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ABSTRACT Background Objective Patients and Methods Results Conclusion The use of the 3D exoscope in cervicofacial reconstruction has demonstrated its effectiveness, yet few studies have compared its utility to that of the microscope.To compare the reliability of microanastomoses performed with both tools, along with postoperative outcomes and user experience.This was a retrospective single‐center study that included all cases of microanastomosed forearm or fibula free flap reconstructions performed between June 2019 and June 2022. For each procedure, microsurgical characteristics were collected and compared. The primary outcome measure was the reliability of anastomoses (lack of intraoperative events and absence of early surgical revisions). Secondary outcome measures pertained to postoperative evolution.Forty patients underwent microanastomosed flap reconstruction (20 forearm flaps, 20 fibula flaps) using either a microscope (n = 10 in each group) or a 3D exoscope (n = 10 in each group). Patient characteristics were comparable between the two groups. No significant difference was observed between the use of the microscope and the 3D exoscope in terms of anastomosis reliability; OR = 2.07 [0.09–130.88], p = 1. No differences were noted between the two groups in postoperative outcomes except for a shorter hospitalization period for patients undergoing forearm flap reconstruction with the exoscope compared to the microscope (p = 0.03).The use of the 3D exoscope appears to be an interesting alternative to the microscope in cervicofacial reconstruction due to similar microsurgical results, good ergonomics and significant pedagogical appeal. [ABSTRACT FROM AUTHOR]

Carcinoma cuniculatum is a variant of squamous cell carcinoma, characterized by a slow growth with progressive crypt-like invasion of deep tissue. This tumor is frequently misdiagnosed as a benign skin lesion both clinically and histopathologically. The final diagnosis is often delayed as it requires a large sample biopsy. We report the case of a 67-year-old patient who presented to us with a recurring chronic ulcer over a surgical scar of 5 years of evolution. Only after a wide resection of the chronic ulcer was it possible to achieve the correct diagnosis of this large and poorly evolving carcinoma. The subsequent reconstruction with a musculocutaneous gracilis free flap allowed the patient to walk again. [ABSTRACT FROM AUTHOR]

Objectives: The popularity of artificial intelligence (AI) in head and neck cancer (HNC) management is increasing, but postoperative complications remain prevalent and are the main factor that impact prognosis after surgery. Hence, recent studies aim to assess new AI models to evaluate their ability to predict free flap complications more effectively than traditional algorithms. This systematic review aims to summarize current evidence on the utilization of AI models to predict complications following reconstructive surgery for HNC. Methods: A combination of MeSH terms and keywords was used to cover the following three subjects: "HNC," "artificial intelligence," and "free flap or reconstructive surgery." The electronic literature search was performed in three relevant databases: Medline (Ovid), Embase (Ovid), and Cochrane. Quality appraisal of the included study was conducted using the TRIPOD Statement. Results: The review included a total of 5 manuscripts (n = 5) for a total of 7524 patients. Across studies, the highest area under the receiver operating characteristic (AUROC) value achieved was 0.824 by the Auto-WEKA model. However, only 20% of reported AUROCs exceeded 0.70. One study concluded that most AI models were comparable or inferior in performance to conventional logistic regression. The highest predictors of complications were flap type, smoking status, tumour location, and age. Discussion: Some models showed promising results. Predictors identified across studies were different than those found in existing literature, showing the added value of AI models. However, the algorithms showed inconsistent results, underlying the need for better-powered studies with larger databases before clinical implementation. [ABSTRACT FROM AUTHOR]

Background Numerous studies have shown that obesity is a risk factor for postoperative complications following breast reconstruction. Hence, obesity has traditionally been considered a relative contraindication to microsurgical breast reconstruction. In this study, we investigated the impact of obesity on outcomes following microsurgical breast reconstruction. Methods A retrospective analysis of 200 consecutive patients who underwent microsurgical breast reconstruction with free abdominal flaps was performed. Subjects were divided into Nonobese (body mass index [BMI] < 30 kg/m 2) and Obese (BMI ≥ 30 kg/m 2) cohorts. Univariate and multivariate analyses were performed to evaluate differences in patient characteristics, complication rates, and efficiency metrics between the two groups. Results Of the 200 subjects included in the study, 128 were Nonobese, 72 were Obese. The prevalence of diabetes (3.9 vs. 16.9%, p = 0.002) and hypertension (14.7 vs. 39.4%, p < 0.001) were significantly greater in the Obese cohort. Among unilateral reconstructions, postoperative length of stay (LOS) was longer among Obese patients (3.1 vs. 3.6 days, p = 0.016). Seroma occurred more frequently in Obese patients following bilateral reconstruction (5.7 vs. 0.0%, p = 0.047). Otherwise, there were no significant differences in complication rates between the groups. On multivariate analysis, BMI was not independently associated with complications, LOS, or operative time. Conclusion The improvements in clinical and patient-reported outcomes that have been associated with postmastectomy breast reconstruction do not exclude obese women. This study indicates that microsurgical breast reconstruction can be performed safely and efficiently in patients with obesity. [ABSTRACT FROM AUTHOR]

Background Oral cavity cancers requiring excision of the oral commissure and free flap reconstruction often requires commissuroplasty to manage oral incontinence. We aimed to evaluate the implications of primary versus delayed commissuroplasty on drooling, and interincisal distance outcomes in this cohort. Methods A retrospective query of head and neck cancer patients operated by a single surgeon from 2017 to 2020 was performed. Patients were included if they underwent free flap reconstruction of the oral commissure, had an immediate or delayed commissuroplasty, and had 2 years of follow-up data including Thomas-Stonell and Greenberg drooling rating scales and interincisal distance measurements. Results Thirty-five patients were included in the review. Twelve patients received immediate commissuroplasty and 23 patients had delayed commissuroplasty. Interincisal distance was similar at baseline, although significantly varied between immediate and delayed commissuroplasty groups at 1 month and 2 years postoperative. Drooling scores were significantly elevated in the group treated with delayed commissuroplasty, but eventually normalized after staged surgery and follow-up. Patients treated with adjunct radiation therapy had lower interincisal distance than patients who did not have radiation. Conclusion Delayed commissuroplasty increased interincisal distance and normalize drooling in patients who required full-thickness excision of the buccal mucosa and oral commissure and free tissue reconstruction. The presented data can help to educate patients on expected postoperative outcomes and likely advocates for a second-stage procedure after completion of adjunct radiotherapy to achieve optimal commissural placement and oral competence. [ABSTRACT FROM AUTHOR]

Background There is an increasing prevalence of marijuana use in the general population yet clinical studies on marijuana's effect on surgical outcomes remain limited. Marijuana's effect on wound healing, venous thromboembolism (VTE) due to endothelial inflammation, and bleeding due to inhibited platelet function have been cited based on animal models but have not been evaluated clinically in patients undergoing microsurgical reconstruction. Methods Retrospective chart review was performed on all patients who underwent abdominal-based free flap breast reconstruction in a single institute from August 2018 to December 2022. Patient self-reported marijuana use, demographics, total narcotic use during hospitalization converted to oral morphine milligram equivalent (MME), and 90-day complications were collected and compared. Results A total of 162 patients were included and 13 patients (8.5%) had reported marijuana use on presurgical history. Marijuana users are more likely to be younger and report concurrent nicotine smoking. Marijuana users were also at a significantly elevated risk of developing symptomatic VTE (15 vs. 1%; odds ratio (OR) 13.4 [95% confidence interval (CI) 1.71–104.2]; p = 0.01) and marijuana use remained a significant risk factor with multivariate analysis. On postoperative 90-day complications, there was no increased risk of flap loss, reoperation, postoperative transfusion, or hematoma associated with marijuana use, and no significantly increased risk for overall donor or recipient site complications. Marijuana users required significantly more narcotics for pain control during hospitalization (100 ± 77 vs. 49 ± 45 MME; p = 0.0003), although they had similar lengths of stay, achievement of mobilization on post operative day (POD)1, and maximal pain scores. Conclusion Marijuana use increases the risks of postoperative VTE and increased postoperative narcotic requirements in patients who underwent abdominal-based free flap breast reconstruction. Future prospective cohort study is required to further understand marijuana-associated risks in microsurgical procedures. [ABSTRACT FROM AUTHOR]

