Comparison of the Radial Forearm Flap and the Thinned Anterolateral Thigh Cutaneous Flap for Reconstruction of Tongue Defects: An Evaluation of Donor-Site Morbidity

Thinned Perforator Flaps in Head and Neck Reconstruction

The authors aim to provide a comprehensive overview of the advancements in head and neck reconstructive surgery using thinned perforator flaps. The article categorizes these flaps based on thickness and discusses the importance of standardized terminology. Critical aspects like flap vascularity, pre-operative planning, and imaging technologies for perforator mapping are examined with practical considerations. The article then delves into various thinning techniques and their applications in head and neck reconstructions, highlighting challenges and concerns. In conclusion, significant progress in reconstructive surgery using thinned perforator flaps has brought advancements in improving surgical precision and patient outcomes in head and neck reconstructions.

Application of Free Flaps in Reconstruction of Head and Neck Soft Tissue Defects With Bone Exposure

BACKGROUND

Reconstruction of head and neck soft tissue defects with bone exposure is both challenging and technically demanding for plastic surgeon. Objectives in head and neck soft tissue defects with bone exposure reconstruction are consistent restoration of functionality while also improving appearance. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 4 years.

METHODS

A retrospective analysis was conducted from June 2019 to June 2023 on 12 patients treated at our hospital for head and neck soft tissue defects with bone exposure due to various causes. These included 4 cases of trauma from car accidents, 1 burn case, and 7 postoperative malignant tumor removals. The defect sizes ranged from 4 × 6 to 15 × 45 cm. Different free flaps were used for repair based on the defect, including 6 anterolateral thigh flaps, 3 forearm flaps, 2 latissimus dorsi flaps, and 1 dorsalis pedis flap. Flaps were designed and harvested to match the defect size and transplanted via anastomosed vessels.

RESULTS

All 12 flaps survived successfully. One patient required flap thinning surgery postoperatively. All patients were followed up for over 3 months, showing good color and texture of the transplanted flaps, satisfactory healing, and significant aesthetic improvement. Donor sites showed significant scarring without functional impairment.

CONCLUSION

Free flap repair for head and neck soft tissue defects with bone exposure is feasible and yields good results.

The application of mixed reality technique in oromaxillo-facial reconstruction with the perforator flap for malignant tumor patients

Objectives

The integration of quantitative imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) with mixed reality (MR) technology holds promise for enhancing the diagnosis, prognosis, and treatment monitoring of cancer. This study compares the characteristics and effects of MR and color Doppler ultrasound (CDU) in the localization of perforator blood vessels in the lower extremities.

Methods

Two techniques were used to locate the perforator vessels in 40 cases of maxillofacial defect repair using perforator flaps from the lower extremities. The number of perforator vessels located in the flap area and the actual number of perforator vessels explored during the surgery were recorded. The recognition rate was calculated and the operation time and blood loss were recorded for each case.

Results

The recognition rates of MR technology and CDU in perforating vessels of the lower limbs were 93.9% and 97.2%, respectively (p > 0.05). The operation time was 52-74 minutes, 65-88 minutes (p > 0.05). The average bleeding volumes were 24 and 56 ml (p < 0.05), respectively. All perforator flaps were alive. One flap had a crisis and recovered after emergency exploratory treatment. Thirty donor sites of the lower extremities were directly sutured, and wounds were closed by abdominal skin grafting in 10 cases.

Conclusion

MR technology for successfully identifying perforator vessels can shorten the operation time, reduce the amount of bleeding in the donor site, and reduce trauma to the donor site.

A 10-year experience in microsurgical reconstruction of the nose with a lower extremity flap

BACKGROUND

Traditionally, radial forearm free flaps are utilized for nasal lining reconstruction when local flaps cannot provide adequate coverage. However, according to our clinical observation, the skin of the forearm flap is relatively thin and prone to collapse. We present a series of nasal reconstructions using free flaps harvested from the lower extremities to determine if the thick flap could provide more support and decrease the tendency of airway collapse.

METHODS

From March 2011 to July 2021, we identified 15 patients who underwent total or subtotal nasal reconstruction with free flap from the lower extremities (10 anterolateral thigh flap, 4 medial sural artery perforator flap, and 1 profunda artery perforator flap). We included 15 patients who underwent free forearm flap reconstruction as controls. The Nasal Obstruction Symptoms Evaluation (NOSE) score was utilized to subjectively evaluate the degree of nasal obstruction symptoms.

RESULTS

The lower extremity group had a lower NOSE score than the forearm group (25.4 vs. 40). It took more time (6.5 vs. 4.2 months) and more surgeries (4.6 vs. 2.6) from the first free flap reconstruction till forehead flap reconstruction in the lower extremity group than in the forearm group, although the total number of surgeries was comparable between the 2 groups (7.2 vs. 8.1).

CONCLUSIONS

Utilizing free flaps from the lower extremities in total or subtotal reconstruction of the nasal lining may decrease the tendency of flap collapse and alleviate airway obstruction symptoms and may also allow reconstruction of surrounding defects simultaneously compared with using forearm flaps.

Ultrathin Anterolateral Thigh Free Flap: An Adipocutaneous Flap with the Most Superficial Elevation Plane

BACKGROUND

Although many efforts have been made to create thinner anterolateral thigh (ALT) flaps, their thickness varies among patients, and the flap may be still too thick to match shallow defects. The authors successfully harvested an ALT flap through the most superficial elevation plane, the superficial fat layer, which was useful to match the shallow defects.

METHODS

All patients who underwent ALT free flap reconstruction for upper and lower distal extremity defects were divided retrospectively into groups by ALT flap elevation plane: thin, above the deep fascia; superthin, at the superficial fascia; and ultrathin, through the superficial fat. Preoperative computed tomographic angiography and duplex ultrasonography planning were used for all patients. Anatomical characteristics of donor subcutaneous tissue and surgical details, including flap thickness, flap size, and incidence of flap necrosis were compared among the groups and between sexes.

RESULTS

The average deep and superficial fascial depths were 16.7 and 10.8 mm, 12.5 and 8.2 mm, and 9.1 and 5.6 mm ( P < 0.05), and the average flap thickness was 5.8 mm, 7.9 mm, and 7.8 mm ( P = 0.29) in the ultrathin, superthin, and thin ALT groups, respectively. No significant intergroup differences existed in flap size or complications. The deep and superficial fascia were located significantly deeper in female patients (9.4 and 6.0 mm in male patients and 14.9 and 9.6 mm in female patients, respectively).

