HARVESTING SURAL FLAP WITH COVERED PEDICLE

Objectives

The aim was to evaluate the viability and the outcomes of the sural flap performed with the pedicle covered by a strip of skin.

Methods

A prospective cohort of 20 consecutive cases were evaluated in terms of flap viability, complication rate, and the amount of skin graft required. The location of the defects was the middle third of the tibia in 3 cases, the ankle and hindfoot in 15 cases, the middle foot in 1 case, and the forefoot in 1 case. The flap design was the same as described by Masquelet. The only modification included a strip of skin over the entire length of the pedicle. The intermediary skin between the donor site and the defect was incised and the skin was undermined to accommodate the pedicle without compression.

Results

All cases had a satisfactory evolution, with adequate healing and without flap loss. Both the donor site and the pedicle were primarily closed in all cases. In one patient, the flap developed a limited area of superficial epidermolysis that healed spontaneously.

Conclusion

the modified sural flap with a covered pedicle is feasible and reliable with a lower rate of complications when compared with the conventional sural flap. Level of Evidence IV, Cohort Studies .

Pilot Study of Additive Effect of "Offloading Ilizarov Frame" To Reduce "Reverse Sural Flap" Surgery Complications: A Clinical Trial

Background

A reverse sural flap is an available surgical technique because it provides robust axial blood circulation to flaps with a substantially larger surface area. We aimed to assess Ilizarov frames outcome after reverse sural flaps among patients with traumatic injuries to the distal portion of the leg.

Methods

Patients with traumatic distal injury of leg in Shoha-e Tajrish Hospital in 2022-2021 were recruited and treated with reverse sural flaps. Interventional group was followed by Ilizarov frames application (group A). For the second group, just conventional dressings and proper positioning were done after surgery (group B). Between the two groups, the duration of surgery, the degree of flap swelling, the time from surgery to discharge and flap failure, surgical site infection, deep vein thrombosis (DVT), and other complications were compared using SPSS 25 software.

Results

Of 26 recruited patients, twenty consented to participate in this study. The average time from initial injury to reconstruction surgery, the mean duration of surgery, the mean time from surgery to discharge and the degree of swelling of the flap was compared between these two groups. The results showed better outcome in Ilizarov group, but the flap swelling grade was the only statistically significant factor between groups (P value= 0.03).

Conclusions

The use of "offloading Ilizarov frames" to protect reverse sural flaps resulted in a considerable reduction in the flap swelling. It is a safe, quick, easy, and effective technique.

Retrospective Study of 114 Free Flaps for Head and Neck Oncological Reconstruction in a Portuguese Tertiary Cancer Center

INTRODUCTION

The Portuguese experience in microsurgical reconstruction of the head and neck after oncological surgery is scantly described. The primary aim of this study was to characterize the use of microvascular reconstruction after head and neck tumor resection in a Portuguese tertiary oncological centerMaterial and Methods: The authors retrospectively evaluated 114 microvascular free flap procedures performed for head and neck reconstruction after oncological resection in a department of Head and Neck Surgery of a Portuguese tertiary oncological center. Patients were operated on from January 2012 to May 2018. Data on patient demographic features, tumour characteristics, perioperative complications, postoperative aesthetic and functional results, survival time and time to recurrence were extracted.

RESULTS

Most tumours mandating microsurgical reconstruction were mucosal squamous cell carcinomas (85%) and were located in the oral region (95.6%). Around 45% of the patients had a T4a tumour and 30% a T2 tumour. Cervical metastases were present in 45.6% of the cases. The radial forearm flap and the fibular flap were the most commonly used microsurgical reconstructive options (58% and 41%, respectively). More than 80% of patients had no post-operative complications. Partial necrosis of the flap occurred in 6.1% of patients, while total flap necrosis occurred in 3.5% of cases. Aesthetic and functional results were considered at least satisfactory in all patients in which the flaps survived.

DISCUSSION

This study is by far the largest series of microsurgical head and neck reconstruction after oncological surgery reported by a single tertiary centre in Portugal. Survival and functional benefits are similar to those reported in other large oncological centres in the world.

