Microvascular Reconstruction Research Articles

Enhancing Anticoagulation Monitoring and Therapy in Patients Undergoing Microvascular Reconstruction in Maxillofacial Surgery: A Prospective Observational Trial.

Background: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. Objective: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. Methods/Design: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. Discussion: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.

Superficial Temporal Recipient Vessels for Craniofacial Microvascular Free-Flaps.

The selection of recipient vessels for microvascular free-flaps is critical in craniofacial reconstruction. Especially the suitability of the superficial temporal vessels is questioned conflictingly in the literature. The aim of this study was to share our experience with microvascular craniofacial free-flap reconstruction and to evaluate a set of factors that are related to the recipient vessels and to determine how these factors influence flap survival. We conducted a retrospective analysis of 39 free-flaps for craniofacial reconstruction that were performed from 2006 until 2020 and evaluated the indication for microvascular reconstruction, recipient vessels, various factors related to the recipient vessels and complications. The most utilized recipient artery was the facial artery, selected in 20 patients followed by the superficial temporal artery selected in 12 patients. The most commonly used recipient vein was the facial vein used in 16 patients, followed by the superficial temporal vein selected in 10 patients and the external jugular vein in 6 patients. Total flap necrosis occurred in one patient. There was no statistically significant association between the selected recipient vessels and patient comorbidities, major and minor complications, revision of anastomosis or flap loss. The results of our study have demonstrated that the superficial temporal artery and vein show similar results when used for face and scalp reconstruction. Considering their technical and aesthetic advantages they may be the first choice recipient vessels in established free-flap treatment algorithms for craniofacial reconstruction.

Ipsilateral Cervicodeltopectoral Flap: A Forgotten Technique, Revival in the Era of Microvascular Reconstruction.

Oral cavity cancer is one of the most common cancers in India responsible for significant morbidity and mortality in Indian subcontinent. Majority of cases present in advanced stages which requires extensive reconstruction following tumor resection. Microvascular free flap reconstruction is now considered standard of care for reconstruction for major head and neck skin-mucosal defects but, many factors still act as hindrance like patient's comorbidities, long operating hours for microvascular reconstruction, logistic and financial issues from patient's side. In such situation it is better to have a backup plan for reconstruction of major head and neck defects using pedicled flaps. Pectoralis major myocutaneous (PMMC) flap has been the workhorse flap for head and neck reconstruction since its introduction four decades ago. But relying too much on PMMC flap for major skin-mucosal defects especially in female patients is associated with complications and risk for flap failure leading to catastrophic and significant patient morbidities. Our study involves the use of two flaps for head and neck reconstuction involving skin-mucosal defects i.e PMMC flap for mucosal defect and cervicodeltopectoral (CDP) flap for skin defect. As of now there has been no retrospective or prospective study done which has given a conclusive statement regarding use of these two flaps simultaneously for head and neck reconstruction to the best of our knowledge. In our experience from the present study, CDP flap offers an excellent alternative for extensive head and neck reconstruction and can be readily included in the surgeon's armamentarium with proper planning and meticulous handling.

Results of contralateral anastomosis of microvascular free flaps in head and neck reconstruction.

Despite various solutions to the issue of ipsilateral vessel-depleted neck in microvascular head and neck reconstruction, concrete data on its safety and implementation are scarce. This paper focuses on the feasibility and success rates of contralateral anastomosis in free flap reconstruction in the head and neck region. This single-center retrospective study at a tertiary referral center includes all patients who underwent free flap reconstruction of the head and neck with contralateral anastomosis between January 1st, 2007 and February 28th, 2021. Primary objectives were frequency, success, and flap-associated complication rates. Secondary objectives were recipient vessels and flap type. Of 318 patients who underwent microvascular reconstruction, anastomosis was performed on the contralateral side of the neck in 32 patients (10.0%). Recipient vessels involved mainly the superior thyroid artery (74.2%; n = 23) and the facial vein (51.1%; n = 23). Thirty patients (93.8%) received a radial forearm free flap. Flap-associated complications occurred in 12.5% of included cases (n = 4): one partial flap necrosis (3.1%), one anastomotic insufficiency (3.1%), one venous thrombosis of the microvascular pedicle (3.1%), and one wound dehiscence (3.1%). All of these complications were resolved without complete flap loss. This study demonstrates that contralateral anastomosis is a successful and safe option in microvascular head and neck reconstruction, especially using a radial forearm free flap. Thus, anastomosing to the contralateral side of the neck can be advocated as a valuable option in the ipsilateral vessel-depleted neck.

