Total Flap Loss Research Articles

Microvascular Free Tissue Transfer for Reconstruction of Complex Abdominal Wall Defects.

Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects. Therapeutic, IV.

Management of postoperative microvascular compromise and ischemia reperfusion injury in breast reconstruction using autologous tissue transfer: Retrospective review of 2103 flaps.

Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion. We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded. Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n=29, 61.7%) or partially salvaged (n=5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n=33, 70.2%), thrombectomy (n=27, 57.4%), tissue plasminogen activator administration (n=26, 55.3%), and vein grafts (n=18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n=33, 70.2%), postoperative steroids (n=17, 38.6%), and postoperative therapeutic anticoagulation (n=27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years. Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.

Durability and versatility of free lattismus dorsi muscle flap in leg defects in tertiary care hospital

Reconstruction of the legs and feet is challenging. Because of the composite tissue defects, inadequate and tight local tissues and poor circulation, soft tissue scarcity around the lower portion of the leg presents a significant challenge to the reconstructive surgeon. The aim of this study was to assess the outcome of free Lattismus dorsi (LD) muscle flap used for soft tissue reconstruction of leg defects. This prospective non-randomized study was conducted on 13 patients with leg defects of different causes attended emergency unit and outpatient clinic of plastic surgery department of plastic surgery and burn unit, Dhaka medical college hospital (DMCH) in the period between July 2017 and June 2018. Durability of coverage, flap success, infection and overall satisfaction were studied. The age distribution of the study population highest number of patients (46.15%) were in middle (31-40 years) age group whereas lowest are in older group (>51 years). Highest number of patients (84.61%) were standard myocutanous type of flap whereas lowest were in (15.31%) were chimeric flap and partial latissimus muscle flap. There were one case of total flap loss. Two patients had seroma formation among them one patient had partial necrosis. The outcome of reconstruction of n=13 patients 76.92% patients discharged with excellent recovery, (15.38%) patients discharged with good outcome, 1 (7.69%) patients had total flap loss. Flap is easy to dissect, anatomical variation is rare, long pedicle length which allow to anastomose with suitable recipient artery and finally donor morbidity is negligible.

Outcome of latissimus dorsi free flap in-case of large scalp defect a single center study

Reconstruction of scalp and calvarial defects following trauma post burn and after tumor ablation frequently requires prosthetic cranioplasty and soft tissue coverage. Furthermore, patients often have advanced disease and receive perioperative radiotherapy following tumor ablation. We evaluated the outcome of scalp reconstruction in traumatic cases with a free Latissimus dorsi (LD) muscle flap in this setting. The aim of this study was to evaluate outcome of latissimus dorsi free flap in-case of large scalp defect. This prospective non-randomized study was conducted on 10 patients with scalp defects following trauma attended emergency unit and outpatient department of burn and plastic surgery, Dhaka medical college hospital (DMCH) in the period between July 2017 and June 2018. Durability of coverage, flap success, infection and overall satisfaction were studied. The age distribution of the study population shows highest number of patients (60%) were in middle (24-30 years) age group whereas lowest are in older group (30-50 years). The lowest age was 24 years and the highest age was 45 years. Highest number of patients (80%) were standard myocutanous type of flap whereas lowest were in (20.0%) were partial latissimus muscle flap. Outcome of the reconstruction (80.0%) were excellent 10% partial flap necrosis occur and total flap loss in 1 (10%) patient. The reconstruction of scalp defects continues to be a challenge for the reconstructive surgeon, who must achieve a satisfactory functional and aesthetic outcome.