CONCLUSIONS

With precise preoperative planning, the most superficially elevated, ultrathin ALT flap can achieve optimal reconstructions of thin body areas. Female patients with thicker thighs and patients with a high body mass index would benefit from this flap.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comparison of T1/2 Tongue Carcinoma with or without Radial Forearm Flap Reconstruction Regarding Post-Therapeutic Function, Survival, and Gender

BACKGROUND

Flap reconstruction is commonly used in advanced tongue carcinoma in order to compensate for the loss of tongue tissue and function. Surprisingly, a large number of reconstructed early-stage tongue cancer can be found. Survival or functional benefits in these cases remain unclear.

METHODS

A retrospective data analysis of 384 surgically treated tongue carcinoma patients was conducted aiming to find epidemiologic and survival differences between patients with (n = 158) or without flap reconstruction (n = 226). A prospective functional analysis was performed on 55 early-stage tongue cancer patients, 33 without and 22 with radial-forearm flap reconstruction, focusing on post-therapeutic swallowing function as the primary endpoint, speech as the secondary endpoint, xerostomia, quality of life, and mouth opening.

RESULTS

Consistent with the current literature, we demonstrated the significantly more frequent use of flap grafts in advanced tongue carcinomas. For the first time, we depicted a higher female ratio in the reconstructed group (p = 0.02). There were no significant differences in survival or functional outcomes between the groups. The none-reconstructed group showed more frequent use of adjuvant C/RT despite presenting fewer N+ stages.

CONCLUSIONS

The higher female ratio in the reconstruction group is plausible due to the anatomically smaller oral cavity and relatively larger carcinoma in women. A higher presence of close margins in the none-reconstruction group may explain the more frequent use of adjuvant C/RT. Since we found no survival or functional differences between the groups, we propose a critical approach toward flap reconstruction in T1/2 tongue carcinoma. At the same time, proportional aspects and adequate resection margins should be taken into account.

"Outcomes of Local versus Free Flaps for Lower Extremity Trauma"

BACKGROUND

Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation.

METHODS

This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation.

RESULTS

357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts.

DISCUSSION

Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.

Tracheal reconstruction: mini-review and anatomical study on the use of antero lateral thigh fascial flap for heterotopical transplantation

Background

The reconstructive tracheal options for extensive lesions still remain limited and although a valid substitute is required unfortunately, the biomechanical tracheal characteristics do not allow an easy replacement. In this study we reviewed the described options and investigated, in human cadaver model, whether thigh fascia can be used, as an alternative to forearm fascia, as recipient site for trachea graft heterotopical allotransplantation.

Anatomical study

In three fresh cadavers, 3 tracheal graft, 6 radial forearm (RF) fascial flaps and 6 antero-lateral thigh (ALT) fascial flaps were harvested. For each flap we simulated the heteretopical transplantation of the trachea in each fascial flap, and the harvesting of the composite graft as a free flap. The composite graft was finally decomposed at bench and the pedicle was injected to confirm fascial vascularization. The main measured outcomes were: flap fascia vascularization after pedicle injection, average time of flap harvesting, number of perforators included in ALT fascial flap and diameter of the vessels for anastomosis. Difficulties were noted, in order to compare RF flap and ALT flap.

Results

Fascia vascularization was confirmed in all cases by pedicle injection. The main difficulty with radial flap was to harvest the fascial layer due to its thinness and its strong adherence to palmaris longus tendon, while the main difficulty with ALT flap was to prevent any traction on the perforators. The average time of flap harvesting and graft inset (by a junior plastic surgeon) was 1 h and 30 min for radial forearm flap and 2 h and 10 min for ALT flap.

Conclusion

Despite many different techniques proposed in the literature, tracheal heterotopical allotransplantation still seemed the most promising, and ALT flap promised be a feasible alternative for heterotopical transplantation of trachea.

Super-thin ALT flap elevation using preoperative color doppler ultrasound planning: Identification of horizontally running pathway at the deep adipofascial layers

INTRODUCTION

Presently, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest a reliable super-thin flap elevation technique.

MATERIALS AND METHODS

From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients' flap outcomes and characteristics of the perforators were analyzed. In addition, the effects of patients' body mass index (BMI) and thickness of super-thin flap were evaluated.

RESULTS

The average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and the vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients' BMI (ranged from 17.4 to 34.2 kg/m²; p = 0.183).

CONCLUSION

The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain the reliability of the super-thin ALT flap.

Higher incidences of neuropathic pain and altered sensation following radial forearm free flap: A systematic review

BACKGROUND

The radial forearm free flap (RFFF) has been used extensively for complex tissue defect reconstructions; however, the potential for significant donor-site morbidity remains a major drawback. Despite an abundance of literature on donor-site morbidities, no consensus has been reached on exact incidences of sensory morbidities that vary largely between 0% and 46%. Incidences of neuropathic pain in the donor site following RFFF still lack, even though clinical experience shows it often occurs. Therefore, the purpose of this systematic review was to identify the incidence of neuropathic pain and altered sensation in the hand following harvesting of a RFFF.

METHODS

A systematic search was performed in multiple databases (Embase, Medline, Cochrane, Web of Science, and Google Scholar). Studies from 1990 onwards that reported donor-site morbidities following harvest of the RFFF were included. Analyzed parameters included hand pain, hypoesthesia, cold intolerance, hyperesthesia, neuroma formation, paresthesia, sharp sensation loss, light sensation loss, and defect closure.

RESULTS

Of the 987 selected studies, 51 eligible articles were selected. The mean level of evidence was 3 (SD 0.6). Twenty articles reported pain as a donor-site morbidity, and the mean incidence of pain reported was 23% (SD 7.8). Hypoesthesia was reported by 37 articles and had a mean incidence of 34% (SD 25). Locations of pain and hypoesthesia included, amongst others, the area of the radial sensory nerve and the skin graft area. The mean incidences of cold intolerance and hyperesthesia were 13% (SD 13) and 16% (SD 15), respectively.

CONCLUSION

The results of this systematic review suggest that 23% of all patients are dealing with neuropathic pain in the donor-site following harvest of an RFFF. Future studies should therefore focus on the prognostic factors and preventive measures of neuropathic pain to further improve clinical outcomes of this widely used flap.

Qualitative and Quantitative Analyses of Donor Site Morbidity Following a Graft of the Acellular Dermal Matrix Versus Primary Fascial Repair After ALT Flap Harvesting

Background

The anterolateral thigh (ALT) flap is one of the most useful flaps in reconstruction because of its reliability, large skin flap territory, and versatility. The relatively small number of side effects is a common reason for preferring this flap. Primary repair is usually performed at the donor site closure; however, this requires substantial tension and causes many donor site morbidities, including pain. We attempted to use acellular dermal matrix graft to overcome these problems.

