Radial Forearm Free Flap Research Articles

(199) Anterolateral Thigh Flap Phalloplasty for Micropenis

Abstract Introduction Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps. Objective The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. Methods A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder. Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. Results The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. Conclusions Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further esthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Disclosure No

(245) Outcomes of Penile Reconstruction for Salvage of Penile Gangrene

Abstract Introduction The most catastrophic complication of penile implant surgery results in either total/partial loss of the penis to such an extent that salvage penile reconstruction or phalloplasty is required. Penile gangrene (or necrosis) is rare and is associated with several patient factors (smoking, diabetes) and surgical factors (sliding technique, revision or a subcoronal incision). Irreversible ischemia with tissue loss will ensue if the prosthesis is not removed immediately. Nevertheless, subsequent corporal fibrosis and penile length loss may preclude an adequate functional penile length. In this situation, total penile reconstruction would be the only option to restore the ability for sexual intercourse and to void while standing. Objective The aim of this series is to assess the risk factors that predispose a select group of patients that require phalloplasty following penile gangrene and their surgical and functional outcomes following reconstruction. Methods All patients following phalloplasty for penile necrosis were identified from a comprehensive prospective database. Potential risk factors for penile necrosis were identified and the type and outcomes of reconstruction summarized. Functional outcomes were assessed by non-validated questionnaire. Results Thirteen patients with a median age of 57 years (range 27-68 years) required phalloplasty following penile necrosis with no incidence of flap loss. Reasons for erectile dysfunction were diabetes (37.5%), Peyronie’s disease (31%) and pelvic trauma (25%). The most common identifiable risk factors was diabetes (60%), followed by smoking (53%), adjunctive procedures like sliding technique or grafting (40%), revision surgery (27%) and infection with delayed explantation (27%). All patients had more than one risk factor for penile necrosis. Penile reconstruction was achieved with the radial artery forearm free flap (62%) and the anterolateral thigh flap (38%). All flaps were designed with an integrated urethra requiring anastomotic urethroplasty. Urethral complications occurred in 46.2% of men (fistulae and strictures) requiring surgical repair (Clavien 3b) while 2 had partial skin graft loss from the donor arm that improved with dressings and antibiotics (Clavien 2). Following phalloplasty, all responders had sensation (46% could orgasm with the neophallus) and 86% were able to void while standing. Most men were satisfied with the esthetic outcome (92%). The questionnaire response rate was 67%. Conclusions Penile necrosis following penile prosthesis insertion is rare and occurs in the presence of risk factors, particularly diabetes and smoking. Penile prosthesis surgery should be considered carefully in this cohort of patients especially for revision surgery or where adjunctive procedures are planned. Infection requires immediate explant of the device. Phalloplasty has good surgical and functional outcomes should reconstruction be required although there is a significant risk of surgical complications. Disclosure No

(520) The Use of Gracilis Muscle Flap in Radial Forearm Free Flap Phalloplasty to Decrease Urethral Fistula Rate: Initial Outcome

Abstract Introduction `- Chang and Hwang, in 1984, described the technique of Radial Forearm Free Flap Phalloplasty (RFFFP). It is now considered to be the standard surgery for phallic reconstruction. Urethral fistula is the most common complication reported in RFFFP and may reach up to 60-70%. Most commonly, the fistula site is at the anastomosis between the native urethra and the neo-urethra. Objective `- to study the impact of gracilis muscle flap wrapping around the native urethra/neo-urethral anastomosis on decreasing the fistula rate. Methods `- A prospective study was conducted at our urology department, from January 2018 till December 2020. - Patients presenting with a micropenis (Stretched penile length <7 cm) underwent RFFFP with gracilis muscle flap wrapping. - The free-flap was harvested from the non-dominant forearm. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein, and the medial and lateral antecubital nerves with the ilio-inguinal and the dorsal penile nerves respectively. - A pedicled gracilis muscle flap was then wrapped around the neo-urethera/native urethral anastomosis to assess its possible role in decreasing the postoperative urinary fistula rate. Results `- Nineteen patients were included in the study with a median age of 26 years (16 - 43) and a BMI of 24 (22-25). The median hospital stay of 14 days (14 - 21) and the median follow-up was 11 months (4 - 13). The median cold ischemia time was 90 mins (70 - 100), estimated blood loss was 500 cc (400 - 500) and operative time was 11 hrs (10 - 12). - A viable phallus was achieved in 13 patients (overall free flap survival 68.4%). - Of the successfully viable phallus cases, 8 cases (42.1%) were complicated by complete disruption of the urethra and the remaining five cases (26.3%) had complete urethral tube. - One case of them developed a fistula at the neo-urethera/native urethral anastomosis, one case had a distal fistula and one case had a ring stricture at the site of anastomosis. - The gracilis muscle flap prevented urethral fistula formation in 4 out of 5 cases (80%) with complete urethral tube. Conclusions `- The use of pedicled garcilis muscle flap wrapping around the neo-urethra/native urethral anastomosis during RFFP might be helpful in reducing the urinary fistulae rates at this site. However, larger comparative studies are needed. Disclosure No

