Flap Success Research Articles

EFFECTIVENESS OF POSTERIOR INTRAOSSEOUS ARTERY FLAP IN COVERAGE OF DORSAL HAND DEFECTS

Background: Hand injuries are a challenging issue, frequently encountered by orthopedic and plastic surgeons. These injuries often involve soft tissue defects that expose muscles, tendons, bones, and neurovascular structures. Prompt coverage of these defects is crucial to prevent infection and necrosis of the exposed tissues. Objective: To determine the effectiveness of the posterior intraosseous artery flap in coverage of dorsal hand defects. Methodology: This descriptive study was carried out at the Burns and Plastic Surgery Unit of Lady Reading Hospital Peshawar, from November 2022 to August 2024 after ethical approval. The sample size was determined to be 75 patients (95% CI, success rate 83.3%)8. The study included patients aged 18-60 years of either gender who presented with dorsal hand defects. Patients were followed up for up to a minimum of 6 months. Data was collected in Proforma and analyzed using SPSS 22. Results: The mean age was 39.13±12.06 years. The male-to-female ratio was 2.1:1. The average duration since trauma was 3.03±1.23 hours. The right hand was most frequently affected (61.3%). The most common mechanism was crush injury (38.7%), followed by degloving (26.7%). The overall flap success rate was 81.3% (Two-tailed p value 0.70 ± 0.045) indicating no significant difference between the observed flap success rate of 81.3% and the expected rate of 83%.8 Conclusion: The posterior interosseous artery flap is beneficial for covering dorsal hand defects due to its single-stage procedure and the ability to provide pliable coverage without the need to sacrifice any major vessels.

Preparation of anterolateral thigh flap from polio-affected lower limb: A safe surgical option that preserves patient's motor function.

The anterolateral thigh (ALT) flap is a commonly used donor site for reconstructive surger, especially in head and neck reconstructions. The flap's success is primarily determined by the quality and quantity of its perforating vessels, which is why clinicians typically prefer harvesting from a healthy leg with intact vascular anatomy. Poliomyelitis typically causes unilateral lower limb paralysis, resulting in muscle atrophy and deformities. Harvesting the ALT flap from the paralyzed leg could preserve the function of the unaffected limb, but this approach is complicated by the atrophy and deformities present in the affected leg, creating substantial challenges. We here report the successful ALT flap harvesting from the polio-affected leg in a 55-year-old male patient for the reconstruction of a tongue defect. The patient diagnosed with Left tongue squamous cell carcinoma, and underwent tongue cancer excision and a modified radical neck dissection. The flap survived and healed well with the patient's tongue tissue. The wound at the donor site on the thigh also healed well. There were no complications observed in either the flap or the donor site. Our experience suggests that harvesting from the paralyzed leg is a safe and feasible procedure that preserves the function of the unaffected limb and may enhance the postoperative quality of life for polio survivors.

"Y" Configuration of the Arterial Pedicle or the Use of a Saphenous Vein Graft for Microsurgical Reconstruction in the Old and Diseased-A Retrospective Study.

Background: Non-healing soft tissue defects pose challenges to treating physicians. Microsurgical reconstruction is a treatment option for achieving wound closure and limb salvage. These free tissue transfers are often challenging due to associated risk factors. This study aimed to evaluate microsurgical reconstruction using specialized microsurgical techniques for non-healing spontaneous or post-traumatic soft tissue defects in an elderly, high-risk patient cohort with peripheral artery disease. Methods: A retrospective study was conducted on patients with radiologically confirmed peripheral artery disease who underwent free tissue transfers between 2004 and 2010. Patients were included in whom one of two surgical techniques was used, including a "Y" configuration of the arterial pedicle, employed either as an interposition graft or as an arterial patch, or the use of a saphenous vein graft. Patient demographics, comorbidities, flap/limb survival, and surgical techniques were analyzed. Results: Twenty patients at a mean age of 68 (+/-9.3) years underwent 21 primary flap surgeries. Trauma-derived soft tissue defects were predominant (55%). Latissimus dorsi muscle flaps were most frequently utilized (52.4%). The flap success rate was 90.5% at a 12-month follow-up, with no secondary amputations recorded. The lost flaps were replaced by additional free tissue transfers without further complications. Conclusions: This study demonstrates the feasibility of free tissue transfers in high-risk patients with complex soft tissue defects and vascular calcifications. Thorough preoperative planning and the application of specialized surgical techniques are crucial for favorable outcomes in challenging clinical scenarios.

