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This study aimed to evaluate the use of microvascular free flaps (MFF) in oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland. A dynamic online questionnaire, using 42–46 questions, was sent to OMF surgeons based in hospitals in Germany, Austria, and Switzerland. The questionnaire was evaluated internally and externally. Aside from general information, data were collected on organizational aspects, approaches, MFF types and frequency, presurgical planning, intraoperative procedures, perioperative medications, flap monitoring, and patient management. Participants mostly performed 30–40 MFF each year (11/53). Most stated that the COVID-19 pandemic did influence MFF frequency (25/53) to varying extents. Radial forearm flap was most frequently used (37/53), followed by ALT (5/53), and fibula flap (5/53). Primary reconstruction was performed by most participants (35/48). Irradiated bony transplants were mostly used for implant placement after 12 months (23/48). Most participants (38/48) used reconstruction plates, followed by miniplates (36/48), PSI reconstruction (31/48), and PSI miniplates (10/48). Regarding the postoperative use of anticoagulants, low-molecular-weight (37/48) and unfractioned heparins (15/48) were widely used, most often for 3–7 days (26/48). Clinical evaluation was mostly preferred for flap monitoring (47/48), usually every 2 h (34/48), for at least 48 h (19/48). Strong heterogeneity in MFF reconstructions in OMFS was found, especially regarding the timepoints of reconstruction, types of osteosynthesis, and postoperative MFF management. These findings provide the chance to further compare the different treatment algorithms regarding relevant MFF aspects, such as postoperative management. This could create evidence-based treatment algorithms that will further improve the clinical outcomes in MFF reconstructions. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare Pectoralis major myocutaneous flap (PMMC) and Free flaps for reconstruction of post ablative defects in patients undergoing treatment for oral squamous cell carcinoma and to understand the reasons for choosing each from a developing nation perspective. In the present study, a retrospective study was conducted of the patients treated by either free flaps or PMMC flaps for reconstructive procedures over a five year period in the Department of Oral and Maxillofacial Surgery, Shri Guru Ram Das Institute of Dental Sciences and Research. Out of 90 PMMC flaps, 44 patients (48.8%) had reconstruction due to lack of micro vascular facility at the center, in 39 patients (43.3%) due to financial constraints and in 7 patients (7%) due to associated comorbities. The overall complication rate in PMMC group was 30% as compared to 28% in Free Flap group. Total flap loss was seen in 3 flaps (2 microvascular and 1 PMMC) while marginal necrosis of skin paddle was seen in 12 patients (13%) in the PMMC group. Though, the selection of PMMC flap over free flap was influenced by many factors, results of this study suggest that PMMC flap still has a major role in post-ablative defect reconstruction even in this era of free flaps, especially in developing countries like India. [Display omitted] [ABSTRACT FROM AUTHOR]

Craniocervical junction chordoma treated with surgery and Proton Beam Therapy evolved with Osteonecrosis and CSF leak. As the vascularization of the head was compromised, we harvested an Anterolateral thigh musculofascial flap to seal the leak. A 56-year-old man presented with a history of chronic headaches and dysarthria with tongue deviation to the right. Magnetic resonance imaging showed a lesion at the craniocervical junction with imaging characteristics compatible with chordoma. Endoscopic endonasal resection was followed by proton beam therapy. Recurrence of the chordoma was subsequently resected via far lateral approach again followed by proton beam therapy accumulating a total dose of 75 Gy. Unfortunately, this led to osteoradionecrosis of the skull base resulting in a cerebrospinal fluid (CSF) leak more than 1 year after treatment. After multiple failed attempts to seal the defect using local vascularized tissue and free fat grafts, the defect was reconstructed with a vastus lateralis free tissue transfer. Six weeks later, the flap had mucosalized, the patient was pain free, and there was no evidence of a CSF leak. In select cases, vascularized free flaps offer a superior reconstruction for osteoradionecrosis because radiotherapy often compromises the blood supply of local tissues. [ABSTRACT FROM AUTHOR]

