Local Flap Reconstruction Research Articles

Is bilateral erector spinae plane block a safe alternative to a difficult epidural?

Sir, Regional anesthesia is an integral component of perioperative pain management in frail geriatric patients. By reducing the central nervous system input of nociception from a surgical site, they not only decrease dose of systemically administered analgesic drugs but also their side effects that lead to enhance recovery. We hereby, describe our experience with a single shot bilateral erector spinae plane (ESP) block for acute postoperative pain in a geriatric patient posted for thoracic surgery. An 80-year-old female patient, with an ulceroproliferative growth (8 cm × 7 cm) over a sternal area with an enlarged bilateral lymph node was scheduled for wide local excision and rotational flap reconstruction for anterior chest wall squamous cell carcinoma. She was a known case of hypertension, and coronary artery disease. She was very apprehensive and did not give consent for epidural insertion (Thoracic epidural analgesia [TEA]) in the awake state. In the operation theater, general anesthesia was given. The TE was attempted twice in the lateral position at the T4 level but was not successful. Then, we planned for ultrasound-guided bilateral single shot ESP block at T4 level [Figure 1]. A total of 15 ml of 0.5% ropivacaine and 2 mg dexamethasone was injected on each side. The intraoperative hemodynamics remained stable without any additional opioid requirement. Postoperatively, sensory assessment was done with the pinprick which revealed reduced sensation from C7 to T6 dermatome on left side and T1-T7 on the other side. Injection paracetamol 15 mg/kg, 8 hourly was advised for postoperative analgesia. Her visual analog score remained in the range of 1–2/10 on rest and 2–3/10 on movement.Figure 1: Image of US guided erector spinae plane block: (a) Sagittal view T3T4 transverse process, and erector spinae muscle (b) needle placed just above the transverse processTEA is recommended as the gold standard regional anesthetic technique in acute postoperative pain management for surgery in the thoracic region. TEA can be technically challenging, especially in the upper thoracic level.[1] Anatomical irregularities in the elderly patients such as curvature or rotation of the spine, degenerative disc and joint changes, distortion, and compression of the epidural space increase this challenge many folds. With the advent of ultrasound in regional anesthesia armamentarium, trends are shifting from central neuraxial block to the fascial plane blocks. ESP block is the most popular amongst these blocks, first described by Forero et al. The transverse processes of the thoracic vertebrae and the erector spinae muscles are the main target points in ESP block. LA injected in this plane diffuses anteriorly to ventral and dorsal rami of spinal nerves, as well as to the paravertebral and epidural space. While Sundararajan and Srinivasan[2] describe the role of ESP block as a sole anesthetic technique in poor cardiopulmonary reserve female. The bilateral ESP block has successfully been used in the cardiac,[3] and major open lower abdominal surgeries[4] as a promising alternative to TEA. Our patient being a geriatric patient with multiple comorbidities was better suited for erector spinae plane block as it offers better hemodynamic stability,[4] and safety profile. To summarize we believe ESP block can be a successful alternative to TEA due to its simplicity, ease of performance, and safety profile. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Is unilateral local flap reconstruction sufficient in large myelomeningocele treatment?

<br><b>Objective:</b> Skin flaps are acceptable methods for surgical treatment of myelomeningocele defects in the neonatal period. Skin flaps (e.g., V-Y advancement, rotation or transposition flaps) are often preferred bilaterally for closure of myelomeningocele defects. This study evaluated the adequacy of an alternative unilateral flap method called “ice cream-cone flap” in repairing large myelomeningocele defects. <b>Patients and Methods:</b> Fifteen newborns who were operated with “ice cream cone flap” due to myelomeningocele defect were evaluated retrospectively. Surgical repair was carried out within 1–3 days of birth. The defect sizes were ranging 10 cm × 8 cm to 4 cm × 4 cm diameter with the mean diameter of 7.2 cm × 5.4 cm. This technique is mainly based on the planning of unilateral advancement flap that resembles the shape of the defect. The technique includes additional procedures such as anchoring of a deepithelialized skin tissue to provide redistribution of the wound closure tension to the lateral side of the flap, and transposition of a skin protrusion to shorten the peripheral border length of the wound. <b>Results:</b> Durable, stable soft-tissue coverage of the defect was obtained in all patients. No hematoma, seroma, infection, and flap necrosis were observed during the postoperative follow-up period. Two patients had partial wound dehiscence which was healed with secondary wound healing. <b>Conclusion:</b> “Ice cream-cone flap” technique is fast, reliable, and easily performed and has the advantage of shorter operative time, less blood loss with minimal wound closure tension.<br>

Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review

Abstract Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.

