Free Flap Research Articles

Hardware Complication Risks in Head and Neck Cancer Patients Undergoing Reconstructive Surgery With Segmental Mandibulectomy

ABSTRACTBackgroundThe primary objective of this study was to ascertain the risk factors associated with hardware complications following segmental mandibular reconstruction in head and neck cancer patients. Additionally, we sought to develop a nomogram model that enables accurate risk prediction.MethodsPatients who underwent segmental mandibulectomy with immediate free or local regional tissue transfer between January 2016 and December 2020 were reviewed. Hardware complications were defined. Patient demographics and perioperative parameters were analyzed.ResultsA total of 510 patients were analyzed. Postoperative radiation therapy (OR = 2.296, 95% CI = 1.339–3.938, p = 0.003), postoperative wound infection (OR = 2.367, 95% CI = 1.472–3.806, p < 0.001), and debridement for flap‐related complications (OR = 5.484, 95% CI = 3.269–9.199, p < 0.001) were identified as independent risk factors. The nomogram model demonstrated good discriminatory ability.ConclusionThis comprehensive analysis identified three independent risk factors, and the nomogram provides a valuable tool for predicting the risks. Further research is needed to validate these findings and explore preventive strategies.

Reconstruction of 2 Independent Facial Defects Using A Single Paramedian Forehead Flap

Background: The paramedian forehead flap (PMFF) has been well established for use in reconstruction limited to a single nasal outer layer defect and has recently gained recognition as an acceptable alternative to traditional methods of lower eyelid reconstruction. The use of a single, pedicled PMFF for the reconstruction of more than one defect has yet to be described. Methods: A 59-year-old male patient was originally diagnosed with large squamous cell carcinoma resulting in radical resection and ipsilateral neck dissection. Postoperative final pathology was read as basal cell carcinoma; due to close margins, the patient required adjuvant radiation therapy. Immediate reconstruction at index surgery included radial forearm free flap; however, the patient subsequently developed left eye symptoms due to lid retraction and nasal symptoms with a left alar defect. The authors report the use of a single pedicled PMFF to reconstruct 2 distinct ipsilateral defects in a radiated patient—nasal ala and lower eyelid. Results: At 6 months post-secondary reconstruction, both recipient sites of the single PMFF appear viable and in adequate position without contraction. The patient has persistent but much improved symptoms related to his eye and nasal defects. Conclusion: A single PMFF can be safely and effectively used in the reconstruction of 2 distinct facial defects in the appropriate patient.

Reconstruction of large post-traumatic segmental femoral defects using vascularised bone flaps: a retrospective case series.

Large femoral defects after trauma, femoral non-unions, fractures complicated by osteomyelitis or defects after bone tumour resection present high burden and increased morbidity for patient and are challenging for reconstructive surgeons. Defects larger than 6 cm and smaller defects after failed spongioplasty are suitable for reconstruction using a free, eventually a pedicled vascularised bone flap. The free fibular flap is preferred but an iliac crest free flap or a pedicled medial femoral condyle flap can be also used. These vascularised flaps are ideal for bridging defects of long bones and can be also used as osteocutaneous or osteomuscular flaps for coverage of soft tissue defect if present. The patients and their families were informed that data will be submitted for publication and they gave their written informed consent prior to the submission. The study was approved by the institutional ethic committee. We analysed a group of eight patients with large diaphyseal or distal metaphyseal femoral defects. A free fibular flap was used in six patients, a pedicled medial ipsilateral femoral condyle flap was used in two patients and a defect in one patient was reconstructed using an iliac crest free flap. All flaps healed completely in all patients and no fracture of the flap was detected during the study period. In one patient, a locking plate broke and was replaced by a compression plate. At the last check-up all patients were able to step on the reconstructed limb with full weight. Although our study comprises a heterogeneous group of cases, they all have been successfully treated by a similar technique, adapted in each case specifically to the needs of the patient. A major limitation parameter of reconstruction by a free vascularised flap is the size of bone defect needed to be reconstructed. In case of a bone defect longer than 6cm and a concomitant soft tissue disruption, a vascularised double-barrel fibula is the preferred. Large femoral defects can be successfully reconstructed with good long-term results using suitable free or pedicled vascularised bone flaps, especially preferring the free fibular flap.

