Cutaneous resurfacing around a permanent tracheostoma with an internal mammary artery perforator flap

Outcomes of internal mammary artery perforator flap in head and neck reconstruction: A systematic review

This study aims to evaluate the functional and prognostic outcomes associated with the internal mammary artery perforator (IMAP) flap in various head and neck defect repairs, given the current lack of clarity on its effectiveness. We performed a systematic review of various databases: PubMed, Embase, Scopus, Web of Science, and ScienceDirect using keywords such as "Internal mammary artery perforator flap" and "IMAP." Screening and data extractions were performed by two individual reviewers. Articles were considered eligible if they included sufficient information on IMAP flap features, their applications in the head and neck, and outcomes. From 264 articles analyzed, 24 studies were included for qualitative analysis. Out of which, 125 patients who received internal mammary artery perforator flaps were included. Most of the patients, 103 (88%), received pedicled IMAP flaps, and 22 (12%) received IMAP free flaps. The second internal mammary artery (IMA) was favored as the single perforator (81.5%), with the combination of the first and second IMA being the primary choice for dual perforators (92.5%). IMAP flaps were predominantly single perforator flaps (65%), with 35% being dual perforator flaps. Among various applications, IMAP flaps are commonly employed in the reconstruction of neck defects (25.5%), pharyngocutaneous fistula repair (20.8%), and burn scar contracture restoration (8%). Only seven (5.6%) patients had flap complications, including venous congestion (1.6%), partial necrosis (1.6%), complete necrosis (1.6%), and incision dehiscence (0.8%). Donor sites were predominantly closed by the primary closure (92%). 3.2% of donor sites had minor complications. The average follow-up was 12.6 (IQR: 6-18) months. This systematic review highlights the effectiveness and safety of IMAP flaps in head and neck reconstruction, with positive outcomes and minimal complications.

Perforator-Based Cross-Midline Flaps of the Trunk: A Paradigm Shift in Flap Design

BACKGROUND

The traditional design for truncal perforator flaps is ipsilateral without midline decussation. The presumed rationale is to minimize the risk of distal flap necrosis. In this article, the authors present their experience and results with contralateral truncal perforator flaps designed and raised crossing the midline.

METHODS

This retrospective analysis included 43 patients (25 men and 18 women) who underwent reconstructive surgery from 1984 to 2021 using a contralateral flap design crossing the midline in the anterior trunk and upper back. Considerations included pathology, location, and the dimensions of the defect and flap. Arithmetic and weighted means with their 95% confidence intervals were estimated to compare ipsilateral and contralateral techniques.

RESULTS

Contralateral flaps used included the internal mammary perforator flap ( n = 28) superficial superior epigastric artery flap ( n = 8), superior epigastric perforator flap ( n = 2), and the second or ninth dorsal intercostal artery perforator flap ( n = 5). All of these flaps, excluding the superficial superior epigastric artery flap, demonstrated length and coverage surface averages that were significantly greater than those of traditional ipsilateral flaps. However, with the contralateral superficial superior epigastric artery, both measures were statistically similar to those of traditional ipsilateral flaps.

CONCLUSION

The anatomical variation design suggests that the trunk midline is not a barrier and that perforator flaps in these two regions may be raised on different longitudinal axes without compromising vitality.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Regional pedicled flaps in prevention and repair of pharyngocutaneous fistulas

BACKGROUND

Pharyngocutaneous fistula (PCF) is a common complication after laryngopharyngeal surgery. It presents incredible difficulties to both doctors and patients and can lead to prolonged hospitalization.

OBJECTIVE

To analyze the pros and cons of the pedicled skin flap in the prevention and repair of PCF and put forward the authors' views and experience about the selection and application of flaps for the treatment of PCF.

METHODS

A literature review of pedicled flap application in PCF was carried out.

RESULTS

Based on the analysis of the characteristics of the pedicled flap in PCF treatment, the advantages and disadvantages are compared.

RESULTS

In the literature, the pectoralis major myocutaneous flap is the most widely used regional pedicled flap for PCF. Many other flaps can be used to prevent and treat PCF. Each kind of pedicled flap has advantages and limitations. This plays a role in the individualized selection and design of PCF to maximize the benefits of patients.

CONCLUSIONS

Taking unity of function, aesthetics, and proficiency of operators into account, choosing the appropriate flap to repair PCF can reduce the occurrence rate of PCF and improve the patient's quality of life.

Case Report: Revisiting the Internal Mammary Artery Perforator Flap: Salvage Option for Circumferential Pharyngo-Esophageal Defects

Patients that present with pharyngeal strictures and pharyngocutaneous fistulas in the context of previous reconstruction and post-operative radiotherapy often report significant morbidity and reduction in quality of life. Reconstruction of such defects present a substantial clinical challenge requiring the importation of unirradiated vascularized tissue to facilitate healing in a friable, fibrotic, and vessel depleted tissue bed. The authors present a case report demonstrating an adaptation of the internal mammary artery perforator (IMAP) flap for reliable reconstruction of circumferential pharyngeal defects with primary tension free closure of the donor site. This technique avoids the use of free tissue transfer in a hostile, irradiated neck. The tubed IMAP flap is an excellent option, serving the purposes of reconstruction as well as addressing the patient's presenting issues of a chronic sinus and pharyngeal stricture inhibiting oral intake.