Sternal wound reconstruction in geriatric patients: A comparison of patient characteristics and outcomes over thirty years.

Outcomes of Repair for Delayed Esophageal Perforation after Anterior Cervical Discectomy and Fusion: A Systematic Review and Case Series.

Primary undifferentiated pleomorphic sarcoma (UPS) of the sternum is rare, and surgical resection remains the mainstay of treatment. Extensive sternal resection necessitates reconstruction to preserve respiratory function, protect mediastinal structures, and maintain upper limb support. Various reconstruction techniques have been described, but optimal methods for high-risk patients remain unclear. We report a case of total sternal resection reconstructed using a sandwich technique with polymethyl methacrylate (PMMA) and polytetrafluoroethylene (PTFE) sheets. A 79-year-old man with multiple comorbidities presented with a painful anterior chest wall mass. Imaging revealed a 3-cm localized sternal lesion, and biopsy confirmed UPS. Total sternal resection was performed, preserving the left pectoralis major muscle for flap coverage. A PMMA sheet sandwiched between PTFE sheets was anchored to the ribs, providing rigid yet lightweight chest wall support. A pedicled pectoralis major musculocutaneous flap covered the defect. Postoperative recovery was uneventful, with preserved pulmonary and upper limb function. Histopathology confirmed negative margins. At 8 months, a solitary left supraclavicular lymph node metastasis was treated with radiotherapy. The patient remains progression-free at 18 months. Total sternal resection followed by sandwich technique reconstruction can provide stable chest wall support while preserving respiratory and upper limb function, even in elderly patients with comorbidities. This case highlights atypical metastatic patterns of sternal sarcomas, emphasizing the need for careful follow-up. The sandwich technique is a safe and reproducible option for extensive sternal reconstruction in high-risk patients.

Abstract Background The risk of secondary malignancy is significantly higher in patients with chronic graft-versus-host disease (cGVHD) than in those without the condition. cGVHD is one of the most common complications following hematopoietic stem cell transplantation (HSCT). Oral squamous cell carcinoma (OSCC) is a recognized late complication, but most reported cases occur within the first decade after HSCT. We present a rare case of OSCC that developed 25 years after HSCT. Case presentation We report a case of OSCC that developed in a 40-year-old woman 25 years after HSCT. The patient had a history of oral cGVHD following transplantation. The patient presented with an indurated mass measuring approximately 25 × 20 mm on the right lateral tongue. Histopathological examination confirmed squamous cell carcinoma. The patient underwent partial glossectomy with functional neck dissection, followed by reconstruction with a pectoralis major flap. Two months later, cervical lymph node metastasis was detected and managed with additional neck dissection, adjuvant radiotherapy (66 Gy), and chemotherapy. She completed all treatments without interruption and has remained disease-free for 41 months, with preserved speech and swallowing functions. Conclusions This case suggests that the risk of OSCC may persist for decades after HSCT, particularly in patients with a history of cGVHD. The exceptionally long latency emphasizes the need for lifelong oral surveillance in HSCT survivors and the importance of multidisciplinary collaboration between hematologists and head and neck surgeons for early detection and management.

Oral cavity cancer is often diagnosed at advanced stages with mandible involvement. Surgical treatment requires the resection of the mandible, and reconstruction using the reconstructive plate is the method of choice. If complications such as dehiscence, infection or sepsis arise, reconstruction is usually performed using a pedicled flap. The aim of the article is to show a safe reconstruction with the pectoralis major flap in a patient with sepsis after the wound dehiscence and exposure of the mandibular reconstructive plate. In a patient with cancer of the floor of the mouth, cancer excision with mandibular resection along with radical neck dissection was performed. Mandibular reconstructive plate was used primarily. On the 7th postoperative day, complete wound dehiscence was observed, followed by a septic state. After the patient condition was stabilized, the reconstruction of the defect using the pectoralis major musculocutaneous flap was performed with no complications. Pedicled pectoralis major flap is safe to use for reconstruction of head and neck defects, even in cases of severe wound infections after extensive oncological surgery.

