Objective Selection Criteria between ALT and Radial Forearm Flap in Oral Soft Tissues Reconstruction

Comparative analysis of volumetric changes between resection volume of oral tongue cancer and post operative volume of radial forearm flaps

OBJECTIVES

This study investigates the relationship between the total volume of oral tongue cancer pre-operatively and the RFFF volume post-operatively.

MATERIALS AND METHODS

A total of 52 DICOM imaging datasets (CT or MRI) of 26 patients were included in this study. The volume of the desired structure was quantified using semi-automatic segmentation using the software ITK-SNAP. All extracted measurements were validated by two further clinicians at separate instances.

RESULTS

The variation of MeanVolTu can be predicted by MeanVolFlap moderately reliable with 59.1% confidence (R-Qua: 0.591). ANOVA Testing to represent how well the regression line fits the data, resulted in the overall regression model being statistically significant in predicting the MeanVolTu (p < 0.001). The flap volume may be predicted using the following algorithm: MeanVolFlap0 = 3241,633 + 1, 322 * MeanVolTu.

CONCLUSION

The results of this study show positive correlation between tumor volume and flap volume, highlighting the significance of efficient flap planning with increasing tumor volume. A larger extraction volume of the radial forearm free flap from the donor site compromises the forearm more, thus increasing the probability of post-operative complications.

CLINICAL RELEVANCE

Radial forearm free flap design in accordance with its corresponding 3D tumor volume.

Radial forearm flap versus antero-lateral thigh flap in oral soft tissue reconstruction: update and statistical analysis on our 77 consecutive cases for an objective selection criteria

BACKGROUND AND AIM

The radial forearm free flap (RFFf) and the antero-lateral thigh flap (ALTf) are considered the "key flaps" for oral cavity reconstruction. Nowadays, the literature lacks of an objective and standardized decision-making algorithm for the flap choice. The aim of this study is to describe a decision-making algorithm concerning the more appropriate flap, RFFf or ALTf, in the reconstruction of intra-oral soft tissues based on the volumetric analysis of the defect with a pre-operative Magnetic Resonance Imaging (MRI), updating our previous surgical experience.

METHODS

We conducted a retrospective observational study including 77 patients who underwent microsurgical reconstruction with RFFf or ALTf after tumor resection of the soft tissues in the oral cavity. During follow-up, patients were evaluated using the UW-QOL questionnaire.

RESULTS

Analyzing the scores of the UW-QOL questionnaire based on the size of the tumor on preoperative MRI we found that for tumor volume <50cc and between 50-70cc, the patients reconstructed with RFFfobtained statistically significant better scores compared to the ALTf group, while for tumor volume >70cc, the patients reconstructed with ALTf reported statistically significant better scores.

CONCLUSIONS

Pre-operative RMI-guided volumetric assessment of oral cancer plays a key role in the planning of adequate soft tissue reconstruction and can objectively help surgeons in the correct choice of the flap (RFFf vs. ALTf) for each case based on preoperative tumor size, suggesting for defects <50cc and between 50 and 70 cc a reconstruction with RFFf, while for defects >70cc a reconstruction with ALTf.

Anterolateral thigh, radial forearm and superficial circumflex iliac perforator flaps in oral reconstruction: a comparative analysis

BACKGROUND

Anterolateral thigh (ALT) and Radial forearm free flaps (RFFF) are historically the most common methods of oral reconstruction. The Superficial circumflex iliac artery perforator flap (SCIP) is an alternative providing a donor site that can be readily closed primarily with improved cosmesis in younger patients, due to its concealability.

METHODS

We reviewed 135 patients who received ALT, RFFF or SCIP flaps for oral reconstruction in our institution. Our aim was to compare operative and perioperative outcomes between each cohort. ANOVA and χ² test were used for statistical analysis.

