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Background: Medial arterial calcification (MAC), a distinct form of vascular pathology frequently coexisting with peripheral arterial disease (PAD), poses unique challenges in limb salvage among patients with diabetes, chronic kidney disease, and end-stage renal disease. This study examines the incidence of MAC and its impact on limb salvage outcomes over a decade of experience at a tertiary limb salvage center. Methods: A retrospective review of all complex lower extremity (LE) reconstructions using local flap (LF) or free tissue transfer (FTT), performed from July 2011 to September 2022, was conducted. Patients were classified into MAC and No MAC groups based on pedal radiography evaluations using the Ferraresi MAC scoring system. The primary outcomes were major lower extremity amputation (MLEA), the need for postoperative vascular intervention, major adverse limb events (MALE; defined as the composite of any unplanned reoperation, MLEA, or postoperative revascularization attempt), and mortality. Results: During the study period, a total of 430 LE reconstructions were performed with LF or FTT. A total of 323 cases (75.1%) demonstrated no MAC while the remaining 107 (24.9%) demonstrated MAC. The MAC group exhibited significantly higher rates of diabetes, PAD, and renal disease. With a follow-up duration of 17.0 (IQR: 33.9) months, the MAC group demonstrated a significantly higher rate of MLEA (24.3% vs. 13.0%, p = 0.006), postoperative vascular intervention (23.4% vs. 8.7%, p < 0.001), MALE (57.0% vs. 25.7%, p < 0.001), and mortality (28.0% vs. 9.9%, p < 0.001). Multivariate analysis identified MAC as independently predictive of MALE (OR: 1.8, CI: 1.1–3.0, p = 0.033). Conclusion: MAC is prevalent among surgical candidates for limb salvage. Patients with MAC represent a significant medical and reconstructive challenge. Radiographic screening for MAC should be considered in all limb salvage candidates with LE wounds, especially in those with diabetes and kidney disease. Assessing MAC is important for better evaluating risk factors and surgical options so as to optimize outcomes in this challenging population. [ABSTRACT FROM AUTHOR]

Background: Non-healing soft tissue defects pose challenges to treating physicians. Microsurgical reconstruction is a treatment option for achieving wound closure and limb salvage. These free tissue transfers are often challenging due to associated risk factors. This study aimed to evaluate microsurgical reconstruction using specialized microsurgical techniques for non-healing spontaneous or post-traumatic soft tissue defects in an elderly, high-risk patient cohort with peripheral artery disease. Methods: A retrospective study was conducted on patients with radiologically confirmed peripheral artery disease who underwent free tissue transfers between 2004 and 2010. Patients were included in whom one of two surgical techniques was used, including a "Y" configuration of the arterial pedicle, employed either as an interposition graft or as an arterial patch, or the use of a saphenous vein graft. Patient demographics, comorbidities, flap/limb survival, and surgical techniques were analyzed. Results: Twenty patients at a mean age of 68 (+/−9.3) years underwent 21 primary flap surgeries. Trauma-derived soft tissue defects were predominant (55%). Latissimus dorsi muscle flaps were most frequently utilized (52.4%). The flap success rate was 90.5% at a 12-month follow-up, with no secondary amputations recorded. The lost flaps were replaced by additional free tissue transfers without further complications. Conclusions: This study demonstrates the feasibility of free tissue transfers in high-risk patients with complex soft tissue defects and vascular calcifications. Thorough preoperative planning and the application of specialized surgical techniques are crucial for favorable outcomes in challenging clinical scenarios. [ABSTRACT FROM AUTHOR]

