free tissue flaps

Reconstruction after pan-plexus root avulsions often includes gracilis free functioning muscle transfer. For elbow flexion reconstruction, the free functioning muscle transfer distal tendon is inserted into the biceps tendon or more distally (i.e., flexor digitorum profundus/flexor pollicis longus tendons) for combined elbow and finger flexion; the theoretical drawback of the latter approach is weaker elbow flexion. The authors compared elbow flexion strength with a biceps tendon versus a flexor digitorum profundus/flexor pollicis longus tendon attachment to determine which insertion point resulted in better elbow flexion. Thirty-nine patients underwent free functioning muscle transfer with either a biceps tendon or a distal attachment. Groups were compared on postoperative elbow flexion strength, preoperative and postoperative Disabilities of the Arm, Shoulder, and Hand questionnaire scores, range of motion, and other surgical and demographic characteristics. A biomechanical analys...

The latissimus dorsi muscle flap represents a valuable option in breast reconstruction but can result in postoperative twitching and retraction, discomfort, arm movement limitations, and breast deformation. These complications can be avoided by denervation of the thoracodorsal nerve; however, the optimal method of nerve management is unknown. This study presents the authors' experience with the outcomes of latissimus dorsi flaps for breast reconstruction in the light of thoracodorsal nerve management strategies. The authors retrospectively collected data from 74 patients who underwent partial or total breast reconstruction with a latissimus dorsi flap alone or with an implant between January of 1999 and October of 2011. Follow-up data were collected at 12 and 24 months postoperatively. In 56 patients (75.7 percent), the latissimus dorsi muscle was denervated at the time of surgery, whereas the thoracodorsal nerve remained intact in 18 patients (24.3 percent). No partial or total...

This study presents a comprehensive radiographic evaluation of bone regeneration within a pedicled muscle flap for the reconstruction of critical size mandibular defect. The surgical defect (20 mm615 mm) was created in the mandible of ten experimental rabbits. The masseter muscle was adapted to fill the surgical defect, a combination of calcium sulphate/ hydroxyapatite cement (CERAMENTTM |SPINE SUPPORT), BMP-7 and rabbit mesenchymal stromal cells (rMSCs) was injected inside the muscle tissue. Radiographic assessment was carried out on the day of surgery and at 4, 8, and 12 weeks postoperatively. At 12 weeks, the animals were sacrificed and cone beam computerized tomography (CBCT) scanning and micro-computed tomography (m-CT) were carried out. Clinically, a clear layer of bone tissue was identified closely adherent to the border of the surgical defect. Sporadic radio-opaque areas within the surgical defect were detected radiographically. In comparison with the opposite non operated control side, the estimated quantitative scoring of the radio-opacity was 46.6% 615, the mean volume of the radio-opaque areas was 63.4% 620. Areas of a bone density higher than that of the mandibular bone (+35% 625%) were detected at the borders of the surgical defect. The micro-CT analysis revealed thinner trabeculae of the regenerated bone with a more condensed trabecular pattern than the surrounding native bone. These findings suggest a rapid deposition rate of the mineralised tissue and an active remodelling process of the newly regenerated bone within the muscle flap. The novel surgical model of this study has potential clinical application; the assessment of bone regeneration using the presented radiolographic protocol is descriptive and comprehensive. The findings of this research confirm the remarkable potential of local muscle flaps as local bioreactors to induce bone formation for reconstruction of maxillofacial bony defects.

To evaluate the functional and oncological outcomes of anterolateral thigh flap reconstruction for salvage laryngopharyngectomy after concurrent chemoradiotherapy for patients with hypopharyngeal carcinoma. A retrospective review was conducted on patients who underwent pharyngoesophageal reconstruction using anterolateral thigh flap after salvage laryngopharyngectomy for recurrent hypopharyngeal carcinoma between June 2003 and May 2010 at Chang Gung Memorial Hospital. The perioperative morbidity, mortality, functional outcomes, and oncological outcomes were evaluated. 33 patients were entered into the study. The mean follow-up time was 19.5±12.3 months. Recurrent pathological TNM stages included 3 (9.1%), 2 (6.1%), and 28 (84.8%) patients with stage II, III, and IV disease, respectively. Mean ICU stay was 10.3 days and the mean hospital stay was 39.9 days. Peri-operative mortality occurred in one patient (3%). 16 patients (48.5%) developed recipient site complications. Among them, 1...

