic ulcer with bone exposure using a somehow forgotten technique of creating burr holes into the bone. Most clinics would promote flap surgery to cover wounds with bone exposure, however, in some cases invasive surgery is not mandatory. We bring up an alternative treatment for such cases. Case: We report a case of chronic ulcers on both lower extremities in a 43-year-old Caucasian male. He suffers from a leukocytoclastic vasculitis and sarcoidosis which is medicated by immunosuppressive medication. The patient‘s wounds were initially treated with mechanical debridement and split-thickness skin grafts, however, his wounds tended to worsen the more they were manipulated and finally resulted in tibial bone exposure. After levelling up his immune suppressive drugs, the wounds finally stabilized but didn’t heal after several weeks of follow-up. The wound was ultimately treated by placing burr holes in the underlying cortical bone. Conclusion: Chronic ulcers with bone exposure at the lower leg are challenging to treat. They often require local or free flap surgery. In some cases, because of underlying systemic disease, it is mandatory to stay away from invasive flap surgery. With this case, we like to put under attention an old technique of decorticating the exposed bone to promote secondary wound healing. It has been described mainly for scalp injuries, however, we have proven the viability of this technique for pretibial wounds as well.

Challenges in Radial Forearm Free Flap Surgery: A Comprehensive Case Analysis of Septic Complications at the Donor Site.

The radial forearm free flap (RFFF) has emerged as a leading option for microvascular reconstruction of head and neck soft-tissue defects. Despite the favorable outcomes conferred by RFFFs, complications such as skin graft loss and tendon exposure can occur. We present the case of a 77-year-old man who underwent RFFF reconstruction after excision of squamous cell carcinoma from the head and neck. The patient subsequently developed flexor tenosynovitis, septic arthritis of the wrist, and osteomyelitis of several carpal bones as a direct result of partial skin graft loss and prolonged tendon exposure at the donor site. To the best of our knowledge, this is the first reported case of this specific complication. Review of the literature reveals the need for continued research into RFFF donor site complications to mitigate the incidence of significant morbidity.

Traumatic Complete Loss of Knee Extensor Mechanism and Its Reconstruction With a Fresh-frozen Patellar Allograft With Patellar and Quadriceps Tendon.

We report on an 18-year-old female who sustained complete loss of her knee extensor mechanism (patella, quadriceps and patellar tendon) due to a motorbike injury with severe soft tissue loss of the ventral aspect of the knee and subsequent infection. After infection control and successful latissimus dorsi free flap surgery, reconstruction of the knee extensor mechanism was performed using a fresh frozen extensor mechanism allograft with patella, quadriceps- and patellar tendon and integrated tibia tuberosity fragment. After a follow-up of 18 months, there was infection free integration of the allograft with a range of motion 0-0-90° (extension/flexion) and pain free gait.

Diluted Indocyanine Green Angiography: A Novel Approach to Free Flap Perfusion Evaluation in Reconstructive Microsurgery.

Assessing perfusion in free flaps is crucial in clinical practice. Indocyanine green (ICG) angiography offers a more objective and reproducible method, utilizing near-infrared imaging to monitor flap vascularization. This study aims to evaluate the efficacy of diluted ICG as a tool for assessing free flap perfusion. This pilot randomized clinical trial compares the fluorescence concentrations of ICG at 3 different dilutions: 5 mg/mL (standard concentration), 2.5 mg/mL (half the standard concentration), and 0.5 mg/mL (one-tenth of the standard concentration). Inclusion criteria required participants to have serum albumin levels above 3 g/dL, hemoglobin levels over 10 g/dL, and no comorbidities. Participants were randomized into 3 groups based on ICG concentration. Fluorescence analysis was performed using ImageJ software to determine mean gray values. Both surgeons and data analysts were blinded to the ICG concentrations administered, ensuring unbiased evaluation. Forty-five patients undergoing free flap surgery, predominantly male (60%) with a mean age of 37.76 ± 19.79 years and a mean body mass index of 21.23 ± 4.49 kg/m², primarily received osteoseptocutaneous fibular free flaps (46.67%), with an average skin flap area of 66.07 ± 46.94 cm². The primary etiology was underlying tumors (84.4%), with the head and neck as the most common reconstruction site (82.2%). The superior thyroid artery was the most frequently used recipient vessel (37.78%). Analysis revealed mean gray values of 64.10 ± 8.27 (5 mg/mL), 79.03 ± 2.7 (2.5 mg/mL), and 33.56 ± 3.47 (0.5 mg/mL), with 2.5 mg/mL yielding the highest value (P < 0.001). Findings suggest using 2.5 mg/mL concentration enhances fluorescence emission, offering a dosage alternative in clinical practice.

