The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: One surgeon's experience in 92 cases

Single-stage computer-assisted approach for tumour resection and functional restoration of Brown class III maxillary defects-titanium mesh and zygomatic implants combined with vascularized anterolateral thigh flap

The functional restoration of Brown class III maxillary defects is a challenging endeavour in oral and maxillofacial surgery. Conventional reconstruction techniques with osseous free flaps have certain limitations, such as the need for multiple operations and greater patient morbidity. This study introduces a single-stage computer-assisted approach for tumour resection and functional restoration of these defects using titanium mesh, zygomatic implants, and a vascularized anterolateral thigh flap (ALTF). Virtual surgical planning was used to simulate tumour resection, titanium mesh placement, and zygomatic implant insertion. Surgery was performed under the guidance of mixed reality and surgical navigation. The tumour was resected by total hemimaxillectomy, and the reconstruction was performed using a pre-bent patient-specific titanium mesh for the orbital floor and two zygomatic implants placed and exposed through tunnels in an ALTF. The ALTF survived without any perioperative complications. A fixed prosthesis with built-in titanium frame was delivered 4 months postoperatively. At the 1-year follow-up, there was no tumour recurrence, the implants were osseointegrated, and aesthetics and masticatory function were satisfactory. An occlusal force of 155 N was attained on the reconstructed side, compared to 127 N on the non-surgical side.

Efficacy and Safety of Microsurgical Pharyngolaryngeal and Pharyngoesophageal Reconstruction: A Systematic Review of the Literature

Restoration of function and complication management after pharyngolaryngectomy remains a challenging task. The aim of our study was to compare the functional and clinical outcomes of pharyngolaryngeal and pharyngoesophageal reconstruction using free flaps, namely jejunal (FJF), anterolateral thigh, and radial forearm, and describe a reconstructive approach for these defects following tumor resection.

Methods

We performed a systematic literature review on PubMed (Medline), Embase and Cochrane Library over the last two decades for articles reporting the surgical reconstructive modalities available after total or partial pharyngeal and/or laryngeal resection using a structured search strategy and strict inclusion and elimination criteria.

Results

Our search identified a total of 677 articles, 112 full texts were fully reviewed for eligibility, and 39 met the inclusion criteria. The use of both FJF and fasciocutaneous flaps is safe. The FJF has optimal swallowing outcomes and a low incidence of major recipient-site complications. Nevertheless, free fasciocutaneous flaps exhibit comparable functional results, while they seem linked with fewer cases of perioperative mortality and flap failure. However, none of the currently available techniques can combine all potential benefits.

Conclusions

Despite these procedures being mainly palliative in nature, the advent of microvascular techniques and utilization of fasciocutaneous free flaps has allowed optimal restoration of function combined with a reduced rate of perioperative and longterm complications. Both FJF and fasciocutaneous flaps can be viable treatment options, depending on the expertise of the surgeon and patient selection, to ensure the best outcomes.

Use of free flaps with supermicrosurgery for oncological reconstruction of the maxillofacial region

Supermicrosurgery involves the dissection and anastomosis of vessels<0.8 mm in diameter with minimal donor site morbidity. This study evaluated the feasibility and outcomes of free flaps using supermicrosurgery to repair oncological defects in the maxillofacial region. Forty-two patients were treated with supermicrosurgery to repair oncological defects in the maxillofacial region between December 2015 and February 2021. The supermicrosurgery technique was used for different types of free flap, including 24 superficial circumflex iliac artery perforator flaps, seven anterolateral thigh flaps, three peroneal artery perforator flaps, five medial femoral condyle osteo-adipofascial flaps, and three profunda artery perforator flaps. An artery-to-artery approach was used in 38 patients; venous grafts for anastomosis were used in four patients to resolve an arterial discrepancy. Forty-one flaps (97.6%) survived. Thirty-six patients (85.7%) healed without any complications; three flaps required revision surgery including one lost, one demonstrated wound dehiscence, and two demonstrated wound infection. Supermicrosurgery is a useful complement to conventional microsurgery in head and neck reconstruction.

