A Comparison of Outcomes of Proximal and Distal Anastomosis Sites of the Facial Artery in Head and Neck Reconstruction.

ABSTRACT: Recipient vessel selection in head and neck reconstruction is based on multiple factors, including defect size and location, patient history, and vessel location, diameter, and length. The authors present a comparison of proximal and distal anastomotic sites of the facial artery. A chart review of head and neck reconstructions using the facial artery as a recipient vessel over a 7-year period was conducted. The anastomosis site was identified as distal (at the inferior mandible border) or proximal (at the origin of the artery). The distal site was utilized for both defects of the midface/ scalp and of the mandible/neck, while the proximal site was exclusively used for mandible/neck defects. The following complications were included in the analysis: facial nerve injury, surgical site infection, thrombosis, flap congestion, flap loss, hardware failure, malunion/nonunion, osteomyelitis, sinus/fistula, hematoma, seroma, reoperation, and 90-day mortality. Fifty-four free tissue transfers were performed. The overall complication rate (including major and minor complications) was 53.7%. Anastomosis level did not have a significant impact on complication rate. In addition, there were no significant differences in complication rates for the distal anastomosis site when stratified by defect location. However, obese patients were more likely to have a complication than nonobese patients. This conclusion may reassure surgeons that factors related to anastomosis level, such as vessel diameter and proximity to the zone of injury, have less impact on outcomes than factors like obesity, which may inform preoperative planning, intraoperative decision-making, and postoperative monitoring.

Colgajos Locales en Reconstrucción Facial. Alternativas de Tratamiento / Local Flaps in Facial Reconstruction. Treatment Alternatives

Los defectos faciales de piel son frecuentemente secuelas producto de carcinomas basoceulares, carcinomas espinocelulares, melanomas, grandes tumores benignos o traumatismos de tejidos blandos. Las unidades y subunidades estéticas de la cara, la textura y color de la piel, junto a otros parámetros deben ser considerados durante la planificación de la reconstrucción mediante colgajos locales. El objetivo de este artículo de revisión bibliográfica fue describir y definir las técnicas más relevantes en los de colgajos locales aplicados en la reconstrucción facial y sus algoritmos actuales, en relación con la unidad o subunidad facial involucrada; sus consideraciones estéticas y cirugía complementaria. Las unidades y subunidades estéticas de la cara se dividen en regiones de la frente, párpados, mejillas, nariz, labios y mentón. Los colgajos de rotación, en isla, de avance y transposición son la base para la mayoría de los colgajos faciales; los más conocidos según la zona donante son: el colgajo frontal, colgajo de rotación y avance de mejilla; colgajo cérvico-facial, y colgajos nasolabiales, entre otros. La elección del colgajo depende de la zona y la unidad estética facial involucrada, siendo importante elegir y usar las líneas, los surcos y márgenes de estas unidades cuando sea posible con el fin de mejorar los resultados estéticos y reducir la posibilidad de secuelas. La cirugía complementaria y los procedimientos estéticos pueden lograr un buen camuflaje de algunas complicaciones estéticas o secuelas.

Skin face defects are frequently sequels of basal cell carcinomas, squamous cell carcinomas, melanomas, and large benign tumors or soft tissue trauma. Aesthetics units and subunits of the face, texture, color, and other parameters must be considered in the local flaps reconstructive planning. This review article aims to describe and define the most relevant techniques of facial local flaps in facial reconstruction and their current algorithms, regarding the unit or subunit, involve, their aesthetics considerations and complementary surgery. The aesthetics units and subunits of the face are divided into forehead, eyelids, cheek, nasal, lips, and chin. There are several well-known concepts and flaps used in these proceedings as rotation, island, advancement, and transposition flaps, and they are the basis for facial local flaps; The most relevant are: forehead flap, cheek advancement, and rotate flap; rhomboid, cervicofacial and bilobed flap, nasolabial flaps. The flap election depends on the zone and unit involve; it is important to choose the lines, sulcus, and borders of these units when is possible to enhance these aesthetics outcomes. These concerning improve the aesthetics outcomes and reduce the aesthetics sequels. Complementary surgery and aesthetics proceedings may accomplish a good camouflage of some aesthetics complications or sequels.

The effect of a three-dimensional instructional video on performance of a spatially complex procedure in surgical residents in relation to their visual-spatial abilities.