Acral Peeling Skin Syndrome: A Rare Skin Disorder

Objective − We report the case of an 8-year-old girl with acral peeling skin syndrome.Case Report − A previously healthy 8-yearold girl presented with a history of flaccid bullous lesions on the plantar surface of her feet, and subsequent peeling and scarring since she was 12 months old. A biopsy of the plantar lesion was carried out and histological examination revealed an acral skin flap characterized only by the presence of an intracorneal bullous cleft, with hypogranulosis and focal parakeratosis. A genetic study was carried out, identifying two pathogenic heterozygous variants in the TGM5 gene. The clinical presentation, histological and genetic examination confirmed the diagnosis of acral peeling skin syndrome.Conclusion − Acral peeling skin syndrome is not a widely known pathology, which means that cases of acral peeling skin syndrome can be misdiagnosed as Epidermolysis bullosa simplex, especially when a genetic study is not available. Particularly in younger children, it is important not to underestimate the diagnosis of acral peeling skin syndrome, given the different prognostic implications between the two diagnoses.

Giant scalp dermatofibrosarcoma protuberans at mid-occipital scalp: A rare case report

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare type of skin cancer that arises in the deeper layers of the skin, most commonly on the trunk and limbs. The presentation of DFSP on the scalp is worth documentation due to its extremely rare occurrence in the literature. Case Description: We describe a case of a 41-year-old female presented with a lump on the back of the head with gradual enlargement. It was solitary with a size 19 × 12 × 10 cm with purulent discharge and intermittent pain. A computed tomography-scan showed an isodense mass at mid occipital without intracranial involvement. Tumor extirpation and the free flap were performed collaborated with plastic surgery. The patient was discharged unremarkably on the 7th postoperative day without any neurological deficits. Conclusion: Our case is distinct because, after 24 months without any adjuvant therapy and without any recurrence, the patient is still doing well. This is a very rare clinical entity.

Wound closure techniques after wide excision for hidradenitis suppurativa: a systematic review and meta-analysis.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease that affects intertriginous skin areas, clinically characterized by recurrent inflamed nodules, abscesses, sinus tracts, and severe scars. Systemic treatments may provide temporary relief, while wide surgical excision offers prolonged disease-free periods. We evaluated the most efficient wound closure methods following wide excision of HS lesions in terms of recurrence, functionality, and quality of life. A systematic literature search was conducted in PubMed, Embase, Cochrane, and ClinicalTrials.gov, adhering to the PRISMA 2020 criteria. We included original studies published until February 2024, focusing on wound closure methods post-wide excision for HS. Data from 121 papers were analyzed using network and direct meta-analysis methods to compare recurrence and postoperative complication rates. From 1181 articles, 121 were included in the meta-analysis after removing duplicates and excluding publications that did not meet the inclusion criteria. Recurrence rates were associated with the type of reconstruction technique as follows: primary closure, 25% (95% confidence interval [CI], 20-30%); skin grafts, 18% (95% CI, 14-22%), and flaps, 12% (95% CI, 9-15%). Secondary intention healing showed a recurrence rate of 28% (95% CI, 23-33%). Flaps were associated with the lowest recurrence rates compared to other surgery techniques.

