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Delay A, Carlier A, Varazzani A, Breton P, Feugier P, Brochet L, Pierrefeu A. Head and neck reconstruction in vessel-depleted necks: Case report of a labio-mental and mandibular reconstruction using an arteriovenous loop. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023; 124:101649. [PMID: 37774971 DOI: 10.1016/j.jormas.2023.101649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/01/2023]
Abstract
Major defects of the facial structures cause severe functional and esthetic impairment. Difficulty in head and neck reconstruction lies in cases of secondary, tertiary, or further reconstruction. This is not a rare situation for patients who had cancer of the upper airways, since the rate of recurrence, second location, or osteoradionecrosis is high. Multiple surgeries and radiation therapy cause significant fibrosis and scar tissues, making any further reconstruction a major challenge for the surgeon when operating patients with vessel- depleted neck. We report our experience with a clinical case of a patient to whom we performed a double free flap reconstruction anastomosed on a vascular loop in a context of vascular cervical desert. In our case, the use of an arteriovenous loop proved to be a reliable approach for a vessel-depleted free tissue reconstruction. This technique has received insufficient attention, yet it provides a means to establish dependable vascular alternatives.
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Affiliation(s)
- Alexandra Delay
- Service de Chirurgie maxillo-faciale et plastique, Centre Hospitalier Universitaire Grenoble Alpes, La tronche, France; Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France.
| | - Adélaïde Carlier
- Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Andrea Varazzani
- Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Pierre Breton
- Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Patrick Feugier
- Service de Chirurgie Vasculaire et Endovasculaire, Hospices Civils de Lyon, Hôpital Édouard Herriot, Lyon, France
| | - Louis Brochet
- Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Antoine Pierrefeu
- Service de Chirurgie maxillo-faciale, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
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Moratin J, Dao Trong P, Semmelmayer K, Mrosek J, Zittel S, Bleymehl M, Ristow O, Freudlsperger C, Hoffmann J, Engel M. Comparison of Antero-Lateral Thigh Flap and Vastus Lateralis Muscle Flap for the Treatment of Extensive Scalp Defects-A Retrospective Cohort Study. J Clin Med 2023; 12:6208. [PMID: 37834851 PMCID: PMC10573281 DOI: 10.3390/jcm12196208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/15/2023] Open
Abstract
Free flap reconstruction is the standard of care for extensive defects of the head and neck area. In this study, two types of free flaps, the antero-lateral thigh flap (ALT) and the vastus lateralis muscle flap, were compared. The primary endpoint was flap success, secondary endpoints were complication rates, hospitalization and surgery time. Cases with defect situations of the scalp and consecutive microvascular free flap reconstructions using either ALT flaps or vastus lateralis muscle flaps between 2014 and 2022 were retrospectively analyzed. Indications, perioperative handling and outcomes were compared. Twenty patients were included in the analysis. Ten patients (50%) received a free flap reconstruction using an ALT flap and ten patients (50%) received a vastus lateralis flap. A simultaneous two-team approach was possible in each case and the flap success rate was 100% with the need for one successful anastomosis revision. The mean defect size in our cohort was 147 ± 46 cm2. There were no significant differences in surgery time, duration of hospitalization or complication rate between both cohorts. Both free flaps, the ALT and the vastus lateralis flap, are suitable for the closure of large scalp defects. They provide high success rates, short surgery times without the need for patient repositioning and low donor-site morbidity. The vastus lateralis muscle flap bares the advantage of being perforator-independent and allows for the preparation of long vessels for anastomosis if needed while baring the disadvantage of a prolonged period of healing via granulation or the need for secondary surgery in terms of covering by split-thickness skin grafts which may interfere with necessary adjuvant treatment in oncological patients.
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Affiliation(s)
- Julius Moratin
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Philip Dao Trong
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany;
| | - Karl Semmelmayer
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jan Mrosek
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Sven Zittel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Moritz Bleymehl
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Oliver Ristow
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Christian Freudlsperger
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Jürgen Hoffmann
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
| | - Michael Engel
- Department of Oral and Cranio-Maxillofacial Surgery, University of Heidelberg, Im Neuenheimer Feld 400, D-69120 Heidelberg, Germany; (K.S.); (J.M.); (S.Z.); (M.B.); (O.R.); (C.F.); (J.H.); (M.E.)