Background Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction. Methods A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann–Whitney tests were used for statistical analysis. Results Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8–13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0–3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733). Conclusion Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the effect of functional status and patient factors on delays in treatment with adjuvant therapy. Methods: Retrospective chart review (2020–2022) was conducted at a single tertiary referral center. Data were collected between January 2020 and October 2022, and 63 patients underwent free flap reconstructive surgery of the head and neck due to the presence of cancer and received adjuvant radiation therapy (RT). The main outcomes measured were Area Deprivation Index (ADI), Beale scores, distance to radiation center, functional status, patient demographics, gender, and length from surgery to initiation of RT. Results: Of the 63 patients who were reviewed, the average age was 65.5 years old and 63.8% were male. The average ADI state score was 5.6 and the national percentile of 77.1. The average Beale score was 3.7. The average distance traveled was 101.1 miles. Thirty‐five patients were living independently, 16 were living in assisted living or received home care, and 15 were dependent or lived in a nursing home. Mann–Whitney U analysis revealed a significant association of increasing levels of dependence to delays in treatment compared to on‐time treatment (p = 0.002). The odds of treatment delay were increased almost 10‐fold for every additional increase in dependency level (OR = 9.87, 95% CI = 1.42–68.83). Conclusions and Relevance: Degree of dependent functional status correlates with delays in postoperative adjuvant RT in patients undergoing free tissue transfer for head and neck cancer. Preoperative risk stratification allows for physicians to address barriers to adjuvant therapy prior to delay. Level of Evidence: 3 Laryngoscope, 134:4979–4984, 2024 [ABSTRACT FROM AUTHOR]

Microsurgical free tissue transfer is the gold standard for reconstructing major bone or soft tissue defects but requires complex training, and specific resources. Therefore, some authors have stated that microsurgery is impossible in low- and middle-income countries. Patients from Khmer underwent free flap surgery at the Children's Surgical Centre in Phnom Penh between 2004 and 2023. Two non-governmental organizations facilitated the program: Rose Charities Cambodia provided the facilities, patients and local staff, and Doctors of the World provided the surgeons, and anesthetists. At least one Khmer surgeon was trained during these operations. Digital data were collected retrospectively, and analyzed in June 2023. Fifty-six free flaps in 54 patients have been performed since 2004. The most frequent sites requiring reconstruction were the head and neck (35.7%), lower limbs (30.4%), and upper limbs (21.4%). The most frequent free flaps were free fibula (44.6%), gracilis (19.6%), and anterolateral thigh (16.1%). Among the 56 flaps, 41 (= 73.2%) were viable long-term and 15 (26.7%) were microsurgical failures. Sixteen flaps underwent revision in the operating room. Twenty-three flap-related complications were reported in 21 patients with mostly vascular thrombosis (n = 12), hematoma (n = 3) and infections (3). However, 83.3% had improved or were cured of their initial pathology after final surgical management. Free flaps performed in our series as part of international surgical collaborations in a low-income country are feasible, but we experienced higher failure rates, and later revisions compared to the results in high-income countries. We identified several solutions to improve the microsurgery outcomes in low-income settings. [ABSTRACT FROM AUTHOR]

Objective: Recent literature studying the impact of blood transfusion on outcomes in patients with head and neck cancer (HNC) have shown that blood transfusions are associated with increased risk of death and higher wound infection rates. The purpose of this study was to implement a lower transfusion threshold while comparing outcomes of free flap patients following initiation of a new transfusion guideline. Methods: A retrospective study of all patients at a tertiary care academic center who underwent free tissue transfer after HNC resection between July 17, 2007 and June 7, 2021. Transfusion criteria were adjusted in 2014; the hematocrit threshold to transfuse was incrementally reduced from 30% in 2007 to 21% in 2017. The main outcomes of interest were overall survival (OS) and recurrence free survival (RFS). Results: A total of 346 patients met the criteria for inclusion in the study. Groups 1 (less strict protocol – 30%) and 2 (stricter protocol – 21%) consisted of 171 and 175 patients, respectively. Fewer units of packed red cells were transfused per patient in group 2 (0.26 vs. 2.87 in group 1, p <.001). Group 1 was associated with worse OS (p =.01; hazard ratio [HR] = 1.7) and RFS (p <.001; HR = 2.5). Comparing only patients with SCC between the two groups also demonstrated poorer OS (p =.01; HR = 1.8) and RFS (p =.006; HR = 2.1) in group 1. Conclusion: In HNC patients undergoing free tissue transfer, stricter transfusion criteria with threshold hematocrit of 21% was associated with improved OS, RFS, and complication rates with no negative impact on free flap survival. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

