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Summary: The medial femoral condyle flap is well-described for reconstruction of small bone defects of the upper and lower extremities. There are limited case reports of its use in other anatomic sites, particularly for reconstruction of complex head and neck defects. In the setting of previous radiation and contaminated fields, vascularized bone is generally preferred to bone grafts, cadaveric allografts, or synthetic implants. The authors present a case series of complex craniofacial defects involving the midface that were reconstructed using medial femoral condyle flaps, focusing on the type of defect and lessons learned from their early experience to promote awareness of this flap among microsurgeons, who may wish to consider the potential of this flap and incorporate its use into their armamentarium., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses., Summary: Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction., Competing Interests: Disclosure:The author has no commercial associations or financial disclosures that might pose or create a conflict of interest with information presented in this article. No funding was received for the work presented in this article., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: The axillary-approach pedicled descending branch latissimus dorsi (LD) mini-flap presents clear benefits in repairing partial mastectomy defects. This study assessed the functional and esthetic outcomes of this flap compared with conventional breast-conserving surgery (BCS)., Methods: From October of 2015 to March of 2017, patients with early breast cancer were enrolled and assigned to the LD group or conventional BCS (CCS) group according to the need of using the pedicled descending branch LD mini-flap for volume replacement. Muscle strength and range of motion (ROMs) of bilateral shoulders, a disabilities of the arm, shoulder and hand (DASH) questionnaire, and an esthetic evaluation were conducted in all patients at 1 year after surgery., Results: Thirty-two patients were assigned in the LD group, and 28 in the CCS group. There was no significant difference in muscle strength, ROMs of the shoulder or DASH scores between LD and CCS groups. The results of esthetic survey also revealed a similarly high level of esthetics in both groups. Donor-site seroma occurred in three patients in the LD group, and no other complication was observed., Conclusions: The pedicled descending branch LD mini-flap enabled larger excision with favorable esthetics, minimal functional impairment, low rate of complications, and high level of satisfaction., (© 2019 Wiley Periodicals, Inc.)