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Krishna D, Khan MM, Dubepuria R, Chaturvedi G, Cheruvu VPR. Reconstruction of Scalp and Forehead Defects: Options and Strategies. Cureus 2023; 15:e41479. [PMID: 37551215 PMCID: PMC10404163 DOI: 10.7759/cureus.41479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
Background Aesthetic reconstruction of scalp and forehead defects with local flaps and minimal donor site morbidity is the primary goal of coverage. While selecting the coverage technique, essential factors such as size, location, and components of a defect, hair-bearing or non-hair-bearing nature of skin, status of the exposed skull, need for radiation, patient condition, availability of local tissue, and the potential for hairline distortion should be kept in mind. Materials and methods This is a retrospective analysis in which 54 patients who underwent soft tissue reconstruction of the scalp and forehead defects were included. The defect size was categorized into four groups: small: <4 cm2, medium: 4-50 cm2, large: 50-200 cm2, and very large: >200 cm2. Reconstruction of all defects was done according to the defect's size, location, and depth. All patients were regularly followed at intervals of two weeks, six weeks, and three months, respectively. The outcome was evaluated in terms of flap survival, flap coverage scale, the requirement of secondary treatment, postoperative complications, and final aesthetic appearance. Results In 54 consecutively treated patients with scalp and forehead defects, the male-to-female ratio was 2:1, and the overall mean age of participants was 34.8 years, ranging from 0.5 to 66 years. The most common etiology of the defect was trauma (16; 29.6%), and the most common location of the defect was combined (16; 29.6%). Rotation flap and primary closure were the most commonly performed procedure, each 12 (22.2%) in number. Out of 12 primary closure cases, two patients developed wound dehiscence because of infection. All cases of skin grafting healed well. All cases of transposition flap with skin grafting at the donor site went uneventful, and the dog ear at the base was revised later. One case of the bipedicle flap in which partial graft loss occurred at the donor area was managed with regrafting. Two cases of single rotation flap, one double rotation flap, and one free latissimus dorsi muscle flap developed distal necrosis. The excellent aesthetic outcome was found in all cases of primary closure and single and double rotation flaps. Conclusions Local flaps have an architecture similar to the recipient site, and low donor site morbidity results in an aesthetically more pleasant outcome. In our experience, scalp defects up to 50 cm2 were covered with the local scalp flaps with primary closure of the donor area. Defects ranging from 50 to 200 cm2 required local scalp flap with skin grafting at the donor area. Free tissue transfers are usually needed when the defect is very large, devoid of the periosteum, or with the calvarial defect.
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Affiliation(s)
- Deepak Krishna
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Manal M Khan
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Rahul Dubepuria
- Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Gaurav Chaturvedi
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
| | - Ved Prakash Rao Cheruvu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, Bhopal, IND
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Soto E, Peacock PW, Clark AR, King TW, de la Torre JI, Patcha P, Fix RJ, Myers RP. A Systematic Review of Microsurgical Pedicle Lengthening in Free Tissue Transfer. Ann Plast Surg 2023; 90:S379-S386. [PMID: 37332209 DOI: 10.1097/sap.0000000000003450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Traumatic injuries that require free tissue flaps for reconstruction may require vascular pedicle extension between the flap and recipient vessels to form a clear anastomosis. Currently, a variety of techniques are used, each with their own potential benefits and harms. In addition, reports in the literature conflict on the reliability of pedicle extensions of vessels in free flap (FF) surgery. The objective of this study is to systematically assess the available literature about outcomes of pedicle extensions in FF reconstruction. METHODS A comprehensive search was performed for relevant studies published up to January 2020. Study quality was assessed using the Cochrane Collaboration risk of bias assessment tool and a set of predetermined parameters was extracted by 2 investigators independently for further analysis. The literature review yielded 49 studies investigating pedicled extension of FF. Studies meeting inclusion criteria underwent data extraction focusing on demographics, conduit type, microsurgical technique, and postoperative outcomes. RESULTS The search yielded 22 retrospective studies totaling 855 procedures from 2007 to 2018 in which 159 complications (17.1%) were reported in patients aged between 39 and 78 years. Overall heterogeneity of articles included in this study was high. Free flap failure and thrombosis were the 2 most prevalent major complications noted: vein graft extension technique had the highest rate of flap failure (11%) in comparison with the arterial graft (9%) and arteriovenous loops (8%). Arteriovenous loops had a rate of thrombosis of 5% versus 6% in arterial grafts and 8% in venous grafts. Bone flaps maintained the highest overall complication rates per tissue type at 21%. The overall success rate of pedicle extensions in FFs was 91%. Arteriovenous loop extension resulted in a 63% decrease in the odds of vascular thrombosis and a 27% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). Arterial graft extension resulted in a 25% decrease in the odds of venous thrombosis and a 19% decrease in the odds of FF failure when compared with venous graft extensions (P < 0.05). CONCLUSIONS This systematic review strongly suggests that pedicle extensions of the FF in a high-risk complex setting are a practical and effective option. There may be a benefit to using arterial versus venous conduits, although further examination is warranted given the small number of reconstructions reported in the literature.
