Radial Forearm Free Flap Research Articles

Anterolateral thigh free flaps and radial forearm free flaps in head and neck reconstruction: A 20-year analysis from a single institution.

BackgroundReconstruction after removal of a malignant tumor in the head and neck region is crucial for restoring tissue integrity, function, and aesthetics. We retrospectively analyzed patients who underwent intraoral reconstruction surgery using radial forearm free flaps (RFFF) and anterolateral thigh free flaps (ALT) at a single institution to provide more information supporting the choice of a reconstruction method after removal of head and neck cancer.MethodsThe charts of 708 patients who underwent head and neck reconstruction between 1998 and 2018 at the Department of Plastic and Reconstructive Surgery at our institution were retrospectively reviewed. Patients’ age, sex, and history of radiation therapy, diabetes mellitus, and smoking were retrieved. The primary cancer site, types of defects, and complications were investigated.ResultsOverall, 473 and 95 patients underwent reconstruction surgery with RFFF and ALT, respectively. RFFF was more often used in patients with cancers of the pharynx, larynx, esophagus, or tonsil, while ALT was more frequently used in patients with cancers of the mouth floor with tonsil or tongue involvement. The proportion of patients undergoing ALT increased gradually. Flap failure and donor site morbidities did not show significant differences between the two groups.ConclusionsRFFF and ALT flaps resulted in similar outcomes in terms of flap survival and donor site morbidity. ALT can be an option for head and neck reconstruction surgery in patients with large and complex defects or for young patients who want to hide their donor site scars.

Reconstruction of medium-size defects of the oral cavity: radial forearm free flap vs facial artery musculo-mucosal flap

BackgroundThe radial forearm free flap (RFFF) is the most commonly used flap for defects of the oral cavity. The facial artery musculomucosal (FAMM) is a safe and effective method to reconstruct medium sized defects of the oral cavity. No comparison exists between the FAMM flap and RFFF.Methods1) Retrospective chart review from 2007 to 2016. 2) Cost difference analysis.ResultsThirteen FAMM flap cases and 18 RFFF met inclusion criteria. The FAMM flap showed a tendency to lower rates of return to the operating room (p = 0.065) as well as lower rates of complications not requiring return to the OR with 1 complication in 1 patient as opposed to 10 patients with 15 complications (p = 0.008). Also, FAMM flap had shorter operative times compared to the RFFF group (7.2HR and 8.9 HR respectively, p = 0.002). The average operative room related costs for a FAMM flap were 6510 CAD vs 10,703 CAD for RFFF (p < 0.0005). Speech and swallowing outcomes were similar (p > 0.05).ConclusionThe FAMM flap can be used for reconstruction of medium-size defects of the oral cavity with functional outcomes similar to the RFFF while decreasing the associated costs and morbidity.Graphical

Use of radial forearm free flap for the reconstruction of hard and soft palate

Improvement functional and aesthetic results of treatment patients with defects of the hard and soft palate after resections for malignant tumors. During the period from 2014 to 2020, 30 patients underwent microsurgical reconstruction of hard and soft palate defects using a radial forearm free flap. For the primary tumor process, surgery was performed in 21 patients (70%), for relapse after chemotherapy, combined or complex treatment - in 9 patients (30%). The majority of patients at the time of surgery had a locally advanced process of the T2 category (12 patients - 40%), T3 (2 patients - 7%) and T4 - 2 patients (7%). Localized stage T1 process was diagnosed in 5 patients (17%). Total flap necrosis was noted in 3 cases (10%) due to venous thrombosis on the 2nd and 3rd days after surgery and arterial thrombosis on the 2nd day. In one observation, on the 2nd day after surgery, a tense hematoma was diagnosed in the zone of formation of microanastomoses without signs of impaired flap perfusion, which required an emergency surgical intervention. All patients returned to their normal meals. No rhinolalia was observed in any of the cases. In one case, a patient with a defect in the anterior part of the hard palate obtained an unsatisfactory aesthetic result deformity of the midface; in all other cases, an excellent aesthetic result was obtained. For defects of the hard palate of posterior localization and minimal or no defect of the alveolar edge of the maxilla (class I, a, b according to Braun, class Ia, Ib according to Okay, class V according to Armany), as well as for the defects of the soft palate, the method of choice is radial forearm free flap. The size of the skin area of the flap can reach 6X8 cm, which makes it possible to replace the combined defects of the hard and soft palate, the lateral wall of the oropharynx, and the retromolar region. The plasticity of the flap makes it possible to reconstruct the total defects of the soft palate by forming it in the form of a duplication.