We used the University of Washington Quality of Life (UW-QoL) questionnaire (version 4) to assess the long-term quality of life (QoL) of patients with oral squamous cell carcinoma treated with or without reconstruction with a microvascular free flap, and all patients with T2–T4 oral squamous cell carcinoma (SCC) treated in this way were eligible for the study. A total of 139 patients’ personal details, medical history, and QoL scores were collected and analysed. The mean (SD) overall QoL score was 73.09 (14.8) for patients with T2–T4 oral SCC. The mean (SD) global QoL scores of patients who had had reconstructions was 75.68 (13.85) and of patients who had not 71.00 (15.34) (t = 1.864, df = 137, p = 0.064). Univariate and multivariate analyses indicated that site of tumour, T stage, and the need for postoperative radiotherapy had significant effects on the global QoL scores. Among patients with T2 oral SCC there was no significant difference between patients who did and did not have reconstructions. However, there were significant differences among patients with T3/T4 SCC in scores for appearance, recreation, mood, anxiety, chewing, swallowing, and speech depending on whether they did or did not have reconstructions. There were significant differences in the domains recreation, chewing, speech, and taste, depending on the primary site of the tumour. We conclude that reconstruction with a microvascular free flap had a beneficial effect on the treatment of SCC and improved the QoL of patients with oral SCC. [ABSTRACT FROM AUTHOR]

Pedicled flaps (PFs) have historically served as the preferred option for reconstruction of large chest wall defects. More recently, the indications for microvascular-free flaps (MVFFs) have increased, particularly for defects in which PFs are inadequate or unavailable. We sought to compare oncologic and surgical outcomes between MVFFs and PFs in reconstructions of full-thickness chest wall defects. We retrospectively identified all patients who underwent chest wall resection at our institution from 2000 to 2022. Patients were stratified by flap reconstruction. End points were defect size, rate of complete resection, rate of local recurrence, and postoperative outcomes. Multivariable analysis was performed to identify factors associated with complications at 30 days. In total, 536 patients underwent chest wall resection, of whom 133 had flap reconstruction (MVFF, n = 28; PF, n = 105). The median (interquartile range) covered defect size was 172 cm2 (100-216 cm2) for patients receiving MVFF versus 109 cm2 (75-148 cm2) for patients receiving PF (P =.004). The rate of R0 resection was high in both groups (MVFF, 93% [n = 26]; PF, 86% [n = 90]; P =.5). The rate of local recurrence was 4% in MVFF patients (n = 1) versus 12% in PF patients (n = 13, P =.3). Postoperative complications were not statistically different between groups (odds ratio for PF, 1.37; 95% confidence interval, 0.39-5.14]; P =.6). Operative time >400 minutes was associated with 30-day complications (odds ratio, 3.22; 95% confidence interval, 1.10-9.93; P =.033). Patients with MVFFs had larger defects, a high rate of complete resection, and a low rate of local recurrence. MVFFs are a valid option for chest wall reconstructions. [Display omitted] [ABSTRACT FROM AUTHOR]

Summary Introduction Microvascular complications after free flap breast reconstruction are devastating, and revision of a compromised breast reconstruction is very challenging. The aim of this study was to review the different characteristics of urgent microvascular revision in DIEP, SIEA and SGAP flaps and to evaluate the final outcome after revision. Materials and methods A retrospective chart review was performed for all patients who underwent an autologous breast reconstruction with a DIEP, SIEA or SGAP flap at the University Hospitals of Leuven between August 1997 and December 2013. The number of revisions, time to revision, reason for revision, and outcome after microvascular free flap revision were analysed. Results A total of 1562 free flaps were evaluated during the study period, of which 4.42% required urgent exploration. DIEP flaps (3.38%) had a statistically significant lower revision rate than SIEA flaps (11.76%) and SGAP flaps (8.42%). Venous insufficiency was the main reason for revision of DIEP flaps (86.7%) and SGAP flaps (62.5%). SIEA flaps mostly failed because of an arterial problem (62.5%). SIEA flaps (62.5%) had a higher revision failure rate than DIEP flaps (37.8%) and SGAP flaps (12.5%). We found a statistically significant difference (p < 0.001) in the outcome of revision in DIEP flaps in correlation to the time to revision. Our overall flap failure rate was 1.79% (DIEP 1.28%; SIEA 7.35%; SGAP 1.05%). Conclusions The DIEP flap remains the most reliable flap for microvascular breast reconstructions. SIEA flaps are only performed when no suitable perforator for a DIEP flap is present. Multiple revisions are no longer performed, as the outcome after more than one revision is very disappointing. The difference in reason for revision between the different flaps led to the introduction of some technical refinements. [ABSTRACT FROM AUTHOR]

