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BACKGROUND: We sought to review our institutions experience with dental implant placement in free flap jaw reconstruction to determine factors impacting restoration of dental occlusion. METHODS: Exactly 48 patients underwent free flap jaw reconstruction with or without dental restoration from 2017 to 2022. Primary outcome was achievement of restored dental occlusion after jaw free flap reconstruction. RESULTS: A total of 48 patients with a mean age of 59.8 ± 16.4 years underwent jaw reconstruction from 2017 to 2022. Ten patients (20.8%) received osteointegrated dental implants. Two patients received a temporary dental prosthesis, 12 ± 4 months after initial reconstruction. Three patients received a final prosthesis, with a mean time to final prosthesis of 17.7 ± 12.4 months. Five patients did not receive any prosthesis despite placement of implants. CONCLUSION: A minority of patients received dental implant placement with free flap jaw reconstruction and only a small subset of these received a definitive dental prosthesis.

Background: The Jaw‐in‐a‐Day (JIAD) procedure aims to achieve immediate functional occlusion via a single‐stage approach to maxillofacial reconstruction. While JIAD has gained popularity since its inception by Levine and colleagues, efficacy and outcome data remain limited. In this report, we discuss our experience with the JIAD technique at an Australian tertiary referral centre. Methods: A retrospective review of all JIAD procedures performed from April 2022 to December 2023 was conducted. Clinicopathologic data reviewed included demographic information, primary diagnosis, anatomical site of disease, and history of pre‐operative radiotherapy. Outcome measures of interest included operative time, number of implants placed, post‐operative complications and implant survival. Results: Nineteen patients were identified for the study. Two maxillary and 17 mandibular JIAD procedures were performed. The most common indications were squamous cell carcinoma (n = 8) and ameloblastoma (n = 5). Surgical complications included recipient site wound infection (n = 3), flap dehiscence (n = 2), haematoma formation (n = 1), and neck abscess associated with partial flap failure (n = 1). No total flap failures were identified. Of the 55 total implants placed, one implant failure occurred 2‐months post‐operatively. No loss of irradiated implants (n = 21) was observed. The median time to adjuvant radiotherapy was 57 days (range, 32–61). Eighteen of 19 patients (95%) achieved immediate dental rehabilitation, and 15/19 patients (79%) retained a functional prosthesis by the end of the follow‐up period. Conclusions: Our series supports the feasibility of single‐stage reconstruction for both benign and malignant indications. Further research is required to understand the long‐term functional, aesthetic, and health‐related quality‐of‐life outcomes with the JIAD technique. [ABSTRACT FROM AUTHOR]

Objectives: To investigate soft-to-hard tissue response following mandibular reconstruction and to develop a predictive model for projecting soft tissue movement. Materials and methods: In this retrospective study, 18 patients receiving mandibular reconstruction using a vascularized iliac flap were enrolled. Various indicators for characterizing the movement of tissues were considered to identify the effective predictors for projecting soft tissue movements. Face-region-specific linear regression models for prediction were constructed and evaluated. Results: The arithmetic mean of hard tissue movement in an extended area had the strongest correlation with the movement of the focal soft tissue, while the arithmetic mean in a regional area (Ram) was a more effective predictor. The linear regression model using Ram, global extrema and distances between them as the predictors performed the best in the lower margin of the face, with an average error of 1.51 ± 1.38 mm. Soft tissue movement in the alveolar process was not correlated with the existence of dentition, only can be predicted by the soft tissue movement below it. The area of the masseter was strongly correlation with Ram, but no other factors. Conclusions: An accurate prediction of soft tissue movements in the lower margin and the alveolar process of the face can be achieved by considering hard tissue and adjacent soft tissue movements. No effective predictor in the masseter area was identified. Clinical relevance: We investigated the relationship between hard tissue movements and the soft tissue responses in the facial area. Through building predictive models for projecting postoperative soft tissue movements, we derive insights for the aesthetic outcome of face surgeries. Clinical trial registration: This study was registered on the Chinese Clinical Trial Registry (registration number: ChiCTR2100054103). [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]

Surgical intervention for medication-related jaw osteonecrosis (MRONJ) is currently the main treatment method, offering a higher healing rate than conservative approaches. However, the management of bony defects after sequestrectomy remains a challenging issue due to poor vascularization from the drug effect. The use of pedicled buccal fat pad (PBFP) for filling bone defects has become common and effective but is limited to the posterior maxillary region. To add to the advantages of the buccal fat pad, we explored a novel treatment approach using a free buccal fat pad (FBFP) to fill bone defects other than the posterior maxilla. While the FBFP has been employed in oral defect reconstruction, currently published cases have been utilized in recipient sites with good blood supply. There has yet to be any usage in poor vascularization defects like MRONJ. This article describes that the FBFP was used to fill the surgical defects of 8 patients who were diagnosed with MRONJ and who underwent sequestrectomy and saucerization. During follow-up visits, there was excellent wound healing and no significant tissue depression. Based on successful treatment experiences, FBFP is a reliable therapeutic option for the management of poor vascularization defects like MRONJ treated through surgical intervention.

Purpose: This study aims to evaluate the factors most associated with early and late complications following microvascular free tissue transfer (MVFTT) after mandibulectomy. Methods: A retrospective review of patients undergoing MVFTT after segmental mandibulectomy from September 2016 to February 2021 was performed across a single academic institution. Surgical variables were collected, including the location of the resultant mandibular defect (anterior vs posterior) and flap type (osseous or non-osseous). The primary outcome variables included postoperative complications (early, <90 days; and late, >90 days) and the patients' functional status (return to oral intake). Descriptive statistics, chi-square test, Fischer's exact test, and 2-sample t tests were used to analyze differences among variables. Results: We analyzed a cohort of 114 consecutive patients with mandibular defects, comprising 57 anterior and 57 posterior defects. Bony free flaps with hardware were used to reconstruct 98% of anterior defects compared to 58% of posterior defects (P <.001). All soft tissue only flaps did not utilize any hardware during the reconstruction. Anterior defects demonstrated more late complications requiring additional surgery (30% vs 9%, P =.04). A secondary analysis of posterior mandibular reconstructions compared soft tissue only flaps and bony free flaps with hardware and showed equivalent rates of early (12% vs 13%, P >.99) and late (9% vs 8%, P >.99) complications requiring additional surgery while demonstrating a similar return to full oral competence (55% vs 46%, P =.52) and recovery of a 100% oral diet (67% vs 54%, P =.53). Conclusion: Osseous free tissue transfer for segmental mandibular defects remains the gold standard in reconstruction. In our patient cohort, anterior mandibular defects are associated with greater late (>90 day) complications requiring additional surgery. Comparable outcomes may be achieved with soft tissue only versus osseous free flap reconstruction of posterior mandibular defects. [ABSTRACT FROM AUTHOR]

