Microvascular Free Flap Research Articles

Is the Sublingual Artery a Reliable Alternative for Intraoral Anastomoses in Head and Neck Free-Flap Reconstruction? Anatomical Basis and Preliminary Results

Background/Objectives: Head and neck free-flap reconstructions are often required to treat tumors or extensive post-traumatic jaw defects. The facial artery is the standard receiving vessel for intraoral microvascular anastomoses. However, its use is associated with several disadvantages, such as lesions of buccal nerve branches of the facial nerve or the parotid duct, as well as variability in course and diameter. The aim of this study is to investigate whether branches of the sublingual artery can be considered as an alternative intraoral supply vessel to the facial artery to avoid these drawbacks. Methods: Twelve formalin-fixed cadaveric heads with 24 sides (n = 24) were dissected. The origin, course, branching pattern, and distribution of the sublingual artery were examined. In addition, the diameters of the branches of the sublingual artery were assessed to identify potential supply vessels for anastomoses. Results: In ten of the twenty-four cases (41.7%), the sublingual artery originated from the lingual artery, and in nine cases (37.5%), the lingual artery originated from the facial artery. The main trunk of the sublingual artery was present in the floor of the mouth in all cases (100%), with a diameter of ≥0.9 mm in vitro (1 mm in vivo). In 15 of the 24 half heads (62.5%), branches of the sublingual artery with ≥0.9 mm were identified in this space, with the main branch being considerably stronger. Conclusions: The large diameter of the sublingual artery in the floor of the mandible suggests that this vessel or its branches could be considered as alternative pedicles for intraoral anastomoses in mandibular microvascular free-flap grafts.

Unfractionated Heparin Administered Every 8 h Outperforms 12 Hourly Administration for Venous Thromboembolism Prophylaxis in Reconstructive Head and Neck Tumor Patients: A 12 Year Retrospective Cohort Study.

Venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), poses a significant risk of morbidity and mortality in surgical patients, especially those undergoing head and neck cancer surgery with microvascular free flap reconstruction. These patients are at a heightened risk of VTE due to numerous patient and surgical risk factors. VTE chemoprophylaxis guidelines in these patients are limited due to a distinct paucity of research. This study aims to contribute to this scarcity of information, providing guidance for surgeons. This retrospective cohort study evaluated the efficacy and safety of subcutaneous unfractionated heparin administered every 8 h versus every 12 h for postoperative VTE prophylaxis in patients undergoing head and neck resections with immediate free flap reconstruction. Data was collected from hospital medical records between January 2010 to December 2021. Patient demographics, operative details, and outcomes, including incidence of VTE and bleeding complications, were analyzed. Among 622 patients, those receiving heparin every 8 h (n = 393) demonstrated a significantly lower rate of VTE (0.8%) compared to 12-hourly group (n = 229; 3.9%) (p = 0.006). Additionally, there were no significant differences in the rates of postoperative hematoma between the two groups (9.4% versus 7.9% respectively, p = 0.510). Our study suggests that an increased daily dose of unfractionated heparin every 8 h for VTE chemoprophylaxis is superior to a 12-hourly regimen with comparable bleeding profiles. Further multicentre, prospective studies are needed to validate these results and compare the efficacy and safety of unfractionated heparin with other agents such as low-molecular-weight heparin in this patient group.

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.

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.

Comparing the Outcomes of Osteocutaneous Radial Forearm and Fibula Free Flaps in the Reconstruction of Mandibular Osteoradionecrosis.