Methods

We analyzed a total of 41 cases (41 flaps) in this study. Among these flaps, we conducted donor fascia suture with artificial dermis in 20 cases (study group) and primary fascial suture in 21cases (control group). Post-operative ambulation recovery times, pain scores, drainage removals, and wound problems of the donor site were recorded.

Results

There were no serious complications, including infection, at the donor sites of all 41 cases. Of 20 cases using the acellular dermal matrix, seroma occurred in 2 cases and partial skin necrosis occurred in 2 cases. In 1 case of skin necrosis, the acellular dermal matrix was removed. However, in comparison to the control group, the group using the artificial dermis recovered ambulatory ability 3.9 days earlier and had a 1.8-point lower visual analogue scale score 5 days post-operatively.

Conclusions

Our study suggested that, if used selectively, the acellular dermal matrix may play an effective role in donor site closure in cases with procedures involving the ALT flap.

Assessment of post-surgical donor-site morbidity in vastus lateralis free flap for head and neck reconstructive surgery: An observational study

BACKGROUND

Vastus lateralis (VL) can be used to reconstruct defects of the head and neck. Whilst the advantages are documented, donor-site morbidity is not well described. This study aimed to assess donor-site morbidity after VL flap harvest. Results will determine future directions for preventative and post-operative care to improve patient health outcomes.

METHODS

Ten participants (mean age 55 years) were assessed for the presence of donor-site morbidity after VL harvest. Musculoskeletal (pain, muscle strength, muscle length and tactile sensation), quality of life (SF-12), lower extremity function, gait (function and speed) and sit to stand were assessed using validated and standardized procedures. The outcomes were compared to age-matched healthy reference values or to the non-operative side. Analyses were conducted using descriptive statistics and non-parametric tests.

RESULTS

There was no difference in muscle strength (knee extension), muscle length, ability to sit-to-stand, or gait function (all P > 0.05). Knee flexor muscle strength was significantly less on the operated leg compared to the non-operated leg (P = 0.02) and walking speed was slower than age-matched healthy values (P < 0.001). Thigh tactile sensation was impaired in 89% of participants. Quality of life was significantly less for the physical health component of the SF-12 (P < 0.001). The mental health component of the SF-12 was similar to healthy controls (P = 0.256).

CONCLUSION

There was no effect on donor site morbidity with regards to knee extensor strength, pain, walking function, ability to sit-to-stand and muscle length. VL harvest affected donor-site knee flexion strength, walking speed, tactile sensation and physical health-related quality of life.

Comparison of Donor Site Morbidity Between Anterolateral Thigh and Radial Forearm Free Flaps for Head and Neck Reconstruction: A Systematic Review and Meta-Analysis

ABSTRACT

This meta-analysis aimed to provide an up-to-date comparison of donor site morbidity (DSM) between patients who underwent head and neck reconstruction with Anterolateral thigh (ALT) and radial forearm free (RFF) flaps. We searched the PubMed, Web of Science, EMBASE, and Cochrane Library databases to identify studies that compared DSM between ALT and RFF patients. Study quality was assessed using the Newcastle-Ottawa Scale. The pooled odds ratio (OR) of each DSM between ALT and RFF patients was estimated using a random- or fixed-effect model depending on the degree of interstudy heterogeneity. Sensitivity and subgroup analyses were performed if substantial heterogeneity was detected. Eighteen cohort studies with 1,018 patients (535 ALT and 483 RFF patients) were included. Compared with RFF, ALT were associated with lower risks of wound dehiscence (OR = 0.2, 95%CI: 0.10-0.42, P < 0.01), strength impairment (OR = 0.18, 95%CI: 0.07-0.47, P < 0.01), and movement impairment (OR = 0.19, 95%CI:0.07-0.49, P < 0.01). A subgroup analysis showed that ALT were associated with a lower risk of donor site numbness among patients undergoing tongue reconstruction (OR = 0.05, 95%CI: 0.01-0.25, P < 0.01), but not among all patients undergoing head and neck reconstruction. The pooled ORs of other DSMs demonstrated no significant difference between ALT and RFF patients. ALT are superior to RFF for head and neck reconstruction in terms of donor site wound dehiscence, strength impairment, movement impairment, and for tongue reconstruction specifically in terms of donor site numbness. No significant differences in the incidence of donor site hematoma/seroma, infection, or dissatisfaction with donor site appearance were identified between ALT and RFF patients.

Reconstruction of Hemiglossectomy Defects With the Lateral Arm Fasciocutaneous Flap

INTRODUCTION

Partial tongue reconstruction requires a thin pliable flap to restore volume and mobility. The lateral arm flap is well suited to this as it is a thin fasciocutaneous flap that has consistent vascular anatomy, reliable perfusion, short harvest time and low donor site morbidity. The authors report our experience with use of this flap for reconstruction of hemi-glossectomy defects.

METHODS

This is a retrospective cohort of patients who underwent reconstruction of hemi-glossectomy and floor of mouth defects with a lateral arm flap, at Aga Khan University Hospital, Karachi (Pakistan) from November 2016 to January 2020. Flaps were harvested from the nondominant upper extremity. Data were collected for patient demographics, size of defect, size of flap, recipient vessels, postoperative complications and functional outcome.

RESULTS

Over a 3-year period, 8 hemi-tongue and extended hemi-tongue, and floor of mouth reconstructions were performed with a lateral arm fasciocutaneous flap. A standard lateral arm flap was harvested in 3 patients and an extended lateral arm flap in 5 patients. Mean flap size was 65.75 cm2 (48-76 cm2). The recipient artery in all cases was the superior thyroid artery. The recipient veins were the common facial vein in 1 patient, the internal jugular in 3 patients, the external jugular in 1 patient and both external and internal jugular in 3 patients. Donor sites were closed primarily. There were no total or partial flap losses. All patients were able to resume an oral diet (unrestricted in 1, soft in 4, pureed in 2 patients). Postoperative speech was intelligible to patients' family in 4 patients and to strangers in 3 patients. One patient succumbed to progressive disease in the early postoperative period. Orocutaneous fistulas developed in 3 patients, all of which healed with nonoperative management.

CONCLUSIONS

The lateral arm fasciocutaneous flap is well suited for reconstruction of hemiglossectomy and floor of mouth defect. It has the advantages of straightforward harvest, thin and pliable soft tissue, and low donor site morbidity.