This study focuses on early recognition of carotid blowout syndrome type 1 (threatened artery) and the results of integrity restoration of the surrounding tissue by a pectoralis major myofascial flap. This retrospective study included all patients in the period 2010-2020 with carotid blowout syndrome type 1 of the common or internal carotid artery, treated by pectoralis major myofascial flap. Fifteen patients with carotid blowout syndrome type 1 were included, all but one after previous radiotherapy with a total dose up to 136 Gray (range 46-136). Median time from diagnosis till treatment was 1 day. None of the patients progressed to actual bleeding (type 2 or 3). Carotid blowout syndrome type 1 should be early recognised and treated by insertion of a pectoralis major myofascial flap that protects the common or internal carotid artery and might prevent progression to a potentially fatal bleed. In our opinion, this policy should be part of the algorithmic approach of this complication.

Oral and maxillofacial defects that were unreconstructed or inadequately reconstructed often lead to aesthetic and functional impairments, resulting in socio-emotional and psychological concerns of patients, which impact their quality of life. This justifies the needs of oral and maxillofacial reconstructive surgery to minimize aesthetic deformity; to restore these functions (mastication, swallowing, speech, etc.); to maintain an adequate airway permeability; thereby, to improve the patients' quality of life. The etiologies of oral and maxillofacial defects include surgical resection of malignant tumors, some benign tumors, aggressive cysts, some infections and inflammatory diseases, defects post severe traumatic injuries, some congenital and developmental deformities, and burns. The free flaps (FF) remain the first choice for reconstruction of large oral and maxillofacial defects because their overall success rate is very high (more than 90%). However, pedicled flaps (PF) still play a role in situations where the use of free flaps presents some limitations and risks. Pectoralis major flap (PMF) and submental island flap (SIF) represent excellent options for the reconstruction of oral and maxillofacial defects; they are good alternatives to free flaps when the latter are contraindicated or their use is limited by the absence of sufficient resources.

The supraclavicular flap (SCF) is a well-established reconstructive option for defects of the head and neck. It combines the pliability of a fasciocutaneous flap with the benefits of locoregional reconstruction. These characteristics enable the flap to be widely applicable in the head and neck region. The anatomy and surgical execution for the supraclavicular flap is reviewed with emphasis on the decision-making process pre- and intra-operatively to improve success along with illustration of a case series of patients. In a retrospective case series of 18 patients in a single institution, the SCF was utilised both as primary and salvage options in head and neck reconstruction. The indications for SCF included skin and soft tissue resurfacing (n = 9), comorbid patients not eligible for free flaps (n = 7) and in salvage surgery (n = 2). We had three flap related complications requiring return to theatre to facilitate healing prior to commencement of post-operative radiotherapy. These included two cases of minor dehiscence which were re-debrided and inset; and one case of flap tip necrosis which was treated with debridement and skin grafting. The supraclavicular flap is a reliable option for locoregional head and neck reconstruction. It also has several advantages over more traditional options such as the pectoralis major flap, providing a more functional and aesthetic result with close to ideal skin colour, pliability, and contour.

Preserving Function in Sternal Reconstruction: Complementary Roles of Pectoralis Major and Internal Mammary Artery Perforator Flaps.

Necrotizing fasciitis of the head and neck is a rare but potentially fatal infection that often arises from odontogenic sources and can rapidly spread along fascial planes to adjacent vital structures. We report a case of a 62-year-old male with diabetes who developed odontogenic necrotizing fasciitis originating from the left mandibular premolar region, which progressed to involve the ophthalmic area. Despite initial incision and drainage with intravenous antibiotics, the infection rapidly advanced with fistula formation and extensive necrosis. The patient underwent repeated debridement, vacuum-assisted closure therapy, and subsequently wide surgical excision followed by reconstructive procedures including a split-thickness skin graft and a pectoralis major flap. With timely multidisciplinary management and strict glycemic control, the patient achieved favorable recovery without recurrence.