RESULTS

There were 37 ALT, 64 RFFF and 35 SCIP reconstructions. Patients reconstructed with SCIP flaps had smaller resection volumes (P < 0.001) and earlier T and N classifications (P = 0.001, P = 0.008), and consequently reduced tracheostomy rates (P < 0.001), reduced need for enteral feeding at discharge (P < 0.001) and shorter length of stay and perioperative times (P < 0.001). SCIP flaps were more common in younger patients (P < 0.01). ALT flaps were used for more advanced disease (P = 0.001) and had larger resection volumes (P < 0.001) and increased need for assisted enteral feeding (P < 0.001). There were no significant differences in flap or donor site outcomes. There were two flap failures, both RFFF.

CONCLUSION

Each flap plays an important role in the reconstruction of oral defects, with larger defects preferentially reconstructed with ALT flaps. SCIP appears to be a reliable alternative in small defects with excellent perioperative and postoperative outcomes.

Current status and evolution of microsurgical tongue reconstructions, part I

Reconstructive surgery in the management of head and neck cancer has evolved to include structure-specific approaches in which organ-specific treatment algorithms help optimize outcomes. Tongue cancer management and reconstruction are surgical challenges for which well-executed reconstructive plans should be completed promptly to avoid delaying any subsequently planned oncologic treatment. Crucial considerations in tongue cancer resection are the significant functional morbidity associated with surgical defects, particularly in terms of speech and swallowing, and the consequent negative impact on patients' quality of life. With the evolution of microsurgical techniques and the development of the perforator flap concept, flap options can be tailored to the characteristics of various tongue defects. This has allowed the implementation of pliable flaps that can help restore tongue mobility and yield subsequent functional outcomes. Using an evolutional framework, we present this series of reviews related to tongue reconstruction. The first part of the review summarizes flap options and flap-related factors, such as volume and tissue characteristics. Related functional aspects are also presented, including tongue mobility, speech, and swallowing, as well as ways to evaluate and optimize these outcomes.

Effect of postoperative radiotherapy for free flap volume changing after tongue reconstruction

OBJECTIVE

The purpose of this study was to evaluate the effect of postoperative radiotherapy (RT) on temporal volume changes with a cutaneous free flap (CF) and a myocutaneous free flap (MCF).

METHODS

The subjects were 24 men and 11 women (mean age, 50.5 ± 15.5 years) with tongue or floor of mouth cancer. Twenty-seven cases of CF and eight cases of MCF were selected. The flap volume change of the reconstructed tongue was calculated using computed tomography (CT) images taken immediately and at one year postoperatively using the DICOM image processing software OsiriX®.

RESULTS

The reduction rate in flap volume at one year postoperatively was 82.0 ± 15% in CF without RT, 70.3 ± 26.1% in CF with RT, 88.5 ± 14.7% in MCF without RT, and 99.5 ± 16% in MCF with RT. The MCF volume was significantly higher compared to the CF volume. Although postoperative RT reduced the CF volume by 30%, there was only a slight reduction in the MCF volume.

CONCLUSIONS

We evaluated the effect of postoperative RT on volume reduction in 35 cases of the reconstructed tongue with CF and MCF using a computer-assisted volume rendering technique. In this study, the effect of RT on volume reduction was different between the CF and MCF.

Upper limb traumatic injuries: A concise overview of reconstructive options

Different options for upper limb reconstruction are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common. Local and regional flaps can represent the reconstructive options for small defects while large wounds require the use of free flaps or distant pedicled flaps. In case of large wound, the use of free flaps rather than distant pedicle flaps is usually preferred. To choose the best reconstructive option, it is essential for the surgeon to have a general overview about the different methods.

In this review the Authors will refer to the most commonly used methods to cover soft tissues injuries affecting the dorsum and the palm of the hand and the forearm (excluding fingers). The aim is to show all flap reconstructive options so as to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

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Reconstruction of traumatic injuries of the upper limbs can be challenging.

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Small defects can be covered by local and regional flaps while large wounds need the use of free or distant pedicled flaps.

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The literature shows different opinions whether to use pedicled flaps (regional or distant) or free flaps.

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Dermal substitutes can be considered in patients who are not suitable for flaps reconstruction.