Reconstruction of Extensive Soft Tissue Defects of Lower Extremity With the Extended Anterolateral Thigh Flap

The anterolateral thigh flap is a classic flap used for various reconstruction defects. However, the flap viability of extended large skin paddles (ie, 240 cm²) was doubted by many surgeons. This study reports successful experience of reconstructing extensive soft tissue defects of lower extremity using extended large skin paddles. Twelve consecutive patients who had undergone reconstruction of defects using an extended anterolateral thigh flap were identified. Patient characteristics (age, sex, defect location, injured structures, and type of flap) and outcome data were analyzed retrospectively. One artery and 2 accompanying veins were anastomosed to vascularize each flap. Follow-up periods ranged from 10 to 91 months postoperatively. The average size of the flaps was 268.75 cm² (range = 220-391 cm²). All flaps were perforator flaps with one perforator except that 2 perforators were used in 3 patients. Two patients suffered partial flap necrosis of the distal portion with delayed healing. In conclusion, the extended anterolateral thigh flap is a considerable option for massive defects requiring composite tissue coverage. This flap is advantageous for reconstructing various complex defects in the lower extremities, providing a pliable and vascularized tissue to cover exposed extensive defects including tendons, nerves, and bones.

Head and neck reconstruction using free flaps: a 30-year medical record review

Background

The free flap surgical method is useful for the reconstruction of head and neck defects. This study retrospectively analyzed the results of head and neck reconstructions using various types of free flaps over the past 30 years.

Methods

Between 1989 and 2018, a total of 866 free flap procedures were performed on 859 patients with head and neck defects, including 7 double free flaps. The causes of vascular crisis and salvage rate were analyzed, and the total flap survival rate calculated among these patients. Additionally, the survival and complication rates for each flap type were compared.

Results

The 866 cases included 557 radial forearm flaps, 200 anterolateral thigh flaps, 39 fibular osteocutaneous flaps, and 70 of various other flaps. The incidence of the vascular crisis was 5.1%; its most common cause was venous thrombosis (52.3%). Salvage surgery was successful in 52.3% of patients, and the total flap survival rate was 97.6%. The success rate of the radial forearm flap was higher than of the anterolateral flap (p<0.01), and the primary sites of malignancy were the tongue, tonsils, and hypopharynx, respectively.

Conclusion

The free flap technique is the most reliable method for head and neck reconstruction; however, the radial forearm free flap showed the highest success rate (98.9%). In patients with malignancy, flap failure was more common in the anterolateral thigh (5.5%) and fibular (5.1%) flaps.

Anterolateral thigh free flaps and radial forearm free flaps in head and neck reconstruction: A 20-year analysis from a single institution

BACKGROUND

Reconstruction after removal of a malignant tumor in the head and neck region is crucial for restoring tissue integrity, function, and aesthetics. We retrospectively analyzed patients who underwent intraoral reconstruction surgery using radial forearm free flaps (RFFF) and anterolateral thigh free flaps (ALT) at a single institution to provide more information supporting the choice of a reconstruction method after removal of head and neck cancer.

METHODS

The charts of 708 patients who underwent head and neck reconstruction between 1998 and 2018 at the Department of Plastic and Reconstructive Surgery at our institution were retrospectively reviewed. Patients' age, sex, and history of radiation therapy, diabetes mellitus, and smoking were retrieved. The primary cancer site, types of defects, and complications were investigated.

RESULTS

Overall, 473 and 95 patients underwent reconstruction surgery with RFFF and ALT, respectively. RFFF was more often used in patients with cancers of the pharynx, larynx, esophagus, or tonsil, while ALT was more frequently used in patients with cancers of the mouth floor with tonsil or tongue involvement. The proportion of patients undergoing ALT increased gradually. Flap failure and donor site morbidities did not show significant differences between the two groups.

CONCLUSIONS

RFFF and ALT flaps resulted in similar outcomes in terms of flap survival and donor site morbidity. ALT can be an option for head and neck reconstruction surgery in patients with large and complex defects or for young patients who want to hide their donor site scars.

Do medial sural artery perforator flaps have better clinical outcomes compared to the rectus abdominis perforator (DIEAP) flap in reconstruction of glossectomy defects? A Prisma guided meta-analysis

BACKGROUND

There is an increasing evidence for the use of thin flaps based on vascular perforators for reconstructive surgeries. The medial sural and deep inferior epigastric artery flaps offer versatility for the reconstruction of major defects of the head and neck.

OBJECTIVES

"Whether medial sural artery perforator (MSAP) flap or rectus abdominis perforator flap is better for the reconstruction of glossectomy defects in terms of functional outcome?"

DATA SOURCES

PubMed, Cochrane Library, clinicaltrials.gov and hand searches.

PARTICIPANTS AND INTERVENTIONS

Patients who underwent tongue reconstruction with either MSAP flap or deep inferior epigastric artery perforator (DIEAP) flap.

STUDY APPRAISAL AND SYNTHESIS METHODS

Based on defined study criteria 6 studies were selected according to Prisma Guidelines. The overall estimated effect was categorized as significant where P < 0.05.

RESULTS

There was no significant difference between both flaps in terms of receptor site complications (P = 0.223). Overall odds ratio (OR) for complications was 1.35 (95% confidence interval [CI]: 0.412-0.736) and the test for overall effect t value was 2.836, P < 0.05. Overall OR was 6.01 (95% CI 0.5-7.45) and the test for overall effect t value was 1.41, P < 0.05 indicating there was a statistical difference in the intelligibility of speech.

LIMITATIONS

Anatomical variations, under-reporting of studies and lack of universal tool for speech intelligibility.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Both the flaps are comparable in terms of functional outcome. Medium-sized defects can be reconstructed with MSAP and composite larger defects would benefit from DIEAP. In females, anterolateral thigh flap still remains the choice for composite reconstructions.

A Head-to-Head Comparison of the Medial Sural Artery Perforator versus Radial Forearm Flap for Tongue Reconstruction

BACKGROUND

 For tongue reconstruction, the radial forearm flap (RFF) is commonly used. In the last decade, the medial sural artery perforator (MSAP) flap has been successfully used with reportedly superior donor-site outcomes. Our study is the first to compare the RFF and MSAP for reconstruction of partial glossectomy defects (<50% of tongue).

METHODS

 We conducted a retrospective review of 20 patients with partial glossectomy defects reconstructed at a tertiary referral center. Patient demographics, perioperative data, and postoperative complications were analyzed. Objective measures of speech, swallowing, and subjective patient satisfaction with their donor site were recorded.

