A Head-to-Head Comparison of the Medial Sural Artery Perforator versus Radial Forearm Flap for Tongue Reconstruction.

BACKGROUND: For tongue reconstruction, the radial forearm flap (RFF) is commonly used. In the last decade, the medial sural artery perforator (MSAP) flap has been successfully used with reportedly superior donor-site outcomes. Our study is the first to compare the RFF and MSAP for reconstruction of partial glossectomy defects (<50% of tongue). METHODS: We conducted a retrospective review of 20 patients with partial glossectomy defects reconstructed at a tertiary referral center. Patient demographics, perioperative data, and postoperative complications were analyzed. Objective measures of speech, swallowing, and subjective patient satisfaction with their donor site were recorded. RESULTS: Ten RFF and MSAP were each used, with a mean partial glossectomy defect size of 40.5 and 43.5%, respectively. The MSAP was significantly thicker (7.8 vs. 4.3 mm, p < 0.05) with a longer harvest time (122.5 vs. 75.0 minutes, p < 0.05). There were no cases of free flap failure. Donor-site healing times were comparable, but the MSAP group experienced significantly less donor-site complications (n = 1 vs. n = 7, p < 0.05). Functional outcomes were comparable with 13 patients achieving normal speech and diet after 3 months (MSAP = 6 vs. RFF = 7, p = 1.00). All patients were satisfied with their donor-site outcome with the MSAP group having a marginally higher score. CONCLUSION: Both flaps are good options for partial glossectomy reconstruction. Though more challenging to harvest, the MSAP gives comparable functional results and has become our first reconstructive option given its superior donor-site outcomes.

Comparison of Outcomes of Fasciocutaneous Free Flaps and Jejunal Free Flaps in Pharyngolaryngoesophageal Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: The literature reports a wide variety of reconstructive methods for pharyngolaryngoesophageal (PLO) defects, the most widely used being anterolateral thigh (ALT), radial forearm (RFF), and jejunal free flaps (JFF). However, there is a lack of uniform agreement among head and neck surgeons as to which technique offers the best results. With an increasing number of salvage PLO extirpations, determining the role of radiotherapy in influencing postoperative complication rates is becoming ever more important. Hence, this study aims to provide an up-to-date comparison of surgical and functional outcomes of the fasciocutaneous ALT and RFF versus the intestinal JFF for circumferential and partial PLO defects and determine whether radiotherapy, both preoperative and postoperative, influences the postoperative fistula and stricture rates in circumferential defects. METHODS: A systematic review and meta-analysis were performed using PubMed for reports published in the most recent 10 years between 2007 and 2017. RESULTS: A total of 33 articles comprising 1213 patients were reviewed. For circumferential defects, fistula and stricture rates were significantly lower in JFF than ALT and RFF. Of note, there was no statistical difference in tracheoesophageal speech and oral alimentation rates between JFF and the FC flaps. For near-circumferential and partial defects, ALT has a significantly lower fistula rate than RFF. There was no statistical difference in stricture and oral alimentation rates between ALT and RFF [corrected]. Fistula rates were significantly higher in patients who had preoperative radiotherapy than those without. However, there was no significant difference in fistula and stricture rates for postoperative radiotherapy. CONCLUSIONS: Jejunal free flaps still remain an excellent first choice for PLO reconstruction of circumferential defects. For near-circumferential and partial defects, ALT seems to have a better performance than RFF. Preoperative radiotherapy was associated with an increased risk of fistula formation in circumferential PLO defects but not postoperative radiotherapy.

Perioperative Vasopressor Use in Free Flap Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: The use of vasopressors in free flap surgery has traditionally been avoided due to the presumed risk of pedicle vasospasm leading to flap failure. However, there is a lack of strong clinical evidence to suggest that their administration during microvascular surgery is absolutely contraindicated. The aim of this study is to clarify the impact of perioperative vasopressor use on free flap outcomes. METHODS: A systematic review was performed of all English-language articles that have compared free flap outcomes between patients who received vasopressors and those who did not. The outcome measures were total flap failure, pedicle thrombosis, and overall flap complications. Meta-analysis was performed using Mantel-Haenszel fixed-effects and DerSimonian and Laird random-effects models. RESULTS: From a total of 130 citations, 14 studies representing 8,653 cases were analyzed. Majority of these did not find any negative effects of vasopressor use irrespective of dose, timing of administration, and method of delivery. Meta-analysis demonstrated that vasopressors were associated with less total flap failure overall (odds ratio, [OR]: 0.71, p = 0.05) and less pedicle thrombosis in head and neck reconstruction specifically (OR: 0.58, p = 0.02). Flap complication rates were similar across all defect types (OR: 0.97, p = 0.81) but appeared to be increased in breast reconstruction (OR: 1.46, p = 0.01). CONCLUSION: Perioperative vasopressor administration does not appear to be as detrimental to free flap survival as has been previously feared. Their role in optimizing hemodynamic stability may have a more beneficial effect on overall flap perfusion and in minimizing the complications of iatrogenic fluid overload.

