Recipient Site Complications Research Articles

Early and late complications in the reconstructed mandible with free fibula flaps.

Background and ObjectivesEvaluation of mandibular reconstructions with free fibula flaps. Identification of factors associated with major recipient site complications, that is, necessitating surgical intervention under general anaesthesia.MethodsSeventy‐nine reconstructions were included. The following factors were analyzed: fixation type, number of osteotomies, site of defect (bilateral/unilateral), surgeon, sex, ASA classification, continuous smoking, pathological N‐stage, age, defect size, flap ischemic time, and postoperative radiotherapy. Proportional hazards regression was used to test the effect on the time between reconstruction and intervention.ResultsSixty‐nine (87%) of the 79 fibula flaps were successful at the last follow‐up. Forty‐eight major recipient site complications occurred in 41 reconstructions. Nineteen complications required surgical intervention within six weeks and were mostly vascular problems, necessitating immediate intervention. These early complications were associated with defects crossing the midline, with an estimated relative risk of 5.3 (CI 1.1‐20, P = 0.01). Twenty‐nine complications required surgical intervention more than 6 weeks after the reconstruction. These late complications generally occurred after months or years, and were associated with smoking, with an estimated relative risk of 2.8 (CI 1.0‐8.3, P = 0.05).ConclusionsFibula flaps crossing the midline have a higher risk of early major recipient site complications than unilateral reconstructions. Smoking increases the risk of late complications.

Complications following immediate compared to delayed deep inferior epigastric artery perforator flap breast reconstructions

PurposeAs more breast cancer patients opt for immediate breast reconstruction, the incidence of complications should be evaluated. The aim of this study was to analyze the recipient-site complications and flap re-explorations of immediate compared to delayed deep inferior epigastric artery perforator (DIEP) flap breast reconstructions.MethodsFor this multicenter retrospective cohort study, the medical records of all patients who underwent DIEP flap breast reconstruction in three hospitals in the Netherlands between January 2010 and June 2017 were reviewed. Patient demographics, risk factors, timing of reconstruction, recipient-site complications, and flap re-explorations were recorded.ResultsA total of 910 DIEP flap breast reconstructions (n = 397 immediate and n = 513 delayed reconstructions) in 737 patients were included. There were no significant differences in major complications or flap re-explorations between immediate and delayed reconstructions. The total flap failure rate was 1.5 and 2.5% in the immediate and delayed group, respectively. Significantly more hematomas (OR 2.91; 95% CI 1.59–5.30; p = 0.001) and seromas (OR 3.60; 95% CI 1.14–11.4; p = 0.029) occurred in immediate reconstructions, whereas wound problems were more frequently observed in delayed reconstructions (OR 1.99; 95% CI 1.27–3.11; p = 0.003). Correction for potential confounders still showed significant differences for hematoma and seroma, but no longer for wound problems (p = 0.052).ConclusionsThis study demonstrated similar incidences of major recipient-site complications and flap re-explorations between immediate and delayed DIEP flap breast reconstructions. However, hematoma and seroma occurred significantly more often in immediate reconstructions, while wound problems were more frequently observed in delayed reconstructions.

How Big is Too Big

Obesity is a major public health concern in the United States, affecting nearly 79 million people. There have been promising results performing microvascular breast reconstruction in patients with obesity; however, the definition of obesity is often poorly defined or does not extend above a body mass index (BMI) of 35. Our goal was to examine outcomes of microvascular breast reconstruction in this questionably more risky population. A retrospective review from 2013 to 2016 was performed of 2 surgeons' experience with abdominally based microvascular breast reconstructions. Women were categorized by BMI into the following groups: normal (18.5-24.9 kg/m), overweight (25.1-29.0 kg/m), class I (30.0-34.9 kg/m), class II (35.0-39.9 kg/m), and class III (>40 kg/m). Demographics included history of tobacco use, breast cancer diagnosis, adjuvant care, and comorbidities. Complications evaluated included donor site (delayed wound healing, fat necrosis, dehiscence, infection, abdominal hernia/bulge, and seroma), recipient site (delayed wound healing and fat necrosis), and need for reoperation. Statistical analyses were performed using analysis of variance and χ test. A total of 90 women (117 breasts) underwent microsurgical breast reconstruction using abdominal tissue. Twenty-seven women (48 breasts) met criteria for class II and class III obesity (BMI 35-53). Mean follow-up was 24 months. No statistically significant difference was found in demographics among all groups. There was a trend toward variability in overall complications across the BMI groups (P = 0.149). Donor site complications had a significant variation across the different BMI groups (P = 0.016). The rate of donor site complications was similar in class II (8/14) and class III (7/13) obese women. Recipient site complications were similar across the BMI groups. We found obese women to have a higher rate of abdominal donor site complications; however, this risk seems to level off at class I or II obesity. We have modified our surgical technique of managing the abdominal donor site to optimize our outcomes in the morbidly obese patient population.