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Affiliation(s)
| | | | | | - Timothy W King
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jorge I de la Torre
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Prasanth Patcha
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - R Jobe Fix
- Division of Plastic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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An JK, Park SO, Chang LS, Kim YH, Min K. Reconstruction of a temporal scalp defect without ipsilateral donor vessel possibilities using a local transposition flap and a latissimus dorsi free flap anastomosed to the contralateral side: a case report. Arch Craniofac Surg 2023; 24:129-132. [PMID: 37415470 PMCID: PMC10365903 DOI: 10.7181/acfs.2023.00129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
Scalp defects necessitate diverse approaches for successful reconstruction, taking into account factors such as defect size, surrounding tissue, and recipient vessel quality. This case report presents a challenging scenario involving a temporal scalp defect where ipsilateral recipient vessels were unavailable. The defect was effectively reconstructed utilizing a transposition flap and a latissimus dorsi free flap, which was anastomosed to the contralateral recipient vessels. Our report underscores the successful reconstruction of a scalp defect in the absence of ipsilateral recipient vessels, emphasizing the importance of employing appropriate surgical interventions without necessitating vessel grafts.
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Affiliation(s)
- Jung Kwon An
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Lan Sook Chang
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Youn Hwan Kim
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Kyunghyun Min
- Department of Plastic and Reconstructive Surgery, Hanyang University College of Medicine, Seoul, Korea
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Shash H, Marzouq S, Alghamdi A, Alrayes M, Alkhaldi SK, Shash H, Abu Quren AM. The 1-2-3 cm Advancement Flap Rule in Scalp Reconstruction. Cureus 2023; 15:e35301. [PMID: 36994305 PMCID: PMC10042496 DOI: 10.7759/cureus.35301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
Background Defects of the scalp are surgically challenging for several reasons: anatomical convexity limits tissue displacement, resistance to advancement is different at different points on the scalp, and there is also interindividual variation. For many patients, the idea of undergoing an advanced surgery such as a free flap is not preferred. Hence, a simple technique with a favorable outcome is needed. We hereby introduce our new technique: the 1-2-3 scalp advancement rule. Objectives The objective of this study is to discover a novel way to reconstruct scalp defects secondary to trauma or cancer, without having the patient undergo a big procedure. Material and Methods A total of nine cadaveric heads were used to test the idea of achieving greater advancement and increased scalp mobility to cover a 4×8 cm-sized defect using our proposed 1-2-3 scalp rule. Three steps performed were advancement flap, galeal scoring, and removal of the outer table of the skull. The measurement of advancement was recorded after each step, and the results were analyzed. Results The mobility of the scalp was calculated from the sagittal midline with identical arcs of rotation. With zero tension, we found that the total distance of advancement with a flap had a mean of 9.78 mm, while the advancement for the same flap after galeal scoring had a mean of 20.5 mm, and after removing the outer table, the mean advancement was 30.2 mm. Conclusion To create a tension-free closure necessary for optimal outcome for scalp defects, our study showed that increased distances were possible using galeal scoring and outer table removal, increasing the distance of advancement by 10.63 mm and 20.42 mm, respectively.
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Common Carotid-to-Internal Jugular Arteriovenous Loop for Single-Stage Microsurgical Reconstruction in the Radiated Vessel-Depleted Neck. J Craniofac Surg 2021; 32:711-715. [PMID: 33705016 DOI: 10.1097/scs.0000000000006953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.
