Pedicled Flap Reconstruction Research Articles

Head and neck reconstruction with pedicled flaps in the free flap era.

SUMMARYNowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.

Surgical Site Infections in Major Head and Neck Surgeries Involving Pedicled Flap Reconstruction.

To evaluate surgical site infections (SSI) after pedicled reconstruction in head and neck surgery. Records of patients with pedicled flap reconstructions between 2009 and 2014 at Massachusetts Eye and Ear were reviewed. Onset of SSI or fistula ≤30 days postoperatively was noted. A free flap cohort was reviewed for comparison. Two hundred and eight pedicled reconstructions were performed for cancer (83%), osteoradionecrosis (7%), and other reasons (10%). Most (72%) cases were clean-contaminated and American Society of Anesthesiologists classification 3 or higher (73%); 63% of patients had prior radiation. The SSIs occurred in 9.1% and were associated with a longer length of stay (P = .004) but no particular risk factors. Seventeen patients developed a fistula (11 without SSI). The SSI rates were not significantly different between pedicled and free flaps, but pedicled flap patients were older, more likely to have had prior surgery and/or radiation, and be methicillin-resistant Staphylococcus aureus positive. In the combined population, multivariate analysis demonstrated clean-contaminated wound classification (P = .03), longer operating time (P = .03), and clindamycin prophylaxis (P = .009) as SSI risk factors. The SSI rate following pedicled flap surgeries was low and similar to free flap surgeries despite a significantly different population. No specific risk factors were associated with developing a pedicled flap SSI.

Endoscopic radical hypophysectomy: how I do it.

Total hypophysectomy it is a classical procedure that currently has many indications especially in patients with Cushing syndrome without good endocrine control. Expanded endonasal endoscopic techniques grant us an alternative standpoint to the classic trans-sphenoidal microscopic approach and a comprehensive assessment of the process METHOD: The author provides technical nuances and describe step by step the radical endoscopic hypophysectomy. The study of cadaveric specimens adds clarifying dissections. Radical hypophysectomy is an easily replicable and safe procedure. The most important morbidity is the intraoperative cerebrospinal fluid (CSF) leakage, which is inherent to this technique and can be successfully prevented with a pedicled nasoseptal flap reconstruction.

Retroauricular pedicled flap for reconstruction of large helix and antihelix defects.

Retroauricular pedicled flap for reconstruction of large helix and antihelix defects.

Clinical follow-up of 16 cases delayed reverse anterolateral thigh pedicled flap for reconstruction of soft tissue defect of the knee

Objective To report clinical follow-up of 16 cases delayed reverse anterolateral thigh pedicled flap for reconstruction soft-tissue defect of the knee. Methods From January, 2006 to January, 2013, 16 patients (10 male, 6 female) with soft-tissue defect in the knee underwent reconstruction with a delayed reverse anterolateral thigh pedicled flap. They ranged in age from 30 to 58 years (mean, 46 years). Soft-tissue defect size in the knee were from 10.0 cm × 12.0 cm-10.5 cm × 20.0 cm. The septocutaneous and musculocutaneous perforator flaps were 5 and 11 cases respectively. The delay period ranged from 9 to 15 days (mean, 12 days). Temporary wound coverage was achieved by vacuum sealing drainage during the delay period. Results One patient developed small wound dehiscence, which spontaneous healed at one month after surgery. All the flaps survived completely. Follow-up period ranged from 2.5-4.0 years (mean, 3 years) postoperatively. A good contour was confirmed at the recipient area. The function of the lower extremity were evaluated with LEM. Very good results were obtained in 9 cases, good in 6 cases and fair in 1 case. Satisfactory clinical results were obtained in this series. Conclusion This technique is safe, reliable, and particularly suitable for patients with diabetes or larger flap. Key words: Anterolateral thigh flap; Perforator flap; Soft-tissue defect; Knee; Repair

Risk Factors for Pedicle Flap Complications in 251 Elderly Chinese Patients Who Underwent Oral and Maxillofacial Reconstruction

