Microsurgical Tissue Transfer Research Articles

Robot-assisted Microsurgery: Lessons Learned from 50 Consecutive Cases.

The potential of robot-assisted surgery in plastic and reconstructive surgery remains to be established, especially in free tissue transfer. This prospective study aimed to present our experience and findings from the first 50 consecutive cases of robot-assisted microsurgery using the Symani surgical system. A prospective database was maintained, recording patient demographics and surgical details for all cases of robot-assisted microsurgery in a large academic institution. All surgeons underwent an intensive training program with the Symani surgical system. A total of 50 patients who underwent robot-assisted microsurgical reconstruction were identified. Free microsurgical tissue transfer was performed in 45 cases, targeted muscle reinnervation in four cases, and lymphovenous anastomoses in a single case. A total of 94 robot-assisted anastomoses and coaptations were performed, (46 venous and 30 arterial anastomoses, 16 nerve coaptations, two lymphovenous anastomoses). Six cases involved perforator-to-perforator anastomoses. Ninety-eight percent of attempted anastomoses were completed using the robot. Size-mismatch anastomoses, seen in 37.8% of cases, took significantly longer. Minor complications occurred in three cases and major in six cases. There were three cases of microvascular compromise requiring revision. One partial flap loss and no complete flap loss occurred. Our study highlights the immense potential of robot-assisted microsurgery, and a feasible and effective modality for various microsurgical procedures, with outcomes comparable to those of conventional microsurgery. Despite challenges, such as increased operating times and higher costs, the technology offers significant advantages, such as enhanced precision and motion scaling. We identify a slow learning curve and a necessity for higher caseloads.

Diagnostical accuracy of hyperspectral imaging after free flap surgery.

Microsurgical free-tissue transfer has been a safe option for tissue reconstruction. This study aimed to analyze the diagnostic accuracy of hyperspectral imaging (HSI) after free-tissue transfer surgery. From January 2017 to October 2019, 42 consecutive free-flap surgeries were performed, and their outcomes were analyzed via HSI. Clinical examination of free-flap perfusion was initially performed. Clinical examination findings were subsequently compared with those of HSI. Potential venous congestion with subsequent necrosis was defined as a tissue hemoglobin index of ≥53%. Student's t-test was used to compare the results of the analysis. The evaluation of sensitivity and specificity for flap failure detection was time dependent using the Fisher's exact test. A p-value of ≤0.05 was considered statistically significant. Microsurgical tissue transfer success rate was 84%. Seven patients presented with venous congestion that caused total flap necrosis. Overall, 124 assessments were made. HSI accurately identified 12 out of 19 pathological images: four as false positive and seven as false negative. The sensitivity and specificity of HSI were 57 and 94%, respectively, compared to those of clinical examination that were 28 and 100%, respectively, within 24 h following tissue transfer. The sensitivity and specificity of HSI were 63 and 96%, respectively, compared to those of clinical examination that were 63 and 100%, respectively, within the first 72 h. A tissue hemoglobin index of ≥53% could predict venous congestion after free-flap surgery. HSI demonstrated higher sensitivity than clinical examination within the first 24 h; however, it was not superior compared to clinical findings within 72 h.

Development and usability of a Mobile Interactive Application (VCPW) for Vascular Crisis Prewarning after Skin Flap Transplantation

In microsurgical tissue transfer, skin flap transplantation is frequently used to heal the surface of a wound. Effective microcirculation surveillance of the skin flap is crucial. However, with traditional monitoring methods-that is, clinical observation-vascular crisis can still occur, thereby impairing postoperative recovery. A smartphone application is required to assist health care professionals in the standardized collection of flap perfusion parameters for flap management. The Vascular Crisis Prewarning Application was created using a design science research methodology that prioritizes users and problems. The system usability scale was used to assess the application's usability among medical practitioners. The application was used at the clinic from December 2020 to September 2022. The unplanned return to the operating room, time to diagnose vascular crisis, and flap survival rate were compared with and without the application. The application consisted of 5 modules: patient addition and basic information entry, flap labeling, flap observation, crisis warning, and case archiving. The average rating for the application's usability among medical practitioners was 97.95 score (SD 2.36). With the application, the time to detect vascular crisis reduced from 26.71 to 16.26 h (P < 0.001), the unplanned return to the operation room increased from 8.18% to 10.24% (P=0.587), and the flap survival rate went from 94.55% to 99.21% (P=0.083). An easy-to-use flap perfusion monitoring and prewarning application for medical practitioners was produced using a user-centered development method. The application provided a more standardized and accurate platform for data collection in flap management and reduced the time to detect vascular crisis. Larger cohort studies are required in the future to better assess the full potential of the application.