The Lateral Thigh Perforator Flap for Autologous Breast Reconstruction: A Prospective Analysis of 138 Flaps

The septocutaneous tensor fasciae latae or lateral thigh perforator flap was previously introduced by the authors' group as an alternative flap for autologous breast reconstruction when the abdomen is not suitable as a donor site. The authors analyzed their experience with the lateral thigh perforator flap and present the surgical refinements that were introduced. A prospective study was conducted of all lateral thigh perforator flap breast reconstructions performed since September of 2012. Patient demographics, operative details, complications, and flap reexplorations were recorded. Preoperative imaging with magnetic resonance angiography was performed in all patients. Surgical refinements introduced during this study included limitation of the flap width and the use of quilting sutures at the donor site. A total of 138 lateral thigh perforator flap breast reconstructions were performed in 86 consecutive patients. Median operative times were 277 minutes (range, 196 to 561 minutes) for unilateral procedures and 451 minutes (range, 335 to 710 minutes) for bilateral. Median flap weight was 348 g (range, 175 to 814 g). Two total flap losses (1.4 percent) were recorded, and 11 flaps (8.0 percent) required reexploration, which resulted in viable flaps. The incidence of donor-site complications was reduced significantly after the surgical refinements were introduced. Wound problems decreased from 40.0 percent to 6.3 percent, seroma decreased from 25.0 percent to 9.5 percent, and infection decreased from 27.5 percent to 9.5 percent. The lateral thigh perforator flap is an excellent option for autologous breast reconstruction, with minimal recipient-site complications. The surgical refinements resulted in a significant reduction of donor-site complications. Therefore, the lateral thigh perforator flap is currently the authors' second choice after the deep inferior epigastric artery perforator flap. Therapeutic, IV.

Reconstruction of full‐thickness cheek defect with chimeric facial artery free flap: A case report

Full-thickness cheek defects represent a difficult challenge for reconstructive surgeons. Multiple techniques have been described, including local, regional, and free flaps. In this report, the reconstruction of a through and through left cheek defect, resulting from a self-inflicted gunshot injury, with a chimeric facial artery free flap is presented. The patient underwent reconstruction with a chimeric full-thickness facial artery free flap, with 9 × 3 cm diameter skin paddle and a 6 × 5 cm myomucosal paddle, was harvested on the contralateral cheek with a 7-cm length of facial pedicle. The flap was transferred via a microsurgical technique and an end-to-end microsurgical anastomosis was performed between the donor and the contralateral facial vessels. The flap was transplanted successfully and there were no donor or recipient site complications with a satisfactory esthetic result 5 years after surgery. This technique may be a good reconstructive option for medium size, full-thickness, cheek defects allowing a "like with like" reconstruction with minimal donor-site morbidity.

Soft palate functional reconstruction with buccinator myomucosal island flaps

Oropharyngeal reconstruction after ablative surgery is a challenge. The results of a retrospective study of 17 patients who underwent total or sub-total soft palate reconstruction with a buccinator myomucosal island flap, between 2008 and 2016, are reported herein. An analysis of flap type and size, harvesting time, and postoperative complications was performed. Patients underwent standardized tests to assess the recovery of sensitivity, deglutition, quality of life (QoL), and donor site morbidity, at >6 months after surgery or the end of adjuvant therapy, if performed. All flaps were transposed successfully. Only minor donor and recipient site complications occurred. The sensitivity assessment showed that touch, two-point discrimination, and pain sensations were recovered in all patients. Significant differences between the flap and native mucosa were reported for tactile (P=0.004), pain (P=0.001), and two-point discrimination (P=0.001) thresholds. The average deglutition score reported was 6.1/7, with only minimal complaints regarding deglutition. The QoL assessment showed high physical (24.6/28), social (25/28), emotional (19.1/24), and functional (24.6/28) scores. No major donor site complications were noted in any patient; the average donor site morbidity score was 8.1/9. Buccinator myomucosal island flaps represent a valuable functional oropharyngeal option for reconstruction, requiring a short operating time and presenting a low donor site morbidity rate.