Outcomes of free flap reconstructive surgery in cancer patients-institutional experience

Background: The success rate of free flap reconstruction following cancer surgery has steadily improved over past decades and has achieved a success rate of 91–99%, but occasional failures still occur. The aim of this study was to identify the outcomes of free flap reconstructions in our institution. The primary objective was to assess the success rates of free tissue transfer. The second objective was to assess independent preoperative, intra-operative, and postoperative risk factors for flap loss after microvascular reconstruction. Methods: All consecutive cancer patients who received a free flap for head and neck, appendicular bone, perineal, and extremity reconstruction between October 2020 and September 2023 in our institute were included. Patient characteristics, surgical data, postoperative complications, and reoperations were collected. Results: A total of 37 patients who underwent reconstruction by free flaps were analysed. The overall flap success rate was 73%. Among 37 patients, 12 (32.4%) had flap complications and 10 (27%) had flap loss. Smoking, comorbidity, and operating time did not show significant association with flap failure whereas the choice of flap, reconstruction post radiation, and reconstruction for recurrent cancers showed significant association with flap loss. Conclusion: The overall success rate of 73% in free flap reconstructive surgery in our study mandates us to modify our treatment policy by careful patient selection, better choice of free flap, improved treatment algorithm in terms of flap monitoring and timing of re-exploration, which will help in reduction of free flap failure rates.

A Combined "Vasculoplastic" Approach to the Vasculopathic Patient Undergoing Limb Salvage: Understanding the Role of Endovascular Revascularization for Lower Extremity Free Tissue Transfer.

Multidisciplinary care with vascular surgery and plastic surgery is essential for lower extremity free flap (LEFF) success in the chronic wound population with diabetes and peripheral vascular disease. There is a lack of understanding on performing targeted direct endovascular reperfusion on a vessel that will be used as the flap recipient. Our study compares outcomes of patients who received targeted revascularization (TR) to the recipient vessel for LEFF anastomosis versus nontargeted revascularization (NR) of arterial recipients prior to LEFF. LEFF patients who underwent preoperative endovascular revascularization (ER) from July 2011 to January 2023 were reviewed. Location of ER, demographics, perioperative details, and outcomes were collected. TR was performed on the same vessel as the flap recipient and NR was located on a different vessel than the flap recipient. A total of 55 LEFF patients were identified. Overall, 50.91% (n = 28) received TR and 49.1% (n = 27) received NR. Average age was 60.3 ± 10.9 years and average Charlson Comorbidity Index was 5.3 ± 1.9. On preoperative angiogram, the TR group had significantly lower rates of ER above the knee (3.6 vs. 33.3%, p < 0.001). Immediate flap success rate was 98.2%, with no differences between groups (p = 1.000). No significant differences were found in rates of any postoperative flap complications (p = 0.898), takeback (p = 0.352), partial flap necrosis (p = 0.648), or dehiscence (p = 0.729). Both TR and NR groups had similar rates of a postoperative angiogram (42.9 vs. 48.2%, p = 0.694) and reintervention (35.7 vs. 40.7% p = 0.701). Amputation rates were similar between TR and NR (17.9 vs. 14.8%, p = 1.000). Close follow-up with vascular and plastic surgery is required for patients who undergo ER prior to LEFF, as nearly half of our cohort required additional endovascular procedures. Overall, we observed no significant differences in complication rates for the TR and NR groups, informing revascularization strategies for free tissue transfer in a highly comorbid chronic wound population.