The aim of this study was to describe the authors' experience in head and neck reconstruction with the tensor fascia lata perforator flap (TFLPF). Between April 2009 and August 2020, 16 patients underwent head and neck reconstruction with a TFLPF. The flaps were designed in a vertical or transverse fashion based on perforators traveling along the medial or lateral aspect of the posterior edge of the tensor fascia lata muscle. Clinical details and postoperative results were recorded and analyzed. The size of the flap ranged from 7 × 5 cm2 to 25 × 9 cm2. The perforators were mostly septocutaneous (11 patients), allowing a simple and straightforward dissection of the perforator and TFLPF in most patients. There were either one or two perforators in all cases. The overall flap survival rate was 100%. All of the flaps healed uneventfully with no delayed wound healing or donor site dysfunction. Follow-up ranged from 18 to 120 months, during which all patients experienced satisfactory functional and aesthetic results, without serious complications at either the recipient or donor site. The TFLPF is a pliable and reliable flap that could be a first choice in selected head and neck reconstruction cases. [ABSTRACT FROM AUTHOR]

The functional restoration of Brown class III maxillary defects is a challenging endeavour in oral and maxillofacial surgery. Conventional reconstruction techniques with osseous free flaps have certain limitations, such as the need for multiple operations and greater patient morbidity. This study introduces a single-stage computer-assisted approach for tumour resection and functional restoration of these defects using titanium mesh, zygomatic implants, and a vascularized anterolateral thigh flap (ALTF). Virtual surgical planning was used to simulate tumour resection, titanium mesh placement, and zygomatic implant insertion. Surgery was performed under the guidance of mixed reality and surgical navigation. The tumour was resected by total hemimaxillectomy, and the reconstruction was performed using a pre-bent patient-specific titanium mesh for the orbital floor and two zygomatic implants placed and exposed through tunnels in an ALTF. The ALTF survived without any perioperative complications. A fixed prosthesis with built-in titanium frame was delivered 4 months postoperatively. At the 1-year follow-up, there was no tumour recurrence, the implants were osseointegrated, and aesthetics and masticatory function were satisfactory. An occlusal force of 155 N was attained on the reconstructed side, compared to 127 N on the non-surgical side. [ABSTRACT FROM AUTHOR]

Surgical intervention for medication-related jaw osteonecrosis (MRONJ) is currently the main treatment method, offering a higher healing rate than conservative approaches. However, the management of bony defects after sequestrectomy remains a challenging issue due to poor vascularization from the drug effect. The use of pedicled buccal fat pad (PBFP) for filling bone defects has become common and effective but is limited to the posterior maxillary region. To add to the advantages of the buccal fat pad, we explored a novel treatment approach using a free buccal fat pad (FBFP) to fill bone defects other than the posterior maxilla. While the FBFP has been employed in oral defect reconstruction, currently published cases have been utilized in recipient sites with good blood supply. There has yet to be any usage in poor vascularization defects like MRONJ. This article describes that the FBFP was used to fill the surgical defects of 8 patients who were diagnosed with MRONJ and who underwent sequestrectomy and saucerization. During follow-up visits, there was excellent wound healing and no significant tissue depression. Based on successful treatment experiences, FBFP is a reliable therapeutic option for the management of poor vascularization defects like MRONJ treated through surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Degloving soft tissue injuries (DSTIs) are defined as detachment of skin and its appendages from underlying muscle fascia. The present study aimed to assess the outcome of open circumferential DSTIs of lower limbs using a staged protocol by utilizing the stored skin graft harvested from degloved skin flaps. Methods: This retrospective study included 12 patients with open circumferential lower limb degloving injuries (Arnez types three and four), with a minimum final follow-up of two years. All the patients were treated using a staged protocol, which included harvesting skin grafts from the degloved skin flaps, followed by refrigerator storage of the graft and stay sutures for the flap. The refrigerator-stored graft was then used to cover the raw areas left after secondary debridement. Results: The mean wound area per patient that required skin grafting was 1082.9 ± 679.0 cm², and mean area of the wound covered by refrigerator-preserved skin graft per patient was 798.7 ± 350.0 cm². One patient needed a latissimus dorsi flap, and three patients with whole limb degloving had to undergo skin grafting for the remnant raw area harvested from the contralateral thigh. None of the patients ended up with amputation. Conclusion: Despite being rare, open DSTIs are very complex injuries with no definitive guidelines for management, especially Arnez type three and four injuries. The staged protocol presented in the present series potentially answers the dilemma. However, larger multi-centric trials are needed to study the outcome of the discussed staged protocol. [ABSTRACT FROM AUTHOR]

This case addressed patient and free flap survival after cardiac arrest with the contentious use of vasopressors amid concerns about potential vasoconstrictive effects on flap vitality. A 59-year-old male with mucoepidermoid carcinoma underwent post-total maxillectomy and double free flap reconstruction (free fibular flap and anterolateral thigh free flap). Intraoperatively, he experienced cardiac arrest after anastomosis due to hypovolemia or hypoxia, requiring external cardiac massage and vasopressor administration. Despite the initial restoration of circulation, subsequent cardiac arrest ensued, necessitating further resuscitation. Postoperatively, vasopressors were also administered due to hemodynamic instability. Contrary to concerns, both flaps demonstrated sustained vitality, challenging prevailing apprehensions about vasopressor-induced vasoconstriction compromising flap viability. This observation suggests that vasopressors may not significantly threaten flap viability, prompting reconsideration of hesitations and encouraging further investigation. The study advocates for a judicious evaluation of vasopressor administration in free flap procedures, enriching clinical considerations for optimal patient care. [ABSTRACT FROM AUTHOR]

Nail growth disturbance commonly takes place after trauma or relevant diseases, such as infections and tumors. However, abnormal growth of the nail plate sometimes occurs without an obvious causative factor. This report presents the case of a patient who underwent male genital reconstruction with a radial forearm free flap for gender affirmation. Although the entire process was smooth, with no accidental events, the second, third, and fourth phalangeal nail plates of the hand from which the flap was harvested showed no evident growth of the fingernail 2 months postoperatively. Nail production was preserved in the remaining fingernails. Typical symptoms, such as redness, swelling, and tenderness, were noted upon clinical observation. Eventually, nail production restarted 5 months after surgery. Steroid and antibiotic treatment was attempted to reduce periungual inflammation. Additionally, close observation with psychological support was conducted. [ABSTRACT FROM AUTHOR]

The superficial temporal artery (STA) bifurcates into frontal and parietal branches. The parietal branch is used as a recipient vessel for scalp reconstruction, but it is absent in approximately 16.3% of individuals. In this case, a 72-year-old woman with an occipital scalp defect lacked both the parietal branch of the STA and the superficial temporal vein. To address this anatomic variation, we used the frontal branch of the STA and the posterior auricular vein as alternative recipient vessels for anterolateral thigh free flap reconstruction. The surgical procedure involved end-to-end microvascular anastomosis of one artery and one vein. Partial flap necrosis occurred postoperatively, but eventually resolved with debridement. The frontal branch of the STA and the posterior auricular vein can serve as reliable alternatives in the absence of the parietal branch. Reconstructive surgeons should be aware of anatomic variations of the STA and adapt their surgical approach accordingly. [ABSTRACT FROM AUTHOR]

