Rectus Abdominis Free Flap Research Articles

Midface microvascular reconstruction after maxillary complex tumor resection: A retrospective study

The study purpose is to review the surgical approach and evaluate the results in managing patients with advanced midface and maxillary complex tumors.The most common anatomical site of the primary tumor was the maxilla, sometimes with extension to the orbit and anterior fossa, parotid and middle ear or even the lip. Surgical resection included maxillectomy in the majority of cases, combined with orbital exenteration or orbitectomy and anterior fossa resection. Parotidectomy and mastoidectomy/core petrosectomy were also performed. Reconstruction was performed with radial forearm osteocutaneous free flap, latissimus dorsi myocutaneous flap with scapular bone flap, lengthening temporalis myoplasty, rectus abdominis free flap, anterolateral thigh flap, in combination with temporalis and vastus lateralis, as well as pectoralis major myocutaneous flap.A total of 36 midface tumor excisions were performed, followed by the appropriate reconstruction. The average follow-up period was 15 years. To date, 23 patients are disease free, while 6 patients presented disease recurrence and 7 patients died during the 15-year follow-up period.Surgical resection remains the gold standard for midface tumors management. When safely performed, combined with microvascular and dynamic face reconstruction, surgery can offer improvement in quality of life and prolong the overall survival.

Functional and contour restoration in severely injured extremities - our approach to reconstruct composite (Multizonal) injuries of foot and ankle

BackgroundCoverage of ankle and foot defects has been challenging. This study highlights the importance of microsurgical free tissue transfer as an opportunity for a surgeon to deal with composite foot defects with variable etiology. MethodA retrospective case review of 28 patients with large Multizonal foot defects resulting from trauma and tumor resections presented to tertiary care hospitals from 2008-to 2021. All defects were reconstructed by free flaps. 14 patients had ALT flaps, 4 underwent free fibula flaps, and 6 had LD flaps and 4 Rectus Abdominis free flaps. Different modalities have been reviewed by literature for the type of flap used, zone involvement, and age groups. Result26 patients were male and 2 females. Most of our patients were adults presenting post-trauma including n ​= ​21 (75%) road traffic accidents n ​= ​17 (60.7%), mine blast injury n ​= ​4 (14.2%), and malignancy in n ​= ​3 (10.7%). Age range was from 5 years to 75 years. Most of the patients had involvement of subunits 3 and 4 followed by a combination with other sub-units. After free microsurgical tissue transfer, 2 patients needed immediate exploration, one had arterial compromise and one had venous insufficiency. All flaps survived. 3 patients underwent flap debulking in the follow-up period. All patients were followed for 2 years and returned to daily activities and near to normal ambulation. ConclusionMicrosurgical free tissue transfer has not only proven its role in post-traumatic composite foot defects but also in malignancies where resection with free margins followed by foot reconstruction poses a major challenge.

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

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

Ex Vivo Thrombolysis to Salvage Free Flaps Using Machine Perfusion: A Pilot Study in a Porcine Model

Mechanical evacuation of capillary thrombi in free flaps is difficult, and often requires thrombolytic therapy. Utilizing machine perfusion systems, the possibility rises to salvage free flaps ex vivo by administering high doses of thrombolytic agents. The primary aim of this pilot study in a porcine model is to investigate the feasibility of ex vivo thrombolysis using an extracorporeal perfusion machine. A model of stasis-induced thrombosis was used in 12 free rectus abdominis flaps harvested from six Dutch Landrace pigs. Compromised flaps were ex vivo perfused with University of Wisconsin preservation solution and treated according to the following study groups: (1) 1 mg of tissue plasminogen activator (t-PA) as additive, (2) 3 mg of t-PA as an additive, and (3) no thrombolytic additive. Microcirculation was assessed using near-infrared fluorescence angiography. Pedicled abdominal flaps were created and thrombus formation was successfully induced. Eleven abdominal flaps were perfused using the modified heart-lung machine setup. Near-infrared fluorescence angiography showed delayed or no filling was noted in the control group. In comparison, the flaps which were perfused with 1 mg t-PA or 3 mg t-PA as additive showed increased fluorescence intensity curves. This pilot study in a porcine model presents a reliable and reproductive stasis-induced thrombosis model in free flaps. By adding t-PA to a custom-made extracorporeal perfusion system, the indocyanine green fluorescence intensity curves increased of all flaps that were perfused with different dosages of t-PA as additives, indicating restoration of capillary pressure and microcirculatory inflow.

