Partial Flap Necrosis Research Articles

Prospective study on the localization of anterolateral thigh perforator vessel based on mixed reality and artificial algorithm.

This paper aims to construct a system integrating mixed reality technology with artificial algorithm and to evaluate its effectiveness in vascular localization during anterolateral thigh perforator flap surgery to provide new insights for clinical practice. Twenty patients undergoing anterolateral thigh perforator flap repair were selected. After attaching positioning devices on the lower limb, CT angiography (CTA) scans were performed. The 2D data obtained were converted into a 3D model of the positioning device and vessels. Mixed reality technology was utilized to achieve 3D visualization of perforator vessels. An artificial algorithm was developed in HoloLens 2 to match the positioning device automatically with its 3D model intraoperatively to overlap the perforator vessels with their 3D models. The number of perforator vessels identified within the flap harvesting area and the actual number detected during surgery were recorded to calculate the accuracy rate of vessel identification based on CTA data reconstruction. The distance between the perforator vessel exit points located by the system and the actual exit points was measured, and the error values were calculated. The surgical time required for the system to harvest the anterolateral thigh perforator flap was documented and compared with the surgical time required by conventional methods. The clinical applicability of the system was discussed. The CTA data reconstruction identified 30 perforator vessels, while the actual number found during surgery was 32, resulting in an identification accuracy rate of 93.75%. The average distance between the perforator vessel exit points located by the system and the actual exit points was (1.65±0.52) mm. The average surgical time for flap harvesting with the assistance of the system was (43.45±4.6) min compared with (57.6±7.9) min required by conventional methods. All perforator flaps survived the procedure. One case of flap infection occurred seven days postoperatively, and one case of partial flap necrosis was treated with symptomatic therapy, resulting in delayed healing. The system constructed in this paper can achieve 3D visualization of perforator vessels through mixed reality technology and improve the accuracy of perforator vessel localization using artificial algorithms, hence demonstrating potential application in anterolateral thigh perforator flap harvesting surgeries.

Angiosome-Guided Revascularization in Local Flap Reconstruction of the Foot and Ankle: Comparable Outcomes With Both Direct and Indirect Revascularization.

Among patients with critical limb ischemia and tissue loss, revascularization is an essential component for limb salvage. Local flaps of the foot and ankle remain a versatile tool in reconstructive limb salvage but is dependent on adequate arterial flow. In patients with arterial occlusive disease requiring revascularization, there is a lack of evidence in the current literature investigating on the necessity of direct arterial flow to the respective angiosome for local flaps reconstruction. Our study thereby compares the outcomes of direct (DR) and indirect (IR) revascularization for local flap success. Patients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. IR was performed in patients where DR could not be performed. DR was defined as an intervention on the same pedicle used for the local flap. IR was defined as an intervention performed on a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, postoperative complications, and long-term outcomes were collected. A total of 33 patients underwent 43 local flap reconstruction with preoperative ER: 58.1% (n = 25) received DR and 41.2% (n = 18) received IR. Patients had a mean CCI of 6.7 ± 1.8, with a high prevalence of diabetes mellitus (93.9%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. In the immediate postoperative period (postoperative day 0 to 12), there were no significant differences in immediate flap success (DR: 100% vs IR: 88.9%, P = 0.169) or partial flap necrosis between (DR: 0.0% vs IR: 16.7%, P = 0.066). Rates of major complications from infection (DR: 28.2% vs IR: 22.2%, P = 0.736), ischemia (DR: 4.0% vs IR: 11.1%, P = 0.562), or dehiscence (DR: 8.0% vs IR: 16.7%, P = 0.634) requiring reoperation were similar between 2 groups. Overall limb salvage rate was 84.9%, and comparable between groups (DR: 78.6% vs IR: 89.5%, P = 0.628). DR and IR achieve similar rates of limb salvage and flap success after local flap reconstruction. A multidisciplinary vasculo-plastic approach that incorporates preoperative arteriogram and revascularization should be utilized for this highly comorbid patient population to achieve optimal success and limb salvage.