The volume of the reconstructed tongue is considered a critical factor for tongue function. Studies investigating the difference in volume loss between the anterolateral thigh free flap (ALTF) and radial forearm free flap (RFFF) used in reconstruction of the tongue after hemiglossectomy are lacking. The aim of this study was to determine whether there is a significant difference in shrinkage between these two flaps. This was a retrospective study of all patients treated for tongue cancer by hemiglossectomy who underwent either ALTF or RFFF reconstruction at the University of Florida College of Medicine between January 2018 and April 2022. Computed tomography scans were used to measure the volumetric changes in the ALTF and RFFF at two time points over a 6-month period. Of the 85 patients assessed, 10 fulfilled the inclusion criteria: five were reconstructed with an ALTF and five with a RFFF. All underwent adjuvant radiotherapy. The mean ALTF percentage shrinkage was 39.6% ± 3.9%, while for the RFFF it was 51.1% ± 6.2% (P = 0.008). Therefore, it is recommended that the difference in volume loss between the two flaps is taken into consideration. It is suggested that in hemiglossectomy cases, the ALTF is made 1.4 times larger than the defect, while the RFFF is made 1.5 times larger. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the three-dimensional (3D) operating exoscope (OE) with the conventional operating microscope (OM) in head and neck reconstruction. A retrospective cohort study was performed including 50 consecutive patients with no history of previous surgery or irradiation (32 male, 18 female; mean age 59.2 ± 13.3 years), who underwent free flap head and neck reconstruction using a 3D OE (n = 25; OE group) or conventional OM (n = 25; OM group). The mean total operative time was 8.0 ± 1.53 h in the OE group and 7.6 ± 1.52 h in the OM group (P = 0.86). The median (interquartile range) anastomosis time was 78.0 (63.0–91.5) minutes in the OE group and 90.0 (75.5–115.0) minutes in the OM group (P = 0.06). The final free flap survival rate was 100%. Only seven patients experienced a free flap reconstruction-related complication, and they were similarly distributed between the two groups (four in the OE group, three in the OM group; P = 0.68). Secondary outcomes (length of hospital stay, tracheostomy dependence, feeding tube dependence) were comparable in the two groups (P > 0.05). The 3D OE is a viable alternative to the conventional OM for performing standard head and neck free flap reconstructive procedures. [ABSTRACT FROM AUTHOR]

Background: Vascularized gastroepiploic lymph node transfer (VGLNT) is a well-accepted surgical treatment for restoring physiological function in chronic lymphedema. However, the inclusion of substantial lymph nodes (LNs) in the flap remains uncertain. This study aimed to identify the anatomical basis for reliable flap harvest for VGLNT. Patients and Methods: The anatomy of perigastric station 4d LNs was studied in healthy cadavers (n = 15) and patients with early gastric cancer (EGC) (n = 27). The omentum was divided into three segments: proximal, middle, and distal from the origin of the right gastroepiploic vessels. The flap dimension, number, location, size of LNs, and caliber of the vessels were reviewed. Eight patients underwent VGLNT for upper/lower limb lymphedema. Results: The mean numbers of LNs in the proximal, middle, and distal segment were 2.5, 1.4, 0.5 in the cadavers, and 4.9, 2.7, 0.7 in the gastrectomy specimens, respectively. The proximal third included a significantly greater number of LNs than the distal third in the cadaveric (p = 0.024) and ECG (p = 0.016) specimens. A total of 95% of the LNs were located within proximal two-thirds of the flap from the vessel origin both in the cadavers (21.0 × 5.0 cm) and in the gastrectomy specimens (20 × 3.5 cm). In VGLNT, the transferred flap was 25.5 ± 6.9 × 4.1 + 0.7 cm in dimension, containing a mean number of 6.5 ± 1.9 LNs. At postoperative 6 months, the volumetric difference was significantly reduced by 22.8 ± 9.2% (p < 0.001). Conclusions: This study provides a distinct distribution pattern of station 4d LNs. Inclusion of the proximal two-thirds of the flap, which carries majority of the LNs, is recommended for VGLNT. [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.

Abstract Background Early oral feeding has been previously postulated to contribute to developing postoperative complications following head and neck reconstructive surgeries using free flaps. This study assessed the association between the timing of oral feeding (early vs. late) and postoperative complications and length of hospital stay among these patients. Method PubMed, Scopus, Cochrane, and Web of Science were searched using terms such as “oral feeding” and “head or neck cancer.” We utilized RevMan software version 5.4 for the analysis. The study defined early oral feeding as feeding within 5-day post-operation, while late oral feeding was defined as feeding after the fifth postoperative day. Five papers that met the inclusion criteria were included in the analysis, with 1097 patients. Results The results showed that early feeding was not significantly associated with postoperative fistulas (RR 0.49, 95% CI 0.23 to 1.05, p-value = 0.07), hematoma/seroma (RR 0.71, 95% CI 0.33 to 1.51, p-value = 0.38), or flap failure (RR 0.84, 95% CI = 0.38 to 1.87, p-value = 0.67). However, early oral feeding was significantly associated with shorter hospital stays than late oral feeding (MD −3.18, 95% CI −4.90 to −1.46, p-value = 0.0003). Conclusion No significant difference exists between early and late oral feeding regarding the risk of postoperative complications in head and neck cancer (HNC) patients who underwent free flap reconstruction surgery. However, early oral feeding is significantly associated with a shorter hospital stay than late oral feeding. Thus, surgeons should consider implementing early oral feeding after free flap reconstruction in HNC patients.

Background: Traumatic injuries to the lower extremities are frequently accompanied by extensive soft tissue loss, combined with vascular damage or exposure of bony tissues, making it difficult to reconstruct; consequently, patients are commonly at risk of amputation. Due to its superior anatomical and biochemical properties, the omental flap has been used to reconstruct soft tissue defects for decades. However, few studies have reported the omental flap's effectiveness in treating severe and complex lower extremity deformities. We attempted to use a laparoscopically harvested omental flap in conjunction with a second-stage skin graft to reduce infections during limb preservation, increase flap survival probability, and restore the aesthetic and functional integrity of the affected extremity. Methods: Seventeen patients with severe lower extremity wounds underwent omental flap transplantation and were followed up for 6 to 12 months to check for surgical complications, evaluate cosmetic results, and ensure proper limb function. Results: There were no complications, such as intestinal adhesion, intestinal volvulus, and peritonitis, with any of the omental grafts. The affected extremities were well-functioning and aesthetically pleasing. Conclusion: Laparoscopically harvested omental flap transplantation with skin grafting is an alternative reconstruction technique for severe lower extremity injuries with massive soft tissue loss and exposed bones and tendons.