Reconstruction of midface defects with the osteocutaneous radial forearm flap: Evaluation of long term outcomes including patient reported quality of life.

Maxillectomy defects significantly impair quality of life. Prosthetics can overcome some of these issues, but has limitations. The role of the osteocutaneous radial forearm free flap (OC-RFFF) has been established for reconstruction of smaller maxillectomy defects, but its role in larger defects is not well defined. We aim to evaluate outcomes after midface reconstruction utilizing the OC-RFFF. Retrospective review of prospective database collected between 2005 and 2014 of midface reconstruction using OC-RFFF in a tertiary care centre. Donor site complications and acute and long-term recipient site complications were measured. Health related quality of life was assessed using the University of Washington Quality of Life (UW-QOL) Questionnaire. A total of 68 midface defects were reconstructed using the OC-RFFF. Acute recipient site complications included three flap failures (4%), and two additional microvascular revision cases for vascular compromise. Late recipient complications included fistula (n = 10, 14%), ectropion (n = 7, 10%), diplopia (n = 6, 9%) and exposed hardware (n = 5, 7%). Resection of cheek skin or orbital rim correlated with orbital complications. The incidence of fistula was not affected by defect size or prior radiation. There were two donor site infections and no instances of forearm fracture. Patients undergoing OC-RFFF repair had mean scores for UW-QOL outcomes higher than published rates of obturator quality of life. The OC-RFFF is suited to a variety of midface defects and can be combined with hardware to reconstruct the orbital floor. Recipient site complications are common, but donor site morbidity is low and outcomes, including HR-QOL, are acceptable.

A Retrospective Volume Matched Analysis of the Submental Artery Island Pedicled Flap as Compared to the Forearm Free Flap: Is It a Good Alternative Choice for the Reconstruction of Defects of the Oral Cavity and Oropharynx?

The submental artery island pedicled flap (SMIF) is an underused alternative for reconstruction of head and neck defects after tumor ablation. The purpose of this study was to perform a comparative evaluation of reconstructive outcomes based on surgical site and ablative defect volume in patients who underwent reconstruction with the SMIF versus the forearm free flap (FFF). A retrospective cohort study of all patients with oral cavity and oropharyngeal defects reconstructed with the SMIF and a cohort of patients with similar volume defects reconstructed with the FFF were compared for oncologic safety and viability of equivalent reconstructive outcomes. All statistical comparisons were assessed by analysis of variance and Fisher exact test. Average age was 61.8years in the SMIF group versus 57.9years in the FFF group. The most common defect was located in the tongue, with squamous cell carcinoma being the most common pathology identified. Flap volumes were similar (SMIF, 38.79cm3; FFF, 39.77cm3). Significant comparative outcomes identified with SMIF versus FFF reconstruction included shorter anesthesia times (815 vs 1,209minutes; P<.001), shorter operative times (653 vs 1,031minutes; P<.001), and less blood loss (223 vs 398mL; P=.04). Postoperative Eastern Co-operative Oncology Group performance score increased more for the FFF than for the SMIF group (+0.33 vs+1.25; P=.0019). Recipient site complication rates were lower for the FFF group (0.17 vs 0.42 per patient) but were not statistically relevant. There were equal rates of recurrence at the local surgical site and no differences in speech and swallowing function. Mean follow-up was 15.5months. This is the first study to compare the SMIF with the FFF for reconstruction of oral cavity defects based on ablative volume deficit. The SMIF is a viable surgical option compared with the FFF that can be considered oncologically safe in the N0 neck, allowing for an excellent esthetic reconstruction, with decreased operative time, hospital stay, and donor site morbidity.