Background In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery. Methods A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery. Results The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed–immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients. Conclusion Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps. [ABSTRACT FROM AUTHOR]

We explored the most suitable osteosynthesis type for mandibular reconstruction using fibula free flap (FFF) given the lack of robust data available. For this, an anonymous survey was e-mailed to 853 head-and-neck surgeons (France) asking about their practices and criteria guiding their osteosynthesis material and method choices. Questions assessed: (1) the most frequently used osteosynthesis type, (2) the explanatory variables related to surgeon career status/surgical specialty, and (3) justifications for osteosynthesis type (scientific, technical, "misuse"). Multivariate logistic regression was performed to test for associations of explanatory variables with plate type or misuse. Overall, 118 (13.8%) surgeons responded, among which flexible non-locking osteosynthesis was preferred (59%). Career status and surgical specialty were significantly associated with material choice. University professors/senior lecturers (OR 5.96 vs academic clinical associates; p = 0.02), but not ear-nose-throat/reconstructive plastic surgeons (OR 0.22 vs maxillofacial surgeons; p = 0.04), were more likely to opt for rigid locking osteosynthesis. Private practitioners preferred flexible non-locking osteosynthesis (OR = 5.03; p = 0.04). Only 18% of surgeons scientifically justified their choices. We considered misuse among 65% of surgeons and this was significantly associated with irregular practice of FFF surgery (OR 2.28 vs > 10 surgeries/year; p = 0.04). Overall, >50% of surgeons mainly rely on habits without scientific arguments assisting in decision-making. [ABSTRACT FROM AUTHOR]

The repair of hemimandibulectomy defects involving the temporomandibular joint (TMJ) is challenging. This study compared the functional outcomes and reconstruction accuracy using a deep circumflex iliac artery (DCIA) flap with and without a virtually planned stock TMJ prosthesis (TMJP) after hemimandibulectomy. Ten patients were assessed: five with a TMJP (TMJP group) and five without (control group). A three-dimensional comparison revealed a mean deviation of 0.11 ± 0.04 mm between the planned and actual DCIA flap with TMJP. The planned and actual TMJP positions differed by 0.56 ± 0.57 mm in height, 0.33 ± 0.24 mm ventrally/dorsally, and 1.18 ± 0.42 mm medially/laterally. Mouth opening, laterotrusion, and midline deviation were significantly greater in the control group than in the TMJP group (P = 0.024, P = 0.008, P = 0.024). The deviation in ventral to dorsal translation for the DCIA flap was slightly higher than reported values in the literature, while height deviation was comparable. Lower deviations in the literature were due to the DCIA flap being used where both TMJs were intact. The in-house virtually planned DCIA flap with stock TMJP yielded results comparable to more expensive patient-specific prostheses. [ABSTRACT FROM AUTHOR]

Introduction: Osteoradionecrosis (ORN) of the mandible is an unfortunate potential sequela of radiotherapy for head and neck cancer. In advanced cases of ORN, mandibulectomy, and free fibula flap reconstruction are required. We hypothesized that patients undergoing fibula free flap reconstruction and mandibulectomy for ORN pose unique challenges and experience more complications than patients undergoing fibula free flaps after oncologic mandibulectomy. Methods: After IRB approval, we created a database of all free fibula flaps for mandible reconstruction from April 2005 through February 2019. Medical records were retrospectively reviewed for patient and surgical characteristics and postoperative outcomes. Results: Four‐hundred seventy‐nine patients met the inclusion criteria (168 ORN vs. 311 non‐ORN patients). Propensity‐matching was performed based on age, BMI, smoking status, preoperative chemotherapy, and virtual surgery planning use, which yielded 159 patients in each group. ORN patients received more double‐skin‐island fibula flaps than non‐OR patients (20.8% vs. 5.7%, p < 0.001). Recipient artery other than the facial artery was utilized more commonly in ORN patients (42.1% vs. 17.0%, p < 0.001). In the unmatched cohort, ORN patients had higher rates of delayed wound healing (26.2% vs. 16.8%, p = 0.01) and surgical site infections (21.4% vs. 13.2%, p = 0.02). Rates of flap loss, return to the operating room, hematoma, operative time, and length of stay were similar between the groups. On logistic regression analysis, osteoradionecrosis was an independent risk factor for delayed wound healing. Conclusion: Based on these data, mandibular reconstruction with fibula flaps for osteoradionecrosis appears more complicated than mandible reconstruction following de novo cancer resection. Surgeons should anticipate employing two skin islands for intraoral and extraoral resurfacing, utilizing unconventional recipient vessels, and managing the delayed wound healing that ensues more commonly than non‐ORN patients. [ABSTRACT FROM AUTHOR]

Background: Fibula free flap reconstruction has revolutionized maxillofacial reconstruction. While immediate dental rehabilitation with dental implants and teeth has shown benefits, it remains uncommon, especially for patients with malignancy. Methods: A retrospective cohort study at a single institution explored immediate dental rehabilitation in fibula flaps for patients with malignant disease. Thirteen patients with malignancies that underwent immediate fibula free flap reconstruction with dental implants and dental prosthesis were included with a minimum of 3‐month follow‐up. Results: Forty eight implants replaced 90 teeth in 13 patients. All implants were integrated at 3 months, with an overall success rate of 87.5%. Two patients experienced delayed (>3 months postoperatively) implant loss due to osteoradionecrosis and infection. Peri‐mucositis occurred in three patients which resolved with treatment. Skin paddles were used in 11 patients and radiation therapy was not delayed for any patient. Conclusion: With proper patient selection, diagnosis of malignancy and the need for osteocutaneous flap reconstruction does not exclude the ability to place immediate implants and deliver an immediate dental prosthesis in head and neck reconstruction. [ABSTRACT FROM AUTHOR]

Background and objectives: Although rare, complications like skin dehiscence and necrosis after neurosurgery pose significant challenges by increasing the risk of infections spreading to the epidural, subdural, or intracerebral spaces. This retrospective, single-center study aims to assess the prior clinical courses, neuroplastic repair, and outcomes of patients with skin defects following cranial neurosurgical procedures, and to outline our interdisciplinary reconstructive protocol. Methods: A retrospective analysis was performed on cranial surgeries conducted at the Department of Neurosurgery, spanning from 2017 to 2023. Patients with skin defects requiring the combined expertise of neurosurgery and plastic surgery for effective treatment were included. The sizes of the skin defects were measured using intraoperative photographs analyzed with the freeware ImageJ software, version 2018. All patients provided informed consent for the surgeries. If informed consent was not possible due to neurological deterioration, consent was sought from adult representatives or next of kin except for acute circumstances. All patients admitted to our hospital agree to the pseudonymized use of their medical data and tissue specimens for research purposes in their treatment contract. Results: A cohort of 24 patients experiencing wound healing complications after neurosurgical procedures underwent a total of 29 interdisciplinary surgeries for the reconstruction of skin, dural, and bone defects. After the neuroplastic surgery, 8 out of 24 patients (33.3%) developed surgical complications, with 6 of these requiring revision surgeries due to persistent cranial infection. In all cases, permanent wound closure was successfully achieved following adherence to the proposed treatment algorithm. Conclusions: Our study underscores the necessity of an integrated neurosurgical and plastic surgical approach to effectively manage wound healing complications in a single stage surgery. Key interventions include differentiation between necrosis and gaping lesions, alongside precise management of neurosurgical issues like cerebrospinal fluid fistulas and hydrocephalus. Plastic surgical expertise in assessing the possibilities and limitations of both local and free flap surgeries is essential. [ABSTRACT FROM AUTHOR]