Revisited Anterolateral Thigh Free Flaps For Reconstructive Microsurgery : One Year Evaluation

Extensive soft tissue defects present a dif!cult problem to the plastic surgeon as they are usually associated with exposed important structures such as vessels, nerves, tendons, joint cavity or bone. Reconstruction of soft tissue defects have a wide range of therapeutic options. We reconstructed soft tissue defect in many areas using free anterolateral thigh flap (ALTF). From Februari 2009 - 2010, 9 cases of soft tissue defects in the face, neck, leg and foot of various etiologic factors were admitted to the plastic and reconstructive surgery unit, Cipto Mangunkusumo general hospital. Trauma is the commonest cause of soft tissue defects of the lower extremity, followed by tumours. The cruris was the commonest site (4 cases, 44,4%). Flap success rate was 66,67 %. Failure was reported 1 cases in this study due to vein compromise. In our hospital, we are quite familiar with Anterolateral thigh flap (ALTF) even though the case is limited. Anterolateral thigh flap (ALTF) is used for reconstruction of various simple and complex soft tissue defects, for big and small defects with cavity (orbita).

USE OF ESTLANDER FLAP IN SMALL TO LARGE LIP AND COMMISSURE DEFECTS - A CASE SERIES

Background: The Estlander flap is an axial-pattern, lip-switch technique used to reconstruct lip defects that include the oral commissure. The Estlander flap is a hardy local flap which can be used to reconstruct defects of small to large defects of both the upper and lower lip. The lips are the principal aesthetic and functional unit of the lower 1/3rd of the face. Alterations to normal lip appearance and motion can have a profound impact on patients daily activities and psychosocial wellbeing. Aim of this case series is to evaluate the versatility of Estlander flap in lip reconstruction with regard to function and aesthetic outcome Material and Methods: From May 2022 to May 2024, single centric case series study was done in a tertiary care center in Southern India. This case series comprised of 6 cases of small to moderate defects of the lip and commissure in our institution. Prospective case series from May 2022 - May 2024.The cases were post traumatic, including RTA, dog and human bite and also included post tumor excision Results: This case series had a 100% flap success and all 6 patients were satisfied with the functional and aesthetic outcome of the surgery. One patient underwent commisuroplasty. Conclusions: By the use of this case series, we can conclude that the Estlander flap is a reliable flap for the reconstruction of small to large sized lip and commissure defects Conflict of interest: None.

Neurovascular anatomy of the platysma muscle for blepharoptosis repair: a cadaveric study.

This study aimed to define a new surgical method using a neurotized platysma free flap to provide dynamic reanimation, enhanced functional recovery, and low morbidity for blepharoptosis repair. Ten hemifaces and neck halves of five formalin-fixed cadavers were included in the study. The origin of the neurovascular structures of the pedicle was identified at the submandibular triangle. A 5 × 3cm platysma flap was dissected. For the recipient side, the main donor vascular structures were observed at the frontal part of the temporal region. The diameters of the donor structures were measured with a digital Vernier caliper. The statistical analysis of the study was performed with Jamovi statistical software version 2.3.36. P < 0.05 was accepted as a statistically significant value. At the donor region, the pedicle included branches of the cervical branch of the facial nerve and the facial artery in all specimens. However, the venous graft pedicle origin could be either the facial vein or the lingual vein. At the recipient region, the mean diameters of the most anterior nerves, arteries, and veins were 1, 2.03, and 2.37mm respectively. In a side comparison of pedicle variables, only pedicle artery diameter and lateral palpebral commissure-anterior superior point of auricula distance had statistically significant differences between hemifaces. A 5 × 3cm size platysma flap located in the submandibular trigone would be a good choice for functional blepharoptosis surgery. The thin structure and the appropriate neurovascular pedicle structure should enable performing a successful flap transfer.

Angiosome-Guided Revascularization in Local Flap Reconstruction of the Foot and Ankle: Comparable Outcomes With Both Direct and Indirect Revascularization.