Challenging frontiers in neuroplastic cranial reconstruction: addressing neurosurgical wound healing complications through interdisciplinary collaboration – an observational study

Background and objectivesAlthough rare, complications like skin dehiscence and necrosis after neurosurgery pose significant challenges by increasing the risk of infections spreading to the epidural, subdural, or intracerebral spaces. This retrospective, single-center study aims to assess the prior clinical courses, neuroplastic repair, and outcomes of patients with skin defects following cranial neurosurgical procedures, and to outline our interdisciplinary reconstructive protocol.MethodsA retrospective analysis was performed on cranial surgeries conducted at the Department of Neurosurgery, spanning from 2017 to 2023. Patients with skin defects requiring the combined expertise of neurosurgery and plastic surgery for effective treatment were included. The sizes of the skin defects were measured using intraoperative photographs analyzed with the freeware ImageJ software, version 2018. All patients provided informed consent for the surgeries. If informed consent was not possible due to neurological deterioration, consent was sought from adult representatives or next of kin except for acute circumstances. All patients admitted to our hospital agree to the pseudonymized use of their medical data and tissue specimens for research purposes in their treatment contract.ResultsA cohort of 24 patients experiencing wound healing complications after neurosurgical procedures underwent a total of 29 interdisciplinary surgeries for the reconstruction of skin, dural, and bone defects. After the neuroplastic surgery, 8 out of 24 patients (33.3%) developed surgical complications, with 6 of these requiring revision surgeries due to persistent cranial infection. In all cases, permanent wound closure was successfully achieved following adherence to the proposed treatment algorithm.ConclusionsOur study underscores the necessity of an integrated neurosurgical and plastic surgical approach to effectively manage wound healing complications in a single stage surgery. Key interventions include differentiation between necrosis and gaping lesions, alongside precise management of neurosurgical issues like cerebrospinal fluid fistulas and hydrocephalus. Plastic surgical expertise in assessing the possibilities and limitations of both local and free flap surgeries is essential.

Assessing Postoperative Quality of Life and Psychological Impact of Free Flap Reconstruction in Advanced Head and Neck Cancer Patients.

Introduction Head and neck cancer (HNC) significantly affects patients worldwide, often resulting in physical disfigurement, functional impairment, and diminished quality of life (QoL). Advanced HNC may necessitate reconstructive surgeries using free tissue transfer, which, despite improving survival, can exacerbate emotional and social challenges such as anxiety, depression, and social isolation. This study aims to evaluate the well-being of patients undergoing free flap surgery for advanced HNC using validated tools. Methods We conducted a prospective longitudinal study of 30 patients with advanced HNC (≥T3, stage ΙΙΙ-IV) who underwent free flap reconstructive surgery at the General Oncological Anticancer Hospital of Athens 'Agios Savvas' between January 2018 and January 2024. Patient-reported outcomes were assessed using three validated questionnaires in Greek: the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Head and Neck Module (EORTC QLQ-H&N35), the Hospital Anxiety and Depression Scale (HADS), and the Brief Pain Inventory (BPI). Statistical analysis was performed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY), with statistical significance set at p < 0.05. Results Among the 30 patients (10 women and 20 men; mean age = 56.6 years), post-surgical assessments indicated significant worsening of symptoms, including increased pain (p < 0.001), swallowing difficulties (p < 0.001), and speech impairments (p < 0.001). Nearly all patients reported increased analgesic use post surgery (p = 0.003), and a significant correlation was found between pain severity and diminished daily functioning, particularly life enjoyment (correlation coefficient = 0.788, p < 0.001). Additionally, 63% of patients (n = 19) were diagnosed with depression and 67% with anxiety (n = 20), with men showing a higher prevalence of depression (p = 0.001). No significant differences in anxiety rates were found between the sexes. Overall, pain severity had a broad impact on both physical and psychological status, contributing to social withdrawal and isolation. Conclusions Patients with HNC who undergo free flap reconstructive surgery face significant challenges in emotional, social, and physical well-being. Depression and anxiety are common but often undetected, especially in men. Pain remains a significant factor affecting QoL and social engagement. Comprehensive care models, including standardized pre- and post-treatment assessments, early mental health screenings, and personalized rehabilitation strategies, are essential to improve outcomes and enhance QoL for HNC patients.