Insufficient neovascularization is associated with high levels of resorption and necrosis in autologous and engineered fat grafts. We tested the hypothesis that incorporating angiogenic growth factor into a scaffold-stem cell construct and implanting this construct around a vascular pedicle improves neovascularization and adipogenesis for engineering soft tissue flaps. Poly(lactic-co-glycolic-acid/polyethylene glycol (PLGA/PEG) microspheres containing vascular endothelial growth factor (VEGF) were impregnated into collagen-chitosan scaffolds seeded with human adipose-derived stem cells (hASCs). This setup was analyzed in vitro and then implanted into isolated chambers around a discrete vascular pedicle in nude rats. Engineered tissue samples within the chambers were harvested and analyzed for differences in vascularization and adipose tissue growth. In vitro testing showed that the collagen-chitosan scaffold provided a supportive environment for hASC integration and proliferation. PLGA/PEG microspheres with slow-release VEGF had no negative effect on cell survival in collagen-chitosan scaffolds. In vivo, the system resulted in a statistically significant increase in neovascularization that in turn led to a significant increase in adipose tissue persistence after 8 weeks versus control constructs. These data indicate that our model-hASCs integrated with a collagen-chitosan scaffold incorporated with VEGF-containing PLGA/PEG microspheres supported by a predominant vascular vessel inside a chamber-provides a promising, clinically translatable platform for engineering vascularized soft tissue flap. The engineered adipose tissue with a vascular pedicle could conceivably be transferred as a vascularized soft tissue pedicle flap or free flap to a recipient site for the repair of soft-tissue defects., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: Lesions involving both the trachea and the esophagus are often considered inoperable because of the lack of reliable reconstruction. The purpose of this study was to review our experience of combined supercharged jejunal and other flaps for tracheal and esophageal reconstruction., Methods: A retrospective review of 5 consecutive cases with combined tracheal and total esophageal defects was performed. The esophageal defect was reconstructed with a supercharged jejunal flap, and the trachea was reconstructed with a free anterolateral thigh flap or a pedicled muscle flap., Results: Primary diagnosis included tracheostoma recurrence after a total laryngectomy for laryngeal cancer in 2 patients and tracheoesophageal fistula due to esophageal stenting for complications from prior treatment for non-Hodgkin's lymphoma, parathyroid cancer, and esophageal cancer in 3 patients, respectively. Tracheal and esophageal reconstructions were staged in 4 patients, and 1 patient received simultaneous reconstruction. Tracheal necrosis developed in 1 patient with a mediastinal tracheostoma, and the patient eventually died of infection 2 months later. The other 4 patients recovered well and resumed an oral diet., Conclusions: Complex and often life-threatening lesions involving both the trachea and the esophagus are not necessarily inoperable. With careful planning, these combined defects can be safely reconstructed with multiple flaps with good functional outcomes and reasonable survival., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Lymphedema is a common, progressive, and often debilitating condition that can occur after breast cancer treatment. Preliminary reports on vascularized lymph node transfer (VLNT) have been promising. We propose an algorithmic approach to simultaneous VLNT with microvascular breast reconstruction (MBR) and provide early results., Methods: All patients who underwent simultaneous VLNT with MBR were included. Postoperative evaluation was performed at standardized time points and included qualitative assessment and quantitative volumetric analysis., Results: Between 2011 and 2013, 29 consecutive patients with refractory lymphedema secondary to breast cancer treatment underwent simultaneous VLNT with MBR. Mean follow-up was 11 months. On average, patients had experienced 3.3 years of lymphedema symptoms with 21 % increased volume in the affected arm compared with the unaffected arm. Using our algorithmic approach, all patients underwent successful breast reconstruction. There were no flap losses, and no patients developed donor site lymphedema. Six patients (21 %) experienced donor site wound complications that resolved with conservative measures; 23 patients (79 %) reported sustained symptomatic improvement after reconstruction. The mean volume differential volumes improved to 20, 19, 14, and 10 % at 1, 3, 6, and 12 months after reconstruction, respectively., Conclusions: Our algorithm provides a reliable approach to optimizing simultaneous abdominal free flap breast reconstruction and VLNT and demonstrates promising results. Long-term studies are warranted to further delineate and improve the safety and efficacy of lymph node transfers.

Introduction: Reconstruction of anterior ear defects is poorly described, but using "like" tissue provides the optimal reconstruction. We present a cadaveric dissection and our experience with the pedicled superficial temporal artery perforator (STAP) flap for reconstruction of partial ear defects., Materials and Methods: Two cadavers were dissected bilaterally (n = 4) following injection of latex and barium sulfate. A retrospective review of 20 consecutive patients undergoing reconstruction with the STAP flap from 2009 to 2012 was performed. Twenty patients underwent reconstruction of anterior ear defects following resection for non-melanoma skin malignancies using a tunneled pedicled STAP flap (scapha: 5, triangular fossa: 2, scapha and triangular fossa: 13)., Results: Two perforators were identified in all dissections with one perforator at the level of the tragus, and the second perforator within 1 cm cephalad to the tragus. Thirteen patients underwent reconstruction following basal cell carcinoma excision and seven patients were reconstructed following excision of squamous cell carcinoma. There were no flap losses, but four flaps (20%) developed congestion at the tip of the flap that resolved without need for flap delay, leeching, or vasodilators. No patients developed complications with the donor site, and no patients underwent revisions. With a mean follow-up of 27.3 months (range: 19-38 months), all patients were pleased with their aesthetic outcomes and alive without recurrent disease., Conclusion: The STAP flap is a pedicled perforator flap providing local "like" tissue that can be utilized for resurfacing of defects involving the anterior upper external ear with minimal donor site morbidity., (© 2014 Wiley Periodicals, Inc.)