(037) Contemporary Surgical and Functional Outcomes of Anterolateral Thigh Flap for Penile Reconstruction

Abstract Introduction The radial forearm free flap phalloplasty is the most commonly used flap for penile reconstruction. The anterolateral thigh (ALT) free flap was proposed in 2006 as an alternative due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap was proposed the same year thus offering greater security of vascular supply for suitable patients. Previous reports have highlighted higher rates of flap loss and low rates of integrated urethra. Objective The aim of the study is to report the contemporary surgical outcomes of ALT phalloplasty. In addition, the functional outcomes of the ALT flap phalloplasty are reported for the first time. Methods All patients undergoing ALT flap phalloplasty were included in the study between 2009 and 2021. Data were extracted from a comprehensive prospective database and the medical records. Functional outcomes were assessed by non-validated questionnaire. Results Seventy-six patients underwent ALT flap phalloplasty with a mean follow-up of 34 months (SEM ± 3.05). Median age of the patients was 32 (IQR 26 – 46) and body mass index was 24 (SEM ± 0.61). A significant minority had a previous phalloplasty (22%). In addition, 7% of patients had other co-morbidities including diabetes and peripheral vascular disease. Over half of all flaps (n=41) were designed with an integrated urethra and 6.6% (n=5) required free flap transfer. The average length of stay was seven days (SEM ±0.47). Post-surgery, five (6.6%) patients experienced total flap loss, with a further three (3.9%) experiencing partial loss. Urethral complications were common with eleven (26.8%) patients developing fistulae and three (7.3%) developing strictures. Fifty-three (69%) patients completed the functional outcomes questionnaire. Forty-three (81%) were generally satisfied with their phalloplasty, while thirty-four (65%) felt they had a good cosmetic outcome. Twenty-eight (53%) had sensation in at least half of their phallus. Eight (17%) experienced troublesome post-micturition dribbling. Conclusions Presented is one of the largest cohort of patients following genital gender affirmation surgery using the ALT flap phalloplasty. Over half of all patients successfully had an integrated urethra (gold standard for urethral reconstruction). Functional outcomes (an important determinant for the choice of a flap) are reported for the first time showing 81% of patients are satisfied despite a challenging cohort with almost a quarter of patients undergoing salvage following previous failed phalloplasty. Disclosure No

Difficulties of nasocutaneous fistula repair, following lacrimal outflow system malignancy resection

ABSTRACT Purpose To evaluate the incidence of nasocutaneous fistula (NCF) development, following en bloc resection of lacrimal outflow system malignancies (LOSM), and describe the methods of surgical repair. Methods Retrospective review of all patients who underwent resection of LOSM with reconstruction and post-treatment protocol at the University of Miami between 1997 and 2021. Results Of the 23 included patients, 10 (43%) developed postoperative NCF. All NCFs developed within one year of surgical resection or completion of radiation therapy. NCF was seen more frequently in patients who underwent adjuvant radiation therapy and those who had reconstruction of the orbital wall with titanium implants. All patients underwent at least one revisional surgery to close the NCF, including local flap transposition (9/10), paramedian forehead flap (5/10), pericranial flap (1/10), nasoseptal flap (2/10), and microvascular free flap (1/10). Local tissue transfer, pericranial, paramedian, and nasoseptal forehead flaps failed in most cases. Two patients had long-term closure; one patient who underwent a paramedian flap and a second who underwent a radial forearm free flap, suggesting that well-vascularized flaps may be the most viable option for repair. Conclusions NCF is a known complication, following en bloc resection of lacrimal outflow system malignancies. Risk factors for formation may include adjuvant radiation therapy and use of titanium implants for reconstruction. Surgeons should consider utilizing robust vascular-pedicled flaps or microvascular free flaps for repair of NCF in this clinical scenario.