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine.

There is a risk for thrombotic complications (2 to 5 percent) associated with microsurgical reconstruction. Current thrombolytic therapy has a salvage rate between 60 and 70 percent, but it is afflicted by bleeding complications (2 to 6 percent). The use of machine perfusion for delivering thrombolytic agents is a new method that could potentially reduce these complications. In this article, the authors compared flap salvage outcomes comparing machine thrombolysis versus a manual flush with tissue plasminogen activator. Sixteen bilateral flaps (12 × 9 cm) were dissected from eight female Dutch Landrace pigs (70 kg). Thrombosis was induced in free rectus abdominis flaps by clamping the pedicle's veins for 2 hours. Flaps were either thrombolysed with 2 mg tissue plasminogen activator (1 mg/ml) during 2 hours of machine perfusion (perfusion group; n = 8) or injected intraarterially (manual group; n = 8) before replantation. Near-infrared fluorescence angiography was used to confirm thrombus formation and to assess tissue perfusion; muscle biopsy specimens were analyzed for ischemia/reperfusion injury directly after thrombolysis and 15 hours after replantation. A higher incidence of secondary thrombosis was seen in the manual group compared to the perfusion group ( n = 6 versus n = 0, respectively; p < 0.001), resulting in two complete flap failures. Fifteen hours after replantation, mean fluorescence intensities were 13.0 (95 percent CI, 10.1 to 15.8) and 24.6 (95 percent CI, 22.0 to 27.2) in the perfusion and manual group, respectively ( p < 0.001), and mean muscle injury scores were comparable, measuring 7.5 ± 1.5. Two hours of machine thrombolysis of compromised flaps in a porcine model showed higher salvage rates compared to a manual injection with tissue plasminogen activator and reduced the incidence of secondary thrombosis. Using machine perfusion systems for ex vivo thrombolysis provides the benefits of local treatment of a composite tissue without the risk of systemic complications and may improve salvage rates and reduce the incidence of secondary thrombosis.

Free rectus abdominis myocutaneous flap for the reconstruction of major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinomas

Objective: To explore the method and plausibility of using free rectus abdominis flap (FRAF) to reconstruct the major and complex defects in the craniofacial regions after ablation of advanced sinonasal carcinoma. Methods: From 2007 to 2018 at No. 980 Hospital of Joint Logistic Supportive Force of People's Liberation Army of China, 13 patients with advanced carcinoma of nasal cavity and paranasal sinuses, including 11 males and 2 females, aged from 33 to 67 years, were treated with FRAF to repair the invasion of skull base, face and orbit. Based on adequate and meticulous preoperative evaluations on patients and tumors, complete resection of tumor bulks was performed. According to the sites, characters and extents of the defects, FRAF was introduced in different ways into reconstruction of major and complex defects in the craniofacial regions after resection of advanced sinonasal carcinomas, restoring the structure and contour of the craniofacial region. Results: Complete resection of tumors was achieved in all cases. For repairing the major and complex defects resulted from tumor ablation, FRAF graft was conducted in 13 patients with advanced sinonasal carcinomas. The recipient vessels were facial artery and vein in 9 cases, superficial temporal artery and vein in 4 cases. Vascular bridging with the external jugular vein was carried out in 2 cases who underwent submandibular neck dissections, in which facial artery and vein were used as recipient vessels. Free fibular flap was used along with FRAF in a case undergone bilateral maxillectomy. Pedicled galea capitis and periosteal flap were applied simultaneously in 3 cases with dura defects at the skullbase resulted from tumor resection. All flaps used in 13 cases survived uneventfully without major complications, with successful repair of defects, reconstruction of structures and restoration of contour of craniofacial regions. Conclusion: With adequate evaluation of resectability of tumors as well as nature and extent of defects after tumor removal, FRAF transplantation is an ideal method and strategy of choice for reconstructing the major and complex defects in craniofacial regions resulted from tumor ablation of advanced sinonasal carcinomas.

