Single Free Flap Research Articles

Abstract 143: Comparative Analysis of Single versus Stacked Free Flap Breast Reconstruction: A Single Center Experience

BACKGROUND: As breast reconstructive microsurgeons increase their armamentarium of flaps with experience, need for stacked and multiple flaps may generate an improved aesthetic outcome. We present our institutional experience of using single vs. multiple free flap breast reconstruction. METHODS: 769 flaps were performed on 427 patients from 2010–2016 by two senior surgeons at a university hospital. 197 of those flaps were either: Stacked PAP flaps, 4-flap (Bilateral PAP+Bilateral DIEP flap), or Double-pedicle DIEP/SIEA flaps. 595 flaps were either: unilateral or bilateral DIEP or PAP flap. Demographic, patient co-morbidities, and flap complications were compared between the 2 groups. RESULTS: Out of 427 patients, 322 patients (595 breast reconstructions) underwent single DIEP or PAP flap while 105 patients (197 flaps in 113 breasts) underwent multiple free flaps. The multiple flap patient group had statistically lower BMI, longer procedure time, had smaller flaps, and higher DVT compared to single flap group. There were no statistical differences in the rates of flap loss (1.3% in multiple flaps versus 1.7% in single flap), wound complication, hematoma, and PE. CONCLUSION: Based on our large experience, stacked/multiple flaps are safe and preferred in properly selected patients with low volume from a unilateral donor site, exhibiting similar complications and success rates compared to single-flap patients. The ability to use multiple donor sites may represent a unique phase of innovation in breast microvascular surgery, with high patient tolerance and aesthetically pleasing results geared towards reconstructing breasts in all subunits. We present our indications and approach for successful multiple flap reconstruction. M. Cho: None. A. Hembd: None. C. Venutolo: None. S.S. Teotia: None. N.T. Haddock: None.

Obliquely-arranged double skin paddles: A novel design to reconstruct extensive head and neck defects with a single fibula or peroneal flap.

To reconstruct extensive head and neck defects usually necessitates double free flaps, which require a time-and-manpower-consuming surgical procedure. We present using a single fibula or peroneal flap with the novel design of obliquely-arranged double skin paddles to reconstruct an extensive head and neck defect. From 1998 to 2016, eight patients with the age of 52.25 (35-71) years old had extensive head and neck defects after oral cancer ablation. All of the defects were through and through with the size of 16.25 (12-24) cm × 8.8 (4.5-11) cm. Six of the defects were due to buccal cancer. One was due to tongue cancer, and another one was due to gingiva cancer. All the defects were reconstructed with obliquely-arranged double-paddle free fibula or peroneal flaps. The long axis of the skin paddles was arranged at certain angle (30-45 degrees) to the long axis of lower leg, and the two separate skin paddles were used as the form of island flaps by isolating the cutaneous perforators to create a true chimeric flap. The skin paddle sizes were 14 cm × 3 cm-24 cm × 11 cm and 9.5 cm × 4.5 cm-13 cm × 8 cm. The average length of harvested fibula was 19 (10-30) cm. All of the eight flaps survived without obvious donor site morbidity. One patient had partial skin necrosis over recipient site, requiring surgical debridements and closure. One patient had superficial necrosis over the edge of outer skin paddle, which healed spontaneously. After the follow-up periods of 1 month to 3 year and 8 months, two patients died of sepsis. Six of them could resume soft diet and had no saliva drooling. The remaining two remained nasogastric diet and had saliva drooling. With the design of obliquely-arranged double paddles, we may maximize the harvested skin area of lateral lower leg to reconstruct an extensive head and neck defect with a single free flap.

Complications of double free flap and free flap combined with locoregional flap in head and neck reconstruction: A systematic review.

The purpose of this clinical review was to assess the feasibility of reconstructing complex head and neck defects with 2 or more free flaps simultaneously. A total of 38 articles were reviewed. The patient population included those who received 2 or more free flaps or a single free flap plus a locoregional flap. The primary outcome assessed was rate of complications. Among double flaps, the minor complication rate was 6.96% and the major complication rate was 20.0%. In comparison, the free flap plus locoregional flap group had higher rates of minor and major complications of 30.4% and 29.5%, respectively. The median operating time was 660 minutes for double flaps and 602 minutes for free flap plus locoregional flap (P = .828). Compared to the single free flap plus locoregional flap, double free flaps are relatively reliable without increasing surgical complications or decreasing flap survival, while only modestly increasing operating times.