Chondroblastic Osteosarcoma of the Mandible: An Uncommon Site for Osteosarcoma

Osteosarcoma is one of the most common types of malignant bone tumors, typically involving long bones such as the femur, tibia, and humerus. However, osteosarcomas occurring in the jaws are exceptionally rare, accounting for approximately 7% of all osteosarcoma cases and just 1% of malignancies in the head and neck region. This type of tumor usually affects individuals in their second and third decades of life. The subtypes of osteosarcoma include osteoblastic, chondroblastic, fibroblastic, small cell, and epithelioid. Chondroblastic osteosarcoma is associated with a poor prognosis, marked by a high recurrence rate, metastatic potential, and poor long-term survival outcomes. Here, we present the case of a 65-year-old woman with a painless swelling over the left cheek for 1 year, which significantly increased in size over the past 3 months, accompanied by trismus, reduced oral intake, and weight loss. Examination revealed a non-tender, hard swelling on the left cheek measuring 20x20cm, with prominent dilated veins. The left external auditory canal was collapsed due to the mass effect. Histopathological examination resulted as chondroblastic osteosarcoma of the left mandible. Computer tomography showed a large lobulated enhancing mass occupying the left cheek, associated with bone erosion and an aggressive periosteal reaction resembling a 'sunburst' pattern involving the ramus extending to the angle of the left mandible. The patient undergone open tracheostomy, left temporary tarsorrhaphy, wide local excision of tumor, left hemimandibulectomy, left partial maxillectomy and anterolateral thigh free flap reconstruction as patient unable to tolerate neoadjuvant chemotherapy.

Imaging Photoplethysmography (iPPG) in Head and Neck Reconstructive Surgery: A Novel Technique for Noninvasive Flap Perfusion Monitoring.

Evaluate imaging photoplethysmography (iPPG) as a novel noninvasive technique to assess flap perfusion in head and neck free flap reconstructive (FFR) surgeries. Intraoperative iPPG was performed in 17 patients undergoing FFR surgery. Imaging consisted of a 30-s video from which perfusion maps were extracted, providing detailed information about blood flow and pulsatility in the flap microvasculature. During each procedure, iPPG acquisitions were acquired representing distinct perfusion conditions of the flap (fully perfused/ischemic/reperfused). When possible, postoperative measurements were performed to assess flap recovery during the critical time period (3 days) and long-term follow-up (30 days). Perfusion maps, displaying iPPG amplitude and delay times, correlated strongly (p < 0.001) with the perfusion status of the tissue. One case of postoperative thrombosis, leading to flap failure, was identified with iPPG. After surgical revision in this case, flap perfusion was restored and confirmed by iPPG. Postoperative follow-up imaging allowed for objective visualization of flap recovery short term (3 days) and up to 30 days after the surgical procedure. This study shows that iPPG is suitable for objective and noninvasive assessment of flap perfusion in head and neck FFR surgery. In addition, postoperative monitoring shows potential for assessing flap perfusion in patients with increased risk of postoperative complications.

The superficial circumflex iliac artery perforator flap in head and neck reconstruction: a retrospective review

Introduction: The superficial circumflex iliac artery perforator flap is a well-established alternative to traditional fasciocutaneous flaps for reconstructive purposes. It is gaining popularity due to short raise time, flap size, ability to provide concurrent raise and donor site concealment. Here we report our initial experience using the superficial circumflex iliac artery perforator flap to reconstruct a variety of defects in the head and neck region. Methods: Eleven patients underwent superficial circumflex iliac artery perforator flap reconstruction for head and neck defects by a single surgeon. Operative details, complications and intermediate outcomes were collected. We reviewed and summarised current published reports on the use of the superficial circumflex iliac artery perforator flap in the head and neck for comparison. Results: At our institution, 11 patients received 12 superficial circumflex iliac artery perforator flaps to reconstruct defects in the head and neck. There were 10 males and one female with a mean age of 60 years, and oncologic resection or complications thereof was the indication for all patients. Defects included five total laryngectomies, four cutaneous defects and two oral cavity reconstructions. The mean flap raise time was 58 minutes and the mean flap size was 92 cm2. Four patients returned to theatre, two for microvascular compromise (one arterial, one venous) and two for salvage operations performed for salivary leak after reconstruction of laryngectomy. Conclusion: Our initial experience with the superficial circumflex iliac artery perforator flap has demonstrated it as a viable and robust free flap for complex head and neck reconstruction.