Background Blood transfusions have been associated with surgical complications; however, these studies are not specific to lower extremity (LE) reconstruction. We evaluated the effect of perioperative packed red blood cell (PRBC) transfusions on LE free flap outcomes in trauma patients. Methods Patients undergoing LE free flap reconstruction following acute injuries from 2016 to 2021 were retrospectively analyzed. The perioperative period for transfusions was defined as ± 3 days from the procedure. Parameters included demographics, perioperative characteristics, and outcomes. Major complications were complications requiring reoperation. Univariate and multivariate analyses were performed to identify associations. Results Of the 205 patients, 48% received PRBCs perioperatively. There was a trend toward higher major complications rate in the transfusion group (19 vs. 10%, p = 0.09). Wound size, injury severity score (ISS), and intraoperative estimated blood loss were greater in the transfusion group (p < 0.01). Preoperative hemoglobin/hematocrit were lower in the transfusion group (p < 0.001). Units of PRBCs transfused were independently associated with major complications on multivariate analysis (odds ratio [OR] = 1.34, confidence interval [CI]: 1.06–1.70, p = 0.015) and length of hospital stay (LOS; OR = 1.05, CI: 1.02–1.08, p = 0.002). Infection, wound size, ISS, and preoperative hemoglobin/hematocrit were independently associated with increased LOS (p < 0.05) but not with major complications. Conclusion The number of units of PRBCs given perioperatively was the only variable independently associated with major complications on multivariate analysis and was one of many variables associated with increased LOS. These findings suggest the usage of restrictive transfusion protocols in trauma patients requiring LE reconstruction. [ABSTRACT FROM AUTHOR]

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n = 5397) were included in the qualitative analysis and nine (n = 4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n = 4015, OR = 0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n = 3881, OR = 0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

Background Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO. Methods Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status. Results A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups. Conclusion This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes. [ABSTRACT FROM AUTHOR]

Background: Arterial anastomoses are still most commonly performed using orthodox hand sewing technique. Various rationale such as non-pliable, atherosclerotic, thick-walled or irradiated vessels limit the competency of coupler devices for arterial micro-anastomosis. Microvascular coupling devices (MCD) are well known for venous anastomoses but arterial MCD have relatively been less navigated in reported literatures. This review outlines the current applications, troubleshooting, safety and efficiency of arterial MCD in free flaps. Methods: Comprehensive search of electronic databases (PUBMED/MEDLINE) in accordance with PRISMA guideline was performed. Data were extracted and collected in four groups of standardised variables. Results: Out of a total of 263 identified articles, 38 studies were analysed and 16 amidst these were included in final data synthesis. Included studies contained a combined total of 2416 patients who went through 521 arterial and 2460 venous anastomoses using 3 M/Synovis coupling devices. Among all coupled arterial anastomoses, 407 were conducted in head and neck free tissue transfer and 114 were performed in breast reconstruction. The aggregate coupled arterial micro-anastomosis success rate reported was 90.01 % (469/521). Only 9.98 % (52 out of 521) manifested pooled incidence of troubleshooting, thrombosis or flap failure. Conclusion: Microsurgeons are resisting the frequent use of arterial coupling devices owing to inherent arterial characteristics, but with suitable vessel selection, arterial coupling may be a powerful tool and can be executed in safe, expeditious and reliable fashion. This study embellishes collaborative suggestions and troubleshooting issues related to arterial coupling, however further assessment would be required with controlled trials.

Background In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps. Methods Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status. Results Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973). Conclusion This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals. [ABSTRACT FROM AUTHOR]

Background: The use of free tissue transfer (FTT) is efficacious for chronic, non-healing lower extremity (LE) wounds. The four pillars of managing patient comorbidities, infection control, blood flow status, and biomechanical function are critical in achieving successful limb salvage. The authors present their multidisciplinary institutional experience with a review of 300 FTTs performed for the complex LE limb salvage of chronic LE wounds. Methods: A single-institution, retrospective review of atraumatic LE FTTs performed by a single surgeon from July 2011 to January 2023 was reviewed. Data on patient demographics, comorbidities, preoperative management, intraoperative details, flap outcomes, postoperative complications, and long-term outcomes were collected. Results: A total of 300 patients who underwent LE FTT were included in our retrospective review. Patients were on average 55.9 ± 13.6 years old with a median Charlson Comorbidity Index of 4 (IQR: 3). The majority of patients were male (70.7%). The overall hospital length of stay (LOS) was 27 days (IQR: 16), with a postoperative LOS of 14 days (IQR: 9.5). The most prevalent comorbidities were diabetes (54.7%), followed by peripheral vascular disease (PVD: 35%) and chronic kidney disease (CKD: 15.7%). The average operative LE FTT time was 416 ± 115 min. The majority of flaps were anterolateral thigh (ALT) flaps (52.7%), followed by vastus lateralis (VL) flaps (25.3%). The immediate flap success rate was 96.3%. The postoperative ipsilateral amputation rate was 12.7%. Conclusions: Successful limb salvage is possible in a highly comorbid patient population with a high prevalence of diabetes mellitus, peripheral vascular disease, and end-stage renal disease. In order to optimize patients prior to their LE FTT, extensive laboratory, arterial, and venous preoperative testing and diabetes management are needed preoperatively. Postoperative monitoring and long-term follow-up with a multidisciplinary team are also crucial for long-term limb salvage success. [ABSTRACT FROM AUTHOR]

