Major Flap Reconstruction Research Articles

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report

Improved Skin Paddle Survival in Pectoralis Major Myocutaneous Flap Reconstruction of Head and Neck Defects

To examine our outcomes with skin paddle survival using pectoralis myocutaneous flaps in reconstruction of the head and neck. The pectoralis major myocutaneous flap has been associated with a notable incidence of distal skin necrosis and flap loss. Our experience has been favorable compared with that reported in the literature. Retrospective medical record review of 81 cases of pectoralis major muscle flap reconstruction performed in 78 patients from 1995 to 2008 using a flap harvest technique that is slightly different from the classic descriptions. Data were obtained regarding coexisting health conditions and perioperative complications, which were divided into major and minor categories. Major complications were defined as total flap failure or greater than 25% skin paddle loss. Minor complications and donor site complications included fistulas that were managed conservatively, wound dehiscence not requiring additional surgery, local infections, seromas, and hematomas. Of the 81 flaps performed, 22 complications were encountered. Total flap loss was not encountered in any patient. The overall major complication rate in myocutaneous flaps was 3 of 76 (4%), with these cases consisting of significant skin paddle loss. Minor complications occurred in 14 of 81 myofascial and myocutaneous flaps (17%). Donor site complications of the chest wall occurred in 5 of 81 flaps (6%). Skin paddle necrosis may be minimized with modifications of the classic technique. We believe that extension of the skin flap over the rectus sheath is the cause of distal skin flap necrosis. The pectoralis major myocutaneous flap remains a valuable reconstructive option in the head and neck.

Shoulder morbidity after pectoralis major flap reconstruction for head and neck cancer

The effect of pectoralis major flap (PMF) harvest on shoulder function, allowing for the effects of neck dissection, has not previously been objectively measured. Twenty-two patients who underwent PMF reconstruction were studied. The control group comprised 35 patients with neck dissection (without PMF). Neck dissections in both groups were classified into 3 grades; grade 1: no neck dissection/selective neck dissection; grade 2: modified radical neck dissection; grade 3: radical neck dissection/extended radical neck dissection. Objective shoulder assessments were carried out using Constant score. Constant score deteriorated with grade of neck dissection (p < .005). The median Constant score for PMF group and neck dissection only group were 82 and 90, respectively (p = .40). Subgroup analysis within neck dissection grade did not show any significant difference, but the effect of PMF was noted to be greatest in grade 2 patients (p = .064). There is minimal or low shoulder morbidity, additional to neck dissection, caused by PMF reconstruction in head and neck surgery.

Reconstruction of the through-and-through oral cavity defect with the fibula free flap

To evaluate our experience with reconstruction of anterior and lateral through-and-through defects of the oral cavity using the fibula osteocutaneous flap. Case series with chart review. Review of patients undergoing reconstruction of through-and-through oral cavity defects between August 2006 and July 2008. Defect size, complications, and need for additional reconstruction were examined. Twelve patients were identified with through-and-through oromandibular defects reconstructed with the fibula. Soft tissue defects were successfully closed using a de-epithelialized segment to create two skin paddles. Four patients required additional pectoralis major flap reconstruction for secondary fibula skin loss (1), neck skin breakdown (1), delayed flap loss (1), and need for additional tissue for closure (1). The versatility of the fibula for through-and-through defects of the oral cavity is underestimated, and in most cases it is appropriate to reserve second flaps for salvage reconstruction.

The Use of a Reverse Flow Sural Fasciocutaneous Flap in a Patient with Multiple Trauma: A Case Report

Provision of soft-tissue coverage for defects in the distal leg and foot is a challenge, especially in patients with multiple injuries and major soft-tissue defects. Major flap reconstruction requires expertise and the results are variable, with high morbidity. We report a case in which a reverse flow sural fasciocutaneous flap was used for treatment of an open fracture-dislocation of the right ankle after repeated debridement in a 64-year-old man with a history of chronic smoking, diabetes mellitus, and hypertension.