To determine risk factors for pedicle flap complications in elderly patients undergoing oral and maxillofacial reconstruction. The authors designed and implemented a retrospective cohort study and enrolled a sample of patients at least 75years old who underwent resection of oral and maxillofacial tumors and pedicle flap reconstruction from January 2004 through December 2013. The primary predictor variable was reconstructive technique grouped into 5 types of pedicle flap. The difference among groups was tested with the χ(2) test and t test. The primary outcome variable was the presence of flap complication, which was divided into minor and major groups. Other variables were grouped into the following sets: demographic, operative, and adjuvant treatments. Univariate, bivariate, and regression statistics were computed and statistical significance was set at a P value less than .05. The study sample was composed of 251 patients with a mean age of 78years and 62.95% were men. Of these, 68.13% had various preoperative systemic diseases. With regard to flap type, 120 underwent reconstruction with a pectoralis major myocutaneous flap, 5 with a submental island flap, 4 with a submandibular gland flap, 13 with a platysma myocutaneous flap, and 109 with a sternocleidomastoid flap. TNM stage (negative correlation) and smoking (positive correlation) correlated with flap type. There were 48 complications, of which 32 were minor and 16 were major; flap failure was observed in only 1 patient. Risk factors associated with complications were types of pedicle flap, age, heart score, hypertension, diabetes, postoperative hypoproteinemia, and drug-induced liver injury. The pedicle flap is suitable and safe for the reconstruction of defects caused by the ablation of oral and maxillofacial tumors in elderly patients. Preoperative evaluation of positive risk factors, including type of surgery and systemic conditions, is very important for the selection of an appropriate flap for such patients.

Pedicle versus free flap reconstruction in patients receiving intraoperative brachytherapy

Introduction This study compared complication rates between pedicle flaps and free flaps used for resurfacing of intraoperative brachytherapy (IOBT) implants placed following head and neck tumour extirpation to help clarify the ideal reconstructive procedure for this scenario. Patients and methods A retrospective review of reconstructions with IOBT at our institution was conducted. Patient and treatment details were recorded, as were the number and type of flap complications, including re-operations. Logistic regressions compared complications between flap groups. Results Fifty free flaps and 55 pedicle flaps were included. On multivariate analysis, free flap reconstruction with IOBT was significantly associated with both an increased risk of having any flap complication (OR = 2.9, p = 0.037) and with need for operative revision (OR = 3.5, p = 0.048) compared to pedicle flap reconstruction. Conclusions In the setting of IOBT, free flaps are associated with an increased risk of having complications and requiring operative revisions.

Breast reconstruction modality and outcomes after mastectomy

BackgroundChoosing a breast reconstructive modality after mastectomy is a critical step involving complex decisions. Postoperative complications can be a significant setback for patients undergoing breast reconstruction. In this study, the results of different reconstructive modalities are recorded and their complications are discussed for further preoperative counseling. Materials and MethodsNinety patients who had undergone breast reconstruction at our institution in the past 5 years were reviewed. Clinical encounters for all reconstruction modalities, namely implant-based, autologous tissue, and combined reconstructions, were assessed. We evaluated several clinical variables, such as type of operation, timing of reconstruction, and early and late complications. ResultsPatients were aged 28–61 years, with a mean age of 44.8 years. The body mass index (BMI) ranged from 16.9 to 31.1 kg/m2, with an average of 22.87 kg/m2. The follow-up duration ranged from 5.6 to 85.9 months, with a mean of 38.3. Thirty-eight, 46, and 6 patients received implant-based reconstruction, autologous reconstruction, and combined reconstruction, respectively. The most common complication recorded in the implant-based group was hematoma (7.9%), whereas re-exploration (6.5%) and abdominal hernia (6.5%) were the most common complications in the autologous tissue reconstruction group. The average age and BMI of the patients who experienced complications were 46.4 years and 22.5 kg/m2, respectively, whereas the average age and BMI for the patients without complications were 44 years and 23 kg/m2, respectively. Complications were most common in patients who underwent adjuvant irradiation and pedicle flap reconstruction (100%). ConclusionIn this small-scale study, we found that an implant-based reconstruction was more frequently performed on older patients. Because of the relatively small average body size and low BMIs of Asian people, obesity is not considered to affect the postoperative complication rate. In addition, postreconstructive irradiation is unlikely to produce additional complications because the patients underwent pedicle flap reconstruction.

Pedicled Flap Reconstruction for Patients With Pressure Ulcers: Complications and Resource Utilization by Ulcer Site.

Pedicled Flap Reconstruction for Patients With Pressure Ulcers: Complications and Resource Utilization by Ulcer Site.

Complications of Head and Neck Reconstructive Surgery Using Axial Pedicled Flap

Objectives: Axial flap surgery is associated with numerous complications. The purpose of this study is to determine the frequency of these complications, and identify possible factors contributory to their occurrence.
 