Among patients with critical limb ischemia and tissue loss, revascularization is an essential component for limb salvage. Local flaps of the foot and ankle remain a versatile tool in reconstructive limb salvage but is dependent on adequate arterial flow. In patients with arterial occlusive disease requiring revascularization, there is a lack of evidence in the current literature investigating on the necessity of direct arterial flow to the respective angiosome for local flaps reconstruction. Our study thereby compares the outcomes of direct (DR) and indirect (IR) revascularization for local flap success. Patients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. IR was performed in patients where DR could not be performed. DR was defined as an intervention on the same pedicle used for the local flap. IR was defined as an intervention performed on a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, postoperative complications, and long-term outcomes were collected. A total of 33 patients underwent 43 local flap reconstruction with preoperative ER: 58.1% (n = 25) received DR and 41.2% (n = 18) received IR. Patients had a mean CCI of 6.7 ± 1.8, with a high prevalence of diabetes mellitus (93.9%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. In the immediate postoperative period (postoperative day 0 to 12), there were no significant differences in immediate flap success (DR: 100% vs IR: 88.9%, P = 0.169) or partial flap necrosis between (DR: 0.0% vs IR: 16.7%, P = 0.066). Rates of major complications from infection (DR: 28.2% vs IR: 22.2%, P = 0.736), ischemia (DR: 4.0% vs IR: 11.1%, P = 0.562), or dehiscence (DR: 8.0% vs IR: 16.7%, P = 0.634) requiring reoperation were similar between 2 groups. Overall limb salvage rate was 84.9%, and comparable between groups (DR: 78.6% vs IR: 89.5%, P = 0.628). DR and IR achieve similar rates of limb salvage and flap success after local flap reconstruction. A multidisciplinary vasculo-plastic approach that incorporates preoperative arteriogram and revascularization should be utilized for this highly comorbid patient population to achieve optimal success and limb salvage.

The Effect of Medial Circumflex Artery Variation on the Success Rate of Gracilis Flap Procedures: A Systematic Review.

This systematic review examines the impact of anatomical variations in the medial circumflex artery (MCA) on the outcomes of gracilis flap procedures in reconstructive surgery. Incorporating 16 studies, this review analyzes how different MCA variants influence the success rates of these procedures. Findings highlight critical MCA variations, including cases of split and double pedicles and differences in pedicle length and branching patterns, which can complicate flap harvesting and vascular anastomosis. The studies consistently underscore the need for precise preoperative imaging and intraoperative adaptability to manage these anatomical differences effectively. Notably, variants with shorter or branched pedicles present higher risks of partial flap loss and complications, particularly in autologous breast reconstruction and lower extremity repairs. The findings support the adoption of advanced imaging protocols, such as high-resolution Doppler and CT angiography, to enable detailed vascular mapping. Interdisciplinary collaboration among anatomists, radiologists, and surgeons is essential for developing comprehensive strategies tailored to individual anatomical landscapes, optimizing both the success and viability of gracilis flaps. The review emphasizes that understanding MCA variability is crucial for enhancing surgical precision and improving patient outcomes. Standardizing preoperative assessment protocols and exploring alternative flap techniques may mitigate risks associated with MCA variations, advancing the field of reconstructive surgery.

Refining a Multidisciplinary “Vasculo-plastic” Approach to Limb Salvage: An Institutional Review Examining 300 Lower Extremity Free Flaps