Anterolateral thigh butterfly free flap for reconstruction of laryngopharyngeal defect: surgical considerations

Background

Reconstruction of a pharyngoesophageal defect remains a challenging problem, especially with involvement of the neck skin. This study aimed to demonstrate the surgical technique of utilising a butterfly modification of the anterolateral thigh flap.

Results

Reconstruction of the pharyngoesophageal defect was accomplished using the butterfly modification of the anterolateral thigh free flap. The flap was tubed on the leg while still being attached to the pedicle, to minimise the ischaemia time.

Conclusion

Butterfly anterolateral thigh free flap allows for multi-layer closure of the neopharynx and can be utilised for reconstruction of pharyngoesophageal and neck skin defects.

Prophylactic fasciotomy of the anterolateral thigh donor site in head and neck reconstruction

INTRODUCTION

The free anterolateral thigh (ALT) flap is a versatile reconstructive option for head and neck defects. Donor site complications are rare but severe; with wound dehiscence, need for secondary closure, and compartment syndrome reported.

OBJECTIVES

We propose prophylactic thigh fasciotomy as a surgical technique to facilitate primary closure while preventing donor site complications during ALT flap harvest.

METHODS

We examined donor site wound characteristics, recipient site wound characteristics, and clinical outcomes for 24 consecutive ALT flaps performed for head and neck reconstruction from 2016 to 2018. All ALT donor sites underwent prophylactic fasciotomy.

RESULTS

There were no incidents of thigh compartment syndrome or wound dehiscence of donor site; one patient underwent primary donor site skin grafting.

CONCLUSION

Prophylactic thigh fasciotomy allows mobilization of soft tissue to facilitate primary tension-free closure of the ALT donor site even for free flaps with a large skin component, while reducing the possibility of compartment syndrome.

Comparison between anterolateral thigh free flap and jejunal flap for tissue reconstruction in patients underwent resection of pharyngoesophageal squamous cell carcinoma after radiotherapy failure: a retrospective study

BACKGROUND

Anterolateral thigh (ALT) free flap and jejunal flap (JF) were commonly used in tissue reconstruction for pharyngoesophageal squamous cell carcinoma (PESCC) with worsening tissue adhesion and necrosis after radiotherapy failure. However, the results of tissue reconstruction and postoperative complications of these two flaps are controversial. The purpose of this study was to compare outcomes between group ALT free flap and group JF in PESCC after radiotherapy failure.

METHODS

Intraoperative information and postoperative outcomes of patients with PESCC after radiotherapy failure who underwent ALT and JF reconstruction from January 2005 to December 2019 were compared and analyzed.

RESULTS

The defect size of ALT (Numbers, 34) and JF (Numbers, 31) was 36.19 ± 11.35 cm² and 35.58 ± 14.32 cm² (p = 0.884), respectively. ALT and JF showed no significant difference in operation time (p = 0.683) and blood loss (p = 0.198). For postoperative outcomes within 30 days both in recipient site and donor site including wound bleeding, wound dehiscence, wound infection, and pharyngocutaneous fistula, ALT free flap and JF showed similar results. Flap compromise (Numbers, 2 VS.3, p = 0.663), flap take backs (Numbers, 1 VS.1, p = 1.000), partial flap failures (Numbers, 4 VS.2, p = 0.674), and total flap failures (Numbers, 0 VS.0, p = 1.000) showed no difference between the two groups. In addition, no significance was found in hypoproteinemia between the two groups (Numbers, 4 VS.2, p = 0.674). ALT free flap was not statistically different from JF in the incidence of dysphagia at the postoperative 6 months (Numbers of liquid diet, 5VS.5; Numbers of partial tube feeding, 6VS.7; Numbers of total tube feeding, 3VS.1, p = 0.790) and 12 months (Numbers of liquid diet, 8VS.7; Numbers of partial tube feeding, 8VS.7; Numbers of total tube feeding, 5VS.5, p = 0.998). The cause of dysphagia not found to differ between the two groups both in postoperative 6 months (p = 0.814) and 12 months (p = 0.845).

CONCLUSION

Compared with JF, ALT free flap for PESCC patients after radiotherapy failure showed similar results in postoperative outcomes. ALT free flap may serve as a safe and feasible alternative for PESCC patients after radiotherapy failure.

