A New Pedicled Internal Mammary Osteomyocutaneous Chimeric Flap (PIMOC) for Salvage Head and Neck Reconstruction: Anatomic Study and Clinical Application

Extended autologous tracheal replacement by a novel pedicled thoraco-chondro-costal flap: a cadaveric proof of concept

OBJECTIVES

Our aim was to report an anatomic model of an autologous flap based on the internal thoracic blood supply: the pedicled thoraco-chondro-costal flap; and establish the feasibility of various types of extended tracheal replacement with this novel flap, according to a newly proposed topographic classification.

METHODS

In a cadaveric model, a cervicotomy combined with median sternotomy was performed. The incision was extended laterally to expose the chest wall. The internal thoracic pedicle was freed from its origin down to the upper limit of the delineated flap to be elevated. The perichondria and adjacent periostea were incised longitudinally to remove cartilages and adjacent rib segments, preserving perichondria and periostea. A full-thickness quadrangular chest wall flap pedicled on internal thoracic vessels was then elevated and shaped into a neo conduit to replace the trachea with the pleura as an inner lining.

RESULTS

Various types of extended non-circumferential and full-circumferential tracheal replacements were achieved with this composite flap. No anastomosis tension was noticed despite the absence of release manoeuvres.

CONCLUSIONS

This model could represent a suitable autologous tracheal substitute, which is long, longitudinally flexible and eventually transversely rigid. No microsurgical vascular anastomoses are required. The technique is reproducible. The perichondria and periostea would regenerate vascularized neo-cartilaginous rings, potentially decreasing the need for long-term stenting. The inner pleural lining could potentially transform into ciliated epithelium as shown in previous preclinical studies.

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

PURPOSE OF REVIEW

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF).

RECENT FINDINGS

Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes.

SUMMARY

There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Head and Neck Reconstruction of the Vessel-Depleted Neck: A Systematic Review of the Literature

BACKGROUND

Damage of the vascular system secondary to radical neck dissection and/or radiotherapy or other treatments has a negative impact on microsurgical reconstruction. The search for adequate recipient vessels is hindered by the complexity of previous procedures.

METHODS

A systematic review of microsurgical head and neck reconstruction in the vessel-depleted neck was performed. The issues analyzed were indications for surgery, more frequently performed flaps, vascular systems used as recipient vessels, outcomes, and complications.

RESULTS

The eligibility criteria were fulfilled by 57 studies published between September 1993 and January 2020. In 8235 patients, 8694 flaps were performed, 925 of which were for a vessel-depleted neck. The most commonly used flap was the anterolateral thigh flap, used in 195 cases (30%), followed by the radial forearm free flap, used in 157 cases (24%). The potential recipient vessels were numerous for arteries (26 options) and veins (31 options). For the 712 flaps with an identifiable recipient artery, the superficial temporal artery was the most commonly used vessel (n = 142, 20%). The superficial temporal vein was the most commonly used vessel for 639 flaps with an identifiable recipient vein (n = 118, 18.5%). Complications amounted to 11%; 80 out of 716 flaps in papers that reported them. Flap losses were reported in 2% of cases.

CONCLUSIONS

Major microsurgical head and neck reconstruction for postoncologic defects depends on appropriate recipient vessels. Vein availability is paramount. Understanding the complexity of this problem is useful for preoperative planning, precise decision-making, and an accurate surgical approach.

Application of a new classification of chimeric anterolateral thigh free flaps

BACKGROUND

The anterolateral thigh free flap is one of the most commonly used flaps in reconstructive procedures. The purpose of this study was to assess this new classification of chimeric anterolateral thigh free flaps.

METHODS

Sixty-five patients underwent free anterolateral thigh chimeric free flap reconstruction of defects in the head and neck region. We summarized the anatomic features of perforators, including the number and origin of the perforators.

RESULTS

Sixty-five cases of femoral anterolateral double island flaps were divided into 3 types: trunk type (type I), 11 cases (16.9%), in which the perforators of two flaps originated in the descending branch and the transverse branch of the lateral femoral circumflex artery; branch type (type II), 45 cases (69.3%), in which both the perforators originated in the descending branch or the transverse branch of the lateral femoral circumflex artery; and bifurcation type (type III), 9 cases (13.8%), in which two perforators originated in the bifurcation of one perforator that originated in the descending branch or the transverse branch of the lateral femoral circumflex artery. All 65 flaps survived and none showed partial necrosis.

CONCLUSIONS

The anterolateral thigh chimeric flap can be divided into 3 types: trunk type (I type), branch type (II type) and bifurcation type (III type).

Soft Tissue Reconstruction for Head and Neck Ablative Defects

Soft tissue reconstruction of head and neck ablative defects is a broad, challenging, and subjective topic. The authors outline goals to keep in mind when deciding on a primary reconstructive option for defects created by oncologic resection. Factors considered in local, regional, and distant flap selection are discussed. Based on the goals of reconstruction and factors involved in flap selection, a defect-based reconstructive algorithm is developed to help choose the ideal reconstructive option. The authors also discuss indications, pearls, pitfalls, and challenges in the harvest and inset of commonly used soft tissue flaps for head and neck reconstructive surgery.