Osteosarcomas of the ribs are rarely reported but have a high potential for pulmonary metastases. The therapeutic strategies for this disease are not well defined. The primary treatment recommendations include wide resection with clear surgical margins and chest wall reconstruction if needed. We present a case of costal osteosarcoma with pleural and lung extension successfully treated by en-bloc thoracic resection with free surgical margins and chest wall reconstruction with rib titanium bars, polypropylene mesh and a rectus abdominis free flap with microvascular anastomoses. This case demonstrates the importance of this therapeutic strategy and highlights the need of early intervention in managing this disease. [ABSTRACT FROM AUTHOR]

Literature suggests that intravenous prophylaxis exceeding 48 h offers no additional benefit in preventing surgical site infections (SSI) in patients with microvascular head and neck reconstruction. However, protocols for antibiotic therapy duration post-reconstruction are not standardized. This study identifies factors predicting prolonged intravenous antibiotic use and antibiotic escalation in patients receiving free flap head neck reconstruction. A retrospective analysis of 446 patients receiving free flap reconstruction was conducted, examining predictors for antibiotic therapy > 10 days and postoperative escalation. 111 patients (24.8%) experienced escalation, while 159 patients (35.6%) received prolonged therapy. Multivariate regression analysis revealed predictors for escalation: microvascular bone reconstruction (p = 0.008, OR = 2.0), clinically suspected SSI (p < 0.001, OR = 5.4), culture-positive SSI (p = 0.03, OR = 2.9), extended ICU stay (p = 0.01, OR = 1.1) and hospital-acquired pneumonia (p = 0.01, OR = 5.9). Prolonged therapy was associated with bone reconstruction (p = 0.06, OR = 2.0), preoperative irradiation (p = 0.001, OR = 1.9) and culture-positive SSI (p < 0.001, OR = 3.5). The study concludes that SSIs are a primary factor driving the escalation of perioperative antibiotic use. Clinical suspicion of infection often necessitates escalation, even in the absence of confirmed microbiological evidence. Microvascular bone reconstruction was a significant predictor for both the escalation and extension of antibiotic therapy beyond 10 days. Furthermore, preoperative radiation therapy, hospital-acquired pneumonia, and prolonged ICU stay were associated with an increased likelihood of escalation, resulting in significantly extended antibiotic administration during hospitalization. Antibiotic stewardship programmes must be implemented to reduce postoperative antibiotic administration time. Trial registration The study was registered approved by the local Ethics Committee (Nr: 18-1131-104). [ABSTRACT FROM AUTHOR]

Facial reconstruction is challenging for plastic surgeons, as it can be difficult to decide the best approach. One technique that has been widely used is the anterolateral thigh (ALT) flap due to its numerous benefits. However, its thickness can be a drawback, especially regarding facial reconstruction. The thinning technique is not a new novel, but how to apply it to the ALT flap to get the best result hasn't been reported yet. Our study involved 117 patients, and we used 73 thinned ALT flaps to determine the best method to increase the flap's safety. After thinning, we significantly reduced the flap's thickness from an average of 22.5 mm to 5.9 mm, making it more suitable for contouring purposes. We apply a thinned ALT flap for coverage, contouring, and recreating the facial 3D structure. The 12/45 flap has the chance to make the multiple-paddle ALT flap, which helps to reconstruct difficult positions even more flexibly. The key to successfully thinning the ALT flap is understanding the perforator's structure and pathway through the fascia. With the thinning technique, we have overcome the limitations of the flap's thickness, making it suitable for use in whole-body reconstruction. The ALT flap can overcome the restriction of its thickness and can be applied even more extensively in whole-body reconstruction. [ABSTRACT FROM AUTHOR]

Introduction The effect of the second wave of COVID-19 was immense in India, specifically in the form of vicious COVID-19-associated mucormycosis. A higher number of radical debridements are required for disease control in combination with antifungal drugs in cases of COVID-19-associated mucormycosis, which results in complex maxillofacial defects. We aimed to evaluate the clinical outcomes in patients with rhino-orbito-maxillary defects due to COVID-19-associated mucormycosis undergoing a single stage delayed free flap reconstruction. Methodology This prospective, single-center, multisurgeon study was performed on eight patients with COVID-19-associated rhino-orbito-maxillary mucormycosis in the department of burns and plastic surgery. The postoperative clinical outcome was evaluated using the University of Washington Quality of Life Questionnaire for patient's quality of life (QOL), aesthetic numeric analog (ANA) scale for patient's satisfaction for aesthetics, and the functional intraoral Glasgow scale for speech and deglutition at 1 and 3 months. Results The median age of the study patients was 40 years, with 75% of the patients being males. Diabetes mellitus (DM) was present in all the patients. Mucormycosis was diagnosed within the first 3 months of COVID-19 infection. Maxillary defect was present in 62.5% of patients, out of which 50% had bilateral maxillary defects. There was significant improvement in the QOL and the aesthetics of patients from 1 to 3 months (p < 0.001). Speech and deglutition were also improved at 3 months, but the difference was not statistically significant. Conclusion Single stage delayed free flap reconstruction can be advocated in patients with COVID-19-associated rhino-orbito-maxillary mucormycosis defect as there is considerable improvement in patients' QOL, aesthetics, speech, and deglutition over a period of time. [ABSTRACT FROM AUTHOR]

Two of the greatest challenges in breast reconstruction are mastectomy skin flap necrosis (MSFN) and autologous flap failure. This review summarizes current evidence regarding the usage of indocyanine green angiography (ICGA) in breast reconstruction, identifies knowledge gaps, and provides directions for future studies. An umbrella review was conducted to identify related syntheses in Embase, Ovid Medline, Scopus, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and the Clinical Trials databases. Data were extracted from systematic reviews (SRs) and meta-analyses (MAs) that discussed the use of ICGA in breast reconstruction. Sixteen syntheses were included (10 SRs and 6 MAs). Syntheses showed much evidence that ICGA usage typically reduces MSFN rates. However, it tends to overpredict necrosis and is best utilized in high-risk patients or those with an unclear clinical picture. ICGA is also useful in autologous breast reconstruction by reducing rates of breast fat necrosis (BFN), total flap loss, and reoperation. ICGA usage may also aid in perforator mapping and selection intraoperatively, with minimal complication risk. Most syntheses had moderate quality scores; however, they were small with significant heterogeneity in protocols and complication definitions. The use of ICGA in breast reconstruction is safe and useful in decreasing rates of MSFN, BFN, and reoperation after free flap reconstruction. [ABSTRACT FROM AUTHOR]

In reconstructive surgery following partial mandibulectomy, the biomechanical integrity of the fibula free flap applied to the remaining mandibular region directly influences the prognosis of the surgery. The purpose of this study is to evaluate the biomechanical integrity of two fixation materials [titanium (Ti) and hydroxyapatite/poly-L-lactide (HA-PLLA)]. In this study, we simulated the mechanical properties of miniplate and screw fixations in two different systems by finite element analysis. A three-dimensional mandibular model was constructed and a fibula free flap and reconstruction surface were designed. The anterior and posterior end of the free flap was positioned with two miniplates and two additional miniplates were applied to the angled area of the fibula. The masticatory loading was applied considering seven principal muscles. The peak von Mises stress (PVMS) distribution, size of fixation deformation, principal stresses on bones, and gap opening size were measured to evaluate the material properties of the fixation. In the evaluation of properties, superior results were observed with both fixation methods immediately after surgery. However, after the formation of callus between bone segments at 2 months, the performance of Ti fixation decreased over time and the differences between the two fixations became minimal by 6 months after surgery. The result of the study implies the positive clinical potential of the HA-PLLA fixation system applied in fibula free flap reconstruction. [ABSTRACT FROM AUTHOR]