Reconstruction of an Extensive Maxillofacial Avulsion Injury Caused by Bear Attack With a Double-Island Anterolateral Thigh Free Flap

ABSTRACT

Bear attack, a relatively rare cause of maxillofacial trauma, could lead to severe facial deformity as well as functional impairment. A 45-year-old male ranger was attacked by a bear and suffered an extensive maxillofacial avulsion injury, resulting in massive soft tissue loss (17.5 × 10 cm2) on his left temporal-facial region with an intraoral defect (3 × 2 cm2), surrounded by pus and necrotic tissue. Computed tomography revealed a comminuted fracture of the mandible, as well as bone defects in the left zygomatic bone, zygomatic arch, and part of the lateral orbital wall. In contrast with tumor resection, this large defect wound resulting from trauma was an infected wound with extensive loss of soft tissue and bone, which presented many operational challenges. The initial goal was to control local infection and then repair the maxillofacial and intraoral defects simultaneously. The left oral mucosal lining and maxillofacial skin after infection control were repaired by transposition of a double-island anterolateral thigh flap, and the fractured mandible was fixed, achieving primary closure for the reconstruction of large soft and hard tissue injuries in the oral and maxillofacial region. Five months postoperatively, the flap had healed and the patient was satisfied with the profile. This patient demonstrated how a rare severe injury caused by a bear attack was treated by preliminary closure of an extremely large post-traumatic oral and maxillofacial defect. The authors recommend the 1 pedicled double-island free anterolateral thigh flap as a worthwhile choice for the reconstruction of complicated oral and maxillofacial tissue defects combined with an intraoral defect. To our knowledge, this is the largest clinical application reported to date of an anterolateral thigh flap (approximately 200 cm2) for a post-traumatic oral and maxillofacial defect.

Anatomical Variations of the Tibialis Anterior Tendon Insertion: An Updated and Comprehensive Review

The tibialis anterior muscle originates on the lateral condyle of the tibia, on the upper two-thirds of the lateral surface of this bone, on the anterior surface of the interosseous membrane and on the deep surface of the fascia cruris. The distal attachment is typically at the medial cuneiform and first metatarsal. However, the tibialis anterior tendon can vary morphologically in both adults and fetuses. Different authors have created new classification systems for it. The main aim of this review is to present condensed information about the tibialis anterior tendon based on the available literature. Another aim is to compare classification systems and the results of previous studies.

Clinical management of squamous cell carcinoma of the tongue: patients not eligible for free flaps, a systematic review of the literature

INTRODUCTION

The management of squamous cell carcinoma (SCC) of the tongue represents the most demanding treatment planning in head and neck surgery. Ablation followed by free flap reconstruction is considered the gold standard, but not all patients are suitable for this strategy. The aim of this review is to provide a comprehensive view of surgical reconstruction possibilities in patients not eligible for free flaps.

METHODS

Following PRISMA recommendations, a systematic literature review was conducted searching for original papers that investigated outcomes of patients treated by surgical ablation for tongue SCC followed by reconstruction with local or pedicled flaps. Selected papers were read and data extracted for qualitative analysis.

RESULTS

Twenty articles met the inclusion/exclusion criteria. The study design was case series in sixteen papers, cohort study in the remaining four. Four different local flaps (BMM, FAMM, NLIF, SMIF) and four regional flaps have been discussed in included studies (IHF, SFIF, SCM, PMMC).

CONCLUSION

The improved anatomical knowledge makes local flaps a reliable alternative to free tissue transfer in cases requiring small-/medium-sized defects. Regional flaps still represent cornerstones in reconstruction of the tongue. Ease of execution, costs-to-benefit ratio, low-rate complications, minimal donor site morbidity represent the best advantages choosing local/regional flaps.

Comparison of the outcomes between free anteromedial thigh flap and anterolateral thigh flap in head and neck cancer reconstruction: Analysis of propensity-score-matched patient cohorts

BACKGROUND

The anterolateral thigh (ALT) flap is a workhorse flap in head and neck cancer reconstruction. The anteromedial thigh (AMT) flap was developed as a rescue or alternative flap whenever the ALT flap is not available; however, the harvest of AMT flap seems to be more challenging in the sense that perforators have multiple variations. This study was designed to compare the outcome of the AMT and ALT flaps in head and neck cancer reconstruction.