Single flap use for synchronous reconstruction of full-thickness upper and lower lip defects due to high-voltage electrical burn

<br>High-voltage electric burns are a major source of morbidity and mortality, with significant socioeconomic and psychosocial implications. Electric burns rarely cause injury to atypical areas including the oral region with a reported incidence of 2.2%–3.5%. The ratio of burn area to total lip is critical for reconstruction options. Locally usable flap choices will be insufficient for subtotal defects of lips. Electrical burn of both lips is a rarely seen entity that is surgically challenging for both lip reconstruction with the minimum morbidity. It is known that a radial forearm free flap (RFFF) is suitable for total lip reconstruction and in addition, is one of the best options for simultaneous upper and lower lip reconstruction using only one RFFF. In this study, a case with both lower and upper lib necrosis, a rarely affected area due to high-voltage electrical burn, is presented. Reconstruction with a free radial forearm flap was successfully performed although the patient was presented in the subacute period as timing.<br>

A Vascular Variation in Radial Forearm Free Flap Harvesting: Distal Branching of the Radial Artery—A Case Report

Study Design: Case report. Objective: By reporting such a rare vascular variation of the radial artery, we aim to make other surgeons aware of comparable vascular variations in radial forearm free flap harvesting. Methods: In this case report, we present an 84-year-old male patient, with a rare distal branching of the radial artery into the deep palmar branch, approximately 7 cm from the wrist. In order to visualize the vascular variation, intraoperative photo documentation took place. Results: The radial free flap harvesting was successful and no postoperative complications were noted. Conclusions: Distal branching of the radial artery into the deep palmar branch may occur in radial forearm free flap harvesting. Since no restrictions in flap perfusion and/or hand perfusion were observed in our case, we recommend radial forearm free flap raising in the traditional way. No changes concerning the design and the positioning of the skin paddle need to be made.

ИСПОЛЬЗОВАНИЕ ЛОСКУТОВ ПРЕДПЛЕЧЬЯ ПРИ ТЯЖЁЛЫХ ТРАВМАХ ВЕРХНЕЙ КОНЕЧНОСТИ И ИХ ПОСЛЕДСТВИЯХ

Objective: Improving the outcomes of surgical treatment of upper limb (UL) injuries by using regional soft tissue flaps. Methods: The analysis of surgical interventions outcomes of integumentary tissue defects and forearm and hand structures of traumatic genesis was conducted in 37 patients. Traumatic injuries to the forearm and hand structures with soft tissue defects occurred in 11 patients, and 26 trauma patients were hospitalized. The patients had superficial soft tissue defects (STDs) involving various areas, accompanied by damage to the underlying neurovascular bundles (NVBs), tendons and bones. Results: Depending on the nature of trauma and the injured tissues’ state, the reconstruction sequence’s principle was followed. In 32 (86.5%) cases, the restoration of functional skin integument and reconstruction of injured anatomical structures of the limb were performed in a single stage. Twostage reconstruction was carried out in 5 (13.5%) patients, with initial STDs repair followed by reconstruction of the NVBs and tendons. Selection criteria for a sequence of surgical repair included the nature of the injury and the severity of the patient’s condition in emergencies. The following grafts were used: RFFF: radial forearm free flap (n=3); RRF: the reverse radial forearm flap (n=25); the ulnar reverse forearm flap (n=6), PIA: posterior interosseous artery flap (n=3). In the immediate postoperative period, compromised blood circulation in the transplanted flaps were observed in 2 (5.4%) cases. Timely diagnosis and treatment resulted in a positive outcome. Long-term functional and aesthetic outcomes of the reconstruction were considered acceptable in all patients. Conclusion: A proper surgical procedure selection for UL structures injuries and their consequences influences long term postoperative aesthetic and functional outcomes. Choice of single or multiple stages of reconstruction largely depends on the location of the defect, the state of the tissues in the recipient area and the nature of the injury to the underlying anatomical structures of the limb. Keywords: Upper limb, injuries and their consequences, soft-tissue defect, flaps.