Outpatient Cosmetic Breast Augmentation with DIEP Flaps

BACKGROUND: Breast augmentation ranks as one of the most commonly performed cosmetic procedures. It is a relatively inexpensive and straightforward procedure that yields good results with low risk. However, potential problems with implants exist such as deflation, leaks, malposition, pain, and capsular contraction. Breast Implant Illness (BII) or Breast Implant Associated Lymphoma (BIA-ALCL) remains a high concern for many patients. As a reliable alternative or treatment for these issues and concerns, the authors describe the use the deep inferior epigastric perforator (DIEP) flap in outpatient cosmetic breast augmentation and mastopexy. METHODS: We reviewed patients who had undergone cosmetic breast augmentation with DIEP flaps over a 12-month period. Any patient who desired breast augmentation, implant exchange, or augmentation mastopexy with concomitant abdominoplasty was considered a candidate for the procedure. Charts were reviewed for all patients who elected to proceed with cosmetic DIEP flaps. All patients underwent our early recovery protocol, including microfascial incisions to harvest the DIEP flaps, and rib preservation in addition to ERAS protocols with intraoperative anesthetic blocks. RESULTS: Eleven consecutive patients underwent bilateral cosmetic breast augmentation with DIEP flaps and mastopexy. Overall, all patients referred dissatisfaction with their abdomen and breasts. Three patients presented with ptotic breasts following recent pregnancies. Four patients were displeased with their breasts following augmentation with prosthetic implants. Three patients were experiencing pain and discomfort due to bilateral capsular contractures, with two of them being consistent with Breast Implant Illness. Lastly, one patient decided to undergo breast augmentation following bariatric surgery. Microfascial incisions for single perforator abdominal flaps (n = 17) averaged 1.7 cm (range 1.3–2.4), while flaps with multiple perforators (n = 5) averaged 2.4 cm (range 2-–2.5). Dissection of recipient IMA vessels was performed without disruption of the rib. No fascia or muscle tissue was taken during flap dissection. All patients had strong Doppler signals before discharge within 23 hours. No partial or total flap losses were reported, without major complications or take-backs. Average follow-up was 15 weeks. One patient required in-office debridement and closure due to suture granuloma at the abdominal incision. One patient developed minimal T-zone necrosis of the mastopexy site, which healed secondarily. Another patient, who had undergone prior mini-abdominoplasty, had limited flap edge necrosis that also healed secondarily. DISCUSSION: Combined breast augmentation or augmentation mastopexy with abdominoplasty is a commonly performed surgical procedure. Patients who desire abdominoplasty and augmentations are ideal candidates for this procedure. Breast augmentation with autologous tissue, particularly the DIEP flap, is an attractive option inherent to the additional abdominal tissue available to harvest. Likewise, women with implant complications like severe capsular contractures, or patients who have concerns for BIA-ALCL or have Breast Implant Illness, yet would like to maintain breast volumes, are excellent candidates. These conditions and the fear of these problems required other reliable options for breast augmentation or removal of implants secondary to refractory illness. Our early recovery protocol allows us to perform microsurgical breast reconstructions and augmentations in an outpatient setting, with outstanding results and no total or partial flap losses, thus offsetting the high costs associated with the DIEP flap.

Evaluating effects of primary defatting for flap thinning on the development of perfusion-related complications in free perforator flap reconstruction.

Primary defatting is suggested as an effective and appealing technique for achieving flap thinning. There has been a long-standing concern regarding its potential adverse effects on flap perfusion, for which limited clinical evidence exists. This study aimed to investigate whether primary defatting negatively influences the outcomes of free perforator flap reconstruction. Patients who underwent upper or lower extremity reconstruction using free perforator flaps between 2002 and 2020 were investigated. They were categorized into two groups according to whether they underwent primary defatting. The association of primary defatting with the development of perfusion-related complications was evaluated. A total of 421 patients were included in the analysis. Perfusion-related complications developed in 61 (14.5%) cases, including 12 cases (2.9%) of total flap loss. In total, 302 patients underwent primary defatting and 119 did not. The patients who underwent primary defatting had a higher body mass index (BMI), lower rate of comorbidities, and smaller harvested flaps than the controls. Both groups had similar rates of perfusion-related complications (13.9% vs. 16.0%, p=.589), including total flap loss (3.0% vs. 2.5%, p=.799). In the multivariate analyses, primary defatting was not associated with the development of perfusion-related complications (p=.957). In the subgroup analyses, the rate of perfusion-related complications did not differ between the two groups regardless of the BMI (≥25 or <25 kg/m2 ), comorbidities, and flap size (≥200, 100-200, or <100 cm2 ). Primary defatting does not appear to be associated with the development of perfusion-related complications in free perforator flap extremity reconstruction.

Free Flap Coverage for Complex Primary and Revision Total Knee Arthroplasty.

Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty. The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years. Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14). Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome. Therapeutic, IV.