RESULTS

 Ten RFF and MSAP were each used, with a mean partial glossectomy defect size of 40.5 and 43.5%, respectively. The MSAP was significantly thicker (7.8 vs. 4.3 mm, p < 0.05) with a longer harvest time (122.5 vs. 75.0 minutes, p < 0.05). There were no cases of free flap failure. Donor-site healing times were comparable, but the MSAP group experienced significantly less donor-site complications (n = 1 vs. n = 7, p < 0.05). Functional outcomes were comparable with 13 patients achieving normal speech and diet after 3 months (MSAP = 6 vs. RFF = 7, p = 1.00). All patients were satisfied with their donor-site outcome with the MSAP group having a marginally higher score.

CONCLUSION

 Both flaps are good options for partial glossectomy reconstruction. Though more challenging to harvest, the MSAP gives comparable functional results and has become our first reconstructive option given its superior donor-site outcomes.

Functional tongue and floor of mouth reconstruction with a chimeric flap after total glossectomy

PURPOSE

Presently, the functional reconstruction of the tongue in patients after subtotal or total glossectomy with the removal of the oral floor muscles and spearing of the larynx remains a complicated and unsolved issue. The aim of this case is to describe a method reconstruction of the tongue in patients after total glossectomy with the removal of the oral floor muscles using the chimeric latissimus dorsi and serratus anterior free flap (chimeric LD + SA flap) with motor innervation.

METHODS

A 62-year-old woman with advanced cancer of the oral cavity was submitted to total glossectomy and then reconstruction with a chimeric LD + SA flap. With this method reconstruction of the tongue was made the creation a large mound (neotongue) lateral to the mandibular arch which can easily reach the palatal arch and also was made suspension of the larynx is essential given the ablative loss of supra-hyoid attachments.

RESULTS

Our preliminary experience shows that this flap is a good reconstructive option for total glossectomy with the removal of the oral floor muscles and with larynx preservation. Functional and objective evaluation of the tongue reconstructed with chimeric LD + SA free flap requires further and standardized evaluation.

Full cheek defect reconstruction using ALTF versus RFF: Comparison of quality of life, clinical results, and donor site morbidity

OBJECTIVES

This study aimed to compare the quality of life (QOL) of patients, clinical results of the recipient site, and morbidities of the donor site between the use of free anterolateral thigh flaps (ALTFs) and radial forearm flaps (RFFs) for reconstruction of full cheek defects following tumor resection.

MATERIALS AND METHODS

We retrospectively reviewed 52 patients who underwent reconstruction of full cheek defects using free ALTFs and free RFFs following tumor ablation at our center. The range of mouth opening, speech, swallowing, facial appearance, donor site complications, and subjective symptoms based on the University of Washington Quality of Life (UW-QOL) questionnaire findings were assessed in the ALTF and RFF groups at 3, 12, and 36 months after surgery.

RESULTS

Quality of life, range of mouth opening, facial appearance, mood and anxiety, donor site appearance, subjective feeling, and functional impairment were better in the ALTF group than in the RFF group based on the physical examination findings and questionnaire scores.

CONCLUSION

This study found better QOL and better functional results at the recipient site and minor morbidities at the donor site with the use of free ALTFs in the reconstruction of full cheek defects.

Free flap reconstruction of sarcoma defects in the setting of radiation: a ten-year experience

Neoadjuvant treatment and surgical resection for sarcoma patients can often leave devastating wounds necessitating soft-tissue coverage in the form of free flaps. There is still debate as to the optimal flap for reconstruction of defects in irradiated fields. We aim to describe our experiences with free fasciocutaneous and free muscle flaps for sarcoma reconstruction in the setting of radiation therapy. A retrospective chart review was conducted encompassing all patients requiring soft-tissue reconstruction secondary to sarcoma resection from January 2010 to June 2019. Patient characteristics, flap viability and post-operative healing outcomes were all recorded and examined. In total, 49 patients who underwent 51 free-flaps were identified. Of these, 30 flaps were fasciocutaneous, while 21 were muscle-based. Most patients received pre-operative radiotherapy (76.5%), although these rates were not different between groups of flap type, and had no significant association with post-operative outcomes. Complication rates (31.3%) and re-operative rates (21.6%) were also comparable between flap types. Diabetes mellitus was significantly associated with delayed wound healing (p < .016), while the presence of peripheral vascular disease had a significant association with post-operative infection (p < .006). This study shows that free fasciocutaneous and free muscle-based flaps are both viable options for soft-tissue reconstruction demanded by sarcoma resection, even in the setting of radiation. Peripheral vascular disease and diabetes mellitus may confer increased wound complications.

Assessment of Functional Recovery and Subjective Donor-Site Morbidity Following Radial Forearm Flap Reconstruction in Small- to Moderate-Sized Palatal Defects

Context

Palatal defects are encountered following tumor extirpation, trauma, or congenitally. Among the known alternatives, radial artery free forearm flap (RAFF) is a versatile flap that confers good results in head and neck reconstruction, but donor-site morbidity has been an issue of discontent among the plastic surgeons. This limitation needs to be studied further and addressed considering the unmatched quality of this tissue.

Aims

This study aims to weigh the impact of the functional edge of this flap against the unpopular donor-site morbidity on a group of patients.

Settings and Design

This is a retrospective analysis of recuperation of palatal function and patient concerns with the donor-site function and cosmesis on 7 consecutive patients with small-to-moderate palatal defects reconstructed with RAFF.

Methods and Materials

Postoperative recovery of speech, palatal movement, and restoration of oromaxillary interface was assessed using objective tests, such as speech intelligibility testing and articulation studies. Simultaneously, subjective donor-site function and cosmesis were assessed using Patient Scar Assessment Scale (PSAS), Upper Extremity Functional Index (UEFI), and donor limb sensory testing.

Results and Conclusion

Mean PSAS score was 8.28/60, and UEFI score reported was 77/80, which reflect high patient satisfaction with the donor site. Nasoendoscopy shows remarkable restoration of palate anatomy. Intelligibility testing depicts near-normal speech understandability, whereas articulation studies revealed distortions post-palatal reconstruction with RAFF. Radial artery free forearm flap should be considered as the forerunner of reconstruction in palatal defects involving less than 50%.

Free Flap Selection and Outcomes of Soft Tissue Reconstruction Following Resection of Intra-oral Malignancy

Introduction: Surgery to resect intra-oral malignancy is a well-established mode of primary treatment. The tissue requirement in this area is for a thin, pliable flap with minimal bulk and this has historically been provided by free tissue transfer with a radial forearm free flap (RFFF). More recently, a role for the anterolateral thigh free flap (ALTFF) has been described, although in populations with a westernized diet, body habitus may preclude use of an ALTFF due to flap thickness, relative to a radial forearm free flap.