Reconstruction after Radical Resection of Arteriovenous Malformation of the Finger Using Sensate Free Radial Forearm Flap Transfer

Reconstruction after Radical Resection of Arteriovenous Malformation of the Finger Using Sensate Free Radial Forearm Flap Transfer

Superficial versus deep system single venous anastomosis in the radial forearm free flap: a meta-analysis

The selection of the superficial or deep drainage system for use with the radial forearm free flap (RFFF) remains controversial. The aim of this study was to identify the optimal drainage system for single venous anastomosis. A systematic review and cumulative meta-analysis was performed to assess superficial and deep system single venous anastomosis for use with the RFFF in postoperative reconstruction of the head and neck. This study included 1073 flaps (495 superficial system-based flaps, 578 deep system-based flaps) reported in six studies. The outcomes assessed in the studies selected for this meta-analysis included venous compromise, flap failure, and the salvage success rate. Venous compromise was more common in the superficial system group (odds ratio (OR) 2.29, 95% confidence interval (CI) 1.36–3.86, P=0.002). The rate of successful salvage was higher with the superficial system (OR 8.19, 95% CI 1.75–38.3, P=0.008). The rate of flap failure was lower in the superficial system group (OR 0.30, 95% CI 0.04–2.48, P=0.27). Although the deep system showed a lower risk of venous compromise, the evidence provided by the meta-analysis was insufficient to determine which type of drainage system is more suitable for single venous anastomosis in RFFF. All included studies were cohort studies; therefore, findings must be interpreted with caution.

Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications and Outcomes

BackgroundMales born with bladder exstrophy-epispadias complex generally have a shorter phallus, split corpora with dorsal curvature, and a scarred and flattened glans, so substitution phalloplasty is often required. AimThe aim of this study was to review the techniques, complications, and outcomes of substitution phalloplasty in bladder exstrophy-epispadias complex patients to determine the ideal surgical procedure and gauge the risks and benefits for the patient. MethodsA systematic review of the literature was performed using PubMed/MEDLINE and the Cochrane Library with the following terms: (“phalloplasty”); ((“epispadias”) OR (“bladder exstrophy”) OR (“cloacal exstrophy”)). We included only full-text articles reporting data about techniques and outcomes of substitution phalloplasty in patients with bladder exstrophy-epispadias complex. OutcomesTo determine whether patients with bladder exstrophy-epispadias complex might benefit from substitution phalloplasty. ResultsWe selected 7 studies involving 47 patients. All the studies were characterized by a low level of evidence and a heterogeneous approach during treatment and outcome assessment. The free radial forearm flap was the most commonly performed technique (89%) with an overall complication rate of 15%. Urethroplasty was performed in 22 of 47 (47%) patients, and in most cases (20/22) a “tube-within-the-tube” technique was performed simultaneously with the phalloplasty (20/47). Urethroplasty complications were recorded in 12 of 22 (54%) patients with 6 fistulae and 6 stenoses. A penile prosthesis was implanted in 32 of 47 (68%) patients and complications occurred in 8 of 32 (25%) patients with 6 erosion. Aesthetic, sexual, and psychological outcomes were satisfactory, but none of the studies used validated instruments for the final assessment. Clinical ImplicationsIt was not possible to formulate any recommendations based on a high level of evidence regarding substitution phalloplasty in patients with bladder exstrophy-epispadias complex. Strength & LimitationTo our knowledge, this is the first review to address bladder exstrophy-epispadias complex patients only. The limitations are mainly represented by the small number of cases because of the rarity of this disease and by the fact that no studies used validated instruments. ConclusionSubstitution phalloplasty in patients with bladder exstrophy-epispadias complex can achieve good functional, aesthetic, psychological, and sexual outcomes. It requires multiple procedures and carries a high complication rate. Multicentric studies including the assessment of patients by means of a validated questionnaire which investigates both sexual function and psychosexual satisfaction are required.Berrettini A, Sampogna G, Gnech M, et al. Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications, and Outcomes. J Sex Med 2021;18:400–409.