Background: The use of free tissue transfer (FTT) is effective for chronic, non-healing lower extremity (LE) wounds, requiring collaboration across plastic, vascular, podiatric, orthopedic, and infectious disease disciplines for comprehensive treatment plants to optimize limb salvage. This study aims to describe our vasculo-pathic approach with 300 LE FTTs, comparing outcomes between the first 200 LE FTT and the most recent 100 procedures performed. Methods: A single-institution, retrospective review of 300 LE FTTs from July 2011 to January 2023 was performed. Patients were compared between the first 200 (Group 1, July 2011 – February 2020) and last 100 flaps (Group 2, February 2020 – January 2023) performed. Patient characteristics, preoperative management, intraoperative details, and outcomes were collected. Results: Group 2 patients had significantly higher rates of diabetes (67.0% vs. 48.5%, p=0.002), peripheral vascular disease (56.0% vs. 24.5%, p&lt;0.001), history of venous thromboembolisms (13.0% vs. 6.0%, p=0.039), venous reflux (81.9% vs. 67.8%; p=0.028), and preoperative venous thromboses on venous testing (25.5% vs. 10.5%; p=0.003) compared to Group 1. Group 2 underwent more pre-FTT endovascular interventions (23.0% vs. 16.5%, p=0.039) and vascular bypasses (4.0% vs. 0.0%, p =0.012). While immediate flap success and amputation rates were similar between the groups, Group 2 had higher rates of partial flap necrosis (7% vs. 3%; p=0.012). Conclusions: The adoption of a vasculo-plastic approach allows LE FTT to remain successful and achieve long-term limb salvage despite a highly comorbid population.

Closure of the Osteocutaneous Fibula Flap Donor Site with a Tonearm (Propeller) Flap: Anatomic Considerations and Surgical Indications

BackgroundSkin graft is frequently used for donor site closure after osteocutaneous fibula free flap (OCFFF) harvest when primary closure is not possible. Partial skin graft loss requiring wound care is a common complication. The purposes of this prospective study were to investigate the perforator anatomy for local propeller/tonearm flap closure and compare outcomes to skin graft closure. MethodsAll patients undergoing OCFFF for head and neck reconstruction from February 2022 to October 2023 were considered for the tonearm flap. Intraoperative perforator anatomy was prospectively recorded. Surgical techniques and criteria for tonearm flap reconstruction were described. A minimum 6-month follow-up was required. Outcome measures included the rate of flap success and wound complications. Results40 consecutive patients were included. The tonearm flap was not possible in 16 patients (40%) due to unfavorable perforator anatomy and 2 patients underwent primary closure. All successful tonearm flaps were eccentrically designed on a proximal lower leg perforator, located 13.5±1.99cm from the fibular head. Most proximal perforators were musculocutaneous through the soleus muscle (n=20, 90.9%), while the rest were septocutaneous (n=2, 9.1%) originating from the peroneal artery. Three patients experienced distal partial flap loss; one required an additional skin graft. Only half of the skin graft cohort (n=99, 50.8%) achieved complete skin graft take. The average skin graft loss was 34.3% and wound care was required for an average 51.6±52.8 days. ConclusionsThe study findings demonstrate that local tonearm flaps, when anatomically feasible, can be successfully performed with superior outcomes compared to skin graft closures.

The Use of Pedicular Arteriovenous Fistula (PAVF) in Microvascular Reconstruction to Enhance Flow Across the Microvascular Anastomoses.

Free flap success rates have improved dramatically over the past three decades, setting a high standard for microvascular reconstruction. However, rates of arterial or venous thrombosis, and subsequent failure, remain high in burn and trauma reconstruction when compared to autologous breast reconstruction and other elective flaps. To address the higher failure rate, we use a novel vascular approach. We create a pedicular arteriovenous fistula (PAVF), allowing the flow to be enhanced across the microvascular anastomoses. We performed a retrospective review of 13 consecutive patients with 14 free flaps who underwent PAVF creation by the first author, AO. All patients who required free tissue transfer for trauma and burn reconstruction were indicated for PAVF during this study period. The flaps in this study included ALT, fibula, parascapular, and partial latissimus. The perforator and pedicle for the flaps were dissected in the usual manner. Distal to the takeoff of the perforator to the flap, the pedicular artery and the larger of the accompanying veins were anastomosed to create the PAVF. Patients were followed for a mean of 171 days Thrombosis was a rare complication in the group with one venous thrombosis (n = 1, 7.14%) and no arterial thrombosis. The most common complication was return to the operating room n = 4 (28.57%), two of which secondary to hematomas (14.29%), one wound dehiscence and one venous thrombosis. This latter patient eventually had partial flap loss. We did not observe flap ischemia due to vascular steal, nor any venous congestion from pressurizing the venous outflow. As opposed to anticoagulation, flow enhancement aims to decrease the risk of thrombosis by reducing stasis. While further data is needed to compare the outcomes of venous enhanced flaps when compared to flaps treated prophylactically with anticoagulation, our initial data suggests that PAVF is a safe procedure and does not result in vascular steal or flap congestion.