Refining a Multidisciplinary “Vasculo-plastic” Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

Background: The use of free tissue transfer (FTT) is effective for chronic, non-healing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plants to optimize limb salvage. This study aims to describe our vasculo-pathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTT and the most recent 100 procedures performed. Methods: A single-institution, retrospective review of 300 LE FTTs from July 2011 to January 2023 was performed. Patients were compared between the first 200 (Group 1, July 2011 – February 2020) and last 100 flaps (Group 2, February 2020 – January 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. Results: Group 2 patients had significantly higher rates of diabetes (67.0% vs. 48.5%, p=0.002), peripheral vascular disease (56.0% vs. 24.5%, p&lt;0.001), history of venous thromboembolisms (13.0% vs. 6.0%, p=0.039), venous reflux (81.9% vs. 67.8%; p=0.028), and preoperative venous thromboses on venous testing (25.5% vs. 10.5%; p=0.003) compared to Group 1. Group 2 underwent more pre-FTT endovascular interventions (23.0% vs. 16.5%, p=0.039) and vascular bypasses (4.0% vs. 0.0%, p =0.012). While immediate flap success and amputation rates were similar between the groups, Group 2 had higher rates of partial flap necrosis (7% vs. 3%; p=0.012). Conclusions: The adoption of a vasculo-plastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.

Racial Disparities in 30 Day Outcomes Following Total Laryngectomy.

Despite the growing literature on racial disparities in the utilization of total laryngectomy (TL), and survival following the treatment of laryngeal cancers, there is a paucity of research in TL cohorts evaluating disparities in the immediate postoperative setting. In a national multi-institutional cohort, TL cases between 2010 and 2021 were identified using relevant Current Procedural Terminology (CPT) codes. Logistic regression analyses investigated the association between race/ethnicity and adverse outcomes within 30 days postoperatively. This study consisted of 1493 patients who underwent TL with or without radical neck dissection. Black patients underwent free flap and pedicled flap reconstruction more frequently than their counterparts (P = .023) and exhibited a 1.532 times higher odds of surgical complications (P < .001). There are increased rates of surgical complications in Black patients undergoing TL. Given the limited oncologic and socioeconomic variables available through National Surgical Quality Improvement Program, future study of disparate postoperative outcomes in this population is recommended.

Maxillary Sinus Mucosa Preservation Versus Mucosal Sacrifice: Radiographic Outcomes After Inferior Maxillectomy and Soft-Tissue Free Flap Reconstruction.

This study evaluates the impact of maxillary sinus mucosa preservation on radiographic outcomes after an inferior maxillectomy and soft-tissue free flap reconstruction. A total of 90 patients in two cohorts (mucosal sacrifice versus mucosa preservation) were evaluated from an institutional dataset. Imaging was reviewed at set time points and sinus scores were allotted based on a modification of the Lund-MacKay system. Patients were evaluated for changes in sinus scores. A univariate (UVA) and multivariate (MVA) analysis was performed. In gp1 (mucosal sacrifice), mean postoperative sinus score was 1.21 ± 1.30 (p = < 0.001) at 24 months. On UVA, advanced T-stage at 12 months (OR 7.143, 95% CI 1.484-34.384, p = 0.014) and 24 months (OR 5.500, 95% CI 1.219-24.813, p = 0.027), and on MVA, advanced T-stage were associated with increased odds for higher sinus score (OR 4.993, 95% CI 1.084-22.995, p = 0.039). In Gp2 (Mucosa preserved), the mean postoperative sinus score was 0.31 ± 0.47 (p = 0.021) at 24 months. On UVA and MVA, no predictors were identified for a higher sinus score. Following an inferior maxillectomy and soft-tissue free flap reconstruction, notably reduced sinus scores were seen in patients with preservation of the remaining maxillary sinus mucosa.

