Flap Reconstruction Research Articles

Snail Flap for Scalp Reconstruction: Technique and Outcomes.

Local flaps are widely described for scalp reconstruction, but there is minimal literature surrounding the snail flap. The objective of this study was to describe the surgical technique and outcomes of scalp reconstruction with the snail flap. This case series retrospectively evaluated all consecutive patients undergoing scalp snail flap reconstruction from January 1, 2019 to February 1, 2024. The primary outcome measure was incidence and extent of complications. Demographic and intra-operative variables were assessed. A total of 44 patients were included with a median age (range) of 74 years (27-88) with scalp defects ranging in size from 3 x 3 cm to 8 x 8 cm (median defect size 5 cm). The mean (SD) flap base-to-defect ratio was 1.82 (0.31). Forty (91%) of the cases were performed outpatient or with overnight observation only. Complications included 9 (20%) wound infections, 12 (27%) patients with necrosis (all minimal), and 2 (5%) patients with hematoma, which were all managed outpatient. The flap survival rate was 100%. The snail flap is easy to perform with high reliability and allows for hair preservation. The morbidity and need for hospitalization are minimal, making it an ideal reconstructive option for elderly or frail patients with moderate-sized scalp defects.

Simultaneous Symmetrizing Surgery on the Contralateral Breast in Unilateral Autologous Breast Reconstruction is Cost-Effective.

BACKGROUND Simultaneous symmetrizing surgery at the time of unilateral free flap reconstruction has been described as a method to facilitate single stage breast reconstruction. However, the impact on cost and number of additional procedures is not well described. METHODS Patients with unilateral free flap reconstruction were identified in national administrative data from 2017-2021 and followed for one year. Patients were stratified by immediate and delayed reconstruction, then further stratified into groups with simultaneous symmetrizing surgery and without simultaneous symmetrizing surgery. Thirty-day complications included transfusion, wound dehiscence, surgical site infection, hematoma/seroma and thromboembolism. Costs of initial hospitalization and subsequent surgeries were determined. Deferred symmetrizing surgeries within one year were identified. Chi-squared and Fisher exact tests, and Wilcoxon tests were used for statistical analysis. RESULTS A total of 1136 patients were identified. 638 were delayed reconstructions: 75 with simultaneous symmetrizing surgery and 563 without. There were no significant differences in patient characteristics or 30-day complications. Within one year of index reconstruction, fewer patients with simultaneous symmetrizing surgery underwent a revision surgery (29% vs 51%, (p=0.001)) or at least one additional procedure (36% vs 57%, p<0.001). Patients with simultaneous symmetrizing surgery had lower total costs ($35,897 vs $50,521, p=0.005). There were 498 immediate reconstructions: 63 with simultaneous symmetrizing surgery and 435 without. There were no significant differences in patient characteristics, 30-day complications, subsequent surgeries or total costs. CONCLUSION Symmetrizing procedures at the time of unilateral reconstruction may decrease cost and number of subsequent surgeries without increasing complications.

Functional outcome of limb sparing surgery of shoulder girdle tumors after free vascularized fibular flap.

Objective: To share the functional outcome of free vascularized fibular flap for shoulder reconstruction using Toronto Extremity Salvage Score (TESS). Study Design: Descriptive Cross-sectional study. Setting: Burns and Plastic Surgery Center, Peshawar. Period: January 2019 to December 2023. Methods: All the patients presented with biopsy proven sarcoma involving proximal humerus were included in this study. Informed consent for data collection was obtained. Patient data regarding demographics, tumor location, extent of lesion, reconstruction and complications was collected from patient records. Six month follow up was done to assess functional recovery of the patient. Toronto Extremity Salvage Score (TESS) was used 6 months post-operatively to assess recovery of the patient using TESS questionnaire. Patient data was analyzed in using an open source software, GNU PSPP version 2.0.0. Results: A total of 11 patients were included in this study. Mean age of the patients was 15±3.5 years. Eight patients (72.7%) were male while 3 (27.3%) were female. Two patients has post-operative bleeding and 1 patient had fracture of fibula. Average TESS score was 61±7.71 years. Eight patients (72.7%) reported a good TESS score while 4 (27.3%) patients scored poor on TESSS Questionnire. Conclusion: Reconstruction of shoulder in sarcoma patients is a complex problem. Both prosthetic and biological reconstructive options present their own set of issues. In our experience, the use of free vascularized fibular flap (FVFF) presents a much better option with lower rate of infection and on average good Toronto Extremity Salvage Score (TESS) Scores.