BACKGROUND: The effect of three-dimensional (3D) vs. two-dimensional (2D) video on performance of a spatially complex procedure and perceived cognitive load were examined among residents in relation to their visual-spatial abilities (VSA). METHODS: In a randomized controlled trial, 108 surgical residents performed a 5-Flap Z-plasty on a simulation model after watching the instructional video either in a 3D or 2D mode. Outcomes included perceived cognitive load measured by NASA-TLX questionnaire, task performance assessed using Observational Clinical Human Reliability Analysis and the percentage of achieved safe lengthening of the scar. RESULTS: No significant differences were found between groups. However, when accounted for VSA, safe lengthening was achieved significantly more often in the 3D group and only among individuals with high VSA (OR = 6.67, 95%CI: 1.23-35.9, p = .027). CONCLUSIONS: Overall, 3D instructional videos are as effective as 2D videos. However, they can be effectively used to enhance learning in high VSA residents.

STA-enhanced vascularized galeal flap for revascularization of moyamoya disease: technical report.

BACKGROUND: A variety of revascularization techniques have been reported for the management of moyamoya disease to prevent risks of stroke. STA (superficial temporal artery)-MCA (middle cerebral artery) microanastomosis, single or double bypass, with temporal muscle or galeal onlay graft has been the standard operative procedure. METHOD: Our rationale of revascularization surgery has been a combination of STA-MCA double bypass using the frontal and the parietal branches of STA and transfer of a highly vascularized thick galeal flap with maintained STA vasculature. CONCLUSION: This STA-enhanced vascularized galeal flap graft is extremely effective for revascularization of moyamoya disease.

The island-type pedicled TRAM flap: Improvement of the aesthetic outcomes of breast reconstruction.

BACKGROUND: The pedicled transverse rectus abdominis myocutaneous flap (TRAM) remains an effective and widely-used method for breast reconstruction despite well-documented donor-site morbidity. We present the island-type pedicled TRAM flap as a way to obtain better and more reliable outcomes in breast reconstruction. METHODS: A retrospective chart review of patients who underwent breast reconstruction with an island-type pedicled TRAM flap was performed. Patient demographics and complications were reviewed. In the island-type pedicled TRAM flap, we transversely resected the upper ipsilateral rectus muscle surrounding the origin of the superior epigastric vessels, preserving only a 1-cm muscle strip including the vascular pedicle to prevent epigastric bulging and inframammary fold (IMF) disruption. The flap was turned over into the ipsilateral breast pocket. The IMF was repaired except for the portion where the pedicle was placed. RESULTS: From January 2013 to November 2017, 88 patients underwent surgery using the island-type pedicled TRAM flap. The etiology of the defect was breast cancer with mastectomy in 86 cases, and paraffinoma in two cases. Seventy-seven patients underwent unilateral reconstruction, and 11 patients underwent bilateral reconstruction. Minor fat necrosis occurred in eight cases. Mild inframammary or epigastric bulging was observed in five cases, and neither partial nor total flap necrosis was observed. The aesthetic outcome of the IMF was evaluated in 55 cases, and 53 cases received good overall scores. CONCLUSION: Although the island-type pedicled TRAM flap is technically challenging because careful dissection and pedicle identification is required, it can provide more reliable and better aesthetic results without an increased risk of vascular compromise.

Opinion: Aortic Graft Infection-Any Guidelines or Just Surgeon's Experience Lines!

Aggressive strategies for thoracic aortic graft infection, including resection of all infected tissues, in situ replacement with a rifampicin-bonded graft, and omental flap installation, resulted in improved survival.

Expertise in Head and Neck Cutaneous Reconstructive Surgery.