Perioperative Blood Transfusion in Traumatic Limb Salvage.

Background Limb salvage following traumatic lower extremity (LE) injury often necessitates blood transfusion for adequate tissue perfusion. Appropriate transfusion decision-making via a risk-benefit analysis could maximize the opportunity for flap survival. This study aims to examine the impact of perioperative blood transfusion on postoperative complications in traumatic LE reconstruction. Methods A retrospective review was conducted at a level 1 trauma center on patients who underwent LE reconstruction between January 2007-October 2023. Patient demographics, comorbidities, perioperative blood transfusions, flap characteristics, and postoperative complications were recorded. Outcomes investigated included postoperative amputation rates, infection, partial flap necrosis, and flap loss. Univariate analysis and multivariable logistic regression were performed to examine the impact of patient factors on flap necrosis. Results In total, 234 flaps met inclusion criteria. Of these, 149 cases (63.7%) received no transfusion during their hospital stay (Tf-) and 85 cases (36.3%) received at least one unit of packed red blood cells intraoperatively through 48 hours following flap placement (Tf+). Overall flap survival rates were similar across both cohorts (Tf+: 92.9% vs Tf-: 96.6%, p=0.198). The Tf+ cohort had significantly higher rates of partial flap necrosis (12.9% vs. 2.0.%, p<0.001), amputation (6.0% vs 0.7%, p=0.015), and postoperative hardware infection (10.6% vs 2.7%, p=0.011) relative to the Tf- cohort. Multivariable logistic regression demonstrated that transfusion status was independently associated with a 5.1 fold increased risk of flap necrosis (p=0.033). Conclusion Transfusions administered intraoperatively through the acute postoperative period were associated with a significantly increased likelihood of flap necrosis. Surgeons should consider a conservative transfusion protocol to optimize flap viability in patients with traumatic LE injuries.

Refining a Multidisciplinary “Vasculo-plastic” Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

Background: The use of free tissue transfer (FTT) is effective for chronic, non-healing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plants to optimize limb salvage. This study aims to describe our vasculo-pathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTT and the most recent 100 procedures performed. Methods: A single-institution, retrospective review of 300 LE FTTs from July 2011 to January 2023 was performed. Patients were compared between the first 200 (Group 1, July 2011 – February 2020) and last 100 flaps (Group 2, February 2020 – January 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. Results: Group 2 patients had significantly higher rates of diabetes (67.0% vs. 48.5%, p=0.002), peripheral vascular disease (56.0% vs. 24.5%, p&lt;0.001), history of venous thromboembolisms (13.0% vs. 6.0%, p=0.039), venous reflux (81.9% vs. 67.8%; p=0.028), and preoperative venous thromboses on venous testing (25.5% vs. 10.5%; p=0.003) compared to Group 1. Group 2 underwent more pre-FTT endovascular interventions (23.0% vs. 16.5%, p=0.039) and vascular bypasses (4.0% vs. 0.0%, p =0.012). While immediate flap success and amputation rates were similar between the groups, Group 2 had higher rates of partial flap necrosis (7% vs. 3%; p=0.012). Conclusions: The adoption of a vasculo-plastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.

Study on Blood Circulation Monitoring After the Tissue Transfer of Ultrathin or Conventional Anterolateral Thigh Flaps.

