Vascularized Flap Research Articles

Revisiting the Use of Deep Temporalis Fascia Grafts in Ophthalmology

ABSTRACT Purpose To report new indications for deep temporalis fascia (DTF) grafts in the ophthalmic field. Methods Monocentric retrospective interventional case series study. All the patients who underwent a DTF graft in an unpublished new indication over the study period (May 2020–October 2023) were included. For each patient, gender, age, graft indication, outcomes, complications, and follow-up duration were collected. In most cases, the DTF graft was covered by a vascularized flap. Results Eight patients underwent a DTF graft over the study period. The indications were: radiotherapy-induced scleral necrosis in three cases, tendinoplasty to replace the inferior rectus muscle tendon invaded by a locally advanced conjunctival carcinoma in one case, Ahmed glaucoma valve tube exposure in one case, intraocular lens with scleral fixation exposure in one case, orbital cerebrospinal fluid fistula (orbitorrhea) in one case, and post-traumatic complete corneal graft loss in one case. The DTF graft was successful in 87.5% of cases after a mean follow-up of 11.4 months. No complications were observed. Conclusions DTF graft is a highly versatile graft that can be easily harvested. New indications for DTF grafts may include the repair of radiotherapy-induced scleral necrosis, the creation of oculomotor tendon and the temporary packing of large ocular tissue loss in an emergency context. Further studies with a longer follow-up are needed to confirm our preliminary results.

Long-Term Treatment Outcome of a Patient with Extensive Circular Soft Tissue Defect of the Distal Third of the Lower Extremity: A Case Report

Background. Open fractures of the lower leg bones associated with extensive soft tissue defects are among the most challenging in trauma surgery.
 Aim of the study is to demonstrate the possibilities of modern reconstructive surgery in the treatment of severe polystructural trauma of the lower limb using a unique clinical example.
 Case description. An 18-year-old patient sustained a polytrauma which included head and extremities injuries as a result of a fall under a moving train. Due to the signs of uncompensated ischemia of the left lower limb at the first stage of treatment the patient underwent emergency left tibial artery thrombectomy, repeated debridement of the left lower leg wound, remounting of the external fixator, and lumbar sympathectomy. The second stage of surgical treatment included free transplantation of a vascularized anterolateral flap of the right thigh. The third stage included staged necrectomies; replacement of the soft tissue defect of the posteromedial surface of the distal lower leg with a sural fasciocutaneous vascularized flap on the distal vascular pedicle from the contralateral tibia; the fourth stage included cutting off the fasciocutaneous cross flap. At the follow-up, 2 years after the end of the treatment the patient complained of persisting swelling of the foot, which occurred during prolonged standing in the upright position and required elastic compression of the ankle joint. The cause of the swelling was impaired lymphatic outflow due to the damage to all venous collaterals in the injury area. She walks with full load on the injured limb without additional support. There is no pain syndrome, foot sensitivity is fully preserved.
 Conclusion. Presented clinical case demonstrates the possibility of successful replacement of an extensive circular defect of the distal lower leg using sequentially free and non-free vascularized tissue complexes.

Vascularized fascial flap for reconstruction of combined oral mucosa-mandibular defects: The multi-modal biological assessment

ObjectiveThe reconstruction of composite defects in the oral and maxillofacial region using vascularized fascial flaps, such as the fibular, iliac, and temporal fascial flaps, has gained increasing attention among surgeons. However, there remains uncertainty regarding the suitability of fascial flaps as transplants, as well as their healing processes and outcomes, due to their non-mucosal nature. This study aims to comprehensively assess the biological aspects of vascularized fascial flaps at clinical, histological, and genetic levels, with the goal of providing essential biological references for their clinical application. Study DesignThis study enrolled three patients who underwent reconstruction of combined oral mucosa-mandibular defects using fibular vascularized fascial flaps between 2020 and 2023. Data regarding changes in the appearance of the fascial flaps, bulk-RNA sequencing, and histological slices of initial fascia, initial gingiva, and transformed fascia were collected and analyzed. ResultsWithin three months, the fascial flaps exhibited rapid epithelial coverage and displayed distinct characteristics resembling mucosa. High-throughput RNA sequencing analyses and histological slices revealed that the transformed fascia exhibited tissue structures similar to mucosa and demonstrated unique advantages in promoting blood vessel formation and reducing scarring through the high-level expression of relevant genes. ConclusionThese findings emphasize the potential and feasibility of utilizing vascularized fascial flaps for oral mucosa reconstruction, establishing their unique advantage as transplant materials, and providing significant biological information and references for their selection and clinical application.