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

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

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer.

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily. A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers. Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients). External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

Analysis of Factors Determining Patient Survival after Receiving Free-Flap Reconstruction at a Single Center-A Retrospective Cohort Study.

Microsurgical tissue transfer revolutionized reconstructive surgery after extensive trauma, oncological resections, and severe infections. Complex soft tissue reconstructions are increasingly performed in multimorbid and elderly patients. Therefore, it is crucial to investigate whether these patients benefit from these complex procedures. To evaluate the outcome for multimorbid patients who underwent microsurgical soft tissue reconstruction and to identify potential risk factors that may increase mortality. This single-center study retrospectively analyzed prospectively collected data of patients receiving free gracilis (GM) or latissimus dorsi muscle (LDM) flap reconstruction between September 2017 and December 2021. Cases were divided into two groups (dead vs. alive), depending on patient survival. Patient demographics, comorbidities and medication, perioperative details, free flap outcome, as well as microcirculation were determined. A total of 151 flaps (LDM, n = 67; GM, n = 84) performed in 147 patients with a mean age of 61.15 ± 17.5 (range 19-94) years were included. A total of 33 patients (22.45%) passed away during the study period. Deceased patients were significantly older (Alive: 58.28 ± 17.91 vs. Dead: 71.39 ± 11.13; p = 0.001), were hospitalized significantly longer (Alive: 29.66 ± 26.97 vs. Dead: 36.88 ± 15.04 days; p = 0.046) and suffered from cardiovascular (Alive: 36.40% vs. Dead: 66.70%; p = 0.002) and metabolic diseases (Alive: 33.90% vs. Dead: 54.50%; p = 0.031) more frequently, which corresponded to a significantly higher ASA Score (p = 0.004). Revision rates (Alive: 11.00% vs. Dead: 18.20%; p = 0.371) and flap loss (Alive: 3.39% vs. Dead: 12.12%; p = 0.069) were higher in patients that died by the end of the study period. Free flap transfer is safe and effective, even in multimorbid patients. However, patient age, comorbidities, preoperative ASA status, and medication significantly impact postoperative patient survival in the short- and mid-term and must, therefore, be taken into account in preoperative decision-making and informed consent.

Hybrid Breast Reconstruction Following Mastectomy

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6 S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i. e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

Thermal, Hyperspectral, and Laser Doppler Imaging: Non-Invasive Tools for Detection of The Deep Inferior Epigastric Artery Perforators-A Prospective Comparison Study.

Perforator flaps have become one of the leading procedures in microsurgical tissue transfer. Individual defects require a tailored approach to guarantee the most effective treatment. A thorough understanding of the individual vascular anatomy and the location of prominent perforators is of utmost importance and usually requires invasive angiography or at least acoustic Doppler exploration. In this study, we aimed at evaluating different non-invasive imaging modalities as possible alternatives for perforator location detection. After a cooling phase, we performed thermal, hyperspectral and Laser Doppler imaging and visually evaluated a possible detection of the perforator for a period of five minutes with an image taken every minute. We identified the most prominent perforator of the deep inferior epigastric artery by handheld acoustic Doppler in 18 patients. The detected perforator locations were then correlated. Eighteen participants were assessed with six images each per imaging method. We could show a positive match for 94.44%, 38.89%, and 0% of patients and 92.59%, 25.93%, and 0% of images for the methods respectively compared to the handheld acoustic Doppler. Sex, age, abdominal girth, and BMI showed no correlation with a possible visual detection of the perforator in the images. Therefore, thermal imaging can yield valuable supporting data in the individualized procedure planning. Future larger cohort studies are required to better assess the full potential of modern handheld thermal imaging devices.

Implementation and Validation of Free Flaps in Acute and Reconstructive Burn Care.

Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.

The use of the fibula flap in post oncologic reconstruction of long bone in pediatric patients: A retrospective cohort study