Methods: An analysis of data was performed retrospectively for 90 consecutive patients with intra-oral malignancy, requiring immediate soft tissue reconstruction by the senior author, at Addenbrooke's Hospital between July 2008 and April 2016. Cases requiring bony reconstruction were excluded. Data on patient age, sex, indication for surgery, tumor location and defect type, complications, success rates, and length of stay were recorded.

Results: The majority of patients received an ALTFF (n = 56) with 38% receiving a RFFF (n = 34). Surgical resection took place in the floor of the mouth most frequently. These were closed with ALTFF and RFFF in 41 and 28 occasions, respectively. A success rate of 97% was observed in the RFFF group; 1 flap developed partial necrosis and required complete revision. In the ALTFF group, there was a 100% flap success rate. ALTFF usage resulted in a reduction in the number of intraoperative (p = 0.021) in addition a reduction in the number of days in ITU (p = 0.01) and post-operative clinic visits (p = 0.025).

Conclusion: We present a series that used predominately the ALTFF to reconstruct intra-oral defects following resection of squamous cell carcinoma in a Western population. The results demonstrate that this treatment can produce at least as comparable results as to the use of a RFFF repair in this population, whilst avoiding the donor site morbidity and aesthetic compromise of a RFFF.

Donor Site Morbidity in Phalloplasty Reconstructions: Outcomes of the Radial Forearm Free Flap

The radial artery forearm free flap (RFFF) is the workhorse technique for phallus reconstruction. The RFFF provides good cosmesis and potential sensory recovery. However, the donor site is large in comparison to other applications of the RFFF which may increase the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength. This study systematically reviewed the current literature to assess the donor site morbidity associated with RFFF phalloplasty (RFFFP).

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

Different locoregional and free flaps were described for oral soft tissues reconstruction after oncological resections; however, free flaps remain the first choice. Among free flaps, the radial forearm flap (RFF) and the anterolateral thigh perforator flap (ALT) are preferred the most. The lack of standardization of the flap choice leaves the selection to the surgeon's experience. The purpose of our observational study is to provide an algorithm to support the flap choice for the reconstruction of oral soft tissues. Sixty patients with squamous cell carcinoma of oral soft tissues were enrolled in our study. All the patients underwent preoperative magnetic resonance imaging (MRI) to measure the three-dimensional size of the tumor. During the follow-up, the patients were evaluated by using the University of Washington-Quality of Life Questionnaire. The questionnaire score was better for small tumors and worse for large tumors in both functional and relational fields. We observed that most of the overlapping results were obtained for small defects and the choice of RFF, as well as for large defects and the use of ALT. We observed that in the preoperative time, it is possible to select which flap between radial forearm and ALT is more appropriate for oral soft tissues defects reconstruction, according to the size of the tumor evaluated by MRI. We propose a decisional algorithm that suggests the type of flap to use between ALT and RFF.

A Unifying Algorithm in Microvascular Reconstruction of Oral Cavity Defects Using the Trilaminar Concept

Although many algorithms exist to classify oral cavity defects, they are limited by either considering a single subsite or failing to provide a concise reconstructive algorithm for the breadth of defects. Based upon our experience as a tertiary referral center, a unifying algorithm is presented that guides free flap selection in this heterogenous population.

Comparison of the subjective satisfaction of the donor site morbidity: Free radial forearm flap versus anterolateral thigh flap for reconstruction in tongue cancer patients

BACKGROUND

The purpose of the study was to compare the differences of the subjective satisfaction of the donor site morbidity between the free radial forearm flap (FRFF) and anterolateral thigh flap (ALTF) for tongue reconstruction.

MATERIAL AND METHODS

One hundred and nineteen patients underwent FRFF or ALTF reconstruction were retrospectively evaluated by a standardized self-established donor site morbidity questionnaire which included 5 domains, sensibility, movement disabilities, cosmetics, social activities and general impacts on the quality of life.

RESULTS

The Cronbach's coefficient alpha of the questionnaire was 0.707. The exploratory factor analysis revealed that the 5 items of the questionnaire might load onto two distinct subscales. Patients with ALTF had higher scores in the sensibility, cosmetics and the composite score (P < 0.05). No significant differences were found in the movement disabilities, social activities and general impacts on the quality of life between the two groups (P > 0.05).

CONCLUSIONS

ALTF has the advantage of better results of donor site morbidity, such as sensibility and cosmetics, over FRFF.

Exclusive tongue tip reconstruction of hemiglossectomy defects using the underrated lateral arm free flap with bilobed design

Background

Tongue reconstruction is challenging with the unique function and anatomy. Goals for reconstruction differ depending on the extent of reconstruction. Thin and pliable flaps are useful for tongue tip reconstruction, for appearance and mobility. This study reports lateral arm free flap (LAFF) as a safe and optimal option for hemi-tongue reconstruction, especially for tongue tip after hemiglossectomy.

Methods

Thirteen LAFFs were performed for hemi-tongue reconstruction after hemiglossectomy from 1995 to 2018. Of the 13 patients, seven were male and six were female, age varying from 24 to 64 years.

Results

All flaps healed uneventfully without complications. Donor sites were closed primarily. The recipient vessels for microvascular anastomosis were mainly superior thyroidal artery, external jugular vein. All patients returned to normal diet, with no complaints regarding reconstructed tongue and donor site.

Conclusion

The LAFF is hairless, thin (especially with lateral epicondyle approach), and potentially sensate. They are advantageous features for tongue tip and hemi-tongue reconstruction. Donor site sacrifices the inessential posterior radial collateral artery, and the scar is hidden under short sleeve shirts. We believe that LAFF can be considered as the first choice flap for hemitongue reconstruction, over radial forearm free flaps.

Long-term donor site morbidity in head and neck cancer patients and its impact on quality of life: a cross-sectional study

Modern head and neck reconstructive surgery offers a multitude of different reconstructive options. In such cases, donor site morbidity is an important factor in the affected patient's decision-making. The aim of this study was to perform an objective comparison of donor site morbidity for the five most frequent microvascular donor sites in head and neck reconstructive surgery (radial forearm, anterolateral thigh, fibula, iliac crest, and scapula) using a uniform testing system. In this cross-sectional study, 117 donor sites were analyzed (106 for malignant disease and 11 for non-malignant disease): 73 radial forearm, 14 scapula, 12 anterolateral thigh, 10 fibula, and eight iliac crest. Testing consisted of range of motion, muscle strength, and sensation. The non-affected side served as the control. Quality of life was assessed using the Washington Quality of Life Questionnaire version 4 in its German translation. Range of motion was restricted in 15 cases (12.8%). Muscle strength was decreased in 58 cases (49.6%). Sensation was reduced in 70 cases (60%). Concerning quality of life, 31.2% of patients were limited in their daily activities. The scapula flap showed the highest incidence of overall donor site morbidity. However, correlation between objective and subjective donor site impairment was weak and the majority of patients experienced only minor limitations.