Modified reverse septal flap: A surgical hint

AbstractEndoscopic resection with transnasal craniectomy (ERTC) and skull‐base reconstruction (SBR) are effective techniques for sinonasal/skull‐base malignancies treatment. Endoscopic endonasal SBR techniques are mainly based on homologue‐free grafts with excellent outcomes, but alternative techniques can be used such as regional vascularized pedicled flaps or local pedicled flap‐like Hadad–Bassagasteguy nasoseptal flap and the septal flip flap (SFF). The purpose of this article is to describe an inferiorly based septal flap aimed to promote mucosal healing and improve patients’ quality of life. We reported a clinical case of 51‐year‐old female affected by olfactory neuroblastoma, Hyams‐Ⅱ, Kadish‐INSICA‐B treated with unilateral ERTC and SBR with fascia lata, SFF, and modified reverse septal flap (mRSF). The mRSF harvesting is described in detail, to obtain a lower hinged flap with random vascularization, which can be rotated to cover the exposed bone of the nasal cavity floor. Endoscopic evaluations immediately showed rapid healing with a minimal amount of nasal crusting, despite the adjuvant treatment and the short time since the surgery. This surgical technique is a simple and viable way to boost nasal healing after endoscopic endonasal surgery and for nasal floor resurfacing after septal removal following a unilateral ERTC.

Application and research advances of delayed sural neurotrophic vascular flap for diabetic foot ulcers

Diabetic foot ulcer is one of the serious complications of diabetes. Diabetic wounds are of great difficulty to repair, causing a high amputation rate and a great burden to patients and their family members and society. Researches showed that the delayed sural neurotrophic vascular flap has a great effect in repairing diabetic foot ulcers. This article mainly reviewed the clinical status and research advances of the delayed sural neurotrophic vascular flap in repairing diabetic foot ulcers, intending to provide a reference for its application and research.

Coverage for the vascular pedicle of a free fasciocutaneous flap using split thickness skin graft with auxiliary procedure to achieve a safe method with no impairment of vessels: a case series and literature review

BackgroundThe vascular pedicle of a free flap is the most critical structure that determines its viability. Most of the times it is covered with local skin flaps raised from the recipient site or with part of the free flap itself. However, there are conditions in which the vascular pedicle can be covered with skin graft. The purpose of the present study is to describe our experience in the use of split-thickness skin grafts (STSG) as an auxiliary procedure for pedicle coverage.MethodsAll patients who underwent microvascular fasciocutaneous free flap reconstruction at the Department of Plastic Surgery of China Medical University Hospital in Taichung from 1986 to 2021 were retrospectively evaluated. Patients who met all of the following criteria were eligible for the study: microvascular free flap reconstruction of any region of the body with a fasciocutaneous flap and cases where tension was detected during skin closure over the pedicle of the flap and STSG was applied as a cover.ResultsThere were 14 cases in this series treated from 1986 to 2021. Among them, 11 cases had no additional skin at the proximal end of the free flap, nor local flap at disposal in the recipient site to cover the vessels. In 3 other cases a vascular bridge flap was used for cross-leg flap transfer without possibility of tension free tubulization to protect the vessels. All reconstruction were successful.ConclusionsDuring microvascular transfer of free flaps, if no skin flap is available to cover the vascular pedicle, skin graft can be used to protect the vessels without compromising the circulation of the flap. Our results, in accordance with the literature, supports the safety of this technique when direct closure of the skin above and near the pedicle is not possible.Level of evidenceLevel IV, Therapeutic.