Acceptance of Vascularized Composite Allotransplantation (Face and Hand Transplant) in Singapore.

Recent advancements and innovations in the burgeoning field of vascularized composite allotransplantation has enabled face and hand transplant to become a reality in the Western world. Plastic surgeons from the United States, France, and Spain have since performed vascularized composite allotransplantation as a novel therapeutic option in patients suffering from severe facial disfigurement and limb loss. Results have demonstrated remarkable functional and esthetic outcomes with improvements in the immense psychological, social, and emotional burdens that can arise in these patients. Despite the success of existing national solid organ transplant programs, face and hand transplant has yet to be established in this region. The specific aims of this study were to assess the attitudes and amount of risk Singaporeans are willing to accept towards receiving or donating face and hand transplants; and hence ultimately evaluate the feasibility of establishing such a program in Singapore.

Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique.

BACKGROUND: End-to-side (ETS) anastomoses are useful when preservation of distal vascularity is critical. The ideal ETS microanastomosis should maintain a wide aperture and have a smooth take-off point to minimize turbulence, vessel spasm, and thrombogenicity of the suture line. We have developed a unique, dependable, and reproducible geometric technique for ETS anastomoses, and analyze its efficacy in our series of patients. METHODS: The geometric ETS technique involves creating a three-dimensional (3D) diamond-shaped defect on the recipient vessel wall, followed by a slit incision of the donor vessel to create a "spatula" fitting this defect. This technique removes sutures from the point of most turbulent blood flow while holding the recipient vessel open with a patch vesselplasty effect. We perform a retrospective review of a single surgeon's experience using this technique. RESULTS: The geometric 3D ETS technique was used in 87 free flaps with a total of 102 ETS anastomoses in a wide range of cases including head and neck, trunk and genitourinary, and extremity reconstruction. Overall, free flap success rates were 98%. CONCLUSIONS: The geometric 3D ETS technique creates a wide anastomosis, minimizes turbulence-inducing thrombogenicity, and mechanically holds the recipient vessel open. It is reliable and reproducible, and when performed properly has been shown to have high rates of success in a large group of free tissue transfer patients.

The utility of the musculocutaneous anterolateral thigh flap in pharyngolaryngeal reconstruction in the high-risk patient.

BACKGROUND AND OBJECTIVES: Prior radiotherapy leads to increased wound complication rates for microsurgical reconstruction of pharyngolaryngeal (PL) defects. Incorporating vastus lateralis muscle together with anterolateral thigh flap (ALT) skin in defect reconstruction is useful in protecting vital structures and reinforcing irradiated neck skin and suture lines. This study shows the utility of the musculocutaneous ALT (MC ALT) in PL reconstruction in previously irradiated patients. METHODS: A single-surgeon, retrospective chart review of all patients with defects of the PL region where an MC ALT was used for reconstruction from February 2014 to May 2016. The harvest of the MC ALT is described. RESULTS: Thirteen consecutive patients underwent reconstruction with a MC ALT flap. All 13 patients had received previous radiotherapy. PL defects included five partial, five subtotal, and three total. There was a 100% flap survival rate with five early recipient site complications including three fistulas, one neck abscess, and one partial muscle necrosis. Three patients (23%) developed strictures requiring dilatation, two of whom had received post-reconstruction radiotherapy. CONCLUSIONS: The use of the MC ALT for reconstruction of PL defects should be considered to mitigate the negative effects of prior irradiation and provide a back-up plan in instances where complications occur.

Implantable Doppler monitoring of buried free flaps during vascularized lymph node transfer.

BACKGROUND AND OBJECTIVES: Reliable flap monitoring is crucial to the success of free tissue transfer, including vascularized lymph node transfer (VLNT). However, no large-scale study has examined implantable Doppler monitoring in VLNT. We aimed to determine whether an implantable Doppler system can reliably monitor flap perfusion during VLNT and also to calculate the sensitivity and specificity of this system for detecting compromise in the monitored vessel. METHODS: An analysis of prospectively collected data of patients who underwent buried VLNT with implantable Doppler monitoring between 2014 and 2015 was performed. RESULTS: A consecutive series of 100 patients underwent VLNT with implantable Doppler monitoring. Five cases required return to the operating room for flap exploration due to a change in Doppler signal quality. All compromised flaps were salvaged. The sensitivity of the implantable Doppler system for flap monitoring was 100%, the specificity was 97.9%, the positive predictive value was 60%, and the negative predictive value was 100%. The false-positive rate was 2%. CONCLUSIONS: This is the largest reported series of implantable Doppler monitoring of free flap perfusion during VLNT. Our experience suggests that this is a safe and effective technique for postoperative monitoring of VLNT.