Background: Deep sternal wound infections (DSWIs) remain a serious complication after median sternotomy, often requiring complex wound management strategies. While modern approaches include vacuum-assisted closure (VAC) and plating techniques, the pedicled pectoralis major muscle flap (PMF) continues to play a pivotal role in surgical reconstruction, especially in cases with sternal destruction or osteomyelitis. Methods: In this retrospective single-centre analysis, 166 patients with DSWI following cardiac surgery were reviewed. Clinical data, comorbidities, laboratory parameters, and surgical management were evaluated. Logistic regression was performed to assess predictors for reinfection and need for reoperation. Results: Initial wound revision was most frequently performed using sternal rewiring (60.2%), followed by reconstruction with a pectoralis major flap (33.7%). Despite initial surgical treatment, 27.1% of patients developed post-revision wound healing disturbances, and 24.1% ultimately required a second surgical intervention. Among second-time procedures, VAC therapy (32.5%) and PMF reconstruction (20.0%) were the most common approaches. Reinfection was significantly associated with higher preoperative EuroSCOREs (p = 0.044), while initial rewiring carried a higher risk of treatment failure compared to the pectoralis major flap (p = 0.0024). Conclusions: In the setting of sternal destruction or osteomyelitis, the pectoralis major muscle flap remains a fast, effective, and robust solution. Despite its long-standing use, it continues to offer excellent vascularized coverage and infection control in complex DSWI cases.

Objective: To evaluate the clinical efficacy of multidisciplinary team (MDT) collaboration in the treatment of deep sternal wound infection (DSWI). Methods: This study was a historical controlled trial. According to the diagnosis and treatment model adopted by the patients, 23 DSWI patients who met the selection criteria and were treated in the Department of Burns and Cutaneous Surgery of the First Affiliated Hospital of Air Force Medical University from June 2022 to March 2023 using the traditional single discipline led diagnosis and treatment model were included in non-MDT group, including 13 males and 10 females, aged (56±11) years; 25 DSWI patients who met the inclusion criteria and were treated using MDT diagnosis and treatment model in the unit from April 2023 to May 2024 were included in MDT group, including 12 males and 13 females, aged (54±10) years. For patients in MDT group, after admission, the MDT, composed of chief physicians from 13 departments including burns and cutaneous surgery, cardiothoracic surgery, intensive care medicine, anesthesiology, pharmacy, nutrition, endocrinology, vascular surgery, laboratory medicine, radiology, ultrasound, transfusion, and rehabilitation, jointly evaluated the condition and developed personalized plans for systematic diagnosis and treatment. For patients in non-MDT group, the diagnosis and treatment were led by surgeons from department of burns and cutaneous surgery after admission. When specialist care was limited, consultation with physicians from relevant departments were requested as needed, and a comprehensive plan for diagnosis and treatment was formulated after summarizing the consultation opinions. Once the conditions of patients in both groups stabilized, a thorough debridement of the chest wound was performed, followed by repair surgery with unilateral or bilateral pectoralis major muscle flap or combined rectus abdominis muscle flap. The time from the first surgery for the infected wound to healing, the number of surgeries performed from admission to wound healing, intraoperative blood loss, and operation duration, perioperative complications, wound infection recurrence within 15 d after muscle flap repair surgery, and corresponding incidences of complications and recurrence of wound infection were recorded, and the patient's satisfaction score evaluated using the Patient Satisfaction Scale at discharge. Results: The time from the first surgery for the infected wound to healing of patients in MDT group was (12.5±2.8) d, which was significantly shorter than (16.3±2.7) d in non-MDT group (with mean difference of -3.8 d, 95% confidence interval of -5.4 to -2.2 d, t=-4.78, P<0.05). Compared with those in non-MDT group, the number of surgeries performed from admission to wound healing and intraoperative blood loss of patients in MDT group were significantly reduced (Z=-2.54, t=-2.20, P<0.05), and the operation duration was significantly shortened (t=-3.41, P<0.05). During the perioperative period, in MDT group, one patient experienced delayed wound healing, and one patient developed a pulmonary infection; in non-MDT group, two patients experienced delayed wound healing, one patient developed pulmonary infection, and two patients developed deep vein thrombosis in the lower limbs. Wound infection recurrence within 15 d after muscle flap repair surgery occurred in one patient in MDT group and 4 patients in non-MDT group, all of whom healed after dressing change. There were no statistically significant differences in the incidence of perioperative complication or wound infection recurrence within 15 d after muscle flap repair surgery between the two groups of patients (P>0.05). The patient's satisfaction score at discharge in MDT group was 97.7±2.4, which was significantly higher than 95.1±3.5 in non-MDT group (t=3.04, P<0.05). Conclusions: For DSWI patients, the MDT diagnosis and treatment model can optimize the treatment plan through joint assessment by physicians from multiple disciplines. It significantly shortens the wound healing time, reduces the number of surgeries and intraoperative blood loss, and improves patient satisfaction without increasing the risk of complications or wound infection recurrence, which is worthy of clinical promotion and application.