Bilateral reconstruction of palmar soft tissues defects of the hands after thermal injury

Introduction Thermal injury to the palmar surface of the hand is usually complicated by flexion desmogenic contracture of the finger joints. This condition is more complicated with significant wound areas and depths of soft tissue destruction. Conventional surgical methods and soft tissue reconstructions may fail to provide full restoration of the hand function.The objective was to present the optimal treatment strategy for patients with scar flexion contractures of the fingers after thermal injury to the palmar surface of both hands using a pediatric case report.Material and methods A child aged 2 years and 4 months underwent surgical treatment to include excision of scars, skin grafting of both hands with a vascularized fasciocutaneous flap raised with the radial artery.Result The patient could regain all types of hand grip on both sides 12 years after surgical treatment. Both hands were aesthetically acceptable.Discussion Treatment of patients with thermal injury and substantial soft tissue damage is a complex disease process. Conservative treatment and surgical procedures using non-vascularized skin flaps are normally used for the condition. These approaches are associated with cicatricial and arthrogenic flexion contracture of the finger joints. The radical treatment includes thorough wound debridement and early flap coverage and wound closure using a flap with an axial-pattern blood supply, free flaps and reverse-flow flaps. The surgical approach helps to avoid flexion contracture of the fingers initiating early restoration of professional, social stereotypes and stereotypes in everyday life.Conclusion The clinical observation has shown the possibility of one-stage organ-preserving surgical treatment using flaps with an axial blood supply.

Utilizing a Second Flap to Address the Effect of Postradiotherapy Soft Tissue Fibrosis in Head and Neck Malignancy.

Background Late effects of adjuvant radiation therapy (RT) on soft tissues can lead to hair loss, pigmentary changes, loss of tissue volume, and fibrosis, which appear months to years after the treatment. These changes are often progressive and are because of tissue hypoxia due to radiation-induced capillary endothelial damage. Tissue hypoxia may be compounded by subclinical infection following minor trauma, exposed hardware, or associated osteoradionecrosis. The combined effect of these factors causes significant deformities in soft tissue, affecting both function and appearance. Such changes are also seen in primarily transferred flaps, which have been radiated, resulting in severe, progressive soft tissue fibrosis, compromising function and aesthetics. In selected cases, a second flap may be needed to restore function and volume. Methods Data of patients who underwent secondary soft tissue transfers for postradiotherapy-related soft tissue changes were collected from the hospital electronic medical records, from January 2019 to 2023. Details regarding the primary surgery, dose, duration of adjuvant RT, time interval between adjuvant RT and secondary soft tissue transfer, indications, and the choice of the second flap were analyzed. Results Twenty-one patients had undergone secondary soft tissue transfer for extensive soft tissue fibrosis. In addition, associated compounding features like exposed implant and volume loss were observed. Two patients with osteoradionecrosis also had associated extensive soft tissue fibrosis necessitating replacement. Out of these 21 patients, 13 had undergone free tissue transfers, while 7 locoregional tissue transfers. Conclusion Late sequelae of adjuvant RT changes usually present from 6 months onwards. The radiated hypoxic tissue, due to capillary damage, leads to a chronic progressive fibrotic stage, causing loss of soft tissue volume and fibrosis. Replacing this tissue with a vascularized flap helps to restore volume and correct these secondary changes, improving overall quality of life.

Evaluation of Tubularized Incised Plate Urethroplasty with Spongioplasty-Dartosoraphy Reinforcement in Pediatric Hypospadias: A Randomized Controlled Study.

The original description of tubularized incised plate urethroplasty (TIPU) was provided by Snodgrass in 1994. The results were significantly improved by several modifications. To decrease the incidence of complications, interposing a vascularized flap after tubularization of the neourethra is recommended. The extent to which the type of interposed tissue has a direct effect on the rate of complications and cosmetic outcomes after TIPU repair is considered the answer to the main hypothesis of this study. This prospective controlled randomized trial was conducted in the Department of Pediatric Surgery, Al-Azhar University, Cairo, Egypt, between May 2019 and May 2023. A total of 220 patients were included in this study. Patients were randomly assigned to either group A or group B. Group A included 110 patients who underwent TIPU with spongioplasty-dartosoraphy reinforcement. The other 110 patients (group B) underwent TIPU with dorsal dartos flap interposition, without spongioplasty. Complications developed in 34 of 220 patients (15.4%). In group A, complications developed in 11 of 110 patients (10.0%). In group B, complications occurred in 23 of 110 patients (20.9%). Although the fistula rate, glanular dehiscence, disruption, and meatal stenosis were not significantly different between the study groups, the skin necrosis rate was significantly lower in group A than in group B. The overall complication rate was significantly lower in group A than in group B. Also, the difference in the mean Hypospadias Objective Scoring Evaluation between the two groups was statistically significant. TIPU with spongioplasty-dartosoraphy reinforcement is an effective modification of conventional TIPU. This modification appears to reduce the rate of complications and yield better cosmetic outcomes.