METHODS

A total of 1,547 ALT and 57 AMT flaps were used for head and neck cancer reconstruction between March 1, 2008 and February 28, 2017. Differences in patient and operative characteristics were compared between the patients undergoing AMT and ALT flap reconstruction. The primary outcome of the free flap was its survival or failure, while the second outcome was the associated complications.

RESULTS

Compared to those who had ALT flap reconstruction, the patients who underwent AMT flap reconstruction had a higher rate of conditions that required reconstruction after previous cancer ablation and recurrence but a lower rate of primary cancer and deeply located cancer. Analysis of the 40 well-balanced pairs of propensity-score-matched patient cohorts revealed that the AMT flaps were associated with a significantly higher failure rate than the ALT flaps (15.0 vs. 0.0%, respectively; p = .026).

CONCLUSION

This study revealed that AMT flaps were associated with a significantly higher failure rate than ALT flaps in head and neck cancer reconstruction in the cohort of total patients and the propensity-score-matched cohorts.

Scalp Reconstruction after Malignant Tumor Resection: An Analysis and Algorithm

Background  An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods  Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results  Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm ² , whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm ² . The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion  Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.

Double-island anterolateral thigh free flap used in reconstruction for salvage surgery for locally recurrent head and neck carcinoma

Salvage surgery is usually the only treatment for recurrent head and neck tumors but often poses a challenge to surgeons due to post-resected defects at 2 or more sites. Here we present the outcomes and rationale for reconstruction by a double-island anterolateral thigh (ALT) free flap following the salvage surgery.Patients treated with double-island ALT free flaps in salvage surgery between September 2012 and January 2017 at West China Hospital, Sichuan University were retrospectively viewed.A total of 18 patients (15 males) underwent reconstruction with double-island ALT free flaps (range from 40 to 77 years old). All patients had recurrent tumors after surgery and/or chemoradiotherapy and were selected for salvage surgery by a multidisciplinary team. The flaps were initially harvested as 7 cm × 7 cm to 16 cm × 10 cm single blocks and then divided into double-island flaps with each individual paddle ranging from5 cm × 3 cm to 10 cm × 8 cm. The average flap thickness was 3.5 cm (range from 2 to 6 cm), and the average pedicle length was 8 cm (range from 6 to 10 cm). A total of 18 arteries and 32 veins were anastomosed. Three patients developed fistula, 1 developed flap failure due to thrombosis and was re-operated with a pedicle flap. One patient died of pulmonary infection 6 months after the operation.Flap reconstruction for complex head and neck defects after salvage surgery remains challenging, but double-island ALT free flap reconstruction conducted by a multidisciplinary team and experienced surgeons would have a role in this setting.

Avoiding Facial Incisions with Midface Free Tissue Transfer

Background:

We have adopted an intraoral microsurgical anastomosis to the facial vessels to eliminate the need for any visible facial incisions.

Methods:

Cadaveric dissection was used to demonstrate accessibility of the facial artery and vein through an intraoral approach. Additionally, 5 patients underwent free tissue transfer for reconstruction of major defects of the midface through an intraoral, transmucosal approach, obviating the need for visible skin incisions.

Results:

The pathology included palatal defects due to mucoepidermoid carcinoma and ischemic necrosis from cocaine abuse, maxillary defects secondary to fibrous dysplasia and avascular necrosis from traumatic blast injury, and a residual posttraumatic bony deformity of the zygoma. Reconstructions were performed with a free ulnar forearm flap, a free vastus lateralis muscle flap, a deep circumflex iliac artery myoosseous flap, a free fibula flap, and a deep circumflex iliac artery osseous flap, respectively. The facial artery and vein were used as recipient vessels for microvascular anastomosis for all cases. Mean follow-up was 12.2 months. All free tissue transfers were successful, and each patient had a satisfactory aesthetic outcome with no associated facial scars.

Conclusion:

This technique can be employed during reconstruction of an array of bony or soft-tissue midface deficits with minimal morbidity. This small series effectively demonstrates the varied pathologies and tissue deficiencies that can be successfully reconstructed with free tissue transfer using an entirely intraoral approach to the recipient facial vessels, resulting in no visible scars on the face and an improvement in the overall aesthetic outcome.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient

BACKGROUND AND OBJECTIVES

Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients.