A Novel Design of V-shaped Radial Forearm Free Flap Facilitates the Direct Closure of Donor Site Wound.

The radial forearm free flap (RFFF) is one of the commonly used flaps in the repair of head and neck soft tissue defects, especially small and medium-sized defects. The free skin grafts from abdomen are usually used to repair the RFFF donor site wound. This study aims to design a novel V-shaped RFFF, hoping that it might facilitate the direct closure of the forearm donor site wound. From August to December in 2019, 20 patients with oral cancers received radical surgeries, and V-shaped RFFFs were designed to repair the soft defects and the forearm donor site wound was directly closed. The patients were followed up for 6 months to assess the final outcome of repair. The results showed that the pre-designed V-shaped RFFF met the needs of soft tissue defect repair, with the size ranging from 24 cm2 to 30 cm2. Fifteen patients with tongue cancers and four with buccal cancers had satisfactory repair results, and only one patient with buccal cancer had mild limitation of mouth opening. There were 3 patients with a small area of ischemia. The mean postoperative hospital stay was 13.85 ± 1.09 days. In 5 patients, wrist tilt motility decreased compared with that before surgery. The postoperative influence score of wrist exercise on daily life was 2.75 ± 0.44 points. In conclusion, the V-shaped RFFF can meet the needs of small and medium-sized defect repair. This novel design can directly close the forearm donor site wound, which avoids surgical trauma to secondary donor site, and significantly reduces related complications.

Italian cost analysis of free flap surgery in head and neck reconstruction using the activity-based costing (ABC)

The aim of the study is to evaluate costs of free flap surgery for head and neck (H & N) reconstructions using the time-driven activity-based costing (ABC) method and to compare them with the refund provided by the Italian National Health System (NHS) amounting to 11,891€. We retrospectively selected 29 consecutive patients underwent free flap reconstruction in 2013 at IRCCS Casa Sollievo della Sofferenza. Patients were divided into three groups: Group 1 (n = 10) included patients receiving radial forearm free flap (RFFF), Group 2 (n = 10) receiving anterolateral thigh (ALT) free flap, and Group 3 (n = 9) composed of patients having fibular free flap. For each patient, costs were calculated using the ABC and divided into instay, surgical, and services costs. We observed an overall mean total cost of 27,802.40€. The mean costs related to hospital stay were 9,800.70€. The mean costs for surgery were 13,097.60€ and amounted to 4,904.10€ for services. RFFF appears to be less costing (25,175.40€) compared with ALT (29,191.60€) and fibula free flap (29,040.20€). ABC is an appropriate method to determine actual costs of free flap surgery by correctly allocating the resources used. The Italian NHS tariff seems to be inadequate to cover the real cost of this type of surgery.

Long-term donor site morbidity after radial forearm flap elevation for tongue reconstruction: Prospective observational study.

