Flap Ischemia Time Research Articles

Complications in Prolonged Intraoperative Ischemia Time in Free Flap Breast Reconstruction: A Systematic Review and Meta-Analysis.

Autologous tissue transfer is an effective option for breast reconstruction post-mastectomy, with microsurgical techniques continually evolving. However, a comprehensive analysis of the relationship between prolonged ischemia time during free flap-based breast reconstruction and increased postoperative complications is still lacking. A systematic review and meta-analysis were conducted following PRISMA guidelines. Methodological quality was evaluated using the MINORS criteria. Studies meeting inclusion criteria were analyzed for total complications, complete and partial flap loss, and secondary outcomes. Data heterogeneity and risk ratios were assessed. Seventeen studies encompassing 5636 patients and 6884 free flaps were included. The mean age of patients was 49.43years (95% CI: 48.27-50.60), with a mean BMI of 26.09 (95% CI: 21.97-30.21), and an average post-harvesting free flap ischemia time of 70.35min (95% CI: 56.71-83.98). These analyses revealed a heightened risk of total complications (RR: 1.99, 95% CI: 1.61-2.46), complete flap loss (RR: 3.15, 95% CI: 1.32-7.52), partial flap loss (RR: 1.91, 95% CI: 0.92-4.00), hematoma (RR: 1.79, 95% CI: 0.96-3.32), and infection (RR: 2.12, 95% CI: 1.32-3.42) in cases with ischemia time exceeding 60min. Venous complications predominated in free flap failure cases. Effectively managing ischemia time could be crucial in free flap breast reconstruction to potentially reduce postoperative complications. Although there is a correlation between managing ischemia time and reducing postoperative complications, further research is needed to investigate the possible causation behind this relationship. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Implementation of In-house Computer-aided Design and Manufacturing for Accelerated Free Fibula Flap Reconstruction of Mandibular Defects in Cancer Patients.

Computer-aided design and manufacturing (CAD/CAM) is widely adopted for optimizing microsurgical reconstruction of mandibular defects. However, commercial solutions are hampered by costs and lengthy lead times, with the latter being problematic in cancer surgery. This study aimed to investigate the efficiency of an in-house CAD/CAM service for expeditious planning and execution of free fibula mandibular reconstruction in head and neck cancer patients. This retrospective cohort study compared cancer patients undergoing segmental mandibulectomy and immediate free fibula flap reconstruction treated before and after implementation of in-house CAD/CAM. The primary endpoint was treatment delay from preoperative consultation to surgery. Cases in the two groups were matched on the number of fibula segments required for mandibular reconstruction. The control group underwent segmental mandibulectomy and fibula flap reconstruction by "freehand." The CAD/CAM group underwent preoperative virtual surgical planning and CAD/CAM of intraoperative cutting guides for the mandibulectomy and fibula osteotomies. Outcomes were compared with the unpaired t test or Wilcoxon rank-sum test. Sixteen patients were included in both groups. Treatment delay did not increase after implementation of in-house CAD/CAM with a median 6 (range 6-20) days wait in the CAD/CAM group and 8 (6-20) days wait in the control group (P = 0.48). Utilization of CAD/CAM significantly reduced fibula flap ischemia time with a mean of 18.4 [95% confidence interval 2.8; 33.9] minutes (P = 0.022). In-house CAD/CAM was implemented for free fibula flap mandibular reconstruction in head and neck cancer patients without causing treatment delay. Furthermore, CAD/CAM reduced fibula flap ischemia time.

Computer-Assisted Surgery in Mandible Reconstruction.

Computer-assisted surgery is the most significant recent advancement in osseous head and neck reconstruction. Computer-aided design (CAD) software allows computerized planning of resection and reconstruction. Computer-aided manufacturing (CAM) can be used to create models, cutting guides, and patient-specific plates. Several studies have shown that these techniques are more accurate and result in decreased flap ischemia times compared with conventional techniques. CAD also facilitates the immediate placement of dental implants. The most useful application of computer-assisted surgery is delayed reconstruction, in which soft tissue contraction and the absence of a specimen as a reference make accurate estimation of the defect challenging. The drawbacks of CAD/CAM are lack of intraoperative flexibility and cost. Some centers have created in-house CAD/CAM processes using open-source software and commercially available three-dimensional printers.