The abdominal wall is perfused anteriorly by the superior and deep epigastric vessels with a smaller contribution from the superficial system. The lateral abdominal wall is perfused predominantly from perforators arising from the intercostal vessels. Reconstruction of soft tissue defects involving the abdomen presents a difficult challenge for reconstructive surgeons. Pedicle perforator propeller flaps can be used to reconstruct defects of the abdomen, and here we present a thorough review of the literature as well as a case illustrating the perforasome propeller flap concept. A patient underwent resection for dermatofibrosarcoma protuberans resulting in a large defect of the epigastric soft tissue. A propeller flap was designed based on a perforator arising from the superior deep epigastric vessels and was rotated 90° into the defect allowing primary closure of the donor site. The patient healed uneventfully and was without recurrent disease 37 months following reconstruction. Perforator propeller flaps can be used successfully in reconstruction of abdominal defects and should be incorporated into the armamentarium of reconstructive microsurgeons already facile with perforator dissections., (© 2014 Wiley Periodicals, Inc.)

Purpose: Tumors that recur following orbital exenteration may not be evident on clinical examination, highlighting the need for imaging surveillance. The goal of this study was to report the imaging characteristics of recurrent tumors following orbital exenteration and free flap reconstruction., Methods: The authors retrospectively reviewed the records of 48 patients who underwent orbital exenteration for the treatment of orbital malignancy and identified 17 recurrent tumors in 17 patients. The lesions were assessed for the presence of a soft tissue mass, imaging characteristics, and fluorodeoxyglucose avidity., Results: The recurrent tumors were detected 1 month to 6 years 10 months (median, 1 year 3 month) after orbital exenteration. On both CT and MRI, all 17 lesions were soft tissue masses at presentation. On CT, the lesions demonstrated heterogeneous to homogeneous to centrally necrotic enhancement; on MRI, the lesions were T1 hypointense to isointense and T2 hypointense to hyperintense. Twelve of the 15 recurrent tumors with available preoperative imaging had an enhancing appearance similar to that of the original tumor. Thirteen of the 17 recurrent tumors were at the margin of a flap placed for reconstruction; the other 4 lesions were remote from the operative site., Conclusion: Recurrent tumors following orbital exenteration and free flap reconstruction demonstrate a wide range of imaging appearances but most often appear as a soft tissue masses often similar in appearance to the primary tumor and arising near the flap margin. Awareness of the imaging features of recurrent disease is important because failure to diagnose recurrence can delay appropriate treatment.

Background: Transit-time flow volume measurement, a non-Doppler-based ultrasound technology, has been shown to accurately evaluate the quality of coronary artery bypass grafts and improve outcomes of cardiac surgery. The authors hypothesized that it would also improve decision making in microvascular free tissue transfer procedures., Methods: The authors measured transit-time flow volume in 52 consecutive free flaps at three times: measurement 1 (in situ), after flap elevation and isolation on its pedicle; measurement 2 (time 1), immediately after anastomosis and reperfusion; and measurement 3 (time 2), 30 minutes after anastomosis and reperfusion. Intraoperative decisions based on transit-time flow volume were documented., Results: Arterial inflow was on average 1.5 times greater than venous outflow, and arterial resistance was 3.59 times greater than venous resistance. Free transverse rectus abdominis musculocutaneous flaps had the highest venous and arterial flows, and free radial forearm flaps had the lowest. Compared with the baseline (in situ) measurement, all flaps had higher flows immediately after transfer (time 1) (p < 0.0001), but no significant differences were seen 30 minutes later (time 2) (p = 0.68). Arterial resistance, however, increased during that interval (p = 0.006). Operative decisions, including selection of the higher flow vena comitans (sometimes the smaller of the two) and when to revise an anastomosis, were modified on the basis of volume findings in 19 of 52 cases (36.5 percent)., Conclusions: Transit-time flow volume provides novel physiologic flap data and identifies flawed anastomoses and higher flow venae comitantes. These data have clinical value in microsurgery and might reduce microvascular complications and improve outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCDE: Diagnostic, IV.