Unconventional Approach to Neck Dissection: A Rare Case of Cervical Kyphosis.

Carcinoma of the head, neck and face is a challenge faced by surgeons worldwide. This case report presents a complicated surgical approach utilised in a patient diagnosed with right lower lip and gingivobuccal sulcus carcinoma, with a fixed neck flexion deformity due to ankylosing spondylitis. The patient, a 55-year-old man with cervical kyphosis, was declared inoperable due to his complex anaesthetic and surgical requirements. We performed a successful wide local excision of the tumour with a right marginal mandibulectomy, and later reconstructed the defect using a left free radial forearm flap.

Comparison of patient-reported upper extremity disability following free flaps in head and neck reconstruction: A systematic review and meta-analysis.

Comparisons of patient-reported donor site morbidity based on the Disabilities in Arm, Shoulder, and Hand (DASH) instrument across upper trunk free flaps in head and neck surgery, including radial forearm (RFFF), osteocutaneous radial forearm (OCRFF), scapular tip (STFF), and serratus anterior (SAFF) free flaps, may help inform donor tissue selection. In this meta-analysis, 12 studies were included and the primary outcome was average DASH score. The pooled DASH scores were 12.14 (95% CI: 7.40-16.88) for RFFF (5 studies), 17.99 (11.87-24.12) for OCRFF (2 studies), 12.19 (8.74-15.64) for STFF (3 studies), and 16.49 (5.92-27.05) for SAFF (2 studies) and were not significantly different. Results suggest that patients generally function well, with minimal to mild donor site morbidity, when assessed at an average of 20 months after flap harvest. These results are based on few effects from primarily retrospective studies of fair quality, and further research is needed.

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

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

D49. Patient Reported and Clinical Outcomes after Radial Forearm vs. anterolateral Thigh Free Flap Reconstruction of Glossectomy Defects: A Preliminary Examination

PURPOSE: Patient reported outcome measures such as FACE-Q, are currently being integrated and evaluated in head and neck reconstruction. This study examines clinical and FACE-Q outcomes in patients that underwent oncologic glossectomy reconstruction with radial forearm (RFFF) vs. anterolateral thigh (ALT) free flaps. METHODS: A retrospective review was performed for patients who underwent partial or hemiglossectomy and primary reconstruction with a RFFF or ALT between 2016-2021. FACE-Q is separated into multiple functional and stress domains where higher scores (0-100) represent better outcomes. Postoperative FACE-Q scores were divided into two time periods for comparison: short-term (0-1 year) and long-term (>1 year). The rate of complications that necessitated return to OR was also examined. RESULTS: 88 patients underwent partial or hemiglossectomy reconstruction with a RFFF, while 43 received an ALT. 56 RFFF and 16 ALT patients filled out at least one postoperative FACE-Q. RFFF patients reported significantly higher short-term satisfaction with their smile (p=0.017) and swallowing function (p=0.048). This cohort also reported significantly better long-term satisfaction with facial appearance (p=0.002), function in eating/drinking (p=0.014), and oral competence (p=0.016), as well as significantly less distress with eating (p=0.005) and facial appearance (p=0.014). There was no significant difference in complication rates between the two cohorts. CONCLUSION: The RFFF may perform better than the ALT in multiple PROM domains after reconstruction of glossectomy defects in the short and long-term. Expansion of this study may provide useful information for shared decision making between patients and providers in head and neck reconstruction moving forward.

A Novel Technique to Convert Static Sling into a Dynamic Sling in Reconstruction of Total Lower Lip Defects Using Palmaris Longus Tendon with Free Radial Forearm Flap and Case Series.