BACKGROUND: The management of skin cancers has evolved with the development of Mohs micrographic surgery and a greater emphasis on surgical training within dermatology. It is unclear whether these changes have translated into innovations and contributions to the reconstructive literature. OBJECTIVE: To assess contributions from each medical specialty to the cutaneous head and neck oncologic reconstructive literature. METHODS: The authors conducted a systematic review of the head and neck reconstructive literature from 2000 through 2015 based on a priori search terms relating to suture technique, linear closure, advancement, rotation, transposition and interpolation flaps, and identified the specialty of the senior authors. RESULTS: The authors identified 74,871 articles, of which 1,319 were relevant. Under suture technique articles, the senior authors were primarily dermatologists (58.2%) and plastic surgeons (20.3%). Under linear closure, the authors were dermatologists (48.1%), plastic surgeons (22.2%), and otolaryngologists (20.4%). Under advancement and rotation flaps, the senior authors were plastic surgeons (40.5%, 38.9%), dermatologists (38.1%, 34.2%), and otolaryngologists (14.4%, 21.6%). Under transposition and interpolation flaps, the senior authors were plastic surgeons (47.3%, 39.4%), dermatologists (32.3%, 27.0%), and otolaryngologists (15.3%, 23.4%). CONCLUSION: The primary specialties contributing to the cutaneous head and neck reconstructive literature are plastic surgery, dermatology, and otolaryngology.

The effect of postoperative closed incision negative pressure therapy on the incidence of donor site wound dehiscence in breast reconstruction patients: DEhiscence PREvention Study (DEPRES), pilot randomized controlled trial.

AIM: Wound dehiscence is a serious postoperative complication associated both with high morbidity and mortality. It has a significant rate of occurrence in breast reconstruction surgeries with a deep internal epigastric perforator (DIEP) and with a profunda artery perforator (PAP) flap. Risk factors for wound dehiscence include smoking, diabetes mellitus, chronic obstructive pulmonary disease, and obesity. The aim of this pilot study was to assess whether postoperative treatment with closed incision negative pressure therapy (ciNPT) decreases the incidence of donor site wound dehiscence in breast reconstruction patients. METHOD: Women undergoing a breast reconstruction with a DIEP or PAP flap were enrolled in a pilot randomized controlled trial and assigned treatment with either ciNPT or adhesive strips. The primary outcome was wound dehiscence upon follow-up after four weeks. Secondary outcomes that were evaluated included wound infection, pain, and allergy. There was no loss to follow-up. RESULTS: This pilot study included 51 women (n = 25 ciNPT, n = 26 adhesive strips). The two groups did not differ significantly in patients demographics or comorbidities. Wound dehiscence occurred in 11 patients (n = 2 ciNPT, n = 9 adhesive strips). This difference was statistically significant: p = 0.038. There were no statistically significant differences in secondary outcomes between the two groups. CONCLUSION: In this pilot study, postoperative treatment with ciNPT decreased the incidence of donor site wound dehiscence in breast reconstruction patients. Further research is ongoing by the same hospital. This trial was registered in the Netherlands Trial Register (NTR) under ID no. NTR5808.

A multi-center, double blind randomized controlled trial evaluating flap fixation after mastectomy using sutures or tissue glue versus conventional closure: protocol for the Seroma reduction After Mastectomy (SAM) trial.

BACKGROUND: Seroma formation is a common complication after mastectomy and is associated with delayed wound healing, infection, skin flap necrosis, patient discomfort and repeated visits to the out patient clinic to deal with seroma and its sequelae. Closing the dead space after mastectomy seems to be key in reducing seroma and its complications. Various methods have been described to reduce the dead space after mastectomy: closed suction drainage, quilting of the skin flaps and application of adhesive tissue glues. The aim of this trial is to compare seroma formation and its sequelae in the various methods of flap fixation. METHODS: This is a multicenter, double-blind, randomized controlled trial in female breast cancer patients undergoing mastectomy, with or without axillary clearance. Exclusion criteria consist of breast conserving therapy, direct breast reconstruction and incapacity to comprehend implications and extent of study and unable to sign for informed consent. A total of 336 patients will be randomized. Patients will be randomly allocated to one of three treatment arms consisting of flap fixation using ARTISS tissue glue with a low suction drain, flap fixation using sutures and a low suction drain or conventional wound closure (without flap fixation) and low suction drainage. Follow up will be conducted up to twelve months post surgery. The primary outcome is the number of seroma aspirations and secondary outcomes consist of number of out patient clinic visits, surgical skin infection rate, shoulder function, cosmesis, health-related quality of life and costs and cost-effectiveness (cost/QALY). DISCUSSION: This is the first study of its kind to evaluate the effect of flap fixation and its sequelae (ie seroma aspirations, number of out patient clinic visits, infection, shoulder function, patient assessed cosmesis, quality of life and cost-effectiveness) in a double blind randomized controlled trial. TRIAL REGISTRATION: This trial was approved by the hospitals' joint medical ethical committee (14-T-21, 2 June 2014). The SAM Trial is registered in ClinicalTrials.gov since October 2017, Identifier: NCT03305757 .