The chimeric medial sural artery perforator flap as the ideal for partial tongue reconstruction: A case series and technical refinements.

BACKGROUND: The medial sural artery perforator free flap (MSAP) has gained increasing popularity in head and neck reconstruction. Its slightly bulkier nature than the radial forearm flap, combined with negligible donor site morbidity, makes it an ideal candidate for the reconstruction of partial glossectomy defects. The ability to harvest the MSAP as a chimeric flap with a portion of the medial gastrocnemius muscle gives it greater flexibility in soft tissue reconstruction. METHODS: A retrospective study of patients with partial glossectomy defects reconstructed using the MSAP by a single surgeon was performed. Perioperative data, donor and recipient site characteristics, complications, and outcomes were analyzed. A video is included to show technical points for the harvest of the flap. RESULTS: A total of 10 patients were included. The average age was 59.1 years, with a mean of 43.5% of the tongue resected. All flaps survived, with no major complications. At follow-up, the patients had regained an average of 86.5% of original speech, with none requiring NG feeding. The average MSAP skin flap thickness was 7.8 mm, with 6 flaps being harvested as chimeric fasciocutaneous muscle flaps. Five flaps incorporated 2 perforators. Two case examples are presented. CONCLUSION: The chimeric MSAP perforator allows for more robust partial glossectomy reconstruction with improved postoperative functional outcomes. It should be considered as the workhorse flap for partial tongue reconstruction.

Novel Endoscopic Transnasal Technique for Anterolateral Thigh Flap Inset Post Nasopharyngeal Carcinoma Resection.

Post-nasopharyngectomy reconstruction for recurrent nasopharyngeal carcinomas has been used for defect coverage and protection of vital structures. With the increasing use of endoscopic transnasal nasopharyngeal extirpation to offset complications faced with open techniques, there is a need for corresponding reconstructive support through a similar approach. We describe a novel endoscopic transnasal anterolateral thigh flap inset technique, combined with a transverse neck incision, in two patients who underwent transnasal nasopharyngectomy. We also include a video presentation of our operative technique. A vastus lateralis fascia free flap was used for one patient, and a vastus lateralis muscle free flap for the other. Both patients were aged 51 years. Mean nasopharyngeal defect size was 20 cm2 (range 12-28 cm2). Average surgical stay was 13.5 days (11-16 days) and flap mucosalization was complete for both patients. No recipient site complications were observed in either patient, although donor site seroma formation was seen in one patient. Average time to speech recovery was 1.5 months (range 1-2 months) for both patients. Time to diet recovery was 2 months for one patient, whereas the other was on long-term percutaneous endoscopic gastrostomy feeding. There were no flap failures or peri-operative mortalities. Endoscopic transnasal anterolateral thigh flap inset to reconstruct the nasopharyngeal space is an effective technique that confers reduced morbidity and potentially better outcomes compared with open techniques.

The Relationship Between Clinical and Indocyanine Green Staging in Lymphedema.

Background: Multiple staging systems for classifying the severity of lymphedema exist. The International Society of Lymphology (ISL) stage is considered standard for clinical reporting, but the relationship between clinical and functional/imaging stage remains poorly defined. Materials and Methods: We reviewed the prospectively collected data of all patients who underwent physiologic lymphedema surgery for a 3-year period by the senior author. Patients who underwent preoperative clinical staging with limb volume calculations and intraoperative indocyanine green (ICG) staging were included. Correlations were examined between ISL stage, ICG stage, and preoperative volume difference. Results: A total of 212 patients met inclusion criteria. ISL stage and preoperative volume difference had a Pearson correlation coefficient of 0.579 [p < 0.001, 95% confidence intervals, CIs (0.479-0.664)]; ICG stage and preoperative volume difference had a Pearson correlation coefficient of 0.338 [p < 0.001, 95% CIs (0.204-0.460)]; and ISL stage and ICG stage had a Pearson correlation coefficient of 0.254 [p < 0.001, 95% CIs (0.114-0.383)]. Conclusion: Clinical ISL stage does not correlate well with ICG stage in patients undergoing physiologic lymphedema surgery.

The Utility of a Master of Business Administration Degree in Plastic Surgery: Determining Motivations and Outcomes of a Formal Business Education Among Plastic Surgeons.

