Does increased free flap size in the head and neck region impact clinical outcome?

PURPOSE: There are few studies analyzing the long-term clinical effects related to increasing the size of head and neck free tissue reconstructions. The purpose of this study was to compare long-term clinical outcomes of patients undergoing very large area (≥200 cm(2)) and large area (100 to 199 cm(2)) free tissue reconstructions of head and neck defects. PATIENTS AND METHODS: Institutional review board approval was obtained before conducting this retrospective cohort study at the authors' university-based tertiary care hospitals. The authors analyzed the charts of consecutive patients with free flaps of at least 100 cm(2) treated from July 2000 to December 2011. Very large area flaps were arbitrarily defined as larger than 200 cm(2). Intraoperative variables, flap success rates, overall survival, and total hospital and intensive care unit (ICU) stays for the 2 groups were analyzed. Fisher exact tests or χ(2) tests were used for categorical variables and Student t tests were used for continuous variables. Log-rank tests were conducted to investigate whether overall survival was significantly different between the 2 groups. Statistical significance was defined as a P value less than .05. RESULTS: The charts of 121 consecutive patients were analyzed. Thirty-eight patients (31%) had very large area flaps (277.1 ± 79.4 cm(2); range, 200 to 576 cm(2)) and 83 patients (69%) had large area flaps (140.1 ± 25.5 cm(2)). There was no difference between flap groups in presenting T4 stage disease (P = .448). Ninety-eight percent of the very large area flaps and 93% of the large area flaps survived. Total hospital stays for the very large area and large area flap groups were 12.8 ± 8.2 and 12.3 ± 8.3 days, respectively (P = not significant). In contrast, ICU stays were increased for the very large area flap group at 7.1 ± 7.5 versus 4.0 ± 4.0 days for the large area flap group (P = .022). The overall median patient survival for the very large area flap group was 7.6 months (95% confidence interval, 5.7-10.0) and that for the large area flap group was 8.4 months (95% confidence interval, 5.4-12.9; P = .376). CONCLUSION: Performing very large area flaps for head and neck reconstruction did not negatively affect clinical outcome. Comparable success rates, total hospital stays, and overall survival can be safely achieved in this difficult patient population. More studies need to be conducted on resource usage.

Flow-through flap for salvage of fibula osseocutaneous vascular variations: a surgical approach and proposed modification of its classification.

The osseocutaneous fibula free flap is commonly used in mandibular reconstruction. Clinically important anatomic variants of the donor vessels have been reported. The authors describe a rare variant encountered while raising an osseocutaneous fibula flap. The fibula was supplied by the peroneal vessels and the overlying skin paddle was supplied by musculocutaneous perforators arising from the posterior tibial vessels. By raising 2 separate free flaps and configuring them in microvascular series with the fibula acting as a flow-through flap, the reconstruction was successful. Although the anatomic variant has been described, the authors' approach to it has not. The benefits of this method over other options include preservation of a skin paddle for monitoring and watertight oral closure and a long pedicle to the skin paddle permitting a wide arc of movement. The authors suggest a modification to the existing classification of perforators to the lateral leg skin to guide intraoperative decision making.

Measurement for subcutaneous fat and clinical applied anatomic studies on perforators in the anterior thigh region.

PURPOSE: To discuss the feasibility of making anterolateral thigh flaps of different thicknesses in the anterior thigh region and to provide clinical guidance on raising anterior thigh polyfoliate (myocutaneous) flaps. PATIENTS AND METHODS: Sixty-six patients who underwent oral and maxillofacial malignant tumor resection and reconstruction with left anterior thigh flaps from October 2008 to April 2009 in the Second Xiangya Hospital were selected as the subjects. The thickness of subcutaneous fat in different parts of the anterior thigh region was measured and the distribution, number, type, and origin of cutaneous perforators in the left anterior thigh region were explored by anatomic observation. RESULTS: The thickness of subcutaneous fat in the anterior thigh region was thinnest in the lower part, medium in the middle part, and thickest in the upper part. The probabilities of cutaneous perforators in the upper, middle, and lower parts of the anterolateral thigh region were 83.3%, 97%, and 89.4%, respectively, and those in the anteromedial thigh region were 51.5%, 84.9%, and 95.5%. On average, there were 4.4 cutaneous perforators in the anterolateral thigh region and 3.3 cutaneous perforators in the anteromedial thigh region of each patient. In addition, 57.6% of patients had cutaneous perforators arising from the descending branch of the lateral circumflex femoral artery in the anteromedial thigh region. CONCLUSIONS: Flaps with different thicknesses could be harvested in different parts of the anterolateral thigh region and polyfoliate (myocutaneous) flaps could be conveniently raised in the anterior thigh region.

[Schmid-Meyer fronto-temporal flap for nasal reconstruction]. / Le lambeau fronto-temporal de Schmid-Meyer dans les reconstructions nasales.