 Methods:
 Study design: Cross-sectional study
 
 Setting: Tertiary public university hospital
 
 Subjects: Records of all patients who underwent axial pedicled flap reconstruction at the otorhinolaryngology ward of our tertiary public university hospital from January 2013 to July 2015 were retrospectively reviewed, and data consisting of age, sex, diagnosis, disease stage, smoking history, alcohol intake, co-morbidities, past operations, pre-operative hemoglobin and albumin, total operative time, total blood loss, location and total area of the surgical defect, and length of hospitalization were tabulated. All complications were listed. Data were analyzed for any potential trends.
 
 Results: A total of 38 patients underwent axial pedicled flap reconstruction in the study period. Nineteen out of 38 (50%) cases involved complications. The most common complication was infection. Most of the complications occurred in males with history of alcohol intake, advanced cancer stage, significant blood loss, recurrent tumors, low pre-operative hemoglobin and albumin levels, and a large area of surgical defect.
 
 Conclusions: The complication rate for axial flap surgery in our series was significant at 50%. Potential risk factors identified were male gender, advanced cancer stage, tumor recurrence, alcohol intake, low pre-operative hemoglobin and albumin levels, significant blood loss, longer operative time, and a larger surgical defect.
 
 Keywords: surgical flaps, myocutaneous flap, axial flap, complications, risk factors
 

The use of dermal regeneration template (Pelnac®) in acute full-thickness wound closure: A case series

Dermal regeneration template (DRT) has been well implicated in the reconstruction of full-thickness burn injury. This case series specifically presents our experience and our clinical application of Pelnac® to achieve wound closure with complex acute full-thickness defect. A retrospective review of patients treated with Pelnac for complex wound defects from 2008 to 2014 at Concord Burns Unit was carried out. Variables such as wound aetiology, wound size and complications were considered. Five patients (four females and one male with a mean age 54 ± 20) all had full-thickness defects (mean defect size 4.3 ± 2.0 % TBSA), some with exposed tendon and bone. The wounds were treated with Pelnac®; the silicone layer was removed at postoperative day 14 and a split-thickness skin graft (0.2 to 0.3 mm) was applied. Clinically, the reconstructed areas demonstrated good granulation tissue at 14 days with good take of the skin graft. There were no major acute graft loss, rejection or associated infection. However, there were small areas of graft loss which did not require re-grafting. DRT provides a safe and efficacious alternative when dealing with acute contaminated full-thickness wounds. Pelnac® seems versatile in obtaining wound coverage in difficult complex wounds, especially in critically ill patients where free or pedicle flap reconstruction would be problematic. Level of Evidence: Level V, therapeutic study.

Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps.

Background:The purpose of this study was to compare patient satisfaction following unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) and free abdominal flap reconstruction.Methods:Patients who underwent unilateral breast reconstruction using pedicled TRAM or free abdominal flaps (muscle-sparing TRAM or deep inferior epigastric perforator flap) and completed the BREAST-Q were identified from 2 prospectively maintained databases. BREAST-Q scores were assessed and compared for Satisfaction with Breasts, Outcome, and Physical Well-being Chest/Abdomen.Results:Of the 138 patients who completed the BREAST-Q, 84 underwent pedicled TRAM flap reconstruction and 54 underwent free abdominal flap reconstruction. Overall, pedicled TRAM flap patients scored higher than free abdominal flap patients on all 4 BREAST-Q scales. This difference reached statistical significance in Satisfaction with Breasts (+7.74; P = 0.02). Similar results were found among patients who completed the BREAST-Q at <3 years postoperation. However, among patients at ≥3 years postoperation, there were no statistically significant differences between the 2 groups, with the pedicled flap cohort scoring higher in Satisfaction with Breasts and Physical Well-being Chest and the free abdominal flap cohort scoring higher in Satisfaction with Outcome and Physical Well-being Abdomen scores.Conclusions:Patients who underwent unilateral pedicled TRAM flap reconstruction experienced greater initial breast satisfaction than patients who underwent unilateral free abdominal flap reconstruction, but satisfaction equalized between the two over time, suggesting that long-term satisfaction may be equivalent between the 2 methods of reconstruction.

Successful treatment of quintuple primary cancer, including esophageal cancer: A case report.