The comparative safety of breast reconstruction in obese patients remains to be clearly defined. This study utilized multi-institutional data to characterize the effect of body mass index (BMI) on breast reconstruction outcomes. Utilizing Current Procedural Terminology (CPT) codes, patients undergoing tissue expander, pedicled transverse rectus abdominis myocutaneous (TRAM) flap, latissimus dorsi flap, and free flap breast reconstruction were identified in the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified as obese (BMI ≥ 30) and non-obese (BMI < 30). Overall postoperative morbidity, flap complications, non-flap complications, and reoperation rates were compared among the groups. Of 12,986 patients who underwent breast reconstruction, 3636 (28.0%) were obese. Overall morbidity was significantly elevated in obese patients across all forms of reconstruction (p < 0.05). BMI was correlated with increased surgical complications for tissue e...

There are currently two accepted neurosurgical methods to perform a bony flap. In an osteoplastic flap, the flap is attached to surrounding muscle. In a free flap, the flap is not attached to adjacent tissues. The former is less common due to its complexity and the extensive time required for the surgery; yet the rate of infection is significantly lower, a clear explanation for which is unknown. The objective of this study was to test the hypothesis that the osteoplastic flap acts as a live implant that resumes its blood flow and metabolic activity; contrasting with the free flap, which does not have sufficient blood flow, and therefore acts as a foreign body. Seven patients who underwent craniotomy with osteoplastic flaps and five with free flaps had planar bone and single photon emission computed tomography (SPECT) scans of the skull at 3-7days postoperative, after injection of the radioisotope, 99m-technetium-methylene diphosphonate (99m-Tc-MDP). We compared radioactive uptake as...

The use of suture anchors has been described in orthopedic, hand, oculoplastic, temporomandibular joint and in aesthetic surgery, but no study reports the use of the Mitek® anchors (Depuy Mitek Surgical Products, Inc. Raynham, Massachusetts) for fixing the free flaps used in oncologic oral and oropharyngeal reconstruction. In this prospective non-randomized study, 9 patients underwent surgical resection of oral or oropharyngeal cancer followed by a free flap reconstruction; mini anchors were used to fix the flap directly to the bone. We collected data regarding the patients, the tumor stage, the surgical procedure, the radiotherapy and the number of anchors used. The average follow-up was 28months (range 24-38).We observed no complications with trans-oral, sub-mandibular and trans-mandibular approach in both oral and oropharyngeal reconstructions. All anchors became osteo-integrated and no complications occurred after radiotherapy. In our opinion this device favors free flap adhesion to the bone. We registered no postoperative complications related to the use of the device which looks suitable for use in irradiated tissues. The radiotherapy did not cause any long-term complications related to the use of Mitek® mini bone anchors.

This paper describes a new protocol for mandibular reconstruction. Computer-aided design/computer-aided manufacturing (CAD/CAM) technology was used to manufacture custom-made cutting guides for tumor ablation and reconstructive plates to support fibula free flaps. CT scan data from a patient with an odontogenic keratocyst on the left mandibular ramus were elaborated to produce a virtual surgical plan of mandibular osteotomy in safe tissue for complete ramus resection. The CAD/CAM procedure was used to construct a customized surgical device composed of a cutting guide and a titanium reconstructive bone plate. The cutting guide allowed the surgeon to precisely transfer the virtual planned osteotomy into the surgical environment. The bone plate, including a custom-made anatomical condylar prosthesis, was designed using the outer surface of the healthy side of the mandible to obtain an ideal contour and avoid the bone deformities present on the side affected by the tumor. Operation time...

Although the fibula osteocutaneous free flap has many proven advantages in restoring mandibular defects, the dimension of available fibula is one of its limitations. The present study aimed to investigate the suitability of dimensions and the quality of harvested fibulae for mandibular reconstruction and dental implant placement in Thais. One hundred fourteen fibulae of 57 adult Thai cadavers were dissected. Total fibular length and the length of harvested fibula were measured. Dimensions of the fibula cross sections available for dental implant placement were recorded. Additionally, the cortical bone thickness and densities of cortical and spongy bones of 60 fibulae were assayed using cone beam computed tomography scan images. Mean total fibular length and mean length of harvested fibulae were 34.2 +/- 2.3 cm and 18.2 +/- 2.3 cm, respectively. A dental implant length of 7 to 10 mm could be placed in the fibula. The mean cortical bone thickness was 2.2 +/- 0.6 mm. The mean densities...

Aim There are a limited number of published studies describing reconstruction with an anterolateral thigh (ALT) flap following lower extremity injury in pediatric patients. The aim of this study was to present our experiences with the application of a free ALT flap not only in the reconstruction of soft tissue defects around the pediatric foot and ankle but also in patients with bone, tendon, and ligament injuries that require repair. Materials and Methods Reconstruction with a free ALT flap was performed in 11 pediatric patients (mean age, 8.9 years; range, 3-15 years) between November 2010 and February 2013. The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. A retrospective evaluation of the applied surgical procedures was performed: flap size, perforator type and number, placement area, site of anastomosis, closure of the donor site, complications, and flap survival. Results The...

