Reconstruction Of Neck Defects Research Articles

Managing complexity with chimerism: ALT-AMT flaps for complex head and neck reconstruction

BackgroundHead and neck cancer is the most common cancer in males and fifth most common in females in India. Inadequate screening programs and non-availability of local healthcare resources leads to late diagnosis and most cases present at an advanced stage. Surgical extirpation often results in complex, large defects. The concept of chimerism is useful in dealing with such extensive defects.MethodsBetween July 2013 and May 2017, all patients who underwent primary reconstruction of head and neck defects following cancer extirpative surgery, with ALT-AMT chimera flap at a tertiary care cancer centre were included in this study. The patient data of age, sex, etiology, defect size, flap size, perforator configuration, anastomotic details, donor site closure, and complications was retrospectively collected as per the designated proforma from the hospital electronic record, departmental case record forms and the first author’s personal logs, and analyzed.ResultsChimeric flaps based on the lateral circumflex femoral artery i.e. ALT plus AMT provide the desired qualities to address the complex defects. All thirteen patients had a large intraoral mucosal defect. Nine cases had a large extra oral skin defect. The average size of ALT was (112.5 cm2 area) and of AMT was (94.9 cm2 area). The combined area of ALT AMT was 28.5 X 9 = 256.5 cm2. All AMT pedicles were joining the ALT pedicle. 1 AMT was lost and all donor sites needed skin grafting.ConclusionChimeric ALT + AMT is a valuable option when complex, large, multidimensional and multicomponent defects need to be reconstructed. The advantage of utilising a single donor site and two independent flaps with a single microvascular anastomosis.Level of Evidence: Level IV, therapeutic study

Outcomes of internal mammary artery perforator flap in head and neck reconstruction: A systematic review.

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications.

Discussion: Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure.

Discussion: Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure.

Effect of Preoperative Neck Radiotherapy on the Reconstruction of Head and Neck Defects With the Supraclavicular Artery Island Flap.

Purpose: The supraclavicular artery island (SAI) flap is commonly used in the reconstruction of head and neck defects. However, the safety of SAI flaps for neck irradiated patient needs to be verified. To investigate the safety of using the SAI flap for patients who have undergone neck radiotherapy, as well as the risk factors for flap complications. Materials and Methods: Sixty-one patients (16 irradiated and 45 nonirradiated) with SAI flap-reconstructed head and neck defects were included, and relevant data were collected retrospectively. The gender, age, body mass index, presence of diabetes mellitus, preoperative albumin level, and flap size between irradiated and nonirradiated patients had no significant difference. Results: No significant difference was observed in the incidence of complications (total, mild, or severe) between the radiotherapy and nonradiotherapy groups. In univariate analysis, preoperative radiotherapy was not associated with postoperative complications of the SAI flap procedure (P = 1.00), while a low preoperative albumin level was a significant risk factor for postoperative complications (P < .05). Conclusions: Our data suggest that preoperative radiotherapy does not increase the risk of SAI flap postoperative complications compared with surgical reconstruction alone.

Superficial Temporal Artery Posterior Branch Flap for Reconstruction of Composite Oral/Perioral Defects.

Defects involving total lower and/or upper lip often extend to intraoral and/or perioral areas. Flaps based on superficial temporal artery, either as pedicled or free flaps, can be used for reconstruction of various head and neck defects. In this clinical study, we tried to demonstrate the application of a pedicled flap based on the posterior branch of superficial temporal artery in 3-dimensional reconstruction of these composite oral/perioral defects as a successful alternative in cases where microvascular tissue transfer cannot be performed. Six male patients with composite perioral/oral defects who underwent reconstruction with a pedicled flap based on the posterior branch of the superficial temporal artery between April 2020 and December 2020 were evaluated retrospectively. Demographic data, topographic data of defects, and the dimensions of the flaps were gathered from patient files. All patients required reconstruction after tumor resection. All flaps survived without any signs of partial or total necrosis. Postoperatively, the patients did not report any oral incompetence or drooling, and they were able to fully close their mouths. Pedicled flaps based on the posterior branch of superficial temporal artery provide reliable results in composite perioral/oral reconstruction.