Back to Basics: Autologous Tissue: 1.5 www.aornjournal.org/content/cme.

Perioperative personnel manage autologous tissue when they care for patients undergoing procedures requiring the use of bone, soft tissue, or other autologous tissue to repair or replace defects. Use of autologous tissue can minimize the risk of rejection, disease transfer, and infection compared with the use of artificial materials. There are important steps to follow when handling autologous tissue to ensure it is safe for replantation and does not become contaminated. This Back to Basics article provides strategies for managing some types of autologous tissue, including bone flaps, parathyroid tissue, skin grafts, and veins. Tissue management strategies include creating strict documentation policies, standardizing processes and communication, and implementing routine audits to assess compliance.

Forequarter Amputation, Thoracic Resection, and Reconstruction on Giant Ulcer Due to Locally Advanced Oncological Disease.

We present the case of a 67-year-old man suffering from a squamous cell carcinoma with extensive thoracic locoregional affection measuring 28 cm. After being considered inoperable at another center, he underwent an aggressive tumor resection and coverage with a free latissimus dorsi flap as a palliative reconstructive procedure that allowed for a considerable improvement of his quality of life.

Therapeutic and Reconstructive Approach of Lower Lip Amputation After Human Bite: Case Report.

In this article, we describe the case of a patient suffering from labial avulsion after a human bite, initially treated with direct closure and reconstructed surgically later on. Also, a brief summary of existent recommendations in scientific literature about the management of bite wounds is provided.

Development of esthetic prosthesis for a patient with severe stigmatizing facial lesions due to cancer: a pilot study.

PURPOSE: Severe physical facial deformities due to surgical interventions can have significant psychosocial consequences to patient's relationships with friends and family and thus, has a considerable impact on their quality of life. We have developed a 3D prosthesis for a 56-year-old woman diagnosed with epidermoid carcinoma at the right hemiface, to improve her quality of life. METHODS: The patient started radiotherapy with modulated intensity. To deal with the advance of the process, a maxilectomy of supra structure with modified radical cervical emptying on the right hemiface was performed. Reconstruction of areas surgically affected by the displacement of islands of skin and muscle (flaps) from healthy regions was initiated. Although the procedure occurred without intercurrences, the patient developed necrosis and loss of the myocutaneous flap. After the removal of the flap, the esthetic result of the treatment was evident causing exposure of subcutaneous and granulation tissues. RESULTS: A computational model was used to develop a 3D structure of the affected area and then used to construct the prosthesis. The prosthesis was applied over the affected area, and the patient was able see her face on the mirror for the first time in years. The patient was grateful and hopeful. CONCLUSION: We have found that the application of this new technology greatly improves the social interaction of patients with deformities due to surgical interventions.

Feasibility of Clinician-Facilitated Three-Dimensional Printing of Synthetic Cranioplasty Flaps.

BACKGROUND: Integration of three-dimensional (3D) printing and stereolithography into clinical practice is in its nascence, and concepts may be esoteric to the practicing neurosurgeon. Currently, creation of 3D printed implants involves recruitment of offsite third parties. We explored a range of 3D scanning and stereolithographic techniques to create patient-specific synthetic implants using an onsite, clinician-facilitated approach. METHODS: We simulated bilateral craniectomies in a single cadaveric specimen. We devised 3 methods of creating stereolithographically viable virtual models from removed bone. First, we used preoperative and postoperative computed tomography scanner-derived bony window models from which the flap was extracted. Second, we used an entry-level 3D light scanner to scan and render models of the individual bone pieces. Third, we used an arm-mounted, 3D laser scanner to create virtual models using a real-time approach. RESULTS: Flaps were printed from the computed tomography scanner and laser scanner models only in a ultraviolet-cured polymer. The light scanner did not produce suitable virtual models for printing. The computed tomography scanner-derived models required extensive postfabrication modification to fit the existing defects. The laser scanner models assumed good fit within the defects without any modification. CONCLUSIONS: The methods presented varying levels of complexity in acquisition and model rendering. Each technique required hardware at varying in price points from $0 to approximately $100,000. The laser scanner models produced the best quality parts, which had near-perfect fit with the original defects. Potential neurosurgical applications of this technology are discussed.