Outpatient surgical management of head and neck keratinocyte cancers in a regional centre: an updated analysis of costs and outcomes.

Australia has the highest global incidence of keratinocyte cancer. Surgically managing keratinocyte cancers in regional Australia presents geographic and economic challenges, which necessitate cost-effective resource allocation. Previous work has outlined the cost benefit for outpatient day surgical excision of head and neck skin lesions that can be closed primarily. We expand on this analysis with the inclusion of graft and local flap reconstructions. A retrospective analysis was completed in a single regional centre across 24 months from July 2022 to June 2024. Patient demographics, lesion characteristics, margin status, cost comparison, and complication rates were recorded. There were 256 excisions for proven or suspected keratinocyte cancers. Basal cell carcinomas comprised 73.1% of lesions, squamous cell carcinoma for 21.9% of lesions, and intra-epidermal carcinoma for 5.1%. Lesion defects were closed primarily in 63.8% while 23.0% underwent full thickness graft reconstruction and 13.2% required local flaps. Involved margins were reported in 8.1% of excisions. Follow-up wound review was undertaken in primary care for 26.1% of all lesion excisions. Average indicative costs were three-to-four times higher for procedures performed in theatre compared to the outpatient setting, and these savings were greatest for graft and local flap reconstructions. There were 20 recorded complications including 16 partial or complete graft failures and one partial flap failure. This study demonstrates further cost effectiveness for graft and local flap reconstruction of head and neck skin excisions under local anaesthetic in the regional outpatient setting, while maintaining low complication and incomplete excision rates.

Intraoperative circulation predict prolonged length of stay after head and neck free flap reconstruction: a retrospective study based on machine learning

Intraoperative circulation predict prolonged length of stay after head and neck free flap reconstruction: a retrospective study based on machine learning

Feasibility and Safety of Pectoralis Major Myocutaneous (PMMC) Flap for Complex Scalp Defect Reconstruction

Feasibility and Safety of Pectoralis Major Myocutaneous (PMMC) Flap for Complex Scalp Defect Reconstruction

Local flap guidance for scalp reconstruction following Mohs micrographic surgery.

Keratinocyte carcinomas (KCs) are commonly located on the scalp and often treated with excision with peripheral and deep en face margin assessment (PDEMA), with Mohs micrographic surgery (MMS) being the most frequently used method. Resection of these malignancies results in wounds with a wide variety of sizes, ranging from small, sub-centimeter defects, to extensive, nearly complete scalp defects. MMS is often the preferred treatment for tumor resection and margin clearance, as it allows for maximal healthy tissue preservation and has the lowest recurrence rates. Multiple local flap reconstruction options exist, and the selection depends on the size and location of the defect. This review highlights the indications, typical locations, potential risks, and advantages of frequently used local flaps on the scalp, accompanied by artistic representations of each flap herein. An exhaustive list of the local scalp flaps discussed in this review includes single, bilateral, and triple rotation flaps, the pinwheel flap, the double hatchet flap, the triple rhomboid flap, both the unilateral and bilateral banner flaps with split thickness skin grafts, A to T flaps, H-plasty flaps, single and double bridge flaps, and the pacman flap. Inelasticity of the scalp inhibits tissue movement so flaps on the scalp must be designed to be much larger than flaps in most other facial locations. One of the greatest benefits of working with local flaps on the scalp is often the presence of hair-bearing skin which provides the reconstructive surgeon the ability to hide significant scars under hair-bearing scalp, and the ability to perform wound repair under local anesthetic immediately following tumor removal by MMS.

Single-Double-Single Barrel (1-2-1) Fibula Free Flap Design for Functional and Esthetic Brown Class III Mandibular Reconstruction.