CONCLUSION

Microvascular reconstruction seems like a reliable treatment option in head and neck oncological surgery at our institution.

Free Fibular Flap and Fibular Graft Double-Strut Tunneling to Fill a Large Tibial Plateau Defect

Introduction

Bony defects resulting from trauma, osteomyelitis, and tumor resection pose significant reconstructive challenges. Free fibular flaps (FFFs) are an excellent option, especially for large defects in the tibia.

Case presentation

In this article, the authors review a case of a 60-year-old male who underwent FFF and fibular graft double-strut tunneling to fill a large tibial plateau defect.

Conclusion

The use of the FFF provides an excellent option for reconstructing long bone large defects (defects > 6 cm). The case presented in this report indicates an expanded application of this technique in treating defects secondary to chronic osteomyelitis in infected tibial plateau nonunion.

Externally Monitored Versus Conventional Buried Flaps in Laryngopharyngeal Reconstruction

Objectives

To compare the surgical outcomes of externally monitored and conventional buried flaps with the goal of determining the usefulness of external monitoring of buried flaps.

Methods

In this case-control study with propensity score matching, 30 patients were evenly divided into externally monitored buried flap and conventional buried flap groups. The total operative time for free flap reconstruction, the flap survival rate, the length of hospital stay, the initial time of a reliable visual assessment, complications, the final diet achieved, and the duration until diet initiation were compared between the groups.

Results

The mean operative time for reconstruction was 115 minutes (interquartile range, 85–150 minutes) and 142 minutes (interquartile range, 95–180 minutes) in the externally monitored and conventional groups, respectively (P= 0.245). The median length of hospital stay was 24 days (interquartile range, 18–30 days) and 27 days (interquartile range, 20–41 days) in the externally monitored and conventional groups, respectively (P=0.298). The median duration until diet initiation was 15 days (interquartile range, 15–21 days) and 18 days (interquartile range, 15–34 days) in the externally monitored and conventional groups, respectively (P=0.466). The final diet, initial time of a reliable visual assessment, and complications were comparable between the groups, but the external skin paddle provided an excellent visual assessment immediately postoperatively in all cases.

Conclusion

The outcomes were comparable between the groups, indicating that externalization of the cutaneous component of a buried flap may be a straightforward and useful technique for monitoring a buried anterolateral thigh free flap in laryngopharyngeal reconstructions. The salvage and false-positive rates of compromised flaps should be compared in large subject groups in future studies to prove that the use of an external skin paddle improves flap monitoring.

HYPOALBUMINEMIA IN MICROSURGICAL FLAPS OF THE MUSCULOSKELETAL APPARATUS

Objective:

To evaluate if the levels of serum total protein and serum albumin are risk factors for surgical complications of free flap limb reconstruction.

Methods:

Consecutive inclusion of all patients undergoing microsurgical flaps for limb reconstruction of complex injuries. We recorded epidemiological and laboratory data, including total proteins and fractions, for descriptive and analytical statistics.

Results:

Our study analyzed one microsurgical flap from 35 patients that underwent complex injuries of the limbs. In total, 23 patients were men, and mean age of all patients was 35 years. After statistical analysis, no influence of pre or postoperative hypoalbuminemia was observed on the incidence of complications. Patients with hypoalbuminemia had a higher length of stay than those with normal albumin levels (p = 0.008).

Conclusion:

We observed that 71% of patients had hypoalbuminemia in early postoperative period and we suggest a nutritional support for patients requiring complex traumatic limb reconstruction. Hypoalbuminemia in patients subjected to microsurgical flaps for the treatment of complex traumatic limb injuries did not influence the complications that required surgical reintervention; However, it was associated with prolonged hospital stay. Level of Evidence II, Retrospective study.

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes

OBJECTIVE

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer.

METHODS

In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge.

RESULTS

The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01).