Cross-Leg Microvascular Free Anterolateral Thigh Flap as a Safe, Viable, and Reserve Option for Reconstruction in a Vessel-Depleted Limb

AbstractWe present the case of a 36-year-old male patient with a posttraumatic composite defect of the lower two-thirds of the anterior aspect of the left leg with exposed necrotic tibia in an old, neglected type 3b fracture of the tibia of 9-month duration. The options for definitive soft-tissue cover include microvascular free tissue transfer and cross-leg flaps. In trauma cases, the surrounding tissue is usually damaged, and the recipient vessels are frequently implicated, ruling out the use of a microvascular free flap. Cross-leg flaps are unachievable due to large defect sizes and lack of appropriate donor tissue. In this case report, we highlight the use of cross-leg microvascular free anterolateral thigh (ALT) flap cover for the composite leg defect. By presenting our case, we aim to advocate the clinical application of cross-leg free flap surgery in vessel-depleted limbs as a safe and viable option.

What happens after the free flap? Evaluation of aesthetic and functional elective revisions

BackgroundMicrovascular free flap reconstruction of a defect, as a single-stage procedure, does not always achieve the desired functional and esthetic result. Revisions may be necessary to achieve ideal contour, symmetry, and suspension of soft tissues, or to support dental rehabilitation. PurposeThe study purpose was to estimate the incidence and identify factors associated with elective free flap revisions.Study design, setting, sample: A retrospective cohort study of subjects who underwent free flap reconstruction was conducted to characterize the rate of elective free flap revision surgery. The study included subjects >18 years old, who underwent head and neck microvascular free flap surgery for any etiology, and both primary and secondary reconstructions, between 2014-2021. Subjects were excluded if they had incomplete records. Predictor variableThe predictor variable was composed of a set of variables, grouped into the following categories: subject demographic data, medical history, disease etiology, anatomical site, and postoperative complications. Main outcome variableThe outcome variable was time to elective revision surgery measured as months from the date of the initial operation to date of elective revision surgery. Elective revision surgery was defined as a procedure to enhance esthetics or function, which directly modifies the original surgical site, not including procedures to correct a complication, treat the original disease process, or emergencies. CovariatesNot applicable. AnalysisKaplan-Meier method was used to analyze the data, with p-value <0.05. Risk factors for elective revisions were analyzed with Cox Hazard ratio. ResultsThe sample was composed of 377 subjects that underwent free flap surgery, with a mean age of 55.9 +/- 15.9. Of these 67% were male, and 33% female, and sixty-two had an elective revision surgery (16.4%), with median follow-up period of 17 months (IQR 9-28). In the Cox regression model, only type of free flap was associated with an elective revision (p<0.05), where radial forearm had the lowest association with elective revision, and fasciocutaneous, latissimus dorsi, and scapula flaps had the highest. Conclusion and RelevanceAchieving basic wound coverage with free flaps can be a challenge, however, surgeons should prepare patients for the potential need for functional and esthetic revisions after free flap surgery to improve patient quality of life.

Sterile Draping of Operative Microscopes in Breast Free Flaps and Surgical Site Infections.