This study was conducted to compare the incidence of postoperative complications related to blood circulation in the treatment of skin defects through the transfer of ultrathin anterolateral thigh (ALT) flaps or conventional ALT flaps. Patients who received ultrathin ALT flap transfer (group A) and conventional ALT flap transfer (group B) due to skin defects at Peking University Shenzhen Hospital from January 2016 to January 2023 were included in this study. The postoperative incidence of ecchymosis, vascular crisis (artery or vein), and flap survival were compared between the 2 groups of patients. In group A, 27 patients recovered and 8 patients reported ecchymosis. In addition, 32 patients achieved flap survival, 1 patient had partial flap necrosis, and 2 patients had complete flap necrosis. In group B, 61 patients recovered and 6 patients reported ecchymosis. In addition, 65 patients achieved flap survival, 1 patient had partial flap necrosis, and 1 patient had complete flap necrosis. Compared with group B, the incidence of ecchymosis was significantly higher in group A (P < 0.05). Postoperative blood circulation monitoring (especially ecchymosis) is an important part of postoperative nursing observation in the treatment of skin defects with ultrathin ALT flap transfer. There is no significant difference in the incidence of postoperative vascular crisis between ultrathin and conventional ALT flap transfer. However, the incidence of nonvenous crisis ecchymosis after ultrathin ALT flap transfer is significantly higher than that after conventional ALT flap transfer.

Effects of Preoperative Hemoglobin on Microsurgical Reconstruction and Perioperative Blood Transfusion Requirement: A Meta‐Analysis and Systematic Review of the Literature

ABSTRACTPurposeAlthough blood loss in microsurgical reconstruction is rarely large enough to be life‐threatening, preoperative anemia can be a particular issue in terms of postoperative morbidity, impaired wound healing, and compromised tissue viability. We seek to review the effect of preoperative hemoglobin (Hgb) levels on perioperative blood transfusion (PBT) requirements and complications to guide management of patients with preexisting anemia undergoing reconstruction.MethodsPubMed, Embase, and Scopus were queried for relevant articles. Inclusion criteria were as follows: original studies investigating outcomes and PBT requirements in flap‐based reconstruction based on preoperative Hgb levels. Patient and study characteristics were analyzed using descriptive statistics. A meta‐analysis was conducted to assess transfusion requirements across the included studies using Stata (version 18.0 Stata Corp, College Station, Texas, USA). The Fisher method was used to aggregate individual study p values into a single combined value to statistically assess the combined findings, where a p value of &lt; 0.05 was set as statistically significant.ResultsOne thousand three hundred and eighty‐nine studies were screened for title and abstract relevance, 14 of which met the inclusion criteria, including a total of 61,116 patients. Meta‐analysis of the studies revealed a PBT requirement of 36.2% for anemic individuals, significantly higher than the 20.0% for those with normal preoperative Hgb levels (p &lt; 0.001), with an average 4.9 versus 2.4 units of packed red blood cells being transfused (p &lt; 0.001). The majority of studies concluded that preoperative anemia was associated with medical complications, such as myocardial infarction, stroke, and infection (p &lt; 0.001). While six studies reported a significant relationship between low preoperative Hgb and flap morbidity (flap loss and partial flap necrosis), two studies found no correlation. The overall postoperative complication rate across the studies was 42.2% among patients with low preoperative Hgb levels, whereas the nonanemic group demonstrated a markedly lower rate of 13.9% (p &lt; 0.001).ConclusionThe existing evidence is strongly suggestive of increased PBT requirement in patients with anemia, highlighting the necessity for preoperative optimization of Hgb levels and intraoperative monitoring. While preliminary evidence demonstrates a relationship between anemia and medical complications, more research is warranted to characterize the specific association between preoperative Hgb levels and flap morbidity.

L-Shaped Scapular and Parascapular Combined Flap forReconstruction of a Large Surface Defect After SarcomaResection Using ICG Angiography: A Case Seriesof6 Patients.

