Free Flap Volume Research Articles

Response to: “Impact of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction still needs to be further verified”

Response to: “Impact of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction still needs to be further verified”

Impact of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction: A systematic review and meta-analysis

BackgroundLimited data exists regarding the effect of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction. However, an adequate free flap volume is an important predictor of functional and patient-reported outcomes in head and neck reconstruction. MethodsA systematic review of Medline, Embase, and the Cochrane Central Register of Controlled Trials was conducted using the Preferred Reporting Items for Systematic review and Meta-analyses (PRISMA) guidelines. A total of 6710 abstracts were screened, and 36 full-text papers were reviewed. Nineteen studies met the inclusion criteria and were used to extract data for this analysis. ResultsWe performed a meta-analysis of 14 2-arm studies comparing the impact of adjuvant radiotherapy vs. no adjuvant radiotherapy. The main analysis revealed that, 6 months postoperatively, irradiated flaps showed a significant reduction of volume (average, 9.4%) compared to non-irradiated flaps. The average interpolated pooled flap volumes 6 months postoperatively were 76.4% in irradiated flaps and 81.8% in non-irradiated flaps. After a median postoperative follow-up of 12 months, the total flap volume was 62.6% for irradiated flaps and 76% for non-irradiated flaps. Four studies reported that chemotherapy had no significant impact on free flap volume. ConclusionCompared to non-irradiated flaps, irradiated flaps were significantly reduced in volume (range, 5% to 15.5%). Clinicians should consider this when planning the surgical reconstruction of head and neck defects. Large-scale prospective studies with standardized protocols and well-defined follow-up measurements could help define the ideal, personalized free flap volume for optimal function and patient-reported outcomes.

Impact of Adjuvant Radiotherapy on Free Flap Volume in Autologous Breast Reconstruction: A Scoping Review.

In autologous breast reconstruction, a sufficient flap volume is fundamental to restore breast shape and ensure an aesthetic outcome. After mastectomy, postoperative irradiation is regularly indicated in the oncological treatment algorithm. When administering radiation therapy after autologous reconstruction, the tissue transferred is inherently irradiated. Although there is evidence that points to a reduction in flap volume after adjuvant radiotherapy, the data have been contradicting and inconclusive. To address this anecdotal evidence, we performed a scoping review of the current literature that addresses the effect of radiotherapy on breast flap volume. Six two-armed studies, comprising a total of 462 patients, reported on the effect of adjuvant radiotherapy on free flap volume changes. Of those, two studies found a significant negative impact of radiotherapy on free flap volume, while the other four studies did not. Reported flap volume changes ranged from no change to a reduction of 26.2%, measured up to two years postoperatively. The selected studies contain varying patient numbers, follow-up timepoints, types of flaps, and measuring methods, contributing to a relatively high heterogeneity. While we present some evidence suggesting a significant impact of adjuvant radiotherapy on breast flap volume, future studies are needed to further investigate this potential correlation.

Free-flap volume correlates with body mass index in patients with tongue squamous cell carcinoma.

This study aimed to investigate the relationship between postoperative reconstructed tongue flap volume (RTFV) and body mass index (BMI) and identify factors affecting the flap volume in patients with tongue squamous cell carcinoma. Thirty-two patients were evaluated for RTFV from computed tomography images and BMI. The first and second evaluations were done at 6 months and 1.5 years after surgery respectively. RTFV rate changes and BMI differences from the first and second evaluations were calculated. The correlation between RTFV rate change and BMI difference was assessed using Spearman's rank correlation coefficient. Multiple regression analysis evaluated the relationship between the flap volume rate change and age, sex, flap type, and BMI difference to identify influencing factors. The flap volume rate change and BMI difference correlated significantly (r = .594, p < .05). BMI difference and flap type were independent factors that affected reconstructed flap volume rate change in multiple regression analysis (p < .05). The flap volume of patients with tongue squamous cell carcinoma correlates with the BMI change in the chronic phase. Patients after tongue reconstruction need to be well nourished to maintain BMI and thus postoperative tongue volume to maintain the quality of life. Level 3.