Vascularized Tissue to Reduce Fistula After Salvage Total Laryngectomy: A Network Meta-analysis.

Salvage laryngectomy is more predisposed to complications than primary operations, with pharyngocutaneous fistula (PCF) being among the most challenging to manage. Vascularized flaps are increasingly employed during salvage laryngectomy, with a previous review finding a PCF incidence of 31.2% and 22.2% after primary and flap-assisted closure respectively. We aim to better define the role of vascularized flaps after salvage laryngectomy by performing an updated review comparing the rate of PCF in those undergoing primary or vascularized flap-assisted closure. Pubmed/Medline, CINAHL, and CENTRAL. An updated literature review was conducted of English language literature from 2003 to 2023. A random effects and network meta-analysis of odds ratios (OR) and pooled proportions were conducted. Literature search found 31 studies, including seven from the previous review. Overall random effects pooled PCF rate was 25% (95% CI 0.21; 0.30, I2 = 72%, p = <0.01), whereas incidence in primary closure was 37% (95% CI 0.32; 0.43, I2 = 60%, p = <0.01) and 19% (95% CI 0.12; 0.20, I2 = 47%, p = <0.01) after flap closure. Pooled OR was 0.39 (95% CI 0.28; 0.55, I2 = 36%, p = 0.04) in favor of vascularized tissues. The number needed to treat was 6.5. The rate of PCF was lower after free and pedicled flaps, and on-lay and patch closure compared to primary closure techniques. Network meta-analysis found all combinations of closure techniques and vascularized tissue were superior to primary closure. The updated analysis has demonstrated a widening in the rates of PCF between primary and vascularized flap-assisted closure. Surgeons should strongly consider the use of free or pedicled flaps in any salvage laryngectomy procedure. Laryngoscope, 134:2991-3002, 2024.

Prediction of vascular complications in free flap reconstruction with machine learning.

This study aims to explore the risk factors of vascular complications following free flap reconstruction and to develop a clinical auxiliary assessment tool for predicting vascular complications in patients undergoing free flap reconstruction leveraging machine learning methods. We reviewed the medical data of patients who underwent free flap reconstruction at the Affiliated Hospital of Zunyi Medical University retrospectively from January 1, 2019, to December 31, 2021. Statistical analysis was used to screen risk factors. A training data set was generated and augmented using the synthetic minority oversampling technique. Logistic regression, random forest and neural network, models were trained, using this dataset. The performance of these three predictive models was then evaluated and compared using a test set, with four metrics, area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. A total of 570 patients who underwent free flap reconstruction were included in this study, 46 of whom developed postoperative vascular complications. Among the models tested, the neural network model exhibited superior performance on the test set, achieving an AUC of 0.828. Multivariate logistic regression analysis identified that preoperative hemoglobin levels, preoperative fibrinogen levels, operation duration, smoking history, the number of anastomoses, and peripheral vascular injury as statistically significant independent risk factors for vascular complications post-free flap reconstruction. The top five predictive factors in the neural network were fibrinogen content, operation duration, donor site, body mass index (BMI), and platelet count. Hemoglobin levels, fibrinogen levels, operation duration, smoking history, and anastomotic veins are independent risk factors for vascular complications following free flap reconstruction. These risk factors enhance the ability of machine learning models to predict the occurrence of vascular complications and identify high-risk patients. The neural network model outperformed the logistic regression and random forest models, suggesting its potential to aid clinicians in early identification of high-risk patients thereby mitigating patient suffering and improving prognosis.

Hypospadias with Intact Prepuce: A Spectrum of Anomalies and their Reconstruction.