Soft tissue sarcomas (STS) pose challenges in management due to large defects following wide resection. Reconstructive options are often limited, especially in patients with large circular defects below the gluteal region. This article addresses the question of how to effectively reconstruct such defects while minimizing donor-site morbidity. We present our experience with using an L-shaped combined scapular and parascapular flap after STS resection, highlighting the novelty of employing indocyanine green (ICG) angiography to ensure optimal blood flow and surgical safety. We retrospectively reviewed patients who underwent STS resection and immediate reconstruction using an L-shaped scapular and parascapular combined flap between October 2022 and April 2024. The feasibility of the procedure was assessed by analyzing the patient demographics, tumor characteristics, defect and flap sizes, operative time, and postoperative outcomes, including donor-site complications and shoulder function. Six patients underwent reconstruction using an L-shaped combined flap with no donor-site complications or significant shoulder dysfunction. The average sizes were 15.7 × 13.7 cm for the defect, 20 × 7 cm for the scapular flap, and 23 × 7.3 cm for the parascapular flap. The average operative time was 7 h and 9 min. The average follow-up period was 10.2 months. Except for one case of partial flap necrosis, all flaps survived completely, highlighting the reliability of the procedure. L-shaped combined scapular and parascapular flaps are promising reconstructive techniques for large surface defects after STS resection with low donor-site morbidity and preservation of shoulder function. The novel application of these flaps for large circular defects below the gluteal region, combined with the use of ICG angiography to ensure flap viability and enhance surgical safety, are key contributions of this study.

Nasolabial Transfer Flap with Auricular Cartilage Graft after Fat Grafting for Nasal Ala Reconstruction in Parry-Romberg Syndrome.

Alar atrophy associated with Parry-Romberg syndrome (PRS) can lead to significant nasal contour deformities. The primary objective of this study was to address nasal alar deformities in PRS patients through the application of a nasolabial transfer flap combined with an auricular cartilage graft after sequential fat grafting. All PRS patients with alar deformities who underwent our reconstructive surgery were included in this case series. Sequential fat grafting was performed on the affected nasolabial area, followed by a nasolabial transfer flap combined with an auricular cartilage graft. Surgical outcome and complications were recorded during postoperative follow-up. From September 2021 to November 2023, a total of 14 PRS patients presenting nasal alar defects underwent nasolabial transfer flap combined with an auricular cartilage graft after sequential fat grafting. Complications at 1 month postoperatively included partial flap necrosis (21%), hyperplastic scarring (14%), undercorrection (14%), overcorrection (7%), and pain (7%). The surgery significantly improved the patient's nasal symmetry. FACE-Q questionnaire indicated the overall aesthetic outcome and quality of life were deemed satisfactory for all patients. After sequential fat grafting, the nasolabial fold transfer flap with an auricular cartilage graft is effective to address alar deformities associated with PRS. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Preferential Use of Subcutaneous Arteries (SCIA-SB and SIEA) in Abdominal-based Autologous Breast Reconstruction with a Modified Flap Design.

Despite its many advantages, the deep inferior epigastric artery perforator flap requires fascial incision and intramuscular dissection, which can lead to pain and weakening of the abdominal wall. The superficial inferior epigastric artery (SIEA) flap offers an alternative to avoid this damage but is often considered unreliable due to its variable anatomy. In this study, we report our experience in autologous breast reconstruction using either the superficial branch of the superficial circumflex iliac artery (SCIA-SB) or the SIEA as the sole flap pedicle. A retrospective study was conducted from August 2022 to December 2023. A total of 17 patients underwent breast reconstruction with 18 flaps (1 bilateral and 16 unilateral reconstructions). The SCIA-SB (14 flaps) or SIEA (4 flaps) served as the exclusive arterial sources. Preoperative vessel identification was performed using color-coded duplex sonography, and the flap design was adjusted accordingly. Intraoperative flap perfusion was assessed via indocyanine green angiography. Demographic, intraoperative, and postoperative data were recorded. The mean follow-up was 5.7 months (range: 3-17 mo). Of the 18 flaps, 1 was lost due to arterial insufficiency. Partial flap necrosis requiring revision occurred in 1 case, whereas minor complications (seroma, wound dehiscence, mastectomy skin necrosis, and infection) were observed in 7 patients. In our experience, either the SCIA-SB or SIEA can be successfully used as a pedicle in autologous breast reconstruction, provided that the abdominal flap design is modified to include their functional angiosomes.