INTRODUCTION: Many surgical techniques have already been described to repair full thickness defects of the inferior part of the nose. The Schmid-Meyer fronto-temporal flap procedure, a little known technique, is based on the old principle of autonomization of a cutaneous flap and uses a tailor-made composite cartilaginous graft placed in the temporal region. This graft is progressively detached and allows mucosal/cartilaginous/and cutaneous nasal repair. Can this technique still be used for nasal full-thickness reconstruction? PATIENTS AND METHOD: Nine cases of nasal reconstruction using this procedure were performed. The 4-steps of the operative technique were described and the results were analyzed retrospectively. RESULTS: This procedure allows, for some specific indications, excellent reconstruction of the ala, the columella or the nasal tip. In eight cases out of nine, the result was judged good or very good by both patients and physicians. In 78%, the reconstruction was performed under local anesthesia. DISCUSSION: The Schmid-Meyer flap procedure may still be used for full-thickness reconstruction of the lower third of the nose because it allows a high quality of nasal reconstruction and few scar sequels.

Classification and pathophysiology of skin grafts.

Flaps and grafts are the 2 main surgical procedures to repair losses of skin tissue. A flap is a full-thickness portion of skin sectioned and isolated peripherally and in depth from the surrounding skin, except along one side, called the peduncle. A graft is a section of skin, of variable thickness and size, completely detached from its original site and moved to cover the zone to be repaired. According to their thickness, skin grafts are classified as split thickness (or partial) and full thickness. The former is further divided into thin, intermediate and thick. Split-thickness skin grafts usually take well, whereas a full-thickness graft only takes if it is relatively small. Grafts are also divided, on the basis of their origin, into the following: autografts, when the donor and recipient are the same individual; homografts, when the donor and recipient are different subjects belonging to the same species; hetero- or xenografts, when the donor and recipient belong to different species. Only autografts can take, whereas homo- and heterografts are rejected. Homo- and heterografts, however, can be useful in particular conditions, for example, extensive burns, because they temporarily ensure vital skin functions.

Clinical evaluation of 3 techniques to augment keratinized tissue without root coverage.

BACKGROUND: The importance of keratinized tissue is a controversial subject. However, in some situations most clinicians would agree that surgical procedures to increase the amount of keratinized tissue without root coverage are indicated. In this study, 3 surgical procedures were compared in their ability to increase the width of keratinized tissue. They are: the epithelized autogenous masticatory mucosa graft (free gingival graft), autogenous predominately connective tissue graft (connective tissue graft), and acellular dermal matrix. METHODS: Forty-five patients referred for treatment of areas with inadequate keratinized tissue were randomly assigned into 1 of 3 groups of 15 each. Each group was treated with 1 of the 3 surgical procedures to increase the width of keratinized tissue. The width of keratinized tissue pre- and postsurgery was evaluated. RESULTS: All 3 groups started with a similar width of keratinized tissue. All of the surgical procedures resulted in a statistically significant increase in the width of keratinized tissue: free gingival graft, 4.1 mm; connective tissue graft, 3.6 mm; and acellular dermal matrix, 4.1 mm. CONCLUSION: A statistically significant increase in the amount of keratinized tissue was obtained with all 3 surgical procedures evaluated.

Reconstruction of superficial skin cancer defects of the nose.

PURPOSE: This article reviewed the results of reconstruction of surface nasal defects after removal of skin cancer. PATIENTS AND METHODS: One hundred patients with 103 surface defects involving various locations on the nose were treated. Management included direct closure, secondary epithelization, full-thickness skin grafts, and local flaps using 1 or 2 stages. RESULTS: Ten nasal defects were treated by direct closure, 8 defects healed by secondary epithelization, and 30 patients were treated with a full-thickness skin graft. Fifty-five defects were reconstructed with local flaps including 30 one-stage and 25 two-stage flaps. CONCLUSION: Many options are available for reconstructing nasal defects that can lead to acceptable aesthetic results. Among the factors that need to be addressed before choosing a procedure for reconstruction of surface nasal defects resulting from skin cancer are size and location of the defect, aesthetic concerns, and the medical status of the patient.

Sign of the changing times: CPT 1999.

Although CPT 1999 contains fewer changes than in past years, coders should take some time to learn them by: familiarizing themselves with the new symbols + and [symbol: see text] reviewing Appendix A for a complete list of modifiers as well as modifiers used in the ambulatory surgery center hospital outpatient setting; reviewing Appendix E for a complete list of add-on codes; reviewing Appendix F for a list of modifier-51-exempt codes; consulting the excludes note found above code 69,990 to identify procedures exempt from the use of the new operating microscope code; examining the specific codes used to identify bronchoscopic procedures; reviewing the parenthetical notes found after code 15,001, directing the coder to also assign the appropriate code for lesion excision; reviewing the changes associated with the coding of destruction of lesions understanding the changes in immunization code assignment; consulting payers for specific reimbursement guidelines.