The role of the rectus abdominis flap in head and neck reconstruction

The rectus abdominis free flap, based on the deep inferior epigastric artery and vein has been used extensively in breast reconstruction. It is a reliable soft tissue donor, has a long pedicle, favourable diameter vessels and is ideally suited for large defects. The distribution of perforators allow for versatility in designing the flap and a variety of patterns of the skin paddle may be used. It can be harvested as a muscle-only or myocutaneous flap. However, despite these advantages, its application in head and neck reconstruction is not widely appreciated.

Reconstructive Options for Composite Maxillary Defects With Orbital Exenteration—The Royal Adelaide Experience

PURPOSE: Composite orbito-maxillary defects following maxillectomy and orbital exenteration remain one of the most sophisticated reconstructive challenges in head and neck surgery. We present the outcomes of a 15-year single-centre review of patients who underwent reconstruction of Cordeiro types IIIB and IV defects, and review the reconstructive options. METHODOLOGY: All patients who underwent maxillectomy with orbital exenteration between 2004 and 2019 were identified from the Royal Adelaide Hospital Plastic Surgery database. Patient’s medical records, operation notes, pre- and postoperative photographs were reviewed. The reconstructive methods were analysed based on defect components—skin, maxilla, orbit, palate, and skull base. RESULTS: A total of 22 patients underwent reconstruction for Cordeiro types IIIB and IV orbito-maxillary defects. The most common pathologies were SCC (59%) followed by melanoma (18%). Fourteen (64%) patients had type IIIB and 8 (36%) had type IV defects. The most commonly used free flaps were rectus abdominis with or without skin paddle (55%), ALT (22%), and ALT/vastus lateralis chimeric flap (14%). Reconstructive options for the skin, maxilla, orbit, palate, and skull base were analysed and described in detail. Flap survival rate was 95%. Other postoperative complications included hematoma (9%) and infection (9%). CONCLUSION: Reconstruction of Cordeiro types IIIB and IV defects should identify and address each defect component to achieve soft tissue coverage, contour, oronasal, and cranionasal separation. The most robust and versatile option is the rectus abdominis free flap. In our experience, bony reconstruction is not required for most Cordeiro IIIB and IV defects.

Free flap transfers for head and neck and skull base reconstruction in children and adolescents - Early and late outcomes

ObjectivesReconstruction of surgical defects by free tissue transfer following resection of head and neck tumors in children are sparse. This study aims to assess the feasibility and safety of free flap reconstruction following surgical ablation of head and neck and skull base tumors in children based on our experience and the recent literature. MethodsData from medical files of all children and adolescents <18 years of age who underwent free flap reconstruction following resection of head and neck and skull base tumors at our tertiary center between 2000 and 2018 were retrospectively reviewed. Data on early and late complications at the primary and donor sites, functional and aesthetic outcome, and tumor control were analyzed. ResultsTwenty-four children (mean age 11.3 ± 5.1 years) were enrolled. Early complications occurred in 14 (56%) and late complications occurred in 8 (32%) of the procedures, with surgical intervention required in 4 (16%). Prior chemoradiation, sarcoma, non-reanimation procedures, and the use of rectus abdominis free flaps were associated with higher complication rates. The final functional and cosmetic outcomes, including mastication, deglutition, and speech, were satisfactory in all patients with one exception. ConclusionsFree flap transfer is a safe and feasible technique for reconstructing head and neck and skull base defects following surgical excision of tumors in children. Early identification and precautionary measures against the effects of potential causes of complications may improve outcome. Larger international cohort studies are warranted.