This novel hybrid single-double-single barrel (1-2-1) design for fibula free flap reconstruction addresses the unique challenges presented by Brown Class III mandibular defects, which involve long-span defects at both bodies of the mandible and the chin. The importance of this design lies in its ability to overcome the limitations of traditional approaches in terms of mandible height and pedicle length, while optimizing both functional and esthetic outcomes.The technique utilizes a combination of single-double-single barrel fibula segments to achieve ideal esthetics and support for dental prosthesis across different areas of the mandible. At the chin, a double barrel design provides proper chin and lower lip projection and supports dental prosthesis at the alveolus, while single barrel segments are used for the mandibular bodies to allow adequate restorative space for dental rehabilitation and save the pedicle length.Favorable outcomes were demonstrated in terms of flap survival, dental implant osseointegration, bony healing, facial aesthetics, and occlusal rehabilitation. By addressing both functional and aesthetic requirements, this technique represents an important advancement in mandibular reconstruction for complex Brown Class III defects. The approach showcases the potential of computer-assisted surgery and innovative flap designs to improve patient outcomes in challenging reconstructive scenarios.

Effects of adjuvant hyperbaric oxygen therapy and real-time fluorescent imaging on deep sternal wound infection: a retrospective study.

Deep sternal wound infection (DSWI) is a rare but devastating complication that is estimated to occur in 1-2% of patients after median sternotomy. Current standard of care (SoC) comprises antibiotics, debridement and negative pressure wound therapy (NPWT). Hyperbaric oxygen therapy (HBOT) appears to be an effective adjuvant therapy for osteomyelitis. The aim of this study was to determine the effectiveness of HBOT and real-time fluorescence imaging (RTFI) in a DSWI treatment protocol and their benefits on infection control. A retrospective analysis of DSWI management was performed. Enrolled patients were divided into two groups: HBOT group and RTFI group. Patients in the HBOT group received SoC, HBOT, NPWT and reconstructive flap surgery. Patients in the RTFI group received the same therapeutic plan as well as treatment with a RTFI device (MolecuLight i:X (MolecuLight, Inc., Canada) to achieve high-quality debridement. Infection status and short-term outcomes within three months were measured. Long-term outcomes were analysed at a 12-month follow-up. Of the 55 patients enrolled: 22 in the HBOT group and 33 in the RTFI group. Infection control status, evaluated in terms of white blood cell counts and C-reactive protein levels, antibiotic use duration, antibiotic costs, reinfection rate and osteomyelitis recurrence rate, were statistically significantly improved in the RTFI group (<0.001, <0.001, 0.042, 0.022, 0.049 and 0.022, respectively). Length of total intensive care unit stay and duration of complete healing were statistically significantly decreased in the RTFI group (<0.001 and 0.046, respectively). Patients with DSWI can benefit from HBOT, especially in terms of in-hospital mortality. RTFI can be used to eliminate bacterial burden and achieve high-quality debridement, which considerably improves infection control and clinical outcomes.

Angle-Adjusted Transverse Thoracodorsal Artery Perforator Flap in Lower Extremity Reconstruction: A Case Series of 63 Patients.

The thoracodorsal artery perforator (TDAP) flap is a viable option for reconstructing various soft tissue defects. Despite its numerous benefits, including reduced donor site morbidity, the TDAP flap has not gained popularity because of its anatomical variations and technical challenges. Herein, we aimed to introduce the application of the angle-adjusted transverse TDAP flap in lower extremity reconstruction and provide novel perspectives, with emphasis of outcomes. We retrospectively analyzed data from patients who underwent lower extremity reconstruction using a novel, modified transverse-TDAP flap at a single center between 2015 and 2019. This modification introduced a more transverse pattern with an innovative angle adjustment of approximately 30°-60°, specifically designed to optimize coverage and adaptability to various defects and aimed to prevent irritation at the posterior aspect of the scar, which could otherwise lead to pain during rehabilitation-addressing a common challenge in traditional TDAP flap designs. We conducted a comprehensive assessment of the TDAP flap, including patient characteristics, surgical details, long-term outcomes, functional evaluation of donor site using the American Shoulder and Elbow Surgeons (ASES) Score, and postoperative complications. Sixty-three consecutive patients who underwent TDAP free flap reconstruction were included. Mean follow-up duration was 54.3 months; most common etiology was trauma (25 cases; 39.7%), followed by diabetes (16 cases; 28.6%). Twenty-six cases (41.3%) involved lesions in the foot, and 11 (17.5%) involved lesions in the distal tibia. Complications included total flap loss in five patients and donor site complications in one patient. As assessed using the ASES, the average functional score of the donor site was 97.8 points. The modified transverse-TDAP flap provides favorable outcomes with minimal donor site morbidity, making it a viable alternative in clinical practice. Its design ensures effective coverage with reduced complications, establishing it as a reliable choice for lower extremity reconstruction.