Operative microscopes are traditionally draped in single-use plastic to prevent infection theoretically. The necessity of this routine in breast free flap surgery is unclear. Alternatively, sterile wrapping of microscope handles would reduce operating room waste and provide a more cost-effective and environmentally sustainable approach to sterility. This study aimed to determine whether the draping technique used during abdominally based free flaps (Ab-FF) influenced the rate of surgical site infections. We conducted a retrospective review of Ab-FF performed consecutively between March 2017 and August 2022. Patient demographics, comorbidities, perioperative data, and postoperative complications were collected. The primary outcomes included postoperative surgical site infections and environmental impact. Of the 281 identified breasts reconstructed with Ab-FF, operating microscopes were sterilely covered with microscope drapes (n = 215) or handle covers (n = 66) composed of polyethylene-based plastic. Overall, postoperative infections occurred in 9.3% of cases (n = 26) in either the recipient breast (n = 11, 3.9%) or abdominal donor site (n = 15, 5.3%), primarily due to S. aureus and Streptococcus species . The handle (n = 6, 9.1%) and drape (n = 20, 9.3%) cohorts had similar infection rates with no sequelae of operative complications. In multivariate analysis, radiation was the only independent predictor of postoperative infection, while bilateral reconstructions were independently protective. Replacing a microscope drape with a handle reduces carbon emissions by 1276 grams of CO 2 and direct costs by $7.84 per item. The principles of "Lean and Green" surgery prioritize reducing operating room generated waste to achieve financial and environmental sustainability. This cohort study of 281 breast free flaps demonstrates that switching from whole microscope draping to handle wrapping was not associated with an increased rate or odds of infection. Adopting a microscope handle wrapping protocol decreased the carbon footprint and operative costs. The results of this study offer evidence to support adoption and further exploration of pragmatic, cost-effective, and sustainable approaches to microsurgical breast reconstruction.

Predicting the Timing and Cause of Microvascular Free Flap Failure: An Australian Study of 1569 Free Flaps.

The aim of the study is to assess the possible predictors of microvascular free flap failure and determine the critical postoperative timing of flap failure, thereby minimizing this adverse outcome. This is a retrospective single-institutional review of 1569 free flap operations. All free flaps with outcome status recorded were analyzed for possible predictors in the development of microvascular compromise. Compromised cases were then analyzed for differences in time to compromise and time to theater takeback between salvaged versus failed free flaps. Of the assessable 1569 free flaps, 31 developed microvascular compromise (2.0%); the salvage rate was 20.0%, and overall failure rate was 1.5%. Osteocutaneous free flaps in head and neck had increased risk of developing free flap failure compared to other flaps (odds ratio = 3.8, 95% confidence interval: 1.2-12.7). Among breast patients, previous radiotherapy had a significant association with flap failure ( P < 0.001). Free flap salvage rates dropped from 38.5% to 7.7% for compromises detected after 24 hours ( P = 0.160), and from 57.1% to 11.1% for free flaps taken back to theater greater than 3 hours after compromise detection ( P = 0.032). Delays in compromise detection and flap takeback to theater resulted in reduced salvage rates, with the critical timing of takeback being under 3 hours. Standardized flap monitoring protocols and incorporation of newer technologies could see faster detection and improved salvage rates. Additional care is required when reconstructing: osteocutaneous head and neck free flaps and previously irradiated breast patients.

Comparison of nerve block and spinal anesthesia in second toe pulp free flap surgery for fingertip reconstruction.

Toe pulp flap surgery is a viable option for soft tissue defects of the fingertips, effectively addressing patient needs and fingertip characteristics. The preferred anesthesia for lower-extremity surgery includes spinal and regional anesthesia. However, the choice between these methods depends on patient safety and surgical efficacy. In this retrospective study, we aimed to ascertain the optimal anesthetic technique by examining the efficacy, safety, pain control, and potential side effects of spinal and peripheral nerve block anesthetics. We included 40 patients aged 18-60 years who underwent partial second toe pulp free flap surgery for fingertip reconstruction. Twenty patients received spinal anesthesia (SA), while the remaining 20 received peripheral nerve block anesthesia. We conducted a comparative analysis of postoperative pain scores, adverse effects, analgesic usage, and patient satisfaction scores associated with each anesthesia method. Independent t-test, Mann-Whitney U test, and chi-squared test were performed. The SA group exhibited hypotension, bradycardia, urinary retention, and postdural puncture headache rates of 10%, 10%, 5%, and 5%, respectively. A significant difference in the timing of first analgesic use was observed (spinal, 3.7 ± 0.8 vs. peripheral nerve block, 13.2 ± 6.6; P = 0.006). Visual analog scale (VAS) scores of the patients at the 2nd, 4th, and 6th h were significantly lower in the peripheral nerve block group (P < 0.001, P < 0.001, P < 0.001, respectively). VAS scores at 12 and 24 h were similar between the groups (P = 0.07, P = 0.135, respectively). Peripheral nerve block anesthesia is superior to SA for partial second toe pulp free flap surgery, offering lower complication rates, reduced postoperative pain, and improved patient comfort.