Correlation of Scholarly Activity and Departmental Clinical Productivity in a Surgical Subspecialty

IntroductionPromotion within academic surgery involves demonstrated excellence in administrative, clinical, and scholarly activities. The present study analyzes the relationship between scholarly and clinical productivity in the field of reconstructive microsurgery. MethodsThis is a retrospective cohort study of microsurgery fellowship directors (MFDs). Data on clinical productivity were obtained from the American Society for Reconstructive Microsurgery and scholarly productivity from Scopus. Outcomes were department annual free flap volume, number of publications, and h-index. Descriptive statistics were calculated, and nonparametric tests were used to compare continuous variables. ResultsThirty-nine MFDs were included in this study. All were plastic surgery residency trained and 38% trained under the independent training pathway. Most underwent formal fellowship training in reconstructive microsurgery (89%). The top three microsurgery fellowships trained 37% of all MFDs. Twenty-five percent of MFDs trained at the institution where they ultimately became program director. Twenty percent of MFDs had an additional degree (4 MS, 2 PhD, and 1 MBA). The median number of annual free flaps performed per institution was 175 (interquartile range [IQR] 122). The median h-index was 17 (IQR 13) resulting from 48 (IQR 99) publications. There was a correlation between department annual free flap volume and h-index (r = 0.333, P = 0.038). ConclusionsThere is a correlation between academic productivity of MFDs and the clinical productivity of their department. This study provides a benchmark for aspiring reconstructive microsurgeons.

Free flap volume changes: can we predict ideal flap size and future volume loss?

Under anticipating free flap volume may lead to deficits in functional and aesthetic outcomes. Alternatively, over anticipating may compromise airway patency, lead to prolonged tracheostomy dependence or poor oral intake, and cause poor cosmetic outcomes. Surgeons face a fine balance in creating a functional reconstruction that accounts adequately for volume changes in the future. Recent studies are elucidating the complex and multifactorial volume changes of free flaps that are dependent on postoperative radiation, flap composition, weight fluctuations, and site of reconstruction. Radial forearm free flaps typically lose about 40% of their volume, regardless of patient-dependent variables. Muscle flaps exhibit significant fluctuations with patient-dependent variables. Adipose-prevalent flaps are likely more resistant to radiation effects but are more dependent on postoperative weight changes in the patient. Free flap volume over anticipation recommendations range from 1.1 to 1.4 times the final volume to account for future atrophy but patient characteristics including postoperative radiation, anticipated weight loss, and flap composition should be incorporated into intraoperative decisions for final flap volume.

Case Volume-Dependent Changes in Operative Morbidity following Free Flap Breast Reconstruction: A 15-Year Single-Center Analysis.

Operative morbidity is a common yet modifiable feature of complex surgical procedures. With increasing case volume, improvement in morbidity has been reported through designated procedural processes and greater repetition. Defined as a volume-outcome association, improvement in breast reconstruction morbidity with increasing free flap volume requires further characterization. A retrospective analysis was conducted among consecutive free flap patients using a two-microsurgeon model between January of 2002 and December of 2017. Patient demographics and operative characteristics were obtained from medical records. Complications including unplanned surgical intervention (take-back) and flap loss were obtained from prospectively kept databases. Individual surgeon operative volume was estimated by considering overall practice volume and correcting for the number of surgeons at any given time. During the study period, 3949 patients met inclusion criteria. A total of 6607 breasts underwent reconstruction with 6675 free flaps. Mean patient age was 50 ± 9.4 years and mean body mass index was 28.8 ± 5.0 kg/m2. Bilateral reconstruction was performed on 2633 patients (66.5 percent), with 4626 breasts (70.5 percent) reconstructed in the immediate setting. Overall, breast and donor-site complications were reported in 507 breasts (7.7 percent) and 607 cases (15.4 percent), respectively. Take-back was required in 375 cases (9.5 percent), with complete flap loss occurring in 57 cases (0.9 percent). Based on annual flaps per surgeon, the incidence of complications decreased with increasing volume (slope = -0.12; p = 0.056). Through procedural efficiency and execution of defined clinical processes using a two-microsurgeon model, increases in microsurgical breast reconstruction case volume result in decreased morbidity. Therapeutic, IV.

Effect of postoperative radiotherapy for free flap volume changing after tongue reconstruction.

The purpose of this study was to evaluate the effect of postoperative radiotherapy (RT) on temporal volume changes with a cutaneous free flap (CF) and a myocutaneous free flap (MCF). The subjects were 24 men and 11 women (mean age, 50.5 ± 15.5years) with tongue or floor of mouth cancer. Twenty-seven cases of CF and eight cases of MCF were selected. The flap volume change of the reconstructed tongue was calculated using computed tomography (CT) images taken immediately and at one year postoperatively using the DICOM image processing software OsiriX®. The reduction rate in flap volume at one year postoperatively was 82.0 ± 15% in CF without RT, 70.3 ± 26.1% in CF with RT, 88.5 ± 14.7% in MCF without RT, and 99.5 ± 16% in MCF with RT. The MCF volume was significantly higher compared to the CF volume. Although postoperative RT reduced the CF volume by 30%, there was only a slight reduction in the MCF volume. We evaluated the effect of postoperative RT on volume reduction in 35 cases of the reconstructed tongue with CF and MCF using a computer-assisted volume rendering technique. In this study, the effect of RT on volume reduction was different between the CF and MCF.