Systematic review of free jejunal flap for secondary esophageal reconstruction.

Esophagus reconstruction could be complicated by leakage, stenosis or graft loss. Salvage surgery may be needed in case of failure of endoscopic treatment or large esophagus defect. Although free jejunal flap is admitted for salvage head and neck reconstruction, few reports assess the results of free jejunal interposition in salvage esophagus reconstruction. We undertook a systematic review whose primary aim is to investigate outcomes of secondary esophageal reconstruction with free jejunal flap in terms of mortality, complications and functional results. We conducted a systematic review of the literature according to the PRISMA 2020 statements searching PubMed and Scopus databases for articles assessing free jejunal flap for secondary reconstruction after failed esophagus reconstruction. References of included studies were also screened. Studies quality was assessed using the JBI Critical Appraisal tools. 562 studies were yielded through databases search and 328 studies were yielded through citations search. 18 articles were included in the systematic review corresponding to a total of 62 patients from 3 to 76 years old. All studies were level of evidence IV case reports or case series. We found that overall mortality was 3.2%, anastomotic fistula rate was 21%, anastomotic stricture rate was 4.8% and graft loss rate was 9.7% with survival of all jejunal regrafts. Solid oral intake was achieved in 93.0% of cases. Jejunal free flap is a pertinent option for secondary esophageal reconstruction but remains a challenging surgery with high risk of complications that requires multidisciplinary team in large volume/tertiary care hospitals.

Risks of Autologous Abdominal Free Flap Breast Reconstruction in Patients With Elevated Body Mass Index.

Obesity is widely recognized as a significant risk factor for postoperative complications of breast reconstruction. Despite extensive research, there remains a lack of consensus regarding the specific complications and outcomes experienced by patients with obesity who undergo deep inferior epigastric perforator (DIEP) flap reconstruction. To provide a clearer understanding of the challenges faced by patients with obesity, we present a single-center outcome analysis of individuals who underwent DIEP flap reconstruction. A cohort of 194 patients who underwent at least 1 DIEP flap was retrospectively analyzed at the University of Nebraska Medical Center utilizing electronic medical records. Patients who underwent DIEP flap breast reconstruction were organized into 5 categories using World Health Organization weight status by body mass index (BMI) obtained from the day of surgery. Surgical complications within 120 days and postsurgical complication-related procedural interventions were also evaluated and compared. Comparisons of variables of interest between weight groups were assessed using Mantel-Haenszel chi-square tests or Spearman correlations. Increases in patient weight category were associated with increased length of operation (P = 0.003), increased rates of breast fat necrosis (P = 0.04), breast wound dehiscence (P = 0.01), abdominal wound dehiscence (P = 0.02), numbers of abdominal complications (P = 0.001), and rates of requiring an intervention (P = 0.03). The findings imply that higher BMI values may lead to a higher likelihood of postoperative complications and the need for intervention. It is crucial for patients with obesity to be aware of the elevated risk associated with rising BMI values.

Versatility of the Anterolateral Thigh Flap for Abdominal Wall Reconstruction.

Abdominal wall reconstruction represents an ambitious and demanding challenge. This study aimed to illustrate the versatility of the anterolateral thigh (ALT) flap in its different designs for the reconstruction of complex defects of the abdominal wall. Charts of patients with complex abdominal wall defects who underwent a reconstruction with an ALT flap at the University Hospital of Zurich (2018-2020) were reviewed retrospectively. Patient characteristics and ALT flaps used were analyzed in detail. Ten patients received a total of 12 ALT flaps. Free flaps were applied to defects in the upper third of the abdomen. All flaps were harvested with a fascial component. An iliotibial tract reinforcement was incorporated in 4 (33%) cases, and 1 case included a muscular component and motor nerve, to provide functional reconstructive potential. A total of 30% of cases experienced complications requiring surgical revision during a mean follow-up of 5 months. The ALT flap represents a workhorse in abdominal wall reconstruction due to its versatility and anatomical proximity. Depending on the localization of the defect, this flap can be used in a pedicled or free microsurgical manner. The fascial component of the ALT fasciocutaneous flap and of the extended iliotibial tract provides stable fascia for reinforcement or fascial reconstruction of the abdominal wall. Raised as a chimeric flap with vastus lateralis muscle and motor branch of the femoral nerve, it is a viable option for functional reconstructions.