Blood Count Parameters can be Useful in Predicting Vascular Events in Microvascular Surgery: Results of a Preliminary Study.

Vascular events are a major cause of flap failure and identifying patients who are at risk is of paramount importance. In the past, many studies have been conducted to investigate the effect of blood count parameters for ischemic events such as peripheral vascular diseases. This study aimed to evaluate whether blood count parameters can have predictive value for vascular events in microvascular flap surgery. Elective cases with free flap microsurgery performed in a single center were reviewed from 2015 to 2019. Demographic data, comorbidities, flap types, perioperative complications, and preoperative blood count parameters from the hospital records were screened. A total of 147 patients were included in the study, taken from the 163 patients undergoing free tissue transfer. The rate of thrombosis and partial necrosis was 8.8%, was 8.2%, respectively, and the total flap loss due to these complications was 5.4%. Only patient age, gender, and length of hospital stay were correlated with flap loss. According to the preoperative blood count results, there were significant differences between vascular events and leucocyte, and neutrophil counts. The findings of this preliminary study suggest that these parameters may be used in predicting vascular events in flap surgery.

PD31-09 USE OF THE DEEP INFERIOR EPIGASTRIC VESSELS FOR ARTERIOVENOUS ANASTOMOSIS IN FREE-FLAP PHALLO-URETHROPLASTY: TECHNIQUE, KEY POINTS, AND LESSONS LEARNED

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) II (PD31)1 Sep 2021PD31-09 USE OF THE DEEP INFERIOR EPIGASTRIC VESSELS FOR ARTERIOVENOUS ANASTOMOSIS IN FREE-FLAP PHALLO-URETHROPLASTY: TECHNIQUE, KEY POINTS, AND LESSONS LEARNED Nance Yuan, Edward Ray, and Maurice Garcia Nance YuanNance Yuan More articles by this author , Edward RayEdward Ray More articles by this author , and Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002032.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Most descriptions of free-flap phalloplasty use the femoral artery and great saphenous vein as recipient vessels. This generally requires end-to-side arterial anastomosis and sometimes interposed vein grafts. Use of the deep inferior epigastric vessels (DIEA/V) as recipient vessels has been rarely reported. We present our technique and experience with using the DIEA/V as recipient vessels for free-flap phalloplasty. METHODS: We retrospectively reviewed consecutive patients who underwent free-flap phalloplasty and/or urethroplasty at a single institution from September 2017 to September 2020. In all cases, the DIEA/V were used as recipient vessels. The DIEA/V pedicle was dissected through skin and fascial incisions in the lower abdomen and externalized through a passageway dissected at the medial aspect of the external inguinal ring. Demographics, surgical details, and outcomes were recorded. RESULTS: 31 flaps were anastomosed to the DIEA/V. Mean age was 38 years; mean BMI was 26.9. Mean follow-up was 22.8 months. 29 patients underwent phalloplasty (22 radial-forearm free flap, 9 anterolateral-thigh free flap). 2 patients underwent radial-artery flap urethroplasty. No femoral vessels or interposition grafts were used. Most (90.3%) flaps had two veins anastomosed, using the DIEV. Microvascular outcomes were excellent. Of 31 cases, there was only one case of operative takeback for venous congestion and one case (3.2%) of total flap loss. We explore the lessons learned from this case. There were six (19.4%) cases of dehiscence, most of which were minor and easily repaired. CONCLUSIONS: Use of the DIEA/V as recipient vessels for free-flap phalloplasty has shown excellent outcomes and is our preferred technique. Advantages associated with use of the DIEA/V include a short, direct course to the recipient vessels, good donor-recipient vessel size-match allowing end-to-end anastomosis instead of end-to-side anastomosis, elimination of risks associated with arterialized interposed veins (including potential aneurysm or blow-out from high-pressure flow), reliable dissection anatomy, and a well-hidden scar. Potential pitfalls to avoid include any factors that could compress the pedicle. In cases where venous outflow may be at risk, we recommend a low threshold to use additional local veins for anastomosis, though we rarely need additional veins given the reliability of the DIEV. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e542-e542 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nance Yuan More articles by this author Edward Ray More articles by this author Maurice Garcia More articles by this author Expand All Advertisement Loading ...