Lower lip reconstruction has been a major challenge for the reconstructive surgeons since time immemorial. Various types of reconstruction had been described for the reconstruction of lower lip ranging from local flaps to free tissue transfer to free functioning muscle transfer. For complete lower lip defects, the free radial forearm flap with palmaris longus tendon has been the standard of reconstruction for many years. Literatures suggests various techniques for utilizing palmaris longus tendon sling as a static as well as dynamic structure. The limitation with static reconstruction is the loss of sling support with time leading to eversion and drooping of the reconstructed lower lip and drooling of saliva. In this article we describe a simpler and novel technique which converts static reconstruction into a dynamic one with a series of 5 patients. Aim of this prospectivestudy wasto evaluate the post operative functional and aesthetic outcome of our technique of total lower lip reconstruction using free radial forearm flap with palmaris longus sling reconstruction. The medical records included were demographics, including age, gender, and reason for the acquired defect, lip reconstructed, reconstructive method, flap survival, and outcomes. At 6months follow up, all patients had satisfactory outcome and were able to take oral diets and none of the patients complained of drooling, an inability to eat in a public setting, or microstomia. This technique which is a simpler modification can be helpful in converting the traditional static sling reconstruction of lower lip into a dynamic one resulting in good aesthetic and functional outcomes.

Medial Sural Artery Perforator Flap: A Middle Ground Between Anterolateral Thigh and Radial Forearm Flaps.

The medial sural artery perforator (MSAP) flap has gained popularity in head and neck reconstruction primarily as a less morbid alternative to the radial forearm free flap (RFFF). However, no direct comparison of thickness exists among the MSAP, RFFF, and anterolateral thigh (ALT) flaps, which together represent the commonly utilized nonosseus-free flaps in head and neck reconstruction. Thus, this study aimed to compare these flap sites and identify predictors of thickness that will aid in reconstructive surgical planning. Cross-sectional study. Tertiary referral hospital. The thickness of skin and subcutaneous tissue at the RFFF, MSAP, and ALT donor sites were measured in 54 adult patients using Doppler ultrasound. General linear models were generated to identify predictors of flap thickness. The mean thickness of the RFFF, MSAP, and ALT flaps was 3.8 ± 2.2 mm, 7.4 ± 3.8 mm, and 9.6 ± 4.7 mm. Body mass index (BMI) was the only statistically significant contributing factor (p < .0001, coefficient: 0.15) for the RFFF. MSAP was affected by age (p = .006, coefficient = 0.06), female gender (p < .0001, coefficient = 3.2), and BMI (p < .001, coefficient = 0.25), while the ALT was affected by female gender (p = .0005, coefficient = 3.3) and BMI (p < .0001, coefficient = 0.35). Thus, the ratio of increase for flap thickness with respect to BMI is 3:5:7 for the RFFF, MSAP, and ALT flaps, respectively. The MSAP is about twice the thickness of the RFFF and 2 mm thinner than the ALT; however, 22% of patients had thicker MSAP than ALT flaps. As the strongest predictors of flap thickness, female gender, and BMI may be taken into consideration during surgical planning for reconstruction.

Reconstruction of Midfacial Defect With Radial Forearm Free Flap

For head and neck reconstruction, especially for reconstruction of midfacial structure, we should consider cosmetic results, functional preservation, and survival of flap. Methods of reconstruction vary from skin graft to free flap. Among those, the radial forearm free flap (RFFF) can be a valuable alternative for defects of midfacial structures such as the eyelid, nose and lip because of its sufficiently long pedicles, lack of bulk and flexibility, all of which enable surgeons to shape the flap into the way they want, and also functionally complement it by using adjacent structures like the palmaris longus muscle tendon. Herein, we introduce various methods of employing RFFF with or without the palmaris longus tendon to get better aesthetic and functional outcomes in reconstruction of midfacial structure.