CONCLUSION

A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

Subjective morbidity following fibular free flap reconstruction in head and neck cancer patients

OBJECTIVE

This study aimed to evaluate the presence of subjective post-operative donor site morbidity after fibula free flap reconstruction in head and neck cancer patients, utilising three validated instruments: the 36-item Short Form Health Survey, the Short Musculoskeletal Function Assessment questionnaire and the Lower Limb Core Scale.

METHODS

In this retrospective study, all head and neck cancer patients who underwent fibula free flap reconstruction between January 2009 and July 2014 were identified. All questionnaires and their respective subcomponents were scored.

RESULTS

Twenty-one cases were included. Patients were found to have a higher Short Musculoskeletal Function Assessment bothersome index (22.42 vs 13.77, p = 0.03), a lower Short Form 36 Health Survey Physical Component Summary score (42.44 vs 50, p < 0.01) and a decreased Lower Limb Core Scale score (47.08 vs 90.52, p < 0.01), compared to US population norms. The Short Form 36 Health Survey Mental Component Summary scores and Short Musculoskeletal Function Assessment function index failed to demonstrate significant differences. Gender affected overall disability.

CONCLUSION

In this study, significant long-term disability was demonstrated after fibular flap reconstruction, as measured by the Lower Limb Core Scale.

Testing a New Anticoagulation Method for Free Flap Reconstruction of Head and Neck Cancers

Objectives

Free flaps are widely used to reconstruct head and neck defects. Despite the improvement in the surgical techniques and the surgeons’ experiences, flap failures still occur due to thrombotic occlusion after small vessels anastomosis. To reduce the possibility of flap loss as a result of thrombotic occlusion, various anticoagulants have been used. In this study we decided to evaluate a new protocol for anticoagulation therapy and its effect on flap survival and complications.

Methods

In this interventional study, 30 patients with head and neck cancer underwent surgical defects were reconstructed by microvascular free flap between 2013 and 2014. In the postoperative period patients have taken aspirin (100 mg/day) for 5 days and enoxaparin (40 mg/day subcutaneously) for 3 days. The flap survival was followed for three weeks.

Results

Given that there was no complete necrosis or loss of flap, the free flap success rate was as much as 100%. The need for re-exploration occurred in 3 patients (10%). Only in one patient the need for re-exploration was due to problem in venous blood flow.

Conclusion

The aspirin-enoxaparin short-term protocol may be a good choice after free flap transfer in reconstruction of head and neck surgical defects.

Surgical Management of Bulky Mediastinal Metastases in Follicular Thyroid Carcinoma

Follicular thyroid adenoma and carcinoma are very common. Benign and malignant lesions are usually indistinguishable from cytology alone and often require confirmatory resection. The spread of follicular carcinoma is usually hematogenous and is treated with surgery and adjuvant radioactive iodine. Very rarely, metastases occur in the mediastinum. Patients usually present with severe compressive symptoms. With proper treatment and follow-up, the prognosis for these type of thyroid malignancies is excellent. In the case presented here, our patient presented to the Universiti Kebangsaan Malaysia Medical Center with a progressively enlarging anterior neck swelling. The swelling had started 10 years before his presentation. We diagnosed him with an advanced thyroid malignancy with bulky mediastinal metastases. After extensive investigations and counseling, we chose to treat the patient with tumor excision and mediastinal metastases resection. Typically, mediastinal resection involves the removal of the sternum and use of an acrylic implant to recreate the sternum. In this case, the sternum and ribs were removed with subsequent myocutaneous flap coverage for the wound defect. Our experience represents an alternative treatment option in cases where implant use is unsuitable.

Scapular Tip Free Flap for Head and Neck Reconstruction

Objectives

Head and neck reconstruction is still challenging in terms of esthetic and functional outcomes. This study investigated the feasibility of the angular branch-based scapular tip free flap (STFF).

Methods

This was a retrospective study of 17 patients undergoing maxillectomy and mandibulectomy and either primary or secondary reconstruction by STFF. This study included surgical, esthetic, and functional outcomes, and detailed data are presented regarding the flap, such as pedicle length, size of the harvested bone, and failure rate. Medical photographs were used to estimate the esthetic outcome, and computed tomography was used to check the flap status postoperatively.