Background: The use of microvascular grafts is the gold standard in oral and maxillofacial surgery for the reconstruction of soft tissue and bony and combined defects. Graft loss is one of the most serious complications in the field of reconstructive surgery. A comprehensive analysis of factors influencing this is, therefore, essential. Methods: This hypothesis-generating study analyzed 251 patient cases of oral and maxillofacial surgery at the University Hospital Düsseldorf from 2016 to 2020 regarding patient- and therapy-specific parameters for their impact on graft survival. Results: Statistically significant influencing factors were found among the 80 parameters examined: treatment with antiplatelet medication and a BMI ≥ 24.5 at the time of surgery had a positive influence on graft survival, while existing diabetes mellitus, atrial fibrillation, tracheostomy, and a longer operation time had a statistically relevant negative influence. Conclusions: This work demonstrates the relevance of patient-specific risk stratification and the need for further research to develop a valid risk profile. Identifying high-risk patients with medium-sized defects, where alternatives to microvascular reconstruction are available, appears to be crucial for the clinical outcome. [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: The radial forearm flap remains the gold standard in phalloplasty in gender-affirming surgery due to its versatility and functional outcome, but the significant donor site morbidity and its impact on daily functioning and aesthetic perception remains understudied. This study provides valuable insights into the mid-term functional and aesthetic outcomes of the forearm in transgender individuals following radial forearm flap phalloplasty using widespread instruments for assessment scoring systems and for the evaluation of postoperative wound healing of surgical interventions in general. Methods: Between January 2013 and March 2018, a total of 47 patients underwent radial phalloplasty at AGAPLESION Markus Hospital, and 20 consented to participate in this cross-sectional, retrospective study evaluating functional and aesthetic outcomes post-radial forearm flap phalloplasty using standardized questionnaires (DASH, POSAS, and SBSES). A univariate median regression of each score was performed to determine the associations with selected variables, and correlation analyses between scores was performed using a nonparametric Spearman rank correlation. Results: Among the 20 participants, the median Quick DASH, DASH functionality, DASH sport and music, and DASH work scores indicated minimal to no functional impairment. Scar evaluations using the PSAS, OSAS, and SBSES scales showed overall patient satisfaction with minimal concerns regarding pigmentation and scar texture. Notably, an increase of 0.27 cm2 in wound surface area added one point to the DASH sport and music score (p = 0.037). Statistical analysis also demonstrated a significant correlation between functional and aesthetic assessment scores. Conclusions: The radial forearm phalloplasty donor site, evaluated by the PSAS, OSAS, and SBSES scales, leads to minimal or no functional impairment; however, the worsening of the DASH sport and music score with increasing wound surface reflects a direct relation between wound size and functional impairment. [ABSTRACT FROM AUTHOR]

The goals of gender-affirming phalloplasty typically include an aesthetic phallus and scrotum, standing micturition, and/or penetrative intercourse. Phalloplasty can be performed using both free and pedicled flaps. Complications include flap-related healing compromise and urethral issues, including stricture and fistula. Phalloplasty has high patient satisfaction and has demonstrated improvement in quality of life. [ABSTRACT FROM AUTHOR]

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications. [ABSTRACT FROM AUTHOR]

Introduction: Reconstructive plastic surgeons have made great strides in the field of breast reconstruction to achieve the best results for patients undergoing treatment for breast cancer. As microsurgical techniques have evolved, these patients can benefit from additional treatment modalities to optimize the results of the reconstruction. Free tissue transfer from alternative donor sites for breast reconstruction is routinely performed, which was not possible in the past. Neurotization is now possible to address the numbness and lack of sensation to the reconstructed breast. For those patients who develop lymphedema of the upper extremity as a result of their breast cancer care, supermicrosurgical options are now available to treat and even to prevent the development of lymphedema. This study presents a narrative review regarding the latest microsurgical advancements in autologous free flap breast reconstruction. Methods: A literature review was performed on PubMed with the key words "autologous free flap breast reconstruction", "deep inferior epigastric perforator flap", "transverse upper gracilis flap", "profunda artery perforator flap", "superior gluteal artery perforator flap", "inferior gluteal artery perforator flap", "lumbar artery perforator flap", "breast neurotization", "lymphovenous bypass and anastomosis", and "vascularized lymph node transfer". Articles that specifically focused on free flap breast reconstruction, breast neurotization, and lymphedema surgery in the setting of breast cancer were evaluated and included in this literature review. Results: The literature search yielded a total of 4948 articles which were screened. After the initial screening, 413 articles were reviewed to assess the relevance and applicability to the current study. Conclusions: Breast reconstruction has evolved tremendously in recent years to provide the most natural and cosmetically pleasing results for those patients undergoing treatment for breast cancer. As technology and surgical techniques have progressed, breast cancer patients now have many more options, particularly if they are interested in autologous reconstruction. These advancements also provide the possibility of restoring sensibility to the reconstructed breast as well as treating the sequela of lymphedema due to their cancer treatment. [ABSTRACT FROM AUTHOR]

Objectives: One stage functional jaw reconstruction is defined as the resection and reconstruction of segmental defects in conjunction with the placement of dental implants in an ideal prosthetic position and loaded with a provisional restoration, during one surgical procedure. The aim of the study is to describe clinical outcomes of patients who underwent one stage functional jaw reconstruction. Methods: Patients who underwent one‐stage functional jaw reconstruction, from January 2013 to March 2016 were recalled in 2022 and 2023. Planning and execution for the reconstruction utilized either analogue or digital techniques. Outcome parameters recorded were treatment‐related outcomes at patient level, implant‐related outcomes and patient‐reported outcome measures. Results: Eighteen patients underwent one‐stage jaw reconstruction with a total of 57 implants. Four patients had maxillary and 14 had mandibular reconstructions. Ten patients underwent postoperative radiotherapy. Ten patients were planned using analogue and eight by digital planning. Three patients had partial flap necrosis, three patients had plate fractures, implant loss was seen in one patient and four patients died during the period. A functional prosthesis was provided in 16 out of the 18 patients. Conclusion: One‐stage functional jaw reconstruction is a predictable method for providing rehabilitation with successful outcomes at 7–11 years. However, caution should be exercised when the treatment modality is carried out in patients with malignant pathologies who have undergone radiotherapy. [ABSTRACT FROM AUTHOR]

Background: This prospective, double-blinded, randomized study aimed to compare the efficacy of dexmedetomidine and fentanyl infusions in maintaining hemodynamics during head and neck free flap surgery, as well as their impact on the relative amount of blood loss. Methods: Twenty patients with American Society of Anesthesiologists physical status I and II scheduled for elective head and neck free flap surgery were enrolled. The patients were randomly assigned to receive either dexmedetomidine (1 µg/kg over 10 min at anesthesia induction, followed by 0.2 to 0.75 µg/kg per hour infusion during maintenance) or fentanyl (1 to 2 µg/kg per hour infusion during maintenance). Intraoperative hemodynamic parameters, blood loss, blood transfusion requirements, surgeon satisfaction, adverse drug effects, and free flap survival up to 7 days were recorded. Results: The dexmedetomidine group achieved a mean arterial pressure (MAP) value between 60 and 70 mmHg at multiple time points (15 min, 3rd, 4th, 5th, and 6th hours), while the fentanyl group did not reach this range at any time point. The intergroup statistical analysis revealed a significant difference only at the 5th hour with (95% CI: -16.17 to -0.62) and P = 0.036. Additionally, the dexmedetomidine group exhibited lower heart rates (< 70/min) at several time points (15 min, 2nd, 3rd, 4th, 5th, and 6th hours) compared to the fentanyl group. The intergroup comparison indicated a statistically significant difference only at the 3rd hour with (95% CI: -20.94 to -0.45) and P = 0.042. Conclusion: Dexmedetomidine can be a useful adjuvant of GA for inducing controlled hypotension and decreasing bleeding in free flap surgery of the head and neck region without any detrimental effect on the free flap survival. [ABSTRACT FROM AUTHOR]