V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP

You have accessJournal of UrologyCME1 Apr 2023V11-03 PENILE RECONSTRUCTION FOR CONGENITAL MICROPENIS WITH THE ANTEROLATERAL THIGH PEDICLED FLAP Aurélie Schirmann, Nim Christopher, David Ralph, and Wai Gin Lee Aurélie SchirmannAurélie Schirmann More articles by this author , Nim ChristopherNim Christopher More articles by this author , David RalphDavid Ralph More articles by this author , and Wai Gin LeeWai Gin Lee More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003337.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Congenital micropenis is defined as a normally formed penis with a stretched penile length less than 2.5 standard deviations below the mean for that man’s age and ethnicity. Micropenis may present as an isolated condition or with other genital or multi-system abnormalities. Penile reconstruction or phalloplasty may be required where topical and systemic hormonal treatment have failed. The most common flap used for phalloplasty is the radial artery forearm free flap phalloplasty. Other alternatives include the anterolateral thigh (ALT), musculocutaneous latissimus dorsi and abdominal flaps.The aim of this video is to illustrate the technique for penile reconstruction using a pedicled ALT flap without integrated urethra. METHODS: A 21-year-old man with micropenis and hypospadias from a disorder of sexual differentiation (46XY) presents for penile reconstruction following multiple failed attempts at hypospadias repair. He requested an ALT flap without integrated urethra because he is dependent on a long-term suprapubic catheter due to a hypocontractile bladder.Intraoperative vascular doppler identified 3 perforators from the descending branch of the lateral circumflex iliac artery of the left leg. The flap was designed centred on the perforators with dimensions of 14cm (length), 13cm (width at base) and 12cm (width at tip). The flap was raised carefully and transferred to the recipient groin. The neophallus was constructed and microsurgical anastomosis of the lateral cutaneous of the thigh to one of the dorsal penile nerves with 8/0 nylon was completed. The partially divided left vastus lateralis muscle was re-approximated and the skin edges drawn in and flattened. The left thigh was then resurfaced with a 14/1000 of an inch split-thickness skin graft from the contralateral thigh. All wounds were dressed. RESULTS: The man had an uneventful post-operative course with careful vascular monitoring, and he was discharged on day 10. He is currently awaiting glans-sculpting and will eventually proceed with insertion of an inflatable erectile device. CONCLUSIONS: Penile reconstruction using an ALT flap can be offered to a well-informed and motivated man with a micropenis following appropriate assessment. As shown, the technique requires careful dissection of the perforator vessels and can usually be transferred as a pedicled flap. Pedicled flaps do not require microvascular anastomosis and therefore have a lower risk of vascular compromise. Further aesthetic and functional refinements like the insertion of an erectile device are possible in later stages, if desired. Source of Funding: None declared © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e999 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Aurélie Schirmann More articles by this author Nim Christopher More articles by this author David Ralph More articles by this author Wai Gin Lee More articles by this author Expand All Advertisement PDF downloadLoading ...

MP02-05 SURGICAL AND PATIENT REPORTED OUTCOMES FOLLOWING PHALLOPLASTY FOR PENILE GANGRENE

You have accessJournal of UrologyCME1 Apr 2023MP02-05 SURGICAL AND PATIENT REPORTED OUTCOMES FOLLOWING PHALLOPLASTY FOR PENILE GANGRENE Wai Gin Lee, Hassan Assiri, Thomas Reid, Nim Christopher, and David Ralph Wai Gin LeeWai Gin Lee More articles by this author , Hassan AssiriHassan Assiri More articles by this author , Thomas ReidThomas Reid More articles by this author , Nim ChristopherNim Christopher More articles by this author , and David RalphDavid Ralph More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The most catastrophic complication of penile implant surgery results in either total/partial loss of the penis to such an extent that salvage penile reconstruction or phalloplasty is required. Penile gangrene (or necrosis) is rare and is associated with several patient factors (smoking, diabetes) and surgical factors (sliding technique, revision or a subcoronal incision). Irreversible ischemia with tissue loss will ensue if the prosthesis is not removed immediately. Nevertheless, subsequent corporal fibrosis and penile length loss may preclude an adequate functional penile length. In this situation, total penile reconstruction would be the only viable option to restore the ability for sexual intercourse and to void while standing. The aim of this series is to assess the risk factors that predispose a select group of patients that require phalloplasty following penile gangrene and their surgical and functional outcomes following reconstruction. METHODS: All patients following phalloplasty for penile necrosis were identified from a comprehensive prospective database. Potential risk factors for penile necrosis were identified and the type and outcomes of reconstruction summarized. Functional outcomes were assessed by non-validated questionnaire. RESULTS: Thirteen patients with a median age of 57 years (range 27-68 years) required phalloplasty following penile necrosis with no incidence of flap loss. Reasons for erectile dysfunction were diabetes (37.5%), Peyronie’s disease (31%) and pelvic trauma (25%). The most common identifiable risk factors was diabetes (60%), followed by smoking (53%), adjunctive procedures like sliding technique or grafting (40%), revision surgery (27%) and infection with delayed explantation (27%). All patients had more than one risk factor for penile necrosis. Penile reconstruction was achieved with the radial artery forearm free flap (62%) and the anterolateral thigh flap (38%). All flaps were designed with an integrated urethra requiring anastomotic urethroplasty. Urethral complications occurred in 46.2% of men (fistulae and strictures) requiring surgical repair (Clavien 3b) while 2 had partial skin graft loss from the donor arm that improved with dressings and antibiotics (Clavien 2). Following phalloplasty, all responders had sensation (46% could orgasm with the neophallus) and 86% were able to void while standing. Most men were satisfied with the esthetic outcome (92%). The questionnaire response rate was 67%. CONCLUSIONS: Penile necrosis following penile prosthesis insertion is rare and occurs in the presence of risk factors, particularly diabetes and smoking. Penile prosthesis surgery should be considered carefully in this cohort of patients especially for revision surgery or where adjunctive procedures are planned. Infection requires immediate explant of the device. Phalloplasty has good surgical and functional outcomes should reconstruction be required although there is a significant risk of surgical complications. Source of Funding: Not applicable © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e12 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Wai Gin Lee More articles by this author Hassan Assiri More articles by this author Thomas Reid More articles by this author Nim Christopher More articles by this author David Ralph More articles by this author Expand All Advertisement PDF downloadLoading ...