Background: While a large body of literature exists involving normative measurements for the craniofacial skeleton, few have analyzed the necessary dimensions that are pertinent in reconstruction using microvascular free flaps., Methods: Cephalometric analysis was performed using 3-dimensional CT scans from 70 adults. Relevant dimensions of the fibula were obtained from a subset of 20 patients., Results: Normative cephalometric values, including various distances and angles, for the mandible and maxilla were obtained and compared to the dimensions of the fibula. Comparisons were made between measurements from men and women, and patients with full dentition and edentulous patients. Schematics for designing mandibular and maxillary reconstructions are presented., Conclusion: When premorbid craniofacial anatomy cannot be discerned in the setting of extensive trauma or tumor involvement, normative dimensions may be a helpful guide for flap design and should be in the armamentarium of surgeons engaged in complex head and heck reconstruction., (Copyright © 2012 Wiley Periodicals, Inc.)

Background: Oncologic defects resulting from extremity amputations are often extensive and require substantial soft tissue for reconstruction., Methods: A review of all patients, who underwent an external hemipelvectomy, forequarter amputation, or hindquarter amputation from 2001 to 2010 at the MD Anderson Cancer Center, was performed., Results: A total of 50 patients were identified; of them, 21 underwent external hemipelvectomy, 22 had forequarter amputation, and 7 had hindquarter amputation. The mean defect size was 644 cm; defects were repaired using fillet flaps (n = 22, 44%), free flaps (n = 4, 8%), or local/regional flaps (n = 24, 48%). Of the fillet flaps, 16 were free flaps and the remaining were pedicled flaps. In all, 29 patients (58%) received preoperative radiation therapy, and 26 patients (52%) received preoperative chemotherapy. Two patients (4%) received postoperative radiation therapy, and 1 patient (2%) received postoperative chemotherapy. Three patients received both pre- and postoperative radiation therapy, and 10 patients were treated with both pre- and postoperative chemotherapy. Patients undergoing free flap reconstruction had significantly fewer complications compared with patients reconstructed using other modalities (2/20 vs. 13/30; P = 0.003). The majority of patients achieved excellent postoperative function, with 73% of upper extremity patients functioning independently and 57% of lower extremity amputees ambulating., Conclusions: Reconstruction for extensive defects following oncologic extremity amputation is often optimally done using free tissue transfer, particularly by salvaging "spare parts" from the amputated limb for a free fillet flap.

Background: Flaps based on the ulnar artery have never gained the same popularity as the radial forearm flap, despite several potential advantages. In this article, the authors describe a true ulnar artery perforator flap with perforator mapping., Methods: Thirty-eight consecutive patients who underwent ulnar artery perforator flap surgery were included in the study. The size, number, and location of perforators were recorded intraoperatively. Preoperative and postoperative grip strength was tested and compared., Results: One to three cutaneous perforators from the ulnar artery were identified and designated as A, B, and C from distal to proximal. Perforator A was present in 79 percent of cases and located 7.3 ± 1.1 cm from the pisiform. Perforator B was present in 95 percent of cases and located 11.4 ± 1.0 cm from the pisiform. Perforator C was present in 87 percent of cases and located 15.9 ± 1.8 cm from the pisiform. All patients had at least two perforators, and 61 percent had three perforators. All flaps were used for head and neck reconstruction and all were successful. Donor-site morbidity was minor. Grip testing demonstrated a transient decrease in grip strength during the postoperative period, and most recovered to the contralateral level by 3 months., Conclusions: At least two perforators are present in the ulnar artery perforator flap territory. This flap is reliable and easy to harvest and has minimal donor-site morbidity. It should be considered as an alternative to the radial forearm flap in select patients.