Anatomical Understanding of Target Subcutaneous Tissue Layer for Thinning Procedures in Thoracodorsal Artery Perforator, Superficial Circumflex Iliac Artery Perforator, and Anterolateral Thigh Perforator Flaps

BACKGROUND

Thinned perforator flaps, reported techniques, and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography.

METHODS

Three stratified fattiness groups consisting of 30 donors were formed for thoracodorsal artery perforator, superficial circumflex iliac artery perforator, and anterolateral thigh flaps. Thickness of the superficial fat and the deep fat layers was measured at specific points in donor sites of the three flaps and the proportion of superficial and deep fat layers to exclude to reach the target flap thickness (4, 6, and 8 mm) was calculated.

RESULT

The median proportion for the superficial fat layer varies depending on donor fattiness. The estimated percentage reduction of thickness after thin flap elevation along superficial fascia was approximately one-third of the whole layer. A variable proportion of each fat layer needs to be excluded to obtain required thinness and in very thick groups, part of the superficial fat layer must be removed to reach any of the target thicknesses for the three flaps.

CONCLUSIONS

The present study demonstrated the frequent need for superficial fat layer manipulation when obtaining a thin perforator flap. To cope with various combinations of donor-site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control superficial fat layer thickness.

Alternative Design for Anterolateral Thigh Multi-Paddled Flaps: The 3-5 System

BACKGROUND The design and harvest of the anterolateral thigh (ALT) multi-paddled flap is a critical step in reconstructive surgeries. However, limited perforator distribution patterns of traditional design methods have gradually emerged in clinical practice. The aim of this study was to investigate the effect of a new technique (the 3-5 system) on ALT multi-paddled flap design. MATERIAL AND METHODS A total of 151 ALT flaps were harvested from 149 patients over a 26-month period. Among them, 100 ALT flaps were examined preoperatively using a handheld Doppler device to localize vascular perforators. RESULTS By detecting perforator penetration points through the vastus lateral muscle (VLM) or the intermuscular septum and perforator entry points to the deep fascia, precise ALT flap perforator distribution patterns were found. Meanwhile, a 3-5 system was developed to design ALT flaps based on these findings. The remaining 51 ALT flaps from 49 patients during a 9-month period did not require the use of preoperative handheld Doppler. In addition, preoperative handheld Doppler and intraoperative findings demonstrated that all ALT flap penetration points through the VLM or intermuscular septum and the perforator entry point in the deep fascia were closely related based on 3 longitudinal lines and 5 horizontal lines. CONCLUSIONS ALT flaps were successfully harvested using a 3-5 system without the need for preoperative handheld Doppler analysis. Moreover, the 3-5 system is a simple and practical approach for preoperative ALT multi-paddled flap design.

Risk factors for delayed healing at the free anterolateral thigh flap donor site

BACKGROUND

The free anterolateral thigh (ALT) flap has been widely used for various kinds of reconstructions. However, delayed healing at the donor site occasionally occurs due to wound dehiscence or the partial loss of grafted skin at the donor site. The aim of the present study was to identify reliable predictive factors for delayed healing at the donor site after the harvest of a free ALT flap.

METHODS

This study included 52 patients who underwent reconstructive procedures using free ALT flaps. The delayed healing group included patients with wounds at the donor site that had not healed over 3 weeks after surgery, and the normal healing group included patients who showed wound healing within 3 weeks after surgery. Multivariate logistic regression models were created to identify the risk factors for delayed healing at the ALT flap donor site.

RESULTS

Among the 52 patients, 24 (46.2%) showed delayed healing at the donor site, and 6 patients required additional operative treatment. A high preoperative body mass index (BMI), smoking, and skin grafting were found to be significantly associated with delayed healing at the ALT donor site. Of the 37 patients who underwent skin grafting, 23 (62%) experienced delayed healing at the donor site.

CONCLUSIONS

A high preoperative BMI, smoking, and skin grafting were risk factors for delayed healing at the free ALT donor site. Skin grafting at the ALT donor site should be avoided in patients with a high BMI or a habit of smoking.

Motor and sensory morbidity associated with the anterolateral thigh perforator free flap

OBJECTIVE

To quantify changes in motor function, sensation, and lower extremity quality of life following anterior lateral thigh free flap (ALT) resection.

METHODS

This mixed methods study contained both a prospective cohort arm (n = 20) and retrospective cross-sectional arm (n = 20). In both arms, patients underwent formal motor and sensation testing of the ipsilateral and contralateral thigh by sphygmomanometry and monofilament testing. In the prospective arm, data was collected preoperatively and at the 6-month and 1-year follow-up visits. In the retrospective arm, consecutive patients with a minimum of 6-month postoperative follow-up were enrolled.

RESULTS

Postoperatively, 82% of participants endorsed some degree of numbness and tingling at the donor site. On monofilament testing, patients from the prospective arm showed decreased sensibility of the midthigh at both the 6- and 12-month assessment (P < 0.01). Two-point discrimination scores were moderately correlated with the cross-sectional surface area of the flap. Donor thighs demonstrated a similar peak isometric quadriceps contraction (retrospective [retro]: 47 ± 24 mmHg, prospective [pro]: 90 ± 36 mmHg) to the unoperated thighs (retro: 43 mmHg ± 22, pro: 69 ± 35.3 mmHg, P = 0.49). When stratified by perforator anatomy, no significant differences were noted. Subjective donor site morbidity measured with the lower extremity function scale demonstrated no statistically significant difference between the preoperative and 12-month postoperative assessment.

CONCLUSION

The ALT flap offers minimal donor site morbidity. Reduced sensibility of the ALT flap is a common complaint among patients. Quadriceps strength is not significantly affected by an ALT free flap harvest.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:1057-1061, 2018.

Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction

BACKGROUND

The purpose of this study was to compare the clinical outcomes and donor-site morbidity between the suprafascial and subfascial harvesting of anterolateral thigh flaps.

METHODS

Sixty-one patients who underwent free flap reconstruction (30 suprafascial and 31 subfascial anterolateral thigh flaps) were included in this study. The patients assessed the subjective donor-site morbidity and satisfaction with the overall functional result using a self-reported questionnaire. The flap characteristics (i.e., perforator number, flap size, and harvest time) and outcomes (i.e., success rate, partial necrosis, infection, hematoma, and fistula) were compared.