Assessment of Freestyle Local Facial Perforator Flaps for Coverage of Facial Defects.

To assess local freestyle facial perforator flaps in the reconstruction of small to medium-sized facial defects. In a case series, local freestyle perforator flaps were used in Suez Canal University Hospital to reconstruct 28 facial defects in 26 patients between 2017 and 2019. Adequate perforators were identified near those defects and flaps were designed as propeller or VY advancement. Four scales from the FACE-Q (satisfaction with facial appearance, satisfaction with the outcome, psychological function, and appearance-related psychosocial distress) and 2 scales from the SCAR-Q (Appearance scale and Symptom scale) were used as well as the observer part of the Patient and Observer Scar Assessment Scale. The mean follow up period was 10 months. Complete reconstruction was achieved in all cases with a high rate of patient satisfaction which was assessed by FACE-Q and SCAR-Q. Moreover, observer assessment by Patient and Observer Scar Assessment Scale score showed high patient satisfaction with the scars with a mean (SD) 15.5 (3.4) and there was a positive correlation between subjective and objective: results (r2 from 0.27 to 0.41, P < 0.01). Regarding complications, bulkiness occurred in 2 flaps, congestion in 2 flaps, dehiscence in 1 flap, and tip necrosis in 5 flaps. Accordingly, secondary intervention in the form of medicinal leech therapy was used in 3 flaps, delayed closure for the dehisced flap and debulking for 1 flap. Local freestyle perforator flap reconstruction is one of the recommended techniques for small to medium-sized facial defects which gives a high aesthetic outcome and patient satisfaction.

A simple way to manage a chronic ulcer at the cranioplasty titanium implant exposure site by dermal autograft and platelet-rich plasma

Abstract Rationale: Titanium implant exposure is not a rare complication after cranioplasty. Usually, we apply a free flap or local flap for reconstruction. Patient concerns: A 56-year-old male with a medical history of gout, hepatitis and chronic renal disease presented with an ulcer and implant exposure after titanium cranioplasty. The flap around the ulcer was too thin to perform local flap reconstruction. Free flap surgery was rejected by the patient. Diagnoses: The ulcer with implant exposure had little exudate without malodor. The underlying wound had epithelial ingrowth and was 1.5 cm × 0.5 cm in size over the left parietal region of the head. The wound culture was staphylococcus lugdunensis-positive. Interventions: Oral antibiotics and biofilm decontamination were used to manage peri-implantitis for 6 weeks. Dermal autografts were harvested with a thickness of 0.020 inches. A 2 mm wide area of de-epithelization was created around the ulcer margin. Platelet-rich plasma was locally injected into the periwound skin. Outcomes: The patient was followed up by telephone at 9 months postoperatively, and the scar condition was stable without recurrent ulcers. Lessons: Dermal autografts with platelet-rich plasma may serve as an alternative method when a local flap is not feasible and the wound defect is smaller than 1 cm2.

Middle-retroauricular Island Flap: A New Axial Flap for Reconstruction of Non-helical Ear Defects.

Background:Surgical treatment of ear carcinomas needs the selection of the appropriate reconstructive techniques, which depends on the location and the dimensions of the defect after excision of the cancer and the quality of blood supply to the peri-lesional skin.The aim of this study was to evaluate the efficacy and reliability of a new axial island retroauricular flap (middle-retroauricular island flap M-RIF) for coverage of non-helical ear defects with direct donor site closure.Methods:All patients, from January 2013 to January 2020, with skin tumors of the non-helix region and undergoing a combined skin-cartilage excision with M-RIF local flap reconstruction under local anesthesia, were enrolled in the study.Results:18 patients (14 men and 4 women) underwent auricle skin-cartilage excision and M-RIF flap reconstruction. The mean age was 65 years (range, 60–85); the type of primary lesions were 12 BCC and 6 SCC. One flap wound dehiscence and one donor site infection and partial necrosis of the posterior auricular skin occurred; no other complications were recorded.Conclusions:The M-RIF flap is a valid surgical option when dealing with non-helical defects of the anterior pinna. It allows the reconstruction of the defect of the entire anterior surface of the auricle apart from the helix and the lobe and primary donor site closure.