To assess long-term donor site morbidity after radial forearm free (RFF) flap harvesting. Enrolled patients were asked to complete the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and undergo wrist motion and hand strength examinations at different time points. The data were prospectively collected and retrospectively analyzed. The postoperative DASH score did not return to normal until 24 months after the operation. The mean postoperative wrist motion degree of flexion was significantly decreased compared to the preoperative level and returned to normal at 12 months after the operation. Similar trends were noted regarding extension, radial abduction, and ulnar abduction. The mean postoperative grip strength was significantly decreased compared to the preoperative level and remained dysfunctional at 24 months after the operation. A similar trend was also noted with regard to tip pinch and key pinch. The long-term negative effect on hand strength is sustained.

Reconstructive Options During Nonfunctional Laryngectomy.

ObjectiveA paucity of data exists regarding surgical outcomes for patients undergoing total laryngectomy for a dysfunctional larynx. Herein, we present the largest study evaluating the method of closure on postoperative fistula rate and swallowing ability.MethodWe performed a retrospective review of patients undergoing total laryngectomy for a dysfunctional larynx after primary radiation or chemoradiation therapy for laryngeal carcinoma from 1998 to 2020. Demographic information, operative details, length of hospitalization, fistula formation, method of fistula treatment, and need for enteral feeding 6 months after surgery were analyzed.ResultsA total of 268 patients were included. Flaps were performed in 140 (52.2%) patients, including radial forearm free flaps (RFFF), pectoralis flaps, and supraclavicular flaps. Sixty‐four (23.9%) patients developed postoperative fistulas. There was no significant difference in the fistula rate between flap and primary closure methods (P = .06). However, among patients who had a flap, RFFF had a significantly lower fistula rate (P = .02). Significantly more patients who had initial closure with a pectoralis flap required an additional flap for fistula repair than those who underwent RFFF or primary closure (P < .05). Last, whereas 87 patients (32.5%) required an enteral feeding tube 6 months after surgery, significantly fewer patients who underwent RFFF were feeding tube‐dependent (P = < .0001).ConclusionHerein, we present the largest study of outcomes after total laryngectomy for dysfunctional larynx. Postoperative fistula rates are high, 23%; however, the majority of patients, 67%, will not require long‐term enteral support. The RFFF is an excellent option demonstrating the lowest rates of postoperative fistula and enteral feeding tube dependence.Level of Evidence4 Laryngoscope, 131:E1510–E1513, 2021

Tactile Hand Sensation Following Split Thickness Radial Forearm Free Flap Phalloplasty

PURPOSE: Radial forearm free flap (RFFF) phalloplasty is often referred to as the gold standard for gender-affirming phalloplasty procedures.1 Forearm neuropathy, a frequently listed complication of RFFF phalloplasty, has yet to be quantified in patients who undergo this procedure with a device as precise as the Pressure Specified Sensory Device (PSSD). The purpose of this study was to determine whether there is a change in tactile hand sensation following RFFF phalloplasty, and whether these changes vary by cutaneous region of the hand. The results of this study will help counsel patients who may view potential neuropathy as a barrier to pursuing this procedure. METHODS: A total of 9 patients undergoing split thickness RFFF phalloplasty were tested preoperatively and 1-week postoperatively for tactile hand sensation. Testing was conducted using a 2-point static (2 PS) test with a Disk-Criminator and PSSD. The testing sites included the cutaneous regions of the dorsal first webspace and the first phalanx of the index finger and pollex of the RFFF donor arm. The 2 PSSD prongs were set at a distance determined by initial testing with the Disk-Criminator. The PSSD measured the threshold of pressure necessary for the patient to discriminate 2 points. Two-sided paired t tests compared the pre- and postoperative pressure values on each of the 3 hand locations. The numerical differences in pre- and postoperative pressures were then compared between each of the 3 locations to determine whether or not there was a difference in postoperative sensation based on hand region. The PSSD pressure values were standardized based on the prong distance determined by the Disk-Criminator, and percent change in standardized PSSD score differences for each cutaneous region was calculated. All tests were considered significant at P < 0.05. RESULTS: There were no significant differences between pre- and postoperative PSSD pressures for all cutaneous regions tested (P > 0.05). However, on average, patients required 8.04% more pressure applied in the dorsal first webspace in order to discriminate 2 points, 8.43% more in the first phalanx of the index finger, and 16.7% more in the first phalanx of the pollex postphalloplasty (all n.s.). Furthermore, when comparing each of the three cutaneous regions to each other, there was no difference in the change in pressures between each region (P > 0.05). In other words, each of the three regions of the hand was similarly impacted by the operation. CONCLUSIONS: The results of this study suggest that while past literature reports cases of numbness and/or tingling post-RFFF phalloplasty,1 immediate postoperative sensation is not significantly different than preoperative sensation. The fear of donor arm neuropathy is a potential barrier for patients seeking this life-changing procedure, yet this study quantifies the degree of neuronal damage and may encourage patients to undergo the procedure. These results will help guide patient-physician conversations regarding RFFF phalloplasty in order to create realistic patient expectations for postoperative outcomes. REFERENCE: 1. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