Bilateral Simultaneous Lumbar Artery Perforator Flaps in Breast Reconstruction: Perioperative Outcomes Addressing Safety and Feasibility.

The lumbar artery perforator (LAP) flap has emerged as an excellent option for breast reconstruction, but its steep learning curve makes it less approachable. Furthermore, length of the operation, flap ischemia time, need for composite vascular grafts, complex microsurgery, multiple position changes, and general concern for safety has led experienced surgeons to stage bilateral reconstructions. In the authors' experience, simultaneous bilateral LAP flaps are feasible, but overall perioperative safety has not been fully explored. Thirty-one patients (62 flaps) underwent simultaneous bilateral LAP flaps and were included in the study (excluding stacked four-flaps and unilateral flaps). Patients underwent two position changes in the operating room: supine to prone and then supine again. A retrospective review of patient demographics, intraoperative details, and complications was performed. The overall flap success rate was 96.8%. Five flaps were compromised postoperatively. The intraoperative anastomotic revision rate was 24.1% per flap (4.3% per anastomosis). The significant complication rate was 22.6%. The number of sustained hypothermic episodes and hypotensive episodes correlated with intraoperative arterial thrombosis ( P < 0.05). The number of hypotensive episodes and increased intraoperative fluid correlated with flap compromise ( P < 0.05). High body mass index correlated with overall complications ( P < 0.05). The presence of diabetes correlated with intraoperative arterial thrombosis ( P < 0.05). Simultaneous bilateral LAP flaps can be performed safely with an experienced and trained microsurgical team. Hypothermia and hypotension negatively affect the initial anastomotic success. In this complex operation, a coordinated approach between the anesthesia and nursing team is paramount for patient safety. Therapeutic, IV.

Breast Reconstruction with DIEP Flap: The Learning Curve at a Breast Reconstruction Center and a Single-Surgeon Study.

Although microsurgical breast reconstruction represents a very interesting and rewarding field of plastic surgery, appropriate microsurgical training is not possible in every plastic surgery department. In this retrospective study, we present the learning curve of our plastic surgery department as a whole and of a single microsurgeon assessing breast reconstruction procedures with a deep inferior epigastric artery perforator (DIEP) flap between July 2018 and June 2021. The present study included 115 patients and 161 flaps. Cases were stratified into single DIEP/double DIEP groups and into early and late groups based on the flap order. Surgery times and postoperative complications were analyzed. Regarding the institution, the length of hospital stay was lower in the late group than in the early group (single 7.1 ± 1.8 vs. 6.3 ± 1.5 days, p = 0.019; double 8.5 ± 3.8 vs. 6.6 ± 1.4 days, p = 0.043). Apart from that, no statistically significant differences were found between the start and end of our study. In terms of the single surgeon, there was a significant improvement in the total surgery time (single 296.0 ± 78.7 vs. 227.5 ± 54.7 min, p = 0.018; double 448.0 ± 85.6 vs. 341.2 ± 43.1 min, p = 0.008), flap ischemia time (53.6 ± 15.1 vs. 40.9 ± 9.5 min, p = 0.007) and length of stay among the compared groups. There was no significant difference in flap loss rate or other complications between the early and late groups. Further performance of surgeries seemed to improve the surgeon's skills as well as the overall experience of the medical institution.

Deep Circumflex Iliac Artery Flap Reconstruction in Brown Class I Defect of the Mandible Using a Three-Component Surgical Template System.