Background: Chronic wounds, particularly in diabetics, result in significant morbidity and mortality and have a profound economic impact. The authors demonstrate that pulsed electromagnetic fields significantly improve both diabetic and normal wound healing in 66 mice through up-regulation of fibroblast growth factor (FGF)-2 and are able to prevent tissue necrosis in diabetic tissue after an ischemic insult., Methods: Db/db and C57BL6 mice were wounded and exposed to pulsed electromagnetic fields. Gross closure, cell proliferation, and vascularity were assessed. Cultured medium from human umbilical vein endothelial cells exposed to pulsed electromagnetic fields was analyzed for FGF-2 and applied topically to wounds. Skin flaps were created on streptozocin-induced diabetic mice and exposed to pulsed electromagnetic fields. Percentage necrosis, oxygen tension, and vascularity were determined., Results: Pulsed electromagnetic fields accelerated wound closure in diabetic and normal mice. Cell proliferation and CD31 density were significantly increased in pulsed electromagnetic field-treated groups. Cultured medium from human umbilical vein endothelial cells in pulsed electromagnetic fields exhibited a three-fold increase in FGF-2, which facilitated healing when applied to wounds. Skin on diabetic mice exposed to pulsed electromagnetic fields did not exhibit tissue necrosis and demonstrated oxygen tensions and vascularity comparable to those in normal animals., Conclusions: This study demonstrates that pulsed electromagnetic fields are able to accelerate wound healing under diabetic and normal conditions by up-regulation of FGF-2-mediated angiogenesis. They also prevented tissue necrosis in response to a standardized ischemic insult, suggesting that noninvasive angiogenic stimulation by pulsed electromagnetic fields may be useful to prevent ulcer formation, necrosis, and amputation in diabetic patients.

Patients undergoing treatment for breast cancer who undergo an axillary dissection and require adjuvant therapies such as radiation and chemotherapy are at high risk of developing lymphedema of the associated extremity. Historically, patients with lymphedema were treated with ablative procedures aimed simply to remove excess fluid and adiposity; however, the field of lymphatic surgery employing super-microsurgery techniques has witnessed tremendous advances in a relatively short period of time. Advancements in surgical instruments, microscope magnification and optics, imaging technology, and surgeon experience have ushered in a new era of hope to treat patients suffering from breast cancer–related lymphedema (BCRL). Here we aim to present the available options for patients suffering from BCRL, and the pinnacle in reconstruction and restoration for these patients. [ABSTRACT FROM AUTHOR]

Using a perfusion decellularization protocol, we developed a decellularized skin/adipose tissue flap (DSAF) comprising extracellular matrix (ECM) and intact vasculature. Our DSAF had a dominant vascular pedicle, microcirculatory vascularity, and a sensory nerve network and retained three-dimensional (3D) nanofibrous structures well. DSAF, which was composed of collagen and laminin with well-preserved growth factors (e.g., vascular endothelial growth factor, basic fibroblast growth factor), was successfully repopulated with human adipose-derived stem cells (hASCs) and human umbilical vein endothelial cells (HUVECs), which integrated with DSAF and formed 3D aggregates and vessel-like structures in vitro . We used microsurgery techniques to re-anastomose the recellularized DSAF into nude rats. In vivo , the engineered flap construct underwent neovascularization and constructive remodeling, which was characterized by the predominant infiltration of M2 macrophages and significant adipose tissue formation at 3 months postoperatively. Our results indicate that DSAF co-cultured with hASCs and HUVECs is a promising platform for vascularized soft tissue flap engineering. This platform is not limited by the flap size, as the entire construct can be immediately perfused by the recellularized vascular network following simple re-integration into the host using conventional microsurgical techniques. Statement of Significance Significant soft tissue loss resulting from traumatic injury or tumor resection often requires surgical reconstruction using autologous soft tissue flaps. However, the limited availability of qualitative autologous flaps as well as the donor site morbidity significantly limits this approach. Engineered soft tissue flap grafts may offer a clinically relevant alternative to the autologous flap tissue. In this study, we engineered vascularized soft tissue free flap by using skin/adipose flap extracellular matrix scaffold (DSAF) in combination with multiple types of human cells. Following vascular reanastomosis in the recipient site, the engineered products successful regenerated large-scale fat tissue in vivo . This approach may provide a translatable platform for composite soft tissue free flap engineering for microsurgical reconstruction. [ABSTRACT FROM AUTHOR]