Systematic review of the free thoracodorsal artery perforator flap for head and neck reconstruction

BackgroundThe thoracodorsal artery perforator (TDAP) flap has gained interest as a option for reconstruction of head and neck defects while minimizing donor site morbidity as compared to traditional workhorse flaps. The primary aim of this systematic review is to assess the postoperative outcomes and efficacy of this flap. MethodsSeveral databases were screened for relevant citations. The quality of studies and risk of bias were evaluated using the MINORS scoring system. ResultsTwenty articles containing 168 patients undergoing at least one TDAP flap reconstruction met the inclusion criteria. There were no incidences of total flap failure and only 10 incidences of partial flap failure (5.95 %). Flap complications and donor site morbidity was low. The average MINORS score of the studies suggested a moderately high amount of bias. ConclusionsBased on limited quality evidence, this review suggests that TDAP flap is a safe and feasible option for head and neck reconstruction with comparable success rates as other commonly used flaps, with low complication rate and donor site morbidity. Further large-scale studies are warranted.

An anterolateral thigh free flap for reconstruction of extensive neck defect in diabetic patient: a case report

Introduction: Reconstruction of the head and neck has challenges due to its three-dimensional structure, tissue complexity, extent of the defect, and clinical scenarios. Advances in microsurgical techniques make free tissue transfer reconstruction a popular choice to address these issues. Anterolateral thigh perforator flap (ALT) is a workhorse flap for head and neck reconstruction due to its long and reliable pedicle, large volume, versatility in composition, and low donor morbidity. However, diabetes mellitus may contribute to developing postoperative complications, such as vascular occlusions and thrombosis, that endanger free flap survival and are associated with poor wound healing. This case report demonstrates the successful utilization of this approach in the closure of extensive neck defects in a diabetic patient. Case Presentation: A 56-year-old male was referred with a 21 cm x 15 cm defect following an odontogenic submandibular abscess. The flaw was extended from the intrabuccal, neck, and one-third of the upper anterior thorax, involving the skin, subcutaneous tissue, and exposed mandibular bone. The patient had previously uncontrolled diabetes mellitus. Surgical debridement, antibiotics, insulin for glucose control, and wound bed preparation were performed. A free fasciocutaneous ALT flap was used for defect closure. The flap was raised template-based, sized 24 × 15 cm, with a pedicle from the descending branch of a lateral circumflex femoral vessel. End-to-end anastomosis of one artery and vein of the superior thyroid vessel was performed. The donor site was closed using a split-thickness skin graft. The surgery and recovery were uneventful. Flap refinement was carried out one month later. The patient underwent a three-month follow-up period, expressing satisfaction with the aesthetic and functional outcomes. Conclusions: Anterolateral thigh perforator flap (ALT) is a workhorse flap for reconstruction of head and neck reconstruction due to its long and reliable pedicle, large tissue volume with various compositions, and low donor morbidity. The LD flap presents as an alternative for free tissue transfer. Regional pedicled flaps can be chosen where microsurgery is not available or suitable. However, vascular compromise and flap failure remain a challenge. Identifying and managing risk factors such as diabetes mellitus are needed to minimize significant complications.

Deep Abscess Formation After Head and Neck Free Flap Reconstruction: A Critical Appraisal of Current Guidelines for Prophylactic Antibiotics in Head and Neck Surgery

Postoperative infections have a major impact on patient recovery, especially when a second surgical procedure is required. In this study, 342 cases from a retrospective cohort of patients undergoing microvascular free flap reconstruction of head and neck defects, were evaluated with respect to the development of deep abscesses. Two different perioperative antibiotic prophylaxis protocols based on amoxicillin-clavulanate and cefazolin with metronidazole were compared. Streptococcus anginosus was found to be the causative pathogen for the development of abscesses in the head and neck region in all cases in this series. An association for the development of abscesses was found with the use of osteosynthesis material and the use of cefazolin with metronidazole.

Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps.

Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.