Computer-assisted surgery is widely used in mandibular reconstruction, but the process is not well described for cases using the deep circumflex iliac artery flap (DCIA) as the donor site. This study aimed to present a DCIA-based three-component surgical template system (3-STS) in patients with a mandibular Brown class I defect. This retrospective cohort study compared clinical outcomes of mandibular reconstruction with DCIA flap using 3-STS or conventional surgical templates. The primary outcome of the study was the accuracy of reconstruction, and the secondary outcomes included surgical time and bone flap ischemia time. Surgery-related parameters and functional outcomes were also recorded and compared. Forty-four patients (23 in the 3-STS group and 21 in the control group) between 2015 and 2021 were included. Compared with the control group, the 3-STS group had higher accuracy of reconstruction, indicated by lower deviation in absolute distance (1.45 ± 0.76 mm versus 2.02 ± 0.89 mm; P = 0.034), and less deviation in coronal and sagittal angles (0.86 ± 0.53 degree versus 1.27 ± 0.59 degrees, P = 0.039; and 2.52 ± 1.00 degrees versus 3.25 ± 1.25 versus, P = 0.047) between preoperative and postoperative computed tomographic imaging. Surgical time and bone flap ischemia time were significantly reduced in the 3-STS group compared with the control group (median time, 385 minutes versus 445 minutes and 32 minutes versus 53 minutes, respectively; P < 0.001). In addition, masseter attachment was preserved in the 3-STS group but not in the control group. No differences were found in adverse events or other clinical variables. The 3-STS can improve accuracy, simplify intraoperative procedures to increase surgical efficiency, and preserve functionality in mandibular reconstruction for Brown class I defects. Therapeutic, III.

Three-Dimensional Video Microscopy: Potential for Improved Ergonomics without Increased Operative Time?

Three-dimensional (3D) video exoscopes are high-magnification stereo cameras that project onto monitors mounted in the operating room, viewable from different angles. Outside of plastic surgery, exoscopes have been shown to successfully improve the ergonomics of microsurgery, though sometimes with prolonged operating times. We compare a single surgeon's early experience performing free flap procedures from 2020 to 2021 using either a binocular microscope or a 3D video exoscope. Ten procedures were performed with the standard operating microscope and 8 procedures with the 3D exoscope. The microsurgeon, having minimal prior experience using an exoscope, reported less neck discomfort following the free flap procedures performed with the exoscope compared with the binocular surgical microscope. Total average operating time was comparable between the standard surgical microscope and the 3D exoscope (13.7 vs. 13.4 hours, p = 0.34). Our early experience using a 3D exoscope in place of a standard optical microscope demonstrated that the exoscope shows promise, offering an ergonomic alternative during microvascular reconstruction without increasing overall operating times. Future studies will compare free flap ischemia time between cases performed using the exoscope and the conventional binocular microscope. Medical Subject Headings authorized following words: free tissue flaps; operating rooms; ergonomics; microsurgery.

Microsurgical Reconstruction in an Orthopedic Hospital: Indications and Outcomes in Adults.

Objective Advances in reconstructive microsurgery in orthopedic surgery provided better functional and aesthetic results and avoided many indications for amputation. In high-volume trauma and orthopedic hospitals, microsurgical reconstruction is essential to reduce costs and complications for these complex orthopedic defects. We describe a microsurgical approach to traumatic wounds, tumor resection, bone defects, and free muscle transfer, performed by an orthopedic microsurgery unit. The objective of the present study was to evaluate predictor factors for outcomes of microsurgical flaps for limb reconstruction, and to provide a descriptive analysis of microsurgical flaps for orthopedic indications. Methods Cross-sectional prospective study that included all consecutive cases of microsurgical flaps for orthopedic indications from 2014 to 2020. Data were collected from personal medical history, intraoperative microsurgical procedure, and laboratory blood tests. Complications and free-flap outcomes were studied in a descriptive and statistical analysis. Results We evaluated 171 flaps in 168 patients; the indications were traumatic in 66% of the patients. Type III complications of the Clavien-Dindo Classification were observed in 51 flaps. The overall success rate of the microsurgical flaps was 88.3%. In the multivariate analysis, the risk factors for complications were ischemia time ≥ 2 hours ( p = 0.032) and obesity ( p = 0.007). Partial flap loss was more common in patients with thrombocytosis in the preoperative platelet count ( p = 0.001). Conclusion The independent risk factors for complications of microsurgical flaps for limb reconstruction are obesity and flap ischemia time ≥ 2 hours, and presence of thrombocytosis is a risk factor for partial flap loss.

The Free Myocutaneous Tensor Fasciae Latae Flap-A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience.