Utility and Outcomes of a Keystone Perforator Island Flap for Reconstruction at Various Anatomical Locations: A Prospective Study.

Background In Yemen, traumatic wounds are prevalent, imposing a substantial burden on plastic surgery teams operating within limited-resource settings. Advanced microsurgical reconstruction options are scarce, and expertise in free flap techniques is limited. While local flaps are commonly used for soft tissue reconstruction, there is a need for simpler, effective alternatives with lower complication rates. This study aimed to evaluate the effectiveness and outcomes of the keystone island perforator flap (KIPF) as a viable alternative for soft tissue coverage in resource-challenged facilities. Methods From February 2021 to December 2023, a single surgeon's team in three plastic and reconstructive surgery departments in Sana'a, Yemen, conducted this prospective study, which included 35 patients who underwent KIPF for various soft tissue defects. We assessed patient demographics, intraoperative variables, and postoperative outcomes, including aesthetic outcomes evaluated using the Patient and Observer Scar Assessment Scale (POSAS) at six months postoperatively. We analyzed the factors influencing flap success and complication rates. Results The mean age of patients was 29 ± 11.75 years, with the majority being males, comprising 86% of the sample. Trauma was the leading cause of tissue defects (77.1%), primarily affecting the legs (57.14%) and feet (11.43%). The mean operative time was 73.57 minutes. Complications occurred in 26% of patients, with flap dehiscence being the most common (11.43%). Ninety-seven percent of patients experienced flap survival, and 91.4% experienced complete wound healing within a median of 16 days.Scar assessments at six months postoperatively indicated satisfactory aesthetic outcomes, with scars resembling normal skin. Conclusion The KIPF technique proves to be a reliable and practical option for soft tissue reconstruction in resource-limited settings. Its simplicity, minimal postoperative care needs, and high flap survival rates make it an advantageous alternative to more complex reconstructive techniques. This study supports the adoption of KIPF as a standard approach in similar environments with limited reconstructive surgery capabilities.

Feasibility of Super-thin Anterolateral Thigh Free Flap for Oral and Pharyngeal Reconstruction.

To highlight the feasibility of employing super-thin ALT free flaps for reconstruction of complex oral cavity and oropharyngeal defects. Retrospective chart review. Sixteen super-thin ALT free flaps were performed in 15 patients between 2020 and 2023 for reconstruction of oral cavity defects (seven oral tongue, three floor of mouth, three buccal, two oropharynx, one lower lip). Flap success rate was 100% with only minor complications reported, with no patient requiring return to the operating room within 30 days and no patient requiring radial forearm free flap reconstruction. One patient experienced partial flap failure, one patient experienced superficial necrosis of the distal skin paddle measuring 1 cm, and one patient was converted intraoperatively to a contralateral traditional ALT free flap due to insufficient perforator size. Average operative time was 509 min, average length of hospitalization was nine days, and two patients required gastrostomy placement prior to discharge for dysphagia. Super-thin ALT free flap harvest technique represents a feasible option for oral cavity and oropharyngeal reconstruction in select patients and does not require additional surgical training, invasive testing, or technology. It can be readily adopted by reconstructive surgeons with a simple adaptation in existing ALT harvest technique. Level 4 Laryngoscope, 2024.

Pre-expanded Local Flaps: Optimal Choice for Repairing Defects Following Extensive Benign Tumor Resection in the Head and Face.