Lower extremity reconstruction is challenging because of its intricate anatomy and dynamic biomechanics. Although microsurgical free tissue transfer offers pivotal solutions to limited local tissue availability, vascular pedicle exposure after free tissue transfer is common. We evaluated a novel method of managing pedicle exposure after free tissue transfer using a reprocessed micronized dermal substitute. Ten patients who underwent lower-extremity reconstruction using free tissue transfer and micronized dermal substitute between January and December 2023 were retrospectively reviewed. When native tissue could not be closed over the pedicle, reprocessed micronized artificial dermal matrix (rmADM) was cut and stacked to protect and stabilize it. Epithelialization was achieved by secondary skin grafting or healing by secondary intention. Flap dimensions, recipient artery and vein, ADM size, time required for granulation tissue maturation and complete epithelialization, and flap outcomes were analyzed. The mean age was 55.80 ± 20.70 years, and six patients (60%) were diabetic. The mean rmADM coverage area was 8.70 ± 8.41 cm2, and the average time required for complete epithelialization was 50.89 ± 14.21 days. Except for one total necrosis due to bypass graft failure, nine limbs were successfully salvaged. Application of rmADM offers numerous advantages, including vascular collapse prevention, moisture maintenance, granulation tissue growth promotion, and pedicle stabilization. [ABSTRACT FROM AUTHOR]

Arterial anastomoses are still most commonly performed using orthodox hand sewing technique. Various rationale such as non-pliable, atherosclerotic, thick-walled or irradiated vessels limit the competency of coupler devices for arterial micro-anastomosis. Microvascular coupling devices (MCD) are well known for venous anastomoses but arterial MCD have relatively been less navigated in reported literatures. This review outlines the current applications, troubleshooting, safety and efficiency of arterial MCD in free flaps. Comprehensive search of electronic databases (PUBMED/MEDLINE) in accordance with PRISMA guideline was performed. Data were extracted and collected in four groups of standardised variables. Out of a total of 263 identified articles, 38 studies were analysed and 16 amidst these were included in final data synthesis. Included studies contained a combined total of 2416 patients who went through 521 arterial and 2460 venous anastomoses using 3 M/Synovis coupling devices. Among all coupled arterial anastomoses, 407 were conducted in head and neck free tissue transfer and 114 were performed in breast reconstruction. The aggregate coupled arterial micro-anastomosis success rate reported was 90.01 % (469/521). Only 9.98 % (52 out of 521) manifested pooled incidence of troubleshooting, thrombosis or flap failure. Microsurgeons are resisting the frequent use of arterial coupling devices owing to inherent arterial characteristics, but with suitable vessel selection, arterial coupling may be a powerful tool and can be executed in safe, expeditious and reliable fashion. This study embellishes collaborative suggestions and troubleshooting issues related to arterial coupling, however further assessment would be required with controlled trials. [ABSTRACT FROM AUTHOR]