BACKGROUND: With the increasing complexity of health care, the knowledge of business in medicine is growing more valuable. Plastic surgeons in all practice settings are constantly forced to navigate endeavors that could be better faced with the leadership, management, and administrative skills honed through a formal business education. The purpose of this study was to gather data and draw conclusions related to the motivations and outcomes of plastic surgeons with a Master of Business Administration degree (MBA). METHODS: An online survey was distributed to plastic surgeons in the United States who have earned an MBA. The survey was divided into 4 main sections: demographics, MBA program description, objective assessment, and subjective assessment. RESULTS: The majority of plastic surgeons with an MBA are in practice at an academic medical center. The 2 most popular tracks of completing the degree are during medical school and after 5 years of practice. A large proportion of plastic surgeons with an MBA experienced changes in their existing career position, namely in patient care and business roles outside of clinical practice. The most important skills surgeons subjectively felt they had improved as a result of their business education were in the areas of leadership, management, and administration. CONCLUSIONS: Overall, all the plastic surgeons felt that their MBA experience met their expectations and would recommend the degree to fellow physicians. Prime motivations included adding a new dynamic to their existing career, satisfying entrepreneurial drive, and gaining credibility in business, with monetary gains being low on the list.

Re-introducing the delto-acromial perforator flap: Clinical experience and cadaver dissection.

BACKGROUND: Although perforator flaps from the pectoral branch of the thoraco-acromial (TA) axis have been well-described, there are few reports of perforator flaps based on the delto-acromial (DA) branches. We have found a reliable perforator coming off the DA branch of the TA axis, and have named a flap based on this vessel the delto-acromial perforator (DAP) flap. We describe our experience with the DAP flap together with a fresh cadaver anatomical study. METHODS: A retrospective review of all DAP flaps performed between December 2012 and January 2015 at our institution, with analysis of operative details, flap characteristics and surgical outcomes. We performed fresh cadaver dissection on 5 hemi-chest walls. RESULTS: The main cutaneous perforator from the deltoid and/or acromial branches is found at the delto-pectoral groove, 8 cm lateral to the TA axis and 8 cm inferior to the acromio-clavicular joint. Five patients underwent DAP flap reconstruction. Three were pedicled and 2 were free flaps. Average pedicle length from the origin of the DA branch was 8 cm, with an arterial diameter of at least 1 mm and vein diameter 1.5 mm. All flaps survived completely. Cadaver dissection showed a consistent perforator arising from the common delto-acromial branch in 4 cadavers, and from the deltoid branch in 1 cadaver. CONCLUSIONS: The DAP flap is a good addition to the armamentarium of reconstructive surgeons when a relatively thin fasciocutaneous flap with minimal hair is desired. It may be used for free tissue or locoregional transfer.

Modification of the Radial Forearm Fasciocutaneous Flap in Partial Pharyngolaryngeal Reconstruction to Minimize Fistula Formation.

Reconstruction of pharyngolaryngoesophageal defects following salvage surgery in patients with a history of chemoradiation is a challenging problem with a high incidence of pharyngocutaneous fistula. The authors describe three cases of successful reconstruction of partial pharyngolaryngoesophageal defects using a modified radial forearm free flap with additional dermal reinforcement and review the literature for innovations in the use of radial forearm free flap for reconstruction of these difficult cases. Modification of the radial forearm free flap makes it a versatile, reliable flap that has become the "go-to" flap for partial pharyngolaryngoesophageal reconstruction.

A Novel Strategy to Supercharge a Deep Inferior Epigastric Artery Perforator Flap after Port-a-Cath Removal.

Autologous breast reconstruction using the deep inferior epigastric artery perforator (DIEP) flap has become increasingly popular because of its unique advantages. However, compared with some other forms of abdominal-based autologous reconstruction, DIEP flaps are associated with an increased risk of venous congestion. Many techniques-or lifeboats-have been introduced to diagnose and treat this potentially devastating complication. In this case report, we describe a novel strategy to augment venous drainage when venous congestion is encountered. A patient presented requesting autologous reconstruction and removal of a venous access catheter that had been used for chemotherapy administration. We performed left delayed breast reconstruction using a single-perforator DIEP flap from the right hemiabdomen. The superficial inferior epigastric vein to this flap was preserved. After removal of the Port-a-Cath from the left chest, we anastomosed the superficial inferior epigastric vein to the fibrous capsular sheath that had formed around the indwelling catheter to allow additional venous drainage. Flow through this conduit was confirmed using Doppler ultrasound. There were no flap-related complications, and the patient was discharged in good condition. Further research is warranted to characterize the indications and limitations of this novel lifeboat.