Investigation of treatment outcomes for severe extremity trauma in an independent orthopedic trauma center: A case series

BackgroundSevere extremity trauma is one of the most challenging injuries to treat. Limb salvage after severe extremity trauma requires rapid revascularization, accurate and appropriate bone and soft tissue reconstruction, and appropriate management to address critical complications. The purpose of this study was to report the treatment outcomes for severe extremity trauma injuries at our independent orthopedic trauma center. MethodsThis study included patients with severe extremity trauma who underwent major vascular repair or soft tissue reconstruction. Bone reconstruction method, presence or absence of revascularization, and flap type were investigated. Complications were investigated, including revascularization failure, flap failure, infection, and ultimately, whether amputation was required. Additionally, we investigated the number of surgeries performed on each patient at the time of initial hospitalization. ResultsThirty-five patients who underwent revascularization or soft tissue reconstruction were included in this study. Plate fixation was performed in 18 patients, intramedullary nail fixation in 8, screw fixation in 1, pinning in 4, and without implant fixation in 4. Revascularization was performed in six patients, and no vascular complications occurred. Pedicled and free flaps were used in 17 and 16 patients, respectively. Partial flap necrosis occurred in four patients, and arterial occlusion occurred in one. Infection occurred in 10 patients who were treated with frequent irrigation and high-concentration antibiotics local infusion therapy. None of the 35 patients required limb amputation. Mean number of surgeries was 12.5. ConclusionsThe limb of all the 35 patients with severe extremity trauma treated at our independent orthopedic trauma center were salvaged.

Freestyle SGAP flaps for sacral ulcers.

Study Design: Retrospective case study. Objective: To study the feasibility and ease of freestyle SGAP perforator flaps for sacral ulcers. Setting: This study was conducted in tertiary care hospital in India.Sacral ulcers are commonly encountered in long-term bedridden patients. Various options to cover these ulcers include the gluteus muscle flaps (v-y, rotation and advancement), fascio-cutaneous flaps, superior and inferior gluteal artery perforator flaps. The superior gluteal artery perforator (SGAP) flap is a reliable option for sacral sore management. Using this flap, only one out of ten patients had partial flap necrosis. None had wound dehiscence nor seroma formation. No recurrence was seen at three months follow-up. This flap can safely be used as a 'free style' flap.

Superficial temporal artery branching pattern in single stage auricular reconstruction: A novel classification

IntroductionThe two most severe complications of single-stage, porous polyethene microtia reconstruction are flap necrosis/framework exposure and frontal nerve paralysis. To reduce these risks, require a temporoparietal fascia (TPF) flap that includes both the parietal and frontal branches of the superficial temporal artery (STA) while sparing the nerve. We propose a classification that helps minimize said complications. Material and methodsFifty-five TPF flaps of 54 microtia patients who underwent single-stage auricular reconstruction from May 2018 to July 2021 were studied. Flaps were harvested using endoscopic techniques. The parietal and frontal branch characteristics and measurements were obtained using a microscope/endoscope. ResultsThe frontal artery might have 1 to 4 branches. If they were close to Pitanguy's line (≤5 mm), there would be a high risk of nerve damage. Parietal (P) and frontal (F) artery diameters <0.5 mm were risk factors for partial flap necrosis. Based on this observation, we proposed 0.5 mm as the diameter threshold to determine whether an arterial branch is hypoplasia or sufficient.From this study, a new classification of STA branching pattern was proposed with five types: PF1 (23.6 %), PF2 (43.6 %), pF1 (3.6 %), pF2 (12.8 %), and Pf (16.4 %); where P/F indicates sufficient branches, p/f indicates absent or hypoplasia ones, and the number indicates single or multiple frontal artery branching. ConclusionThe risk of flap necrosis and frontal nerve damage is due to abnormalities of the frontal artery of the STA in the TPF flap. Understanding the anatomical classification with clear visualization during flap harvest ensures a successful outcome.

Flap-Based Reconstruction in Patients with Autoimmune Disease: An Institutional Experience with the Deep Inferior Epigastric Perforator Flap and Review of the Literature.