Revisit to Old Friends: Abdominal and Groin Flaps For Upper Extremity Soft Tissue Reconstruction

Revisit to Old Friends: Abdominal and Groin Flaps For Upper Extremity Soft Tissue Reconstruction

Oncological outcomes of the facial artery musculomucosal flap for oral cavity reconstruction.

Facial artery musculomucosal (FAMM) flaps are used for reconstruction of oral cavity squamous cell carcinoma (OCSCC). This study evaluates the oncologic safety of the FAMM flaps for OCSCC reconstruction, given the need to preserve the facial artery and vein during elective neck dissection. Retrospective single surgeon case series of all patients undergoing FAMM flap reconstruction for OCSCC from 2016 through 2023. Case analysis included tumor location, classification and staging, surgical details, and post-operative outcomes including locoregional and overall disease control. Twenty-one patients underwent FAMM reconstruction after resection for OCSCC. Age ranged from 40 to 85years old (mean 61), 15 (71%) were male. Sixteen (76%) patients underwent neck dissection. Follow-up ranged from 0 to 81months (mean 28). One patient (5%) recurred in ipsilateral neck level IV, one (5%) had a second primary tumor, and three patients (14%) developed distant metastases. FAMM flap represents a safe and reliable option for reconstruction after OCSCC. In our series there was no significant increased risk of locoregional recurrence.

Pectoralis Major Myocutaneous Flap For Reconstruction Of Major Neck Defects Following Surgery For Head And Neck Tumors. A 5-Years Multicenter Experience

Pectoralis Major Myocutaneous Flap For Reconstruction Of Major Neck Defects Following Surgery For Head And Neck Tumors. A 5-Years Multicenter Experience

Long-Term Postoperative Donor Site Musculoskeletal Morbidity after Osseous Free Flap Harvest.

Complex ablative maxillary and mandibular defects often require osseous free flap reconstruction. Workhorse options include the fibula, scapula, and osteocutaneous radial forearm flap (OCRFF). The choice of donor site for harvest should be driven not only by reconstructive goals but also by donor site morbidity. The goal of this study is to evaluate the long-term postoperative musculoskeletal morbidity at the donor site after osseous free flap harvest. Cohort study and cross-sectional analysis. A retrospective review of patients who underwent free flap harvest at 1 of the 3 donor sites from 2015 through 2021 was performed. An additional cross-sectional analysis at ≥1 year postoperatively was performed from 2021 to 2022 using validated patient-reported orthopedic surveys: Disabilities of the Arm, Shoulder, and Hand for scapula or OCRFF harvest, and Foot and Ankle Ability Measure for fibula harvest. Single, high-volume tertiary care institution. Among 731 eligible patients, 162 (22.1%) answered the telephone surveys and were included. Functional differences between operated and nonoperated sides were 18.5% (scapula, n = 33), 13.5% (OCRFF, n = 29), and 10% (fibula, n = 98). Postoperative physical therapy (for all donor sites), ipsilateral neck dissection (for scapula and OCRFF), and extent of bony resection (for OCRFF) were not factors associated with long-term morbidity. Acute donor site complications were most common in fibula patients and were associated with worse long-term functional outcomes (7.5% difference; 95% confidence interval, -14.0 to -1; P = .03). There is acceptable long-term musculoskeletal morbidity at the donor site after osseous free flap harvest, and patients should be counseled appropriately.

Impact of technological advancements on short-term outcomes in flap reconstruction after soft tissue sarcoma resection: A retrospective comparative analysis