Introduction: Free tissue transfer is now done routinely for Head & neck reconstruction. A suction drain is needed for efficient drainage of the neck post-dissection & with it arises a new dilemma, challenge or obsession amidst the practicing surgeons about the safe and efficient placement of suction drain in an anatomical location so that it does not injure or impair the anastomosis but will still be able to carry out its role efficiently. No prior studies are available regarding the safe practice. Hence the aim of our study was to explore & establish a reliable manoeuvre where the drain could be introduced in a safe and efficient way. From April of 2017-February of 2024 a prospective study was carried out in which cases of 517 patients were taken into account who underwent head and neck reconstruction using a free tissue transfer procedure where the suction drain tube was placed in the dependent part of the neck (i.e. the posterior triangle region) & the margin of sternocleidomastoid muscle was fixed with the pre-vertebral layer of the cervical fascia. The drain was secured externally with a percutaneous non- absorbable suture. Study Design: A prospective Study. Study Period: April 2017- February 2024. Observation: A thorough observation was carried out & no evidence of drain induced anastomotic complications were reported. Conclusion: Hence it can be assumed that this particular method of drain placement is both safe & efficient and it can act as a beacon among the surgeons who suffer a from a dilemma & challenge about where to place the drain safely & efficiently. [ABSTRACT FROM AUTHOR]

This article discusses a study on the use of indocyanine green (ICG) fluorescence endoscopy in the resection of sinonasal tumors. The study found that ICG fluorescence endoscopy is feasible and can help improve complete tumor resection. The researchers also noted the need for further research to determine the optimal timing and dose of ICG injection. The study included a small number of cases and a heterogeneous group of advanced stage sinonasal tumors, so more research and observation are necessary to develop a proper usage protocol. [Extracted from the article]

Autologous breast reconstruction using abdominally based perforator flaps has become increasingly popular following mastectomy for breast cancer. Of these, the deep inferior epigastric artery perforator (DIEP) flap represents one of the most popular techniques. However, surgeons must remain cognizant of anatomic variations in the abdominal wall vasculature that could complicate or preclude planned DIEP flaps. In this case, a 64-year-old female with a history of prior tubal ligations and caesarean sections underwent preoperative computed tomographic angiography (CTA) for planned autologous breast reconstruction with a DIEP flap. CTA revealed complete absence of the left deep inferior epigastric artery, with a sizeable left abdominal wall perforator visualized receiving retrograde flow from a crossing midline branch originating from the contralateral right deep inferior epigastric system. This vessel traversed the midline in a superficial plane in the subcutaneous tissue. Despite this aberrant anatomy, the surgical team successfully raised a unilateral DIEP flap based on the right pedicle. This case represents a unique anatomical variation of the abdominal wall and emphasises the importance of preoperative imaging when planning abdominally based free flaps. [ABSTRACT FROM AUTHOR]

The reconstruction of esophageal defects with restoring vocal functions is challenging. Major disadvantages of using a fasciocutaneous flap include the requirement for a long suture line for tubularization, the slow healing of mucosa‑skin anastomoses, and the necessity of using a voice prosthesis through a tracheoesophageal puncture. The transfer of the ileocolon flap is a totally autologous option for the simultaneous reconstruction of the esophagus and voice function. The ileocecal valve mechanism within the ileocolon flap obviates the need for the insertion of a voice prosthesis, and the terminal ileum acts as the voice tube which directs the air from the trachea to the neo‑esophagus. In this report, we describe in detail the surgical technique of the free ileocolon flap transfer for this indication, as well as modifications aimed at reducing complication rates. [ABSTRACT FROM AUTHOR]

Background The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction. Methods We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m 2. Outcomes of interest were defined by International Classification of Diseases, Tenth Revision (ICD-10) codes. A two-sample t -test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m 2 served as the control. Cohorts were balanced on age, race, and ethnicity. Results We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m 2 , 1,867 had a BMI of 25 to 29.99 kg/m 2 , 1,396 had a BMI of 30 to 34.99 kg/m 2 , and 559 had a BMI of 35 to 39.99 kg/m 2. Patients with a BMI of 25 to 29.99 kg/m 2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m 2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure. Conclusion Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making. [ABSTRACT FROM AUTHOR]

Background The microsurgical treatment of lymphedema has been well-studied and has been shown to be effective, especially in cancer-related lymphedema. Posttraumatic lymphedema (PTL) is a debilitating condition that remains understudied and underreported, and surgical techniques for PTL treatment are not well-represented in the literature. The purpose of this study was to systematically review all published reports of physiologic surgical interventions for PTL. Methods A search was conducted on PubMed, MEDLINE, Embase, and Web of Science, from January 1, 2000 to December 6, 2022, using keywords "PTL," "lymphedema," and "surgery" to identify reports of PTL treated with microsurgical lymphatic reconstruction techniques. PTL cases treated with ablation, debulking, or decongestive therapy were excluded. Results A total of 18 records that met the inclusion criteria were identified, representing 112 patients who underwent microsurgical operations for PTL. This included 60 cases of lymph flow restoration (LFR) via lymph axiality and interpositional flap transfer, 29 vascularized lymph node transfers, 11 lymphatic vessel free flaps, 10 lymphovenous anastomoses (LVAs), and 2 autologous lymphovenous transfers. Outcomes were primarily reported as clinical improvement or LFR by lymphatic imaging. All studies showed qualitative improvement of symptoms and reports with quantitative data showed statistically significant improvements. Conclusion PTL is currently underrepresented in lymphedema treatment literature, however, our results show that microsurgical techniques are successful in treating lymphedema in PTL patients. Increasing awareness of PTL and establishing standardized diagnostic criteria and treatment options will help clinicians better understand how to diagnose and treat this condition. Prospective and comparative studies are needed to determine true prevalence of PTL and optimal treatment strategies. [ABSTRACT FROM AUTHOR]

Background A comprehensive understanding of changes in health-related quality of life after head and neck cancer surgery is necessary for effective preoperative counseling. The goal of this study was to perform a longitudinal analysis of postoperative quality of life outcomes after fibula free flap (FFF) mandible reconstruction. Methods A retrospective review was performed for all patients who underwent oncologic mandible reconstruction with an FFF between 2000 and 2021. Completion of at least one postoperative FACE-Q questionnaire was necessary for inclusion. FACE-Q scores were divided into five time periods for analysis. Functional outcomes measured with speech language pathology (SLP) assessments and tracheostomy and gastrostomy tube status were analyzed at three time points. Results One hundred and nine patients were included. Of these, 68 patients also had at least one SLP assessment. All outcomes as measured by the various FACE-Q scales did not improve significantly from the immediate postoperative time point to the last evaluated time point (p > 0.05). SLP functional outcomes showed some deterioration over time, but these were not significant (p > 0.05). The percentage of patients who required a tracheostomy (18 to 2%, p = 0.002) or gastrostomy tube (25 to 11%, p = 0.035) decreased significantly from the immediate postoperative time point to the last evaluated time point. Conclusion Subjective quality of life outcomes do not change significantly with time after oncologic FFF mandible reconstruction. Reconstructive surgeons can use these results to help patients establish appropriate and achievable quality of life goals after surgery. Further studies are warranted to elucidate the impact of specific relevant clinical variables on postoperative quality of life. [ABSTRACT FROM AUTHOR]