Autoimmune diseases are associated with characteristic chronic inflammation, aberrations in tissue perfusion, and hypercoagulability, and thus have considerable implications for local and free-flap reconstruction. We seek to summarize the current evidence on outcomes of flap-based reconstruction in patients with pre-existing autoimmune disease and present our experience with autologous breast reconstruction in this population. PubMed, Embase, Scopus, Cochrane, and Web of Science were searched for relevant articles, and pertinent data were presented qualitatively. Institutional data were queried for patients who underwent autologous breast reconstruction with deep inferior epigastric perforator (DIEP) flaps between 2015 and 2024. A retrospective review was conducted to identify DIEP patients with a history of autoimmune disease. Data on patient demographics, medication history, flap outcomes, and perioperative complications were collected. The majority of existing studies found no increased independent risk of flap complications. However, other complications, predominantly wound dehiscence, were independently associated with autoimmune disease. Regarding immunosuppressant therapy, the literature demonstrated that perioperative glucocorticoid use was consistently associated with all complications, including seroma, infection, wound disruption, and partial flap loss.Our 13-patient institutional experience identified no cases of total flap loss or microvascular thrombotic complications. There was one case of partial flap necrosis further complicated by abdominal site cellulitis, and one case of recipient-site dehiscence managed with local wound care. No patients required re-operation for flap or donor-site complications. The literature suggests that flap reconstruction can be performed safely in patients with autoimmune conditions, which was also supported by our institutional experience. While there is likely minimal risk of microsurgical complications in the context of free tissue transfer, donor-site morbidity and wound dehiscence remain major concerns for patients with a history of autoimmune disease. Limiting the use of immunosuppressive agents, especially corticosteroids, may potentially improve outcomes of flap reconstruction.

The Free Flap Reconstruction of Facial Defects after Squamous Cell Carcinoma Excision.

Background and Objectives: Cutaneous squamous cell carcinoma is the second most common skin cancer. There are many methods for the reconstruction of facial subunit defects after skin cancer excision. The face is vital to a person's life and should be reconstructed considering functional and aesthetic aspects. Despite a variety of flap types and techniques, it is still challenging to meet the various demands. The aim of this study was to compare free flaps for facial reconstruction after resection of cutaneous squamous cell carcinoma. Materials and Methods: This study included 14 patients from January 2021 to June 2023. Patients who underwent facial SCC resection and subsequent reconstruction using free flaps were analyzed retrospectively. Age, sex, and localization were recorded. Follow-ups ranged from 5 to 21 months, with an average of 13 months. Results: All free flaps survived well except one case of partial flap necrosis. In most patients, good to excellent functional and aesthetic results were obtained. The donor site healed uneventfully in all patients. Conclusions: Free flap reconstruction is an excellent choice in wide skin oncologic defects. In terms of texture, it also could be a good surgical method. The use of a fraxel laser can progressively facilitate improved color matching with the surrounding skin.

Facial Artery Perforator Flap for Perioral and Perinasal Oncologic Defect Reconstruction: Surgical Technique and Postoperative Outcomes.

Facial artery perforator (FAP) flap is a versatile and reliable one-step facial reconstruction technique. However, its full potential remains underutilized due to a lack of clear guidelines and rigorous technique requirements. This study report the use of FAP flaps in our centre for the management of perioral and nasal oncologic defects, focusing on surgical technique performed and post-operative management. We conducted a retrospective review of all patients who underwent reconstruction with a perioral or perinasal FAP flap only following tumor resection over a 4-year period (n = 29). Parameters measured included flap survival, complication rates, surgical technique performed, and the need for touch-up procedures. Patients were grouped based on age, defect size, and location and outcomes were compared across these groups. The mean histological tumor defect area was 331 mm2. During at least 6 months of follow-up, no local recurrence was observed. Twenty-seven (93.1%) flaps survived completely. Major postsurgical complications occurred in seven (23.8%) patients, including complete flap necrosis (1), partial flap necrosis (1), flap collapse (1), venous congestion (1), wound dehiscence (1), and local infection (2). A higher complication rate was associated with nose tip defects (80.0% vs. 12.5%, p = 0.007). Touch-up procedures were more frequently required for reconstructions involving the nasal sidewall and dorsum (53.8% vs. 13.3%, p = 0.04). Based on our experience, the FAP flap is highly effective for the reconstruction of the upper lip, nasolabial fold, and certain oncologic nasal defects. However, specific defect locations, such as the nose tip, may be associated with higher complication rates, necessitating careful patient selection and surgical planning.