Background Anastomotic thrombosis following free tissue transfer (FTT) on or after day 5 ("late thrombosis") is reported to have extremely low rates of salvage. Analysis of our institution's experience with FTT was performed to make recommendations about the optimal management of late thrombosis, and to identify any variables that are correlated with increased salvage rates. Methods The study included patients who underwent FTT between 1986 and 2014, then suffered anastomotic thrombosis on or after postoperative day 5. Twenty-six variables involving demographic information, flap characteristics, circumstances of the thrombotic event, and details of any salvage attempt were analyzed. Patients whose FTT were successfully salvaged and those whose were not were statistically compared. Results Of the 3,212 patients who underwent FTT, 23 suffered late thrombosis (0.7%), and the salvage rate was 60.8% (14 of 23). The salvage rate for reconstruction of the head and neck was 53...

Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies. Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies. Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT. In group A, f...

To provide surgeons and clinicians with a critical review of microvascular reconstructive options and their expected outcomes after head and neck cancer resection in the elderly. Medline, Isiweb, and Cochrane databases. A literature search was performed in May 2014 and included studies published between 2000 and 2014. Keywords were used for articles identification, and inclusion criteria were defined for consideration in the present review. Evaluation of the pertinent literature is hampered by a number of biases, such as a lack of general consensus of a definition of "elderly," differences among scales used to quantify comorbidities, and subjective evaluation of flap-related and systemic complications. However, our findings showed no differences in terms of free flap success, surgical complications, or mortality rate between older and younger patients. Moreover, recipient site complications do not seem to be affected by age. Microvascular reconstruction in the elderly can ...

Surgical treatment of advanced cancers of the hypopharynx inevitably impairs swallowing, respiration and phonation. The purpose of this study was to analyze the functional results after circumferential pharyngolaryngectomy (CPL) and flap reconstruction, in order to offer decisional guidelines for the choice of the most effective reconstructive method. We performed a retrospective analysis on the medical records of patients submitted to reconstructive surgery after CPL from July 1991 to November 2011. 75% of the 94 patients underwent reconstruction with a free flap (group A), while 25% underwent reconstruction with a pedicled flap (group B); 80% of patients in group A and none in group B were discharged with a free diet; 14% of patients in group A and 26% in group B were unable to resume oral feeding and were discharged with NG-tube or PEG. None of the patients acquired a satisfactory oesophageal voice; 17% of patients in group A and 7% in group B underwent voice restoration with tra...

Surgical treatment of advanced cancers of the hypopharynx inevitably impairs swallowing, respiration and phonation. The purpose of this study was to analyze the functional results after circumferential pharyngolaryngectomy (CPL) and flap reconstruction, in order to offer decisional guidelines for the choice of the most effective reconstructive method. We performed a retrospective analysis on the medical records of patients submitted to reconstructive surgery after CPL from July 1991 to November 2011. 75% of the 94 patients underwent reconstruction with a free flap (group A), while 25% underwent reconstruction with a pedicled flap (group B); 80% of patients in group A and none in group B were discharged with a free diet; 14% of patients in group A and 26% in group B were unable to resume oral feeding and were discharged with NG-tube or PEG. None of the patients acquired a satisfactory oesophageal voice; 17% of patients in group A and 7% in group B underwent voice restoration with tra...

Although surgery is still the most important treatment modality in the management of head and neck cancer, radiotherapy (XRT) is increasingly being used, either as (neo)adjuvant therapy or as primary treatment with or without concurrent chemotherapy.1,2 Despite significant im-provements in reconstructive (micro)surgery over the last years, which have made more extensive tumor resections feasible, about two thirds of patients still require adjuvant XRT or concurrent chemoradiotherapy to improve oncologic outcome.2 Consequently, the majority of patients with head and neck cancer are at risk of developing osteoradionecrosis (ORN) of the jaws as a complication of XRT. ORN is themost serious and important complicationofXRT. It was defined byMarx in 1983 as the presence of exposed bone in an irradiated field that fails to heal within a 3-month period.3 The reported incidence of ORN in literature ranges from 0.9 to 35%.However, a recent large retrospective reviewof 830patients with head an...