RESULTS

The success rates of suprafascial and subfascial anterolateral thigh flaps were 96.7 and 96.8 percent, respectively. There were no significant differences in flap size, harvest time, or overall complication rates. The suprafascial anterolateral thigh flap group experienced fewer abnormal sensations (p < 0.001) and better subjective satisfaction at the donor site than did the subfascial anterolateral thigh flap group (p = 0.03).

CONCLUSIONS

In terms of reducing donor-site morbidity, the suprafascial anterolateral thigh flap group showed fewer sensory disturbances in donor thighs and exhibited better patient satisfaction than did the subfascial anterolateral thigh flap group, but meticulous dissection of tiny perforators above the fascia is required for the former procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comprehensive Analysis of Donor-Site Morbidity following Free Thoracodorsal Artery Perforator Flap Harvest

BACKGROUND

The authors evaluated donor-site morbidity following free thoracodorsal artery perforator flap harvest comprehensively and investigated patient-and operation-related factors that might contribute to adverse outcomes.

METHODS

A retrospective analysis was conducted for all cases of free thoracodorsal artery perforator flap reconstruction performed between January of 2002 and December of 2014. Donor-site morbidity was evaluated in three aspects: postoperative complications, scar-related problems, and functional impairment. The Quick-Disabilities of the Arm, Shoulder and Hand questionnaire was administered postoperatively to assess donor-site function.

RESULTS

A total of 293 patients were analyzed. The median follow-up period was 19.0 months. Donor-site complications developed in 33 patients (11.3 percent). Wound dehiscence (7.4 percent) and seroma (3.0 percent) were the most common complications. Harvesting thoracodorsal artery perforator flaps on multiple perforators or segmental latissimus dorsi muscle-chimeric flaps increased the rate of seroma formation but did not affect other donor-site morbidities significantly. Patient American Society of Anesthesiologists classification was a significant predictor of wound dehiscence and overall donor-site complications. Thirty-one patients (10.6 percent) had scar-related problems, including 18 hypertrophic and 13 widened scars. A transverse skin paddle design had a significant protective effect on developing scar-related problems, compared with the nontransverse design. The mean Quick-Disabilities of the Arm, Shoulder and Hand questionnaire score was 2.68 (range, 0 to 18.2), and 90 percent of patients scored less than 10. Flap dimensions were positively correlated with the questionnaire score.

CONCLUSIONS

The present study suggests that the free thoracodorsal artery perforator flap is associated with low donor-site morbidity and minimal dysfunction. Careful consideration of patient condition and thoughtful planning could further minimize donor-site morbidity.

CLINICAL QUESTION/LEVEVL OF EVIDENCE

Therapeutic, IV.

Comparative Skin Evaluation After Split-Thickness Skin Grafts Using 2 Different Acellular Dermal Matrices to Cover Composite Forearm Defects

PURPOSE

The combination of acellular dermal matrix (ADM) and split-thickness skin graft (STSG) has been widely adopted to overcome functional and cosmetic limitations of conventional STSG. In this study, we evaluated the efficacy of this combination using 2 types of ADM: cadaveric acellular dermal matrix (CDM) and bovine acellular dermal matrix (BDM).

METHODS

We recruited 72 patients undergoing autologous STSG to cover radial forearm free flap donor sites. They were included in 1 of 3 therapeutic groups: group 1, STSG using CDM (n = 29); group 2, STSG using BDM (n = 20); and group 3, STSG only (n = 23). Functional skin values for skin elasticity, humidification, transepidermal water loss, and color were determined. Values were compared between graft sites and adjacent normal (control) skin, and between grafted areas of each group.

RESULTS

All skin defects were successfully reconstructed without graft loss. Groups 1 and 2 demonstrated better elasticity than did group 3, based on the analysis using the ratio of grafted area to control. Grafted areas in all 3 groups exhibited less moisture than did control normal skin. There was less transepidermal water loss in group 1 than in group 3, which implied that CDM application had better barrier capacity against water evaporation. Graft sites of groups 1 and 3 exhibited darker and redder color compared with control areas.

CONCLUSIONS

Composite forearm defects were successfully restored and exhibited acceptable quality after treatment with an ADM plus STSG. Applying either CDM or BDM under a STSG was a suitable procedure, as verified by objective measurements. Elasticity was well preserved in CDM and BDM groups. However, both ADMs revealed functional impairment of humidification.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

True functional reconstruction of total or subtotal glossectomy defects using a chimeric anterolateral thigh flap with both sensorial and motor innervation

BACKGROUND

The purpose of this study was to report the motor functional outcomes and sensory recovery of patients who had undergone total or subtotal glossectomy for oral squamous cell carcinomas reconstructed with chimeric anterolateral thigh (ALT) flaps.

METHODS

Six patients, 4 men and 2 women, with a mean age of 49.5 years (range, 36-73 years) were included in the study. All patients were treated with chimeric ALT, including the vastus lateralis muscle with its motor nerve and skin paddle with its innervating nerve. All patients were administered functional tests involving sensory recovery, intelligibility, and swallowing. Flap sensibility was evaluated using light touch sensation with the Semmes-Weinstein monofilament test, 2-point discrimination according to the Weber sensitive test, warm and cold temperature sensations, and pain sensation. Intelligibility was scored by a speech therapist on a scale from 1 to 5. Swallowing was assessed by electromyography, deglutition scores (on a scale of 1 to 8), and modified barium swallow. Donor-site morbidities were recorded.

RESULTS

Mean follow-up was 26.6 months (6 months-5 years). The flaps were successful in all 6 patients. The donor site was closed primarily and no complications were seen in the follow-up period. Normal extension of the knee joint and no evidence of lateral patella instability occurred. Speech intelligibility was good (4) in 3 patients and acceptable (3) in 3. Deglutition scores were 6 in 2 patients, 5 in 2, and 4 in 2. Modified barium swallow revealed that 4 patients experienced bolus transit, but 2 required a liquid swallow to promote bolus transit. Electromyographic recordings showed innervations of the vastus lateralis muscle with active generation of motor unit potentials in 4 patients when trying to elevate the tongue. This was not performed in 1 patient, and 1 other had macroscopic muscle contractions. All sensory tests were satisfactory in all parameters.

CONCLUSIONS

The results of this reconstructive option were satisfactory in terms of motor function and sensitive assessment of the neotongue. This technique is strongly recommended for patients with total or subtotal glossectomy.

Functional assessment: Free thin anterolateral thigh flap versus free radial forearm reconstruction for hemiglossectomy defects

Background

To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap.

Material and Methods

The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery.

Results

Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P>0.05).

Conclusions

Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity.

Key words:Free thin anterolateral thigh flap, free radial forearm flap, hemiglossectomy, reconstruction, morbidity.