Background: Flap monitoring plays an important role in avoiding morbidity in free flap. Clinical monitoring is considered the gold standard, but it is subjective. Digital thermal imaging captures and displays the infrared radiation emitted from an object. This is useful in assessing temperature difference between two surfaces, as well as variation of temperature. Smartphone thermal imaging can be used to assess the tissue perfusion, which requires little training. Materials and Methods: The aim was to assess the validity of Digital Thermal Imaging in early diagnosis of flap failure, compared to conventional clinical methods. Eleven patients of microvascular-free flap reconstruction for defects following malignancy and trauma were included in the study for January 25, 2019–March 25, 2021. Flaps were monitored using three different methods – clinical monitoring, biochemical monitoring, and digital thermal imaging done at the following interval: (1) intraoperative (end of surgery), (2) hourly – for the first 48 h, (3) every 4th hourly on postoperative days 3–5, and (4) every 6th hourly on postoperative days 5–10, and the results were tabulated. Results: Flap temperature was observed to be higher compared to the surrounding skin when there was an event of venous thrombosis. The surrounding skin temperature was to be measured on the side opposite to the side where the flap was raised to do vascular anastomosis. The increase in the temperature difference almost coincided with the clinical and biochemical indicator of failing flaps. Conclusion: Monitoring of the flap temperature and comparing it with the surrounding skin temperature can be incorporated along with the gold standard. It is a simple, objective, and noncontact method compared to clinical monitoring and biochemical methods. A large sample size, multicentric, randomized controlled study is required to validate the same.

Abstract Objectives Review of the current and relevant literature to develop a list of evidence‐based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence 2a.

Objective: To examine if perioperative blood transfusion affects overall survival (OS) and recurrence‐free survival (RFS) in head and neck cancer patients who undergo free tissue reconstruction. Design: Retrospective cohort study. Methods: The medical records of free tissue flaps between 2007 and 2010 were reviewed. Differences in demographics and clinical factors based on the level of transfused packed red blood cells (PRBC) were examined using chi‐squared tests, Kruskal–Wallis tests, and/or ANOVA tests. Survival time was compared using a Cox proportional hazard model. Results: Data were available for 183 patients. Patients who had PRBC transfusion significantly differed from the non‐transfused group by flap type, flap with bone, Charlson Comorbidity Index (CCI), and hemoglobin and hematocrit. When stratified into three groups based on units of PRBC; flap type, flap with bone, CCI, preoperative hemoglobin, and hematocrit were found to differ significantly. The 2‐year Kaplan–Meier plot demonstrated improved OS for those who did not receive any PRBC transfusion. The use of more than 3 units of blood decreased 2‐year OS significantly when compared to the non‐transfused group. Finally, after adjusting for CCI using a Cox proportional hazard model, survival was significantly affected by CCI. Conclusion: After controlling for patient age, oncologic stage, cancer subsite, histology, type of free flap, vascularized bone‐containing flap, recurrence type, CCI, and preoperative hemoglobin and hematocrit, patients who received 3 or more units of PRBC in the perioperative period had significantly decreased OS. RFS did not differ between the transfused versus non‐transfused groups. Level of Evidence: Level 4. [ABSTRACT FROM AUTHOR]

Background Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. Methods A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. Results Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. Conclusion Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements. [ABSTRACT FROM AUTHOR]

Objective: To report the microorganisms and their antibiotic sensitivity profile from tissue cultures and stains at the time of anterolateral thigh fascia lata (ALTFL) rescue flap for management of mandibular osteoradionecrosis (ORN). Methods: Retrospective chart review of patients who underwent ALTFL rescue flap for native mandibular ORN between 2011 and 2022. Results: Twenty‐six cases comprising 24 patients (mean age 65.4 years, 65.4% male) with mandibular ORN from whom tissue cultures and gram stain were obtained at the time of ALTFL rescue flap. 57.7% grew bacterial species, while 34.6% grew fungal species. Multibacterial speciation was noted in 26.9% of cultures. A combination of bacterial and fungal growth was also seen in 15.4% of cases. All gram‐positive cocci (GPC) were pansensitive to antibiotics except for one case of Staphylococcus aureus, which was resistant to levofloxacin. Gram‐negative bacilli (GNB) species were isolated in 50.0% of cases. All fungal growth was due to Candida species. No growth was noted in 23.1% of cases. Multidrug resistance was noted in 53.8% of cases when GNB was isolated. Conclusion: We report 76.9% of our cases of mandibular ORN had microbial growth from tissue cultures obtained at the time of the ALTFL rescue flap. Fungal growth was noted in a substantial number of cases and should be obtained as a specimen when pursuing culture‐driven antibiotic therapy. Most GPCs were pansensitive to antibiotics, while GNBs were often the harbinger of multidrug resistant mandibular ORN. Level of Evidence: 4 Laryngoscope, 134:166–169, 2024 [ABSTRACT FROM AUTHOR]