What Free Flaps Are Surgeons Using for Palatal Fistula Repair in Patients with Cleft Palate? A Systematic Review.

Recalcitrant palatal fistulas in patients with cleft palate history sometimes require free flap reconstruction. This study reviews the literature on described flaps and outcomes. A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All study designs were included. Non-English articles were excluded. Patients with a history of cleft palate who underwent free flap reconstruction for a oronasal fistula. Free tissue transfer for a palatal fistula repair. Information regarding defect and flap characteristics were reviewed. Surgical outcomes such as flap loss rates, rates of recurrent fistula formation, and speech outcomes were also obtained. Our search returned 894 articles, of which 23 were included. All studies were retrospective case series and reports. A total of 65 patients were described with an average age of 19.3 (range 3-55) years and a median fistula size of 8.00 cm2 (range 2.54 cm2 - 24 cm2). The most common flap was the radial forearm flap (n = 37). Nine patients (13.8%) had recurrent fistula formation with surgical revision successful in all cases in which the patient returned to the operating room. There were two partial flap losses and no total flap losses. Speech outcomes showed improvement in 27 patients across 10 studies. Palatal fistula repair with free tissue transfer is safe with an acceptable risk profile and low flap loss rate. Early recurrence due to partial flap necrosis and dehiscence are successfully managed with flap readvancement.

A single-center retrospective comparison of muscle versus cutaneous free flaps for posterior elbow defect reconstruction

IntroductionComparative data regarding free flap outcomes for elbow defect reconstruction is still lacking. This study aims to compare complication rates of free muscle (MFs) versus cutaneous flaps (CFs) for posterior elbow reconstruction. MethodsIn a single-center retrospective analysis, patients with free MFs and CFs for posterior elbow reconstruction from 2000 until 2021 were analyzed. Retrospective chart review included patient demographics, operative details, and postoperative complications. Compared outcomes of interest were microvascular complications, partial or total flap necroses, wound dehiscence, hematoma or flap infection, and donor-site complications. ResultsSixty-six free flaps (CFs: n=42; MFs: n=24) were included, with a trend over time towards using CFs (64%). MFs were used for larger defects (CF: 175 ± 82 vs MF: 212 ± 146 cm2; p=0.13). Outcome analysis revealed an equal distribution of microvascular complications (10% vs 13%; p=0.7), partial flap necrosis (7% vs 8%; p>0.9), wound dehiscence (7% vs 4%; p>0.9), evacuation of hematoma (10% vs 4%; p = 0.7), and infection (0% vs 4%; p = 0.4). Total flap necrosis requiring additional flap surgery was necessary in one CF (2%) and in no MF (0%) (p>0.9). ConclusionSurgical outcomes, flap necrosis rates, and microsurgical complications did not differ between CFs and MFs. Both flap types are safe and effective options. The free anterolateral thigh and latissimus dorsi flaps represent indispensable workhorses for the reconstruction of extensive elbow defects.

Surgical outcomes of profunda artery perforator flap in head and neck reconstruction: A systematic review and meta-analysis.