Anterolateral thigh free flap surgery for medial malleoli fracture with extensive dorsal foot skin defect: A case report

Severe foot deformities, especially those affecting the dorsum of the foot, can make it difficult to perform daily activities. For example, mild pain when walking can be felt on the dorsal aspect of the foot, and toe contractures can make it difficult to wear non supportive shoes. Reconstructive surgeons face a great deal of difficulty in providing a suitable flap in accordance with the "like for like" reconstructive principle. The best outcomes for reconstructing small- to medium-sized dorsal foot lesions have been reported using local flaps and pedicled flaps. Reconstruction of large dorsal foot deformities is, however, hardly studied. In this work, we report our experience reconstructing large dorsal foot lesions using the free anterolateral thigh (ALT) flap.

Microsurgery in low- and middle-income countries: Results of 20 years of experience in Cambodia

BackgroundMicrosurgical free tissue transfer is the gold standard for reconstructing major bone or soft tissue defects but requires complex training, and specific resources. Therefore, some authors have stated that microsurgery is impossible in low- and middle-income countries. MethodsPatients from Khmer underwent free flap surgery at the Children’s Surgical Centre in Phnom Penh between 2004 and 2023. Two non-governmental organizations facilitated the program: Rose Charities Cambodia provided the facilities, patients and local staff, and Doctors of the World provided the surgeons, and anesthetists. At least one Khmer surgeon was trained during these operations. Digital data were collected retrospectively, and analyzed in June 2023. ResultsFifty-six free flaps in 54 patients have been performed since 2004. The most frequent sites requiring reconstruction were the head and neck (35.7%), lower limbs (30.4%), and upper limbs (21.4%). The most frequent free flaps were free fibula (44.6%), gracilis (19.6%), and anterolateral thigh (16.1%). Among the 56 flaps, 41 (= 73.2%) were viable long-term and 15 (26.7%) were microsurgical failures. Sixteen flaps underwent revision in the operating room. Twenty-three flap-related complications were reported in 21 patients with mostly vascular thrombosis (n = 12), hematoma (n = 3) and infections (3). However, 83.3% had improved or were cured of their initial pathology after final surgical management. ConclusionsFree flaps performed in our series as part of international surgical collaborations in a low-income country are feasible, but we experienced higher failure rates, and later revisions compared to the results in high-income countries. We identified several solutions to improve the microsurgery outcomes in low-income settings.

Areal differences in the rate of operative care for cancer of the head and neck within one hospital district in Northern Finland

Abstract Aim The relationship between socioeconomic status (SES) and cancers of the head and neck has been described previously. The present study investigated areal differences in the rate of operative care of cancers of the head and neck in terms of SES and rural–urban areas. Methods This retrospective cohort study included operations performed in Northern Finland between 1 January 2014 and 31 December 2019. SES and the rurality of the residence was determined using postal codes. Results Patients from the low-income areas were older and had higher American Society of Anesthesiologists classification than patients from middle- and high-income areas. The number of operated thyroid and parotid gland tumours was higher in the high-income areas (n = 36 [33.0%] vs n = 21 [18.8%] and n = 330 [28.6%], p = 0.049). Patients living in low- or median-income areas were more likely to live in rural areas than patients living in high-income areas (n = 55 [49.1%] and n = 62 [59.0%] vs n = 44 [40.4%], p = 0.024). The age-weighted rate of operations was higher in low-income areas than in high-income areas (29.3 [23.9–29.3] vs 17.9 [14.5–21.2]), and the age-weighted rate of free-flap surgery was highest in the low-income areas (16.8 [12.4–21.2] vs 8.2 [5.7–10.6] and 9.6 [7.0–12.1] /100,000 inhabitants/year). Conclusion There are significant areal differences in the rate of ablative head and neck surgery. Significantly higher rates were found in low-income areas and in rural areas.

Shear Wave Elastography of the Skin following Radial Forearm Free Flap Surgery in Transgender Patients: Observational Study.