The aim of the study was to perform a detailed analysis of the clinical characteristics of megameatus with intact prepuce (MIP) and to audit our results of reconstructive surgeries on MIP. Design: Retrospective analysis. Setting: Pediatric surgery department of tertiary level. Subjects, methods: Hospital records and pictures of MIP operated over a 9-year period. Age, size of penis, circumcised or not, shape of glans, external urethral meatus (EUM), urethral plate (UP), chordee, distal urethra, reconstructive surgery, and complications were analyzed. Postoperative result was objectively assessed by Hypospadias Objective Scoring Evaluation (HOSE). Twelve of 254 hypospadias were MIP (incidence = 4.72%). The mean age at operation was 38.25 months (12-87 m). Patients sought circumcision or surgical correction of anomaly. Two patients were precircumcised. MIP was coronal 7, subcoronal 3, and glanular 2. Meatus was wide in 10 and normal in 2. Glans penis was wide in 9 and conical in 3. UP was wide (9), moderately wide (2), or narrow and shallow (1). In two cases of wide deep UP, distal septum was present. Distal urethra was nondilated in all but 1, which had megalourethra. Reconstructive surgery was Tubularized Urethral Plate Urethroplasty (7 cases) or classical Snodgrass (Tubularised incised plate urethroplasty (TIPU), with superimposed vascular dartos flap (5 cases). The megalourethra underwent partial excision and TIPU. Distal UP-septum was incised. Urethral injury (2 cases) and UP injury (1 case) were intraoperative complications. One postoperative complication (ventral glans necrosis) resulted. The mean follow-up period was 4.79 months (1-12 m). In the postoperative follow-up, 11 (92%) had HOSE score 14-16, whereas one had HOSE 13. Some hypospadias cases which have intact prepuce have no megameatus; hence, they cannot be termed MIP. All cases of hypospadias having intact prepuce can be covered by the umbrella term "Hypospadias with Intact Prepuce (HIP);" MIP is a large subgroup under HIP. HIP presents with a spectrum of anomalies of glans, EUM, and UP. Repair by tubularization of UP without or with midline incision gives excellent results.

Effect of Perioperative Blood Transfusion on Postoperative Complications of Free-Flap Reconstruction for Oral Cancer: Analysis of Propensity Score-Matched Cohorts

Abstract Background It has been confirmed in other fields that perioperative blood transfusion (PBT) will increase the incidence of complications after free-flap reconstruction and increase the risk of patients returning to the operating room within 48 hours after the initial operation. However, for head and neck tumors, whether PBT is related to postoperative complications is debatable. The aim of this study was to control the demographic and comorbidity characteristics of patients by propensity score matching (PSM) as well as to investigate the relationship between PBT and postoperative complications after oral cancer free-flap reconstruction. Methods A total of 597 patients who underwent microvascular free tissue transfer in two top three hospitals in Southwest China from January 2015 to July 2023 were retrospectively reviewed. The study population was divided based on PBT within 24 hours of the start of the operation and to ensure homogeneity between groups by using the PSM. The primary outcomes were postoperative complications; secondary outcomes were to explore the intraoperative risk factors of PBT. Results A total of 597 patients were included. Among them, 90 patients received a PBT. Those patients were successfully matched with 86 similar patients who did not receive a transfusion on a ratio of 1:1. This study did not find that patients receive a transfusion had a significantly higher risk of vascular pedicle thrombosis (p = 1.000), hematoma (p = 1.000), flap failure (p = 0.398), flap-related complications (p = 0.470), and other medical complications (p = 1.000). After controlling the preoperative confounding factors and adjusting the logistic regression model, it was concluded that the tumor location-mandible (odds ratio [OR] = 19.923, 95% confidence interval [CI]: 1.213–327.302, p = 0.036) and operation time (OR = 1.011, 95% CI: 1.008–1.014, p &lt; 0.001) were the intraoperative risk factors for PBT. Conclusion PBT is not associated with an increased probability of postoperative complications. Mandibular tumor may have a higher risk of PBT.

Free Flap Perfusion in Microvascular Head and Neck Reconstruction: Influence of the Number of Ischemia Intervals and Ischemia Duration-A Retrospective Study.