Abdominal perforator exchange flap (APEX): A classification of pedicle rearrangements.

Abdominal-based reconstruction is the most commonly performed method for breast reconstruction after mastectomy using the patient's own tissues. DIEP flap has allowed to reduce the donor site morbidity but the incidence of bulging or hernia remains still high, especially when flap is based on multiple perforators. Abdominal Perforator Exchange flap (APEX) represents a further step forward in preserving the abdominal wall structures by disassembling the pedicle components and their reconstitution at the end of the dissection. In this study, we explore the possible anatomical configurations of perforators exchange for APEX, providing a simple classification of perforators reconstitution patterns and the possible clinical implications. A retrospective study was conducted on patients who received APEX flap for abdominal based breast reconstruction. Preoperative CT scans and procedure descriptions were analyzed to identify the vascular patterns during flap harvesting and the pedicle reconstitution sites. The onset of abdominal wall and flap related complications were investigated. APEX flap was performed on 51 women and four vascular patterns were identified. We identified the Type A pattern in 36 cases (70.6%), the Type B pattern in 8 (15.7%), and the Type C pattern in 5 (9.8%). We performed an extra-anatomical reanastomosis (Type D) in only two case (3.9%) (p= .09). We recorded anastomotic problems in five pedicles' reconstitution and the odds ratio showed a possible correlation between the localization of pedicle division and the anastomosis problems (p> .05). No total or partial flap loss was recorded during this study. Marginal fat necrosis was clinically observed in three cases, which had very large flaps. No bulging or hernia was recorded. Our perforators exchange classification for abdominal-based flap helps clinician in planning the surgery and also in describing the procedure easily allowing a more efficient communication. This classification could be used to approach perforator flaps with multiple vessels at other anatomical locations as well.

Evaluation of an Extended-duration Chemoprophylaxis Regimen for Venous Thromboembolism after Microsurgical Breast Reconstruction.

Background:Patients undergoing free flap breast reconstruction are at a high risk for venous thromboembolism based upon Caprini scores. Guidelines for venous thromboembolism prophylaxis recommend high-risk groups receive extended chemoprophylaxis for several weeks after gynecological, orthopedic, and surgical oncology cases. Extended prophylaxis has not been studied in free flap breast reconstruction. The purpose of this study was to compare outcomes of free flap breast reconstruction patients who received extended venous thromboembolism (VTE) prophylaxis with those who received standard inpatient-only prophylaxis.METHODS:Patients undergoing microsurgical breast reconstruction were divided into two groups: standard VTE prophylaxis (Group I) and extended prophylaxis (Group II). Both groups received prophylactic subcutaneous heparin or enoxaparin preoperatively and enoxaparin 40 mg daily postoperatively while inpatient. Group II was discharged with a home regimen of enoxaparin 40 mg daily for an additional 14 days.RESULTS:In total, 103 patients met inclusion criteria (36 patients in Group I, 67 patients in Group II). The incidence of VTE was 1.5% in Group II compared with 2.8% in Group I (P = 0.6). There was no difference in reoperative hematoma between Group I (n = 0) and Group II (n = 1) (P = 0.7). Total flap loss was 2.2%.Conclusions:Although this retrospective pilot study did not show statistical significance in VTE between those receiving extended home chemoprophylaxis (1.5% incidence) compared with inpatient-only chemoprophylaxis (2.8%), the risk of bleeding complications was similar. These results indicate that a larger, higher powered study is justified to assess if an extended home chemoprophylaxis protocol should be standard of care post free flap breast reconstruction.

Impact of patients’ gender on microvascular lower extremity reconstruction

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients’ gender: male vs. female. Retrospective data analysis evaluated patients’ demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

Versatility of Superficial Temporal Artery Pedicle for Postburn Facial Reconstruction: Our Center experience.