A Comparative Analysis of Outcomes of Free Nipple Areolar Grafting in Autologous Breast Reconstruction.

Preserving the nipple areolar complex (NAC) increases satisfaction in breast reconstruction. This study aims to describe outcomes using free NAC grafts in microvascular breast reconstruction. A case-control study evaluated prospective outcomes of microvascular breast reconstruction with free NAC grafts compared with matched controls with tattoo or local flap nipple reconstruction. Eligible patients for NAC grafting required correction of ptosis or nipple malposition. Postoperative photographs were rated for complications and aesthetics by the four study authors and two additional unbiased board-certified plastic surgeons. Satisfaction was measured with the BREAST-Q. Twenty patients who underwent 35 autologous breast reconstructions were analyzed. Nipple areolar reconstruction with grafts was completed with 13 NACs in 7 patients. The majority of free NAC grafts (11/13, 85%) were completed in immediate reconstruction, and 15% (2/13) were completed in delayed reconstruction. Partial graft hypopigmentation (mean 18.0%, standard deviation [SD] 7.5) was noted in all grafts. Less than half of grafts had areas of depigmentation (6/13, mean 6.1%, SD 7.5). Minor areas of partial loss occurred in 6/13 grafts (mean 2.9%, SD 4.6). Nipple projection was maintained in 54% of nipples (7/13). Depigmentation, hypopigmentation, graft loss, and projection were not statistically correlated with NAC aesthetic or overall aesthetic rating. However, NAC size (p = 0.003), position (p = 0.022), and symmetry (p = 0.028) were all correlated with aesthetic outcomes. Outcomes and satisfaction were similar to those seen with local flap reconstruction, although partial loss was less common in NAC grafts. Nipple reconstruction can successfully be performed in microvascular breast reconstruction using free grafts. Although partial graft hypopigmentation is common, smaller areas of graft loss or depigmentation are anticipated and do not affect aesthetic outcomes. The use of free NAC grafts may allow additional patients to use their own nipples as part of their microvascular reconstruction and avoid secondary NAC reconstruction procedures.

Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb

Few studies have been conducted to explore the utility of the Integra® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process. We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments. A total of 14 patients with 15 reconstructions (average age = 48years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35cm2 (range: 3-150cm2). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4). The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.

Treatment and Outcomes for Cutaneous Periauricular Basal Cell Carcinoma: A 16-Year Institutional Experience.

ObjectiveTo report a single institutional experience with the surgical management of cutaneous periauricular basal cell carcinoma.Study DesignRetrospective chart review.SettingTertiary academic center.MethodsRetrospective chart review of 71 patients diagnosed with periauricular basal cell carcinoma managed surgically from 2000 to 2016. Data were analyzed with descriptive statistics.ResultsThe median age at diagnosis was 73.0 years (interquartile range, 13.0). Of all lesions, 2.8% (n = 2) were preauricular, 80.3% (n = 57) auricular, and 16.9% (n=12) postauricular. Auricular subsites included conchal bowl (36.6%, n = 26), helix (21.1%, n = 15), antihelix (1.4%, n = 1), peritragus (5.6%, n = 4), triangular fossa (1.4%, n = 1), external auditory canal (2.8%, n = 2), and lobule skin (1.4%, n = 1). Surgical approach included wide local excision (80.3%, n = 57), partial auriculectomy (8.5%, n = 6), and total auriculectomy or other combinations of surgical methods (11.3%, n = 8). Due to aggressive pathology, 3 cases required concurrent parotidectomy, neck dissection, ear canal sleeve resection, or mastoidectomy. In sum, 52.1% (n = 37) of cases had clear margins on first pass in the operating room; 25.4% (n = 18) required further resection; and 12.7% (n = 9) demonstrated final positive/overturned margins read as negative from the frozen sections. Reconstruction included full-thickness (25.4%, n = 18) or superficial-thickness (29.6%, n = 21) skin grafts and local flap reconstruction (25.4%, n = 18), while 5.6% (n = 4) required combinations of free flap and/or other reconstruction techniques; 14.1% (n = 10) did not undergo formal reconstruction.ConclusionPeriauricular basal cell carcinoma occurs in anatomically diverse locations in and around the ear, and multiple surgical methods are required for successful treatment.