Treating extensive benign tumors of the head and face presents a longstanding challenge, necessitating efficacy at the lesion site, and postoperative esthetic considerations for the donor area. This study aims to explore the clinical outcomes of pre-expanded local flap reconstruction for extensive benign tumors of the head and face post resection. From March 2018 to March 2023, a total of 18 patients with extensive benign tumors of the head and face were admitted, including 13 cases of nevus, 2 cases of hemangioma, 2 cases of neurofibroma, and 1 case of verruca. Based on the location and size of the lesions, suitable local areas were selected for tissue expansion, and expanders were implanted for regular saline injections over 8 to 16 weeks. After reaching the desired expansion, resection of the head and facial tumors and local flap reconstruction were performed. Postoperatively, data on patients' information, tumor types, tumor area, expansion volume, postexpander complications, vascular condition after flap transfer, and donor site condition were collected. In this series of 18 patients, benign tumors of the head and face were completely repaired through 1 to 2 stages of tissue expansion surgeries. Postimplantation complications included hematoma in 1 case and infections in 2 cases, with one instance of expander infection leading to surgical failure. However, all other patients achieved adequate expansion, successful flap survival post-transfer, and experienced no other complications. Follow-up over 6 to 24 months showed no recurrence at the lesion sites, with flaps maintaining consistent color, texture, and thickness matching surrounding skin tissue. In addition, donor site healing was excellent, with no obvious surgical scars. Pre-expanded local flap reconstruction is an ideal method for repairing extensive benign tumors of the head and face postresection.

Optimizing Lower Extremity Local Flap Reconstruction in Peripheral Vascular Disease.

Local flaps remain a valuable reconstructive tool as a means for limb salvage for patients with advanced arterial disease. Our single-center, retrospective cohort study aims to compare the outcomes of different patterns of blood flow affected by vascular disease to pedicles in local flap reconstruction of the foot and ankle. A retrospective review of 92 patients and 103 flaps was performed. On angiograms, pattern of blood flow to the flap pedicle was determined to be direct inline flow (DF) or indirect flow (IF). Patterns of IF were either by arterial-arterial connections (AC) or unnamed randomized collaterals (RC). Primary outcomes were immediate flap success and limb salvage. Comparative analyses were performed using the χ2 and Fisher tests for categorical variables. Among all flaps, 73.8% (n = 76/103) had DF and 26.2% (n = 27/103) had IF. Both groups experienced similar rates of immediate flap success (DF = 97.3% vs IF = 92.6%, P = 0.281) and limb salvage (DF = 75.% vs IF = 66.7%, P = 0.403). However, the rate of contralateral amputation was significantly higher in the IF group (26.9% vs 5.3%, P = 0.006). When comparing the 3 distinct patterns of blood flow (DF vs AC vs RC), pedicled flaps were more commonly supplied by DF and AC, while random pattern flaps were more commonly supplied by RC (P = 0.042). Alternative routes of revascularization can maintain local flap viability and achieve similar rates of limb salvage but risks contralateral amputation. We found that pedicled and local muscle flaps require inline blood flow or blood supply by ACs. Meanwhile, random pattern flap can be supported by random collaterals.

Efficacy of Platysma Myocutaneous Flap in Advanced Oral Submucous Fibrosis – A Prospective Study

Abstract Introduction: Platysma myocutaneous flap used for intraoral reconstruction is an axial-pattern flap based on the submental branch of the facial artery; however, its vascular anatomy is complex in nature. Its efficacy in the reconstruction of oral defects following oral cancer resection is well established, even after facial artery ligation. The aim of this study is to evaluate the efficacy of platysma myocutaneous flap in oral submucous fibrosis (OSMF) patients. Materials and Methods: The study included 85 OSMF patients (Grades III and IV). Platysma myocutaneous flap was used for the reconstruction of fibrotomy defects in all patients. All patients were followed up for a period of up to one year. Mouth opening was the chief parameter evaluated intraoperatively and postoperatively. The complications such as flap dehiscence, partial skin loss, tip necrosis, haematoma and paraesthesia at the donor site were also recorded. Results: The mean mouth opening value (in mm) increased from 13.00 ± 1.93 and 6.50 ± 2.35 to 32.72 ± 5.19 and 31.20 ± 4.77 at the end of one year in Grade III and IV groups, respectively. A gradual improvement in pain score was noted. Only minor complications occurred in 8.2% patients. Major flap loss was not seen in our series. Discussion: Proper dissection plane, avoiding muscle tearing during flap elevation, maintaining adequate pedicle, creating a tunnel of sufficient width and proper intraoral flap orientation are the major factors affecting flap success rates. Our study demonstrated that the platysma myocutaneous flap is a promising and effective option for reconstructing buccal mucosa defects in OSMF patients.