P-66322411-77 - Indication for temporary tracheotomy in microvascular reconstructions in the head and neck area

<h3>Purpose</h3> Different airway management options in microvascular head and neck reconstructive surgery are being widely discussed. To prevent overtreatment, it is important to carefully weigh intubation versus tracheotomy. The aim of this study was to establish a guideline that helps in the decision-making process. <h3>Methods</h3> Medical records of patients treated between January 2016 and December 2018 were reviewed. Only non- primarily tracheotomised patients were included in this study. The cohort was divided into patients with and without airways complication during hospitalization. The data collected include age, gender, diagnosis, ASA score, Mallampati classification, localisation of reconstruction, type of flap, extend of neck dissection, comorbidities, days spent in the intensive care unit, length of hospitalization, loss and administration of fluid and blood during surgery, and reason for airways complication. Statistical analyses were performed using IBM SPSS 27. <h3>Results</h3> 64 case files were reviewed with 9 patients experiencing airway complications. Patients with intraoral or multiple locations of pathologies were more likely to suffer from airway complication. Analysis of the patient group with complications showed that 77.8% had undergone voluminous reconstruction using, for instance, fibular flaps. Nicotine and alcohol consumption also seemed to increase the risk. <h3>Conclusions</h3> To confirm these findings, further prospective studies with a greater patient cohort need to be conducted whereby flap size should be given special consideration when deciding on the appropriate airway management.

The Use of Arteriovenous Bundle Interposition Grafts in Microsurgical Reconstruction: A Systematic Review of the Literature.

Microvascular reconstruction frequently requires anastomosis outside of the zone of injury for successful reconstruction. Multiple options exist for pedicle lengthening including vein grafts, arteriovenous loops, and arteriovenous bundle interposition grafts. The authors performed a systematic review of arteriovenous bundle interposition grafts to elucidate indications and outcomes of arteriovenous grafts in microvascular reconstruction. A systematic review of the literature was performed using targeted keywords. Data extraction was performed by two independent authors, and descriptive statistics were used to analyze pooled data. Forty-four patients underwent pedicle lengthening with an arteriovenous graft from the descending branch of the lateral circumflex femoral artery. Most common indications for flap reconstruction were malignancy ( n = 12), trauma ( n = 7), and diabetic ulceration ( n = 4). The most commonly used free flap was the anterolateral thigh flap ( n = 18). There were five complications, with one resulting in flap loss. Arteriovenous bundle interposition grafts are a viable option for pedicle lengthening when free flap distant anastomosis is required. The descending branch of the lateral circumflex femoral artery may be used for a variety of defects and can be used in conjunction with fasciocutaneous, osteocutaneous, muscle, and chimeric free flaps.

Micro-vascular reconstruction of complex post traumatic ankle and foot defects with free anterolateral thigh flap: single centre experience

Background: Ankle and foot reconstruction is challenging for plastic surgeon due to paucity of local soft tissue and poor blood supply. Anterolateral thigh (ALT) free flap become popular reconstructive option where microsurgical expertise available.Methods: Retrospective study of 26 patients of complex post traumatic ankle and foot defect underwent free anterolateral thigh free flap reconstruction during 2 years duration.Results: ALT free flap provides satisfactory reconstructive option with only 8% flap loss in our study and minimal donor site morbidity. Flap thinning required in 19% patients on long term for adequate shoe fitting.Conclusions: ALT free flap provide like with like tissue replacement for foot and ankle reconstruction with supple skin cover for subsequent surgeries if required.

Rerouting the internal thoracic vessels as recipient vessels in head and neck reconstruction: Comparison of two anatomic approaches

IntroductionThe vessel-depleted neck situation is a challenge for the surgeon in search of suitable recipient vessels for microvascular reconstruction of the head and neck. The internal thoracic vessels (ITVs) have proven useful as “rescue” recipient vessel resource. The objective of this report is to assess the feasibility of using ITVs by rerouting the pedicle for free flap reconstruction of the head and neck by comparing two different approaches. Material and MethodsTwo surgical approaches were assessed: the classical one is parasternal, but cardiac surgeons commonly use median sternotomy. We conducted an anatomical study, comparing on the same subject the lengths and diameters of both internal thoracic artery (ITA) and internal thoracic vein (ITV) at the sixth, fifth, and fourth intercostal spaces (ICSs) through parasternal approach on one side and by median sternotomy on the other side. ResultsThe study was performed on 13 subjects. We found a superiority of length of the ITVs with the median sternotomy approach. Regarding the mean length of the ITA, the sternotomy approach allowed a significant greater length with 119/89/67 mm, compared with parasternal approach with 91/62/42 mm, respectively at the sixth, fifth, and fourth ICS (p<0.001). Similarly, we observed a significant greater length of the ITV with 116/85/63 mm versus 89/62/42 mm (p<0.001).The mean arterial and venous diameters were 2.9 mm and 2.1 mm in the sixth ICS, 3.3 mm and 2.3 mm in the fifth ICS, and 3.9 mm and 2.9 mm in the fourth ICS, respectively. ConclusionThese results help to guide the choice of surgical approach and the level of harvesting.