Reverse submandibular gland flap: An alternative for reconstruction of medium-sized oral defects

Despite the development of microsurgery, local flaps still play an essential role in the reconstruction of head and neck defects. The submandibular gland flap (SMGF) has proven to be a reliable method for repairing medium-sized defects. It requires a shorter duration of general anesthesia and has fewer donor site complications compared to the free flap. However, the restricted vascular pedicle length limits its application. Retrograde flow is one solution. The authors describe a novel technique of using reverse submandibular gland flap (RSMGF) for the reconstruction of oral cavity defects. Additional vascular pedicle length was obtained by ligating the proximal end and dissecting the distal end of the facial vessels, thus extending its application range. The RSMGF is technically feasible and suitable for repairing medium-sized defects of the oral cavity (cT2 stage tumor) like buccal mucosa, especially for the elderly in poor general condition, for whom free flaps are not applicable.

Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure.

Finite options exist to address free flap failure. There is a lack of consensus on the standard treatment for secondary reconstruction in such cases. Herein, the authors determined the survival rate of a second flap following a total loss of an initial free flap during head and neck reconstructions and evaluated whether there was a difference in the rate of secondary flap necrosis depending on the timing of reconstruction salvage. The authors retrospectively reviewed 1572 free flaps for head and neck reconstruction from 2010 to 2022. Patients who underwent secondary surgery with flaps after failure of a primary free flap were included. Patients were divided into three groups based on the time for secondary flap reconstruction from the time of primary reconstruction (group A, 0 to 5 days; group B, 6 to 30 days; and group C, >30 days). The authors identified 64 cases of complete flap loss after primary reconstruction requiring secondary reconstruction. Pedicled flaps were used in 34.4% of the cases, whereas a second free flap was used in 65.6% of the cases. Overall, the flap failure rate for secondary reconstructions was 6.7% in group A, 35.3% in group B, and 6.7% in group C ( P = 0.022). For free tissue transfer, the success rate of a secondary reconstruction was 92.3% in group A, 28.57% in group B, and 93.3% in group C. The authors favor an early microsurgical reconstruction (≤5 days) following primary reconstruction in cases of free flap failure. If early reconstruction cannot be performed, a deferred reconstruction with free tissue transfer (>30 days) should be considered. Therapeutic, III.

Reconstruction of Head and Neck Defects Using Medial Sural Artery Perforator Free Flap.

To study the use of medial sural artery perforator(MSAP) free flap in head and neck reconstruction. This was a prospective study. The patients with cancers of head and neck underwent excision of tumor along with neck dissection, and MSAP free flap was used for reconstruction. The free MSAP flaps were used in 30 patients to reconstruct head and neck soft tissue defects. There were sixteen male and six female patients with the median age of 40 years. The most common site of tumor resection was the tongue (14 cases), followed by buccal mucosa (12 cases), neck skin(2 cases), skin over parotid(1 case) and lip(1 case). Average flap size was 56 cm2. Thickness of the flap ranged from 4 to 8mm. The length of the vascular pedicle ranged from 8 to 14cm (12cm mean) which provides sufficient length during vessel anastomosis. Arterial diameter ranged from 1.0 to 1.5mm(Average - 1.25mm) and venous diameter of both veins in pedicle ranged from 1.5 to 2.5mm(Average - 2mm) in size. Most flaps were based on two perforators. Primary closure was attained in 11 cases whereas 19 patients required split thickness skin graft(STSG). The average flap harvesting time was 45min. Flap was failed in two cases. MSAP is good alternative to FRAFF in the reconstruction of defect after resection of head and neck cancer.

Audit of head and neck defect reconstruction.

Objective: To share our experience with reconstruction of the head and neck defects and to standardize the reconstruction options for such defects. Study Design: Descriptive Cross Sectional study. Setting: Burns and Plastic Surgery Center, Peshawar. Period: November 2018 to December 2022. Material &amp; Methods: Data was collected from medical records about the patient demographics, mechanism of injury and type of procedures done. Defect size was classified into small (&lt; 3 cm), medium (4 cm to 8 cm) and large (&gt; 8 cm). Data was analyzed using SPSS. Results: Over the study period, 112 (70%) male and 48 (30%) female patients, with mean age of 44.36 + 21.35, were operated. The main cause of head and neck defects, were malignant lesions; 60% (n=96) cases. The most common site of was nose, either alone or in combination with surrounding areas. In 54 (33.4%) cases, the reconstructed defects were of medium size, followed by large defects (n=52, 32.5%). In 79 (49.4%) cases, the defects were reconstructed with local flaps, followed by pedicled flaps; 70 (43.8%) cases. Free flap reconstruction was performed in 11 (6.9%) cases. The most common free flap was fibula based (n=4). Complications were observed in 4.4% cases. Conclusion: The most common defects in head and neck region are on nose. In most cases the etiology is lesion excision. Other common defects encountered are scalp, eyelids and ear. Most of the defects can be covered with local flaps with very low complication rate.