Background: Flap monitoring plays an important role in avoiding morbidity in free flap. Clinical monitoring is considered the gold standard, but it is subjective. Digital thermal imaging captures and displays the infrared radiation emitted from an object. This is useful in assessing temperature difference between two surfaces, as well as variation of temperature. Smartphone thermal imaging can be used to assess the tissue perfusion, which requires little training. Materials and Methods: The aim was to assess the validity of Digital Thermal Imaging in early diagnosis of flap failure, compared to conventional clinical methods. Eleven patients of microvascular-free flap reconstruction for defects following malignancy and trauma were included in the study for January 25, 2019-March 25, 2021. Flaps were monitored using three different methods - clinical monitoring, biochemical monitoring, and digital thermal imaging done at the following interval: (1) intraoperative (end of surgery), (2) hourly - for the first 48 h, (3) every 4th hourly on postoperative days 3-5, and (4) every 6th hourly on postoperative days 5-10, and the results were tabulated. Results: Flap temperature was observed to be higher compared to the surrounding skin when there was an event of venous thrombosis. The surrounding skin temperature was to be measured on the side opposite to the side where the flap was raised to do vascular anastomosis. The increase in the temperature difference almost coincided with the clinical and biochemical indicator of failing flaps. Conclusion: Monitoring of the flap temperature and comparing it with the surrounding skin temperature can be incorporated along with the gold standard. It is a simple, objective, and noncontact method compared to clinical monitoring and biochemical methods. A large sample size, multicentric, randomized controlled study is required to validate the same. [ABSTRACT FROM AUTHOR]

Background: Today, the surgical approach in the treatment of complex injuries is changing in that complex and intricate procedures, such as microvascular surgery, are no longer kept as a last resort. In Plastic and Reconstructive surgery, microvascular surgery has been described in the treatment of extensive tissue defects using free tissue transfer. This study discusses the incorporation of microvascular training in residency programs, as well as identifying the factors that influence residents' confidence in performing microsurgery without supervision. Methods: This is a cross-sectional study conducted on thirteen current and former Plastic and Reconstructive surgery residents who practiced microsurgery during the past 8 years at the American University of Beirut Medical Center in Lebanon. Results: Nine residents (69.2%) started scrubbing in and became actively involved in microsurgery procedures at the PGY IV level with the majority being exposed to cases every 2–3 weeks (69.2%). Residents were mostly exposed to breast (100%) and orthopedic reconstruction (92.3%), and facial trauma reconstruction was the least practiced (46.2%). Eleven residents (84.6%) reported that music and choice of OR staff assisting in the operation significantly affected their speed and performance. Eleven residents (84.6%) were satisfied with the training program, and ten found the training program beneficial for their career (76.9%). Conclusion: Our findings suggest that residents who had a higher workload and were actively involved in microsurgery early during residency felt more confident in performing the procedure by themselves. The choice of operating staff, playing music, and the presence of different attendings in the operating room were found to affect the speed and performance of residents. Level of evidence: Level V, Risk/Prognostic. [ABSTRACT FROM AUTHOR]

Background: Recent advances in burn care have significantly improved the survival rate of patients with extensive burn injuries, placing greater emphasis on reconstruction to improve the long-term outcomes of scar deformities. Anterior and lateral neck contractures are common after burn injuries; they limit range of motion, complicate airway management and create significant cosmetic deformities. Traditional methods have been used to release contractures and improve function. However, they are subject to variable results, residual neck tightness, recurrence and suboptimal cosmetic appearance. Microvascular free tissue transfer is a more technically challenging and time-consuming method, but it offers the potential to overcome the long-term limitations of simpler options. In this paper, we present our experience with microvascular free flaps for the release of burn scar contractures of the neck as a potential high-quality permanent solution. Methods: Over a 10-year period, nine free flaps were performed on burn patients with total body surface area (TBSA) burns between 20 and 70%, who developed moderate to severe neck contractures. Four anterolateral thigh (ALT) flaps, four radial forearm free flaps (RFFFs) and one ulnar forearm flap were used to release neck contractures. Results: All nine flaps were completed successfully with significant improvement in the neck’s range of motion. Good aesthetic results were achieved with smooth contour and thin coverage. Overall, the patients were satisfied. However, five out of nine cases required at least one secondary procedure for flap defatting to reach optimal results. Conclusion: Post-burn scar contractures of the cervical region compromise the cosmetic appearance and airway security of recovering burn patients, imposing a significant impact on their psychological and functional quality of life. Consequently, cervical contractures can be prioritized when planning reconstruction for burn patients. Free flaps can be considered an important and reliable method of reconstruction for neck contracture deformity following burn injuries.