Pedicled Anterolateral Thigh and Radial Forearm Free Flap Phalloplasty for Penile Reconstruction in Patients With Bladder Exstrophy.

Male patients with exstrophy-epispadias complex have a congenitally short penis. Adolescent and adult patients often desire penile reconstruction to enable penetrative intercourse. When penile lengthening using local tissue and/or skin graft is unsuitable, phalloplasty is performed. We provide updated experiences using radial forearm free flap and pedicled anterolateral thigh flap phalloplasty techniques over a 6-year period in exstrophy-epispadias complex patients. Consecutive patients who underwent radial forearm free flap or pedicled anterolateral thigh flap phalloplasty between 2013 and 2019 were reviewed. A total of 11 patients were identified, including 8 with classic bladder exstrophy and 3 with cloacal exstrophy. In each case, flap dimensions, donor and recipient vessels and nerves, complications, outcomes and subsequent surgical procedures are reported. A radial forearm free flap was performed in 6 patients and a pedicled anterolateral thigh flap in 5. Flap survival was observed in all cases and 5 patients subsequently received an inflatable penile prosthesis. Among patients undergoing a pedicled anterolateral thigh flap, there was 1 mortality from acute pulmonary embolism, and the other 4 required at least 1 debulking procedure. Phalloplasty is an important procedure in patients with exstrophy-epispadias complex with severe penile inadequacy. Both techniques have favorable long-term outcomes, although the pedicled anterolateral thigh flap frequently requires a later debulking procedure. The radial forearm free flap is preferred but if the radial forearm is overly thin and the risk of inflatable penile prosthesis extrusion is high, the pedicled anterolateral thigh flap is an acceptable alternative.

Discussion of “Phantom Penis: Extrapolating Neuroscience and Employing Imagination for Trans Male Embodiment”

ABSTRACT As described by Straayer, the phantom penis in transgender men combines feelings of loss and potential and may contribute to self-authentication and pleasure following phalloplasty. To align their gender identity with their body, some transgender men choose to undergo a phalloplasty procedure. For the reconstructive surgeon, the goals of phalloplasty typically are summed as an aesthetically pleasing, sensate phallus with both tactile and erogenous sensation that is capable of standing micturition and penetrative intercourse. Many surgical techniques for phalloplasty have been described, with the radial forearm free flap being the most commonly used. To optimize erogenous sensation, nerve coaptation to the dorsal clitoral nerve in conjunction with burying the denuded clitoris at the base of the neophallus is often performed. While surgical technique contributes to sensory recovery, there is likely a complex interplay between physiology, anatomy, endocrinology, and psychology as they pertain to orgasm and sexuality following phalloplasty. The reconstructive surgeon should engage in a shared decision-making approach with their patient and attempt to optimize aesthetic and sensory outcomes in order to facilitate sexual function following surgery.