In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion. Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration. Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis. The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.

Myomucosal island flaps for oropharyngeal reconstruction

The oropharynx represents one of the most challenging areas to reconstruct for the head and neck surgeon. The buccinator myomucosal island flaps pedicled on the facial artery [tunnelized facial artery myomucosal island flap (t-FAMMIF)] or the buccal artery [buccal artery myomucosal island flap (BAMMIF)] are an ideal reconstructive option for moderate size defects measuring up to 8–9cm. Two fresh specimens have been used to show the step-by-step surgical technique of both island flaps. Design and flap extension, dissection plane, identification of the vascular pedicle, flap rotation and insetting are described. Reconstructive indications and the pros and cons of each one are discussed in this article. Myomucosal island flaps represent a very useful and versatile option for the functional reconstruction of the oropharynx. A detailed knowledge of the vascular anatomy of the cheek is key to obtain a large flap while minimizing the risk of complications.

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization.

Autonomization is a physiological process allowing a flap to develop neo-vascularization from the reconstructed wound bed. This phenomenon has been used since the early application of flap surgeries but still remains poorly understood. Reconstructive strategies have greatly evolved since, and fasciocutaneous flaps have progressively replaced muscle-based reconstructions, ensuring better functional outcomes with great reliability. However, plastic surgeons still encounter challenges in complex cases where conventional flap reconstruction reaches its limitations. Furthermore, emerging bioengineering applications, such as decellularized scaffolds allowing a complex extracellular matrix to be repopulated with autologous cells, also face the complexity of revascularization. The objective of this article is to gather evidence of autonomization phenomena. A systematic review of flap autonomization is then performed to document the minimum delay allowing this process. Finally, past and potential applications in bio- and tissue-engineering approaches are discussed, highlighting the potential for in vivo revascularization of acellular scaffolds.

Capitellum Reconstruction Using Metatarsal Head Vascularized Transfer

Treatment for the sequelae of capitellum fractures is not commonly described in the literature. We present a unique case of a capitellum reconstruction with a vascularized ossseus graft from the second metatarsal bone. A woman of 53 years old fell down and presented a capitellum fracture that was fixed with two cannulated screws, after 6 months the radiograph showed signs of necrosis of the capitellum, the patient was disabled and a surgery was offered. We reconstructed her capitellum by means of a vascularized osteochondral flap from the second metatarsal bone, and end-to-side anastomosis to the radial artery was performed and two cannulated screws were used to fix the graft to the humeral lateral column. After almost two years of follow up the patient is free of pain and is able to perform the activity of the daily live. The vascularized transfer from the foot is a valid technique for the reconstruction of the capitellum in non-synthesizable fractures mainly when the lateral column of the humerus is affected. The complications in the donor site are minimal.

Three cases of uncommon medication‐associated osteonecrosis of temporal bone

AbstractIntroductionMedication‐related osteonecrosis of the temporal bone is rare and has been reported to be associated with the use of anti‐resorptive and biologic agents. Here, we present the first case of tyrosine‐kinase inhibitor‐related external auditory canal (EAC) osteonecrosis as well as two cases related to anti‐resorptive therapies.MethodsA retrospective case series.ResultsCase one: an 84‐year‐old female presented with chronic otitis externa and osteonecrosis of EACs bilaterally. She had a history of osteoporosis treated with denosumab and risedronic acid. She successfully underwent left EAC reconstruction using an inferiorly‐based pedicle periosteal flap while the right ear canal was managed conservatively. Case two: a 69‐year‐old male presented with osteonecrosis of the right EAC. He had a history of osteoporosis treated with alendronic acid and zoledronic acid. His osteonecrosis is conservatively managed with local debridement and antibiotic application. Case three: a 60‐year‐old male presented with osteonecrosis of the right inferior EAC. He had a history of chronic myelogenous leukemia treated with a tyrosine‐kinase inhibitor, imatinib. After failing conservative therapy, he underwent right ear canal reconstruction using a periosteal vascular pedicle flap without complication and experienced complete resolution to his symptoms.ConclusionAnti‐resorptive agents and/or tyrosine kinase inhibitors may lead to dysregulation of bone remodeling and result in rare cases of temporal bone osteonecrosis. When a local debridement and antibiotic therapy fail, definitive surgical excision of necrotic bone with subsequent reconstruction of the EAC may offer patients a possible resolution in symptoms.