Superficial temporal artery (STA) is the one of the terminal branches of external carotid artery. Superficial temporal artery divides into frontal and parietal terminal branches. Various types of locoregional flaps can be based on the STA as a pedicle to provide effective and robust cover. In this article, we shall discuss the various applications of STA and its terminal branches as a pedicle for postburn facial reconstruction in our clinical experience of more than 20 years. This is a retrospective review of 531 cases of postburn facial reconstruction using STA and one its terminal branches as a pedicle done at Department of Plastic and Reconstructive Surgery, Lok Nayak Hospital, which is tertiary care government hospital in New Delhi for burn care from March 2000 to March 2020. We started use of this flap initially for postburn ear reconstruction cases and slowly expanded our indications over the period of time due to its high vascularity and versatile nature. There were 269 females and 262 males included in this review. We have used STA and one its terminal branches as a pedicle to our advantage with varied indications and excellent results. We had minor complications which were easily manageable with 7 cases of partial flap loss and zero case of total flap loss. We shall discuss all the details in our review. We wish to conclude that STA and one its terminal branches as a pedicle offers excellent versality and vascularity for postburn facial reconstruction with good long-standing results.

Deep inferior epigastric perforator free flap in elderly women for breast reconstruction: The experience of a tertiary referral center and a literature review.

A general belief is to consider elderly patients as poor candidates for free flap reconstruction, which does not reflect our 20-year experience for breast reconstruction (BR). The aim of this study was to determine the safety and benefits of BR using deep inferior epigastric perforator (DIEP) free flap in the elderly population. We conducted a retrospective study of all consecutive BRs using DIEP flaps in patients 65years or older at the European Georges Pompidou Hospital from January2011 to December2019. Postoperative complications were reported as minor or major. We used a descriptive approach to analyze the main characteristics of the patients included. Surgical patient-reported outcomes and quality of life were assessed using the validated BREAST-Q questionnaire. Eighty-three DIEP flaps were performed in 79patients (4bilateral flaps) for BR. Sixty-six percent of the patients (52/79) did not present any complication. Total flap loss occurred in 3BR (3.6%), arterial thrombosis in 4BR (4.8%), and venous thrombosis in 8BR (9.6%). The average duration of inpatient stay was 9.5 (±2.7) days. Forty-one of 69eligible patients completed the questionnaire (response rate 59.4%). Patients reported high satisfaction and well-being scores. The mean Q score for psychosocial well-being was 75.4 (±16.7) and 59 (±13.3) for satisfaction with breasts. In our retrospective cohort, DIEP flap BR in elderly population had similar success and complication rates compared with those in younger patients, as well as high satisfaction scores. The free flap should be encouraged for BR in women over 65years of age, and personal motivation as well as physiologicalage considered as main criteria for patient selection.

Safety and donor site morbidity of the transverse musculocutaneous gracilis (TMG) flap in autologous breast reconstruction-A systematic review and meta-analysis.

The transverse musculocutaneous gracilis (TMG) flap has gained popularity for breast reconstruction. However, the literature regarding its donor site morbidity is heterogeneous. This systematic review sought to clarify the evidence on donor site morbidity. A systematic literature search was conducted. We included all articles reporting on donor-site morbidity of the TMG flap for breast reconstruction. The results were analyzed in R and its extension meta. A generalized linear mixed model was used to combine proportions and their 95% confidence intervals (CIs) in a random-effects meta-analysis. Nineteen articles provided an overall sample of 843 TMG flaps. The total flap loss was low at 2% (95% CI, 1%-3%). All patients were normal weight (pooled body mass index 22.75, 95% CI, 21.88-23.63). The incidence of wound dehiscence (8%, 95% CI, 4%-16%), seroma (4%, 95% CI, 2%-7%), hematoma (2%, 95% CI, 1%-4%) and infection (0%-5%) on the TMG donor site was low. Functional impairments included sensory disturbance (0%-74%), motoric deficits (0%-50%), and changes in the genital region (0%-24%), all of which were modest. This review confirms the safety and low donor site morbidity of the TMG flap in normal-weight patients, which is comparable to that of other popular free flaps in breast reconstruction.