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Abstract
Soft tissue wounds in the scalp are a common occurrence after trauma or resection of a malignancy. The reconstructive surgeon should strive to use the simplest reconstructive technique while optimizing aesthetic outcomes. In general, large defects with infection, previous irradiation (or require postoperative radiation), or with calvarial defects usually require reconstruction with vascularized tissue (ie, microvascular free tissue transfer). Smaller defects greater than 3 cm that are not amenable to primary closure can be treated with local flap reconstruction. In all cases, the reconstruction method will need be tailored to the patient's health status, desires, and aesthetic considerations.
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Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity. Arch Orthop Trauma Surg 2021; 141:165-171. [PMID: 33130937 PMCID: PMC7815614 DOI: 10.1007/s00402-020-03635-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 10/15/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity. METHODS We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest. RESULTS 14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient. CONCLUSION The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.
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Modified Cranioplasty and Latissimus Dorsi Flap for an Exophytic Invasive Brain Tumor. J Craniofac Surg 2020; 32:1838-1840. [PMID: 33196617 DOI: 10.1097/scs.0000000000007225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT We describe the clinical case of a 62-year-old man with an atypical grade II meningioma, invading bone and scalp, and present a step-by-step video description of a modified technique for cranioplasty and scalp reconstruction with latissimus dorsi flap. By using this technique, we aim to minimize the space between the dura and the flap, which would decrease the risk of fluid collections and infections.
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Fliss E, Zaretski A, Maoz-Halevy ED, Gur E, Yanko R. Scalp and Skull Reconstruction in Patients Irradiated for Tinea Capitis in Childhood: The Scalp Exchange Procedure. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2020. [DOI: 10.1055/s-0040-1716418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Background Approximately 70,000 Israelis underwent scalp irradiation for tinea capitis infection during their childhood, as did many other children worldwide. Long-term follow-up data showed that these children had an increased risk of aggressive and multiple nonmelanoma skin cancers, meningiomas, and other malignancies. Resection of these lesions creates a defect of soft tissue, bone, and dura, and requires scalp and skull reconstruction with local or free flaps in the irradiated field.
Methods Sixteen patients with a history of childhood scalp irradiation underwent scalp and skull reconstruction in our department (2000–2018). Data on demographics, oncological status, operative details, and postoperative outcome were retrospectively collected and analyzed.
Results The study group included 11 males and 5 females (average age at surgery, 70 years). The most common lesions were meningiomas (n = 9) and basal cell carcinomas (n = 8), and the most common indication for reconstruction was chronic exposure of deep structures (skull, dura, brain tissue, and titanium mesh; n = 9). Thirteen patients underwent primary free flap reconstruction and three underwent primary local flap reconstruction. Flap failure requiring reoperation occurred in one patient of the free flap reconstruction group (7%) and in all three patients of the local flap reconstruction group.
Conclusion Long-term consequences of childhood depilatory treatments of the scalp by irradiation are now surfacing. Our experience showed that in such cases, surgeons should aim for a more aggressive approach with wide resection and primary free flap reconstruction, and that favorable long-term functional and aesthetic results can safely be achieved using this reconstruction approach.