Feasibility of virtual surgical simulation in the head and neck region for soft tissue reconstruction using free flap: a comparison of preoperative and postoperative volume measurement

In the head and neck region, preoperative evaluation of the free flap volume is challenging. The current study validated preoperative three-dimensional (3D) virtual surgical simulation for soft tissue reconstruction by assessing flap volume and evaluated fat and muscle volume changes at follow-up in 13 head and neck cancer patients undergoing anterolateral craniofacial resection. Patients received 3D virtual surgical simulation, and the volume of the planned defects was estimated by surgical simulation. Following en bloc resection of the tumor, the defect in the skull base was covered using a rectus abdominis myocutaneous flap. Following surgery, computed tomography scans were acquired at day 1 and at 6 and 12 months. Virtual planned defect was on average 227 ml (range, 154–315) and was 10% smaller than the actual flap volume in patients without skin involvement of the tumor. Between day 1 and 12 months post-surgery, the volume of fat and muscle tissue in the free flap dropped by 9% and 58%, respectively. Our results indicate that 3D virtual surgical simulation provides essential information in determining the accurate volume of the required free flap for surgical defect repair and may thus help improve surgical planning and functional and esthetic outcome.

Predictors of Free Flap Volume Loss in Nonosseous Reconstruction of Head and Neck Oncologic Defects.

Free tissue reconstruction of the head and neck must be initially overcorrected due to expected postoperative free flap volume loss, which can be accelerated by adjuvant radiation therapy. In this study, we aim to identify patient and treatment-specific factors that may significantly contribute to this phenomenon and translate these characteristics into a predictive model for expected percent free flap volume loss in a given patient. Patients with a history of oral cavity and/or oropharyngeal cancer who underwent nonosseous free flap reconstruction were reviewed between January 2009 and November 2018 at a tertiary care center. Demographics/characteristics, total radiation dose, radiation fractionation (RF), and pre/postradiation free flap volume as evaluated by computed tomography imaging were collected. Free flap volume was measured by a fellowship-trained neuroradiologist in all cases. Only patients receiving adjuvant radiotherapy with available pre/postradiation imaging were included. Multivariable linear regression modeling for prediction of free flap volume loss was performed with optimization via stepwise elimination. Thirty patients were included for analysis. Mean flap volume loss was 42.7% ± 17.4%. The model predicted flap volume loss in a significant fashion (P = .004, R2 = 0.49) with a mean magnitude of error of 9.8% ± 7.5%. Age (β = 0.01, P = .003) and RF (β = -0.01, P = .009) were individual predictors of flap volume loss. Our model predicts percent free flap volume loss in a significant fashion. Age and RF are individual predictors of free flap volume loss, the latter being a novel finding that is also modifiable through hyperfractionation radiotherapy schedules.

A simple calculation for the preoperative estimation of transverse rectus abdominis myocutaneous free flap volume in 2-stage breast reconstruction using a tissue expander.

BackgroundFlap volume is an important factor for obtaining satisfactory symmetry in breast reconstruction with a transverse rectus abdominis myocutaneous (TRAM) free flap. We aimed to develop an easy and simple method to estimate flap volume.MethodsWe performed a preoperative estimation of the TRAM flap volume in five patients with breast cancer who underwent 2-stage breast reconstruction following an immediate tissue expander operation after a simple mastectomy. We measured the height and width of each flap zone using a ruler and measured the tissue thickness by ultrasound. The volume of each zone, approximated as a triangular or square prism, was then calculated. The zone volumes were summed to obtain the total calculated volume of the TRAM flap. We then determined the width of zone II, so that the calculated flap volume was equal to the required flap volume (1.2×1.05×the weight of the resected mastectomy tissue). The TRAM flap was transferred vertically so that zone III was located on the upper side, and zone II was trimmed in the sitting position after vascular anastomosis. We compared the estimated flap width of zone II (=X) with the actual flap width of zone II.ResultsX was similar to the actual measured width. Accurate volume replacement with the TRAM flap resulted in good symmetry in all cases.ConclusionsThe volume of a free TRAM flap can be straightforwardly estimated preoperatively using the method presented here, with ultrasound, ruler, and simple calculations, and this technique may help reduced the time required for precise flap tailoring.

The effect of adjuvant radiotherapy on radial forearm free flap volume after soft palate reconstruction in 13 patients.

The effect of adjuvant radiotherapy on radial forearm free flap volume after soft palate reconstruction in 13 patients.