The present study reports the rare case of a patient with quintuple primary cancer that underwent systematic treatment, including surgical intervention. A 63-year-old male patient was initially diagnosed with primary esophageal cancer and hypopharyngeal cancer. The patient underwent total pharyngolaryngoesophagectomy using a thoracoscopic method and reconstruction using the free jejunal flap and gastric tube and was subsequently administered adjuvant chemotherapy (80 mg/m2 intravenously on day 1, cisplatin; 800 mg/m2 continuous intravenous administration on days 1-5, 5-fluorouracil). At 66 years old, the patient was diagnosed with left maxillary sinus cancer and underwent chemoradiotherapy (four 100 mg/m2 arterial cisplatin injections; 70 Gy/35 f radiotherapy, 2 Gy per day over 35 days). At 68 years old, the patient was diagnosed with gastric tube cancer and underwent gastric tube resection followed by pedicled jejunum flap reconstruction. At 69 years old, the patient was diagnosed with tongue cancer and underwent resection and reconstruction of the tongue by pectoralis major myocutaneous flap. Six years subsequent to the primary surgery, the patient remains alive, without metastasis of the lesions. To the best of our knowledge, the present study is the first report of a patient that underwent a curative procedure for the treatment of five primary multiple cancers in five organs, including esophageal cancer.

The freestyle pedicle perforator flap: a new favorite for the reconstruction of moderate-sized defects of the torso and extremities.

BackgroundPerforating vessels are a consistent anatomical finding and well described in the current literature. Any skin flap can be raised on a subcutaneous pedicle as long as it contains at least one supplying perforator. Perforator flaps have been interlinked with microsurgery and generally not widely performed by the general plastic surgeons. The aim of this paper is to present the simplicity of pedicled perforator flap reconstruction of moderate-sized defects of the extremities and torso.MethodsWe retrospectively reviewed the charts of 34 patients reconstructed using 34 freestyle pedicled perforator flaps for moderate-sized defects of the truncus and extremities. We registered indications, flap size and localization, success rate, and complications. Most importantly, we describe a simple approach to the design of freestyle pedicled perforator flaps and elaborate on technical aspects in the context of current literature.ResultsThe reconstructive goals were achieved in all cases without any total flap loss or major complications. Minor complications occurred in 7/34 (21 %) cases consisting of venous congestion leading to distal tip necrosis or epidermolysis; partial flap loss was significant in 4 cases, however never more than 10 % of the total flap size. Reconstruction was performed on the lower limb in 13 cases, upper limb in 12, and 9 cases were on the truncus. The angle of rotation was 90° in 21 cases and 180° in 13 cases. The most common indication was reconstruction of oncological skin defects; melanoma 19, BCC 6, SCC 2, other 7. The flap size varied from 1.5×3 cm to 12×22 cm. The perforator identification was done by intraoperative exploration in 17 cases and by color Doppler ultrasonography in 17 cases.ConclusionsModerate-sized defects of the torso and extremities can be successfully reconstructed by pedicled perforator flaps. The flap dissection is simple, and the complication rates comparable to other reconstructive options.Level of evidence IV, therapeutic study

Patient-Reported Satisfaction and Quality of Life Following Unilateral Pedicled and Free Abdominal Flap Reconstruction

