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Summary Background Accurate mapping of perforators prior to flap reconstruction and early detection of poor flap perfusion reduces the risk of flap failure. Infrared thermography (IRT) has recently regained popularity within reconstructive surgery to aid flap design, reduce operative time and assess flap viability based on surface temperature changes. The aim of this review is to quantify the diagnostic ability of IRT in perforator mapping preoperatively and monitor flap perfusion perioperatively. Methods We conducted a systematic review of literature and included all studies that evaluated the use of IRT for perforator mapping and flap perfusion monitoring. We used a mixed-effects logistic regression bivariate model to estimate the summary sensitivity and specificity and constructed hierarchical summary receiver operative characteristic (HSROC) curves. Outcome We identified 18 studies and observed IRT to have sensitivities of 99.6% and 89.6% with specificities of 99.9% and 96.0% for perforator mapping and flap monitoring, respectively. Moreover, IRT recognises patterns of perfusion within interperforator zones through visualisation of angiosomal rewarming and may improve flap outcomes.

There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects.A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates.Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013).The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.

Introduction Early postoperative compression of free flaps for lower limb reconstruction remains controversial. It may reduce venous congestion and promote the resolution of oedema. However, concerns remain regarding inadvertent pedicle compression, which may lead to flap failure. The aim of this systematic review was to determine the safety and effectiveness of this intervention. Methods A systematic review was designed in compliance with PRISMA. MEDLINE and EMBASE databases were searched. Parallel screening, selection of eligible studies, and data gathering were carried out by two independent authors. A formal risk of bias assessment was included along with the appraisal of outcomes. Results A total of 847 abstracts were retrieved and 262 free flaps for lower limb reconstruction were identified in ten eligible articles. The overall flap failure rate for patients who underwent early postoperative compression was 1.6%. Apart from flap failure rates, there were no other outcomes consistently reported and none of the studies included a no-compression group for comparison. Discussion All included studies had methodological flaws, resulting in a high risk of bias. Nevertheless, there was consistent reporting of flap failure as a postoperative outcome. Compression of free flaps in the context of lower limb reconstruction does not appear to be associated with a higher flap failure rate compared with other series. Compression bandages may reduce the pain associated with dangling regimes. However, there is no evidence to support that free flap compression in the context of lower limb reconstruction is associated with any other clinical benefit.

Highlights • Pedicled flap reconstruction in the head and neck is still an alternative if free flaps are not possible. • Angiography of the subclavian artery is not a standard procedure in the surgical planning of pedicle flap harvesting. • In exceptional cases, we recommend angiography of the neck and thoracic vessels. • The application of a temporary pharyngostoma is still an option in extraordinary circumstances., Introduction Pedicled flap reconstruction still plays an essential role in head and neck surgery as an alternative to free grafts. Two standard methods are the pectoralis major and the deltopectoral flap, which are generally characterized by their reliable perfusion. This case describes bilateral arteriosclerosis of the subclavian artery as a possible cause of flap failure. Presentation of case We report on a 65-year-old patient with a multilevel carcinoma of the right pharynx. Due to the unique patient history, a free flap reconstruction was not possible. After resection of the primary, we performed reconstruction with a pedicled pectoralis major flap. Discussion Postoperatively, we observed necrosis of the pectoralis major flap. Secondary defect reconstructions were performed with a deltopectoral flap first from the right and then, in the case of necrosis, from the left side. Stenosing arteriosclerotic plaques of the subclavian artery on both sides were the cause of flap failure. Conclusion Preoperative angiography of the subclavian artery is not a standard diagnostic procedure in the surgical planning of pedicled flap reconstruction in the head and neck region. In exceptional cases, we recommend angiographic imaging of the supplying vessels to make a more precise flap selection and avoid complications.