Total laryngectomy is an operation mainly employed in recurrent laryngeal and hypopharyngeal carcinoma after previous radiotherapy. The most feared complication after this procedure is a pharyngocutaneous fistula. An extremely rare complication is the development of osteomyelitis of the cervical spine, which is associated with high rates of neurological impairment and epidural empyema, often requiring surgical treatment. This report describes the case of a patient with neck and shoulder pain and progressive motor weakness of the left deltoid and biceps muscle, caused by a pharyngo-cervicospinal fistula with spinal empyema. This condition resulted in destructive osteomyelitis of the cervical spine. A successful reconstruction of the cervical spine and neopharynx was performed using a free vascularized fibula bone and skin graft in a complex area because of previous treatments. It appears that no similar case has been described previously. [ABSTRACT FROM AUTHOR]

Various methods currently exist to guide fibular osteotomy positioning in fibula free flap mandibular reconstruction, but patient-specific navigation methods and cutting guides require experience, and may be time-consuming and/or expensive. This study describes a robot-guided osteotomy technique for mandible reconstruction using a fibula free flap according to virtual preoperative planning. The method was assessed on five 3D-printed models and a cadaveric model. The precision of the robot-guided osteotomy was evaluated by measuring the deviations between the lengths and angles of the fragments obtained and those of the virtual planning. The average deviation of the anterior and posterior crest lengths was 0.42 ± 0.29 mm for the 3D-printed models and 1.00 ± 0.53 mm for the cadaveric model. The average angle deviation was 1.90 ± 1.22° and 1.94 ± 0.69° for the 3D-printed and cadaveric models, respectively. The results of this preclinical study revealed that fibular osteotomy positioning guidance using a robot-positioned cutting guide may be a precise, easy-to-use technique that could be tailored for fibula free flap mandibular reconstruction. [ABSTRACT FROM AUTHOR]

Background: Early oral feeding has been previously postulated to contribute to developing postoperative complications following head and neck reconstructive surgeries using free flaps. This study assessed the association between the timing of oral feeding (early vs. late) and postoperative complications and length of hospital stay among these patients. Method: PubMed, Scopus, Cochrane, and Web of Science were searched using terms such as "oral feeding" and "head or neck cancer." We utilized RevMan software version 5.4 for the analysis. The study defined early oral feeding as feeding within 5-day post-operation, while late oral feeding was defined as feeding after the fifth postoperative day. Five papers that met the inclusion criteria were included in the analysis, with 1097 patients. Results: The results showed that early feeding was not significantly associated with postoperative fistulas (RR 0.49, 95% CI 0.23 to 1.05, p-value = 0.07), hematoma/seroma (RR 0.71, 95% CI 0.33 to 1.51, p-value = 0.38), or flap failure (RR 0.84, 95% CI = 0.38 to 1.87, p-value = 0.67). However, early oral feeding was significantly associated with shorter hospital stays than late oral feeding (MD −3.18, 95% CI −4.90 to −1.46, p-value = 0.0003). Conclusion: No significant difference exists between early and late oral feeding regarding the risk of postoperative complications in head and neck cancer (HNC) patients who underwent free flap reconstruction surgery. However, early oral feeding is significantly associated with a shorter hospital stay than late oral feeding. Thus, surgeons should consider implementing early oral feeding after free flap reconstruction in HNC patients. [ABSTRACT FROM AUTHOR]

Purpose: Complex traumatic upper extremity injuries often require microvascular free tissue transfer for adequate soft tissue coverage or functional reconstruction. The need for rapid coverage is acknowledged, but the optimal timing for reconstruction remains a subject of debate. Methods: A retrospective review was conducted of patients who underwent free flap reconstruction for upper extremity injuries after trauma from March 2012 to August 2018 in South Korea at a facility specializing in extremity trauma. Surgical timing was categorized according to the classification of Godina into early (within 72 hours after injury) and delayed (from 72 hours to 3 months after injury) reconstruction. Patients' demographic characteristics, methods of free tissue transfer, flap failure rates, postoperative infections, total hospital stays, and the number of operations required were analyzed. Results: In total, 80 free tissue transfers were conducted on 76 patients. The demographics and characteristics of patients in the early and delayed reconstruction groups showed no significant differences. Early reconstruction was associated with a significantly lower infection rate, shorter average hospital stay, and a lower average number of operations, without showing a significant difference in the flap failure rate. Conclusion: The results of this study indicate that early reconstruction within 72 hours after trauma significantly reduces infection rates, the length of hospital stays, and the number of required operations. This study underscores the importance of timely intervention in upper extremity free flap reconstruction for optimal patient outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the medico-economic impact of the MACD Coupler™ system in comparison with HSA for end to end veno-venous anastomosis during free flap transfer. A retrospective case-control study was performed in an academic institution, from March 2019 through July 2021, to analyze medical and economic outcomes of patients managed for head and neck reconstruction with free flap transfer. 43 patients per group were analyzed. Rates of initial success, re-intervention, complications and flap transfer failure were not different between groups. Use of MACD increased the cost of medical devices between Coupler and Control groups with respectively K€ 0.7 [0.5; 0.8] and K€ 0.1 [0.5; 0.8] (p = 0.001) and decreased the cost for operating staff with respectively K€ 4.0 [3.4; 5.2] and K€ 5.1 [3.8; 5.4] (p = 0.03). The total management costs were not different between groups with respectively a total median cost of K€ 18.4 [14.3; 27.2] and K€ 17.3 [14.1; 23.7] (p = 0.03). In conclusion, the cost of the Coupler™ is significant but is partly offset by the decrease in operating staff costs. The choice of one or the other technique can be left to the discretion of the surgeon. [ABSTRACT FROM AUTHOR]

Subtotal or total glossectomy for advanced tongue cancer has an adverse impact on swallowing. The purpose of this retrospective study was to analyse postoperative swallowing outcomes and to determine the ideal reconstruction method in these patients. The clinical and swallowing data of patients with tongue cancer who underwent subtotal glossectomy at the study institution between 2005 and 2019 were reviewed retrospectively. Data were available for 101 patients. The most common reconstruction method was a free rectus abdominis musculocutaneous flap (69 cases). The postoperative feeding tube dependency rate was 11.1% at discharge and 9.4% at 1 year. During the study period, laryngeal suspension and/or a cricopharyngeal myotomy was performed in 39 patients (38.6%), with 25 of these operations performed after 2017. Patients treated in 2017–2019 were significantly more able to take thin liquid (P < 0.001) and lost less weight (P = 0.015) compared to those treated in 2005–2016. Multivariate analysis of 61 patients who did not undergo laryngeal suspension and/or cricopharyngeal myotomy showed significant feeding tube dependency in those aged 65 years and older (P = 0.004). Thin liquid intake was significantly improved after subtotal glossectomy with laryngeal suspension, which led to better postoperative swallowing and improved quality of life. [ABSTRACT FROM AUTHOR]