Surgical debridement, vacuum therapy and pectoralis plasty in poststernotomy mediastinitis

In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with M. pectoralis muscle flaps as treatment for deep sternal wound infections. Our group performed a retrospective analysis of 3630 consecutive cardiac surgical patients using median sternotomy from 11/2004 to 11/2007. After removing sternal wires, necrotic debris and potentially infective material, restabilisation of the sternum was performed and VAC therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Of the analysed patients 16 female and 29 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus odds ratio (OR 3.5), chronic obstructive pulmonary disease (COPD) (OR 2.9), use of bilateral mammarian artery (OR 2.0) and obesity (1.8). The median age of patients with deep sternal infections was similar to control patients. Staphylococcus epidermis was the most common pathogen (37.8%) followed by Enterococcus faecilis (22.2%) and Staphylococcus aureus (17.8). In 22.2% no pathogen could be detected. The 30 day mortality was 0%, the in-hospital mortality was 15.6%. The results of our studies demonstrate that vacuum therapy in conjunction with early and aggressive debridement is an effective strategy for treating poststernotomy mediastinitis. We consider pectoralis major muscle flap reconstruction as a safe technique and regard it as the primary choice for wound closure in poststernotomy mediastinitis.

Lateral thoracic flap for donor site repair of pectoralis major myocutaneous flap

To study the use of the lateral thoracic flap to repair a pectoralis major flap donor site defect when primary closure is not possible. Prospective study. All patients requiring pectoralis major flap reconstruction after tumour extirpation in the head and neck region, whose chest wall donor defects could not be closed primarily, were recruited to the study; lateral thoracic flaps were performed to close the wounds. Ten patients were recruited between July 2005 and November 2007. The patients were between 48 and 76 years of age. The lateral thoracic flap size ranged from 5 x 8 cm to 9 x 12 cm. All secondary donor sites in the lateral chest wall were closed primarily. There was no flap necrosis and the secondary donor sites healed without complications. The lateral thoracic flap is safe and reliable technique for reconstructing the chest wall donor defect from the pectoralis major flap when primary closure is not possible.

Surgical excision of extensive anal condylomata not associated with risk of anal stenosis

Surgical treatment of extensive and confluent anal condylomata results in large open wounds, which in other contexts of anorectal surgery (e.g., hemorrhoidectomy), have been associated with a relevant risk of stricture formation. The aim of our study was therefore to revisit the issue and assess this risk and the general morbidity in patients undergoing extensive excision and fulguration of anal warts. Records of 41 consecutive patients undergoing with excision/fulguration of extensive, i.e., >50% confluent anal condylomata were retrospectively reviewed. Excluded were patients with a lesser degree of warts and patients lost to follow-up before complete wound healing. Data recorded included patient characteristics and evolution of the local area after the surgery. Forty-one patients (40 males and one female) underwent excision and fulguration of a large anal condyloma with an average follow-up of 6 months (range, 1-36 months). The majority of patients (97.6%) were HIV-positive with 80% taking antiretroviral medication. Half of the patients had not received any previous medical or surgical treatment, whereas one fourth had undergone surgical excisions or fulgurations before. Recurrent warts developed in 19 patients (46.3%). The surgical morbidity after the extensive excision consisted of bleeding (22%). However, none of the patients showed any evidence or complaints of postoperative stricturing and anal stenosis at follow-up. Excision of extensive anal condylomata has a known high probability of recurrences, but the risk of developing anal stenosis is low. Careful primary excision of even confluent warts can therefore be safely performed without major primary flap reconstructions.