The Utilization of a Nitric Oxide Generating Serum for Improving Vascularity in Wound Healing

Introduction: Poor vascularity in injured or operated tissue predisposes the patient to poor healing. Many disease states such as diabetes mellitus, atherosclerosis, and Raynaud’s Disease exhibit delayed or compromised healing. Post-radiated tissue is another example of poor healing potential. Any surgical wound, local, regional, or free flap reconstruction, can see delayed healing or lack of healing with poor blood supply. Nitric oxide (NO) is an endothelial cell, endogenously produced, free radical gas. It is a potent vasodilator and inhibitor of platelet aggregation. A NO producing serum has recently been developed (Pneuma Nitric Oxide, Austin Texas). This is the first study to examine the potential efficacy of a NO generating serum in the wound healing population. Objective: The objective of this study is to examine the potential efficacy of a Nitric oxide generating serum in the wound healing patient population Method: Twenty-five patients were studied in two centers between December 2018 and June 2020. Prior to utilizing NO serum, a double-blind, placebo controlled (glycerin) safety study was performed on 10 patients. There were no allergic or irritation reactions to NO serum in this population. NO serum was applied to non-healing diabetic ulcers, vascular compromised non-healing wounds, surgical incisions, split thickness grafts, full thickness grafts, regional and free flaps. Patients were followed weekly and photographed regularly to monitor healing until total healing was reached. Results: Without exception, the study population showed a more rapid and improved quality of healing in the wounds that were treated with Nitric oxide generating serum as compared to control sites. Rapid reepithelialization, wound contraction, less bruising and edema were commonly seen. Neo-vascularization was more rapid in surgical flap cases. Burn wounds healed dramatically. Conclusion: This study shows the benefits of a Nitric oxide- generating serum in the wound healing patient population. The vasodilatory and capillary recruitment capabilities of Nitric oxide are hypothesized as key factors leading to this improved healing. NO is also paramount in the differentiation and proliferation of fibroblasts, keratinocytes, monocytes, and macrophages. Topically, NO has also been shown in the literature to have strong anti-bacterial, anti-fungal, and anti-viral roles. NO serum is a valuable addition to the armamentarium of wound healing protocols.

The role of the plastic surgeon in wound repair after spinal surgery

BackgroundWound complications, including dehiscence and surgical site infections, following spinal surgery have the potential to be devastating both to the patient and to the hospital system. Complications can occur in a wide range of patients including diabetics, those of low or high BMI and those of old age. Obese patients and those with increased subcutaneous fat are at particularly high risk for wound complications, which may be mitigated through use of local flap reconstruction by a Plastic Surgeon. Case DescriptionA 28 year-old female with morbid obesity presents with multiple lumbar transverse process fractures and complex sacral and pelvic fractures requiring closed reduction and percutaneous fixation of the pelvic ring followed by posterior spinal fusion. The patient was closed tension-free by the neurosurgery team and ultimately dehisced requiring consultation and management by Plastic Surgery. OutcomeThe patient underwent debridement and reconstruction with a gluteus maximus myocutaneous flap advancement without complication. ConclusionsWound management after spinal surgery is a complex problem, which may be prophylaxed through early identification of high-risk patients and preoperative consultation of Plastic Surgery. Patients with increased thickness of subcutaneous fat are at particularly high risk for postoperative complications, including infection and dehiscence, secondary to increased tissue manipulation and necrosis.

Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure

AbstractBackground Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malignancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field.Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed.Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n = 9) and basal cell carcinomas (n = 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n = 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group.Conclusion Long-term consequences of childhood depilatory treatments of the scalp by irradiation are now surfacing. Our experience showed that in such cases, surgeons should aim for a more aggressive approach with wide resection and primary free flap reconstruction, and that favorable long-term functional and aesthetic results can safely be achieved using this reconstruction approach.

A Method to Reproduce Symmetry in Midfacial Reconstruction: A Report of 19 Cases.