Large soft tissue defects of the face often require free flap-based reconstruction. To avoid a conspicuous patch-like appearance, choosing flaps with a color similar to that of the adjacent facial skin is crucial. This study aimed to identify the flap types that show the best color match via objective color evaluation. Patients who underwent free flap-based facial reconstruction between 2013 and 2023 were retrospectively reviewed. Based on standardized photographs, average color samples of the flap skin paddle and adjacent skin were obtained. The color differences were compared by flap type at two different time points, early (within 1–3 months, post-operative) and late (after 1 year, post-operative), using the delta E value. Fifty-eight free flaps were analyzed, including 22 thoracodorsal artery perforator (TDAP) flaps, 17 anterolateral thigh (ALT) flaps, nine superficial circumflex iliac artery perforator (SCIP) flaps, and eight radial forearm (RF) flaps. In the analysis of early outcomes, the RF flaps showed the least color difference, followed by the SCIP and TDAP flaps, and the ALT flaps showed the greatest difference, with the differences being significant. Most cases showed generally improved color matching over time. Time-dependent changes were significant in the ALT and TDAP flap groups. In the analysis of late outcomes, all flap types showed delta E values less than 10, with the RF flaps showing the least color difference, followed by the SCIP flap. The four workhorse flaps provided acceptable outcomes with long-term improvements. The RF flaps provided the best color matching in the long run. [ABSTRACT FROM AUTHOR]

Surgery remains mainstay modality of treatment of STS of extremity. In majority of patients, primary closure is possible following surgical resection of the tumor. Primary closure of wound may not be feasible in tumors with large area of skin involvement and sometimes following a whoops procedure. We analyzed postoperative complications and oncological outcomes in patients who underwent free flap reconstruction. Thirty-seven patients who required a free flap for reconstruction of the defect following resection of the STS were included in the study. There were 26 men and 11 women with a mean age of 40 years. Seventy-three percent tumors were in lower limb; 62% patients had undergone a whoops procedure elsewhere. Flaps were fasciocutaneous in 19, myocutaneous in 15, and free muscle transfers in 3 patients. Seventeen patients had early surgical site complications. Nine patients had early flap failures. Of the 9, 6 patients had total loss of flap and in 3 the flaps were salvaged. Two patients had partial loss (< 50% of total area) of flap. Four patients had edge necrosis and two had suture diastasis. Nine patients had late surgical site complications. Four had post-radiotherapy wound dehiscence. Late SSI was noted in two. Late joint contracture and chronic lymphedema was seen in one patient each. One died due to sepsis. Statistically significant association was not found between patient, tumor or treatment-related factors and complications or flap failures. Mean duration of surgery was 7.73 h. Twenty-three patients required multiple surgeries due to complications. Mean time to initiate adjuvant therapy from the date of surgery was 47 days. Mean OS of the group was 67 ± 7.3 months. Mean RFS was 58 ± 7.8 months. Single-stage free flap reconstruction following surgical resection of extremity sarcoma is a viable option of reconstruction while salvaging the limb. Though associated with high rate of early surgical site complications, they are manageable. [ABSTRACT FROM AUTHOR]

The enhanced recovery after surgery (ERAS) pathway is designed to facilitate recovery after surgery by packaging evidence-based protocols specific to each aspect of the perioperative period, including the preoperative, intraoperative, postoperative, and post-discharge periods. The ERAS pathway, which was originally developed for use with colonic resection, is now being expanded to include a variety of surgical procedures, and the ERAS Society has published a consensus review of the ERAS pathway for head and neck surgery with free tissue transfer reconstruction (HNS-FTTR). The ERAS pathway for HNS-FTTR consists of various important protocols, including early postoperative mobilization, early postoperative enteral nutrition, abolition of preoperative fasting, preoperative enteral fluid loading, multimodal pain management, and prevention of postoperative nausea and vomiting. In recent years, meta-analyses investigating the utility of the ERAS pathway in head and neck cancer surgery have also been presented, and all reports showed that the length of the postoperative hospital stay was reduced by the implementation of the ERAS pathway. The ERAS pathway is now gaining traction in the field of head and neck surgery; however, the details of its efficacy remain uncertain. We believe the future direction will require research focused on improving the quality of postoperative patient recovery and patient satisfaction. It will be important to use patient-reported outcomes to determine whether the ERAS pathway is actually beneficial. [ABSTRACT FROM AUTHOR]

The radial forearm free flap (RFFF) is associated with donor site morbidity. This study aimed to quantify the functional and aesthetic outcomes after closure of the RFFF donor site using triangular full-thickness skin grafts (FTSGs) harvested adjacent to the flap or traditional split-thickness skin grafts (STSGs). The study included patients who underwent oral cavity reconstruction with an RFFF between March 2017 and August 2021. The patients were divided into two groups based on the donor site closure method: FTSG or STSG. The primary outcomes were biomechanical grip strength, pinch strength, and range of wrist movements. Subjective donor site morbidity, aesthetic and functional results were also analysed. The study included 75 patients (FTSG n = 35; STSG n = 40). Postoperatively, there was a statistically significant difference in grip strength (P = 0.049) and wrist extension (P = 0.047) between the FTSG and STSG groups, in favour of the STSG. Differences between the groups in pinch strength and other wrist motions were not statistically significant. The harvesting time was significantly shorter for the FTSG (P = 0.041) and the appearance of the donor site was better (P = 0.026) when compared to the STSG. Cold intolerance was more frequent in the STSG group (32.5% STSG vs 6.7% FTSG; P = 0.017). Subjective function, numbness, pain, hypertrophic scar, itching, and social stigma did not differ significantly between the groups. Compared with the STSG, the FTSG showed better cosmesis and avoided additional donor sites, with clinically negligible differences in hand biomechanics. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to introduce and evaluate a modified one-and-a-half-barrel fibular technique guided by occlusion for functionally reconstructing mandibular defects. Materials and Methods: Fifteen patients underwent mandibular reconstruction with the modified one-and-a-half-barrel technique and simultaneous insertion of dental implants. A vascularized fibular segment was used to reconstruct the alveolar ridge of the neomandible with dental implants loaded simultaneously. The inferior border was reconstructed with a nonvascularized segment. Panoramic radiographs were taken 1 week, 6 months, and 12 months after the surgery to measure the vertical height of the fibular segment, calculate the bone resorption rate at different time points, and observe the implant marginal bone loss and crown-to-implant ratio. The OHIP-14 questionnaire was employed to evaluate the perceived outcomes of oral rehabilitation. Results: The vertical height of the vascularized and nonvascularized fibular segments 1 week, 6 months, and 12 months after the surgery was 14.51 ± 1.93, 14.19 ± 1.88, and 13.81 ± 1.78 mm; and 8.65 ± 0.98, 7.72 ± 0.94, and 7.25 ± 0.93 mm, respectively. The bone resorption rate of vascularized and nonvascularized fibular segments was 2.20% ± 1.04% and 10.69% ± 5.73%, respectively, in the first 6 months, and 2.67% ± 1.44% and 6.16% ± 2.75%, respectively, in the latter 6 months, showing a significantly higher resorption rate in the nonvascularized segment (P < .05). The implant marginal bone loss after functional loading was significantly greater than that before dental rehabilitation (P = .001). The OHIP-14 total scores were 20.07 ±10.24, 19.00 ± 7.82, and 3.93 ± 1.87 before surgery, at 6 months, and at 12 months after surgery, respectively (P = .000). Conclusion: The proposed technique not only guarantees the esthetic appearance of patients but also achieves a suitable vertical height to facilitate the placement of the implant at the same time. [ABSTRACT FROM AUTHOR]