The esthetic outcome of lower limb reconstruction

In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.

Long-term Results of Mandibular Reconstruction Using Mandibular Reconstruction Plate After Resection of Mandibular Region Against Malignant Tumor

PURPOSE: In the mandibular reconstruction after resection of the mandibular region against malignant tumor, there are cases where a method using a mandibular reconstruction plate is selected depending on the patient’s general condition or stage. Problems of infection, manifestation, breakage of plate in the lower jaw. This time, we investigated long-term outcome of surgery on mandibular reconstruction using reconstruction of lower jaw performed at our hospital, surgery >10 years ago. However, there are few reports of long-term results. METHODS: From January 1993 to December 2008, for patients who underwent reconstruction of the mandible using the mandibular reconstruction plate at the National Cancer Center Hospital East after mandibular region resection, using a medical record and retrospectively. RESULTS: There were 52 patients who underwent mandibular reconstruction using the mandibular reconstruction plate during the same period, among which 38 patients were able to use medical record. In 38 cases, 26 men, 12 females, average age 78 ± 15 years old, all cases were cases of mandibular cancer. All of the cases were done with the mandibular reconstruction plate and the flap used was 28 free rectus abdominis flaps, 7 anterolateral thigh flaps, and 3 forearm flaps. The follow-up period was 38.6 ± 7 months (1–169 months), 5 cases of wound departure, 5 infections, 2 cases of infection, and 3 cases of plate exposure as postoperative complications. Thirty-three of 38 deaths occurred within 10 years, and 5 cases were observed after ≥10 years, among which 4 cases did not cause problems on the mandibular reconstruction plate. DISCUSSION: Mandibular cancer requiring reconstructive surgery often has advanced disease stage and has poor prognosis. In addition, patients are often older, and long-term follow-up was accompanied with difficulties. Long-term results were examined in the range that could be observed.

Free tissue transfer with the free rectus abdominis flap in high-risk patients above 65 years: A retrospective cohort study

Though technically feasible, free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To minimize the operative treatment time and complication rates, we choose the rectus abdominis muscle (RAM) flap. Between 2012 and 2017, 34 patients (mean age: 74±7 years, range: 65-89 years) with comorbidities underwent defect reconstruction with a free RAM flap. Recipient-sites were: lower extremity (65%), trunk (18%), upper extremity (12%), and head and neck (6%). The ASA status was 2 in 11 patients, 3 in 21 patients, and 4 in 2 patients. Twenty patients (59%) received additional vascular surgery. Three patients (9%) underwent simultaneous restoration of fractures. The mean operative time (OT) was 325±75min. There was no total flap loss. Partial flap loss occurred in one patient (3%). The incidence of surgical and medical complications was 32% and 38%: 11 patients experienced a total of 22 surgical complications, of which 15 were major (requiring additional surgery) and 7 minor (conservative treatment). One patient died postoperatively because of progressive respiratory failure. Prolonged OT was highly associated with hematoma formation requiring re-operation (p = 0.01). ASA status was a significant predictor for postoperative critical care monitoring (p = 0.03). Reconstruction was successful in 31 out of 34 patients (91%) during a mean follow-up time of 17.7 ± 8.8 months (range: 2-51 months). The free RAM flap has proven as a reliable and efficient tool in the armamentarium of reconstructive microvascular surgeons with some advantages in the treatment of multimorbid patients older than 65 years.