Management of poststernotomy mediastinitis with vacuum therapy following pectoralis plastic

Aims: In cardiac surgery poststernotomy mediastinitis continues to be a serious cause of morbidity and mortality. We report our experience with vacuum-assisted closure (VAC) therapy followed by reconstruction with soft tissue flaps as treatment for deep sternal wound infections. Method: We performed a retrospective analysis of 4200 consecutive cardiac surgical patients (pts) using median sternotomy from 11/2004 to 8/2007. After removing of sternal wires, necrotic debris and potentially infective material restabilization of the sternum were performed and VAC-therapy was employed. Wound closure and subsequent reconstruction were performed using a bilateral pectoralis muscle plasty. Results: Of the analyzed patients 15 female and 28 male patients suffered from deep sternal wound infections and were treated with VAC. The most common risk factors were diabetes mellitus (OR 3.5), COPD (OR 2.9), use of bilateral mammarian artery (OR1.6) and obesity (1.3). Median age of patients with deewp sternal infections was 69y and 68y in control-pts. Staphylococcus epidermis was the most common pathogen (37.8%) followed by enterococcus faecilis (18.9%) and staphylococcus aureus (13.5). In 13.5% no pathogen could be detected. The 30d mortality was 0%, the in hospital mortality was 13.9%. Due to bleeding complications 6 pts underwent re-surgery. In one patient a partial necrosis of the muscle was observed. Conclusion: The results of our studies demonstrate that vacuum therapy is an important tool for treating poststernotomy mediastinitis. We consider pectoralis major flap reconstruction as a safe technique and regarded it as an important adjunct to the treatment of poststernotomy mediastinitis.

Free radial forearm flapversuspectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis

The free radial forearm flap has replaced the pedicled pectoralis major myocutaneous flap and it has become the 'workhorse flap' used by many head and neck reconstructive surgeons for soft tissue reconstructions. Cost implications of radial forearm flap reconstruction within the context of the overall health care in a particular system need to be investigated particularly before it is labelled as 'costly only'. Forty patients who underwent immediate free radial forearm flap reconstruction for oral or oropharyngeal soft tissue defects were matched with patients who underwent pectoralis major myocutaneous flap reconstruction for similar defects. The 2 years of which the overall management costs according to the hospital perspective were calculated were divided into four periods: operative period, the postoperative phase, follow-up during first year and follow-up during second year after discharge. The total costs within the first 2 years were comparable at approximately 50,000 Euros. The lower costs of hospital admission (24 days versus 28 days; P = 0.005) in the postoperative phase outweighed the higher costs of the surgical procedure (692 min versus 462 min; P < 0.005) in radial forearm flap patients when compared with pectoralis major flap patients. Oral and oropharyngeal reconstruction with radial forearm flap is not more costly than pectoralis major flap reconstruction. Given the better functional outcome and the present cost analysis, reconstruction of oral and oropharyngeal defects is preferably performed using free tissue transfer.

Anterolateral Thigh Free Flap Reconstruction after Temporal Bone Resection

Oncologic lateral temporal bone resection can result in large soft-tissue defects and exposed bone and dura. Inadequate coverage can result in severe complications such as osteomyelitis, meningitis, or delay in adjuvant therapy. Successful reconstruction of these composite defects requires well-vascularized soft tissue with a large cutaneous component. Patients undergoing lateral bone resection often have medical comorbidities favoring a timely surgical procedure. This study evaluates the role of the anterolateral thigh free flap in reconstruction of defects after temporal bone resection. We performed a retrospective review of six consecutive patients undergoing temporal bone resection, parotidectomy, neck dissection, and immediate reconstruction. The patients had a mean age of 62 years. All defects were reconstructed with the anterolateral thigh free flap. Flap survival was 100%. There were no flap-related complications and no delay of adjuvant therapy. Vein grafts were not required to lengthen the vascular pedicle. One patient underwent cosmetic flap revision. All six procedures were done with a two-team approach and concomitant flap harvest. This allowed for similar operative times as sequential pectoralis major pedicled flap reconstruction. The anterolateral thigh free flap is a reliable and time-efficient method of reconstructing composite defects after temporal bone resection.