Total Ankle Arthroplasty: Risk Factors For Subsequent Flap Coverage

Category:Ankle Arthritis; Ankle; DiabetesIntroduction/Purpose:Total ankle arthroplasty (TAA) results in improved patient outcomes and preserved range of motion for patients with end-stage arthritis. Wound complications following these procedures, while rare, can have a significant impact on patient morbidity, particularly when they require return to the operating room and flap coverage. We sought to determine the risk factors associated with the need for flap coverage over TAA, and hypothesized that intraoperative variables such as additional procedures to provide angular correction would play a more important role than patient-specific variables.Methods:We performed a single center retrospective review of primary total ankle arthroplasties from April 2007 - February 2019. Patients demographics and medical comorbidities were collected in addition to concomitant procedures performed at the time of TAA such as tibial osteotomies, removal of hardware, and subtalar fusion. Multivariable, main effects logistic regression models were performed to evaluate the impact of specific concomitant procedures during primary TAA on the rate of subsequent flap coverage with adjustment for age, sex, and medical comorbidities.Results:2,124 TAA resulted in 29 flaps after an average of 1.1 (range 0-5) surgeries and 89.7 (range 18-591) days after the index arthroplasty. The most common flap was a radial forearm free flap performed in 15 (51.7%) patients. Patients requiring flap coverage were significantly older (p=0.044), were more likely to be diabetic (p=0.029), and were more likely to present to the ED and be readmitted within 90-days of their surgery (p<0.001). In a multivariable model controlling for age, gender, and diabetes diagnosis, patients with flaps were more likely to have a concomitant osteotomy (OR 3.720, 95% CI 1.693-8.177; p=0.001) at the time of there TAA. Other concomitant procedures did not show a significant association with subsequent need for flap coverage.Conclusion:Simultaneous procedures during TAA may place patients at higher risk of wound breakdown, specifically requiring flap coverage. In particular, osteotomies, namely tibial osteotomies for realignment, carry a special risk for wound healing difficulty. This should be considered as the indications for TAA continue to expand.

Gender reassignment from female to male : Phalloplasty

The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals. The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty. Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25years. Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%. Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows ahigh heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

Versatility of the Radial Forearm Free Flap in Head and Neck Reconstruction. A Study of 58 Cases

IntroductionThe radial forearm free flap (RFFF) is a widely used tool in head and neck reconstructive surgery. It stands out as a relatively simple flap to achieve; it is versatile and has features that enable the reconstruction of complex head and neck defects. The aim of the study was to present our results using the RFFF in the reconstruction of seated defects in the head and neck area. Material and methodsA retrospective, observational and analytical study that included 58 cases of RFFF interventions, performed between January 2002 and July 2019. The data studied were the age and sex of the patients, location of the tumour, histological type, previous radiation therapy (RT), number of venous anastomoses performed in the surgery and body temperature in the immediate postoperative period, at 24 and 48 h following surgery. ResultsThe percentage of viable RFFF was 82.8%. None of the variables analysed appear to be a risk factor for flap failure. The most frequent cause of flap failure was venous thrombosis. ConclusionsMicrovascularised flaps play an important role in reconstructive surgery, the RFFF being one of the most interesting for head and neck reconstruction. It is a very versatile tool that allows the reconstruction of many of the sites where the head and neck surgeon operates.

Metastatic implantation of oral cancer in forearm: An unusual presentation

Metastatic implantation of cancer cells at a free flap graft donor site is a very unusual presentation. The possible mechanism is accidental contamination of the graft site by instruments used for surgery on the primary site. The other potential causes are the hematogenous spread of the tumor and de novo tumorigenesis. This report describes the case of a 65-year-old gentleman with carcinoma of the left buccal mucosa, which underwent wide local excision of the growth with type III modified radical neck dissection with radial forearm free flap reconstruction and subsequently developed a metastatic nodule over the graft donor site after 3 months. The nodule was excised with an adequate margin after which the patient refused to undergo any further treatment. Proper care taken while dealing with the tumor as well as the graft donor site shall avoid such iatrogenic complications due to possible accidental contamination of the graft donor area.