METHODS

A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described.

RESULTS

Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy.

CONCLUSIONS

The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Microsurgical Forehead Reconstruction

Reconstruction of the forehead remains challenging. Especially in cases of large or even complete forehead defects, local flaps and skin grafting may not be an option, necessitating free flap coverage. The aim of this retrospective case series was to develop an algorithmic surgical approach as well as to evaluate surgical and aesthetic outcomes of microvascular-based forehead reconstructions, using gracilis muscle or anterolateral thigh flaps in 15 cases. The mean size of the defects was 84.6 (range: 25-160, ±44.1) cm, all with significant area of bone exposure. The free flap reconstructions included 7 gracilis muscle flaps, covered with 1.2-mm-thick unmeshed split-thickness skin grafts, and 8 anterolateral thigh flaps with a mean size of the free flaps of 160 (range: 56-300, ±78.6) cm. In all patients, wound healing at the donor site was uneventful. Minor complications occurred in 3 patients and required small revision procedures. This case series demonstrates that microsurgical reconstruction of multiple entities of forehead defects poses a reliable method, especially in large and complex defects. In our opinion, given low risks for major complications and superior aesthetic results, the gracilis muscle flap covered with unmeshed split-thickness skin graft is ideally suited to reconstruct the forehead and should be one of first choices.

Vastus lateralis myofascial free flap in tongue reconstruction

In the last decade, the antero-lateral thigh free flap (ALT) has become the most popular free flap for tongue reconstruction because of less donor site morbidity and better cosmetic outcomes. However, fascio-cutaneous ALT may be insufficient to reconstruct major tongue defects, while its muscular-cutaneous variant (using the vastus lateralis muscle) may be too bulky. The present study describes our preliminary experience of tongue reconstruction with vastus lateralis myofascial flap, which could potentially offer unique advantages in head and neck reconstruction including adequate bulk when needed, optimal functional results and obliteration of dead space thus preventing fistulas and infections with minimal morbidity.

Soft tissue repair for tibialis anterior tendon ruptures using plate and screw fixation technique in combination with anterolateral thigh flaps transplantation

Background

Traumatic ruptures of the tibialis anterior tendon are rare but can cause substantial functional deficiencies. This study aimed to evaluate the feasibility of a surgery for soft tissue repair of traumatic rupture of the tibialis anterior tendon by using a plate and screw fixation repair in combination with the free anterolateral thigh flaps transplantation.

Methods

Eight consecutive patients with anterior tibialis tendon ruptures who visited orthopedics departments from February 2008 to February 2012 were included in our study. The ruptured tendon was reconstructed with plate and screw fixation technique, and the tissue defects were repaired with anterolateral thigh free flaps. The complications and American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores were evaluated. Postoperative manual strength test was performed using a 0 to 5 scale.

Results

All flaps survived without any complications. The average preoperative and postoperative AOFAS ankle-hindfoot scores of the patients were 51 and 95, respectively. Good ankle dorsiflexion strength against strong resistance was observed in eight ankles postoperatively (manual strength of one patient was 4/5, the others were 5/5), and a substantial improvement in strength was noted compared with the preoperative examination.

Conclusion

Soft tissue repair for tibialis anterior tendon rupture using plate and screw fixation technique in combination with anterolateral thigh flaps transplantation is a feasible technique and yield satisfactory results.

Comparison of Clinical and Functional Outcomes Using Pectoralis Major and Cutaneous Free Flaps for Hypopharyngeal Squamous Cell Carcinoma

Background

The purpose of this study was to compare postoperative morbidities and functional outcomes of pectoralis major myocutaneous (PMMC) flap and cutaneous free flap reconstruction approaches in hypopharyngeal squamous cell carcinoma patients.

Methods

We retrospectively reviewed records from 99 patients who underwent hypopharyngeal reconstruction with a cutaneous free flap (n=85) or PMMC flap (n=14) between 1995 and 2013. Morbidity was classified into hospitalization, medical, or flap-related complications. Functional outcomes were classified into oral re-alimentation and decannulation time.