Postpneumonectomy esophageal fistula: a combined radiological-endoscopic technique

We report a case of a 70-year-old man who presented with a long-standing esophagocutaneous fistula following a pneumonectomy for aspergilloma. Major surgical procedures, including a pectoralis major flap reconstruction, a pedicled omental transposition and a radial forearm flap transposition, failed to obliterate the fistula. Seven years after initial surgery the esophagocutaneous fistula was successfully treated by means of a minimally invasive joint endoscopic and radiological technique. A radiographic catheter was passed through the fistula. The catheter and the guide wire were manipulated into the esophageal defect and into the upper esophagus. Under endoscopic vision, the catheter was then advanced over the guide wire and out of the patient's mouth. A T-tube was sutured to the catheter outside the mouth, pulled down through the esophagus, and into the esophageal defect and out through the chest wall, leaving the T-part of the tube within the esophagus. The patient made a good recovery and was discharged 7 days later. He was able to resume oral intake 3 weeks after the procedure.

Morbidity and Cost Differences between Free Flap Reconstruction and Pedicled Flap Reconstruction in Oral and Oropharyngeal Cancer: Matched Control Study

To compare morbidity and cost in patients who underwent primary reconstruction with free tissue transfer with those with pectoralis major myocutaneous flap (PMMF) reconstructions after ablation of oral and oropharyngeal squamous cell carcinoma. Over a 6-year period, 36 patients had PMMF reconstructions and 127 patients had a variety of free flap (FRF) reconstructions after oral and oropharyngeal cancer ablation. Correction for confounding patient and disease variables was performed by matching all PMMF patients to a randomly selected cohort of FRF patients for age, sex, International Union Against Cancer-American Joint Committee on Cancer T category, tumour subsite, and radiotherapy status. This resulted in two groups of 32 patients each, with the flap reconstruction being the only variable. The following outcome variables were analyzed: operative time; blood loss; admission length, including intensive care unit and coronary care unit stay; complications; secondary interventions; readmissions; and feeding status. Cumulative costs of nursing care, hospital supplies and charges, surgeon's fees, and anesthesiologist's fees were calculated. Statistical analysis applied the paired Student's t-test and the chi-square test. Of all morbidity parameters, only operative time was significantly longer for FRF (p < .0001). Analysis of other outcome variables and costs showed no statistically significant differences (p > .05). There is no evidence that morbidity and cost differ between the pedicled flap and free tissue transfer reconstruction strategies, other than lengthier operating room time for FRF.

A Foreign Body Granuloma in the Neck Mimicking Metastatic Tumour: A Lesson to Learn

A considerable number of articles on retained gauze in the abdomen and thoracic have been reported in the literature. Of these, retained gauze swab in the neck has not been previously reported. We present the case of a 41-year-old man who had persistent right neck swelling of nine months duration following excision of a right cheek tumour and pectoralis major flap reconstruction. Routine haematological investigations including ESR, Mantoux test and Chest X-ray were normal. Cytological examination was consistent with chronic granulomatous lesion while CT scan features were suggestive of metastatic disease. Neck exploration eventually revealed a gauze swab that was left inside his neck. Our aim is to raise awareness amongst surgeons and to improve operating-room etiquette.

The use of outcome scores in surgery of the shoulder

The pursuit of ‘best practice’, health economic planning, the increasing awareness and expectations of patients, pressure from politicians and the media, and the emergence of league tables for surgeons are some of the reasons why orthopaedic surgeons are encouraged to adopt evidence-based

Retrospective study on the need of intensive care unit admission after major head and neck surgery.