Reconstruction in Salvage Surgery for Head and Neck Cancers.

Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers. This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017. The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported. Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor. Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

Association of low skeletal muscle mass and systemic inflammation with surgical complications and survival after microvascular flap reconstruction in patients with head and neck cancer.

BackgroundSkeletal muscle mass (SMM) and chronic inflammation are associated with postoperative complications and survival.MethodsPatients with head and neck cancer (HNC) undergoing microvascular free flap reconstruction were included. SMM and neutrophil‐to‐lymphocyte ratio (NLR) were measured and their association with treatment outcomes analyzed.ResultsFive hundred and fifty‐four patients were included. Predictors for complications were elevated NLR in all flaps (OR 1.5), low SMM in radial forearm flap (OR 2.0), and elevated NLR combined with low SMM in fibula flap surgery (OR 4.3). Patients with solely elevated NLR were at risk for flap‐related complications (OR 3.0), severe complications (OR 2.2), and when combined with low SMM for increased length of hospital stays (LOS) (+3.9 days). In early‐stage HNC, low SMM (HR 2.3), and combined elevated NLR with low SMM (HR 2.6) were prognostics for decreased overall survival.ConclusionsSMM and NLR are predictive for poor outcomes in patients with HNC undergoing microvascular reconstruction.

Regional block pilot for microvascular free-flap breast reconstruction.

e18646 Background: With increasing focus on improving patient outcomes and decreasing narcotic use, healthcare has prioritized the use of multidisciplinary, multimodal, and evidence-based approaches to perioperative management through enhanced recovery after surgery (ERAS) pathways. Currently, microsurgical breast reconstruction with or without concurrent mastectomy commonly may employ regional anesthesia in the preoperative and intraoperative techniques. To optimize perioperative analgesia, an ERAS protocol was piloted at a quaternary care academic center implementing a pre-operative anesthesia placed regional block with preference for anterior quadratum lumborum blocks. Methods: A total of 161 patients were enrolled in this single center Continuous Quality Improvement (CQI) project. The project consisted of 72 baseline, 20 pilot, and 69 after pilot patients who underwent unilateral (n = 65) or bilateral (n = 96) deep inferior epigastric perforator (DIEP) flap reconstruction either immediately (n = 87) or delayed (n = 74) after mastectomy. In the 20 CQI pilot group, anesthesiologists pre-operatively placed bilateral anterior quadratus lumborum blocks (aQLB) under direct ultrasound guidance. After positively observed metrics, the official ERAS pathway was implemented into clinical practice, allowing for subsequent accrual of 69 additional patients. We compared this after pilot group to 72 baseline patients who underwent a surgeon-placed intraoperative transversus abdominus plane (TAP) block using liposomal bupivacaine. Statistics data was tracked using a dedicated clinical EMR dashboard. Baseline patients were matched to the after pilot cohort based on laterality and timing of DIEP flap reconstruction. Results: The ERAS pathway with anesthesia-placed aQLB was associated with lower post-operative daily opioid consumption from 27.2 MME to 10.2 MME. Average pain scores, post-anesthesia care unit (PACU) length of stay, hospital length of stay, as well as re-admissions and complications were not statistically different before and after the implementation of the ERAS pathway. Conclusions: Anesthesia placed pre-operative aQLB is a safe and effective opioid-reducing pain control modality for DIEP flap reconstruction with or without mastectomy. Prospective and controlled studies will be important for the precise impacts of aQLB in DIEP procedures in an ERAS protocol.[Table: see text]