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Affiliation(s)
- Ehud Fliss
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Arik Zaretski
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal D. Maoz-Halevy
- Department of Neurology, Sheba Medical Center affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eyal Gur
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ravit Yanko
- Department of Plastic and Reconstructive Surgery, The Microsurgery Unit, Tel-Aviv Sourasky Medical Center, Affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Tecce MG, Othman S, Mauch JT, Nathan S, Tilahun E, Broach RB, Azoury SC, Kovach SJ. Complex oncologic resection and reconstruction of the scalp: Predictors of morbidity and mortality. Arch Craniofac Surg 2020; 21:229-236. [PMID: 32867412 PMCID: PMC7463124 DOI: 10.7181/acfs.2020.00206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/18/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Oncologic resection of the scalp confers several obstacles to the reconstructive surgeon dependent upon patient-specific and wound-specific factors. We aim to describe our experiences with various reconstructive methods, and delineate risk factors for coverage failure and complications in the setting of scalp reconstruction. METHODS A retrospective chart review was conducted, examining patients who underwent resection of fungating scalp tumors with subsequent soft-tissue reconstruction from 2003 to 2019. Patient demographics, wound and oncologic characteristics, treatment modalities, and outcomes were recorded and analyzed. RESULTS A total of 189 patients were appropriate for inclusion, undergoing a range of reconstructive methods from skin grafting to free flaps. Thirty-three patients (17.5%) underwent preoperative radiation. In all, 48 patients (25.4%) suffered wound site complications, 25 (13.2%) underwent reoperation, and 47 (24.9%) suffered from mortality. Preoperative radiation therapy was an independent risk factor for wound complications (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.1-7.3; p = 0.028) and reoperations (OR, 4.45; 95% CI, 1.5-13.2; p = 0.007). Similarly, the presence of an underlying titanium mesh was an independent predictor of wound complications (OR, 2.49; 95% CI, 1.1-5.6; p= 0.029) and reoperations (OR, 3.40; 95% CI, 1.2-9.7; p= 0.020). Both immunosuppressed status (OR, 2.88; 95% CI, 1.2-7.1; p= 0.021) and preoperative radiation therapy (OR, 3.34; 95% CI, 1.2-9.7; p= 0.022) were risk factors for mortality. CONCLUSION Both preoperative radiation and the presence of underlying titanium mesh are independent risk factors for wound site complications and increased reoperation rates following oncologic resection and reconstruction of the scalp. Additionally, preoperative radiation, along with an immunosuppressed state, may predict patient mortality following scalp resection and reconstruction.
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Affiliation(s)
- Michael G Tecce
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jaclyn T Mauch
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Shelby Nathan
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Estifanos Tilahun
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robyn B Broach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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CSF disturbances and other neurosurgical complications after interdisciplinary reconstructions of large combined scalp and skull deficiencies. Neurosurg Rev 2020; 44:1583-1589. [PMID: 32648016 PMCID: PMC8121737 DOI: 10.1007/s10143-020-01347-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/18/2020] [Accepted: 07/03/2020] [Indexed: 11/27/2022]
Abstract
Combined scalp and skull deficiency due to malignant scalp tumors or sequelae of intracranial surgery present challenging entities for both neurosurgeons and reconstructive treatment. In complex cases, an interdisciplinary approach is needed between neurosurgeons and cranio-maxillofacial surgeons. We present a considerably large series for which we identify typical complications and pitfalls and provide evidence for the importance of an interdisciplinary algorithm for chronic wound healing complications and malignomas of the scalp and skull. We retrospectively reviewed all patients treated by the department of neurosurgery and cranio-maxillofacial surgery at our hospital for complex scalp deficiencies and malignant scalp tumors affecting the skull between 2006 and 2019, and extracted data on demographics, surgical technique, and perioperative complications. Thirty-seven patients were treated. Most cases were operated simultaneously (n: 32) and 6 cases in a staged procedure. Nineteen patients obtained a free flap for scalp reconstruction, 15 were treated with local axial flaps, and 3 patients underwent full thickness skin graft treatment. Complications occurred in 62% of cases, mostly related to cerebrospinal fluid (CSF) circulation disorders. New cerebrospinal fluid (CSF) disturbances occurred in 8 patients undergoing free flaps and shunt dysfunction occurred in 5 patients undergoing local axial flaps. Four patients died shortly after the surgical procedure (perioperative mortality 10.8%). Combined scalp and skull deficiency present a challenging task. An interdisciplinary treatment helps to prevent severe and specialty-specific complications, such as hydrocephalus. We therefore recommend a close neurological observation after reconstructive treatment with focus on symptoms of CSF disturbances.
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Münchow S, Dragu A, Rammelt S, Reeps C, Stiehler M. Plastic-Reconstructive Treatment Algorithm for Dead Space Management Following Septic Total Hip Arthroplasty Removal: AV Loop and Two-Stage Free Myocutaneous Latissimus Dorsi Flap. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2020; 159:674-680. [PMID: 32588403 DOI: 10.1055/s-0037-1599649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND A 61-year-old patient presented with a right Girdlestone hip and wound dehiscence due to extensive dead space after radical debridement and septic arthroplasty removal. A two-stage reconstruction with the application of a subcutaneous autologous arterio-venous (AV) loop using an autologous vena saphena magna (VSM) interposition graft followed by a free latissimus dorsi flap was performed. METHOD We decided to perform a two-stage procedure with AV loop creation in the first step and free flap transplantation seven days after it. In the first step, an AV vascular loop was prepared by transplanting the contralateral VSM interposition graft to the inguinal femoral vessels with subcutaneous passage of the venous loop. In the second step after 7 days, the wound was closed by a two-team approach. One surgical team completed the wound debridement, while the other team harvested the flap by microsurgical preparation of the thoracodorsal pedicle in the right axilla. Upon completed harvest, the flap was placed into the wound to fill the periosseous dead space, and the anastomosis was performed in an end-to-end fashion. RESULT The patient remained free of infection with a well-healed flap. He was mobilized on crutches with partial weight bearing on the operated leg. A lower extremity prosthesis with pelvic support was customized.