Results

The overall flap-related complication rate was higher in the PMMC flap group (n=8, 57.1%; P=0.019), but the medical morbidity rate was higher in the cutaneous free flap group (n=68, 80%; P=0.006). The rate of pneumonia was higher in the cutaneous free flap group (n=48, 56.5%; P=0.020). Pulmonary premorbidity was the variable most significantly associated with pneumonia (odds ratio=3.012, P=0.012). There was no statistically significant difference in oral re-alimentation and decannulation time between the two groups.

Conclusions

Although the functional superiority of free flaps has been reported in many studies, our results do not support this hypothesis. One limitation of our study is the relatively smaller flap size and fewer PMMC flap cases compared with the cutaneous free flap group. The low postoperative medical morbidity incidence rate in the PMMC flap group was clinically significant; however, the free flap group had more flap-related complications. Thus, PMMC flaps should be considered a viable option, especially for patients with pulmonary premorbidities.

Transfer of anterolateral thigh flaps in elderly oral cancer patients: complications in oral and maxillofacial reconstruction

PURPOSE

Although a promising approach, the use of anterolateral thigh (ALT) free flaps has been limited in the reconstruction of oral and maxillofacial defects in elderly patients. The aim of this study was to estimate the frequency of postoperative complications and identify factors associated with complications.

PATIENTS AND METHODS

The authors designed and implemented a retrospective study on the frequency of postoperative complications in elderly patients. They enrolled a sample composed of patients who underwent ALT free flap transfers for the repair of defects created during oral and maxillofacial cancer surgery from February 2002 to March 2013. The χ(2) test, t test, and multivariate regression model were used.

RESULTS

A total of 1,100 patients were studied (859 men and 241 women). One hundred four patients (9.5%) were at least 70 years old (elderly group) at the time of surgery; the other 996 patients were younger than 70 years (younger group). The overall success rate of ALT free flap transfer was 97.2% (97.0% in the younger group, 99.0% in the elderly group; P > .05). The overall complication rate was 27.5% (27.2% in the younger group, 29.8% in the elderly group; P = .572). Multivariate analysis showed that operation time, American Society of Anesthesiologists class, and comorbidity were independent risk factors for postoperative complications in elderly patients.

CONCLUSIONS

Oral and maxillofacial reconstruction using ALT free flaps in elderly patients can achieve outcomes similar to those obtained in younger patients. Limiting the operation time is important for improving surgical outcomes.

Super-microdissected local flaps for the coverage of temporal defects

INTRODUCTION

Skin graft is still a method of choice for the coverage of temporal defects. But there are some disadvantages like a "patch" appearance, the need of dressing or longer healing time. Numbers of local flaps have been described for closing skin defects on temporal region. Yet, they may cause distortion of the surrounding tissues, especially in the temporal hairline and eyebrow. We present a series of seven local flaps based on small branches (SB) of the superficial temporal artery (STA) for the coverage of temporal defects, and discuss their advantages.

PATIENTS AND METHODS

Supermicrodissection of SB of the STA was performed to obtain local flaps for reconstruction of temporal defects after skin cancer excisions in seven patients. Patient's age ranged from 70 to 88 years old and the diameter of defects ranged from 4 to 6 cm. All procedures were performed under local anesthesia except one. In all cases, defects were obtained after skin cancer excisions.

RESULTS

The operative time ranged from 55 to 75 min. All flaps survived with an average follow-up of 8 months, reconstructions have maintained a cosmetically pleasing result.

CONCLUSION

We believe that SB flaps may be a new option for reconstruction of temporal defects with the advantages of local flaps, without the inconvenience of a skin pedicle. Moreover, these flaps raise the question of the use of SB based flaps for the coverage of moderate-sized skin defects anywhere in the body, and open new fields in reconstructive surgery.

A prospective study of medial sural artery perforator flap with computed tomographic angiography-aided design in tongue reconstruction

PURPOSE

To investigate the application of the medial sural artery perforator flap in hemiglossectomy reconstruction and evaluate the value of preoperative computed tomographic angiography (CTA) for perforator location.

PATIENTS AND METHODS

Nine patients received medial sural artery perforator flaps for tongue reconstruction from August 2013 to January 2014. Of the 9 patients, 5 were male and 4 were female, with a mean age of 51 years (range 22 to 67). The number, location, and course of the perforators were measured on the CTA preoperatively.