Abstract Background Lower lip squamous cell carcinoma is a significant subtype of head and neck cancer, constituting about 25–30% of cases. Traditional surgical methods, like primary closure, have limitations in managing large resections of lip tumors. Recent advancements in surgical techniques, particularly free flaps, have shown promising results in addressing these challenges. The Y-shaped anastomosis is an innovative approach aimed at enhancing the efficiency of microvascular free flap surgeries for improved lip cancer reconstruction outcomes. Case presentation A 77-year-old Persian male with lower lip squamous cell carcinoma underwent tumor resection with a 2 cm safety margin, bilateral neck dissection, and lip reconstruction using the right radial forearm free flap. The surgery incorporated a Y-shaped anastomosis to improve venous pedicle outcomes. Conclusion In this case, it was decided not to open the first anastomosis but to add the second end to the side one to provide two vascular supports for the venous anastomosis. Y anastomosis makes the surgery easier and decreases complications resulting from vascular size mismatch.

Background and objective. The outcomes and survival of microvascular flaps depend not only on surgical technique but also on various perioperative variables. Therefore, it is crucial to provide ideal conditions for the patient to ensure the survival of free flaps. We present our experience with standardized perioperative variables and additionally we conduct a brief retrospective comparison of the population undergoing free flap reconstruction before the implementation of control measures for these variables and the population in which this control was standardized. Methods. Patients undergoing microsurgical reconstruction with free flaps from 2020 to 2023 were managed under a set of predetermined standardized measures. The analysis includes 14 perioperative measures, considering flap loss as the dependent variable. Additionally, minor complications such as infections, dehiscences, hematomas and partial necrosis, among others, were documented. Each result was analyzed and compared with current scientific evidence to determine its utility. Results. A total of 86 patients were evaluated with cancer being the most common indication for surgery, followed by trauma. The flap loss rate was 5.8%, with thrombosis being the most frequent complication (80%). Minor complications included dehiscences, hematomas, and partial flap necrosis. The overall infection rate was 1.2%. Conclusions. Our study highlights the importance of various pre, intra and postoperative variables that directly or indirectly influence flap survival. Furthermore, it demonstrates that, in our case series, the standardized institutional perioperative management measures used have a positive outcome in the majority of patients, promoting the survival of free flaps and reducing the rate of minor complications. [ABSTRACT FROM AUTHOR]

Background: Lower lip squamous cell carcinoma is a significant subtype of head and neck cancer, constituting about 25–30% of cases. Traditional surgical methods, like primary closure, have limitations in managing large resections of lip tumors. Recent advancements in surgical techniques, particularly free flaps, have shown promising results in addressing these challenges. The Y-shaped anastomosis is an innovative approach aimed at enhancing the efficiency of microvascular free flap surgeries for improved lip cancer reconstruction outcomes. Case presentation: A 77-year-old Persian male with lower lip squamous cell carcinoma underwent tumor resection with a 2 cm safety margin, bilateral neck dissection, and lip reconstruction using the right radial forearm free flap. The surgery incorporated a Y-shaped anastomosis to improve venous pedicle outcomes. Conclusion: In this case, it was decided not to open the first anastomosis but to add the second end to the side one to provide two vascular supports for the venous anastomosis. Y anastomosis makes the surgery easier and decreases complications resulting from vascular size mismatch. [ABSTRACT FROM AUTHOR]

This case report presents two female-to-male (FTM) patients, aged 21 and 35 years, respectively, who underwent phalloplasty and urethral reconstruction at our institution. The patients' requests included a phallus >9 cm, concealed donor-site scars, and the ability to void while standing. In the first case, a 4.5×13-cm radial forearm free flap (RFFF) taken from the nondominant side was retrieved and anastomosed to the deep inferior epigastric artery and vein. Simultaneously, a 10×16-cm pedicled anterolateral thigh (ALT) flap was relocated to the genital area and wrapped around the RFFF after nerve coaptation. The second case involved a 5.5×14-cm RFFF and a 20×13-cm pedicled ALT flap using a similar procedure. Both cases had stable double flaps with no complications, and Foley catheters were removed at 14 days and 3 months after surgery, respectively. Double-flap phalloplasty is thus a viable option for patients with a short forearm circumference or a preference for a less visible forearm scar. [ABSTRACT FROM AUTHOR]

Purpose: Ablation of malignant neoplasms of the scalp usually leaves extensive defects. Free musculocutaneous transfer using the latissimus dorsi muscle with a skin graft has been the gold standard for restoring such defects; however, this approach may be limited by potential functional morbidity and delayed healing of the grafted skin. This study presents a case series of microsurgical reconstruction with thoracodorsal artery perforator (TDAP) flaps for extensive scalp defects after radical oncologic resection. Methods: Consecutive patients with malignant scalp tumors who underwent wide local excision and defect coverage with TDAP free flaps between April 2019 and January 2023 were evaluated. Operation-related data and surgical outcomes, including donorand recipient-site complications, postoperative shoulder function, and aesthetic results, were thoroughly assessed. As an oncologic outcome, local recurrence was also recorded. Results: Eleven patients who underwent reconstruction with an average flap size of 223.2 cm² (range, 160.0-406.0 cm²) were identified. The flaps were based on an average of 2.4 perforators. The donor-site wound was closed primarily in all cases. All flaps achieved complete wound healing within an average of 2 weeks and presented stable resurfacing of the scalp with satisfactory morphological outcomes. No functional shoulder disability was observed in the postoperative period. Five patients exhibited local recurrence but were appropriately treated in a timely manner. Conclusion: The free TDAP flap could be a potential, effective reconstructive tool for extensive scalp defects of oncologic origin and can overcome the recipient- and donor-site complications associated with the conventional procedure. [ABSTRACT FROM AUTHOR]