We report a rare case of delayed pneumothorax and persistent laryngeal edema following mandibular reconstruction using a rib-including pectoralis major osteomyocutaneous flap in a high-risk post-chemoradiation patient. A 53-year-old cachectic male with a history of chemoradiotherapy for hypopharyngeal carcinoma developed a second primary squamous cell carcinoma of the right buccal mucosa with mandibular invasion. Due to multiple comorbidities and prior radiation, he underwent segmental mandibulectomy and reconstruction using a pectoralis major flap incorporating a vascularized fifth rib segment. The postoperative course was complicated by delayed right-sided pneumothorax requiring chest tube drainage and progressive laryngeal edema requiring tracheostomy and enteral feeding. These complications were likely due to prior irradiation, rib harvesting, and impaired healing. This case demonstrates the feasibility of rib-including pectoralis major flaps for salvage mandibular reconstruction when free-flap surgery is contraindicated, and highlights the importance of prolonged multidisciplinary surveillance of delayed thoracic and airway complications in previously irradiated patients.

Background: The gold standard for reconstructive surgery is free flap reconstruction. Nevertheless, in developing nations, the high volume of cases, along with infrastructural and resource limitations, has led to the continued use of pectoralis major musculocutaneous flap (PMMC). This article seeks to share our experiences with the harvesting of PMMC flap and the associated outcomes. Methods: A total of 45 patients were retrospectively assessed for reconstruction over a period of 5 years (January 2019 to February 2024). Of these, 30 patients underwent reconstruction using the PMMC flap following a stream lined protocol. The outcomes of the reconstruction, categorized as either successful or unsuccessful, along with any complications that arose, were thoroughly evaluated. Data was analyzed using SPSS version 26.0.and presented a numbers and percentages. Results: The largest proportion of patients fell within the 41–60 age range, accounting for 63.33%. The buccal mucosa was identified as the most frequent location for primary lesions, affecting 21 patients (70.00%). Among the 30 patients who received PMMC flap reconstruction following a standardized technique making it a streamlined protocol, there were no instances of complete flap loss, resulting in a success rate of 100%. However, one case did report necrosis of the breast mound where standardization was not considered. Conclusions: Based on our experience, PMMC flap remains a practical choice for reconstruction, particularly in settings with limited resources. Present approach was standardized by clearly defining the steps of the flap elevation by making it thin and less bulky, increasing its reach, minimizing the donor site morbidities and reducing the donor site deformities. With this stream lined protocol even a junior most plastic surgeon can perform the surgery confidently without facing significant complexity.