Systemic allopurinol administration reduces malondialdehyde, interleukin 6, tumor necrosis factor α, and increases vascular endothelial growth factor in random flap Wistar rats exposed to nicotine.

Smoking poses a risk to flap viability, with nicotine being a major contributor to the formation of free radicals. Allopurinol, known for its antioxidant properties, has been shown to enhance tissue survival in ischemic conditions by reducing the production of reactive oxygen species (ROS). This study aims to assess the impact of allopurinol on the viability and success of skin flaps in Wistar rats exposed to nicotine. This study examined skin flap survival in nicotine-exposed rats treated with allopurinol. Twenty-eight rats were separated into two groups. During 1 month of nicotine exposure, the treatment group received systemic allopurinol 7 days before and 2 days after the flap procedure, while the control group received no allopurinol. Pro-angiogenic factors, proinflammatory factors, anti-inflammatory factors, and oxidative markers were assessed on the 7th day after the flap procedure using enzyme-linked immunosorbent assay method. Macroscopic flap viability was evaluated on the 7th day using Image J photos. As an oxidative marker, malondialdehyde levels were significantly lower in rats given allopurinol than in controls (P &lt; 0.001). The levels of interleukin 6 and tumor necrosis factor α, as markers of inflammatory factors, were significantly lower in the group of rats given allopurinol compared to controls (P &lt; 0.001). The level of angiogenesis in rats given allopurinol, measured by vascular endothelial growth factor levels, was also higher in the treatment group compared to controls (P &lt; 0.001). Macroscopically, the percentage of distal flap necrosis in Wistar rats given allopurinol was lower and statistically significant compared to controls (P &lt; 0.001). Xanthine oxidoreductase is part of a group of enzymes involved in reactions that produce ROS. Allopurinol, as an effective inhibitor of the xanthine oxidase enzyme, can reduce oxidative stress by decreasing the formation of ROS. This reduction in oxidative stress mitigates the risk of ischemic-reperfusion injury effects and significantly increases the viability of Wistar rat flaps exposed to nicotine.

Management of large head and neck defects in the vessel-depleted neck.

Surgery, radiation, and chemotherapy are often utilized in the treatment of head and neck cancer. These treatments can cause extensive scarring within the neck and can limit the viability of recipient vessels for further microvascular reconstruction. Patients with vessel-depleted necks provide a significant challenge for microvascular surgeons and are a topic of much discussion in the field. While reconstruction in the vessel-depleted neck is an active area of interest, the patient population is rare. Therefore, single institution series with small numbers comprise the majority of published literature. Recent publications describe techniques for identifying adequate recipient vessel options outside of the field of treatment with excellent free flap outcomes. Further, recent summary articles describe techniques for addressing issues with pedicle length that can arise when using vessels that are far from the defect to be reconstructed. When viable vessel options are available within the treatment field, these recipient vessels can be used with good reliability and free flap success. If in-field recipient vessels are not available, minimal access incisions can be used to identify superficial temporal, angular, contralateral facial, or transverse cervical vessels. Further away from the treatment field, internal mammary vessels can be harvested through open or robotic approaches. If the use of these distant vessels creates issues with pedicle length, interposition vein grafts, arteriovenous (AV) loops, or flow-through flaps can be used to augment vessel length.