Summary Background Obesity is often considered a relative contra-indication for microvascular autologous breast reconstruction. We hypothesize that although obesity is associated with increased post-operative complications, abdominally based microvascular post mastectomy breast reconstruction can still be achieved with high rates of success. This study analyses the relationship between increasing body mass index (BMI) and post-operative complications at a high volume specialist centre, with a particular focus on serious complications. Methods and Results Nine hundred and sixty patients undergoing 1460 microvascular breast reconstructions were included in the study. Obese patients (BMI ≥ 30 kg/m2) accounted for 37.7% of the cohort and were more likely to have co-morbidities, a history of smoking and bilateral reconstruction. Post-operative surgical complications occurred in 156 patients (16.3%) and medical complications occurred in 10 patients (1.0%). There was no significant difference between the flap failure rates in patients with normal BMI Conclusion This large single-centre study demonstrates that although obesity increases the risk of overall complications, microvascular breast reconstruction can be safely and successfully achieved in the vast majority of patients. Obese patients should be carefully counselled pre-operatively, but increased BMI should not be considered a contra-indication for microvascular breast reconstruction.

Autologous microsurgical flap reconstruction has become commonplace in most plastic surgery units, and the success rates of this procedure have markedly increased over recent years. However, the possibility of flap failure still needs to be considered. A review of the literature reveals that the critical period for flap-threatening complications is the first 24-48 post-operative hours; however, the window for the onset of these complications remains open for up to 7 days post-operatively. In this study, we focus on the timing of flap complications, aiming to elucidate the time period over which meticulous flap monitoring can positively contribute to flap salvage rates. The relevant literature on the study topic was collated and reviewed in conjunction with the senior author's case series, which consisted of a total of 335 free flaps used during a 2-year period for breast and head and neck reconstruction or limb trauma. Patients' series were then divided into groups according to the complications timing. The correlation between the timing of complications and the flap salvage rate was investigated among the groups. Overall analysis of both the literature and our own data on 335 free flaps showed a progressive reduction in flap salvage rate during post-operative days; the correlations between the times of complication onset and the flap salvage rates in all groups were significant up to the third post-operative day. The correlations between salvage rates and later complications were not significant. Our results suggest that hourly flap monitoring should be compulsory during the first 48 post-operative hours, but clinical monitoring four times daily should be sufficient thereafter.

Purpose Stable coverage of complicated defects located between the craniocervical and cervicothoracic junction following wound healing disturbance after spinal surgery can be challenging. Especially in cases where devices are exposed, well-vascularized coverage is required to achieve stable wound conditions. Therefore, the aim of the present study was to evaluate the clinical outcome of the lower trapezius island myocutaneous flap (LTIMF) as a possible treatment option. Materials and methods Four patients with a mean age of 68.8 years (ranging from 50 to 93 years) with wound healing disturbance following spinal surgery leading to defects of the dorsal neck/upper back refractory to conservative treatment and surgical debridement were included. All defects were reconstructed with a LTIMF based on the transverse cervical artery. Results Mean follow-up was 16.5 months (ranging from 5 to 30 months). No major flap failure occurred; minor complications in three patients including lateral superficial skin necrosis were easily handled. In all patients, excellent functional and aesthetic results were achieved. Conclusion The lower trapezius island myocutaneous flap represents a reliable treatment option to cover complicated defects located between the craniocervical and cervicothoracic junction following wound disturbance after spinal surgery.

Summary Purpose The deep inferior epigastric perforator (DIEP) flap provides excellent results when performed by a trained surgical team. However, the beginning of the procedure is often complicated. To date, few authors have published their initial experiences. This study presents our team's experience using a DIEP flap in breast reconstruction. Methods From June 2008 until December 2013, the same leading operator performed 132 consecutive DIEP flaps. Breast reconstructions were immediate ( n = 18) or delayed ( n = 114), unilateral ( n = 110) or bilateral ( n = 11). The learning curve was assessed using the operating time, ischemic time, postoperative hospital stay, and complications. For statistical comparisons, unilateral reconstructions were divided into five chronologic groups of 22 consecutive DIEP flaps and two chronologic groups of 55 flaps. Results The average time of surgery was 291 min (range, 185–645) for unilateral breast reconstruction and 513 min (range, 400–790) for bilateral breast reconstruction. The global complication rate was 24.5%. In the unilateral series, the time of surgery decreased progressively from 415 min to 233 min ( P = 4.8 × 10 −8 ). The mean postoperative hospital stay was reduced from 7.14 days to 6.32 days ( P = 0.042). The complications and flap failure rates had regular time distributions. Initially, the revision rate reached 50% for the first ten unilateral cases but decreased rapidly and remained steady at 6% for the following cases ( P = 0.0012). Conclusions Our initial experience of DIEP flap breast reconstruction showed a significant improvement of surgical performances exceeding 50 cases, with a critical ten first case period.