SURG-51. DECOMPRESSIVE HEMICRANIECTOMY IN HIGH-GRADE GLIOMA PATIENTS: CLINICAL AND RADIOGRAPHIC OUTCOMES

Abstract BACKGROUND Decompressive hemicraniectomy (DHC) is an uncommonly needed treatment in high-grade gliomas (HGG), most used for refractory increased intracranial pressure (ICP) from vasogenic edema, mass effect, or related complications. Outcomes and imaging following DHC are not well described. METHODS We retrospectively identified cases of DHC for HGG at our institution since 2019. RESULTS Three patients with HGG underwent DHC (2 females, ages 39-70) for newly diagnosed (2 patients) or recurrent tumor (1 patient). Causes of increased ICP were tumor/vasogenic edema (2 patients) or abscess (1 patient). Subsequent cranioplasty was performed in 2 patients: at 1.8 months after DHC in one patient, and at 8.6 months in another patient who developed sinking skin flap syndrome (SSFS). SSFS presented as progressive worsening of tumor-related neurologic deficits after completion of radiation therapy with no change in imaging, followed by frank signs of increased ICP 8 months after DHC. Two patients died of disease progression (5.3 months and 9.1 months after DHC), and one patient remains alive at 13.5 months (patient with SSFS; neurologic deficits virtually resolved after cranioplasty repair). Imaging will be described for all patients. CONCLUSION DHC can be a life-saving intervention in HGG. When feasible, early cranioplasty should be considered to avoid complications, including SSFS, which may present with neurological deficits without corresponding imaging change.

Use of 3D Exoscope for Free Flaps Microanastomosis in Head and Neck Reconstruction.

The use of the 3D exoscope in cervicofacial reconstruction has demonstrated its effectiveness, yet few studies have compared its utility to that of the microscope. To compare the reliability of microanastomoses performed with both tools, along with postoperative outcomes and user experience. This was a retrospective single-center study that included all cases of microanastomosed forearm or fibula free flap reconstructions performed between June 2019 and June 2022. For each procedure, microsurgical characteristics were collected and compared. The primary outcome measure was the reliability of anastomoses (lack of intraoperative events and absence of early surgical revisions). Secondary outcome measures pertained to postoperative evolution. Forty patients underwent microanastomosed flap reconstruction (20 forearm flaps, 20 fibula flaps) using either a microscope (n = 10 in each group) or a 3D exoscope (n = 10 in each group). Patient characteristics were comparable between the two groups. No significant difference was observed between the use of the microscope and the 3D exoscope in terms of anastomosis reliability; OR = 2.07 [0.09-130.88], p = 1. No differences were noted between the two groups in postoperative outcomes except for a shorter hospitalization period for patients undergoing forearm flap reconstruction with the exoscope compared to the microscope (p = 0.03). The use of the 3D exoscope appears to be an interesting alternative to the microscope in cervicofacial reconstruction due to similar microsurgical results, good ergonomics and significant pedagogical appeal.

Navigating the Complexities of Radiation Injuries: Therapeutic Principles and Reconstructive Strategies

Radiation injuries, particularly those resulting from therapeutic or accidental exposure, present complex challenges for medical management. These injuries can manifest localized skin damage or extend to deeper tissues, presenting as various clinical entities that require treatment strategies, ranging from conservative management to complex surgical interventions. Radiation treatment constitutes a fundamental component of neoplastic management, with nearly two out of three oncological instances undergoing it as an element of their therapeutic strategy. The therapeutic approach to radiation injury consists of expanding prophylactic measures while maintaining the efficacy of treatment, such as conservative treatment or local debridement followed by reconstruction. The armamentarium of reconstructive methods available for plastic surgeons, from secondary healing to free tissue transfer, can be successfully applied to radiation injuries. However, the unique pathophysiological changes induced by radiation necessitate a careful and specialized approach for their application, considering the altered tissue characteristics and healing dynamics. The therapeutic strategy is guided by both the severity and progression of the injury, with the primary aim of restoring functionality and aesthetic aspects while simultaneously minimizing the risk of complications. This paper explores the various conditions encompassed by the term “radiation injury,” reviews both non-surgical and surgical therapeutic strategies for managing these injuries, and highlights the unique challenges associated with treating irradiated tissues within specific oncological contexts.