Segmental mandibulectomy and reconstruction of resulting defect can be performed via intraoral approach (IOA) or extraoral approach (EOA). Both approaches have advantages, disadvantages, indications, and contraindications to consider during their selection. To compare IOA vs EOA of segmental mandibulectomy and microvascular reconstruction with fibula free flap (FFF). We conducted a retrospective cohort study in which 51 patients who underwent segmental mandibulectomy and microvascular reconstruction with FFF from 2020 to 2024 were included, especially 17 patients by IOA and 34 patients by EOA, representing both groups of this study. Clinical characteristics, surgery parameters, and patients' prognosis were evaluated. Patients' satisfaction and Derriford Appearance Scale (DAS59) were assessed during follow-up. Ameloblastoma was the most frequent diagnosis (52.9% managed by IOA vs 70.6% by EOA); FFF was frequently positioned as double barrel (94.1% managed by IOA vs 88.2% by EOA). Compared with EOA group, IOA group had less intraoperative blood loss (mean difference [MD] = −112.2, 95% confidence interval [CI]: −178.9 to −45.5, p = 0.001), higher satisfaction score (MD = 1.3, 95% CI: 0.9 to 1.7, p ˂ 0.001), and lower DAS59 score (MD = −0.5, 95% CI: −0.7 to −0.2, p ˂ 0.001). Both IOA and EOA were found safe and feasible, presenting similar perioperative features and postoperative outcomes. Patients managed with IOA were more satisfied with aesthetic outcomes than patients managed with EOA. In the absence of simultaneous immediate implant during mandibular FFF reconstruction, after stability of FFF on the defect site, patients should always be referred to an implantologist and/or prosthodontist for teeth restoration to improve functional and aesthetic outcomes. [Display omitted] [ABSTRACT FROM AUTHOR]

Introduction: Intraoperative fluid management is one of the most important factors affecting optimal perfusion in the microcirculatory area in patients that undergo flap surgery. While insufficient fluid administration in the intraoperative period leads to flap complications and organ dysfunction, volume load can cause complications such as edema in the denervated flap tissue, the opening of the sutures, or fat necrosis. The Infrared Fluorescent Angiography Perfusion Evaluation Device (SPY) is one of the many noninvasive techniques that evaluate the well-being of microcirculation at the tissue level. This device monitors and scores the perfusion distribution in the flap area. This retrospective study aimed to investigate the effect of fluid resuscitation in head and neck free flap transfer surgery on flap quality and patient outcomes according to the change in SPY scores. Material and Method: This study included 39 ASA I–II patients who were aged 18–60 years and underwent simultaneous free flap reconstruction of the head and neck between 2015 and 2021. Patients' blood pressure, body temperature, hemoglobin, pH, and lactate values were recorded at both baseline and end of the operation. Also, the SPY "Infrared Fluorescent Angiography Perfusion Evaluation Device" scores, the amount of intraoperative fluid and transfusion, bleeding and urine output, and the duration of mechanical ventilation, anesthesia and surgery, and the duration and amount of drainage, the length of stay in hospital and intensive care unit, and the presence of flap infection, detachment, necrosis and loss, and re-exploration rate were recorded for the patients. Results: The difference between the first and last measured SPY values was observed to be positively correlated with the length of stay in the hospital and intensive care unit and the duration of drainage. There was a positive correlation between the length of stay in the hospital and intensive care unit and the duration of drainage, the amount of drainage, as well as the duration of anesthesia and the duration of surgery (p < 0.001). A positive correlation was found between the amount of drainage and the amount of crystalloid solution administered (r = 0.36, p < 0.05). In patients with flap infection, the difference between SPYfirst and SPYlast, the duration of anesthesia, and the duration of surgery were significantly higher. The amount of crystalloid solution given and bleeding and the duration of anesthesia and surgery were found to be significantly higher in mechanically ventilated patients (p < 0.05). Conclusions: It has been concluded that SPY-guided fluid management can be beneficial in preventing morbidities, such as extended hospital and intensive care stay, by reducing flap infection, mechanical ventilation duration, and drainage, with early diagnosis of insufficient perfusion. [ABSTRACT FROM AUTHOR]

Background and Objectives: The deltopectoral (DP) flap represents a reconstructive option for the head and neck. It is a fasciocutaneous flap raised from the anterior chest wall below the clavicle. Its role partially declined with the arise of free flaps. However, it still remains a valid option in patients that could not undergo a reconstruction with free flaps. The aim of this retrospective study was to evaluate the role of the DP flap in head and neck reconstruction, with a focus on surgical outcomes and complications. Materials and Methods: Thirty-one patients who underwent head and neck reconstruction with DP flap were included in the study. The delayed technique was not used in any procedure to harvest the flap beyond the deltopectoral groove. The patients' characteristics, the recipient site, the closure of the donor site, and the flap-related complications were recorded. Results: The median time to autonomization of DP flap was 23 days. Postoperative complications were observed in 10 subjects (32.3%). A partial necrosis was seen in five patients (16.1%), while a complete necrosis developed only in one case (3.2%). The diabetes mellitus was the only parameter associated with postoperative complications. In particular, the percentage of necrosis in subjects with or without diabetes was 66.7% and 8.0%, respectively. Conclusions: The DP has a wide range of applications in head and neck reconstruction, and a low complication rate can be observed. The delayed technique does not necessarily need to be applied, and the flap can be extended beyond the deltopectoral groove when necessary. However, patients with diabetes mellitus have a higher risk of postoperative necrosis of the distal portion of the flap. [ABSTRACT FROM AUTHOR]

Objective: Miniplates offer superior clinical handling and facilitate postoperative removal after mandibular reconstruction but unfavorable load distribution under high stress has been shown. This study aimed to compare the clinical outcome of patient-specific 3D-printed (PS-3D) titanium miniplate with reconstruction plate fixation in three-segmental LCL-type reconstructions for the first time. Methods: Patients undergoing three-segmental LCL-type mandibular reconstruction after malignant tumor resection between April 2017 and July 2023 were analyzed in a retrospective single-center study. Inclusion criteria were primary reconstruction using a fibula free flap and PS-3D titanium mini- or reconstruction plate fixation. Complication rates were recorded and analyzed within 6 months after surgery using the N -- 1 Chi²- and unequal variance t-test. Results: 38 patients (10 females, 28 males; mean age 61.4 ± 7.6 years) met the inclusion criteria. In 14 patients (36.8%) miniplates were used in the anterior region. Rates of fixation failure, plate exposure, incomplete osseous union, wound infection, soft tissue, and overall complications did not differ significantly between the two plate systems. Conclusion: Complication rates did not differ significantly between PS-3D miniand reconstruction plates in three-segmental LCL-type mandibular reconstructions. Given their advantages in clinical handling and postoperative removal, PS-3D miniplates can be a viable alternative also in larger mandibular reconstructio [ABSTRACT FROM AUTHOR]