This study represents the surgical experience of 4481 microvascular free flap cases performed at the authors' institution in China, between 1979 and 2013. Four thousand four hundred and eighty-one patients underwent reconstruction with 4640 flaps: 56% radial forearm flaps, 8% iliac crest flaps, 13% fibula flaps, 10% anterolateral thigh flaps, and other flaps. In the overwhelming majority of cases, the flap transfer was required following tumour resection (97.5%). Three hundred and twenty minor complications (6.9%) occurred. One hundred and eighteen major complications (2.5%) were encountered: 114 cases of failure (2.4%) and four deaths. Among the 118 cases with major complications, 26 - 22.0% - had received radiotherapy; this proportion was higher than the 6.9% in the minor complications group and 8.1% in the non-intervention group. Venous thrombosis was the most common complication at the recipient site and was the main cause of flap failure. When a compromised flap is identified, surgical re-exploration should not be delayed. This study confirms that free flaps are reliable in achieving successful reconstruction in the head and neck region; however this technique requires extensive clinical experience. Owing to the large number of flap options, microsurgeons should always pay attention to the details of the different surgical defects and choose the most appropriate flap.

The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis.An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003-2013 national activity.The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site (n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision (n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm (n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days (P0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66-3.38; P0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed.Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes.

Local skin flaps have revolutionized reconstructive surgery. Mechanical loading is critical for flap survival: Excessive tissue tension reduces blood supply and induces tissue necrosis. However, skin flaps have never been analyzed mechanically. Here we explore the stress profiles of two common flap designs, direct advancement flaps and double back-cut flaps. Our simulations predict a direct correlation between regions of maximum stress and tissue necrosis. This suggests that elevated stress could serve as predictor for flap failure. Our model is a promising step towards computer-guided reconstructive surgery with the goal to minimize stress, accelerate healing, minimize scarring, and optimize tissue use.

Authors analyzed 89 cases (86 patients) of lower limb extensive soft tissue defects reconstruction during 1978 to 2013. The mean age is 37 years and 2 months old (range: 5-84 years old). A total of 71 males and 15 female were included. Free flaps were used in emergency in 23 cases for principally covering Gustilo 3B open lower limb fracture and in a later stage for 66 cases all referred from their center for coverage of exposed bone, with frequently osteomyelitis. About the selection of free flaps, in 47 cases we used a latissimus dorsi flaps, 12 cases of epiploon free transfer (in septic area), 10 cases of gracilis transfer and 10 serratus anterior flaps. There are one medial gastrocnemius flap, 2 composite soleus and fibular free flap, 2 antebrachial flap, one inguinal myoosteocutaneous flap, 1 transferred from the other lower limb and one inguinal cutaneous flap. There are 18 free flap losses: one in emergency and 17 after delayed reconstruction. Authors retrospectively analyzed the results (complications, osteomyelitis) according to the timing for lower extremity reconstruction. They found a low infection and flap failure rates (4%) when the coverage is made in the same operating time than initial fracture fixation, they increase to 60% for osteomyelitis and to 23% for flap failure when the reconstruction is delayed.