RESULTS

Of the 9 medial sural artery perforator flaps, 8 survived and 1 had developed necrosis. Thirteen perforators had been visualized by CTA, and 10 of these were used in the operation. No significant difference was found between the CTA location and the intraoperative findings in the perforators' distribution. The mean diameter of the medial sural artery was 1.0 ± 0.3 mm and of the concomitant vein was 2.0 ± 0.7 mm. The mean pedicle length was 9.7 ± 1.0 cm, with 5.1 ± 1.7 cm of the main trunk and 4.6 ± 2.1 cm of the perforator. The average number of muscular vessel branches was 23.9 ± 6.9, with 12.2 ± 5.1 from the main trunk and 10.1 ± 4.4 from the perforators; 1 (10%) perforator was septocutaneous and 9 (90%) were myocutaneous.

CONCLUSIONS

The medial sural artery perforator flap is appropriate for medium-size tongue defect reconstruction, with a long pedicle of matching caliber, adequate tissue volume, and minimal donor site morbidity. CTA is a valuable and necessary method for preoperative assessment of the perforator's location.

Does increased free flap size in the head and neck region impact clinical outcome?

PURPOSE

There are few studies analyzing the long-term clinical effects related to increasing the size of head and neck free tissue reconstructions. The purpose of this study was to compare long-term clinical outcomes of patients undergoing very large area (≥200 cm(2)) and large area (100 to 199 cm(2)) free tissue reconstructions of head and neck defects.

PATIENTS AND METHODS

Institutional review board approval was obtained before conducting this retrospective cohort study at the authors' university-based tertiary care hospitals. The authors analyzed the charts of consecutive patients with free flaps of at least 100 cm(2) treated from July 2000 to December 2011. Very large area flaps were arbitrarily defined as larger than 200 cm(2). Intraoperative variables, flap success rates, overall survival, and total hospital and intensive care unit (ICU) stays for the 2 groups were analyzed. Fisher exact tests or χ(2) tests were used for categorical variables and Student t tests were used for continuous variables. Log-rank tests were conducted to investigate whether overall survival was significantly different between the 2 groups. Statistical significance was defined as a P value less than .05.

RESULTS

The charts of 121 consecutive patients were analyzed. Thirty-eight patients (31%) had very large area flaps (277.1 ± 79.4 cm(2); range, 200 to 576 cm(2)) and 83 patients (69%) had large area flaps (140.1 ± 25.5 cm(2)). There was no difference between flap groups in presenting T4 stage disease (P = .448). Ninety-eight percent of the very large area flaps and 93% of the large area flaps survived. Total hospital stays for the very large area and large area flap groups were 12.8 ± 8.2 and 12.3 ± 8.3 days, respectively (P = not significant). In contrast, ICU stays were increased for the very large area flap group at 7.1 ± 7.5 versus 4.0 ± 4.0 days for the large area flap group (P = .022). The overall median patient survival for the very large area flap group was 7.6 months (95% confidence interval, 5.7-10.0) and that for the large area flap group was 8.4 months (95% confidence interval, 5.4-12.9; P = .376).

CONCLUSION

Performing very large area flaps for head and neck reconstruction did not negatively affect clinical outcome. Comparable success rates, total hospital stays, and overall survival can be safely achieved in this difficult patient population. More studies need to be conducted on resource usage.

Free Flap Reconstruction of Head and Neck Defects after Oncologic Ablation: One Surgeon's Outcomes in 42 Cases

Background

Free flap surgery for head and neck defects has gained popularity as an advanced microvascular surgical technique. The aims of this study are first, to determine whether the known risk factors such as comorbidity, tobacco use, obesity, and radiation increase the complications of a free flap transfer, and second, to identify the incidence of complications in a radial forearm free flap and an anterolateral thigh perforator flap.

Methods

We reviewed the medical records of patients with head and neck cancer who underwent reconstruction with free flap between May 1994 and May 2012 at our department of plastic and reconstructive surgery.