Clinical analysis of diversity of defect repair with supraclavicular island flap after head and neck tumor surgery

Objective:To investigate the diversity and clinical effect of supraclavicular island flap in repairing the defect after head and neck tumor surgery. Methods:A retrospective analysis was performed on 30 patients who received the repair of head and neck defects with supraclavicular island flaps at Department of Otorhinolaryngology Head and Neck Surgery of the First Affiliated Hospital of Chongqing Medical University from January 2017 to March 2023. The sites and types of defects, intraoperative blood loss, time of flaps preparation, areas of flaps, survival of the flaps and other complications were recorded. Results:A total of 30 patients were enrolled, including 26 males and 4 females, aged 36-82 years. Among them, 22 patients with hypopharyngeal partial defect were repaired （19 patients with ipsilateral defect and 3 patients with contralateral defect）. In addition, 2 patients were repaired with contralateral pectoralis major musculocutaneous flap around the hypopharynx, the neck skin defect was repaired in 2 patients, the parotid skin defect was repaired in 2 patients, the temporal bone skin defect was repaired in 1 patient, and the cervical esophageal defect was repaired in 1 patient. The average blood loss during the operation was 8 ml, and the average time was 32 min. The flap areas ranged from 5.0 cm×4.0 cm to 20.0 cm×8.0 cm. 27 of 30 flaps survived（90.0%）, and pharyngeal fistula occurred in 6 patients after operation（4 flaps survived after local dressing）. One patient was complicated with venous thrombosis（the flap necrosis after local dressing）. Shoulder and neck functions（lift, internal rotation and abduction） were not significantly affected in 29 patients, and the function of 1 patient with shoulder infection was not affected after treatment. Conclusion:Supraclavicular island flap is a highly vascularized axial fascial flap. It is easy to make, thin, and soft in texture, and can be used to repair different sites and types of postoperative head and neck tumor defects with a low donor site complication rate. Good results in post-operative repair of head and neck tumors are worth promoting.

Application of a modified osteotomy and positioning integrative template system (MOPITS) based on a truncatable reconstruction model in the precise mandibular reconstruction with fibula free flap: a pilot clinical study

BackgroundMandibular defects can greatly affect patients' appearance and functionality. The preferred method to address this issue is reconstructive surgery using a fibular flap. The current personalized guide plate can improve the accuracy of osteotomy and reconstruction, but there are still some problems such as complex design process and time-consuming. Therefore, we modified the conventional template to serve the dual purpose of guiding the mandible and fibula osteotomy and facilitating the placement of the pre-bent titanium.MethodsThe surgery was simulated preoperatively using Computer-Aided Design (CAD) technology. The template and truncatable reconstruction model were produced in the laboratory using 3D printing. After pre-bending the titanium plate according to the contour, the reconstruction model was truncated and the screw trajectory was transferred to form a modified osteotomy and positioning integrative template system (MOPITS). Next, the patient underwent a composite template-guided vascularized fibula flap reconstruction of the mandible. All cases were reviewed for the total operative time and accuracy of surgery.ResultsThe procedures involved 2–4 fibular segments in 15 patients, averaging 3 fibular segments per procedure. The osteotomy error is 1.01 ± 1.02 mm, while the reconstruction angular error is 1.85 ± 1.69°. The preoperative and postoperative data were compared, and both p > 0.05. During the same operation, implant placement was performed on four patients, with an average operative time of 487.25 ± 60.84 min. The remaining malignant tumor patients had an average operative time of 397.18 ± 73.09 min. The average postoperative hospital stay was 12.95 ± 3.29 days.ConclusionsThis study demonstrates the effectiveness of MOPITS in facilitating precise preoperative planning and intraoperative execution of fibula flap reconstruction. MOPITS represents a promising and reliable tool for reconstructive surgery, particularly for inexperienced surgeons navigating the challenges of mandible defect reconstruction.