The aim of this study was to conduct a 1-year full esthetic evaluation of the treatment outcomes of gingival recession using the root coverage esthetic score (RES) system. One hundred patients with 195 single or multiple recessions were treated using different techniques. One year after surgery, the clinical outcomes were evaluated. Only 21 of 195 (11%) treated recessions obtained the maximum RES score (10), while 68 recessions (35%) showing complete root coverage obtained lower scores. Both single and multiple recessions treated with a coronally advanced flap with or without connective tissue grafting achieved similar RES scores. Free gingival grafts showed the lowest score.

The purpose of this study was to evaluate the donor site morbidity of the free ulnar forearm flap (UFF). Consecutive patients undergoing free UFF between 1982 and 2009 were retrospectively reviewed. In addition, detailed assessment of hand function and donor site cosmesis was performed in the most recent 50 patients followed up for at least 12 months. In all, 62 of the 242 free UFF donor sites (26%) were closed directly and the remainder required split thickness skin grafting. Donor site complications included total (n = 1) and partial (n = 17) skin graft loss and persistent hypertrophic scarring (n = 4). There was minimal incidence of cold intolerance, parasthesia, and pain; no reduction in joint mobility, grip and pinch strength, and sensory dysfunction, with excellent donor site cosmesis. UFF has several advantages, including the possibility of direct closure of the donor defect, and reduced morbidity and excellent donor site cosmesis.

OBJECTIVE Although the fibula osteocutaneous free flap has many proven advantages in restoring mandibular defects, the dimension of available fibula is one of its limitations. The present study aimed to investigate the suitability of dimensions and the quality of harvested fibulae for mandibular reconstruction and dental implant placement in Thais. MATERIAL AND METHOD One hundred fourteen fibulae of 57 adult Thai cadavers were dissected. Total fibular length and the length of harvested fibula were measured. Dimensions of the fibula cross sections available for dental implant placement were recorded. Additionally, the cortical bone thickness and densities of cortical and spongy bones of 60 fibulae were assayed using cone beam computed tomography scan images. RESULTS Mean total fibular length and mean length of harvested fibulae were 34.2 +/- 2.3 cm and 18.2 +/- 2.3 cm, respectively. A dental implant length of 7 to 10 mm could be placed in the fibula. The mean cortical bone thickness ...

Breast cancer is the most common malignant tumor and the leading cause of death among females. Most women with breast cancer will undergo breast-conserving surgery (BCS) or lumpectomy, simple or total mastectomy, modified radical mastectomy or bilateral mastectomy. Breast reconstruction solves many of the problems. The goal is to return the patient to a near-normal state so that she is not handicapped in her daily living. Breast reconstruction is also intended to offer psychological benefits to women treated by mastectomy following a diagnosis of possibly terminal cancer. In these case reports, we reported two successful cosmetic reconstruction cases. The first case was a 39-years-old female with non-recurrent breast cancer consulted and was referred by the oncology surgeon to the Plastic Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Dr. Sardjito General Hospital. She wanted to undergo breast reconstruction. We planned to operate three years following mastec...

Hospital readmissions are a marker of surgical care delivery and quality that are progressively more scrutinized. To provide a comprehensive analysis of 30-day readmissions for patients with head and neck cancer who underwent free flap reconstruction to highlight the rate, causes, and associated patient risk factors. Retrospective cohort study at a single tertiary care academic institution. The study consisted of 249 patients who underwent microvascular reconstruction of a presumed head and neck oncologic defect from January 1, 2000, through June 30, 2014. Follow-up continued through July 30, 2014. Microvascular reconstruction of an oncologic head and neck defect. Incidence of 30-day all-cause readmissions, patient risk factors, and readmission indications. Regression analyses were conducted to discern patient-level risk factors related to 30-day readmissions. Among the 249 patients, the 30-day all-cause readmission rate was 14.5%, while the unplanned readmission rate was 11.6%. The...

Flap edema can often compromise an otherwise successful lower-extremity microsurgical reconstruction. To train a flap toward maturity, various wrapping and dangling protocols have been described. Mixed tissue oxygenation of a myocutaneous free flap for lower-extremity reconstruction is examined as measured by ViOptix with wrapping and unwrapping during dangling at different postoperative time points. The results are compared with the nonaffected lower extremity and additional healthy controls. Upon dangling a reconstructed lower extremity, the tissue oximetry recording of a free flap descended rapidly until the leg was reelevated and then continued at this low level with a gradual return to the predangling baseline. The extent of this drop in tissue oxygenation depended upon positioning, and the length of time to reach its baseline upon reelevation decreased as flap matured postoperatively. In addition, wrapping of a reconstructed lower extremity also decreased the overall drop in tissue oxygenation level and the time to recovery while having no effect on the control. Results of this prospective study can lead to an increased understanding of free flap physiology in lower-extremity reconstruction and can further validate and refine our postoperative management strategies regarding dependency and edema control.