Pediatric sarcomas are the most common malignancies of bones in childhood. With advances in adjuvant treatment, limb salvage surgery has become common, increasing the demand of skeletal reconstruction. Traditional practice included bone grafting and transport. Recently, microsurgical tissue transfer in pediatric patients has become a well-accepted practice, with the fibula as an ideal biologic construct for long bone reconstruction. We aim to assess the success rate of this operation, including flap survival, bony union, weight-bearing ambulation, and complications. We identified 10 pediatric patients who underwent reconstruction of long bones (femur, humerus, or tibia) with a free fibula flap from January 2015 to January 2020. All patients received neoadjuvant chemotherapy 4 weeks prior to the surgical procedure followed by adjuvant chemotherapy. The average follow-up time was 15 months. We had no partial or total flap loss. Three of our patients passed away in the first post-operative year due to metastatic disease. In the remaining 7 patients, we had two long-term complications. The fibula of one patient did not exhibit hypertrophy, yet weight-bearing ambulation was achieved. The other patient had nonunion proximally that required bone grafting at 8 months post-operatively. After that, the same patient fractured her fibula and required surgical fixation. She was eventually able to achieve weight-bearing ambulation. The vascularized fibula flap is a reliable tool for reconstruction in children. Flap survival is similar to that of adults. Complication rate is low compared to that for other forms of reconstruction.

Muscle Cuff in Distal Pedicled Adipofascial Sural Artery Flaps: A Retrospective Case Control Study.

Background:Amputation after open tibial fracture occurs in 3% of cases. The rate increases when flap reconstruction is required. The standard care involves microsurgical tissue transfer although the pedicled reverse sural artery adipofascial flap (PRSAF) is a local alternative in patients endangered by a prolonged operative time. Incorporation of a gastrocnemius muscle cuff in this flap can be used to fill dead space and increase healing potential. Literature shows superior survival rates for both PRSAF and inclusion of a muscle cuff in comparison with the cutaneous version. The aim of the study was to compare the outcome of the PRSAF and the musculoadipofascial version (PRSMAF). We hypothesize that the PRSMAF provides similar lap viability and flap-related complication rates as does the adipofascial version. The muscle component may reduce the long-term osteomyelitis rate.Methods:Patients were evaluated retrospectively after reconstruction with either PRSAF or PRSMAF. Preoperative osteomyelitis, flap survival, complications and osteomyelitis clearance were analyzed.Results:The study shows preliminary results supporting the potential use of the PRSMAF. We compare either 23 PRSMAF or 20 PRSAF flaps. We found no statistically significant differences in flap survival or in complication rate.Conclusions:Although the anatomical situation may sometimes dictate the use of a free flap, a technically less-complicated option may in some cases offer a viable alternative. This study shows that the PRSMAF can serve as an alternative for complex bone defects in the limb, though it does not provide statistical improvement to the PRSAF.

Assessing flap perfusion after free tissue transfer using hyperspectral imaging (HSI)

Hyperspectral imaging (HSI) is a new device for monitoring microcirculation. The aim of this study is to describe hyperspectral imaging after free tissue. We assessed 22 patients from our department who underwent hyperspectral imaging monitoring. Four parameters were measured: tissue oxygenation, tissue hemoglobin index, deep tissue near-infrared perfusion index, and water distribution. Measurements were taken from normally perfused flaps, areas of locally impaired perfusion, and complete flap malperfusion daily within the first 7 days. Statistical differences were determined using Student’s t tests. Receiver operating characteristic curves were illustrating the reliability of each parameter. Ten free anterolateral thigh flaps and eight free latissimus dorsi flaps were included. One flap was subsequently lost. Of 184 total measurements, 119 were taken in normally perfused flap areas, 63 in areas of locally impaired perfusion due to partial flap necrosis, and 2 were taken of a flap without perfusion due to arterial occlusion. In the latter case, tissue oximetry and tissue hemoglobin index were 3% (normally perfused flaps 37.5±12.6% (p<0.05) and 23.7±19.4% (p<0.05), respectively), whereas for locally impaired perfusion tissue, hemoglobin index was raised to 76.8±19.9% (p<0.05) and tissue oximetry and deep tissue near-infrared perfusion index were reduced to 28.8±15.8% (p<0.05) and 24.0±16.9% (p<0.05), respectively. A tissue hemoglobin index of ≥ 53% had a sensitivity of 92% and a specificity of 93% for the detection of locally impaired perfusion. Other parameters were less reliable. HSI is a useful tool for flap monitoring after microsurgical tissue transfer. It provided accurate information which correlated with clinical assessments and guided decision-making regarding revision because it can easily detect impaired flap perfusion dueto arterial occlusion or venous stasis. It also defined locally impaired perfused tissue at theflapborder. Level of evidence: Level IV, diagnostic study.

Comparison of venous couplers versus hand-sewn technique in 4577 cases of DIEP-flap breast reconstructions - A multicenter study.