Results

The data were collected from April 2013 to April 2014. Eight patients underwent maxillary reconstruction, and nine underwent mandibular reconstruction. Maxillary defects usually included unilateral alveolar structures and the palate; mandibular defects were usually those involving mandibular angle and short segment. Vein grafting was not required in any of the patients. Flap failure occurred in one of the 17 patients (5.9%) with successful reconstruction after revision. Of the eight maxillectomy patients, orbital revisions for diplopia after maxillary reconstruction were performed in two patients (25%), and oroantral fistula repair was performed in one patient (12.5%).

Conclusion

This study demonstrated the reconstructive advantages of the angular branch-based STFF, long pedicle, low flap failure, 3-dimensional nature of bone and soft tissues (chimeric flap), and small rate of donor site morbidity with free ambulation. This flap is an excellent option for use in complex three-dimensional head and neck reconstruction.

Results of free flap reconstruction after ablative surgery in the head and neck

Objectives

Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve.

Methods

The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed.

Results

The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases.

Conclusion

The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.

Outcomes of microvascular free flap reconstruction for mandibular osteoradionecrosis: A systematic review

INTRODUCTION

Osteoradionecrosis of the mandible is a devastating complication of radiotherapy in patients with head and neck cancer. Many cases present at a late stage, from months to years following completion of radiation therapy. When medical treatment fails, surgery may be required with a variety of free flaps available for microvascular reconstructive techniques.

OBJECTIVE

To conduct a systematic review of the literature investigating the outcomes of free flap reconstruction of the jaw in mandibular osteoradionecrosis and determine the failure rates of different flap tissue.

METHODS

A systematic literature search was performed using Medline (Ovid) Pubmed and Embase databases and Google Scholar. Primary outcome measures were flap failures and complications, with donor site complications representing the secondary outcome measure. Analysis of pooled outcomes was undertaken for different flaps.

RESULTS

333 articles were identified and 15 articles met the final inclusion criteria, detailing 368 primary free tissue flap transfers. There was a flap failure rate of 9.8%. There were 146 post-operative complications (39.7%), the most common being fistula formation (8.4%), hardware plate exposure (7.1%) and flap wound infections (6.5%).

CONCLUSION

The fibula is the workhorse free flap for reconstruction in mandibular osteoradionecrosis. Evidence to date is largely limited with the need for larger powered multi-institutional prospective studies to determine the ideal flap donor tissue and evaluate patient and treatment predictors of free flap outcomes in order to tailor the best patient-based surgical approach for mandibular osteoradionecrosis.

Early coverage of upper extremity electrical injury wounds

Background

An appropriate and well-timed surgery has great impact on a patient’s treatment and can prevent further damage to partially injured structures which if untreated will be lost leading to severe disability. In the present study we report our experience with early coverage of electrically injured upper extremity vital structures with encouraging results.

Objectives

The aim of this study was to evaluate the results of early flap coverage (less than two weeks) after electrical injury in the induced wounds of upper extremity.

Materials and Methods

The records of electrically injured patients referred during a 10- year period to Firuzgar Medical Center were evaluated. After one or two sessions of debridement, the wounds were covered by distant or pedicled flaps and the results were evaluated according to the number of surgeries, complications and return to work time.

Results

Thirty patients were registered in this study, mean age at the time of injury was 26.43 (SD = 10.41) years; 40% of patients had right upper extremity injury, 23.3% had left and 36.7% had bilateral injury. 43.4% of patients had no complications, amputation rate was 23.3% and nerve injury was seen in 13.3% of patients. Mean days of return to work was 132.57 (SD = 64.99). In 11 patients distant flaps were used, 9 patients with graft only and 7 patients had a combination of graft and regional flaps.The dominant hand involvement in electrical injury is very high.

Conclusions

We suggest that the routine treatment protocols of serial debridement until all the wound acquires a bed of granulation tissue should be revised, because the vital structures such as tendons and nerves will have undergone dessication necrosis and a young worker will be crippled for life. Early coverage of partially injured vital structures is gaining acceptance and this paper confirms the above mentioned treatment protocol.