Recalcitrant Invasive Skin Cancer of the Scalp: Combined Extirpation and Microsurgical Reconstruction Without Cranioplasty.

Recurrent invasive skin cancer of the scalp and calvarium is a difficult problem for which universally accepted treatment protocols have not been established. The authors present their 10-year experience with treatment of this specific subset of scalp reconstruction patients and present a successful treatment algorithm that is well suited to this patient population. The authors retrospectively reviewed all patients of microsurgical scalp reconstruction performed from 2005 to 2015 that involved invasive cutaneous malignancies of the scalp and calvarium. Eleven patients met inclusion criteria. There were 9 squamous cell carcinoma, 1 basal cell carcinoma, and 1 melanoma. Seven received radiation prior to resection, 2 were irradiated postoperatively, and 2 were immunosuppressed. Seven had a history of prior scalp reconstruction. The median scalp defect size was 141 cm. All the patients underwent craniectomy and the median cranial defect size was 71 cm. Cranioplasty was not performed in any patient. There were no intraoperative complications or flap loss. Recipient site complications included hematoma in 1, 1 seroma, 2 cerebral spinal fluid leaks, 3 partial skin graft loss. There was 1 donor site seroma in a patient who had a latissimus dorsi flap. All the patients reported satisfaction with the overall result and none were limited in activities by the existing cranial defect. This is the largest series published to date that focuses exclusively on management of cutaneous malignancies with intracranial invasion. Wide resection with craniectomy, and reconstruction with microvascular free tissue transfer without cranioplasty provides safe and reliable treatment of recalcitrant invasive scalp skin cancers with low morbidity and without major complications. Pre and postoperative radiation is well tolerated with this approach. The patients in this series were of advanced age and of a lifestyle for which cranioplasty is unnecessary for return to regular activities.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient.

Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients. A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described. Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy. The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Tailored approach to oromandibular reconstruction in patients with compromised lower limb vessels.

The purpose of this study was to compare outcomes for segmental reconstruction of the mandible between patients who underwent reconstruction with a fibula flap (group 1), and those with an alternative osseous free flap in which the fibula flap was unsuitable either for defect reasons (group 2) or in which the fibula flap could not safely be harvested because of compromised leg vessels (group 3). One hundred fifty-two patients who underwent osseous free flap reconstruction of a mandibular segmental defect between January 2008 and June 2014 were identified from operating records. Outcomes between groups was compared. The flap success rate was 97% and the late recipient-site complication rate was 19%. There was no difference in flap success or complication rates between groups. Bony reconstruction of the mandible can be achieved with no compromise in flap success even where preoperative vascular studies or the nature of the defect deem the fibula unsuitable. © 2017 Wiley Periodicals, Inc. Head Neck 39: 916-920, 2017.

Comparison of free perforator flaps with local propeller perforator flaps for acute lower extremity reconstructions

Objectives: Adequate coverage of traumatic complex lower extremity wounds is often challenging for reconstructive surgeons. Local perforator flaps have gained wide acceptance as an alternative in soft tissue coverage of complex lower extremity defects over the last decade. Here, we report our experience with distal lower extremity reconstructions performed either with free or local perforator flaps. In the literature, no studies have been conducted that directly compare free flaps to propeller flaps; our aim here was to compare non-microvascular microsurgical flaps with free flaps for coverage of traumatic lower extremity wounds. Methods: 28 patients operated on for lower extremity defects and reconstructed either with free or local perforator flaps between February 2011 to June 2015 were included in the study. Age, gender, defect sizes, etiologies, and operation times were reviewed. Postoperative recipient and donor site complications, hospital stay, and additional surgical procedures were also analyzed. Results: There were 24 male and four female patients. Mean age was 43.11 years (range: 30 to 65 years) in the free perforator flap group and mean age was 44 years (range: 30 to 70 years) in the local perforator flap group. Hospital stay and overall operation time was significantly higher in the free flap group. There was no statistically significant difference in complication rates between either group. Conclusions: Concerning many advantages, like decreased operative time, avoiding micro anastomosis, and reconstruction with like tissues, we suggest that propeller perforator flaps can be the first-line reconstructive choice. These flaps can be used successfully by reconstructive surgeons in small clinics and they may prevent unnecessary tertiary medical center referrals as well as extended hospitalizations, long operation times, and increased costs.