Venous anastomosis remains to be a challenging step in microsurgical tissue transfer and venous complications constitute to a common reason for free flap failure. While several studies have compared mechanical vs. hand-sewn venous anastomoses, there is no large-series study comparing the type of anastomosis exclusively in DIEP flap breast reconstructions. Between 2011 and 2019, 3926 female patients underwent 4577 free DIEP-flap breast reconstructions in 22 different breast cancer centers. Patient data was collected via an online database, files were screened and cases were divided into a hand- (HA) and a coupler-anastomosis (CA) group. Complications were accounted for and the two groups were then compared. Mean ischemia time was significantly shorter in the CA group (46.88 ± 26.17 vs. 55.48 ± 24.70 min; p < .001), whereas mean operative time was comparable (316 ± 134.01 vs. 320.77 ± 120.29 minutes; p=.294). We found no significant difference between both groups regarding the rate of partial (CA: 1.0% vs. HA: 1.3%) and total flap loss (CA: 2.2% vs. HA: 1.8%). However, revision rates were significantly higher in the CA group (CA: 10.5% vs. HA: 7.9%; p=.003), with higher numbers of arterial (2.3 vs. 0.9%; p < .001) and venous thromboses (3.4 vs. 1.8%; p=.001) accounting for this finding. All taken into account, our findings do support the feasibility of venous coupler anastomoses in principle, however the inflationary use of coupler devices should be evaluated critically.

The use of smartphone thermography to more safely unmask and preserve circulation to keystone advancement flaps in the lower extremity

BackgroundThe keystone perforator flap is a simple, popular form of advancement flap that can solve many defects of the lower extremity that can avoid consideration of a microsurgical tissue transfer. The actual circulation to this local flap subtype has not yet been delineated. The recent introduction of inexpensive thermal imaging cameras that can be coupled with a SmartPhone allows thermagrams of these flaps where “hot spots” are known to correspond to the location of pertinent perforators that will provide the requisite flap vascularization. MethodsOver the past year, 10 patients were considered for a keystone flap of the lower extremity in lieu of a skin graft or free flap. All patients had a “cold challenge” or thermal stress followed by a thermal recovery recorded by serial thermography to determine perforator “hot spot” location as well as their absence or “cold spots.” Flaps were designed and harvested according to these findings. ResultsIn one patient, inadequate “hot spots” were found in all adjacent donor regions that could have allowed a keystone flap alternative. Instead, more safely a skin graft was done. The other 9 patients had 10 flaps. Intra-operative thermagrams predicted 100% flap survival for 9 flaps and marginal ischemia for 1 flap, and was a correct assessment in all cases. Dehiscence occurred in the latter flap that healed by secondary intention, while the rest healed uneventfully. ConclusionThe use of the SmartPhone for thermography is a simple, rapid, cheaper means for the evaluation of viability of keystone flaps in all surgical phases. This provides a safe method for checking not only flap circulation, but also identification of “cold spots” or flap regions where means to augment advancement by deep fascia interruption or undermining will not interfere with flap perfusion. There is virtually no learning curve in acquiring the skills to use this device, which should now allow anyone to raise actually any kind of local perforator flap as they find suitable.

Flap Reconstruction of the Hand.

After studying this article, the participant should: 1. Be familiar with local, regional, and free flaps for reconstruction of the hand. 2. Be able to identify potential sources of tissue for vascularized coverage using an algorithmic approach to provide stable and functional reconstruction of the hand. 3. Recognize the controversies and complications unique to flap reconstruction of the hand. The goal of this continuing medical education module is to provide the practicing reconstructive surgeon with a framework in which to think about reconstruction of the hand. The hand has unique functional and aesthetic characteristics that must be considered when choosing the optimal methods for reconstruction. There are a number of reliable local and regional flaps that can be used to treat the hand requiring soft-tissue coverage and/or vascularized bone graft. The "reconstructive ladder," originally described by Mathes and Nahai, is based on the principle of using the simplest approach that adequately restores form and ideally optimizes function. In cases where the simplest techniques prove to be inadequate, local and regional flaps and, ultimately, microsurgical tissue transfer should be considered.

Microvascular reconstruction for tumors of the head and neck in the pediatric population

Introduction: Microsurgical tissue transfer in the pediatric population is challenging for several reasons– small vessel diameter, flap size, difficulties with postoperative flap monitoring, and difficulty in anticipating tissue growth and remodeling. In addition, head-and-neck reconstruction is uniquely difficult due to the functional deficits after ablative surgery. We present our series of microvascular reconstruction for tumors of the head and neck in the pediatric population. Materials and Methods: Retrospective review of microvascular reconstruction performed in our institution for benign and malignant tumors of the head and neck for patients aged

Role of trapezius turnover flap in complex posterior cervical wounds

The trapezius turnover muscle flap is a very useful and effective solution for complex wounds in the posterior cervical area after neurosurgical interventions. However, it is one of underused flaps in plastic surgery practice. The trapezius flap should be considered as the first choice when regional fasciocutaneous flap options are unavailable after radiotherapy and when patients are unsuitable for long-term microsurgical tissue transfer operations due to their age and general condition. The protection of the upper 1/3rd of the trapezius muscle during elevation of the flap could prevent the development of a drooping shoulder.