Background Multiple preoperative, intraoperative and postoperative decisions can influence the outcome of microsurgical breast reconstruction. We have simplified the decision-making process by incorporating a number of algorithms into our microsurgical breast reconstruction practice and critically review our results in this study. Methods Prospectively maintained databases for all microsurgical breast reconstructions performed by a single surgeon over a nine-year period were examined to determine: patient demographics; operative details including flap choice, donor and recipient vessel selection; and, details of intraoperative and early postoperative ( Results 406 Consecutive free flap microsurgical breast reconstructions (164 unilateral and 121 bilateral) were performed in 285 patients over the study period. Deep inferior epigastric artery perforator (DIEP) flaps (88%, n=359) were used most commonly followed by muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps (11%, n=44), and fascial-sparing TRAM (FS-TRAM) flaps (0.7%, n=3). One-hundred-seventy-one (48%) DIEP flaps were based on a single perforator while 188 (52%) had multiple perforators. The internal mammary (IM) artery and vein were used as the recipient vessels for 99% (n=403) of flaps. A second venous anastomosis was required for 11.8 percent (n=48) of flaps. Partial flap failure occurred in nine (2.2%) flaps while total flap failure occurred in two flaps (0.5%). Minimum follow-up was three months. Conclusions Incorporating a number of algorithms into our practice has enabled us to simplify the decision-making processes involved in microsurgical breast reconstruction and to consistently obtain successful surgical outcomes.

Summary Background The treatment of post-traumatic osteomyelitis of the lower leg and the foot remains a challenge in reconstructive surgery. Material and methods Eighty-six patients with lower leg post-injury chronic osteomyelitis were included in a retrospective, non-controlled clinical study conducted from 1995 to 2006. All study patients were managed by distally based sural neuro-fascio-cutaneous perforator flap. An endpoint survey was conducted after flap surgery and had a mean follow-up period of 5.5 years, wherein the response rate was 48%. Results Seven patients had a short-term flap failure (8%; 95% CI 3−16%). An additional eight patients (7%) had flap necrosis of less than one-fourth of the flap that healed without surgical revision. Based on the endpoint data, the long-term success rate was 87% (95%, CI 72–96%). Local and/or systemic physiological compromise was a risk factor for flap failure. Other assumed risk factors had no statistically significant impact on short- or long-term results. Conclusion Sural perforator flap is a robust flap with low failure rate, even in high-risk patients. The success rate compares favourably with results of free flap transfers in the management of post-traumatic osteomyelitis. The flap has a wide range, and the surgical technique is rather simple. The sural flap is a feasible option for post-traumatic reconstructions of osteomyelitis, especially in low-resource settings.

Reconstruction after circumferential pharyngolaryngectomy is a challenging problem. Reconstruction methods should ensure an appropriate mucosa lining of the digestive tract, preferably already tubulized, and peristalsis. Despite the high reported success rates, the jejunum flap is still occasionally lost due to thrombosis of the pedicle and/or fistula formation. Five cases of circumferential pharyngolaryngectomy in which failure of the jejunum loop was managed with a second free or pedicle flap are presented. A second free jejunum was reliable in selected patients, depending on time of detection of flap necrosis, on bacterial control of the wound and on the vascular or general conditions. For this reason, careful monitoring of the flap and clinical signs of necrosis in the first 5 post-operative days is crucial to prevent the formation of fistulas and infection and to increase the possibility of using this kind of salvage surgery. Pedicle flaps should be used only in the event of severe complications because of their high risk of post-operative salivary fistulas.

From March 2000 to June 2002, 74 deep inferior epigastric perforator (DIEP) flaps were performed in 73 female patients for oncological post-mastectomy breast reconstruction in Chang Gung Memorial Hospital. The mean age was 44.2 years and mean body weight was 56.6 kg. Twenty-five breast reconstructions were immediate and 49 were delayed. The average size of the flap was 30.1x12.0 cm and the mean number of perforators was 2.2. The average weight of the harvested flap was 595 g and 85.6% (mean: 509 g) of the flap was used for shaping the new breast mound. Zone IV was not discarded, except in one case. Total flap failure and donor site morbidity was not encountered. Only one flap was revised due to venous congestion (1.4%) and successfully salvaged. Partial flap loss occurred in two patients (2.7%). Fat necrosis was detected in 10 cases (13.5%) and sizes ranged from 2x2 to 4x5 cm. The numbers of perforators and the percentage of the used flap weight/total flap weight were not related to the complications. The free DIEP flap and inclusion of zone IV is a reliable and valuable method of breast reconstruction and provides superior aesthetic outcomes.