Efficacy of anterolateral thigh flap in oro-mandibular reconstruction

The purpose of this research was to evaluate the efficacy of utilizing the anterolateral flap from the thigh region for reconstructing the oro-mandibular defects when compared to other forms of flap reconstruction. A propensity score-matched analysis of patients with an oncologic head and neck defect who underwent microvascular reconstruction was performed. Two surgical groups, i.e., ALT (anterolateral thigh flap and bridging Plate) only and DFF (simultaneous soft tissue and vascularized bone flap), were created. Incidence and subsequent management strategies for postoperative plate exposure were evaluated along with complications, overall survival, and postoperative quality of life (QoL). Sixty-two patients were 1:1 propensity matched (31 per group). The DFF group had a significantly larger soft tissue and bone defect than the single-flap group. The 5-year probability of not having a plate exposure was 45.5 and 47.4% for the double-flaps and single-flap groups, respectively (p = 0.186). The ALT-only group had a significantly higher rate of wound infections (38.7% vs. 12.9%, p = 0.02). The incidence of flap loss, re-exploration, inpatient mortality, plate fracture, medical complications, and overall survival were not significantly different.

Inframammary Fold Banking of the Non-Dominant Superficial Epigastric Vein (SIEV) in Unilateral Autologous Breast Reconstruction: A Simple and Helpful Backup Option for Revision Surgery

Free flaps from the lower abdomen represent the workhorses of modern autologous, microvascular breast reconstruction. Rare signs of venous congestion often become evident during the primary index operation, but a secondary shift of the initially dominant drainage of the DIEV system to the SIEV system with consequent malperfusion is a feared, rare event requiring urgent decision, and complex skill using vein grafts and additional anastomosis to restore a sufficient venous outflow. For secondary anastomosis of the SIEV, especially in stacked flaps, a vein graft to the DIEV or retrograde IMV may be necessary, but this requires an additional donor site, thus prolonging procedure time during the emergency operation and resulting in additional scars of the graft’s donor site. We report on a versatile, easy technique of scheduled inframammary fold banking of the dissected, flushed, and clipped non-dominant superficial epigastric vein (SIEV) in unilateral autologous breast reconstruction during the index operation. The banked graft may service as an easy and convenient accessible vein graft in the rare event of secondary shifting of the initial dominant drainage of the DIEV to the SIEV system with the need for urgent re-operation. We retrospectively evaluated the management and outcome of all suitable patients receiving autologous breast reconstruction with a unilateral abdominal DIEP or MS-Tram flap accompanied by banking of the SIEV in the breast pocket between 2017 and 2020 in the present study. In two out of 42 patients (4.8%) receiving autologous breast reconstruction with an abdominal DIEP or MS-TRAM flap with banking of the SIEV in the breast pocket, secondary malperfusion of the flap with progressive venous congestion occurred during the first 48 h perioperatively, between 2 and 37 (mean: 19.5) hours after skin closure. In both cases malperfusion was due to secondary SIEV system dominance, and the banked vein was used as an interpositional graft to the retrograde IMV (case 1) or the DIEV (case 2). Revision surgery lasted between 95 and 121 (mean: 108) minutes without the need for further vein graft harvesting, and further healing was uneventful. Based on the limited cases, inframammary fold banking of the non-dominant SIEV is a versatile, beneficial, and feasible concept with scarce additional dissection time and can be done in all unilateral breast reconstructions to have a reliable graft for emergency re-exploration. It is a useful approach in the context of spare part surgery and tissue banking to safeguard against the rare instance of venous congestion and need for an interpositional graft.

Microvascular reconstruction of the orbit and adjacent regions: A case series

ObjectiveThe purpose of this paper is to present our clinical experience with microvascular free flaps for reconstructing defects of the orbit and adjacent regions. Patients and methodsWe reviewed retrospectively our oncologic patients treated from 2011 to 2019. ResultsSixteen patients were treated with 21 flaps. Later, five of these patients required ten additional “salvage” flaps to obliterate fistulas or seal the skull base. A stable healed wound was achieved in all cases, eventually. ConclusionsBased on our experience, a timely referral to a head and neck unit is critical to try and avoid the recurring tragedy of patients undergoing multiple insufficient resections and eventually dying, despite extensive surgery and radiotherapy at an advanced cancer stage. Bone free flaps are safer than bone grafts or implants when the receiving area has poor vascularity due to previous interventions or when adjuvant radiotherapy is required. In addition, the vascularised medial femur condylar flap is well suited for reconstructing small bone defects of functional or aesthetic significance.

Knockdown of NRSF Alleviates Ischemic Brain Injury and Microvasculature Defects in Diabetic MCAO Mice.