Introduction Surgical treatment of bisphosphonate-related osteonecrosis of the jaws (BRONJ) combines excision of adequate damaged bone and watertight coverage by appropriate vascularized tissue. Local tissues are preferred when possible. This study compares local mucoperiosteal flaps with mylohyoid flaps with special emphasis on their influence on wound healing. Material and methods A total of 195 patients with BRONJ in the mandible were included in this prospective study. The control group ( n = 169) were treated with a mucoperiosteal flap, whereas patients of the study group ( n = 26) received a mylohyoid flap. Results Recurrence of BRONJ was significantly reduced ( p = 0.023) as was extent of necrosis ( p = 0.001) in patients with mylohyoid flaps. Discussion This study demonstrates the importance of a sufficient mucosal coverage in surgical treatment of BRONJ. The mylohyoid flap provides an additional tissue coverage, which seems to account for the significantly reduced rate of disease recurrence. Conclusion The vascularized mylohyoid flap is an important tool in the complex and challenging surgical care of BRONJ. [ABSTRACT FROM AUTHOR]

Background Free flap transplantation may not be feasible in patients with inadequate or absent recipient vessels. We report successful mandibular composite reconstructions without anastomosis in three consecutive patients with vessel-depleted neck. Based on clinical reports describing early neovascularisation, temporary extracorporeal perfusion of flaps was maintained until the flaps had become independent from the extracorporeal blood supply. Methods A blood transfusion bag filled with the patients' arterialised blood was connected to the flap artery and set under rhythmic compression to ensure continuous blood supply to the flap. The returning venous blood was collected but not reinfused. Extracorporeal circulation was sustained for 10–13 days until flaps had become independent from the external blood supply. Flap viability was assessed every 2 h using combined laser Doppler flowmetry and remission spectroscopy. Results Successful bony reconstructions were achieved in all three consecutive patients substantiated by MRI-, CT-scan or bone scintigraphy. Neovascularisation occurred within the soft tissues of all flaps with the exception of one skin paddle, which later developed necrosis. Systemic transfusion of 12–25 units of packed red cells was necessary to compensate for the blood loss. Conclusions With this technique, transplantation of composite free flaps becomes feasible even in the absence of recipient vessels, opening up new treatment options to a broad range of complex surgical problems. Blood reinfusion should be pursued in the future to avoid excessive blood transfusions. The trial is registered with ClinicalTrials.gov , number NCT02449525 . [ABSTRACT FROM AUTHOR]

Introduction Bisphosphonate related osteonecrosis of the jaws (BRONJ) is a recognised unwanted effect of these drugs which affect bone remodelling. Treatment options range from conservative approaches through local bone debridement to free flap reconstruction following segmental resection. This current study aims to evaluate clinical outcomes after microvascular tissue transfer in BRONJ patients. Material and methods A total of 212 BRONJ patients were included in this prospective investigation. Those who met defined inclusion criteria and received a surgical intervention were reviewed regularly during a follow-up period of at least 6 months. Results Twenty-five patients (11.8%) received free flap reconstructions. A mean of 2.12 local debridements were performed before microvascular tissue transfer. A mean of 29.25% showed BRONJ recurrence after minimalist surgical intervention, compared to significantly less in patients after resection and free flap reconstruction. The postoperative fistula rate was significantly higher in patients, who received mucoperiosteal flaps. Discussion This study underlines the importance and effectiveness radical resection and free flap reconstruction in the complex and challenging surgical treatment of BRONJ patients in a large patient cohort study. Nevertheless, all patients received radical intervention after failure of minimally invasive treatment. An individualized analysis and planning is necessary to identify appropriate patients for free flap reconstructions. [ABSTRACT FROM AUTHOR]

Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap. [ABSTRACT FROM AUTHOR]

Abstract: Buerger's disease presents a difficult challenge, with its uncertain etiology and lack of a standardized therapy, and is often refractory to treatment. In the present report, we have described the case of a 43-year-old male with Buerger's disease, a refractory ulcer on his right great toe, and severe pain at rest. We obtained favorable results using a hybrid therapy that combined distal bypass with a free temporoparietal fascial flap. Postoperatively, the flap healed, and the patient's pain resolved. After more than 3 years of follow-up, he had had no recurrence of the foot ulceration, and the patency of the bypass graft had been confirmed using Doppler flowmetry. We believe that the hybrid therapy we devised for the present patient (ie, combined distal bypass with a free temporoparietal fascial flap) is an effective treatment of Buerger's disease with pedal ulceration. The therapeutic strategies for this condition should not adhere to a single treatment modality; rather, they should combine available treatment modalities according to each individual patient's condition. [Copyright &y& Elsevier]

Objectives: Little is understood about what happens to the vascular pedicle following free tissue transfer in the head and neck region. The viability of a free flap completely depends on the vascular supply by its vascular pedicle until neovascularization occurs from surrounding tissues. The aim of this study is to find out how long a vascular pedicle lasts following free tissue transfer in the head and neck region.Materials and Methods: Patients were recruited from the Maxillofacial Unit at the Royal Brisbane & Women's Hospital. A Doppler ultrasound was used to map the vascular pedicle immediately postoperatively, at 2weeks, 6weeks, 3months and 6months.Results: Fifty-seven consecutive free flaps underwent colour Doppler ultrasonography at the timepoints described demonstrating the status of the vascular pedicle. All the patients underwent reconstructive head and neck surgery with a wide variety of soft tissue and composite free flaps.Conclusion: This study is the first to document the fate of the vascular pedicle over a long time period for a wide variety of head and neck free flaps. This information is important when undertaking revision surgery to the free flap, or planning the vascular supply for a second or third free flap to the head and neck region. [ABSTRACT FROM AUTHOR]

Background: There are several reports of ossification occurring along the pedicle of fibular free flaps in head and neck microvascular reconstruction, but the incidence of pedicle ossification of other osseous flaps in head and neck surgery has never been investigated.Methods: A retrospective chart review was conducted for all patients undergoing free flap reconstruction in the head and neck between 2005 and 2016. Patients were included if they had reconstruction with an osseous free flap and if they had computed tomography (CT) scans at least 1 month post-operatively. Available CT images were reviewed for each patient.Results: Three-hundred thirty four osteocutaneous free flaps were performed. The average age was 64 years (range 8-89). There was slight male predominance with 63.5% of the cohort being male (n = 212). One hundred fifty-five patients had fibular flaps (45%), 108 had radial forearm flaps (34%) and 71 had scapular flaps (21%). One hundred fibulas had available imaging, 73 forearms had available imaging, and 44 scapulas had imaging post-operatively. Of the images reviewed, pedicle ossification was identified in 21 fibular flaps (21%). None of the radial forearm or scapular flaps developed pedicle ossification.Discussion: Pedicle ossification is relatively common in osteocutaneous free flap reconstruction and is uniquely associated with fibular. The presence of pedicle ossification is benign and does not compromise the flap, though it can create concern in cancer surveillance as the lesion is often identified as a new neck mass. As such, head and neck surgeons should be aware of this relatively frequent finding. [ABSTRACT FROM AUTHOR]