Free muscle sparing vertical rectus abdominis myocutaneous flap

Introduction: Abdominal region is a unique donor area in the reconstructive surgery to provide numerous flaps. The aim of this study is to show effectivity of the free vertical rectus abdominis muscle (VRAM) flap in the complex wounds reconstruction without damaging integrity of the rectus abdominis muscle and sacrificing the opposite deep inferior epigastric artery. Materials and Methods: The study population was composed of all patients who applied to our department for evaluation and management of the complex wounds reconstruction with the free muscle sparing (MS) vertical rectus abdominis flap, between September 2011 and October 2015. Results: We utilized the free MS vertical rectus abdominis flap to closure complex wounds in seven patients (6 males and 1 female) in our department. Etiologies were malign skin tumors, amputation stump, unstable scar, and crush injury in three, two, one, and one patients, respectively. All MS vertical rectus abdominis flaps survived completely. A hematoma developed in the recipient site in one case, and it was immediately evacuated without any problem. Conclusions: Free MS vertical rectus abdominis flap is a quite easy and reliable flap to harvest from abdominal wall, reducing the possibility of bulging or hernia formation with less morbidity of the donor site.

Successful Long-term Extracorporeal Perfusion of Free Musculocutaneous Flaps in a Porcine Model

BackgroundExtracorporeal perfusion is a technique that aims to safely prolong tissue preservation by reducing ischemia-reperfusion injury. Free muscle flaps provide a sensitive research model due to their low ischemic tolerance. However, long-term perfusion of free muscle flaps is scarcely researched. The aim of this study was to compare tissue damage in musculocutaneous flaps during 36 h of extracorporeal perfusion versus static cold storage. Materials and methodsBilateral free rectus abdominis flaps were harvested from five Dutch Landrace pigs (weight: 53-59 kg). Flaps were treated for 36 h according to the following study groups: (1) cold storage at 4°C-6°C (n = 4), (2) perfusion with histidine-tryptophan-ketoglutarate (HTK) at 8°C-10°C (n = 3), (3) perfusion with University of Wisconsin solution (UW) at 8°C-10°C (n = 3). Perfusion fluid samples (creatinine kinase, blood gas) and biopsies for quantitative polymerase chain reaction were collected at multiple time points. Microcirculation was assessed at 24 h of preservation using indocyanine-green fluorescence angiography. Flap weight was measured at the start and end of the preservation period. ResultsSuccessful and stable perfusion for 36 h was achieved in all perfused flaps. The mean creatinine kinase increase in the perfusion fluid was comparable in both the groups (UW: +43,144 U/L, HTK: +44,404 U/L). Mean lactate was higher in the UW group than in the HTK group (6.57 versus 1.07 mmol/L). There were homogenous and complete perfusion patterns on indocyanine-green angiography in both the perfusion groups, in contrast to incomplete and inhomogeneous patterns during cold storage. Expression of genes related to apoptosis and inflammation was lower in perfused flaps than in the cold storage group. Weight increase was highest in the HTK group (78%; standard deviation [SD], 29%) compared with UW (22%; SD, 22%) and cold storage (0.7%; SD, 4%). ConclusionsLong-term extracorporeal perfusion of free rectus abdominis flaps is feasible. Outcomes in the perfusion groups seemed superior compared to cold storage. Hypotheses gained from this research need to be further explored in a replantation setting.

Nipple-areolar complex ischemia and necrosis in nipple-sparing mastectomy

IntroductionNipple-sparing mastectomy (NSM), combined with immediate breast reconstruction, has become the preferred surgical option to achieve better patient satisfaction and aesthetic outcome. However, nipple-areolar complex (NAC) ischemia and necrosis are common complications following nipple-sparing technique. Materials and methodsWe performed a retrospective analysis of 220 breasts that underwent NSM and immediate reconstruction from May 2010 to December 2016 at our institute. For accurate evaluation of ischemia rate after nipple-sparing mastectomy, we suggested a nipple-areolar ischemia grading system. We also found association between various factors and complications of nipple-areolar complex through statistical analysis. ResultsAmong 220 breasts that underwent NSM in 207 patients, ischemia occurred in 141 (64.1%) breasts. However, necrosis required surgical reoperation in only 69 (31.3%) breasts. Patient factor affecting NAC complications was existence of ptosis. Also, surgical techniques for periareolar incision as well as oncologic surgeon's technique impacted NAC necrosis. Reconstruction methods including direct-to-implant, latissimus dorsi island flap with implant, and transverse rectus abdominis free flap showed higher rate of necrosis compared to tissue-expander reconstruction. ConclusionWe clarified factors that affect NAC necrosis. Among them, modifiable factors were skin tension and periareolar incision. When periareolar incision is necessary, lower periareolar incision is safer than upper periareolar incision to preserve vascularity of NAC.