ABSTRACTBACKGROUNDReconstruction of facial skin defects remains a clinical challenge. With aging, ptosis of tissue over fixed structures creates an important facial feature known as the tear trough. This study aimed to evaluate the efficacy and aesthetic outcome of a novel surgical technique that reproduced this facial feature while avoiding ectropion during midfacial skin defect repair.METHODSNineteen patients with midfacial skin defects received local flap reconstruction combined with an anchoring suture. The flap was designed in a unilateral pedicled V-Y pattern. When the flap was advanced to cover the defect, one or two sutures that connected the dermis of the flap with the infraorbital periosteum were made to reproduce the tear trough line.RESULTS: Midfacial defects were successfully repaired with the V-Y flap in all 19 patients. No lower eyelid ectropion or conspicuous scars were noted in any of the patients. Further, the tear trough was successfully reconstructed in each patient. Facial symmetry was maintained with static positioning and animation.CONCLUSIONSThe combination of local V-Y flap reconstruction with anchoring sutures to reproduce facial feature lines is an effective technique in midfacial skin defect repair.

Rhomboid Flap Reconstruction after Mastectomy for Locally Advanced Breast Cancer.

In patients undergoing mastectomy for locally advanced breast cancer (LABC), surgical skin flap reconstruction is sometimes required in order to cover large skin defects. This study assessed the efficacy of local, cutaneous (rhomboid) flap reconstruction after mastectomy by comparing data from patients with LABC requiring local flap reconstruction after mastectomy and those that underwent mastectomy alone. Data from 68 patients with LABC who underwent mastectomy were reviewed retrospectively; 14 underwent local (rhomboid) flap reconstruction after mastectomy (local flap group) and 54 underwent direct closure after mastectomy (direct closure group). A pinch test was performed to determine the closure method. Data on the operation, postoperative complications, and postoperative quality of life (QOL) were compared between groups. It was possible to close defects in the local flap group that were significantly larger than those in the direct closure group (p=0.0002). There was no significant difference in postoperative complications between groups. Although operative duration was significantly longer in the local flap group than in the direct closure group (p=0.016), the average difference was only 25 minutes. There was no significant difference in variables related to postoperative QOL. Rhomboid flap reconstruction was effective for covering large defects after mastectomy in patients with LABC.

Transforming the lower eyelid longitudinal incision direction to conceal the closure line: Longitudinal incision horizontal closure

Small lower eyelid marginal lesions are commonly treated with full-thickness pentagonal excision.1 Repairing the resulting wedge defect (Fig 1, A) using primary closure or local flap reconstruction inevitably results in a longitudinal wound closure line perpendicular to the lower eyelid margin and poor cosmetic results. Concealing the vertical closure line in the lower eyelid is challenging.

Management of scrotal soft tissue defects in patients with Fournier’s gangrene

Introduction: Fournier’s gangrene is a necrotizing fasciitis caused by mixed aerobic and anaerobic bacteria resulting in loss of skin and subcutaneous tissue in the perineal area. Various techniques have been described for the reconstruction which we intend to study and thereby propose a reconstructive algorithm. Methods: From June 2018 to October 2019, twenty patients aged between 35–80 years with Fournier’s gangrene were posted for reconstruction of scrotal soft tissue defect. Depending on the size of the defect and amount of tissue loss, patients underwent various procedures for reconstruction which included primary closure, advancement flaps and fasciocutaneous flaps. Patients were followed up post-operatively for 3 months. Results: All patients posted for reconstruction had a single stage, stable, and well-vascularized soft tissue coverage in scrotal defect cases without significant major complication. Seven patients underwent secondary closure, six patients underwent advancement flaps, five patients underwent medial thigh flaps with two patients undergoing SSG in addition to advancement flap. Patients were assessed based on restoring anatomy, cosmetic function and psychological satisfaction. There was good functional as well as acceptable cosmetic outcome in the patients without any significant complications. Conclusion: Most reconstructive techniques provide reliable coverage. In defects confined to lesser than 50% of scrotum, local advancement flap reconstruction is the ideal tension free closure. Medial thigh flap is recommended for defects larger than 50% of the scrotum.

Treatment of Fingertip Injuries.

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.

Sequential reconstruction for recurrent head and neck cancer: A 10-year experience.