Objective: This article evaluates the reconstructive potential and functional outcomes, as well as the risks and potential perioperative complications of using free flaps in patients with advanced-stage malignant laryngeal neoplasms who require salvage surgery and reconstruction. Additionally, it assesses the effectiveness of various flap harvesting and in-setting techniques, including the performance of microvascular anastomoses. Materials and Methods: This retrospective study included 13 male patients (age range 47–76 years) diagnosed with laryngeal neoplasms, who were referred to the Department of Otolaryngology at the University of Verona between 2017 and 2022. All patients underwent salvage total laryngectomy followed by concurrent reconstructive surgery utilizing microvascular flaps. Recovery of function (phonation) and incidence of complications were evaluated in a follow-up of at least three years. Results: Only one patient experienced necrotic failure of the microvascular free flap, probably due to post-op complications. The patient required revision on the 10th day after surgery and was reconstructed using a pedicled pectoralis major muscle flap. Two patients developed a pharyngocutaneous fistula. Other three patients had pharyngoesophageal stenosis, two experienced recurrence, and one patient passed away due to septic shock. All patients achieved satisfactory functional outcomes regarding vocalization, while complete oral intake was restored in eight patients. Conclusions: Considering the limited sample size, the findings suggest that microvascular flaps represent a feasible option for reconstructing advanced laryngeal tumors, though complication rate may still be considerable. Tailoring reconstructive approaches to individual patients may enhance surgical outcomes.

Medication-related osteonecrosis (MRONJ) and osteoradionecrosis (ORN) present a significant reconstructive challenge. Assessing the suitability of pedicled flap (PF) reconstruction in the context of a compromised tissue bed is essential for effective surgical management. This systematic review evaluates the outcomes of PF reconstruction in MRONJ and ORN. PubMed, Ovid (MEDLINE ALL, Embase), and Cochrane CENTRAL were searched for outcomes of PF reconstruction from inception through to November 2024. A total of 48 studies met inclusion criteria (32 MRONJ, 16 ORN). Analysis included 575 patients (MRONJ: n=478; ORN: n=97) receiving 607 flaps (MRONJ: n=509; ORN: n=98). The pooled success rate was 90% (95% CI: 87% to 92%) for MRONJ and 98% (95% CI: 94 to 100%) for ORN. Both conditions showed an 18% pooled complication rate (MRONJ: 95% CI, 14% to 23%; ORN: 95% CI: 11% to 28%). In MRONJ, buccal fat pad flap was most common (n=189, 37.13%), while submental island flap with mylohyoid muscle showed the highest success rate (94%, 95% CI: 67% to 99%). There were significant differences in complication rates across flap types (p<0.0001), with the mylohyoid flap showing the lowest rate (9%, 95% CI: 2% to 36%). For ORN, pectoralis major musculofascial flap was most common (n=36, 36.73%). Pedicled flaps demonstrate high success rates (>90%) in MRONJ and ORN reconstruction, supporting their use as a reliable option in compromised tissue beds. Flap selection should be individualised based on defect characteristics and patient factors. Further research is needed to better define indications and optimise patient selection.

Pectoralis major myoplasty for closure of open window thoracostomy (March 2021). This video shows the dissection and rotation of a pectoralis major flap based on the thoracoacromial pedicle to close a post-pneumonectomy empyema space complicated by a late bronchopleural fistula. Postoperative follow-up confirmed flap viability and complete obliteration of the cavity.