Objectives: The present study aimed to compare the influence of vertically coronally advanced flap (V-CAF) and free gingival graft (FGG) techniques on shallow vestibule depth (VD). Materials and methods: Parallel-arm randomized clinical trial was conducted on 38 sites treated with either FGG or V-CAF. Periodontal variables (VD, recession depth and width, probing depth, clinical attachment level, keratinized tissue height (KTH), and tissue thickness (TT)), clinician- and patient-based subjective variables were assessed. Results: All periodontal variables showed significant improvements in both groups at all follow-up intervals compared to baseline (p < 0.05). Both groups increased VD compared to baseline. RC and CRC were similar after treatment for both techniques. FGG provided a greater increase in KTH (p < 0.001) and VD (VD1, p = 0.02 and VD2, p < 0.001) while V-CAF exhibited more TT gain (p = 0.002). Except overall tissue appearance that was better in V-CAF (p < 0.001), no inter-group significant difference existed in patient-based variables. Conclusions: Both techniques were significantly effective in VD increasing. While both techniques were equally successful in RC, V-CAF provided higher TT gain and better tissue appearance. V-CAF can be chosen instead of FGG in the treatment of recessions with shallow VD. Clinical relevance: It can be recommended to prefer V-CAF instead of FGG in the treatment of shallow vestibule. Trial registration number: NCT05777811 (clinicaltrials.gov). [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to determine if there is a difference in dimensional change of a free soft tissue autograft (FSTA) with epithelium compared to without epithelium. The secondary aim is to determine the patient and professional evaluation of color match and graft texture between the two groups. Methods: Patients with ≤2 mm keratinized tissue indicated for a FSTA were randomly assigned to control group (FSTA with epithelium) or test group (de‐epithelialized FSTA). The vertical and horizontal measurements of the grafts were taken at surgery, and 1, 3, and 6 months postoperatively. Patients were asked to evaluate the color match at each postoperative time point on a 21‐step Numeric Rating Scale (NRS‐21). Professional assessment of color match and graft texture were evaluated on images at the same time points. Results: Forty‐six patients and 55 grafts were included in the study. For change in graft height, width, and area, there were no significant differences between the treatment groups at any time point. Graft height and area in both groups decreased significantly from baseline to month 1 (p <.001), but no other difference was significant over time. When patients and professionals used the NRS‐21 for evaluation of color match between the graft site and the surrounding soft tissue, there was no significant difference between the treatment groups. Similarly, evaluation of texture match on color images and black‐and‐white images revealed no significant differences between or within groups. Conclusion: De‐epithelialized FSTA showed no difference in dimensional change or color and texture match compared to FSTA with epithelium. [ABSTRACT FROM AUTHOR]

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Some surgeons have raised concerns regarding the sympathectomy-like effect of epidural anesthesia during lower limb microvascular reconstruction. The combined spinal-epidural (CSE) anesthetic technique incorporates several benefits of spinal and epidural techniques in a single approach. The aim of this study was to analyze the postoperative outcomes of patients undergoing soft-tissue reconstruction of the lower limb by implementing the CSE anesthesia approach. We reviewed medical records from patients who underwent lower limb reconstructive procedures under CSE anesthesia with free tissue transfer from January 2017 to December 2020. We evaluated the postoperative outcomes. Thirty-eight patients underwent microvascular reconstructive procedures of the lower extremity over the study period. The average age and BMI were 38.4-year and 28 kg/m2. All patients only had one postoperative rescue dose with epidural anesthesia. The most common type of flap used was the anterolateral thigh flap (53%). The average splinting time and length of stay (LoS) were 8.4 days and 18.4 days, respectively. Donor-site complications included wound dehiscence (3%) and surgical site infection (3%). Recipient-site complications included partial flap loss (8%) and total flap loss (10%). No pro re nata morphine analgesia was used. Tramadol and/or ketoprofen were administered for postoperative analgesia. The average time to start physiotherapy and to resume daily activities were 10 days and 29 days, respectively. The CSE anesthesia for microvascular reconstruction of the lower limb demonstrated a similar success rate compared to historical records. CSE provided adequate pain management and none of the patients required postoperative monitoring in the ICU. [ABSTRACT FROM AUTHOR]

Postoperative delirium (POD) following microvascular head and neck reconstruction negatively impacts patient outcomes, and only a few risk factors have been identified. The aim of this study was to identify additional risk factors for POD after intraoral reconstruction with microvascular free flaps. Data from 377 patients who underwent intraoral microvascular free flap reconstruction between 2011 and 2019 were analysed retrospectively. Preoperative, intraoperative, and postoperative variables were compared between 40 patients with POD and 40 patients without POD who were matched for previously identified risk factors (i.e., sex, age, American Society of Anesthesiologists class, preoperative arterial hypertension, tracheotomy, operation time, and blood transfusion). A multivariable regression analysis was then performed to identify risk factors associated with POD. POD occurred in 50 (13.3%) of the 377 cases studied; the median time of onset was postoperative day 2. Excessive preoperative alcohol consumption (odds ratio 9.22, 95% confidence interval 1.09–77.97; P = 0.041) and postoperative transplant revision (odds ratio 25.72, 95% confidence interval 1.26–525.43; P = 0.035) were identified as risk factors for POD. The identification of patients at high risk of POD based on these two risk factors may allow early adjustment of diagnostic and therapeutic modalities to improve outcomes and reduce healthcare costs. [ABSTRACT FROM AUTHOR]

Congenital melanocytic nevus (CMN) is a benign condition that either is present at birth or develops in the first weeks of life. Surgical removal is typically performed to improve cosmetic appearance and reduce the risk of malignant transformation. In this report, we present the case of a 26-year-old woman with a medium-sized CMN on her left breast. The nevus measured 14×8 cm, and the patient desired a single-stage excision. However, this approach would result in a large skin defect that would be challenging to reconstruct using a local flap or skin graft. Moreover, it could potentially compromise the maintenance of natural sagging and the contour of the breast. Consequently, we opted to place a thin thoracodorsal artery perforator free flap following the removal of the CMN. The patient was satisfied with the overall surgical results. By utilizing this free flap for reconstruction, we successfully preserved the natural shape and contour of the breast without complications such as postoperative hypertrophic scarring or contracture at the recipient site.

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

BACKGROUND: Frontal sinus cranialization with closure via bifrontal pericranial flaps is the gold standard for separating the nasofrontal recess from the intracranial cavity for posterior table defects. Despite the high success rate, cerebrospinal fluid (CSF) leak may persist and is particularly challenging when vascularized reconstructive options from the bicoronal incision are exhausted. OBJECTIVE: To assess a novel endonasal technique using an adipofascial radial forearm free flap delivered to the frontal recess through a Draf sinusotomy to repair complex CSF leaks from the frontal sinus. METHODS: A retrospective review of 3 patients (all male; ages 42, 43, and 69 yr) with persistent CSF leak despite frontal sinus cranialization and repair with bifrontal pericranium was performed. Etiology of injury was traumatic in 2 patients and iatrogenic in 1 patient after anaplastic meningioma treatment. To create space for the flap and repair the nasofrontal ducts, endoscopic Draf III (Case 1, 3) or Draf IIb left frontal sinusotomy (Case 2) was performed. The forearm flap was harvested, passed through a Caldwell-Luc exposure, and placed within the Draf frontal sinustomy. The flap vessels were tunneled to the left neck and anastomosed to the facial vessels by the mandibular notch. RESULTS: Intraoperatively, the flaps were well-seated and provided a watertight seal. Postoperative hospital courses were uncomplicated. There were no new CSF leaks or flap necrosis at 12, 14, and 16 mo. CONCLUSION: Endoscopic endonasal free flap reconstruction through a Draf procedure is a novel viable option for persistent CSF leak after failed frontal sinus cranialization.