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Affiliation(s)
- Sandra Münchow
- Department for Plastic and Hand Surgery, Carl Gustav Carus University Hospital, Dresden
| | - Adrian Dragu
- Department for Plastic and Hand Surgery, Carl Gustav Carus University Hospital, Dresden
| | - Stefan Rammelt
- University Centre for Orthopaedic and Trauma Surgery, Carl Gustav Carus University Hospital, Dresden
| | - Christian Reeps
- Department for Visceral, Thoracic and Vascular Surgery, Carl Gustav Carus University Hospital, Dresden
| | - Maik Stiehler
- University Centre for Orthopaedic and Trauma Surgery, Carl Gustav Carus University Hospital, Dresden
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Weitz J, Spaas C, Wolff KD, Meyer B, Shiban E, Ritschl LM. A Standard Algorithm for Reconstruction of Scalp Defects With Simultaneous Free Flaps in an Interdisciplinary Two-Team Approach. Front Oncol 2019; 9:1130. [PMID: 31709189 PMCID: PMC6823187 DOI: 10.3389/fonc.2019.01130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022] Open
Abstract
Reconstructions of complex scalp after ablative resection or by post-traumatic tissue loss, can present difficulties regarding recipient vessel selection, functional, and aesthetic outcome. The harvesting method for many microvascular free flaps requires a need for changing patients position during surgery and makes a simultaneous interdisciplinary two-team approach complicated, which is a major disadvantage regarding safety and operation time. The ideal flap for scalp reconstruction has yet to be described, although the microvascular latissimus dorsi flap is frequently referred to as the first choice in this context, especially after resection of large defects. The purpose of this study is to compare two different microvascular free flaps for a simultaneous scalp reconstruction in an interdisciplinary two-team approach applying a standardized algorithm. All consecutively operated complex scalp defects after ablative surgery from April 2017 until August 2018 were included in this retrospective study. The indications were divided into neoplasm or wound healing disorder. Two microvascular flaps (latissimus dorsi or parascapular flap) were used to cover the soft tissue component of the resulting defects. Seventeen patients met the inclusion criterion and were treated in an interdisciplinary two-team approach. Skull reconstruction with a CAD/CAM implant was performed in 10 cases of which four were in a secondary stage. Nine patients received a parascapular flap and eight patients were treated with latissimus dorsi flap with split thickness skin graft. Anastomosis was performed with no exception to the temporal vessels. One parascapular flap had venous insufficiency after 1 week followed by flap loss. One latissimus dorsi flap had necrosis of the serratus part of the flap. All other flaps healed uneventful and could be further treated with adjuvant therapy or CAD/CAM calvarial implants. Regarding overall complications, flap related complications, flap loss, and inpatient stay no statistical differences were seen between the diagnosis or type of reconstruction. The parascapular flap seems to be a good alternative for reconstruction of complex tumor defects of the scalp besides the latissimus dorsi flap. Stable long-term results and little donor site morbidity are enabled with good aesthetic outcomes and shorter operation time in an interdisciplinary two-team approach.