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Patient related factors and surgical background can significantly interfere with the surgical reconstructive solution.

Breast Cancer-Related Lymphedema: Recent Updates on Diagnosis, Severity and Available Treatments

Breast cancer-related lymphedema (BCRL) represents a global healthcare issue affecting the emotional and life quality of breast cancer survivors significantly. The clinical presentation is characterized by swelling of the affected upper limb, that may be accompanied by atrophic skin findings, pain and recurrent cellulitis. Cardinal principles of lymphedema management are the use of complex decongestive therapy and patient education. Recently, new microsurgery procedures have been reported with interesting results, bringing in a new opportunity to care postmastectomy lymphedema. However, many aspects of the disease are still debated in the medical community, including clinical examination, imaging techniques, patient selection and proper treatment. Here we will review these aspects and the current literature.

Extended and unusual indications in jaw reconstruction with the fibula flap: An overview based on our 30-year experience

Since the introduction of fibula flap as a reconstructive technique, an evolution of indications has been observed. Our first report of a traumatic mandibular reconstruction using fibula flap was in 1992. The vast majority of indications for surgery, are: malignant tumors, benign neoplasms, osteoradionecrosis and traumas. Nevertheless, extended indications have been described such as the treatment of dentoalveolar defect without bone discontinuity or reconstruction of maxilla defect up to type III (A and B), according to Cordeiro's classification. Unusual indications include cleft palate malformations with bone discontinuity less than 6 cm. Moreover, a particular attention should be focus on fibula flap harvest with more innovative technologies than traditional use of monopolar or bipolar and their advantages in pre and postoperative management.

Soft tissue coverage of the upper limb: A flap reconstruction overview

Different opinions about the reconstructive choice for upper limb are described in literature: advancement or rotation flaps, regional flaps and free flaps are the most common reconstructive options. Local and regional flaps can be used to cover small defects while large wounds require the use of free flaps or distant pedicled flaps. The coverage of large wounds opens a discussion about when to use free flaps and when distant pedicled flaps. This review will describe the different methods used for the coverage of soft tissues injuries affecting hand and/or forearm (excluding fingers). The aim is to show all flap reconstructive options in order to support the inexperienced surgeon during the management of traumatic injuries of the upper limb.

Factors related to delayed treatment: A case report of a huge cutaneous horn and review of the literature

We present a case of a man with a giant cutaneous horn over his frontal region. This case has been presented for the size of the lesion, due to delayed treatment, and to illustrate the reasons why the growth of this lesion has been possible in a western country, in the 21st century. It was a solitary, not painful lesion which caused significant aesthetic problems. The diagnosis was based on an ultrasonographic study and the treatment of choice was a surgical excision. This case is an opportunity to review the literature about the cutaneous horns, to talk about the main causes of delayed diagnosis and treatment of cutaneous lesions and, to define the role of the specialist in the assessment of emotions and patient support.

The Telematic solutions in plastic surgery during COVID-19 pandemic

During the COVID-19 pandemic, surgical elective procedures were stopped in our plastic surgery unit. Limitations for consultations and for follow-up of previous surgical procedures were imposed in order to minimize the risk of contagion in waiting rooms and outpatient clinics. We have identified telemedicine as an alternative way to follow patients during the lockdown. Nevertheless, we have experienced different difficulties. We have not had the possibility to use a secure teleconferencing software. In our unit we had not technological devices. Surgeons in our department were not able to use remote video technology for patient management. Guidelines for an appropriate selection of patients which could be served via telemedicine had to be created. Telemedicine must be regulated by healthcare organizations for legal, ethical, medico-legal and risk management aspects. Even if we have experienced an important need to use telematic solutions during the COVID-19 lockdown, liability and risk management issues has greatly limited this possibility in our unit. The need of telemedicine in the time of COVID-19 pandemic has encouraged us to implement future virtual encounters in order to reduce unnecessary in-person visits by taking into consideration all legal, ethical and medico-legal aspects.