Introduction: Deep sternal wound infections (DSWI) after cardiac surgery pose a significant challenge in reconstructive surgery. In this context, free flaps represent well-established options. The objective of this study was to investigate the clinical outcome after free myocutaneous tensor fasciae latae (TFL) flap reconstruction of sternal defects, with a special focus on surgical complications and donor-site morbidity. Methods: A retrospective chart review focused on patient demographics, operative details, and postoperative complications. Follow-up reexaminations included assessments of the range of motion and muscle strength at the donor-site. Patients completed the Quality of Life 36-item Short Form Health Survey (SF-36) as well as the Lower Extremity Functional Scale (LEFS) questionnaire and evaluated aesthetic and functional outcomes on a 6-point Likert scale. The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS) were used to rate scar appearance. Results: A total of 46 patients (mean age: 67 ± 11 years) underwent sternal defect reconstruction with free TFL flaps between January 2010 and March 2021. The mean defect size was 194 ± 43 cm2. The mean operation time was 387 ± 120 min with a flap ischemia time of 63 ± 16 min. Acute microvascular complications due to flap pedicle thromboses occurred in three patients (7%). All flaps could be salvaged without complete flap loss. Partial flap loss of the distal TFL portion was observed in three patients (7%). All three patients required additional reconstruction with pedicled or local flaps. Upon follow-up, the range of motion (hip joint extension/flexion (p = 0.73), abduction/adduction (p = 0.29), and internal/external rotation (p = 0.07)) and muscle strength at the donor-sites did not differ from the contralateral sides (p = 0.25). Patient assessments of aesthetic and functional outcomes, as well as the median SF-36 (physical component summary (44, range of 33 to 57)) and LEFS (54, range if 35 to 65), showed good results with respect to patient comorbidities. The median VSS (3, range of 2 to 7) and POSAS (24, range of 18 to 34) showed satisfactory scar quality and scar appearance. Conclusion: The free TFL flap is a reliable, effective, and, therefore, valuable option for the reconstruction of extensive sternal defects in critically ill patients suffering from DSWIs. In addition, the TFL flap shows satisfactory functional and aesthetic results at the donor-site.

Intraoperative Microvascular Complications in Autologous Breast Reconstruction: The Effects of Resident Training on Microsurgical Outcomes.

Academic medical centers with large volumes of autologous breast reconstruction afford residents hand-on educational experience in microsurgical techniques. We present our experience with autologous reconstruction (deep inferior epigastric perforators, profunda artery perforator, lumbar artery perforator, bipedicled, and stacked) where a supervised trainee completed the microvascular anastomosis. Retrospective chart review was performed on 413 flaps (190 patients) with microvascular anastomoses performed by postgraduate year (PGY)-4, PGY-5, PGY-6, PGY-7 (microsurgery fellow), or attending physician (AP). Comorbidities, intra-operative complications, revisions, operative time, ischemia time, return to operating room (OR), and flap losses were compared between training levels. Age and all comorbidities were equivalent between groups. Total operative time was highest for the AP group. Flap ischemia time, return to OR, and intraoperative complication were equivalent between groups. Percentage of flaps requiring at least one revision of the original anastomosis was significantly higher in PGY-4 and AP than in microsurgical fellows: PGY-4 (16%), PGY-5 (12%), PGY-6 (7%), PGY-7 (2.1%), and AP (16%), p = 0.041. Rates of flap loss were equivalent between groups, with overall flap loss between all groups 2/413 (<1%). With regard to flap loss and microsurgical vessel compromise, lower PGYs did not significantly worsen surgical outcomes for patients. AP had the longest total operative time, likely due to flap selection bias. PGY-4 and AP groups had higher rates of revision of original anastomosis compared with PGY-7, though ultimately these differences did not impact overall operative time, complication rate, or flap losses. Hands-on supervised microsurgical education appears to be both safe for patients, and also an effective way of building technical proficiency in plastic surgery residents.

Machine Learning for Predicting Complications in Head and Neck Microvascular Free Tissue Transfer.