Vertically Set Sombrero-shaped Abdominal Flap for Asian Breast Reconstruction after Skin-sparing Mastectomy.

Immediate autologous breast reconstruction after skin-sparing mastectomy is an esthetically superior method, and a free abdominal flap is often used. However, in Asian patients, little redundant abdominal skin and thin subcutaneous tissue are common, necessitating the development of a more suitable flap design and setting. We devised a narrow flap, the sombrero-shaped flap (S-flap), set vertically, to reduce postoperative abdominal morbidity without sacrificing cosmetic results. To assess this new flap design and setting, the recipient- and donor-site complications of consecutive patients treated by S-flap (n = 40) and conventional flap (C-flap) (n = 22) were retrospectively investigated. Postoperative abdominal pain, stiffness, and patient activity were also assessed in each group with our original grading scale. Compared with the C-flap group, the S-flap group had a significantly lower skin paddle vertical height (mean, 14.0 and 10.2 cm, respectively; P < 0.001), lower abdominal stiffness (P = 0.023), and higher rate of double-pedicled flap use (27.3% and 52.5%, respectively; P < 0.048). The rates of donor and recipient site complications, postoperative abdominal pain, and activity did not significantly differ between the groups. For immediate breast reconstruction after skin-sparing mastectomy in Asian patients, our newly designed S-flap and vertical flap setting achieved cosmetically good, consistent results with low abdominal morbidity, even though the abdominal flap was thin and narrow. The viability of the S-flap, including medial fan-shaped adipose flap, was reliable, even though the flap often required elevation with double pedicles.

Free flap surgery in the elderly: Experience with 110 cases aged ≥70 years

We report our experience with free tissue transfer in the elderly based on a retrospective review of patients aged ≥70 years who underwent surgery during a 7-year period. A total of 110 free tissue transfers in 104 patients, with a mean age of 78 years (range: 70-92 years), were identified for inclusion. The demographic and operative variables and postoperative medical and surgical complications were analyzed. Sixty-four of the 110 procedures encountered at least one complication. Medical complications were observed in 25 cases and were predominantly pulmonary, whereas surgical complications occurred in 54 cases in addition to one perioperative death. Successful free tissue transfer was achieved in 105 of the 110 flaps. There was no statistically significant difference in the rate of postoperative complications between patients aged 70-79 years and those aged ≥80 years. Anesthetic time was a statistically significant predictor of postoperative medical complications (odds ratio 1.345, 95% confidence interval 1.117-1.663, P=0.001). Preoperative comorbidity status, graded according to the ACE-27 index, was a statistically significant predictor of flap recipient site complications. Free tissue transfer may be performed in aging patients with a high degree of technical success and low operative mortality. Chronological age alone should not be used as a criterion when evaluating a patient for free tissue transfer. The patient's premorbid status should be carefully assessed. To minimize postoperative medical complications, duration of general anesthesia should be kept to a minimum.

A Case Series of Complex Recalcitrant Wounds Treated with Epidermal Grafts Harvested from an Automated Device.

Introduction: Epidermal grafting has several advantages over full-thickness or split-thickness grafts in the treatment of complex non-healing wounds. These include the low risk of donor site complications, minimal patient discomfort, and abstention from the operating room. Traditionally, the lack of reliable epidermal harvesting techniques has limited its clinical utilization. The development of an automated suction blister epidermal graft (SBEG) harvesting device may facilitate clinical utilization of this technique. The authors present a case series of multimorbid patients who were poor surgical candidates and were treated with this technique.Methods: A retrospective review of all patients treated with CelluTome™​ Epidermal Harvesting System (KCI, an Acelity company, San Antonio, TX) prior to May 2016 at our institution was conducted.Results: A total of 12 patients underwent 14 epidermal grafting procedures. Multiple comorbidities were identified, including smoking (33%), immunosuppression by immunotherapy or steroids (25%), chronic venous insufficiency (25%), diabetes mellitus (25%), malignancy (25%), polysubstance abuse (17%), HIV/AIDS (17%), and peripheral artery disease (8%). Among the two acute wounds (≤ 3 months) and 10 chronic wounds, the average wound size was 49.1 cm2 (± 77.6 cm2) and the median wound duration was 5.7 months (interquartile range: 4.1 - 15.8 months) before SBEG was attempted. These complex wounds had failed prior therapies, such as local wound care (100%), incision and drainage (58%), vacuum-assisted closure (33%), split-thickness skin graft (16%), and hyperbaric oxygen (8%). Following the procedure, all donor sites healed within one week. Three patients were lost to follow-up. Of the remaining nine patients, four patients had complete resolution of their wounds at a median follow-up of 13.1 weeks (interquartile range: 6.8-17.3 weeks). Among those with partial resolutions, the average wound size was 4.2 cm2 (± 2.1 cm2) with an average wound reduction of 79% (± 23%). No donor or recipient site complications were observed.Conclusions: The automated SBEG harvesting device is an effective and safe option for treating complex non-healing wounds in multimorbid patients who may be poor surgical candidates. This procedure demonstrates minimal contraindications to its use and donor or recipient site complications.