Results

The patients included 36 men and 6 women, with a mean age of 59.38 years. The most common primary tumor site was the tongue (38%). The most commonly used free flap was the radial forearm free flap (57%), followed by the anterolateral thigh perforator free flap (22%). There was no occurrence of free flap failure. In this study, risk factors of the patients did not increase the occurrence of complications. In addition, no statistically significant differences in complications were observed between the radial forearm free flap and anterolateral thigh perforator free flap.

Conclusions

We could conclude that the risk factors of the patient did not increase the complications of a free flap transfer. Therefore, the risk factors of patients are no longer a negative factor for a free flap transfer.

Functional tongue reconstruction with the anterolateral thigh flap

BACKGROUND

A retrospective study was conducted to evaluate the advantages of anterolateral thigh (ALT) flap in tongue reconstruction.

METHOD

From September 2008 to February 2012, patients receiving ALT flap tongue reconstruction were included in the study. Patients undergoing ALT flap were compared with those undergoing similar surgery with radial forearm flap (RFF). The medical records of the included patients were reviewed, and a questionnaire was used to assess acceptability of the surgery.

RESULTS

All flaps (both ALT and RFF) were successful In the ALT group, most patients were satisfied with the appearance of the reconstructed tongue and the intelligibility of their speech, and there were fewer complications with this technique compared with the RFF.

CONCLUSION

The ALT flap is an ideal method for tongue reconstruction. The thickness and volume of the ALT flap can be adjusted based on the individual extent of the defect, and it can not only provide bulk but also ensure mobility, and it has other advantages also, including a long pedicle and low donor site morbidity.

Distally based saphenous neurocutaneous perforator flap combined with vac therapy for soft tissue reconstruction and hardware salvage in the lower extremities

The complex wound with the exposed hardware and infection is one of the common complications after the internal fixation of the tibia fracture. The salvage of hardware and reconstruction of soft tissue defect remain challenging. In this report, we presented our experience on the use of the distally based saphenous neurocutaneous perforator flap combined with vacuum-assisted closure (VAC) therapy for the coverage of the soft tissue defect and the exposed hardware in the lower extremity with fracture. Between January 2008 and July 2010, seven patients underwent the VAC therapy followed by transferring a reversed saphenous neurocutaneous perforator flap for reconstruction of the wound with exposed hardware around the distal tibia. The sizes of the flaps ranged from 6 × 3 cm to 15 × 6 cm. Six flaps survived completely. Partial necrosis occurred in one patient. There were no other complications of repair and donor sites. Bone healing was achieved in all patients. In conclusion, the reversed saphenous neurocutaneous perfortor flaps combined with the VAC therapy might be one of the options to cover the complex wound with exposed hardware in the lower extremities.

Ulnar forearm free flaps in head and neck reconstruction: systematic review of the literature and a case report

OBJECTIVE

Under the assumption that the ulnar artery is the predominant blood supply to the hand, radial forearm free flaps (RFFF) generally have been preferred over ulnar forearm free flaps (UFFF) in head and neck reconstruction. The objective of this study is to create the first and only systematic review of the literature regarding UFFF in head and neck reconstruction, assessing the usage, morbidity, complications, and rationale of its use.

METHODS

A systematic review of the literature was conducted using PubMed, including Mesh terms and manual searches. Articles not in English were excluded.

RESULTS

Seventeen articles of the 80 articles identified by our search criteria met inclusion criteria; a total of 682 cases of UFFF were identified, including our patient case. Fifty-five percent of the cases involved use of the Allen's test. Mean flap size was 6.1 × 10.5 cm. Of the 432 cases reporting flap survival, 14 (3.2%) flap losses were reported, 13 total (3.0%), and one partial (0.2%). The UFFF was preferred to the RFFF due to decreased hirsutism (61%), better cosmetic outcomes (91%), and better post-operative hand function with reduced donor site morbidity (73%). For the case report, an UFFF was used successfully for lid reconstruction and resurfacing in a 72-year-old man who presented with late ectropion and exposure keratopathy following maxillary resection for leiomyosarcoma.

CONCLUSIONS

This is the first and only systematic review of the literature to date of UFFF in head and neck reconstruction. Our review demonstrates that the UFFF rarely results in flap loss, donor site morbidity, or hand ischemia, instead providing enhanced outcomes. With its many surgeon-perceived advantages and minimal morbidity, the UFFF may become a preferred forearm flap for head and neck reconstruction.