Background Extensive crush injuries to forearm pose a unique problem where replantation of uninjured hands to the forearm is not immediately possible due to difficulties in delineating tissue necrosis. Ectopic hand implantation preserves the hand and allows replanting the hand back to the forearm stump, but the tissues preserved in the stump could be inadequate to provide good hand function. In these subsets of cases, forearm reconstruction with composite flaps may offer a better chance of getting good hand function.

The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures. Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016–2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha < 0.05. When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic. Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure. [ABSTRACT FROM AUTHOR]

Objectives: Review of the current and relevant literature to develop a list of evidence‐based recommendations that can be implemented in head and neck surgical practices. To provide rationale for the multiple aspects of comprehensive care for head and neck surgical patients. To improve postsurgical outcomes for head and neck surgical patients. Methods: Extensive review of the medical literature was performed and relevant studies in both the head and neck surgery and other surgical specialties were considered for inclusion. Results: A total of 18 aspects of perioperative care were included in this review. The literature search included 276 publications considered to be the most relevant and up to date evidence. Each topic is concluded with recommendation grade and quality of evidence for the recommendation. Conclusion: Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. Current and future advances in head and neck cancer research will serve to strengthen and add new principles to a comprehensive ERAS protocol. Level of Evidence: 2a. Since it's conception, enhanced recovery after surgery (ERAS) protocols have continued to push for comprehensive and evidence based postsurgical care to improve patient outcomes. Head and neck oncology is one of the newest fields to develop a protocol. Due to the complexity of this patient population and their postsurgical needs, a multidisciplinary approach is needed to facilitate recovery while minimizing complications. This article summarizes current and future principles in head and neck ERAS protocols. [ABSTRACT FROM AUTHOR]

Introduction: The main purpose of reconstructive surgery (RS) is to restore the integrity of soft tissues damaged by trauma, surgery, congenital deformity, burns, or infection. Microsurgical techniques consist of harvesting tissues that are separated from the vascular sources of the donor site and anastomosed to the vessels of the recipient site. In these procedures, there are some preoperative modifiable factors that have the potential to influence the outcome of the flap transfer and its anastomosis. The management of anemia, which is always present in the postoperative period and plays a decisive role in the implantation of the flap, covers significant importance, and is associated with clinical and laboratory settings of chronic inflammation. Methods: Chronic inflammatory anemia (ACD) is a constant condition in patients who have undergone RS and correlates with the perfusion of the free flap. The aim of this treatment protocol is to reduce the transfusion rate by maintaining both a good organ perfusion and correction of the patient's anemic state. From January 2017 to September 2019, we studied 16 patients (16 males, mean age 38 years) who underwent microsurgical procedures for RS. Their hemoglobin (Hb) levels, corpuscular indexes, transferrin saturation (TSAT) ferritin concentrations and creatinine clearance were measured the first day after surgery (T0), after the first week (T1), and after five weeks (T2). At T0, all the patients showed low hemoglobin levels (average 7.4 g/dL, STD 0.71 range 6.2–7.4 g dL−1), with an MCV of 72, MCH of 28, MCHC of 33, RDW of 16, serum iron of 35, ferritin of 28, Ret% of 1.36, TRF of 277, creatinine clearance of 119 and high ferritin levels (range 320–560 ng mL−1) with TSAT less than 20%. All the patients were assessed for their clinical status, medical history and comorbidities before the beginning of the therapy. Results: A collaboration between the two departments (Department of Transfusion Medicine and Department of Reconstructive Surgery) resulted in the application of a therapeutic protocol with erythropoietic stimulating agents (ESAs) (Binocrit 6000 UI/week) and intravenous iron every other day, starting the second day after surgery. Thirteen patients received ESAs and FCM (ferric carboxymaltose, 500–1000 mg per session), three patients received ESAs and iron gluconate (one vial every other day). No patients received blood transfusions. No side effects were observed, and most importantly, no limb or flap rejection occurred. Conclusions: Preliminary data from our protocol show an optimal therapeutic response, notwithstanding the very limited scientific literature and data available in this specific surgical field. The enrollment of further patients will allow us to validate this therapeutic protocol with statistically sound data. [ABSTRACT FROM AUTHOR]