Functional outcome after one-stage flap reconstruction of the hypopharynx following tumor ablation

The main objective of this study was to evaluate functional outcome in terms of food passage of the three different reconstruction techniques that are currently most often used for hypopharyngeal reconstruction in our institution. A retrospective observational database research was conducted of all patients that underwent hypopharyngeal reconstruction for carcinoma of the hypopharynx or larynx from 1992 until 2014 in the University Medical Center Groningen. The following techniques were most commonly used and therefore analyzed: the pedicled pectoralis major flap, the radial forearm free flap and the anterolateral thigh free flap. Our primary outcome food passage was measured after 1 year and classified in gastric tube fed, fluids, semisolid or solid. Complications were registered according to the Clavien Dindo classification in five different grades. Comorbidity was scored using the Adult Comorbidity Evaluation Index. 58 patients were included. 51 patients survived one year follow up, 25 % returned to a solid diet, 40 % returned to a semi-solid diet and 20 % remained feeding tube dependent. Overall flap success rate was 88 and 35 % developed a pharyngocutaneous fistula. Multivariable ordinal regression showed that reconstruction with free flaps, a near-circumferential surgical defect, a higher body mass index and no comorbidity showed significantly better functional outcomes in the food passage. For recipient site complications, both free flaps and a shorter surgery time resulted in less severe complications. This study shows that the use of free flaps is superior to the use of the pectoralis major flap, and that it should therefore be reserved as a second choice.

Palato-maxillary reconstruction by the angular branch-based tip of scapula free flap.

The angular branch (AB)-based tip of scapula free flap is a valuable reconstructive option in palato-maxillary defects needing significant structural support. We herein retrospectively evaluate our surgical series with special focus on functional outcomes and postoperative morbidity. Ninety-seven consecutive palatomaxillary oncologic resections were performed at our institution between August 2008 and November 2015. The analysis focused on those reconstructed by an AB-based tip of scapula free flap (N=18; 19%). A prospective assessment of donor site morbidity was performed by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in 12 (67%) patients. Among patients reconstructed by an AB-based tip of scapula free flap, 13 (72%) had a Class II and 5 (28%) a Class III defect according to Okay classification. Flap success rate was 94%, with one failure requiring an anterolateral thigh flap. Eight (44%) patients experienced recipient site complications, while donor site problems occurred in two only (11%). Eleven (61%) subjects were able to maintain a normal and 7 (39%) a soft-to-firm diet. The mean DASH score was 10.5. Our results confirm that the AB-based tip of scapula free flap is a reliable choice in palatomaxillary reconstruction, with both satisfactory functional outcomes and negligible donor site morbidity.

Fat Grafting with Tissue Liquefaction Technology as an Adjunct to Breast Reconstruction.