Background: Ultrasound shear wave elastography (SWE) noninvasively measures the stiffness of tissue by producing and measuring tissue deformation. Scar formation, a crucial aspect of wound healing, can lead to functional and aesthetic complications when pathological. While SWE has shown promise in dermatological evaluations, its role in surgical scar assessment remains underestimated. Our study aims to investigate SWE in evaluating surgical scars at the donor site after forearm free flap surgery in transgender patients. Methods: After radial forearm free flap harvesting, the donor site was grafted with a split-thickness skin graft with or without interposition of Matriderm. Eleven patients were evaluated more than one year after surgery, using SWE alongside scar characteristics, sensory outcomes, and patient satisfaction surveys. Results: Our study revealed no significant difference in stiffness (p > 0.15), pigmentation (p = 0.32), or erythema (p = 0.06) between operated and non-operated sides. The interposition of Matriderm did not influence the stiffness. Patients significantly (p < 0.0001) reported a loss of discrimination. Patients' subjective scar evaluation appeared in line with our quantitative and objective results. Conclusions: This study contributes to the evolving understanding of SWE's role in scar assessment, highlighting its feasibility in evaluating surgical scars. However, continued research efforts are necessary to establish SWE as a reliable and objective method for surgical scar evaluation and management.

Extending applications of WALANT for free flap harvest and transfer to repair the finger defects.

The use of wide-awake local anaesthesia no tourniquet (WALANT) in free flap surgery has been limited and discouraged because of the concern that the adrenaline will cause vasoconstriction. We report our positive experience in free flap harvesting and transfer.Level of evidence: IV.

Is It Possible to Monitor the Safest Time to Perform Secondary Surgery on Free Flaps? A Clinical Evaluation of the Tewameter®.

Background and Objectives: Postoperative monitoring, following free flap surgery, plays a crucial role in ensuring the survival of the flap. However, in microsurgery, not only the immediate postoperative monitoring period but also the choice of the right time for secondary surgeries is crucial for the free flap survival. There is no clear consensus concerning the right choice of timing for secondary surgery. Our aim was to evaluate transepidermal water loss (TEWL), with the objective evaluation tool Tewameter® in free flap surgery to monitor flap autonomization. Materials and Methods: Transepidermal water loss was assessed in 20 patients with microsurgically transplanted free anterior lateral thigh (ALTP) flaps. The transplantation of the ALTP-flap and the postoperative care were administered in accordance with the standard of care of the department. Measures were taken on the free flap and normal skin at follow-ups of 1, 3, and 6 months after initial free flap transplantation. Results: Transepidermal water loss gradually increased to the values found in normal skin, after 6 months. The differences between the two areas demonstrated the smallest variance after 6 months, specifically in the ALTP-flap region. The largest disparities were observed between month 1 and month 6, followed by month 3 and month 6, and month 1 and month 3. Conclusions: Free flap autonomization and physiology are complex processes. TEWL might be a valuable parameter to monitor flap autonomization. Our results indicate that TEWL in the free flap is nearly "normal" after six months. For a clear consensus of when to perform individual secondary surgery, further studies are needed.

Association between blood transfusion and outcomes of free flap head and neck cancer surgery

ObjectiveInvestigate the impact of patient risk factors and blood transfusions in Head and Neck free flap surgeries. Study designRetrospective chart review. SettingSingle tertiary referral center. Methods400 patients were included undergoing free flap reconstruction from 2014 to 2020. The primary outcome measures were red blood cell transfusion and volume transfused. Race, sex, flap location and tissue type, pathology, dependent functional status, length of stay, and cancer recurrence were evaluated for association with red blood cell transfusion intraoperatively and/or postoperatively. Transfusions were indicated on patients with Hemoglobin <7–8 and/or symptomatic anemia. ANOVA and Chi2 statistical analysis were performed. The significance was set at p ≤0.05. ResultsOf the 400 patients included, 58 required red blood cell transfusion. Of these 67.8 % were males, racial demographics included 9.00 % African American, 1.30 % Asian, 1.00 % Hispanic/Latino, 87.8 % White, 1.00 % other. African American patients received a higher volume of transfused red blood cells versus white patients (855.00 mL vs. 437.07 mL, p = 0.005). Length of stay was significantly associated with red blood cell transfusion (5.95 days vs. 7.22 days, p ≤0.001). Dependent functional status and need for red blood cell transfusion were associated (p = 0.002). Type of free flap was associated with need for red blood cell transfusion (p ≤0.001) with anterolateral thigh flaps being the most common resulting in transfusion (34/58). ConclusionRed blood cell transfusion was significantly associated with race, dependent functional status and length of stay. Certain free flaps have a higher risk of blood transfusion.