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Affiliation(s)
- Jochen Weitz
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Christophe Spaas
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
| | - Ehab Shiban
- Department of Neurosurgery, School of Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany.,Neurosurgery Department, University Hospital of Augsburg, Augsburg, Germany
| | - Lucas M Ritschl
- Department of Oral and Maxillofacial Surgery, School of Medicine, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
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Matschke J, Armbruster R, Reeps C, Weitz J, Dragu A. AV loop free flap: an interdisciplinary approach for perineal and sacral defect reconstruction after radical oncological exenteration and radiation in a colorectal cancer patient. World J Surg Oncol 2019; 17:154. [PMID: 31477142 PMCID: PMC6721242 DOI: 10.1186/s12957-019-1698-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/28/2019] [Indexed: 11/17/2022] Open
Abstract
Background The free flap transfer of a latissimus dorsi flap (LDF) for the closure of sacral wound defects after pelvic exenteration and radiation therapy offers a successful tool of the plastic surgeon. This case report shows the successful coverage using an upstream arterio-venous (AV) loop in combination with an LDF. Case presentation We describe the case of a patient who underwent a pelvic exenteration and radiation therapy due to a local recurrence of rectal cancer. The initially used VRAM flap could not ensure a satisfactorily wound closure. An interdisciplinary approach first yielded an AV loop using both greater saphenous veins and was connected to the arteria and vena femoris followed by a free LDF transfer, which was performed 11 days later. The result was an excellent reconstructive and plastic coverage of the sacral wound defect with a well-perfused LDF. The long-term result showed a perfectly integrated flap in the sacral region. Conclusion We recommend the free LDF for the coverage of large wound defects in irradiated areas after the failure of VRAM flap. If an AV loop is necessary within the flap transfer, we recommend conducting two procedures to guarantee the perfusion of the AV loop.
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Affiliation(s)
- Jan Matschke
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany.
| | - Rafael Armbruster
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Christian Reeps
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jürgen Weitz
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Adrian Dragu
- Department of Plastic and Hand Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, TU Dresden, Dresden, Germany
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Ludolph I, Horch RE, Arkudas A, Schmitz M. Enhancing Safety in Reconstructive Microsurgery Using Intraoperative Indocyanine Green Angiography. Front Surg 2019; 6:39. [PMID: 31334246 PMCID: PMC6614526 DOI: 10.3389/fsurg.2019.00039] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/13/2019] [Indexed: 11/25/2022] Open
Abstract
Intraoperative assessing and postoperative monitoring of the viability of free flaps is of high relevance in reconstructive microsurgery. Today different methods for the evaluation of tissue perfusion are known. Indocyanine Green angiography is an emerging technique among plastic surgeons with a broad scope of applications especially in microsurgical free flap transfer. We demonstrate the value and clinical application of this technique based on representative selected cases where Indocyanine Green angiography was used in microsurgical free flap transfers from different anatomic donor sites during the operation. Hereby perforator selection, flap tailoring, changes of blood flow and patency of anastomoses was judged and decision making was based on the angiographic findings. This method has proven to be valid, reproducible and easy to use. The application is not limited to the evaluation of skin perfusion, but is also applicable to muscle tissue or chimeric or composite flaps. Reliable judgement is especially given for the extent of arterially perfused tissue following complete flap dissection. Moreover, this real-time angiography revealed a high sensitivity for the detection of poorly perfused flap areas, thus supporting the conventional clinical judgement and reducing complications. In summary Indocyanine Green angiography has the potential to reduce flap related complications and to contribute to enhancing and extending the possibilities of free flap surgery.
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Affiliation(s)
- Ingo Ludolph
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg FAU, Erlangen, Germany
| | - Marweh Schmitz
- Department of Plastic and Hand Surgery and Laboratory for Tissue Engineering and Regenerative Medicine, University Hospital of Erlangen, Friedrich-Alexander-University of Erlangen-Nuernberg FAU, Erlangen, Germany
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Sokoya M, Misch E, Vincent A, Wang W, Kadakia S, Ducic Y, Smith J. Free Tissue Reconstruction of the Scalp. Semin Plast Surg 2019; 33:67-71. [PMID: 30863215 DOI: 10.1055/s-0039-1678470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Reconstruction of scalp defects can be accomplished by many methods, but larger defects, especially those in which the periosteum is absent or calvarial defects are present, require free tissue transfer. Various methods of scalp reconstruction, as guided by the defect components and size, are presented herein, with a focus on free tissue transfer. Different free flaps for scalp reconstructed are described with a comparison of their advantages and disadvantages. Overall, free tissue transfer for scalp defects provides a reliable, durable, and cosmetically adequate reconstructive option.
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Affiliation(s)
| | - Emily Misch
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | - Aurora Vincent
- Otolaryngology, Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Weitao Wang
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
| | - Sameep Kadakia
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Wright State University, Dayton, Ohio
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Jesse Smith
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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