This study aims to evaluate the efficacy of the profunda artery perforator (PAP) flap in head and neck reconstruction. A single arm meta-analysis was performed for flap survival rate (primary outcome), reoperation for major complication, and overall complication rates (secondary outcomes). The search strategy yielded a total of 295 potentially relevant publications, of which 13 were included. A total of 305 patients (males: 80.8%, n = 232/281), with a median age of 56.1 years (n = 305/305; 95% CI 53.9-63), who underwent a total of 307 PAP flap reconstructions for head and neck defects were included. Flap survival rate was 100% (n = 306/307; 95% CI 99.6%-100%), with a reoperation rate for major complications of 3.7% (n = 15/307; 95% CI 1.85%-6.1%) and an overall complication rate of 26.5% (n = 92/307; 95% CI 15.7%-38.9%). Notable postoperative complications included wound dehiscence (n = 15/307, 4.9%), delayed healing (n = 14/307, 4.6%), and wound infection (n = 12/307, 3.9%). Partial flap necrosis and hematoma occurred in 2.6% of cases (n = 8/307), while arterial and venous thrombosis were documented in 0.7% (n = 2/307) and 1.3%, respectively (n = 4/307). The application of the PAP flap in head and neck reconstructions showed several favorable aspects, such as an exceptionally low flap failure rate, versatility in achieving variable dimensions, and a relatively low incidence of complications. PAP flap might be considered as a compelling alternative to the traditionally employed soft tissue free flaps in head and neck reconstruction.

The free vastus lateralis-And conjoined vastus lateralis anterolateral thigh/tensor fascia lata flap for oncological chest wall reconstruction.

A reconstructive option for extensive chest wall reconstruction is the free myocutaneous vastus lateralis muscle (VL) flap which can be performed in isolation or in conjunction with a fasciocutaneus anterolateral thigh (cVLALT) and/or myofasciocutaneous tensor fascia lata flap (cVLTFL). We aimed to directly compare the outcomes of these reconstructive options. Patients who underwent oncological chest wall reconstruction with a free VL, cVLALT, or cVLTFL flap between February 2010 and 2022 were included in this retrospective study. Patient demographics, surgical characteristics, as well as medical and reconstructive outcomes, were evaluated. The operative outcomes between myocutaneous VL, cVLALT, and cVLTFL flap reconstructions were compared. A total of 41 patients underwent chest wall reconstruction with a free myocutaneous VL (n = 25; 61%), cVLALT (n = 14; 34%), or cVLTFL Three acute flap thromboses occurred in the entire cohort (3/41, 7%), with one myocutaneous VL flap failing because of recurrent venous thrombosis during the salvage procedure. Total flap necrosis was seen in two cases (5%; VL flap: n = 1; cVLALT flap: n = 1), and partial flap necrosis in one VL flap (1/25, 4%) and in the distal ALT portion of three cVLALT flaps (3/14, 21%). No significant difference was seen between isolated VL and conjoined VL flaps regarding the partial (p = .28) or total flap necrosis rate (p = .9). The free (conjoined) VL flap provides reliable outcomes for obliterating dead space achieving durable reconstruction of complex chest wall defects.

Vasopressor use in partial flap necrosis in free flap transplant patients with vascular comorbidities: A retrospective study

Intraoperative use of vasopressors in free flap surgeries is controversially debated. The predominant concern is that pedicle blood supply will decrease leading to post-operative complications. This study examined the role of intraoperative vasopressors, specifically norepinephrine, in free flap partial necrosis based on the patients’ comorbidities. We retrospectively analyzed 192 patients who received free flap treatment between 2006 and 2021 and were stratified based on vascular comorbidities. We assessed the role of intraoperative vasopressors using multivariate analysis. Patients who were administered vasopressors did not have a significantly higher risk of partial flap necrosis compared to patients who were not administered vasopressors (OR: 1.439, 95% CI: 0.618-3.348, p=0.399). Upon stratifying by vascular comorbidities, we found that patients with two or more vascular comorbidities who were administered vasopressors had a significantly higher risk of developing flap necrosis (OR: 3.882, 95% CI: 1.266-14.752, p=0.046), indicating that vasopressor use in patients with multiple vascular comorbidities is a risk factor for partial flap necrosis. To minimize the risk of flap marginal necrosis in patients with vascular comorbidities, we recommend limited use of vasopressors or minimizing the flap area to preserve vascularization.