BackgroundMost patients with head and neck cancer successfully undergo oncologic resection followed by free or local flap reconstruction, depending on the tumor’s size and location. Despite effective curative resection and reconstruction, head and neck cancer patients still face a high risk of recurrence and the possibility of a second primary cancer. Moreover, surgeons hesitate to perform sequential reconstruction following curative resection for several reasons. Few large-scale studies on this subject are available. Therefore, we retrospectively evaluated the outcome of sequential head and neck reconstruction to determine the possible risks.MethodsIn total, 467 patients underwent head and neck reconstruction following cancer resection at our center from 2008 to 2017. Of these cases, we retrospectively reviewed the demographic and clinical features of 58 who had sequential head and neck reconstruction following resection of recurrent cancer.ResultsOur study included 43 males (74.1%) and 15 females (25.9%). The mean age at the initial operation was 55.4±15.3 years, while the mean age at the most recent operation was 59.0±14.3 years. The interval between the first and second operations was 49.2±62.4 months. Twelve patients (20.7%) underwent surgery on the tongue, and 12 (20.7%) had procedures on the oropharynx. Thirty-four patients (58.6%) received a sequential free flap reconstruction, and 24 patients (41.4%) were treated using locoregional flaps. No cases of flap failure occurred.ConclusionsOur findings suggest that patients who need additional operations with recurrent head and neck cancer could optimally benefit from sequential curative resections and reconstructions.

Anterolateral thigh free flaps for the reconstruction of scalp angiosarcoma – 18-year experience in Chang Gung memorial hospital

Scalp angiosarcoma is a rare and highly aggressive cutaneous malignancy with poor prognosis and high recurrence rate. Multimodality approach is currently the treatment protocol for resectable angiosarcoma, including wide local excision and postoperative radiation. This single-institution study reviews the 18-year experience of the surgical treatment of scalp angiosarcomas. A retrospective chart review was performed on patients with scalp angiosarcoma who received wide local excision and free flap reconstruction from 2001 to 2018. The type of free flap, safety margin, outer cortex burring, and dose for radiation were recorded. Kaplan-Meier plots were computed. Eight male patients (mean age of 74.4 years old) were enrolled in the series. Tumor sizes ranged from 3 × 3 to 8 × 13 cm. All patients underwent wide local excision and outer cortex burring (cortical curettage). Seven (87.5%) scalp defects were reconstructed with anterolateral thigh free flap. All patients received adjuvant radiation therapy for tumor bed and margins. Chemotherapy was adopted for the management of local recurrence (37.5%) or distant metastasis (37.5%). The 2-year and 5-year survival rates are 72.9% and 38.9%, respectively, and 1-year and 2-year disease-free rates are 37.5% each. Scalp angiosarcoma is a rare and highly aggressive cutaneous malignancy with poor prognosis. Anterolateral thigh free flap is a good reconstructive option due to its ability to cover large cutaneous defects with minimal need for skin grafting. Multimodal treatment protocol, including wide local excision with cortical curettage, and adjuvant radiation (regular basis) and chemotherapy (local recurrence or distant metastasis) may offer improved 1-year survival rate (100%).

Current approaches to cleft lip revision

Cleft lip repair requires multidisciplinary follow-up throughout a child's life and often requires lip revision surgery in adolescence to restore function and symmetry of the lip. There is significant variability in the approaches taken for lip repair and therefore a review of current techniques and subsequent guidance to secondary cleft lip repair is warranted. New methods of secondary reconstruction can be divided into superficial or muscle related. Recent suggestions for superficial reconstruction include botulinum toxin injection, silicone gel sheeting, local flap reconstruction, fat grafting, and CO2 laser ablation. Suggestions for muscular reconstruction include pedicled prolabial flaps, modified Abbe flap, and orbicularis oris eversion. Secondary cleft lip deformities can be classified as superficial or muscle related. Superficial problems require relatively minor treatments such as laser, local scar revisions, small local flaps, mucosal excision, or fat grafting. Muscle deformities generally require total lip revision and rerepair as a first step to achieving longstanding improvements in lip esthetics and function. Cleft lip revision should only be considered in concert with the patient, be based on the patient's concerns and desires, and offered at the appropriate timeline to improve social integration and/or psychosocial wellbeing.