The Medial Sural Artery Perforator Flap versus Other Free Flaps in Head and Neck Reconstruction: A Systematic Review

The medial sural artery perforator (MSAP) flap is a versatile fasciocutaneous flap, and yet is less commonly utilized than other free flaps in microvascular reconstructions of the head and neck. The aim is to conduct a high-quality Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)- and Assessment of Multiple Systematic Reviews 2 (AMSTAR 2)-compliant systematic review comparing the use of the MSAP flap to other microvascular free flaps in the head and neck. Medline, Embase, and Web of Science databases were searched to identify all original comparative studies comparing patients undergoing head and neck reconstruction with an MSAP flap to the radial forearm free flap (RFFF) or anterolateral thigh (ALT) flap from inception to February 2021. Outcome studied were the recipient-site and donor-site morbidities as well as speech and swallow function. A total of 473 articles were identified from title and abstract review. Four studies met the inclusion criteria. Compared with the RFFF and the ALT flaps, the MSAP flap had more recipient-site complications (6.0 vs 10.4%) but less donor-site complications (20.2 vs 7.8%). The MSAP flap demonstrated better overall donor-site appearance and function than the RFFF and ALT flaps ( p = 0.0006) but no statistical difference in speech and swallowing function following reconstruction ( p = 0.28). Although higher quality studies reviewing the use of the MSAP flap to other free flaps are needed, the MSAP flap provides a viable and effective reconstructive option and should be strongly considered for reconstruction of head and neck defects.

Use of Customized Thickness Anterolateral Thigh Flap in Head and Neck Reconstruction

Objective: This study demonstrates different techniques of anterolateral thigh flap (ALT) with the appropriate surgical planes according to the thickness of the defect, which have not been previously found in the literature, with our reconstruction experiences. &#x0D; Materials and Methods: A retrospective study was performed including 26 flaps in 25 patients who underwent reconstruction of head and neck defects with different surgical planes of ALT flap including subfascial, superthin, suprafascial, chimeric and composite flaps from March 2017 through December 2020. Flap planes were chosen according to the thickness of the defect, determined during surgery by using caliper. We evaluated the characteristics, flap thicknesses, complications and need of revision surgery in postoperative period. &#x0D; Results: One of the superthin flaps was totally lost; there was not any other flap loss. Three patients died in postoperative period. Although appropriate plane of the flaps was chosen, 4 of all 26 flaps needed revision surgery. One of the patients who was performed lip reconstruction with superthin ALT flap had bulky appearance needed liposuction in postoperative 6 months and 3 patients who received subfascial ALT flaps were performed debulking surgeries. &#x0D; Conclusion: ALT flap is a versatile, reliable flap which can be harvested in different planes according to the thickness of the defect in head and neck region. The ALT flap with convenient thickness provides definitive reconstruction in a single stage without revision surgeries and the most optimal aesthetic results can be obtained.

Using a breast reduction to access a pedicled myocutaneous pectoralis major flap for anterior neck defect reconstruction: a case report

The authors describe a case where the pectoralis major flap was used to reconstruct a supraclavicular defect with a simultaneous breast reduction.

Radial Forearm Free Flap for Head and Neck Defect Reconstruction: An Up-to-date Review of the Literature

The radial forearm free flap has emerged as the mainstay of free flaps for oral cavity soft tissue reconstructions because of its versatility and ability to be used in the reconstruction of large and medium-sized defects. This flap is commonly used to restore head and neck defects, including full-thickness lip and oral cavity defects. This flap offers the opportunity to cover severe defects of the facial region due to its long vascular pedicle and elasticity. In addition to its ease of being harvested, the radial forearm free flap provides a sensate, pliable, and thin skin paddle with a long vascular pedicle. However, it can cause severe morbidity at the donor site, mainly due to exposure of the flexor tendon that results from a failed harvesting of the skin graft, changed sensation in the radial nerve, aesthetic deformity, and reduced range of motion and grip strength. This article aims to review all the up-to-date studies discussing the use of radial forearm free flap in head and neck reconstruction.