Diabetes is one of the well-established risk factors of stroke and is associated with a poor outcome in patients with stroke. Previous studies have shown that the expression of neuron restrictive silencer factor (NRSF) is elevated in diabetes as well as ischemic stroke. However, the role of NRSF in regulating an outcome of diabetic ischemic stroke has not been completely understood. Here, we hypothesized that diabetes-induced NRSF elevation can aggravate brain injury and cognition impairment in ischemic stroke. The diabetic ischemic stroke mice model was established by 8 weeks of high-fat-diet feeding and 5 days of streptozotocin injection followed by 30 min of middle cerebral artery occlusion (MCAO). We found that diabetes enhanced the MCAO-induced elevation of NRSF in the hippocampus in accompany with an elevation of its corepressors, HDAC1, and mSin3A, and decrease of β-TrCP. By using histological/immunofluorescence staining and neurobehavioral testing, our results showed that the brain damage and learning/memory impairment were aggravated in diabetic ischemic mice but significantly attenuated after stereotaxic injection of NRSF-shRNA. Meanwhile, by performing whole-brain clearing with PEGASOS, microvascular reconstruction, western blotting, and ELISA, we found that NRSF-shRNA markedly alleviated the vasculature disorders and rescued the suppression of NRP-1, VEGF, and VEGFR2 in the hippocampus of diabetic ischemic mice. Therefore, our results demonstrated for the first time that the elevation of hippocampal NRSF plays an important role in alleviating brain injury and cognitive disabilities in diabetic ischemic mice, potentially via the reduction of NRP-1/VEGF signaling.

Factors Impacting Discharge Destination Following Head and Neck Microvascular Reconstruction.

Determine which variables impact postoperative discharge destination following head and neck microvascular free flap reconstruction. Retrospective review of prospectively collected databases. Consecutive patients undergoing head and neck microvascular free flap reconstruction between January 2010 and December 2019 (n= 1972) were included. Preoperative, operative and postoperative variables were correlated with discharge destination (home, skilled nursing facility [SNF], rehabilitation facility, death). The mean age of patients discharged home was lower (60 SD ± 13, n= 1450) compared to those discharged to an SNF (68 SD ± 14, n= 168) or a rehabilitation facility (71 SD ± 14, n= 200; p< 0.0001). Operative duration greater than 10 h correlated with a higher percentage of patients being discharged to a rehabilitation or SNF (25% vs. 15%; p< 0.001). Patients were less likely to be discharged home if they had a known history of cardiac disease (71% vs. 82%; p< 0.0001). Patients were less likely to be discharged home if they experienced alcohol withdrawal (67% vs. 80%; p= 0.006), thromboembolism (59% vs. 80%; p= 0.001), a pulmonary complication (46% vs. 81%; p< 0.0001), a cardiac complication (46% vs. 80%; p< 0.0001), or a cerebral vascular event (25% vs. 80%; p< 0.0001). There was no correlation between discharge destination and occurrence of postoperative wound infection, salivary fistula, partial tissue necrosis or free flap failure. Thirty-day readmission rates were similar when stratified by discharge destination. There was no correlation with the anatomic site, free flap donor selection, or free flap survival and discharge destination. Patient age, operative duration and occurrence of a medical complication postoperatively did correlate with discharge destination. 4 Laryngoscope, 133:95-104, 2023.

Outcomes with culture-directed antibiotics following microvascular free tissue reconstruction for osteonecrosis of the jaw

ObjectivesRadiation (ORNJ) and bisphosphonate-related (BRONJ) osteonecrosis of the jaw represent challenging entities to treat, with many patients requiring segmental resection and reconstruction with microvascular free tissue transfer (MFTT) in the setting of failed conservative therapy. Microvascular reconstruction is associated with higher post-operative complication rates when performed for advanced osteonecrosis versus oncologic defects. We hypothesize that basing antibiotic therapy on cultures obtained from the healthy bone marrow following resection during MFTT for ORNJ or BRONJ reduces rates of post-operative wound and surgical complications. Materials and methodsIn a retrospective cohort study spanning January 2016 to October 2018, 44 patients undergoing MFTT for ORNJ or BRONJ were identified. Patients were categorized into two cohorts: residual healthy marrow culture (n = 11; RHM), treated with antibiotics guided by cultures from healthy appearing mandible, and all others (n = 33; AO), treated with antibiotics guided by cultures from resected necrotic bone or purulent drainage. Patient, reconstruction, and outcome variables were compared via appropriate statistical tools. Results81.8% of the RHM cohort versus 24.2% of the AO cohort received long-term IV antibiotics. Rates of post-operative wound complications, including those necessitating operative management, were significantly lower in the RHM cohort. Rates of flap failure were similar across both groups. ConclusionAdministration of long-term IV antibiotics directed by native mandible cultures may decrease complication rates following MFTT for ORNJ or BRONJ by treating residual, smoldering infection. Concurrently, transplantation of well-vascularized free tissue likely improves antibiotic delivery. Findings are crucial for the development of a standardized treatment algorithm following microvascular reconstruction for advanced osteonecrosis.