Comparison of Fasciocutaneous and Muscle-based Free Flaps for Soft Tissue Reconstruction of the Upper Extremity.

The authors evaluated retrospectively the results of 164 free flaps in 149 patients with upper extremity defects. Chart reviews were performed from April 2000 to June 2014, analyzing flap choices, complication, and success rate assessment for patients >18 years old, with a soft tissue defect of the upper extremity. Chosen flap types were classified as fasciocutaneous (including adipocutaneous) and muscle-based, respectively. We comparatively analyzed total flap loss, flap survival after microsurgical revisions, and susceptibility rates for thromboses rates and partial flap necrosis. Defect size was larger when muscle-based flaps were used (231 ± 38.6 versus 164 ± 13.7 cm2, P < 0.05). Outcome analysis revealed a tendency towards higher arterial thrombosis rates for muscle flaps (10.2% versus 4.3%) and venous thrombosis rates for fasciocutaneous flaps (2% versus 7%). Total flap loss (6.1% versus 7.8%) and flap survival after vascular revisions (75% versus 70.6%) showed comparable rates. Partial flap necrosis was generally higher in muscle-based flaps (22.4% versus 8.6%, P = 0.02) with impact on patients' hospital stay (37.2 ± 4.69 and 27.11 ± 1.62 days, n = 115, P = 0.01), while no differences in partial necrosis rates were noted in flaps larger than 300 cm2 (25% versus 10%, P = 0.55). There was a trend over time towards using fasciocutaneous-based flaps more frequently with a final overall percentage of 83.7% between 2012 and 2014. Microsurgical tissue transfer to the upper extremity is safe and reliable, but flap-type specific procedural and measures should be taken into consideration. Total flap loss as well as flap survival after microsurgical revisions are not altered between these flaps. They differ, however, in their susceptibilities for thromboses rates, partial flap necrosis and thus require individual risk stratification and flap placement.

Influence of early elective tracheostomy on the incidence of postoperative complications in patients undergoing head and neck surgery

BackgroundThe incidence of postoperative complications after head and neck surgery is high. This study evaluated the influence of early elective tracheostomy on the incidence of postoperative pneumonia and delirium.MethodsWe reviewed the data of all patients who had undergone removal of an oropharyngeal tumor and microsurgical tissue transfer at our department in a two year period. Pearson’s Chi-squared test and the Fischer’s exact t-test were then used to measure the influence of patients’ preexisting conditions and risk factors and of early elective tracheostomy on the incidence of postoperative complications.ResultsIn total, 47 cases were analyzed. Patients with an endotracheal tube were ventilated for a longer time (3.4 days vs. 1.5 days) and were transferred to the regular ward later (after 6.9 days vs. 4.7 days) than patients with tracheostomy. Only 1 (2.1%) of the patients with a tracheostomy developed pneumonia in contrast to 5 intubated patients (10.6%) and only 2 patients with a tracheostomy developed postoperative delirium (9.5%) in contrast to 8 intubated patients (30.8%).ConclusionEarly primary tracheostomy in patients undergoing resection of oropharyngeal cancer seems to have numerous benefits, such as lower complication rates with regard to pneumonia and postoperative delirium and shorter duration of both mechanical ventilation and intensive care unit (ICU) stays. Further studies have to evaluate if these benefits also influence morbidity and mortality rates.

Prelamination of the latissimus dorsi flap for reconstruction in head and neck surgery

Free microsurgical tissue transfer of the latissimus dorsi flap may be indicated for the restoration of intra- and extraoral defects, especially when a large-sized skin island flap is required. In many cases, use of the latissimus dorsi flap for coverage of large-sized intraoral defects results in bulkiness due to the proportion of subcutaneous fat. Prelamination of free flaps appears to be a promising technique to overcome this flap bulkiness. This modification in flap design could improve the postoperative functional outcome, as well as reduce donor site morbidity. This article presents four novel clinical cases, in which the patients underwent prelamination of the latissimus dorsi flap with local skin grafts during oral cancer treatment in order to reduce the thickness of the free flap and allow tension-free primary closure of the donor site. These attempts successfully covered large-sized intraoral defects, achieving good functional outcomes with minimal donor site morbidity.