Titanium plates and screws are common material used for rigid bone flap fixation after retrosigmoid craniotomy such as microvascular decompression (MVD). We conducted this study to evaluate outcomes of the free bone flap cranioplasty without fixation in MVD and compared its postoperative complication rate with routine methods. We retrospectively reviewed all patients who underwent MVD at our institution from May 2017 to August 2022. Patients were divided into two groups according to whether the bone flap was fixed or not. Follow-ups periods spanned 6–28 months after the operation. Of 189 patients who underwent MVDs via retrosigmoid approach, 79 cases (42%) had their bone flaps replaced without titanium fixation after craniotomies (< 3 cm x 3 cm). Compared to fixed bone flap group, free bone flap group had shorter operative time (105.56 ± 15.87 min vs. 113.72 ± 17.80 min, P = 0.001), less in-patient costs (¥23059.66 ± 4488.54 vs. ¥27714.82 ± 2705.74, P < 0.001), and less proportion of postoperative headache and incisional pain (43.0% vs. 60.9%, P = 0.015). One case of incisional cerebrospinal fluid leak happened in free bone flap group while one case of incisional infection happened in fixed bone flap group. No statistical difference in bone flap displacement, duration of postoperative hospital stays or complication rate was found between the two groups. Nineteen patients in free bone flap group received long-term CT follow-up and all were proved to have good skull union. This study proves that free bone flap cranioplasty in MVD without titanium plate fixation can shorten the operation time and reduce hospitalization expenditure without increasing complication rates. [ABSTRACT FROM AUTHOR]

This report describes two similar cases in which the distal forearm was compressed between the rib cage and floor for a prolonged period owing to immobility, resulting in severe compartment syndrome and extensive penetrating necrosis in the forearm. The cases were a 59-year-old man with cervical spondylolisthesis and a 65-year-old man suspected of having Parkinson's disease. A distinctive necrotic pattern characterized by necrosis in the volar and dorsal compartments, preservation of the lateral compartment, and retention of the radial artery was commonly observed in both cases. Despite the anticipated nonfunctional outcome of the salvaged limb, a two-lobed free latissimus dorsi musculocutaneous flap transfer with interposition of the thoracodorsal nerve in the median nerve defect was performed in both cases. Although the salvaged limbs were nonfunctional, the patients were able to use it for activities such as getting up and other daily tasks. [ABSTRACT FROM AUTHOR]

Background: Owing to its unique characteristics, the lateral circumflex femoral artery perforator (LCFAP) flap is often preferred for repairing head wounds with exposed skulls. However, given the vascular distribution in the head, particularly the veins, can lead to postoperative complications such as venous congestion of the flap. The rates of vascular exploration and necrosis in these flaps are significantly higher than in other body regions. Therefore, it is crucial to identify a safe and effective method for venous anastomosis of free flaps in the head region. Methods: This retrospective case series study included 10 patients with large head soft tissue defects treated at the Burn and Plastic Surgery Department of the Affiliated Hospital of Zunyi Medical University from January 2020 to December 2022. The head defects were reconstructed using LCFAP flaps, with flap veins anastomosed to the external jugular vein in the neck, either directly or via a bridging technique. Results: Among the 10 adult patients with massive head wound defects, 7 (70%) were men. The patients' mean age was 53.0 years (48--59 years). The wound defects were caused by trauma in 6 (60%) patients and by tumors in 4 (40%) patients. Postoperatively, no significant complications occurred, and all LCFAP flap survived without necrosis. Conclusion: The descending branch of the LCFAP flap effectively repairs massive head wound defects. The venous anastomosis method for this flap is associated with a low incidence of venous complications and a high patency rate, making it a clinically valuable reference. [ABSTRACT FROM AUTHOR]

Background: Perforator mapping is a mandatory tool for the preoperative planning of a microsurgical free flap, especially in breast reconstruction. Numerous methods for mapping have been described. In this study, we investigate the combined use of Dynamic Infrared Thermography (DIRT) and Colour Doppler Ultrasonography (CDUS) only to see whether it can eliminate the need for Computed Tomography Angiography (CTA). Methods: A prospective study was conducted on 33 patients with deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. DIRT, followed by CDUS and CTA, was performed preoperatively and perforators were confirmed intraoperatively. Results: From 135 hot spots found on DIRT, 123 perforators were confirmed by CDUS (91.11%). A total of 86.66% of the perforator vessels detected on CTA have their correspondent on DIRT, while 95.12% have their correspondent on CDUS. No statistically significant difference (p > 0.05) was found comparing DIRT vs. CTA and CDU vs. CTA. The average DIRT time was 121.54 s and CDUS 232.09 s. The mean sensitivity for DIRT was 95.72% and 93.16% for CDUS. Conclusion: DIRT combined with CDUS can precisely and efficiently identify suitable perforators without the need for CTA in DIEP breast reconstruction. [ABSTRACT FROM AUTHOR]

BACKGROUND: Coverage of soft tissue defects following surgery at the trochanteric area is challenging. Revision surgery in case of compromised wound healing may lead to soft tissue defects requiring reconstruction with pedicled or free flaps. Previous access to the hip joint may jeopardize neurovascular structures relevant to the flap. OBJECTIVE: In this study, we evaluated if the use of a pedicled anterior lateral thigh (ALT) flap is a valuable option for soft tissue reconstruction. METHODS: In this retrospective study, seven patients were included. Defect etiology was tumor resection in one case, screw osteosynthesis in another case and total hip arthroplasty in three cases. All patients underwent reconstruction by proximal pedicled anterior lateral thigh (ALT) flap. RESULTS: Pedicled ALT flap was a safe procedure in all cases. One patient showed delayed wound healing with need for additional surgery. No further complications were observed. CONCLUSIONS: Pedicled ALT flap transfer represents a reliable option for soft tissue coverage in the trochanteric area after primary surgery such as hip arthroplasty, osteosynthesis or tumor resection. [ABSTRACT FROM AUTHOR]

Anterior mandible defects result in loss of support for the tongue, floor of the mouth and lower lip, resulting in impairment of airway, feeding, and speech. We treated four patients with these "Andy Gump" deformities. Reconstruction was performed with two free flaps: a fibula osteocutaneous flap for the anterior mandible and floor of the mouth, and a soft tissue free flap for the lip, chin, and anterior neck. The lower lip was suspended cranially with fascia or tendon grafts ± mini-temporalis turndown flaps. All flaps survived completely. All patients were tube feed-dependent before surgery; they all resumed an oral diet. All tracheostomies were decannulated. Lip competence was restored as evidenced by cessation of drooling. Speech improved from unintelligible to intelligible with frequent repetitions. Objective assessment was performed with the functional intraoral Glasgow scale; the mean FIGS score improved from 3.25 (range 3–4) to 11 (range 9–13). We conclude that composite anterior mandible and tongue defects have large tissue requirements that require multiple free flaps. Reconstruction leads to significant improvement in function. [ABSTRACT FROM AUTHOR]

Background: Non‐graftable or composite defect reconstruction represents a major challenge to the reconstructive surgeon, with many wounds requiring local flap or free microvascular tissue transfer approaches. The recent advent of synthetic skin substitutes such as Biodegradable Temporizing Matrix (BTM) have revolutionized the management of complex defects including those caused by burns, trauma and infection, with low‐morbidity and low‐complexity surgery. However, limited data exist supporting their use in cancer reconstruction in Australia. Methods: We performed a prospective cohort study of patients undergoing cancer resection and reconstruction with BTM between February 2021 and February 2023 in our institution. Reported outcomes included matrix integration, infection, and return to theatre. Results: Twelve patients underwent reconstruction of primary or secondary defects following cancer resection during this period. Eight patients were male, four female, mean age at surgery was 70 years. Pathology resected included squamous cell carcinoma (SCC) and melanoma of the head and neck, sarcoma resection of the lower limb, and osteoradionecrosis (ORN) of the scalp. T‐stage of primary tumours ranged from T2 to T4 and one in‐transit metastasis of melanoma. Four patients were treated with radiotherapy, two of whom received postoperative radiotherapy (PORT) and two who received neoadjuvant radiotherapy, three additional patients had an intervention to a previously irradiated wound bed for recurrence or ORN. Overall matrix integration was 83% (10/12), with a 50% integration rate (2/4) observed in the post‐radiotherapy group, requiring return to theatre for alternative reconstructive approaches. Conclusion: We report our experience with a synthetic dermal matrix (BTM) in cancer reconstruction, the largest cohort of this type in the Australian literature. BTM represents an exciting reconstructive tool for the cancer reconstructive surgeon, with a high rate of success and low morbidity. [ABSTRACT FROM AUTHOR]