Simultaneous reconstruction of orbital defect and parotid contour deformity by a single muscle-sparing VRAM flap with double-skin islands

Reconstruction of complex three-dimensional defects or defects in separate locations after ablative head and neck surgery can be achieved with two simultaneous free flaps, a combination of a free flap and a pedicle flap, or a single multi-island free flap. The rectus abdominis flap is often used for reconstructions with a single multi-island free flap, but the flap is excessively bulky in some cases, leading to the unnecessary sacrifice of muscle. To overcome this issue and to preserve the muscle, we used a single muscle-sparing vertical rectus abdominis musculocutaneous flap with two completely separated skin islands based on two different skin perforators to simultaneously reconstruct separate locations (the orbit and parotid region) after orbital exenteration and total parotidectomy. Our findings highlight the feasibility of simultaneously reconstructing orbit and parotid contour deformities with a single double-island flap.

A Modified Approach to Extensive Oromandibular Reconstruction Using Free Fibula Flaps.

In select patients with advanced disease resulting in large composite tissue defects, consideration is often given to multiple flap reconstruction. The authors propose an alternative option. Using virtual surgical planning the authors demonstrate how modest sacrifice in projection translates into a substantial decrease in the volume and surface area of soft tissue needed, in turn maximizing soft tissue coverage with a single fibula free flap. The authors used 3-dimensional virtual surgery to simulate angle-to-angle reconstructions using free fibula flaps. The reference 3-segment reconstruction was done using symphyseal projection to the plane perpendicular to the anterior nasal spine, a customary landmark. Additional simulations were then performed using recessed projections 0.5 mm, 1 cm, 1.5 cm, and 2 cm posterior to anterior nasal spine plane. Program analytics were used to calculate the surface area and volume of the floor of mouth. With projection recessed by 1 cm, surface area decreased 22% to 14 cm. With projection recessed by 2 cm, surface area decreased 44% to 10 cm. With a 3-segment construct converted to a 2-segment construct, surface area decreased 22% to 14 cm. This demonstrates for the first time an official analysis of an intraoperative modification that sacrifices little and gains a lot. Ultimately, 1 compound flap can be used in extensive reconstructions with increased confidence that it will not be overly stressed.

Comparison of Single vs Double Free Flap Breast Reconstruction: 30-Day Outcomes from the American College of Surgeons NSQIP Dataset

Comparison of Single vs Double Free Flap Breast Reconstruction: 30-Day Outcomes from the American College of Surgeons NSQIP Dataset

Synchronous reconstruction of bilateral osteoradionecrosis of the mandible using a single fibular osteocutaneous flap in patients with nasopharyngeal carcinoma.

The reconstruction of bilateral osteoradionecrosis (ORN) of mandibular defects using a single free bone flap is rarely performed because extensively radiated neck tissue with severe fibrosis is usually unsuitable for vascularized reconstruction. Thirty-one patients with nasopharyngeal carcinoma (NPC) underwent bilateral reconstruction of advanced ORN in the mandible using a single fibular osteocutaneous flap. Clinical factors associated with the operation were assessed, including classification of mandible defects, types of recipient vessels, perioperative complications, and postoperative outcomes. All of the fibular osteocutaneous flaps survived completely, with the exception of 1 inner skin paddle that presented partial necrosis in a reconstruction of through-and-through defects. All patients experienced an improvement in cosmetic results 6 months after the reconstruction, whereas 23 patients experienced improved mouth opening compared to the preoperative condition. Advanced bilateral ORN in patients with NPC could be synchronously reconstructed with a single fibular osteocutaneous flap. © 2015 Wiley Periodicals, Inc. Head Neck 38: E-E, 2016.

Feasibility of Using External Jugular Vein and Its Branches as Y- and X-Shaped Vein Grafts for Bridging of Arterial Defects and Providing Additional Arterial Sources for Free Flap Applications in Rat Model