BackgroundTissue liquefaction technology (TLT) delivers warmed saline from the liposuction cannula tip at low pressure pulses to disaggregate adipocytes. This technology differs significantly from that used in other liposuction devices including water jet-assisted liposuction. Here we introduce our early experience with this technology in the setting of fat transfer for revision breast reconstruction.MethodsA retrospective chart review of 136 consecutive patients who underwent fat harvest with TLT and subsequent transfer into 237 breast reconstructions was conducted at a single institution. This two-surgeon series examined donor and recipient site complication rates over a median follow-up of 143 days [87–233].ResultsThe overall complication rate was 28.7 %, of which the majority (22.1 %) was fat necrosis at the recipient site as documented by any clinical, imaging, or pathologic evidence. The abdomen served as the donor site for half of the cases. Donor site complications were limited to widespread ecchymosis of the donor site notable in 10.4 % of cases. Twenty-five percent of patients had received postmastectomy radiotherapy prior to fat transfer. Prior to revision with fat transfer, implant-based breast reconstruction was used in 75.5 % of cases, and autologous flaps in the remainder. Fat transfer was combined with other reconstructive procedures 94.1 % of the time.ConclusionsTLT can be used to harvest adipocytes for fat transfer with donor site morbidity and recipient site complications comparable to other modalities. The efficiency and quality of harvested fat makes this technology appealing for wide spread adoption during fat transfer.Level of Evidence IVThis journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Gracilis Flap Reconstruction of the Perineum: An Outcomes Analysis

Immediate reconstruction of perineal defects secondary to abdominoperineal resection (APR) or pelvic exenteration with pedicled flaps decreases postoperative wound complications when compared with direct closure in high-risk patients. Although some authors have been proponents of abdominal-based flaps, here we evaluate the role for thigh-based flaps founded on acceptable outcomes and low morbidity. Consecutive patients referred to a single surgeon between January 2012 and August 2015 who underwent perineal reconstruction with a pedicled gracilis flap were identified. Patients were evaluated for routine preoperative variables and outcomes data were analyzed, including time to healing and abdominal and perineal complications. Forty patients were included in the study, with a mean follow-up period of 2 years. There were no 30-day mortalities and 37 patients (92.5%) were alive at the last follow-up. Five patients (12.5%) experienced donor site complications and 16 patients (40%) had recipient site complications, including hematoma, seroma, or dehiscence. Minor complications were seen in 10 (25%) patients, and 7 (17.5%) patients had major complications. Obesity (odds ratio= 7.5; p= 0.01) and active smoking status (odds ratio= 9.3; p= 0.01) were significantly associated with minor complications, and a history of neoadjuvant chemoradiation (odds ratio= 21.4; p= 0.04) was a significant risk factor for any complication. The overall complication rate with this technique is comparable with the more commonly used vertical rectus abdominis myocutaneous flap, but the potential for, and severity of, donor site complications is reduced with this technique. As such, gracilis flaps can be considered an acceptable alternative to abdominal flaps for selected perineal wounds.

Reconstruction following abdominoperineal resection (APR): Indications and complications from a single institution experience

Abdominoperineal resection (APR) is the surgical treatment of low-lying rectal cancers and other pelvic malignancies. Plastic surgery offers a means to close these complicated defects through obliterating dead space, providing tension-free closure, and introducing vascularized tissue into a radiated field. The indications for reconstructive surgery and choice of reconstruction are debatable. This study aims to identify when and which reconstruction is preferred. A retrospective comparative analysis was performed on all patients undergoing APR at Stanford Hospital between 2007 and 2013. Data points included demographics, disease, operative positioning, and postoperative complications. Univariate analysis and multivariate logistic regression analysis were performed to identify markers of flap reconstruction and complications. A total of 178 APRs were performed, of which 51 underwent flap reconstruction. The odds ratio of all complications between flap and primary closure was not significant at 1.36 (0.69-2.66). Independent predictors for flap reconstruction included prone positioning, anal squamous cell carcinoma (SCC), prior smoking, and neoadjuvant chemoradiation therapy. Univariate predictors of flap reconstruction included female gender and combined vaginectomy. Independent predictors of complications included current and prior smoking. Muscle flap closure had lower recipient site complications than V-to-Y advancement closure (20% vs. 50%, p=0.039). Flap reconstruction following APR is associated with prone positioning, neoadjuvant chemoradiation, female gender, prior smoking, and anal SCC resections. Pedicled muscle flaps had a significantly lower rate of recipient site complications than V-to-Y advancement flaps and therefore should be the flap reconstruction of choice. The vertical rectus abdominis myocutaneous flap was superior to the gracilis flap in terms of the overall reduction of complications.