Introduction: The flaps, whose function is to reduce or redirect tension during a closure, are classified based on their primary movement: transposition, advancement, and rotation, each with its characteristics, indications, and peculiarities. Combining the qualities of the transposition flaps with those of rotation, which make up the S-Apple flap, makes it more versatile and with better aesthetic results than the bilobed flap, which denotes the archetype for the appearance of the S-Apple. Method: Having the rotation and transposition flaps as an archetype, four flaps are made in the S-Apple flap, which are rotated and transposed to close the defect. This is excised in a circular format for the oncological safety of margins. The “S” of the flap is traced at a 30° angle in relation to the defect. The arm dimension must be the same diameter as the defect, with the flaps transposed as in a z-plasty, and the flap rotated to cover the defect, resulting from the exeresis of the lesion. Results: No necrosis, infection, dehiscence, recurrences, trapdoor scars, or rotation point elevation were observed. The scars were classified as satisfactory and extremely satisfactory. Conclusion: The S-Apple flap proved versatile and easy to mark with excellent aesthetic and functional results.

Introduction: Bevacizumab is among the most frequently used drugs in cancer treatment. There is evidence that some anti-angiogenic drugs reduce flap survival, but it is unclear whether this applies to Bevacizumab. We investigated the effect of Bevacizumab on the viability of free flaps in rats. Methods: The animals were randomly assigned to one of three groups. The Graft group received intravascular saline and was submitted to a full-thickness skin graft. The Flap-Saline and the Flap-BVZ groups underwent a free groin flap after receiving, respectively, intravascular saline solution or intravascular administration of Bevacizumab. Results: The Graft group showed a lower percentage of the viable area (22.81%) relative to the Flap-Saline (83.98%; p

Background: Custom-made alloplastic temporomandibular joint replacement (ATMJR) is not validated in irradiated patients. However, in specific situations, after previous reconstructive surgical failures, the authors hypothesized the role of a customized ATMJR after radiotherapy. Methods: A 65-year-old male patient was referred to Instituto Português da Face—Lisbon, Portugal—after failed attempts of mandibular reconstruction secondary to oral carcinoma resection and partial hemi-mandibulectomy plus radiotherapy of 60 total Grays. Primary reconstruction was performed with fibula free flap. Due to failure, secondary reconstructions were performed with osteosynthesis plate without success. The patient was unable to have adequate mastication and deglutition due to a severe crossbite. The authors treated the patient with an extended customized alloplastic temporomandibular joint replacement (F0M2). Results: With 3 years of follow-up, the patient showed an improvement in masticatory function, mandibular motion, pain levels, and overall quality of life. No complications were observed related to ATMJR. Conclusions: The presented case described how ATMJR, although not a validated option after radiotherapy, can be considered to restore functionality in complex cases with bone and soft tissues problems. [ABSTRACT FROM AUTHOR]

Background: Abdominal resection ([Ab-R]) is considered an absolute contraindication to abdominally based free flaps (Ab-FF). Yet, as Ab-FF is the current gold standard for autologous breast reconstruction, AQ2 the notion is controversial. Given that the technical feasibility and presumed risk of harvesting Ab-FF after Ab-R are related to postoperative vasculature, we sought to expand the literature by performing an imaging-based study comparing the vascular anatomy of patients undergoing either Ab-FF or Ab-R. Methods: We conducted a retrospective study of patients who underwent Ab-FF or Ab-R between 2018 and 2022 across three institutions. Patients were included if they had preoperative or postoperative computed tomography (CT) imaging with intravenous contrast of the abdomen of sufficient quality. Demographic, clinical, and operative characteristics were recorded, and abdominal wall vasculature was quantitatively analyzed using three-dimensional rendered CT scans. Individuals were categorized as preoperative "controls," "Ab-FF," or "Ab-R" for statistical comparison. Results: Of the 378 screened individuals, 64 individuals had either preoperative (n = 64) and/or post-Ab-FF (n = 12) or post-Ab-R (n = 10) images considered to be of sufficient quality to be included in our analysis. We observed that the mean diameter of superior vessels (at the origin) of postoperative images (Ab-FF 2.5 mm, Ab-R 2.6 mm) differed significantly from those observed preoperatively (control 1.5 mm). While all 12 cases of Ab-R revealed "prominent" (> 2 mm) superior vessels, these patterns were far less common in controls and after Ab-FF (P < 0.001). A subanalysis of individuals with pre- and postoperative images revealed that the prominent superior vessels appeared postoperatively and significantly more often after Ab-R than after Ab-FF (P = 0.001). Conclusions: This anatomic study demonstrates that the vascular patterns of the abdominal wall significantly differ after abdominal wall excision. Prominent superior vasculature was observed in all postoperative cases after Ab-R, whereas Ab- FF presented more often with prominent recanalization of inferior vessels. These findings enrich the understanding of the vascular response to Ab-R and Ab-FF and highlight areas for future investigation on the possibility of performing Ab-FF after Ab-R. Level of evidence: Level III, risk/prognostic study [ABSTRACT FROM AUTHOR]

Background and objective. The lateral arm flap is a coverage resource for the hand surgeon that has a wide variety of uses and applications due to its versatility and ease of collection with little morbidity from the donor site. The aim of this research is to carry out dissections of the lateral arm flap in cadavers of the Colombian population to describe the main anatomical variants and establish reference points for the development and improvement of current surgical techniques. Methods. Anatomical descriptive study of 10 upper limbs from fresh-frozen cadavers in which dissections were performed to document the main perforators of the lateral flap of the arm in the Colombian population. Distance measurements were taken from the perforators to the lateral epicondyle and ratios were obtained according to percentages of limb size. Likewise, the number of perforators in each quadrant and the diameter of the pedicles were quantified. Results. The results showed that in the lateral arm flap the order of appearance of the perforators from distal to proximal corresponds to 13, 19, 26 and 35% of the distance of the arm (between the epicondyle and the acromion); most of the perforators were found in the second quadrant, the second and fourth have less variation compared to the other perforators, the proximal pedicles have a larger diameter than the distal ones, the radial nerve was found at the exit the intermuscular septum on average 14.08 cm (+/- 0.83) from the epicondyle, this is a key reference for a careful dissection in order to avoid injury to it. Conclusions. In our study population, the lateral arm flap is highly versatile with a good number of perforators for its nutrition, which allows the surgeon multiple coverage options. The bone perforators of the distal humerus must be protected in the most distal portion to avoid complications such as bone necrosis, especially in children. An anterior approach to the pedicle axis allows them to be preserved, minimizing the risk of this potential complication. Our findings are consistent with previously published studies. [ABSTRACT FROM AUTHOR]

Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes. All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student's T-test, Chi-squared test, Fisher's exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction. Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively. We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results. [ABSTRACT FROM AUTHOR]