The present article aims to study the pattern and need of Intensive Care Unit admission after major head and neck operations. A retrospective study was undertaken of the hospital records of patients who underwent major head and neck operations during the period from February 1997 to February 2000 at the Division of Head and Neck Surgery, Department of Surgery, the Chinese University of Hong Kong. A total of 268 consecutive elective major operations were carried out over the 3 year period. The patients' age ranged from 14 to 82 years with a mean of 55 years. The male to female ratio was 4:1. Forty-seven patients underwent an operation with a combination of major resection, neck dissection, flap reconstruction and tracheostomy ('flaps group'). Two hundred and twenty-one patients had major head and neck operations without the need of flap reconstruction ('non-flaps group'). Three (6.3%) out of 47 patients (flaps group) were admitted to intensive care unit (ICU) immediately after the operation. Only one patient (2.2%) out of the remaining 44 patients was admitted for emergency treatment 3 weeks post operation. All four patients recovered uneventfully. In the non-flaps group of 221 patients, there were 12 (5.4%) planned admissions and 2 (0.96%) unplanned admissions to ICU. In the group of planned admissions, one out of the 12 patients died. The other two patients who were not planned for ICU admission died of basal meningitis that was disease-related rather than related to the intensity of postoperative care. The overall admission rate to ICU was 18 (6.7%) out of 268 patients. The overall mortality was 1.1% (one planned, two unplanned). The present study showed that it is safe and cost-effective to discharge the majority of patients after major head and neck operations back to a specialist ward for nursing care.

Split pectoralis major muscle flap reconstruction after clavicular-manubrial resection

Resection of the clavicular head and clavicular-manubrial junction is required in cases of chronic osteomyelitis or tumor. This article describes a technique for soft tissue coverage in an infected or irradiated area after resection using a split pectoralis major rotational muscle flap.

Quantitative and qualitative analysis of tracheoesophageal voice after pectoralis major flap reconstruction of the neopharynx

Although tracheoesophageal voice restoration is accepted after reconstruction of the neopharynx with the pectoralis major myocutaneous flap, the character of such voice is not well described. Six patients reconstructed with the pectoralis major flap after laryngopharyngectomy underwent successful voice restoration with the Blom-Singer prosthesis. Voice was evaluated by a standardized protocol and compared with voices of control subjects treated with total laryngectomy and similar voice restoration. The patients with pectoralis major flaps produced similar intensity levels for soft voice (53.7 dB vs. 55.6 dB) and loud voice (61.3 dB vs. 65.3 dB) when compared with controls ( p > 0.05). No significant differences ( p > 0.05) were noted for fundamental frequency (F0) between patients with pectoralis major flaps and controls for soft (62.3 Hz vs. 85.4 Hz) and loud (109.8 Hz vs. 133.8 Hz) voice. Jitter was also comparable. Trained and naive listeners completed qualitative analyses for 10 parameters and judged that control patients had significantly better voice for most parameters. This finding demonstrates that dependable voice is attainable after pectoralis major flap reconstruction of the neopharynx. Although this voice does not differ significantly from voice after standard laryngectomy for acoustic parameters, perceptual analysis does reveal significant differences. (Otolaryngol Head Neck Surg 1998;118:771-6.)

Is the pectoralis myocutaneous flap in intraoral and oropharyngeal reconstruction outdated?

Our experience with 224 immediate pectoralis major myocutaneous flap reconstructions in patients with carcinomas of the oral and oropharyngeal cavities is presented. Although flap-related complications developed in 53% of the patients, all flaps survived, and we had no major skin paddle loss. The incidence of reoperation due to flap-related complications was 2%. All other complications were minor and did not affect the length of hospitalization. Analysis showed no significant risk factors for the development of complications. Because of fistula formation, infection, or metal exposure, plate removal was necessary in 10% of the AO fixation plates used in cases of mandibular swing. This occurred in 68% of the anterior and 22% of the lateral mandibular reconstructions performed with a reconstruction plate (P < 0.05). We conclude that a reconstruction plate is unsatisfactory for anterior mandibular continuity reconstruction and debatable for lateral mandibular reconstruction. At present, anterior defects are reconstructed with free vascularized osteocutaneous flaps that should probably also be used for lateral mandibular reconstruction. Furthermore, in a large number of series, it is reported that free flaps also have high complication rates and 5-10% flap loss. As all pectoralis major flaps survived in our series, it still remains a good choice in intraoral and oropharyngeal reconstruction when there is no necessity to reconstruct bone.

Quantitative and qualitative analysis of tracheoesophageal voice following pectoralis major flap reconstruction of the neopharynx

Quantitative and qualitative analysis of tracheoesophageal voice following pectoralis major flap reconstruction of the neopharynx