The use of tensor fasciae latae was first described as a rotation or island flap and evolved into a free flap in the late 1970s. This series of 85 patients undergoing free tensor fasciae latae transfer includes complex head and neck, abdominal wall and lower limb reconstruction. The overall success rate was 93% (79 patients), partial flap loss, 5% (four cases), and flap failure, 2% (two patients). Twelve patients (14%) required unplanned return to theatre for exploration resulting in a 75% salvage rate. We believe this series demonstrates the great versatility of this flap and highlights particular indications for its use.

As head and neck reconstructive surgery has passed into the new millennium, free-tissue transfer assumes a front and center role, both for repair of major ablative defects and correction of more subtle problems, such as facial contour defects and facial paralysis. One of the major forces behind the increased acceptance and use of this technology is its high degree of reliability, now 96% to 98% successful in most large series. This level of success is directly related to improvements in surgical technique and the quality and number of fellowship training programs. Because the consequences of flap failure can be so devastating, significant attempts to decrease thrombosis rates (currently 3.7%) are ongoing [61]. This article reviews some of the ongoing basic science and clinical investigations that may have an impact on clinical microvascular practice.

In breast reconstruction with a free flap following mastectomy, the recipient vessels most widely used are in the axillary system, which limits flap movement and flexibility in breast shaping. In addition, scarring and fibrosis can make dissection of the vessels difficult. We have performed 22 breast reconstructions using a free transverse rectus abdominis myocutaneous (TRAM) flap anastomosed to the internal mammary (thoracic) vessels. There has been no flap failure. The surgical techniques and the advantages and limitations of the internal mammary system are presented and the internal mammary vessels compared with the axillary vessels as a recipient vascular system.

Twenty patients who had had upper limb reconstruction using the lateral arm free microvascular flap are reviewed. The size of the flap, modifications to the flap, and complications were documented. There was one flap failure, and nine flaps required surgical thinning at a second procedure. This sole disadvantage was outweighed in clinical usage by the advantages and versatility of the lateral arm flap.

We read with great interest the letter from Chaput et al. regarding the use of the serratus anterior muscle pedicle as recipient vessels in DIEP flap breast reconstruction. The national comparative audit of mastectomy and breast reconstruction surgery in England 2 included 476 cases of immediate free flap breast reconstruction and 566 cases of delayed free flap breast reconstruction. The overall free flap failure rate was 1.98%. In our own department the total failure rate is 0.48% for free flap breast reconstruction (unpublished data). Chaput et al. reported a significantly higher flap failure rate of 19% using this technique, although Santanelli di Pompeo reports a much higher success rate. We have not adopted this technique in our department, but broadly agree with the advantages and disadvantages previously proposed. We feel that this pedicle may have value in a salvage scenario, as reported by Caulfield et al. However, we would only adopt it with caution based on these contrasting reports. Yours sincerely.

A method of surgical compartmentalisation of the neck is reported. This technique can be used in order to maintain suction drainage without compromising the flow of the anastomoses when an end-to-side technique in the internal jugular vein is used.

Review of 72 cases of free flap transfer showed that flap failure was associated with thrombocytosis and open wounds and that complications were associated with open wounds. Specific biologic variables, therefore, may underlie flap failure and complications, and investigation of these variables could lead to reduced morbidity.

The accepted method of treatment for acute, contaminated, upper extremity wounds is serial debridement and delayed closure. Emergency free tissue transfer challenges these concepts by advocating radical debridement and early closure of these wounds. The use of emergency free tissue transfer in the upper extremity allows early motion and possibly lowers the rates of infection, nonunion, flap failure, and the length of hospital stay. The decision to carry out emergency free tissue transfer is made after evaluating the patient's systemic condition and the following factors: (1) extent of debridement, (2) bacterial load, (3) fracture type, (4) anatomical location of the wound, and (5) presence of exposed vital structures. When conditions are ideal, emergency free tissue transfer may be the best choice for closure of acute, contaminated, upper extremity wounds.