Preliminary Study of Temporal Change in Free Flap Volume after Tongue Reconstruction

The purpose of this study was to investigate three-dimensionally temporal change in flap volume after free flap reconstructive surgery in tongue cancer patients. The results revealed an average change in flap volume of 82.3% at 1 year postoperatively. Change in tongue volume at approximately 6 months postoperatively showed a correlation with triglyceride levels. A correlation was also found between albumin levels and tongue volume at 1 year onwards postoperatively. The goal of such surgery in patients with tongue cancer is to reconstruct a functional tongue. Taking postoperative change in tongue volume into consideration is therefore of importance in minimizing postoperative dysphagia.

Three-dimensional prediction of free-flap volume in autologous breast reconstruction by CT angiography imaging

The diagnostic use of computer tomography angiography (CTA) to identify perforating blood vessels for abdominal free-flap breast reconstruction was extended to estimate the three-dimensional (3D) preoperative flap volume and to compare it with the real intraoperative flap weights in order to (1) evaluate the accuracy of CTA-based 3D flap volume prediction, and (2) to analyze abdominal tissue estimation for required breast volume reconstruction. Preoperative CTA was performed in 54 patients undergoing unilateral breast reconstruction with a free, deep, inferior epigastric artery perforator flap. 3D flap volumes ([Formula: see text]) based on CTA data were calculated and compared with the actual intraoperative flap weight (g). In addition, a breast volume to flap volume ratio was calculated to analyze whether the estimated 3D abdominal flap volume would match that of the breast to be removed. 40 CTA data sets (74.1 %) fulfilled the technical requirements for a reliable determination of flap volume. 3D CTA flap volume prediction showed no relevant differences to the actual flap weight (p = 0.44) and high correlations (r = 0.998, [Formula: see text]), allowing a prediction accuracy within 0.29 [Formula: see text] 3.0 % (range: from [Formula: see text]8.77 to 5.67 %) of the real flap weight. Significantly larger flap volumes were harvested compared with the actually required breast volumes ([Formula: see text]), leading to an average of 21 % of the remnant flap tissue potentially being discarded. CTA-based 3D flap volume prediction provides accurate preoperative guidelines concerning the needed amount of abdominal tissue that can be harvested to achieve acceptable symmetry.

Functional outcome after partial glossectomy with reconstruction using radial forearm free flap

The purpose of this study was to investigate the relationship between the radial forearm free flap (RFFF) volume changes and speech and swallowing outcomes. The study included 18 subjects with squamous cell carcinoma of the oral tongue. Average percentage changes in flap volume between 3 and 12 months was 19.2%. Postoperative free flap volume changes were significantly and negatively correlated with the word and sentence intelligibility (Y=-0.338X+43.641, r(2)=0.383, p=0.006 and Y=-0.246X+34.322, r(2)=0.321, p=0.014, respectively). A significant positive correlation was also found between word and sentence intelligibility and floor of mouth resected, postoperative irradiation. Postoperative flap volume changes between 3 and 12 months were correlated with reduced posterior bolus movement by tongue (p=0.002), reduced tongue base to posterior pharyngeal wall contact (p=0.002), reduced laryngeal elevation (p=0.005), increased aspiration (p=0.005), delayed oral (p=0.010) and pharyngeal transit time (p=0.011). Floor of mouth resected, tongue base resected, and postoperative irradiation also influenced the swallowing outcomes. This study shows that postoperative flap volume changes are significantly related to speech and swallowing outcomes in patients undergoing partial glossectomy reconstructed with RFFF.

Quantitative analysis of free flap volume changes in head and neck reconstruction

The purpose of this study was to determine whether free flap volume decreases or increases in the long-term postoperative period. We used a retrospective analysis of 17 patients to measure muscle and fat volume in free flap with 3-dimensional (3D) images using the AZE Virtual Place Lexus64. Seventeen patients underwent free flap reconstruction with rectus abdominis musculocutaneous flaps (n = 11) or anterolateral thigh flaps (n = 6). Median follow-up was 28.9 months (range, 2.1-48.4 months). Total flap volume was significantly decreased in flaps including ≥40% muscle (p = .011). Mean final muscle volume was 50% at an average of 12 months. Final fat volume was significantly higher for cases with no evidence of disease (mean, 116.7%) than for died-of-the-disease cases (mean, 70.3%; p = .007). Use of free flaps with a high ratio of fat to muscle is sustainable and can gain volume over time, as transplanted fat can increase depending on host condition.

Decrease in the free flap volume caused deterioration of swallowing function after subtotal glossectomy in a patient with tongue cancer： a case report

Decrease in the free flap volume caused deterioration of swallowing function after subtotal glossectomy in a patient with tongue cancer： a case report