PURPOSE: In 2012, 12,533 abdominal flap breast reconstructions were performed in the USA, 63.8% of all autologous breast reconstructions performed.1 The purpose of this study was to compare patient-reported satisfaction and quality of life between unilateral pedicled and free abdominal flap reconstruction using the BREAST-Q. METHODS: Women undergoing unilateral post-mastectomy breast reconstruction using pedicled or free abdominal flaps were identified from two prospectively maintained databases at two sites in North America from 2008-2013, and were asked to complete the following BREAST-Q scales post-operatively: Satisfaction with Breasts, Satisfaction with Outcome, Psychosocial Well-being, Sexual Well-being, Physical Well-being Chest, and Physical Well-being Abdomen. BREAST-Q scores (range 0-100) were assessed for each domain and compared between pedicled and free abdominal flap patients based on time from reconstructive surgery to BREAST-Q completion. Higher scores indicate greater satisfaction/outcome. RESULTS: Of the 138 patients who completed the BREAST-Q, 84 (60.9%) underwent pedicled flap reconstruction and 54 (39.1%) underwent free flap reconstruction. Pedicled patients were older (mean 54.3 years v 51.4, p=0.02), had longer length of time from reconstruction to BREAST-Q completion (mean 3.98 years v 2.90, p<0.01), and were more likely to have undergone immediate reconstruction (77.4% v 61.1%, p=0.03). Among patients who completed the BREAST-Q at < 3 years post-op (N=55), pedicled patients scored higher than free flap patients in all six scales, with this difference reaching statistical significance in Satisfaction with Breasts (+11.6, p=0.01) and Sexual Well-being (+15.0, p=0.03). However, among patients at ≥ 3 years from time of surgery to BREAST-Q completion (N=83) there were no significant differences between the two groups on any of the BREAST-Q scales, with pedicled patients scoring higher in Satisfaction with Breasts (+5.2, p=0.30), Psychosocial Well-being (+3.3, p=0.53), Sexual Well-being (+3.7, p= 0.52), and Physical Well-being-Chest (+2.6, p=0.45), and free flap patients scoring higher in Satisfaction with Outcome (+5.3, p=0.36) and Physical Well-being Abdomen (+5.1, p=0.35) CONCLUSIONS: Decision-making in breast reconstruction can be difficult as patients are often offered many options, including pedicled and free abdominal flap reconstruction. In this study, patients who underwent unilateral pedicled flap reconstruction had greater initial satisfaction compared to those who underwent free flap reconstruction. However, among patients at ≥ 3 years post-op, there were no statistically significant differences between the two groups on any of the BREAST-Q scales. Thus, patients may be equally satisfied with either reconstruction, or rather patient satisfaction equalizes between the two over time. These results can be used to facilitate clinical and patient decision-making in the setting of autologous breast reconstruction.

Advantages and limitations of free and pedicled flaps in reconstruction of pharyngoesophageal defects.

The current review will focus on head and neck reconstructive techniques for the pharyngoesophagus. This article reviews the changing patterns of flap usage and will evaluate the advantages and disadvantages of selected pedicled and free flaps for pharyngoesophageal reconstruction. A number of flaps are reviewed with particular emphasis on recent developments. The literature reports on a variety of options available to reconstruct pharyngoesophageal defects. Pedicled flaps have a role in partial defects and select short to moderate circumferential length defects. The standard for long segment circumferential defects continues to be the fasciocutaneous free flaps and the jejunum free flap. The exact nature of the pharyngoesophageal defect, patient characteristics, and flap availability should be considered when choosing the best option for reconstruction.

Successful Deep Inferior Epigastric Perforator Flap Breast Reconstruction Following Prior Deep Inferior Epigastric Source Vessel Ligation

INTRODUCTION: Deep inferior epigastric perforator (DIEP) flaps represent an excellent method of breast reconstruction. Its success is predicated upon careful dissection of the dominant deep inferior epigastric (DIE) perforators and the patency of its associated source vessels. Prior ligation of the DIE vessels would thereby negatively impact DIEP flap harvest. If collateral branches maintain the patency of these source vessels, DIEP flap harvest may still be possible. We have successfully performed two bilateral DIEP breast reconstructions following prior ligation of the DIE source vessels. METHODS: A retrospective review of two cases of DIEP breast reconstruction was performed following prior ligation of the DIE source vessels. The characteristics and findings in these specific cases were analyzed. RESULTS: The first patient had multiple failed attempts at bilateral breast reconstruction using implants and latissimus flaps. The right chest wall had been previously radiated. A bilateral salpingo-oophorectomy had been performed for ovarian carcinoma via a Pfannenstiel incision. The DIE source vessels were found to be ligated and transected bilaterally from her gynecologic procedure near their origin at the iliac vessels. Although diminutive in size, intercostal collaterals near the hemoclips maintained source vessel patency and bilateral DIEP reconstruction was completed. The second patient had prior latissimus-based breast reconstructions with submuscular implants. This was complicated by a right-sided infected seroma and bilateral implant capsular contracture. She had undergone a prior delay procedure for possible pedicled TRAM flap reconstruction but did not wish to sacrifice her rectus muscles. CT angiography was performed of the abdomen and pelvis for possible gluteal artery perforator flap reconstruction. Despite clips on the DIE vessels near their origin, they appeared patent and of suitable caliber with sufficient length for bilateral breast reconstruction. Bilateral DIEP breast reconstruction was successfully performed without any associated complications. CONCLUSION: Successful DIEP flap reconstruction depends upon the patency of the DIE source vessels and sufficient perforators to maintain normal flap perfusion. Prior ligation of the DIE source vessels would therefore negatively impact successful flap harvest. If, however, collateral vessels maintain the patency of these source vessels, DIEP flap reconstruction can thereby be carried out successfully as demonstrated by these two cases. Radiologic imaging can aid in identifying such cases.

