A retrospective analysis of the surgical outcomes of different free vascularized flaps used for the reconstruction of the maxillofacial region: Hand-sewn microvascular anastomosis vs anastomotic coupler device

Comparison of the microvascular anastomotic Coupler™ system with hand-sewn suture for end to end veno-venous anastomosis for head and neck reconstruction with free flap transfer: Medico-economic retrospective case-control study

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon.

Safety and reliability of the internal jugular vein for venous anastomoses in head and neck oncological reconstruction: A retrospective study

This study aimed to assess the efficacy of utilizing the internal jugular vein (IJV) as the primary recipient site for venous anastomoses in head and neck oncological reconstruction. Patients who underwent a free flap reconstruction of the head and neck were retrospectively included. Venous anastomoses were preferentially performed less than 1 cm from the IJV, either end-to-side (EtS) on the IJV, or end-to-end (EtE) on the origin of the thyrolingofacial venous (TLF) trunk. When the pedicle length was insufficient to reach the IJV, anastomoses were performed EtE to a size-matched cervical vein. Of the 246 venous anastomoses, 216 (87.8%) were performed less than 1 cm from the IJV, including 150 EtS on the IJV (61.0%), and 66 EtE on the TLF trunk (26.8%). Thirty veins (12.1%) were anastomosed EtE on other cervical veins more than 1 cm from the IJV. Two venous thromboses occurred (0.9%) and were successfully managed after revision surgery. There was no evidence of an increased thrombosis rate in high-risk or pre-irradiated patients. These findings suggest that the internal jugular vein is safe and reliable as a first-choice recipient vessel for free flap transfers in head and neck oncological reconstruction.

Quality of Life and Aesthetic Satisfaction in Patients Who Underwent the “Commando Operation” with Pectoralis Major Myocutaneus Flap Reconstruction—A Case Series Study

The “commando operation” is an extensive surgical procedure used to treat patients with oral squamous carcinoma and metastasis in the cervical lymph nodes. While the procedure can be curative, it is also very mutilating, which consequently has a major impact on the patient’s quality of life. Several studies showed that the procedure is associated with loss of certain functions, such as impairments in speech, chewing, swallowing, and loss of taste and appetite. Furthermore, some of these impairments and their degree depend on the reconstruction method. However, the data regarding the functional impairments and aesthetic results in patients who underwent the “commando operation” along with the pectoralis major myocutaneus flap reconstruction are still inconclusive. This study included 34 patients that underwent partial glossectomy, ipsilateral modified radical neck dissection, pectoralis major myocutaneus flap reconstruction, and adjuvant radiotherapy. A structured questionnaire was used to evaluate aesthetical results and functional impairments as well as to grade the level of satisfaction with the functional and aesthetic outcomes both by the patients and by the operator. Most of the patients stated that their speech (N = 33; 97%) and salivation (N = 32; 94.2%) severely changed after the operation and that they cannot chew (N = 33; 97%) and swallow (N = 33; 97%) the same as before the operation. Moreover, almost half of the patients (N = 16; 47%) reported that they have severe sleep impairments. However, only few of the included patients stated that they sought professional help regarding the speech (N = 4; 11.7%), eating (N = 5; 14.7%), and sleeping (N = 4; 11.7%) disturbances. Additionally, there was a statistically significant difference between the operator and the patients in the subjective assessment of the aesthetic results (p = 0.047), as operators gave significantly better grades. Our results imply that this procedure and reconstructive method possibly cause impairments that have an impact on the patients’ wellbeing. Moreover, our outcomes also suggest that patients should be educated and rehabilitated after the “commando operation” since most of them were reluctant to seek professional help regarding their impairments. Lastly, sleep deficiency, which was observed after the procedure, should be further explored.

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

BACKGROUND

Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.

METHOD

This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.

RESULT

A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs' vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.

CONCLUSION

In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

The effect of mesenchymal stem cells lyophilisate femoral artery of rat anastomosis: A histopathological and histomorphometric study

BACKGROUND AND OBJECTIVE

Mesenchymal Stem Cells (MSCs) are well known for their tissue regeneration enhancing effect and their contribution to immune regulation. However, their contribution to the healing process of femoral artery anastomosis, especially to endothelialization, has not been studied sufficiently in the clinic. This study was carried out to evaluate the effects of MSC-lyophilisate from the human umbilical cord on anastomosis experimental study in rats histopathologically.

METHOD

After intraperitoneal anesthesia was applied to the rats, the femoral artery was exposed with a 2 cm incision in the right femoral region. After the artery was cut in the experiment and sham groups, femoral artery end-to-end anastomosis was performed using the primary suture technique. MSC-lyophilisate was poured in powder form onto the anastomosed outer surface of the vessel in the treatment group and saline solution was poured to the sham group. No intervention was made to the control group. The data analysis was performed with IBM SPSS Statistics 25.

RESULTS

In the experiment group, flattening of the inner elastic lamina, morphological changes and vacuolization in the muscle fibers, inflammation in the adventitia and significant vascular wall thickening were observed in the femoral arteries of the rats after the intervention. According to the histopathological scoring results, tissue samples belonging to sham and experimental groups showed marked pathological findings such as endothelial damage, flattened areas where the folded structure in the inner elastic lamina disappeared, muscle fiber degeneration and inflammation in the adventitia.

CONCLUSION

Human umbilical cord-origin MSC-lyophilisate application holds an important place in femoral artery surgery. We evaluate that it will be meaningful to determine the MSC-lyophilisate dose for hemostasis without creating thrombus after anastomosis. MSC-lyophilisate will be used to provide hemostasis in areas with local bleeding in the future. In addition, it is recommended to make plans for an in-depth examination of possible problems and cases in future studies.

Differences in free flaps’ reconstructions with and without coupling device for venous anastomosis

<br><b>Introduction:</b> Introduction of the coupler devices for anastomoses of neck vessels changes planning and performance of the surgical procedures. The Rigid ring of the coupling devices keeps a vein open and less prone to occlusion. Therefore, this should improve the flap survival rate and surgery duration.</br> <br><b>Aim:</b> The aim of the study was to point out the differences in surgery planning between couplers and sutures for venous microsurgical anastomoses.</br> <br><b>Methods:</b> The medical records of 209 patients who underwent 212 microvascular free flap reconstructions from January 2011 till December 2017 were retrospectively analyzed; 103 received radial forearm free flap (RFFF); 43 – anterolateral thigh flap (ALTF); 51 – fibula free flap (FFF); 15 – iliac crest free flap (ICFF). In 189 cases, reconstruction was performed simultaneously with tumor resection and in 23 cases, reconstruction was secondary, after previous oncological treatment. Among 443 anastomoses, suturing was used for 212 arteries and 127 venous anastomoses, while coupling was used for 104 venous anastomoses.</br> <br><b>Results:</b> The mean surgery duration for suturing was 452.82 min vs 358.88 min for coupling (P<0.05). Differences in flap survival and partial necrosis rates between coupling and suturing groups were not statistically significant (P>0.05). Donor vessel distribution in the neck was significantly different in both groups. Estimated costs of the surgical procedures performed with and without coupler devices were not equal.</br> <br><b>Conclusions:</b> The use of couplers for venous anastomosis in free flap head and neck reconstructions impacts the surgery process by shortening surgery duration which leads to cost reduction.</br>