Machine learning (ML) is a type of artificial intelligence wherein a computer learns patterns and associations between variables to correctly predict outcomes. The objectives of this study were to 1) use a ML platform to identify factors important in predicting surgical complications in patients undergoing head and neck free tissue transfer, and 2) compare ML outputs to traditionally employed logistic regression models. Retrospective cohort study. Using a dataset of 364 consecutive patients who underwent head and neck microvascular free tissue transfer at a single institution, 14 clinicopathologic characteristics were analyzed using a supervised ML algorithm of ensemble decision trees to predict surgical complications. The relative importance values of each variable in the ML analysis were then compared to logistic regression models. There were 166 surgical complications, which included bleeding or hematoma in 30 patients (8.2%), fistulae in 25 patients (6.9%), and infection or dehiscence in 52 patients (14.4%). There were 59 take-backs (16.2%), and six total (1.6%) and five partial (1.4%) flap failures. ML models were able to correctly classify outcomes with an accuracy of 65% to 75%. Factors that were identified in ML analyses as most important for predicting complications included institutional experience, flap ischemia time, age, and smoking pack-years. In contrast, the significant factors most frequently identified in traditional logistic regression analyses were patient age (P = .03), flap type (P = .03), and primary site of reconstruction (P = .06). In this single-institution dataset, ML algorithms identified factors for predicting complications after free tissue transfer that were distinct from traditional regression models. 2c Laryngoscope, 2020.

OPTIMIZATION IN DIEP FLAP BREAST RECONSTRUCTION (DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP) WITH THE HELP OF CT(A) AND 3D MAPPING

Introduction: deep inferior epigastric perforator flap (DIEP-flap) reconstruction provides the most acceptable aesthetic result among autologous breast reconstruction. However, a thorough preoperative assessment of the individual vascular anatomy of the deep lower epigastric vessels (DIEA/V) is still challlenging. Usage of CT(a) allows define individual anatomical features such as: intramuscular stroke, tortuosity of vessels and their branches which is an essential thing for reducing of the operation time, flap ischemia time, decreasing the complication rate. Material and methods: with the help of Radiology Department, we have launched a new protocol for planning of the DIEP flap surgery. As a preoperative preparation, we perform CT angiography (CTA) according to a specific protocol, which allows us to reduce the trauma of aponeurosis and the rectus abdominis muscle. Сonclusion: preoperative CT angiography, performed according to a special scanning and post-processing protocol, allows us to optimize the planning of the surgical intervention and improving the results of breast reconstruction. Detailed study of the topography of the vessels of the anterior abdominal wall leads to a decrease in tissue injury of the anterior abdominal wall. This article describes the importance of CT angiography, for the preoperative preparation (visualization) as a crucial step in preparing for the DIEP reconstruction of the breast.

Application of combined transverse upper gracilis flap and adductor magnus perforator flap in breast reconstruction

To explore the clinical application of combined transverse upper gracilis flap and adductor magnus perforator flap in breast reconstruction of breast cancer patients after mastectomy. Between August 2016 and February 2017, the combined transverse upper gracilis flap and adductor magnus perforator flap was used in 12 cases of breast cancer patients who received modified radical surgery for breast reconstruction. All patients were females with the age of 32 to 59 years (mean, 41.5 years). There were 7 cases in left side and 5 cases in right side. Eight cases were received breast reconstruction by one-stage operation and 4 cases by two-stage operation. In one-stage operation cases, pathological diagnosis includes invasive ductal carcinoma in 4 cases and invasive lobular carcinoma in 4 cases. The disease duration ranged from 2 to 9 months (mean, 4.5 months). In two-stage operation cases, the time interval between mastectomy and breast reconstruction ranged from 12 to 70 months (mean, 37.4 months). The length of flap was 20-28 cm, the width of flap was 5.5-7.5 cm, the thickness of flap was 2.5-4.5 cm. The length of gracilis flap pedicle was 6.5-9.2 cm, the length of adductor magnus perforator flap pedicle was 7.5-10.4 cm. The weight of flap was 295-615 g. The ischemia time of flap ranged from 95 to 230 minutes (mean, 135 minutes). All flaps were successfully survived. All incisions of recipient donor sites healed by first intention. All patients were followed up 7-14 months (mean, 9.5 months). The reconstructed breasts' shape, texture, and elasticity were good and no flap contracture deformation happened. Only linear scar left in the donor sites, but the function of thighs was not affected. No local recurrence happened during follow-up. With appropriate patient selection and surgical technique, the combined transverse upper gracilis flap and adductor magnus perforator flap can be a valuable option as an alternative method for autologous breast reconstruction.