Venous grafting has been widely used in microsurgical training. Different types of vascular grafts have been described in experimental models. In this study we describe for the first time the Y- and X-shaped vein grafts (YVG, XVG) with accompanying drain-out branches as a new tool for the microsurgical training and free flap applications in rats. Twelve adult male Lewis rats were used in this study. The dissections were performed to determine the average diameter and harvestable length of vein grafts in eight rats. In four rats vein grafts were applied for bridging of the common carotid artery gap, whereas the drain-out branches were used as the arterial source for single and bilateral free groin flap applications. The venous anastomoses of groin flaps were performed in end-to-end fashion to the external jugular vein and its branches. The patency of anastomoses was checked 72 hours after repair. The average length of the harvestable vein branches ranged between 5.2 to 11.8 mm. The average surgery time for repair of the arterial gap with the vein grafts was 40 minutes. The ischemia time for single and bilateral groin flap transfer using YVG and XVG was 30 and 70 minutes, respectively. The patency of the interpositional vein graft was 100%. Flap survival rates were 50%. These vein grafts can be used as an alternative technique for reconstruction of tissue defects that require arterial gap repair with single or multiple free flap applications and also as a new microsurgical training model.

Sequential free tissue transfers for simultaneous upper and lower limb salvage

The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free-flap limb salvage cohorts. Seventy-four free flap limb salvage cases were performed over the 10-year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients.

Bilateral condylar reconstruction utilizing a single segmentalized free fibula flap: a case series

Introduction: There are many options for condyle reconstruction using autogenous and alloplastic materials. The use of nonvascularized, vascularized and prosthetic options is well described for unilateral and bilateral condyle reconstruction. The aim of this report is to describe a novel technique using a single segmentalized fibula free-flap for bilateral condyle reconstruction in three patients. To date are no reports detailing the use of a single fibula free flap, segmentalized to reconstruct bilateral mandibular defects.

Total scalp reconstruction with bilateral anterolateral thigh flaps

Large scalp defects can require complicated options for reconstruction, often only achieved with free flaps. In some cases, even a single free flap may not suffice. We review the literature for options in the coverage of all reported large scalp defects, and report a unique case in which total scalp reconstruction was required. In this case, two anterolateral thigh (ALT) flaps were used to resurface a large scalp and defect, covering a total of 743 cm(2). The defect occurred after resection and radiotherapy for desmoplastic melanoma, with several failed skin grafts and local flaps and osteoradionecrosis involving both inner and outer tables of the skull. The reconstruction was achieved as a single-stage reconstruction and involved wide resection of cranium and overlying soft-tissues and reconstruction with calcium phosphate bone graft substitute, titanium mesh, and two large ALT flaps. The reconstruction was successfully achieved, with minor postoperative complications including tip necrosis of one of the flaps and wound breakdown at one of the donor sites. This is the first reported case of two large ALT flaps for scalp resurfacing and may be the largest reported scalp defect to be completely resurfaced by free flaps. The use of bilateral ALT flaps can be a viable option for the reconstruction of large and/or complicated scalp defects.

Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation

PurposeThe purpose of this study was to consider the indications and evaluate the clinical advantages and disadvantages including, results and complications, of immediate reconstruction using a latissimus dorsi (LD) free flap and reconstruction plate (R-plate) in advanced oro-mandibular tumour resection. Methods and materialsOur cohort included 116 patients who underwent LD free flap and R-plate reconstruction. Flap survival, postoperative function, donor/recipient site complication and aesthetics were evaluated. ResultsOur series demonstrated a 99.1% flap survival rate. One case required a contralateral LD free flap reconstruction after the initial flap failed due to pedicle kinking. Twelve patients needed the plate to be removed and replaced (n=4, plate fracture; n=2, plate exposure) or definite reconstruction with free fibular flap and implant installation. Donor site complications included seroma accumulation, scarring, and discomfort of the shoulder girdle. The size of the skin paddle ranged from 6×10cm to 12×18cm (12 were double paddled).The facial contour was acceptable without sagging of the flap. The flap was tolerant to irradiation and was resistant to the exposure of the plate at the symphyseal arch. ConclusionOur series of primary reconstruction with LD free flaps and R-plates showed the retention of mandibular function and the reconstruction of considerably large soft tissue can be achieved successfully. This reconstruction scheme can be indicated for large-volume defects in the oro-mandibular area when the area cannot be covered by a single osteocutaneous free flap, has undergone extensive oncologic resection for advanced or high recurrence rate malignancy and when immediate postoperative chemotherapy and/or irradiation is necessary.