Early Results of a Collaborative Multispecialty Mangled Extremity Algorithm for Acute Limb Salvage with Incorporation of Long Saphenous Arterial-Venous Loops for Free Flap Reconstruction in the Community Hospital Setting

Salvage of the mangled lower extremity is both technically challenging and time-consuming. It requires the collaborative efforts of multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitation of a successful limb salvage program with creation of a mangled extremity algorithm. An integral part of this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Use of a long saphenous arterial-venous (AV) loop has been cited, but minimal data are available with larger inflow vessels in the acute trauma setting. We describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Since June 2016, eight patients admitted from the trauma service with mangled lower extremity injuries were identified and placed into the protocol. All eight patients sustained severe crush injuries with large tissue defects and insufficient distal runoff for healing but deemed salvageable by multispecialty assessment. Mangled Extremity Severity Scores were tabulated. Patients (seven male and one female) ranged in age from 21 to 44 years. Per protocol, repeated débridement was performed until successful sterilization of the wounds was accomplished. Eight long saphenous vein AV loops were anastomosed to the popliteal vessels for free flap reconstruction. All patients were followed up after AV loop creation for vascular complications and wound assessments. All eight patients had sterilization of the wounds with open reduction and internal fixation of the fracture site before vascular reconstruction. Mean débridement to surgical site sterilization was 4.3 washouts (range, 2-7). Successful popliteal AV loop creation with great saphenous vein was completed in 100% of patients without vascular complications or steal events (Fig 1). Free flap tissue transfers were completed using six rectus abdominis and two latissimus dorsi muscles within 7 days of the loop creation (Fig 2). Patency rate of the AV loop was 100% with eight successful flap transfers and 88% (seven of eight) amputation-free survival at 1 year. One flap did not survive because of recurrent bacterial infection of the hardware. The seven patients with successful procedures reached preoperative ambulatory status within 3 months after their final operation. Although this is a small cohort of patients, incorporation and use of our mangled extremity protocol to guide limb salvage proved successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.Fig 2Immediate postoperative rectus abdominis free flap tissue transfer to right lower extremity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Free flap reconstruction for diabetic foot limb salvage

Background: Although free flap is gaining popularity for the reconstruction of diabetic foot ulcers, it is unclear whether free flap reconstruction increases the chances of postoperative independent ambulation. The aim of this study is to evaluate the relationship between free flap success and postoperative ambulation.Methods: This study reviewed 23 cases of free flap reconstruction for diabetic foot ulcers between January 2007 and March 2014. Free rectus abdominis, latissimus dorsi, and anterolateral thigh flaps were used in ten, eight, and five patients, respectively. A comparison was made between free flap success and postoperative independent ambulation using Fisher’s exact test.Results: Two patients developed congestive heart failure with fatal consequences within 14 days postoperatively, resulting in an in-hospital mortality rate of 8.7%. Five patients lost their flaps (21.7%). Of the 16 patients who had flap success, 12 achieved independent ambulation. Five patients with flap loss did not achieve independent ambulation, except one patient who underwent secondary flap reconstruction using a distally based sural flap. Fisher’s exact test revealed that independent ambulation was associated with free flap success (p = 0.047).Conclusion: The present study indicates that free flap reconstruction may increase the possibility of independent ambulation for patients with extensive tissue defects due to diabetic ulcers. Intermediate limb salvage rates and independent ambulation rates were favourable in patients with successful reconstruction. The use of foot orthoses and a team approach with pedorthists were effective to prevent recurrence.