Peri-operative risk factors for complications of free flaps in traumatic wounds - a cross-sectional study.

Indication of free tissue transfer for limb reconstruction continues to grow, and despite the good results with this treatment option, complications can impair the functional results and cause a raise in health costs, with prolonged hospitalization. Therefore, peri-operative surgical information and comorbidities were described and analyzed, for identification of independent risk factors for complications of free flaps results for traumatic wounds. For our knowledge, intraoperative ischemia time of free flap was not previously studied for post-traumatic limb reconstruction, which could influence results, in these traumatic cases, with the highest rates of complications among microsurgical flap reconstructions. From July 2014 to January 2017, all patients with free flaps for limb reconstruction were consecutively included. Data on personal medical history, intra-operative microsurgical procedure, and laboratory tests were collected and complications analyzed. Descriptive and inferential statistics were performed. Sixty-two free flaps for traumatic limb reconstruction in 60 patients were studied. We observed a higher rate of complications in patients who underwent surgery > sevendays after the trauma, patients with obesity, when used recipient veins from the superficial system for drainage of the flap, and in those in whom the ischemia time of the free flap was higher in univariate analyzes. After logistic regression, the remaining independent risk factors for complications were ischemia time of free flap > two hours and obesity. The presence of thrombocytosis was associated with partial flap loss. The independent risk factors for complications were ischemia time of free flap > two hours and obesity.

Reconstruction of Porcine Critical-Sized Mandibular Defects with Free Fibular Flaps: The Development of a Craniomaxillofacial Surgery Model

Vascularized bone flaps are the well-known standards of care for reconstruction of segmental mandibular defects ≥ 6 cm. We developed a large animal critical-sized mandibular defect model in which osseous free fibula flaps were used for reconstruction.In this study a total of eight 3-month-old Yorkshire pigs underwent 6 cm full-thickness resection of the left hemimandible. An osseous free fibula flap from the left leg was harvested and contoured to the mandibular defect. Bone placement and plate position was confirmed with fluoroscopy. Animals were followed with serial radiographs and clinical evaluations.Free fibulas were transferred successfully in all eight animals. The average operative time was 346 minutes, and the average flap ischemia time was 86 minutes. The average volume ratio of reconstructed hemimandibles to nonoperated control hemimandibles was 0.72 ± 0.33. The average maximum fracture load was 689 ± 262 N, and the average ratio of biomechanical fracture load for these samples compared with contralateral control hemimandibles was 0.88 ± 0.25.It is concluded that the porcine osseous free fibula flaps can be reliably harvested and viably transferred to critical-sized posterior mandibular defects with acceptable long-term results. The described microsurgical large animal model is acceptable for use in craniomaxillofacial experimentation.

The relationship between the intercostal distance, patient height and outcome in microsurgical breast reconstruction using the second interspace rib-sparing internal mammary vessel exposure

Rib-sparing internal mammary vessel (IMV) exposure in breast reconstruction is becoming common, with a smaller space in which to perform the microanastomoses. The objectives were to determine whether patient height could be used as a proxy measurement for intercostal distance (ICD), assess whether the complication rate or the flap ischemia time are affected in such surgery, and provide anatomical data about ICDs. Data were collected from 95 consecutive patients (109 breasts) undergoing free flap breast reconstruction using rib-sparing vessel exposure over a 3-year period by one surgeon. Pearson's product moment correlation coefficient was used to assess the relation between height and ICD, body mass index (BMI), operative times, and flap outcomes. There was no correlation between patient height and ICD (r = 0.087), age, BMI, recipient vessel preparation time, and flap ischemia time. Being able to predict patients with a small ICD in whom microsurgery may be more challenging can influence surgical planning. The anatomy of the intercostal spaces is variable and was not predictable in relation to height, BMI, or age. Height was not a reliable proxy for ICD and where there is a concern about the available ICD it is suggested that it is measured directly through preoperative imaging. This study found no increase in the complication rate and flap ischemia time using the rib-sparing IMV exposure technique.