With the widespread use of cosmetic surgery blepharoplasty, sunken upper eyelid deformities have become a common complication after blepharoplasty. Upper eyelid depression seriously affects the appearance of the eye and may be accompanied by incomplete lid closure and corneal ulceration. The main principles of repairing upper eyelid deformity after blepharoplasty are to restore normal anatomical relationships, release adhesions, and perform tissue filling to restore tissue volume. Tipped tissue flaps and free tissue grafts have been used to repair sunken upper eyelid deformities after blepharoplasty with good clinical results. Different treatment methods should be used for different cases of sunken upper eyelid deformity, depending on the patient's condition and complaints. Now, a review of the progress of treating upper eyelid depression after blepharoplasty with tipped tissue flaps and free tissue grafts is presented in conjunction with the analysis of domestic and international literature and a comprehensive comparison. [ABSTRACT FROM AUTHOR]

Microsurgical autologous breast reconstruction (MABR) remains the gold standard technique of breast reconstruction, providing a durable, natural, and aesthetically pleasing result. However, some patients may not be candidates for a traditional deep inferior epigastric perforator (DIEP) flap, either due to abdominal tissue paucity, the need for higher-volume reconstruction, or prior surgical procedures. In these patients, alternative flaps must be considered to achieve the optimal result. Such configurations include the conjoined (or double pedicle) DIEP flap, and alternative flaps such as the lumbar artery perforator (LAP) and profunda artery perforator (PAP) flaps, which can be combined in a stacked fashion. By combining multiple flaps in a conjoined or stacked fashion, breast reconstruction can be optimized to fulfill the three critical components of breast reconstruction in restoring the skin envelope, breast footprint, and conus shape. When harvesting multiple flaps, the surgical sequence of events must be meticulously planned to ensure an efficient and successful operation. Preoperative imaging can aid the surgeon in identifying the ideal perforator, assess for side branches for possible intra-flap anastomoses, expedite the operative time, and decrease intraoperative complications. Reconstructive surgeons should be familiar with the variety of configurations with conjoined and/or stacked flaps to address patient-specific reconstructive needs. [ABSTRACT FROM AUTHOR]

Background: Free muscle flaps can develop significant postoperative edema and wound exudation, thereby increasing interstitial pressure and potentially compromising microcirculation. While concerns exist regarding negative pressure wound therapy (NPWT) to compress free flaps and hinder monitoring, recent studies have indicated a reduction in edema and an increase in blood flow. Objective: To compare microcirculation in free latissimus dorsi muscle (LDM) flaps dressed with and without NPWT. Methods: This retrospective cohort study analyzed prospectively collected data of patients who received free LDM flap reconstruction. Patients were separated into two groups according to management with or without NPWT. Microcirculation was evaluated continuously for up to 72 h utilizing laser doppler flowmetry and tissue spectrometry. Results: In total, n = 61 patients (26 females, 35 males) with an average age of 56.90 (17.4) years were included. NPWT was applied in 12 patients, while a regular cotton dressing was used in 49 patients. Overall, no significant differences in the number of minor and major complications were observed between groups. Both groups showed an increase in microvascular flow over the investigated time period. The flow showed higher absolute values in the NPWT group, reaching statistical significance at 12 h post-anastomosis, p = 0.038. There was a tendency for lower rHb values in the NPWT group, without reaching statistical significance. Conclusions: The presented study confirms the increase in microvascular flow after NPWT application. Whilst ensuring continuous free flap monitoring utilizing laser doppler flowmetry and spectrometry, the data further support the safety of NPWT application without risking vascular compromise due to external compression. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined the preoperative risks and healthcare costs related to free flap revision in hypopharyngeal cancer (HPC) patients. Methods: A 20-year retrospective case–control study was conducted using the Chang Gung Research Database, focusing on HPC patients who underwent tumor excision and free flap reconstruction from January 1, 2001, to December 31, 2019. The impacts of clinical variables on the need for re-exploration due to free flap complications were assessed using logistic regression. The direct and indirect effects of these complications on medical costs were evaluated by causal mediation analysis. Results: Among 348 patients studied, 43 (12.4%) developed complications requiring re-exploration. Lower preoperative albumin levels significantly increased the risk of complications (OR 2.45, 95% CI 1.12–5.35), especially in older and previously irradiated patients. Causal mediation analysis revealed that these complications explained 11.4% of the effect on increased hospitalization costs, after controlling for confounders. Conclusions: Lower preoperative albumin levels in HPC patients are associated with a higher risk of microvascular free flap complications and elevated healthcare costs, underscoring the need for enhanced nutritional support before surgery in this population. Level of evidence: 3. [ABSTRACT FROM AUTHOR]

BACKGROUND Electrical burn injuries are more severe than thermal burns as they often extend into the subcutaneous tissue and cause necrosis of muscle, tendon and bone. Moreover electrical burns can occur at multiple sites requiring multiple staged procedures and reconstruction of soft tissue defects. Managing these defects, which expose vital structures, is challenging and must be tailored to the individual patients situation. Among various options for resurfacing the electrical burn wounds, pedicled loco-regional flaps offer simplest solution to cover exposed vital structures such as bones, tendons and vessels. AIMS AND OBJECTIVES 1. To find out simple loco-regional pedicled flap options to cover complex soft tissue defects caused by electrical burns involving different anatomical regions. 2. To study versatility and utility of pedicled flaps in electrical burn reconstruction. 3. To study the complications and management of pedicled flaps. METHODS The present study was conducted in the Department of Plastic Surgery, King George hospital, Vishakhapatnam from March 2024 to May 2024 for a period of 3 months. Electrical burns patients with soft tissue defects exposing vital structures, reconstructed by pedicled loco-regional flaps were included in the study. Patients requiring different resurfacing options from skin grafting to free flaps were excluded in the study. Electrical burns patients not giving consent for the study and patients who require amputations are excluded from study. A total number of 30 patients of electrical burns who require loco-regional pedicled flaps were included in the study after preoperative consent and necessary documentation. RESULTS Among 30 patients included in our study, males were more prevalent (25 men and 5 women) with a male to female ratio of 5:1, as trauma requiring flap cover was dominantly high in males. The median age was 33.6 years (range 16- 60). The median duration of hospital stay was 8 days (range 4-18). Among these upper limb defects (13) are more in number, scalp defects are 9, upper back and shoulder defects are 4, and lower limb defects are 4 in number. For reconstruction of these defects we have used 9 pedicled flaps for scalp defects, 5 groin flaps for hand and wrist defects, 2 abdominal flaps for forearm defects, 2 cross finger flaps for finger defects (entry wounds), 2 louvre flaps for multiple defects of palmar surface of fingers (contact burn), 2 thenar flaps for pulp defects of finger (entry wounds) and 3 reverse sural artery flaps for plantar defects (exit wounds) 1 medial plantar artery flap for exit wound on plantar aspect of foot. 4 out of 30 flaps (6.6%) were infected in the postoperative period, managed by appropriate antibiotics. In 2 out of 30 flaps (3.3%) we have encountered venous congestion which settled in late post-operative period. Marginal flap necrosis of 2-4 cm was seen in 4 out of 30 flaps (6.6%). CONCLUSION An effective and dependable method for rebuilding intricate soft tissue abnormalities resulting from electrical burns is the loco-regional pedicled flap. These can be particularly useful for patients in the hands of young plastic surgeons in emerging burn centers where higher surgical facilities are not available. [ABSTRACT FROM AUTHOR]