Free Flap Reconstruction of Extensive Defects Following Resection of Large Neurofibromatosis

Neurofibromatosis type 1 (NF-1) is a locally invasive tumor that can grow extensively with diffuse infiltration into surrounding tissue. Resecting a large neurofibroma can result in an extensive defect that is difficult to reconstruct and can cause both aesthetic and functional deformities. From 2000 to 2010, 5 patients with NF-1 underwent radical resection and immediate reconstruction with 6 free flaps at our institution. All patients presented with recurrent tumor, and involved head and neck region in 4 and foot in 1 patient. Ages ranged from 18 to 75 years. The follow-up ranged from 1 to 94 months. Defect sizes ranged from 84 to 252 cm. A single free flap was used in 4 cases and 2 free flaps were used in 1 case. All the flaps survived. Complications included loss of skin graft, necrosis of the distal tip of a flap, and wound dehiscence. All complications were successfully managed with minor surgical procedures. Immediate reconstruction using a free flap after resecting a large neurofibroma is a safe and reliable method that facilitates radical resection of the tumors that are difficult to resect and that may result in an extensive defect.

Two for the price of one: Recycling a free flap

Free flaps are now an established, successful, method of reconstruction for complex soft tissue defects. Improvements in microsurgical techniques, anatomical understanding and instruments have resulted in the evolution of free flap surgery to now encompass synchronous double free flap surgery and "free style" type flaps based on perforators. Although there have been reports of a single free flap split in two to reconstruct a defect at a single site, we report what we believe to be the first case of a single free groin flap used to reconstruct two distant and separate defects sequentially.

Lower extremity soft tissue reconstruction with free flap based on subscapular artery

The purpose of our study was to evaluate the results of the reconstruction of the lower extremity defects with free flaps based on the subscapular artery. Between January, 1998 and December, 2008, 51 patients (mean age 26 years; 16 female and 35 male) presenting with a lower extremity defect underwent a reconstructive surgery with flaps based on the subscapular vascular system. Thirty-seven percent of the defects were located in the crus, 19% in the sole, 16% in the heel, and 14% in the dorsum of the foot. Eighty and a half percent of the patients had traffic-accident-related and 13.5% had burn-related tissue defects. Fifty-three percent of the patients presenting with lower extremity defects underwent reconstruction with latissimus dorsi muscle flaps, 21% with free serratus muscle and/or fascia flaps, 14% with free parascapular fasciocutaneous flaps, and 12% with free combined latissimus muscle and serratus muscle and/or fascia flaps. Anastomoses of 80% of the patients were performed on their posterior tibial artery and accompanying veins and/or foot dorsal veins. End-to-end anastomosis was performed on 14 patients, while 35 patients received end-to-side anastomosis. Six patients were treated with cross free flaps, of which 4 received cross latissimus, 1 cross serratus, and 1 cross combined serratus and latissimus flaps. End-to-side anastomoses were performed on these patients on the cross-leg tibialis posterior artery. The cross-leg anastomosis was freed 4 weeks later. In the early period, venous occlusion was observed in 4 patients and arterial and venous occlusion was present in 1 patient. New anastomoses were performed in these patients. Partial necrosis was observed in 2 patients. The average follow-up period was 61 months. Pressure-related late ulcerative lesions developed in 4 patients. The lesions of these patients were repaired by debridement and primary suturing or partial thickness skin grafts. The subscapular vascular system based flaps have an optimal vascularity once they are prepared with adequate pedicles, causing minimal donor site morbidity. These flaps are a safe and effective alternative in lower extremity reconstruction. On the other hand, in the absence of appropriate recipient vessels, single or combined cross-leg free flaps may provide successful repair.

Reconstruction of lateral through and through oro‐mandibular defects following oncological resections

Resections of oromandibular squamous cell carcinoma involving lateral mandible, oral cavity, and the skin, lead to composite oromandibular defects that can be approached in several ways depending on the extension of the bone defect, of the soft tissue and cutaneous resection, the patient's general status and the prognosis. Purpose of the study is to evaluate retrospectively functional and esthetic outcome obtained with different reconstructive technique employed. A retrospective evaluation of 42 patients has been performed. The study population consisted of 24 males (57.1%) and 18 females (42.9%), ranging in age from 25 to 81 years (mean, 62.6 years). The primary location of the tumor was the mandibular alveolar crest (18 cases), retromolar trigon (9), floor of the mouth (8), cheek (5), and oral commissure (2). For reconstruction a single free flap technique was used eight times; a double free flap technique, seven times; free and locoregional flap association, 25 times; and a single locoregional flap and two associated locoregional flaps, one time each. Postoperative follow-up ranged from 12 to 144 months. Final results were evaluated with regards to deglutition, speech, oral competence, and esthetic outcome. When free bone-containing flaps or two free flaps technique were used, the functional results were better (normal diet, 67%-71%; good oral competence, 100%-71%; good or intelligible speech, 100%-86%). When free and locoregional flap association was chosen, the esthetic results were best (excellent, 76%; acceptable 24%; poor 0%). The worst results were obtained with the use of a single free soft tissue flap and with the use of single or double locoregional flap technique. Bone reconstruction of the lateral mandible is indicated whenever possible. In elderly or poor prognosis patients acceptable results can be achieved with free soft tissue flaps techniques. When the defect involves different structures of the oral cavity, the best results are provided by the association of two free flaps. Finally, the association of free and locoregional flaps is a good option for external coverage reconstruction.