A large squamous cell carcinoma over the zygoma- a rare presentation reconstructed with mustarde advancement rotation cheek flap

Background & Objectives: The use of Mustarde advancement rotational cheek flap for moderate to advance facial defects is a simple and effective alternative among other local, regional, free flaps like rhomboid flap, bilobed flap, cervical flap and for repair of the large defect of the facial skin with microvascular free flap like rectus abdominis free flap are used for facial reconstruction. Instead of using more complex free flaps, this flap can be considered as an alternative. Method: Mustarde advancement rotational cheek was harvested by carrying superior part of incision cephalad towards temple. Result & Interpretation: Defect site showed satisfactory healing with reduced morbidity with satisfactory result. Conclusion: Mustarde advancement rotational cheek flap proved to be useful alternative for surgeons for reconstruction of large facial defects with minimal morbidity. It can definitely replace the other complex flaps in most instances. In this article, we report the use of Mustarde advancement rotational cheek flap to reconstruct the facial defect. Keywords: Mustarde Advancement Rotation Cheek Flap Ectropion, Epiphora, Tarsal Plates

Relationship between BMI and Postoperative Complications with Free Flap in Anterolateral Craniofacial Reconstruction

Background:Although we have seen tremendous advancement in microsurgery over the last 2 decades and free tissue transfer has become standard for head and neck reconstruction, surgeons still struggle to prevent postoperative complications. We examined the relationship between body mass index (BMI) and postoperative complications in patients undergoing rectus abdominis free flap transfer after anterolateral craniofacial resection.Methods:This was a retrospective review of reconstructive surgery using rectus abdominis musculocutaneous free flap in patients with locally advanced maxillary sinus carcinoma from 2003 to 2014 (n = 35, 27 men and 8 women; average age, 60.9 ± 7.8 years). All patients underwent craniofacial reconstruction after anterior and middle cranial fossa skull base resection and maxillectomy (class IV, subtype a) with palatal resection. Patients were categorized based on sex, BMI, and other parameters.Results:Recipient-site infection occurred in 11 patients (31.4%), cerebrospinal fluid leakage in 6 (17.1%), partial flap necrosis in 2 (5.7%), total flap necrosis in 1 (2.9%), and facial fistula in 4 (11.4%). Women showed partial flap necrosis significantly more frequently (P = 0.047), probably owing to poor vascular supply of the subcutaneous fat layer. Patients with low BMI (<20 kg/m2) showed recipient-site infection (P = 0.02) and facial fistula (P = 0.01) significantly more frequently owing to insufficient tissue volume and poor vascular supply.Conclusion:Postoperative recipient-site infection and facial fistula occurred mainly in low-BMI patients. Surgeons should take care to achieve sufficient donor tissue on low-BMI patients. Using a prosthetic obturator in low-BMI patients for craniofacial reconstruction can be a good alternative option to reduce postoperative complications due to insufficient donor tissue volume.

Plastic surgery of extended defects after exenteration of the pelvis

Extended resections of pelvic malignancies, especially in cases of recurrent malignancies, result in the formation of large tissue defects in the region of the pelvic floor and perineum, which are difficult to deal with. Both after extra levator rectal excision and pelvic exenteration, wound healing deficiencies and local infections of the perineal wound are frequent. Primary closure is often impossible due to a lack of tissue substance after resection and an additional previous radiotherapy in most cases. This can result in poor or non-healing wounds, a consecutive need of complex care and an increased risk of secondary problems including tumour recurrences. A permanent wound closure of good quality can therefore only be achieved by plastic surgery. This can be done by local or distant muscle flaps with or without skin, for example, the gluteus maximus flap, the vertical rectus abdominis muscle flap (VRAM) or free flaps such as the latissimus dorsi flap.