This study compares the outcomes of osteocutaneous radial forearm free flap (OC-RFFF) and fibula free flap (FFF) reconstruction of mandibular osteoradionecrosis (ORN). Retrospective review of patients undergoing OC-RFFF/FFF reconstruction for mandible ORN between 2005 and 2020 at a tertiary center. Patient characteristics, postoperative complications, and functional outcomes were evaluated using chi-squared and logistic regression analysis. Fifty-six patients were included (OC-RFFF: 38; FFF: 18). Significantly more OC-RFFF patients had lateral mandible defects (94% vs. 61%, p = 0.0014). There were significantly more patients with exposed intraoral bone in the OC-RFFF group (23% vs. 0% p = 0.02), but no significant differences in hardware complications or flap failure. Donor site partial skin graft loss was more common in the FFF group (22% vs. 2.6%, p = 0.016), but no other significant differences in donor site morbidity were seen. Bivariable analysis showed no impact of flap type, tobacco/alcohol use, diabetes, or hypothyroidism on postoperative complications. Sixty percent of OC-RFFF, and 67% of FFF, patients resumed an oral diet after surgery. Oral diet was not impacted by flap type (OR = 0.769, 95% CI = 0.201-2.706, p = 0.688). The OC-RFFF is an acceptable option in the reconstruction of ORN involving the lateral mandible, though there is increased risk of bone exposure. These findings can help guide surgeon selection of microvascular free flap donor sites and appropriate patient counseling.

Evaluation of flap complications following pectoralis major myocutaneous flap reconstruction for oral cancers

BackgroundOral cavity cancer is among the leading cause of cancer death in India. Pectoralis major myocutaneous flaps (PMMC) are still widely used for the reconstruction of defects pertaining to head and neck region, though free flaps are considered to be gold standard. The study was aimed to identify the risk factors involved in post - operative complications of PMMC Flap for oral subsites. MethodsA total of 266 patients operated in an oncology institute over 2 years of time was evaluated based on their demographic data, pre and post-surgery details, post-operative flap morbidity were collected retrospectively from master case sheets from January 2022 to January 2024. Factors such as age, gender, stage of disease, diabetic status, and hypoprotenemia and radiation therapy were seen, analysed to find their relation in causing flap complications. ResultsTotally 266 patients were included for analysis and 16.9 % had major flap complications. On detailed analysis, it was seen that larger bipaddled flaps had higher flap complication rate, highest being wound infection. ConclusionPMMC Flap is a viable option for head and neck cancer reconstruction, specifically in cases where free microvascular flaps are not done routinely and patient presents with multiple comorbidities. Careful patient selection, pre – operative optimization, operating surgeon experience and post-operative care are contributing factors to reduce flap complications.

ThP1.4 - Evidence-Based Perioperative Improvements in Microvascular Breast Free Flap Reconstruction: An Audit-Centric Evaluation &amp; Retrospective Cohort Study

Abstract Aim This audit aimed to evaluate and improve the results of microvascular breast free flap reconstruction by implementing an enhanced perioperative care approach. Method All microvascular breast free flap reconstructions between June to August 2023 were included. Additionally, a three year retrospective review was conducted in adherence to ABS and the BAPRAS guidelines. Our team plans to introduce an evidenced-based modified Enhanced Recovery After Surgery (ERAS) protocol via MDT collaboration with a focus on pre-operative and post-operative care to improve postoperative outcomes. Results During June – August 2023, 22 flaps were performed with an average length of stay (LOS) of 5.47 days (target &amp;lt;3d). There were no unplanned readmissions, an 18% return to theatre (RTT) rate and a total complication rate of 18%. Over the past three years, out of 323 flaps, there was a 13% RTT rate with no unplanned readmissions. Suggested modifications to reduce length of stay include pre-surgical counselling and nutritional loading. Post-operatively, using a multi-modal opioid sparing analgesia (MOSA) regime, along with laxatives, early mobilisation and feeding has proven to enhance recovery. Pre-admission patient optimisation, VTE and perioperative antibiotic prophylaxis have been shown to reduce rates of flap failures and post-operative complications. Effective wound care, post-discharge support and physiotherapy are also crucial in accelerating recovery and preventing readmissions. Conclusion Implementing these ERAS modification to our current protocol is predicted to significantly improve post-operative recovery, thus improving surgical outcomes. This underscores the potential for continual improvement in patient care through an efficient evidence-based perioperative pathway.