Microsurgical free tissue transfer has become the standard for complex head and neck reconstruction. One of the most feared scenarios is the so-called "vessel-depleted neck" (VDN), in which prior surgery, irradiation, or multiple reconstructions are thought to preclude suitable recipient vessels. However, definitions of VDN remain inconsistent, and many patients are not truly "depleted." A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines. PubMed and Web of Science were searched (1980-2025) using terms related to "vessel-depleted neck," "recipient vessels," and "head and neck reconstruction." Eligible studies included case series, cohorts, and case reports describing reconstructive strategies following prior neck dissection, irradiation, or multiple reconstructions. Fifty-six reports met the inclusion criteria. In addition, we contextualized these findings with the Chang Gung Memorial Hospital (CGMH) experience of >10,000 microvascular reconstructions. The review identified a spectrum of recipient vessel options and technical innovations. Common second-tier choices included the transverse cervical vessels, superficial temporal system, and contralateral cervical vessels. Less common strategies involved cephalic vein transposition, internal mammary vessels, thoracoacromial, or subclavian system. Techniques to overcome pedicle length constraints included vein grafts, Corlett loops, vascular bridge flaps (VBFs), and in situ pedicle lengthening. Local and regional flaps, such as the pectoralis major (PM) and supraclavicular flaps, provided salvage options when free flaps were not feasible. At CGMH, even after multiple reconstructions, ipsilateral vessels (transverse cervical, superior thyroid, facial artery) remained usable in most patients, with contralateral or vein graft use required in fewer than 20%. The concept of a "VDN" is often overstated and may serve as a psychological barrier to optimal reconstruction. Most patients retain viable recipient vessels, and free flaps remain achievable with careful planning and surgical expertise. We advocate reframing these cases as "vessel challenged necks," emphasizing technical demands rather than depletion, to improve decision-making and outcomes.

Introduction: Cervical cellulitis or necrotizing cervical fasciitis are soft tissue infections that develop from dental or pharyngeal sites and, if not recognized early, can spread to the mediastinum. The initial clinical signs are sometimes vague and can lead to a delay in diagnosis. The key examination is cervical and thoracic computed tomography. Treatment consists of extensive and repeated tissue excisions combined with antibiotic therapy targeting aerobic and anaerobic bacteria. We report the case of a patient with known diabetes presenting with cervico-thoracic cellulitis of cutaneous origin complicated by descending mediastinitis. highlighting the importance of early diagnosis, surgical treatment, and reconstructive surgery. Aims: We aimed to report a rare case of cervicothoracic cellulitis complicated by descending mediastinitis in a diabetic patient. Presentation of Case: We report here an observation of cervicothoracic cellulitis complicated by mediastinitis in a 66-year-old man who presented with anterior cervicothoracic swelling accompanied by oozing skin ulceration with pus discharge in the context of fever and general asthenia. Blood tests revealed an inflammatory and infectious syndrome and ketoacidosis. A cervical-thoracic CT scan confirmed the diagnosis of cervicothoracic cellulitis complicated by descending mediastinitis. An emergency cervicotomy with extensive debridement and drainage was performed. Bacteriological testing identified multisensitive Staphylococcus aureus, which led to targeted antibiotic treatment. Due to significant tissue loss, reconstructive surgery was performed. The postoperative course was that of a full recovery. Conclusion: Cervicothoracic cellulitis is a serious condition requiring urgent treatment and multidisciplinary medical and surgical care. CT imaging guides surgical planning, while surgical debridement of necrotic tissue, targeted antibiotics, and reconstruction techniques are essential for achieving favorable outcomes.

Pharyngocutaneous fistula is a common complication after total laryngectomy or laryngopharyngectomy, especially in the setting of salvage surgery after (chemo)radiation. Alongside with the established pectoralis major flap and free flaps, the supraclavicular artery island flap (SCAIF) offers a promising versatile alternative. This retrospective case series analyzed five patients undergoing surgery with SCAIF in the setting of salvage laryngectomy or laryngopharyngectomy at the University Hospital Zurich between January and December 2024. All patients were male with histories of smoking and alcohol use. Defect sizes varied from small fistulas to circumferential pharyngeal reconstructions. Average hospital stay was 14.2 days with a mean follow-up of 11.6 months. Most patients returned to oral feeding within approximately 44 days after surgery. Complications included one abscess requiring drainage and one fistula also requiring revision. The SCAIF proved to be a versatile pedicled flap for reinforcement or closure of postoperative pharyngocutaneous fistula after laryngectomy or laryngopharyngectomy. • Supraclavicular artery island flap is a versatile pedicled flap. • Closure of pharyngocutaneous fistula after salvage surgery can be challenging.