Two for One

It is thought that free muscle flaps may remain dependent on their original pedicle for more than 1-year postoperation, particularly in the lower extremity of patients with peripheral vascular disease. We present the first case report of bilateral lower extremity salvage with a single rectus abdominis myocutaneous free flap by transecting the main pedicle. The pedicle of the free flap, going to the contralateral extremity, was safely divided at 6-weeks postoperation. A tourniquet was used to compress the pedicle at the division point to assess viability of the flap distal to the point of occlusion prior to transection of the flap.

Curious Complication after Oroesophageal Reconstruction with Free Jejunal Flap: Intussusception-like Deformity of Transferred Jejunum

Regions of oropharyngeal cancer, hypopharyngeal cancer, and cervical esophageal cancer in a 70-year-old man were surgically resected and reconstructed with a free jejunal flap. Postoperatively the patient showed severe dysphagia and a chimneylike protrusion in the oral cavity. In a second operation, a dorsal, longitudinal incision for phimosis was made to release the stenosis; however, the dysphagia persisted, and peristalis seemed to interfere with deglutition. Here, we discuss the cause of the dysphagia, a complication of total reconstruction of oroesophageal defects with a single free jejunal flap, and the procedures of reconstruction.

Post-burn upper, mid-face and nose reconstruction using a unilateral extended superficial temporal artery-based flap

Facial burns represent between one-fourth and one-third of all burns [1]. Deformities resulting from a totally burned face present as a profound challenge to the reconstructive plastic surgeon. Burns of the head and neck present a particularlycomplex problem, as they involve critical structures, important functionally and cosmetically; they are usually extensive, involving adjacent tissues, limiting reconstructive possibilities. Whether acute facial burns should be excised and grafted is still controversial [10]. Traditionally, skin grafting has been used for resurfacing but with limited success in case of damage of the deeper facial structures. When possible, loco-regional flaps are themethod of choice. When the burns are extensive, adequate amounts of reliable regional tissue are not available. The use of tissue expanders or expanded full-thickness skin grafts is another alternative [2,11,15]. Free tissue transfers and prelaminated flaps have revolutionized burn reconstruction. Angrigiani et al. reported a novel method for total face reconstruction using the bilateral extended scapular free flaps. The donor site morbidity is, however, relatively high with a large scar extending across the entire back and, moreover the nose needs separate reconstruction [3]. Fujiwara et al. [3] used a single large free flap resulting from expansion of the back skin for reconstruction of the entire face including the nose. However, free flaps

The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps

Neck contractures after burn produce restrictions in motion and unacceptable aesthetic outcomes. Proper planning and tissue selection is essential to minimize donor site morbidity while optimizing outcomes. A classification system and treatment algorithm aids in achieving this goal. Between December 1999 and January 2003, 40 burn patients underwent release and reconstruction with free perforator flaps. Neck extensibility and zone of injury were evaluated. Choice of reconstruction was based on available tissue, restriction degree and zones involved. Cervical territories were classified according to movement restrictions and amount of improvement. Reconstructive territories were classified as central above (CA), central below (CB), central above and below (CAB) and lateral (L). Single, split, double and preexpanded free flaps were used for the reconstructions. Maximal gain in motion was noted at 4 weeks and maintained for the average 11 months follow-up. Types of reconstructive territories showed significant effects on range of motion while etiology and time between injury and reconstruction showed no impact on the functional outcome. Classification of neck territories aids in improving outcomes while minimizing donor morbidity. The central above territory, when reconstructed with free flaps, yielded the most rewarding improvement. A classification and treatment algorithm aids in achieving significant improvements in range of neck motion while taking into consideration the donor sites.