Postoperative Sedation in Free Microvascular Tissue Transfer in Head and Neck Cancer: A Comparison of Fentanyl and Morphine

Background and Aims: Head-and-neck cancer surgeries with microvascular free flap reconstruction require endotracheal tube retention for 24–48 h postoperatively. Many regimes have been used for analgesia and sedation. The efficacy of fentanyl and morphine for post-operative analgosedation was compared by evaluating the need for additional sedatives to achieve optimum sedation scores. The secondary objective included analgesia, haemodynamic stability and a re-exploration rate. Methods: This was an open-label prospective study. A sample size of 36 was calculated in each group with α = 0.05 and a power of 80% to detect a 50% difference between the groups. Ninety adult patients were allocated to receive either fentanyl (Group F) or morphine (Group M). The Richmond agitation sedation score, Behavioural pain scale score, requirement of rescue hypnotic drug, pulse rate, systolic and diastolic blood pressures and re-explorations were recorded postoperatively. Haemodynamic parameters and sedation were analysed by two-way repeated measures of analysis variances. Pain scores were analysed using the Chi-square test. Results: When titrating to optimal sedation, in Group M, more patients needed intravenous midazolam boluses (n = 42, 93.3%) as compared to Group F (n = 33, 73.3%) (P = 0.011). More subjects in Group M required propofol infusion (n = 15, 33.3%) than in Group F (n = 4, 8.9%) (P = 0.009). Mean behavioural pain scores were significantly higher in Group M (score 1: P = 0.005 and score 2: P =0.001). The difference in the mean systolic, diastolic blood pressure, pulse rate, respiratory rate and re-exploration rate between the two groups was statistically insignificant. Conclusion: For analgesia-based sedation of spontaneously breathing intubated patients after head-and-neck cancer reconstructive surgeries, fentanyl is more effective than morphine in terms of ease of titration, sedation quality and analgesia. Both are safe for post-operative sedation regarding haemodynamic stability, tube retention and maintenance of spontaneous respiration.

The risk of free flap revision and subsequent medical costs in patients with hypopharyngeal cancer.

Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients. A 20-year retrospective case-control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis. Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12-5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders. Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population.

Initial experience with ovine forestomach matrix graft for glossectomy defect reconstruction: A case series

Soft tissue reconstruction of oral cavity defects, such as glossectomy defects secondary to malignancy, pose a challenge for head and neck, oral, and maxillofacial surgeons. Reconstruction options for mucosal defects include primary closure, healing by secondary intention, full mucosal and split-thickness skin grafts, pedicled flaps, and microvascular free flaps. Biological grafts have become an integral part of the modern reconstructive ladder and are widely used for the regeneration of various soft tissue defects, including oral defects. This case series describes our initial experience using ovine forestomach matrix grafts in tongue and oral cavity reconstruction. Oral reconstruction using ovine forestomach matrix grafts was undertaken on three patients post wide excision and resulted in good functional and cosmetic outcomes. The rate of tissue formation provided by the graft and the grafts’ relative resistance to the hostile environment of the oral cavity support further clinical research to validate the use of these devices in oral reconstruction.

Reconstruction of functional human lips utilizing a prelaminated flap.

Lips form a structure that are difficult to reconstruct after a traumatic avulsion injury or cancer ablative surgery secondary to loss of volumetric muscle mass. Traditional tissue engineering approaches of in vitro fabrication of mature tissue constructs can supply an alternative to the current surgical standard of care for functional lip reconstruction. We demonstrate a hybrid approach that combines the advantages of in situ muscle flap prefabrication with in vitro fabrication of an autogenous mucocutaneous construct as the laminate for prelamination to form a designer microvascular muscle free flap for lip reconstruction.