Secondary Mandible Reconstruction with Computer-Assisted-Surgical Simulation and Patient-Specific Pre-Bent Plates: The Algorithm of Virtual Planning and Limitations Revisited

Despite the known advantages of virtual surgical planning and three-dimensional (3D) printing, translation of virtual planning to actual operation is a challenge, especially in secondary mandibular reconstruction. Patients who underwent secondary microvascular mandibular reconstruction were retrospectively reviewed and categorized into three categories as follows: (i) defect not crossing the midline (category I); (ii) defects crossing the midline with availability of previous imaging data (category II) and; (iii) defects crossing the midline with unavailability of previous imaging data (category III). The resulting 3D printed models were used as an effective guide for plate bending during secondary reconstruction surgery. Accuracy of the reconstruction was evaluated by superimposing post-operative images over virtual plan. Out of eleven patients, five were category I, three were category II, and three were category III. The mean linear discrepancy between the planned and post-operative position was measured. A Mann-Whitney U test was conducted to compare mean discrepancy among the groups showed no significant difference between group I and group II (p &gt; 0.05) whereas comparison of groups I and II with group III showed a significant difference (p &lt; 0.01). The proposed algorithm for the generation of defect template for manual plate bending during secondary reconstruction of mandibular defects is valid with acceptable accuracy in various defect configurations.

The evolving role of the superficial temporal vessels as anastomotic recipients in challenging microvascular reconstruction of the upper two-thirds of the face

Free-tissue transfer is now the standard of care in reconstructing head and neck defects. Microvascular reconstruction of the upper two-thirds of the face, particularly following recurrent malignant disease, however, remains a challenge. Retrospective review of all patients undergoing microsurgical reconstruction for defects of the upper two-thirds of the face between 2015 and 2019 revealed 17 free-tissue transfers where the superficial temporal vessels (STVs) were used as recipient vessels. Perioperative data, including return to theatre (RTT) and flap success rates were evaluated. Three patients required reoperation for vascular compromise. One of these patients ultimately lost the flap resulting in flap survival of 94%. This flap failure was, however, secondary to external factors distant to the flap and the anastomosis. In this patient, subsequent attempt at microvascular reconstruction was carried out successfully using contralateral neck vessels and vein grafts. We demonstrate the STVs are safe and reliable in microsurgical reconstruction for a variety of defects. Close proximity to the resection, reconstructing with flaps with a short pedicle, negating the need for neck access and/or high-risk anastomosis in a previously irradiated/operated vessel depleted neck are all highlighted indications. The pre-auricular/temporal access is familiar to the reconstructive surgeon and has excellent post-operative aesthetic results. We discuss key advantages of this approach and highlight potential complications and learning points - underlining the benefit of this approach for the head and neck reconstructive surgeon.

Handgrip Strength Predicts Poorly the Surgical Outcome or Length of Hospitalization in Patients With Surgically Operated Oral Cancer.

Handgrip strength has been used to evaluate the potential of elderly patients to survive different medical conditions or procedures, or to predict the nutritional status and length of hospitalization. The aim of this study was to evaluate the use of handgrip strength as a predictor of the length of hospitalization and need for prolonged intensive care in patients with oral malignancies requiring surgical resection and simultaneous primary reconstruction with microvascular free flap. This is a retrospective study of 37 head and neck carcinoma patients operated between 2012 and 2014 who had undergone a handgrip force test. The microvascular free flaps used were: radial forearm flap (n=23), anterolateral thigh flap (n=10), and iliac crest free flap (n=4). Average stay at the hospital was 13.3 days after the operation and there was a 2.9-days need for intensive care. Handgrip strength did not predict susceptibility to complications, duration of hospitalization, or 12-month survival in the study population. Other anamnestic and medical factors and not handgrip strength should be considered when evaluating operability of the patient or their individual risks for microvascular reconstruction.