Submental island pedicled flap for reconstruction of oral soft defects after oral cancer ablation

To evaluate the effectiveness of the submental island pedicled flap (SIPF) for the repair of oral soft defects following oral cancer ablation. Thirty consecutive patients undergoing resection of oral cancer followed by reconstruction with SIPF from February 2010 to March 2013 were reviewed. The effectiveness complications, oral function recovering and oncologic outcomes after reconstructive operation with SIPF were evaluated.SPSS software was used to analyze the data. The dimensions of SIPF ranged from a minimum of 4 cm×6 cm to a maximum of 6 cm×15 cm. Of the 30 flaps, 28 were survival completely, one had superficial necrosis but healed with treatments, and one failed due to complete necrosis, with a survival rate of 96.7% (29/30). Operative time ranged from a minimum of 4.5 hours to a maximum of 7.5 hours, mean 6.8 hours, and hospital stay time was 11-18 days, mean 13 days. Thirteen patients (43.3%) received tracheotomy before SIPF operation. Surgical or postoperative complications included temporary marginal mandibular never palsy in one case, neck hematoma in one case, hydrops in the mandibular region in 7 cases, and neck infectionin in 2 cases. Postoperative functional results showed mouth opening was normal in 23 patients, light limitation of mouth opening in 6 cases and obvious limitation of mouth opening in one case. The speech function was re-obtained satisfactorily in 29 patients, but one case with poor speech function. Most patients showed normal swallowing function, of them 26 patients on a full oral diet, 3 patients on a soft diet and one patient on a liquid diet only. Postoperative follow-up time was for 6-19 months (median 13 months), and 4 patients had local recurrence and 2 patients had cervical lymph node metastases. The SIPF is safe, reliable and simple for the reconstruction of middle-small oral soft defects following resection of early-stage oral cancer.

Lymph fasciocutaneous lateral thoracic artery flap: anatomical study and clinical use.

The lateral thoracic flap was first studied in the mid-1970s but its use has been limited because of pedicle anatomical variations. However, after the development of lymph node transfer surgery, the axilla/upper lateral thorax presented as a promising donor area. Through a detailed anatomical study, the lateral thoracic flap was evaluated regarding its vascularization and composition. Later, it was used for pedicle and free flap reconstructions. A total of 40 flaps were dissected in fresh cadavers and the characteristics of the lateral thoracic pedicle and its relationship to the upper lateral thoracic axillary lymph nodes (LTLN) were analyzed. We performed six pedicle flap reconstructions around the shoulder area and a free lymph node transfer for lower limb lymphedema. In the cadaveric dissections, the lateral thoracic pedicle branched off the axillary vessels and was found to be a primary level I axillary lymph node irrigator before reaching the skin. The cutaneous portion of the artery was present in 87.5% of the dissections. Arterial caliber was an average of 1.3 and venous, 2.6 mm. Five to seven lymph nodes were isolated with each pedicle and a lymph fasciocutaneous flap could be designed. In seven clinical cases, all of the flaps survived. Functioning lymph nodes were visualized on lymphoscintigraphy after their transfer to the ankle. Donor area had an inconspicuous evolution. Lateral thoracic flap is a feasible flap with low donor area morbidity in a concealed region that can be harvested with upper LTLN for transplantation.

Free flap failure in head and neck reconstruction

The purpose of this study was to determine the causes of head and neck free flap loss and to evaluate outcomes after subsequent microvascular and non-microvascular reconstruction. Patients who experienced free flap loss between 2000 and 2012 were reviewed. There were 40 flap losses out of 3090 free flaps (1.3%). Twenty-eight patients underwent subsequent free flap reconstruction of which 27 free flaps were successful (96.4%), which was not significantly different from our initial flap success rate (p = .81). Of patients who underwent subsequent free flap reconstruction for oral/pharyngeal defects, 100% had >80% speech intelligibility and 87.5% were tube feed independent. By comparison, 42.9% of patients who underwent subsequent pectoralis major flap reconstruction had intelligible speech (p = .01) and 25.0% were independent of tube feeds (p = 0.02). Subsequent free flaps after initial free flap losses can be successful in selected patients. Functional outcomes after subsequent free flap reconstruction are favorable compared to pedicled flap reconstruction.