Clinical Significance of Hyperhomocysteinemia in Free Flap Failure: A Case Report

AbstractFailure of a microvascular free flap remains rare, yet multiple failures can occur, particularly in the presence of hypercoagulable conditions. This case series highlights our experience with a rare hypercoagulable state: hyperhomocysteinemia.We present two cases of patients with hyperhomocysteinemia in this report. High-dose heparinization was administered to both patients, resulting in successful salvage of one flap and failure of the other. Notably, one patient had a history of prior free flap failures. However, after correcting hyperhomocysteinemia, subsequent free flaps were successful.In cases of detected complications, a coagulability study is warranted, and adjustments to anticoagulation treatment may be necessary. Furthermore, when a history of flap failures is evident, screening for hyperhomocysteinemia may be warranted, with correction made prior to reconstruction.

Impact of Preoperative Multidisciplinary Conference on Head and Neck Reconstruction Outcomes.

Head and neck oncologic resections with microvascular reconstruction are lengthy and complex procedures with inefficiencies in the operating room (OR) associated with increased complications and higher costs. Multidisciplinary care has become increasingly used to provide improved care for complex patients; however, the potential role of this has not yet been studied in head and neck microvascular free flap procedures. Patients between 2016 and 2022 treated before and after implementation of the conference were included. Primary outcome was total procedure time (TPT). Demographics, operative details, and postoperative complications were also collected. 233 patients were included in the preconference group and 330 in the post-conference group. Preconference mean (SD) age was 61.6 (12) years versus 62.9 (12) years in the post-conference group. The post-conference group was associated with shorter mean (SD) TPT (629 [117] vs. 719 [134] minutes), less mean (SD) estimated blood loss (ESD) (230 [201] mL vs. 306 [211] mL), fewer prolonged lCU stays (>1 day), and fewer returns to the operating room (RTOR). The post-conference group was associated with TPT ≤9 h (p < 0.001) on multivariate analysis. Factors associated with TPT greater than 9 h include history of head and neck radiation (p = 0.003), bony reconstruction (p = 0.05), stage IVa (p = 0.009), and stage IVb cancer (p < 0.001). Implementation of the multidisciplinary conference in head and neck surgery was associated with reduced TPT and reduced OR return. Our study suggests preoperative planning conferences may improve surgical efficiency and outcomes in head and neck oncologic resections with microvascular free flap reconstruction. 3 Laryngoscope, 2024.

3D modeling of anterior 2/3rds glossectomy reconstruction: A volume based donor site evaluation

ObjectiveAnterior 2/3rds glossectomy results in significant patient morbidity due to speech and swallowing impairment. Microvascular free flap reconstruction compensates for large volume defects. Flap volume is based on the adipose content of the donor site and varies by patient body mass index (BMI) and donor site location. We sought to correlate flap thickness at different donor sites with patient BMI to determine optimal donor site selection. MethodsPatients with CT scans of the oral cavity, thorax and lower extremity were identified and included. The volumes of the anterior 2/3rds of the tongue were measured and recorded using computed tomography-generated modeling. Pre-muscular tissue thicknesses at anterolateral thigh (ALT), deep inferior epigastric artery (DIEP), latissimus dorsi, and parascapular donor sites were measured. The donor site adequency was defined as reconstructing the tongue volume within 10% of the ideal volume required and stratified based on patient BMI. ResultsIn 144 patients, the average anterior 2/3rds glossectomy defect was 100.3 cm3. Glossectomy defect size was highly correlated with BMI (p < 0.001). The DIEP flap had the largest volume (155.4 cm3), followed by latissimus (105.6 cm3), parascapula (97.8 cm3), and ALT (60.5 cm3). For patients with BMI ≤ 30, the DIEP flap best reconstructed native tongue volume (up to 113 % of native tongue volume). In patients with BMI > 30.1, native tongue volumes were approximated by the latissimus flap (89–92 % of native tongue) and parascapular flap (85–95 % of native tongue volume). In BMI > 30.1 the DIEP flap provided excess tissue bulk (129–135 % of native tongue volume). ConclusionThe DIEP flap more closely approximates the volume needed to reconstruct anterior two-thirds tongue defects for BMIs ≤ 30. The subscapular system flaps provided the best volume match for BMIs > 30 and the DIEP flap provided excess tissue bulk which could be adjusted in the reconstruction process.