Effects of negative pressure wound therapy on an axial congested rabbit skin flap model without any bare surface

One of the most important problems encountered in reconstructive surgery is partial or total flap loss, and venous congestion is the most common reason. It should be solved as early as possible. The purpose of this study is to investigate the effects of Negative pressure wound therapy (NPWT) on an ideal congested rabbit skin flap model without any open wound. The current study included 28 female, adult, New Zealand albino rabbits. Animals were divided into four groups according to the duration of NPWT to be applied. An axial pattern ideal congested skin flap was designed on the posterior surface of the ear. After surgical intervention on the right ears, we applied NPWT treatment for 2, 4, 6 and 8 days. The left ears were followed without any treatment. Samples were taken for edema, congestion and neo-angiogenesis examination. There was no significant difference between the NPWT applied group and control group in the 2nd, 4th, 6th, and 8th days for edema and neo-angiogenesis and no differences in the 2nd, 6th, and 8th days for congestion. NPWT group had a higher flap survival rate than the control group but without a significant difference. This study used an ideal congested rabbit skin flap model imitating venous congestion. Our findings illustrate that NPWT treatment does not have a significant effect on the congested skin flap model we utilized where a closed system was created maintaining a skin barrier without a bare surface of the flap. Level of Evidence: Level I, experimental study

Computer-Aided Design and Manufacturing versus Conventional Surgical Planning for Head and Neck Reconstruction: A Systematic Review and Meta-Analysis.

Virtual surgical planning and computer-aided design/computer-aided manufacturing (CAD/CAM) for complex head and neck reconstruction has a number of cited advantages over conventional surgical planning, such as increased operative efficiency, fewer complications, improved osseous flap union, immediate osseointegrated dental implant placement, and superior functional and aesthetic outcomes. The authors performed a systematic review and meta-analysis of the available evidence on CAD/CAM maxillofacial reconstruction with the primary purpose of determining which approach is more efficacious. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a PubMed and Embase database search was performed to identify English-language, human-subject studies of CAD/CAM-assisted head and neck reconstruction. All comparative studies were included in a meta-analysis to identify differences in operative time, ischemia time, surgical-site occurrence, microvascular complication, and partial or total flap loss between the two groups. All included studies (comparative and noncomparative) were used in the systematic review, summarizing the various flap characteristics, technical nuances, and functional and aesthetic outcomes. Twelve articles were included in the meta-analysis, representing 277 patients in the CAD/CAM group and 419 patients in the conventional group. CAD/CAM was associated with 65.3 fewer minutes of operating room time (95 percent CI, -72.7 to -57.9 minutes; p < 0.0001) and 34.8 fewer minutes of ischemia time (95 percent CI, -38 to -31.5 minutes; p < 0.0001). There were no significant differences in surgical-site occurrence, nonunion, flap loss, microvascular complications, or hardware-related complications. CAD/CAM is associated with shorter operating room and ischemia times. There are no significant differences in flap or hardware-related complications between CAD/CAM and conventional surgical planning.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction.

The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

The use of machine learning for predicating complications of free flap head and neck reconstruction.

e18633 Background: The use of machine learning (ML) in plastic and reconstructive surgery has increased over the last decade. However, its use to predict surgical outcomes in head and neck reconstruction has not been well studied. The goal of this study is to assess the performance of ML algorithms trained to predict surgical outcomes of head and neck free flap reconstruction. Methods: Our study cohort included routinely collected data from 4000 patients who underwent free flaps for reconstruction of head and neck defects between January 2005 and December 2018. We developed and tested nine supervised ML algorithms to predict three outcomes of a.) any complication, b.) any major recipient-site complication, and c.) total flap loss. Results: In our sample, 33.7% of patients experienced any complication, 26.5% experienced a major complication at the recipient site and 1.7% experienced total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = .61, sensitivity = .60). Regularized regression had the best performance for predicting major recipient site complication (AUROC=.68, sensitivity = .66), and decision trees were the best predictors of total flap loss (AUROC = .66, sensitivity = .50). Conclusions: We demonstrated that ML models trained using routinely collected data can make clinical useful predictions about who will experience complications. Our models correctly identified between half and two-thirds of patients who experienced post-surgical complications including total flap loss. These models can be applied to readily available clinical and perioperative data to facilitate decision making. Further performance improvements are likely possible with the inclusion of additional variables related to patient health and behavior.

Technical Considerations and Outcome Analysis of Using Extended Bipaddle Pectoralis Major Myocutaneous Flaps for Reconstructions of Large and Complex Oral Cavity Defects: Expanding the Horizons.

The online version contains supplementary material available at 10.1007/s13193-021-01345-1.