Computer-Assisted Orthognathic Surgery Combined With Fibular Osteomyocutaneous Flap Reconstruction to Correct Facial Asymmetry and Maxillary Defects Secondary to Maxillectomy in Childhood

Maxillectomy in childhood not only causes composite primary defects but also secondary malformation of the middle and lower face. In the case presented, we introduced computer-assisted planning and simulation of orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction to correct complex craniofacial deformities. Virtual orthognathic surgery and maxillary reconstruction surgery were undertaken preoperatively. LeFort I osteotomy, with bilateral sagittal split ramus osteotomy and lower border ostectomy, was performed to correct malocclusion and facial asymmetry. Maxillary reconstruction was accomplished using a fibular osteomyocutaneous flap. The patient recovered uneventfully with an adequate aesthetic appearance on 3D computed tomography. Our experience indicates that orthognathic surgery combined with fibular osteomyocutaneous flap reconstruction can used to correct complex facial asymmetry and maxillary defects secondary to maxillectomy. Computer-assisted simulation enables precise execution of the reconstruction. It shortens the free flap ischemia time and reduces the risks associated with microsurgery.

Mandibular Reconstruction with Fibula Flap Using a Simple and Cost-Effective Template

To the Editors, We read with great interest the article by Yadav et al. [1] regarding their technique for central segment reconstruction of the mandible with a free fibula flap. The authors present a great study of the surgical technique and include a comprehensive discussion. We too have performed mandibular reconstruction with free fibula wedge osteotomy and a template, as described in this letter. A 50-year-old man was diagnosed with an oropharyngeal carcinoma (T4N0M0) on his left side and was treated with chemoradiotherapy. The treatment resulted in a complete response at the primary tumor site. However, 1 year after completion of treatment, the patient was diagnosed with recurrence at the same site (rT4N0M0). The patient underwent extended pharyngectomy and segmental resection of the mandible with modified radical neck dissection followed by reconstruction of the mandible with a pedicled transverse rectus abdominis musculocutaneous flap and a reconstruction plate. Three years after reconstruction, the reconstruction plate was exposed (Fig. 1). Computed tomography showed no recurrence. The decision was made to remove the plate and reconstruct the mandible using fibula flaps. Fig. 1 Three years after reconstruction of the mandible with a pedicled transverse rectus abdominis musculocutaneous flap and a reconstruction plate, the reconstruction plate was exposed The operation was performed as follows. First, we removed the reconstruction plate and the left mandibular condyle and debrided the surrounding tissue. Then we bent the template into the shape of the desired mandible contour at the recipient site (Fig. 2). Next, we performed fibula wedge osteotomy to harvest 3 segments of fibula between the midline and the condyle, 30, 30, and 45 mm long, respectively, using the bent template as a guide. Free fibula bone wedges were fixed between the segments and the segments were temporarily fixed to one another using miniplates with the template used as a guide (Fig. 3). Then the fibular artery and vein were clamped and cut, and the fibula flaps were transferred to the recipient site. In this case, it was not necessary to modify the contour 3-dimensionally after the flaps were transferred to the recipient site. After transfer of the flaps, all the joints were fixed by attachment of additional miniplates, and vascular anastomoses were made between the fibular artery and the right facial artery and between the fibular vein and the external jugular vein. One month later, the reconstructed section of the mandible had the desired form (Fig. 4). Fig. 2 Intraoperative photograph. The template was bent into the shape of the desired mandible contour at the recipient site (arrow) Fig. 3 Intraoperative photograph. The free fibula bone wedges were harvested and joined together using miniplates with the bent template used as a guide before the fibular artery and vein were clamped and cut Fig. 4 Panoramic radiograph after mandibular reconstruction We agree with the techniques described by Yadav et al. for mandibular reconstruction, specifically, use of free fibula flaps harvested by wedge osteotomy and use of a template to achieve the desired shape. The fibula is a bone with a regular shape and constant thickness along its length, and its characteristic segmental blood supply allows great freedom with respect to the number of osteotomies that can be performed and their position [2]. If the osteotomies are performed before ligation of the vascular pedicle, the ischemia time is shorter, and the odds of transfer of viable bone increase. Our technique shortens the flap ischemia time and the total operation time. Also, our technique results in a satisfactory mandibular contour at significantly lower cost than use of a computer-generated template.