Microvascular Free-Flap Head and Neck Reconstruction: The Utility of the Modified Frailty Five-Item Index.

Microvascular free tissue transfer is a common tool for the reconstruction of oncologic head and neck defects. Adequate preoperative assessment can aid in appropriate risk stratification and peri-operative optimization. The modified five-item frailty index (mFI-5) is a validated risk-assessment scale; however, its utility in head and neck free-flap reconstruction is unknown when compared with other common risk factors. A retrospective, single-institution chart review (2017-2020) was performed. Patient demographics, defect and repair characteristics, pre- and peri-operative factors, and flap outcomes were recorded. A high mFI-5 score was defined as greater than 2. The total score, as well as other patient factors, was correlated to postoperative flap complications. A total of 214 patients were deemed appropriate for conclusion. The mean age was 63.9 ± 12.8 years. There were an even number of males (52.8%) and females (47.2%). A fifth of subjects (20.8%) underwent preoperative radiotherapy. There were 21 cases (9.8%) of complete flap loss. A total of 34 patients (29.4%) experienced any postoperative complication related to flap outcomes. An elevated mFI-5 was significantly associated with a higher overall rate of postoperative complications (39.7 vs. 29.4%, p < 0.019) and total flap loss (16.7% vs. 6.6%, p < 0.033). Preoperative radiation was found to be associated with an increased complication rate (p < 0.003). The mFI-5 score may be a potentially significant tool in the risk stratification of patients undergoing head and neck free-flap reconstruction as opposed to commonly utilized risk factors. Preoperative radiotherapy is significantly associated with postoperative complications. Appropriate preoperative assessment may help tailor patient care preoperatively.

Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction.

Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. Retrospective cohort study. Single tertiary academic medical center. An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.

Patient-specific Implants Improve Volumetric Surgical Accuracy Compared to Stock Reconstruction Plates in Modern Paradigm Virtual Surgical Planning of Fibular Free Flaps for Head and Neck Reconstruction

BackgroundVirtual surgical planning (VSP) for composite microvascular free flaps has become standard of care for oncologic head and neck reconstruction. Controversy remains as to the use of three-dimensional (3D)-printed titanium patient specific implants (PSI) versus hand-bent stock reconstruction plates. Proponents of PSIs cite improved surgical accuracy, reduced operative times, and improved clinical outcomes. Detractors purport increased cost associated with PSIs and presumed equivalent accuracy with less expensive stock plates. PurposeThe study purpose was to measure and compare the 3D-volumetric accuracy of PSI versus stock reconstruction plates among subjects undergoing VSP-guided mandibular fibular free flap reconstruction. Study Design/Setting/SampleA retrospective cohort study of subjects undergoing VSP-guided fibular free flap reconstructions at Mayo Clinic between 2016-2023 was performed. Subjects were excluded for non-VSP guidance, midfacial reconstruction, non-fibular free flaps, and lack of requisite study variables. Predictor VariableThe primary predictor was the type of reconstruction plate utilized (PSI versus stock plate). Main Outcome VariableThe main outcome was volumetric surgical accuracy of the final reconstruction compared to the preoperative surgical plan by root mean square error (RMSE) calculation. Lower RMSE values indicated a higher surgical accuracy. CovariatesCovariates included age, sex, race, smoking status, ASA classification, Charlson Comorbidity Index, preoperative diagnosis, and number of fibular segments. AnalysisDifferences in surgical accuracy were assessed between pre- and post-operative segmented scans using volumetric overlays from which RMSE values were calculated. Univariate and multivariate modeling of plate type to RMSE calculation was performed. Statistical significance set to p<0.05. ResultsTotal of 130 subjects were identified, 105 PSI and 25 stock plates. Calculated mean RMSE in millimeters (mm) for stock plates was 1.46 (SD: 0.33) and 1.15 (SD: 0.36) for PSIs. Univariate modeling demonstrated a statistically significant difference in RMSE of 0.31 (95% CI: 0.16-0.47) (p<0.001) equating to a 21.2% (p<0.001) improved volumetric surgical accuracy for PSIs. The association of improved volumetric accuracy with PSIs maintained in all multivariate models controlling for confounding. Conclusion and RelevanceIn modern era VSP-guided head and neck fibular free flap reconstruction, patient-specific 3D-printed titanium implants confer a statistically significant improvement in volumetric surgical accuracy over stock reconstruction plates.