Sinking skin flap syndrome: A rare complication following a craniectomy

Sinking skin flap syndrome is a rare condition in which neurological deterioration is seen following a large craniectomy. Patients present with sensorimotor deficits and altered mental status which may be difficult to distinguish clinically from other causes of neurological deterioration in post-craniectomy patients. The radiologist’s role is critical in such cases for early detection and prompt initiation of treatment. We present a case of sunken skin flap syndrome in a 66-year-old man following a large craniectomy done for a stroke.

Simultaneous reconstruction of tibial osteomyelitis-complicated soft tissue defects using free flap transplantation in conjunction with the masquelet technique: a retrospective study

ObjectiveTo investigate the clinical effect of anterolateral femoral free flap combined with Masquelet technique in the treatment of tibial osteomyelitis with wound surface.MethodsA retrospective study was conducted to analyze the clinical data of 25 patients with tibial osteomyelitis combined with defected wounds in Xijing Hospital of Fourth Military Medical University from Jun 2017 to Oct 2021. After one-stage treatment with free flap combined with Masquelet technique, the infection index, lower extremity function score (LEFS), and Mazur ankle function score were compared before bone defect repair and at the last follow-up.ResultsThe anterolateral femoral free flaps of 25 patients in phase I survived. The healing time of bone fracture after stage II operation was 8–12 months [(7.2 ± 0.9) months]. At the last follow-up, the infection index was significantly lower than that before bone defect repair (P < 0.01). The LEFS and Mazur ankle function scores [(56.2 ± 7.9) and (78.2 ± 16.1)] of the affected limb were significantly higher than those before bone defect repair [(26.0 ± 8.6) and (44.7 ± 18.2)] (P < 0.01). Wounds of all patients’ legs healed well, without complications (foot drop, joint dysfunction, or deformity in the affected limbs).ConclusionThe anterolateral femoral free flap combined with Masquelet technique is an effective treatment strategy for tibial osteomyelitis combined with soft tissue defects. This technology can effectively repair limb trauma, inhibit infection, and improve flexion and extension functions of knee and ankle joint.

Long-term follow-up of thumb reconstruction with a heterotopic replanted finger: case report and literature review

ObjectivesThis work aimed to study the long-term outcome and function of a heterotopic replanted finger.MethodsRetrospective analysis of two cases of successful finger reconstruction after finger heterotopic replantation. One case was a severed thumb, and the other case was a severed finger. The average follow-up time was 10 years. The clinical outcome and function of the heterotopic replanted finger, including range of motion, grip strength, and sensory recovery, were analyzed,. A comparative analysis was conducted with patients who underwent thumb replantation in the same period.ResultsThe two heterotopically replanted fingers survived. Five months after the heterotopic replantation surgery, a new thumb was reconstructed using the heterotopically replanted thumb and the free tarsometatarsal joint from the foot. In the other case, the finger was reconstructed 1 year later with a free anterolateral thigh flap and the heterotopically replanted finger. The movement of the thumb, the pinching of the fingers, the clenching of the fist, and the feeling recovery were all good. The patient was capable of independently performing daily life and work activities such as eating, dressing, writing, and so on. There was no significant difference in hand function between the patients who received in situ finger replantation and heterotopic replantation during the same period.ConclusionFor severed fingers that cannot be replanted in situ in an emergency situation, heterotopic replantation and secondary reconstruction may be a feasible and practical surgical method.

Comprehensive treatment of the patient with venous trophic ulcer

Improving the results of treatment for patients with varicose veins in the lower extremities, complicated by trophic ulcers, is an urgent task for modern medicine. A long-term, recurrent course of the disease leads to a reduction in working capacity and deterioration in quality of life, as well as permanent disability for patients, whose treatment causes special economic problems. At present, there are virtually no effective methods for conservative therapy, leading to prolonged unsuccessful treatment of such patients. This article presents the clinical case of a 63-year-old patient undergoing complex treatment for chronic lower limb venous insufficiency of class C6 according to the CEAP classification. Conclusion. An effective complex method for treating trophic ulcers in patients with chronic venous disease involves the correction of venous hemodynamic disorders (in this case, through radiofrequency ablation), as well as primary surgical treatment for the ulcerative defect, and simultaneous autodermaplasty with a perforated skin flap.

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

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