Background Pharyngoesophageal (PE) reconstruction is complex, with a diverse set of reconstructive considerations. This large series examines the impact of various defect characteristics and reconstructive modalities on outcomes. Patients andMethods A retrospective review identified 349 cases from2000 to 2011. Patients were grouped according to defect extent and location. Groups were compared by comorbidities, flap type, donor and recipient site complications, postoperative diet, and tracheoesophageal speech. Results Of 349 cases, 193 (55.3%) PE defects were circumferential and 156 (44.7%) were partial. The majority of defects resulted from laryngopharyngectomy (72.5%), most reconstructed with the anterolateral thigh flap (60%). There were 15.5% total esophagectomies, all of which received supercharged jejunal flaps. Of 349 patients, 81 patients (23.2%) had recipient site complications and 51 patients (14.6%) had donor site complications. The fistula rate trended higher in circumferential defects (11 vs. 6%, p = 0.144), and the stricture rate was significantly higher (9.3 vs. 3.8%, p = 0.044). In total, 302 patients (86.5%) had an oral diet after reconstruction, 64 (18%) of whom required supplemental tube feeds. Among 147 patients (42%) who received tracheoesophageal puncture (TEP), 19 (12.9%) eventually failed. Approximately 87% of patients with TEPs achieved fluent speech. The 5-year survival was low for all groups, ranging from 0 to 35%. Conclusions PE reconstruction can be performed safely, and most patients will achieve functional speech and swallowing. Swallowing function is worse when the larynx is removed, and the stricture rate is higher with circumferential defects. Specific technical measures can reduce the rate of common complications. Level of Evidence The level of evidence of this article was level III. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although obesity has previously been associated with poor outcomes after mastectomy and breast reconstruction, its impact across the WHO obesity classification spectrum and the differential effects of various optimization strategies on patient outcomes have yet to be delineated. We sought to examine the impact of WHO obesity classification on intraoperative surgical and medical complications, postoperative surgical and patient-reported outcomes of mastectomy and autologous breast reconstruction, and delineate outcomes optimization strategies for obese patients. STUDY DESIGN: This is a review of consecutive patients who underwent mastectomy and autologous breast reconstruction from 2016 to 2022. Primary outcomes were complication rates. Secondary outcomes were patient-reported outcomes and optimal management strategies. RESULTS: We identified 1,640 mastectomies and reconstructions in 1,240 patients with mean follow-up of 24.2 ± 19.2 months. Patients with class II/III obesity had higher adjusted risk of wound dehiscence (odds ratio [OR] 3.20; p < 0.001), skin flap necrosis (OR 2.60; p < 0.001), deep venous thrombosis (OR 3.90; p < 0.033), and pulmonary embolism (OR 15.3; p = 0.001) than nonobese patients. Obese patients demonstrated significantly lower satisfaction with breasts (67.3 ± 27.7 vs 73.7 ± 24.0; p = 0.043) and psychological well-being (72.4 ± 27.0 vs 82.0 ± 20.8; p = 0.001) than nonobese patients. Unilateral delayed reconstructions were associated with independently shorter hospital stay (β -0.65; p = 0.002) and lower adjusted risk of 30-day readmission (OR 0.45; p = 0.031), skin flap necrosis (OR 0.14; p = 0.031), and pulmonary embolism (OR 0.07; p = 0.021). CONCLUSIONS: Obese women should be closely monitored for adverse events and lower quality of life, offered measures to optimize thromboembolic prophylaxis, and advised on the risks and benefits of unilateral delayed reconstruction. [ABSTRACT FROM AUTHOR]