Antiresorptive agents enhance ossification of free flap reconstructions of the mandible: a radiological retrospective cohort study.

The aim of this study was to investigate the effect of antiresorptive agents on the ossification of reconstructed mandibles by free bone grafts for the first time. A total of 38 reconstructions of the jaw were retrospectively evaluated for ossification between bone segments by two raters based on postoperative panoramic radiographs. The study group (n = 13) had segmental resection of the mandible and free bone flap reconstruction due to medication-related osteonecrosis of the jaw (MRONJ). The control group (noMRONJ, n = 25) comprised segmental mandibular resections and free bone flap reconstructions due to tumors, chronic osteomyelitis, or trauma without any radiation. Ossification time and influencing factors were evaluated. Both duration of surgery (346 ± 90min. vs. 498 ± 124min.; p < 0.001) and hospitalization (8.7 ± 2.8 days vs. 13.4 ± 5.3 days, p = 0.006) were shorter in the MRONJ group compared to the noMRONJ group. Ossification after mandibular reconstruction was significantly faster in the MRONJ study group [224 days, interquartile range (IQR) 175-287] compared to the control group (288 days, IQR 194-445; p < 0.001). Moreover, good initial contact between the segments resulted in faster ossification (p < 0.001) in the MRONJ group. Ossification rate between original and grafted bone or between grafted bone segments only did not differ in both the study and control groups (MRONJ, p = 0.705 vs. control, p = 0.292). The type of antiresorptive agent did not show any significance for ossification. The rate of wound healing disturbances did also not differ between the study and control groups (p = 0.69). Advanced MRONJ (stage 3) can be resected and reconstructed safely with free microvascular bone flaps. Antiresorptive agents enhance the ossification of the bone segments. Optimal initial contact of the bone segments accelerates bone healing. Surgery and hospitalization are markedly shortened in this vulnerable group of MRONJ patients compared to oncologic patients.

Hair Transplantation on the Baldness Region with Free Latissimus Dorsi Flap for Scalp Reconstruction: A Case Report

AbstractScalp reconstruction, particularly with complex defects and infection risks, often favors microvascular free flaps. However, this method can result in unavoidable alopecia and undesirable aesthetics. This report describes a novel case where hair transplantation via follicular unit extraction (FUE) was applied to a free myocutaneous flap. A 44-year-old woman with Moyamoya disease suffered intracerebral hemorrhage a decade ago. Craniotomies and autologous bone cranioplasties led to wound dehiscence, with subsequent failed local flaps and skin grafts, and identification of a methicillin-resistant Staphylococcus aureus infection. The final scalp defect, measuring 13 × 9 cm, was reconstructed using a free myocutaneous latissimus dorsi flap. Nine years post-surgery, a 1,500-unit FUE hair transplantation procedure was conducted. The transplanted hair exhibited robust survival with adequate blood supply, achieving a satisfactory 80 to 85% survival rate at 12 months. This resulted in a notable improvement in the patient's external alopecia, with reported high levels of satisfaction. Free flaps offer a valuable method for scalp defect reconstruction; however, they may not ensure optimal aesthetic satisfaction due to alopecia. Nonetheless, successful FUE hair transplantation on a myocutaneous free flap can yield satisfactory aesthetic results.