Hemoglobinopathies such as sickle cell disease (SCD) are traditionally considered a relative contraindication to free tissue transfer, due to concerns that erythrocyte sickling will increase the risk of microvascular thrombosis and flap failure. This article describes a case report with the successful use of free tissue transfer in a patient with SCD and provides a systematic literature review on free tissue transfer in SCD. A retrospective chart review was performed of a patient with SCD who underwent free tissue transfer at the authors' institution. A systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using the keywords “free tissue transfer,” “free flap,” or “microsurgery” and “sickle cell” on PubMed, Ovid/Medline, and Scopus. A 29-year-old male with delayed presentation of an electrical burn to the face and scalp underwent wound closure with a free anterolateral thigh flap. Key management principles included red blood cell transfusion to keep hemoglobin S under 30% and hemoglobin greater than 10 g/dL, maintenance of hydration, normothermia, adequate analgesia, and postoperative anticoagulation. Systematic literature review identified 7 articles describing 13 cases of free tissue transfer in 10 patients with SCD, with combined complete free flap success in 10 of the 13 flaps. Free tissue transfer can be successfully performed in patients with SCD. However, evidence on the optimal management of this unique patient population in the perioperative period after free tissue transfer is limited to case reports in the literature.

AbstractPedicled flap options have been currently used as a first-line option, especially in developing countries. Several regional flaps are used for complex head and neck (H&N) deformities, such as pectoralis major flap, deltopectoral flap, and forehead flap. Free Tissue Transfer (FTT) is usually used in a large defect that cannot be closed with a regional flap. Recently there has been a resurgence of interest in using cervico-humeral tissue, specifically the supraclavicular flap (SCF). We report one case of pharyngocutaneous fistula following total laryngectomy and neck dissection, which was successfully managed using SCF. Prompted by this case, we present a scoping review of the literature with a specific clinical question, search terms applied, and a critical appraisal was conducted to the selected literature. The finding supports the viability and versatility of SCF as an excellent reliable alternative to FTT and provides evidence for its inclusion in the head and neck reconstructive surgery armamentarium.

Background : Mandibular defects can be caused by a vast number of pathologies which may compromise both function and aesthetics of the lower face region. Over the years, a range of reconstructive techniques were developed, leading to the current gold standard—free-flap transfer. The aim of this study is to present the experience of the senior author (HC) over the last 25 years, based on 218 cases of mandibular reconstruction with vascularized free bone transfer. Methods: This is a retrospective observational study that includes 218 patients submitted to segmental mandibular excision and immediate reconstruction with free flaps between 1996 and 2021. Collected data included gender, age, etiology, defect size and location, selected flaps, microsurgical recipient vessels, flap bone osteotomies, complications, and flap failure. Functional and aesthetic results were evaluated by a direct examination and also through a questionnaire. Functional outcomes were evaluated regarding diet type (unrestricted, soft, liquid) and speech (normal, perceptible, imperceptible). The Voice Handicap Index-10 Portuguese validated version was also used. Aesthetic outcomes related to symmetry and also oral rehabilitation (absence, presence: dental implants or removable dental prosthesis) were evaluated, as well. Results: Aetiology for the oromandibular defect included malignant tumours (n = 73), osteoradionecrosis (n = 57), benign tumours (n = 41) and defects related to previous tumour excision (n = 23). A total of 225 reconstructive surgeries with 239 free flaps were performed in 218 patients. The most commonly selected flap was the fibula flap (n = 125), followed by the iliac crest flap (n = 69) and the radial forearm flap (n = 26). The sequentially linked flow-through flap concept was used in 13 cases. Total flap necrosis occurred in 15 patients. Functional and aesthetic outcomes were evaluated in 23.9% (50 patients). In 71% of the interviewed, the diet is unrestricted, in 80% the speech is perceptible, and 44% of them had oral rehabilitation procedures. Conclusions: Mandible reconstruction implies the restoration of form and function of the mandibular bone apparatus as well as aesthetics, and for that reason, the authors consider the free bone flaps as the paramount technique for complex oromandibular reconstruction. Level of evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma. [ABSTRACT FROM AUTHOR]