Quality of life in post-tongue reconstruction: a comprehensive systematic review and meta-analysis of radial free forearm flap versus anterolateral thigh flap

Quality of life in post-tongue reconstruction: a comprehensive systematic review and meta-analysis of radial free forearm flap versus anterolateral thigh flap

Regulating Microvascular Free Flaps Reconstruction in "Schobinger Stage 4" Arteriovenous Malformations of Face.

Objectives Arteriovenous malformations (AVMs) are high-flow, aggressive lesions that cause systemic effects and may pose a risk to life. These lesions are difficult to treat as they have a tendency to recur aggressively after excision or embolization. So, it requires a regulating free flap with robust vascular flow averting the postexcisional ischemia-induced collateralization, parasitization, and recruitment of neovessels from the surrounding mesenchyme-a phenomenon precipitating and perpetuating the recurrence of AVM. Materials and Methods Sixteen patients (12 males and 4 females) with AVMs Schobinger type 4 involving face were treated from March 2015 to March 2021 with various free flaps: three free rectus abdominis flaps, one free radial forearm flap, and twelve free anterolateral thigh flaps were used for reconstruction following the wide local excision of Schobinger type 4 facial AVM. The records of these patients were analyzed retrospectively. The average follow-up period was 18.5 months. The functional and aesthetic outcomes were analyzed with institutional assessment scores. Results The average size of the flap harvested was 113.43 cm 2 . Fourteen patients (87.5%) had good-to-excellent score ( p = 0.035) with institutional aesthetic and functional assessment system. The remaining two patients (12.5%) had only fair results. There was no recurrence (0%) in the free flap group versus 64% recurrence in the pedicled flap and skin grafting groups ( p = 0.035). Conclusion Free flaps with their robust and homogenized blood supply provide a good avenue for void filling and an excellent regulating effect in inhibiting any locoregional recurrences of AVMs.

Characteristics and outcomes of transoral robotic surgery with free-flap reconstruction for oropharyngeal cancer: a systematic review.