Abstract Background: Soft tissue sarcomas (STS) are rare malignancies requiring extensive surgical resection, often leading to significant soft tissue defects. Flap reconstruction is crucial for restoring function and appearance. Recent reconstructive microsurgery advancements, including high-resolution indocyanine green (ICG) imaging and ultra-high-frequency ultrasonography (UHFU), have revolutionized preoperative planning and intraoperative guidance. We aimed to compare the surgical procedures and short-term outcomes of patients undergoing immediate flap reconstruction before and after our department’s adoption of these technologies. Methods: We retrospectively analyzed 276 patients who underwent immediate flap reconstruction postsarcoma resection between May 2014 and December 2023. They were categorized into pre and post-technology groups based on the introduction of ICG angiography and UHFU in July 2019. We collected demographic, surgical, and postoperative data and compared outcomes using Fisher’s exact and t-tests. Results: The muscle preservation rate at the donor site was significantly higher in the post-Tech than in the pre-Tech group (no muscle damage: 65% vs. 37%, incision muscle damage: 25% vs. 26%, and muscle resection: 10% vs. 37%; p&lt;0.01). The proportions of complications (21% vs. 36%, p=0.01), flap complications (17% vs. 30%, p=0.01), partial flap loss (5% vs. 17%, p&lt;0.01), and flap dehiscence (9% vs. 25%, p&lt;0.01) were low in the post-Tech group. In the stratified analysis of free-flap reconstruction, the post-Tech group had a shorter operative time (7:01 vs. 8:13, p=0.03) and fewer takebacks due to compromised flap perfusion (4% vs. 15%, p=0.03) compared to the pre-Tech group. Conclusions: The introduction of ICG angiography and UHFU has improved surgical outcomes in STS flap reconstructions. These technologies facilitate precise preoperative planning and intraoperative decision-making, resulting in reduced operative times, low complication rates, and enhanced muscle preservation at the donor site.

A Multidisciplinary Approach to Managing Multiple Tuberous Xanthomas in a Pediatric Patient with Familial Hypercholesterolemia Type II: A Rare Case

Background: Familial hypercholesterolemia (FH) is a rare inherited disorder characterized by high cholesterol levels, primarily high levels of low-density lipoprotein cholesterol (LDL-C). This condition can lead to premature cardiovascular disease. A less recognized but significant manifestation of FH is the development of multiple tuberous xanthomas, which are exogenous masses or fatty deposits on the skin. Case presentation: This report describes the case of a 4-year-old female child who presented to the Dermatology, Venereology, and Aesthetics Department of Dr. M. Djamil General Hospital Padang with multiple yellowish, painless, and non-itchy lumps on her body. These lumps were located on her knuckles, hands, elbows, buttocks, knees, back of knees, ankles, and feet. The lumps had been progressively increasing in size over the past month. Her medical history revealed that she first developed a yellowish lump on her right ankle two years prior, which gradually spread to other areas of her body. A dermoscopic examination showed a yellow-brown structureless area, and laboratory tests confirmed hypercholesterolemia with elevated LDL levels. Her triglycerides were normal, and both of her parents also had hypercholesterolemia. A histopathology examination confirmed the diagnosis of xanthoma. The patient was diagnosed with tuberous xanthomas and treated with simvastatin 1x10 mg, along with surgical excision of the xanthomas and flap reconstruction under general anesthesia. Conclusion: This case highlights the importance of a multidisciplinary approach in managing multiple tuberous xanthomas in a child with FH. While surgical excision can effectively remove the lesions, ongoing lipid-lowering therapy is crucial to prevent recurrence and reduce cardiovascular risks associated with FH. Collaboration among dermatologists, pediatric cardiologists, and pediatric nutritionists is vital to ensure comprehensive care and enhance the patient's overall quality of life.

Submandibular Gland Flap Reconstruction for Oropharyngeal Defects After Transoral Robotic Surgery (TORS)

ABSTRACTBackgroundTo describe utilization and outcomes of submandibular gland flap (SGF) reconstruction after transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC).MethodsA multi‐institutional retrospective case series of patients who underwent TORS for OPSCC followed by SGF reconstruction with harvest via transcervical approach from 1/1/2016 to 4/1/2023.ResultsIn total, 14 patients underwent SGF reconstruction after TORS for OPSCC. All patients had HPV‐positive disease, predominantly in early local (N = 10 with pT1/pT2 disease, 71%) and regional stages (N = 11 with pN0/pN1 disease, 79%). Most patients received adjuvant radiation treatment (N = 9, 64%). Median hospital LOS after surgery was 4 days (IQR 2 days) with median functional oral intake scale (FOIS) score of 5 (IQR 0.8) at 1–3 weeks after surgery.ConclusionsSGF reconstruction is a useful technique for closure of appropriately selected TORS defects requiring reconstruction beyond healing by secondary intention and mobilization of adjacent tissue but not large enough to warrant free flap reconstruction.