Free Radial Forearm Fasciocutaneous Flap in the Treatment of Distal Third Tibial Osteomyelitis

Osteomyelitis of the lower limb, associated with soft-tissue defects, is a reconstructive challenge. Microvascular free-tissue reconstruction is an important surgical option with the superiority of free muscle and myocutaneous flaps being explored by various publications. Muscle flaps provide good quality vascularized tissue which can be contoured into defects, but their bulk can often lead to the reconstruction having a suboptimal aesthetic outcome. This result is usually most evident in the lower third of the tibia. We present our series of free radial forearm fasciocutaneous flaps for reconstruction of distal third tibial soft-tissue defects following debridement of osteomyelitic foci and bony stabilization. A retrospective case-note review of 20 patients treated with free radial forearm fasciocutaneous flap reconstruction of distal third tibial soft-tissue defects following excision of osteomyelitis and adjacent scar tissue, and bony stabilization between January 1999 and December 2006 was conducted. There were 20 patients who had established osteomyelitis of the distal third of tibia following previous open fractures. The mean size of the soft-tissue defect at the time of the free fasciocutaneous flap procedure was 72.3 cm(2) and the mean bony defect was 3.4 cm. The mean duration of the procedure was 417 minutes and flap ischemia time did not extend beyond 60 minutes in any of the cases. Overall flap survival was 100% and all patients had radiologic bony union at a mean of 5.73 months. The average period of follow-up was 22.5 (range, 19-36) months, and none of the patients had a recurrence of the disease during the follow-up period. Free fasciocutaneous flap reconstruction for soft-tissue defects of the lower limb in our series was seen to be safe, reliable, and provided an aesthetic outcome with high patient satisfaction rates. We advocate the use of free fasciocutaneous flaps for small-to-moderate sized defects of the distal third of the tibia after debridement for chronic osteomyelitis. Although we have used radial forearm flaps in our series, more modern free fasciocutaneous flaps with less donor-site morbidity may be preferred.

Yüksek Enerjili Balistik Yaralanmalar Sonucu Oluşan Mandibula Kemik Kayıplarının Rekonstrüksiyonunda Serbest Vasküler Fibula Flebi Operasyon Zamanlamasının Tespiti

Free tissue transfers are commonly used popular approach with respect to the development of microsurgery. In the present study, we aimed to evaluate the relationship between the operation timing and the succes of the free fibula flap operations for 11 cases, which were applied for mandible reconstruction after the high velocity gundshot wound of face in Cukurova university, Department of Plastic, Reconstructive and Aesthetic surgery between 1986-2004. The ages of the patients were between 17-42 (Mean age 25.8). Ten of them were male (%90.9) and one of them female (%9.1). Defect of the mandible bone were measured between 4 to13 cm. Nine of them were also required to the reconstruction of soft tissues. Nine patients were operated for free flap transfer during the first year and 2 of the patients were operated after the 1 year as a late reconstruction. Free flap failures were noted independently defect size and localizations for three patients, which were operated at l.month, 12.month and after 1 year as a late reconstruction. Free flap failure were noted especially at groups of 10-30 ages and 40-50 ages. Two of them were reoperated but the succes of flap was achieved at the group of 20-30 ages. Flap ischemia time was found to be directly proportional to the flap failure rate. Flap success rate (%100) were achieved at the operations betvveen the 2 and 7 months (mean 4.4 months) with less than 1 mm decrease of bicortical cortical thickness of flap. In conclusion, free flap reconstructipn of mandible defect after the high velocity gunshot wound can be achieved with better results at 4.4 months and between the 30-40 years of ages.