Lyric hearing aid: a rare cause of benign necrotising otitis externa/external ear canal cholesteatoma.

An 80-year-old Caucasian man presented with an incidental and asymptomatic lesion in his right ear thought to be secondary to his use of hearing aids for presbycusis. He used Lyric hearing aids, designed for 24 hours-a-day use for 4 months at a time and had no other previous otological problems. He underwent a bony meatoplasty and vascular flap reconstruction via a retroauricular approach to remove the lesion for histological analysis and regrafting of the area. The lesion was confirmed on histopathology as an ear canal cholesteatoma.

Modified lumbar artery perforator flaps for gluteal pressure sore reconstruction.

BACKGROUND: Gluteal perforator flaps (GPFs) are the most useful for gluteal region pressure sore reconstruction. However, application is difficult if the surrounding area has scar tissue from previous operations or trauma, especially with recurrent sores. We describe the use of modified lumbar artery perforator flaps when GPFs cannot be used. METHODS: Between May 2009 and April 2014, 51 patients underwent gluteal pressure sore reconstructions with gluteal (n = 39) or modified lumbar artery (n = 12) perforator flaps. Patients in the modified lumbar artery perforator group had scar tissue from trauma or previous surgery. In this retrospective review, we analyzed patient age and sex, defect size and location, operative time, follow-up duration, immediate postoperative issues, flap necrosis, dehiscence, re-operation, donor-site morbidity and recurrence. Complications and clinical outcomes were compared between groups. RESULTS: We found no significant differences in patient demographics, surgical complications or clinical outcomes. There were eight cases of temporary congestion (20.51%) and four of partial flap necrosis (10.25%) in the gluteal perforator group. In the modified lumbar artery perforator group, there were three cases of temporary congestion (25%) and one of partial flap necrosis (8.33%). No pressure sores recurred during follow-up in either group. CONCLUSION: GPFs are the gold standards for gluteal pressure sores, but modified lumbar artery perforator flaps are relatively easy and useful when GPFs cannot be used due to scar tissue.

Posterior Thigh Flap Pedicled on the Cutaneous Vessels Arising From the Popliteo-posterior Intermediate Artery: A Report of 5 Cases.

Surgical repair of soft tissue defects of the knee and leg remains challenging. Using a case study approach, the anatomy of the popliteo-posterior intermediate cutaneous artery was examined, and a reverse island flap method was developed and implemented. After obtaining informed consent, 5 patients (1 woman, 4 men, age range 31 to 57 years) underwent the experimental use of a reverse island flap with a posterior thigh flap pedicled on the cutaneous vessels arising from the popliteo-posterior intermediate artery to repair soft-tissue defects of the knee and leg. The defects were caused by burned skin below the knee (n = 1), progressive skin necrosis in the knee after fracture surgery (n = 2), and skin infections associated with diabetes mellitus (n = 2). Skin defect sizes ranged from 15 cm x 5 cm to 30 cm x 12 cm. These large defects did not heal spontaneously; wound duration ranged from 1 week to 1 year, and all patients had refused defect repair with free flaps. Patients received posterior thigh flaps pedicled on the popliteo-posterior intermediate artery with areas ranging from 17 cm x 6 cm to 25 cm x 12 cm. All patients were treated with antibiotics and local dressings (iodoform and alcohol) changed daily post surgery, and blood supply was monitored by assessing the texture and color of the flap and venous regurgitation (ie, vein drainage disturbance). Four (4) of the five flaps survived completely. In 1 patient, partial survival of the flap, which had a good blood supply despite a venous circulation disorder, occurred: in this case, complete survival was achieved after treatment with a retrograde fascial flap and skin grafting. The appearance and texture of all flaps were satisfactory (ie, patients underwent only 1 operation, healing time was approximately 2 weeks, flap quality was close to normal skin, the donor site closed directly, and the shape and function of the knee and leg recovered well). No donor site abnormality was observed, and no postsurgical infection occurred. More research is needed, but the use of a reverse island flap with a posterior thigh flap pedicled on the cutaneous vessels arising from the popliteo-posterior intermediate artery may be a feasible option to repair soft tissue defects of the knee and leg.