Transoral robotic surgery (TORS) approach for the treatment of oropharyngeal cancer allows for reduced patient morbidity, amongst other advantages over the traditional lip-splitting mandibulotomy method. Free-flap reconstruction is commonly utilized in head and neck cancer surgeries; however, safety and outcomes of this technique in TORS procedures have not been well studied. The objective of this study was to perform a systematic review to evaluate the efficacy and safety of TORS with free-flap reconstruction (TORS-FFR) for oropharyngeal cancer. A systematic search of Scopus, EMBASE, CINAHL and PubMed databases was completed. Following PRISMA guidelines, case series/reports, retrospective and prospective cohort studies were included. Primary outcomes measured were deaths and complication rates associated with TORS-FFR for oropharyngeal cancers. Secondary outcomes included functional swallowing and airway outcomes, operative time and length of hospital stay. Twenty-one studies met the inclusion criteria comprising a total of 132 patients. The mean patient age was 58.4years. The most frequent complication was infection (8.9%) followed by flap wound dehiscence (4.2%). The average total operative time was 710min (n = 48), while average length of hospital stay was 13.5days (n = 48). Reconstructions were most commonly fashioned from radial forearm free flaps (RFFF), with anterolateral thigh flaps (ALT) representing the second most common free-flap subtype. TORS-FFR procedures for oropharyngeal cancer are safe, with low serious complication rates. This surgical approach may be associated with decreased length of hospital stay; however, further studies are required to better characterize post-operative outcomes.Level of evidence 1a.

Management of an Unusual Avulsion Trauma of Total Esophagus During Upper Gastrointestinal Endoscopy.

An esophageal defect usually resulted from surgical ablation of tumors or corrosive injury. Staged reconstructions are required usually in extensive defects. This study aimed to present a rare iatrogenic complication of total esophageal avulsion injury during upper gastrointestinal endoscopic treatment and to perform staged reconstructions to create a neoesophagus. In the presented case, staged reconstructions with a tubed deltopectoral flap and a supercharged colon interposition flap were performed to reconstruct the hypopharynx and esophagus. However, recurrent choking occurred because of the extent of injury involving the epiglottis. A tubed free radial forearm flap connected to the lower buccogingival sulcus was used to create a new route for food passage. The patient resumed oral intake after rehabilitation. The avulsion injury of the total esophagus is rare and devastating. Staged reconstructions with a tubed deltopectoral flap, a supercharged colon interposition flap, and a tubed free radial forearm flap would be a safe and reliable method.

Monopolar electrocautery versus sharp dissection in the neck dissection: a retrospective study

The cold scalpel/scissors (CS) and the monopolar electrocautery (ME) are still the most commonly used instruments for neck dissection in head and neck oncology. However, a direct comparison of these techniques does not exist. This study aims to compare these techniques concerning blood loss, the decline of hemoglobin levels, and surgery duration. Data on 200 patients who received tumor resection, neck dissection and either a radial forearm free flap (RFFF)or a primary closure (PC) were examined retrospectively. The patients were divided according to the performed defect closure (RFFF or PC) and the main instrument usedfor the beck dissection (Group 1: RFFF and ME, Group 2: RFFF and CS, Group 3: PC and ME Group 4: PC and CS). The intraoperative blood loss, decline of hemoglobin values and surgery duration were analyzed and compared between the corresponding groups. The patients where the ME was used lost on average 409.93 ml (group 1 vs. 2) and 242.4 ml (group 3 vs. 4) less blood. The median decrease in the hemoglobin levels was by 1.01 g/dL (group 1 vs. 2) and 0.85 g/dL (group 3 vs. 4) lower for the ME. The median surgery duration was by 102 min (group 1 vs. 2) and 83 min (group 3 vs. 4) shorterfor the ME. All differences were statistically significant. Traditional scalpel and scissors used for neck dissection lead to significantly higher blood loss and longer operation time than the monopolar electrocautery.

Shape-modified radial forearm flap: does it still have a role in upper extremity reconstruction?

ObjectivesTo carry out a radial forearm flap, the radial artery is usually harvested, incurring severe donor site morbidity. Advances in anatomical knowledge discovered constant radial artery perforating vessels, enabling the subdivision of the flap into smaller components suitable for a wide range of differently shaped recipient sites, with marked reduction of downsides. Material and methodsEight pedicled or free shape-modified radial forearm flaps were used to reconstruct upper extremity defects between 2014 and 2018. Surgical technique and prognosis were examined. Skin texture and scar quality were assessed on the Vancouver Scar Scale while function and symptoms on the Disabilities of the Arm, Shoulder and Hand score. ResultsAt a mean follow-up of 39 months, no cases of flap necrosis, impaired hand circulation or cold intolerance were found. ConclusionThe shape-modified radial forearm flap is not a new technique, but is poorly known by hand surgeons; in contrast, our experience showed it to be reliable, with acceptable functional and esthetic outcomes in selected cases.