Retalho miocutâneo infra-hióideo em defeitos de cabeça e pescoço: experiência de uma única instituição

ABSTRACT Introduction: The infrahyoid flap is a pedicled flap with a simple harvesting technique. It may be an alternative for free flaps in elderly or patients with multiple comorbidities. This article evaluates 15 patients submitted to reconstruction of head and neck defects. Case report: Case series of patients submitted to infrahyoid flap reconstruction in a referral center. We evaluate surgical and functional outcomes associated with reconstruction with infrahyoid flap from November of 2013 to May of 2017. Conclusion: Infrahyoid flap is a thin and flexible flap with low rates of complications and does not require another surgical team. The majority of the patients had complete functional rehabilitation. Keywords: Reconstructive Surgical Procedures. Myocutaneous Flap. Surgical Flaps. Head and Neck Neoplasms.

Multiple simultaneous free flaps for head and neck reconstruction: A multi-institutional cohort

ObjectivesTo describe the experience of two tertiary academic centers with multiple, simultaneous free flaps for complex head and neck defect reconstruction. MethodsPatients undergoing multiple, simultaneous free flaps from 2017 to 2022 were retrospectively reviewed. ResultsSeventy-one patients (64.8% male, median age 61 years) were identified and underwent 143 free flaps. The leading surgical indication was squamous cell carcinoma (n = 48, 67.6%). Defect sites included oral cavity, maxilla, pharynx, parotid, skull base, and scalp. The most common free flap combinations were fibula (FFF) with anterolateral thigh flap (n = 33, 46.5%), radial forearm (RFFF) with scapula (n = 11, 15.5%), and RFFF with FFF (n = 10, 14.1%). Median operative time was 12 h. Median length of hospitalization was 10 days. At last follow-up (median 6 months), 141 flaps (98.6%) survived without partial nor complete flap failure. ConclusionMultiple, simultaneous free flaps are a rare, yet reliable option for head and neck reconstruction in select patients with defects involving several tissue types, multiple functional areas, or large volumes.

Comparison between free posterior tibial flap and free radial forearm flap for head and neck reconstruction: an anatomical study and a retrospective comparative cohort study

Both free posterior tibial flap (FPTF) and free radial forearm flap (FRFF) are commonly used for head and neck defects. They have many similarities in embryology, histology, and anatomy, but their advantages and disadvantages in head and neck repair have not been fully recognized. This study aimed to compare the cadaveric anatomy and clinical application of FPTF and FRFF for the reconstruction of head and neck defects after tumor resection. Anatomical dissection was performed on 10 fresh adult cadavers. The general characteristics of both flaps and the sites of recipients and donors were collected. A total of 31 and 25 patients underwent FPTF and FRFF construction, respectively. The patient medical records were assessed to obtain the clinical characteristics. Characteristics of the flap such as size, pedicle length, and clinical process data were collected and compared. The appearance, sensory disturbance, and effect on quality of life and daily activity were evaluated. The posterior tibial artery was present and observed in all patients. The posterior vascular pedicle was longer than the radial artery. There was no difference between the diameters of arteries of FPTF and FRFF; however, the diameters of their veins differed. In terms of flap characteristics, FPTF was significantly larger and had a longer vascular pedicle than FRFF (40.68±11.07 vs. 53.77±29.02 cm2, P=0.03; 8.48±1.66 vs. 11.10±2.39 cm, P=0.00). Patients in the FPTF group had a significantly shorter total hospital stay (FRFF: 26.48±8.33 d; FPTF: 18.58±6.68 d), postoperative hospital stay (FRFF: 17.60±5.53 d; FPTF: 10.94±3.62 d), and flap harvest time (FRFF: 87.00±20.92 min; FPTF: 65.00±17.56 min) than FRFF group. There were far more complications of the donor site in the FRFF group than in the FPTF group. Also, according to the patients' subjective evaluations of the donor site, FPTF was superior to FRFF (P=0.00). FPTF is a reliable alternative to FRFF for head and neck reconstruction. These techniques share similar certain embryogenesis and anatomical characteristics but FPTF possesses unique aesthetic and clinical application advantages.