Técnica de injerto de piel / Skin graft trechnique

Se explica la técnica de injerto de piel total, como opción en el tratamiento de lesiones malignas. Se la desarrolla paso a paso y se brindan conceptos generales de injertos

Modification of two-flap method and framework construction for reconstruction of atypical congenital auricular deformities.

A single-stage two-flap method utilizing an anteriorly based subcutaneous pedicled skin flap and a mastoid fascial flap has been applied successfully for reconstruction of lobule-type microtia. This paper presents three modifications of the two-flap method, with which atypical congenital auricular deformities necessitating both framework construction and coverage were reconstructed successfully. In middle and upper auricular deformities such as a concha-type or a scapha-type microtia, a cranially based postauricular skin flap and lower mastoid fascial flap were used. For upper auricular deformities such as microtia representing lop-ear deformity, a narrow cranially based postauricular skin flap (Grotting flap) and upper mastoid fascial flap were used. For lower auricular deformities such as total absence of the earlobe, a cranially based skin flap and lower mastoid fascial flap were utilized. In each deformity the framework was totally or partially constructed with autogenous costal, conchal, or septal cartilage or their combination according to the size or shape of the defect. Fifty-two atypical auricular deformities were corrected with the modified two-flap method and framework construction. The follow-up has ranged from 4 months to 3 years (average 18 months). No major surgical complications occurred in this series. Representative cases reconstructed with each modified method are shown. While the shape of the cartilage framework is sculptured according to the type and degree of deformity in each patient, the modified two-flap method not only adequately covers the cartilage but also preserves the fabricated framework in its natural contour and position in the diverse varieties of atypical congenital auricular deformities.

The role of the venous system in the abdominal flap of the rat.

The abdominal flap of the rat has become a popular model with investigators. Recently, researchers have been reporting survival of skin flaps with varying blood supplies. We studied the viability of skin flaps on a consistent model with varied blood supply. An 8 x 9 cm flap was raised in 40 male Sprague-Dawley rats. The viability of the flaps could be studied in 25 rats. The survival of a pedicled flap based on the left inferior epigastric artery and vein was compared with that of a pedicled flap with enhanced venous drainage. The survival of a venous flap based on the paired inferior epigastric veins and the paired long thoracic veins was compared with that of an arterialized venous flap. A composite graft was used as a control for all groups. A qualitatively improved survival was found in the pedicled venous-enhanced group (66 percent) compared with the pedicled flaps (56 percent) (p > 0.05). An improved survival was found in the arterialized venous flap (57 percent) compared with the venous flap (40 percent) (p < 0.05). All flaps had improved survival compared with the composite graft (0.6 percent) (p < 0.05).

Timing, magnitude, and utility of surgical delay in the TRAM flap: I. Animal studies.

Surgical delay is an effective technique, but the precise timing of the delay effect and the required extent of the delay procedure are uncertain. We endeavored to study flap survival as a function of the duration of the delay period in a rat transverse rectus abdominis myocutaneous (TRAM) flap model. Two specific delay procedures (limited and extensive) were utilized, and flap survival was assessed after delay periods of 3, 7, 10, 14, 21, and 30 days (n > or = 7, all groups). A delay of 7 days or greater resulted in statistically significant improvement in flap survival in all groups. The delay effect appeared to be maximal at 14 days, and in the extensive delay group, a 14-day delay resulted in statistically greater flap survival than a 7-day delay. Improvement in flap survival was greater when an extensive delay procedure was used. Although the model system has limitations, the rat TRAM flap appears to be a suitable model for the study of the delay phenomenon. Possible clinical correlations are addressed in part II.

Timing, magnitude, and utility of surgical delay in the TRAM flap: II. Clinical studies.

Transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction was performed in 15 patients 1 week after a preliminary delay procedure. The indications for surgical delay were obesity, smoking, prior radiation therapy, a requirement for large volumes of transmidline tissue, or combinations of these risk factors. The delay procedure consisted of outpatient ligation of the deep and superficial inferior epigastric vessels. Prior to and 1 week following the delay procedure, noninvasive Doppler examinations of the superior epigastric vessels were performed. Following the delay procedure, the diameter of the superior epigastric artery increased from 1.3 +/- 0.2 to 1.8 +/- 0.3 mm (p < 0.001) and the calculated superior epigastric artery flow increased from 7.25 +/- 0.8 to 18.2 +/- 2.7 ml/min (p < 0.001). Breast reconstruction in these high-risk patients was successful without major ischemic complications, but a tendency toward unreliability of zone IV was noted. This clinical observation is consistent with the findings in our animal studies (part I). The preliminary delay procedure was well tolerated with minimal morbidity. We feel that a preliminary delay procedure is a very useful option for breast reconstruction patients at high risk for TRAM flap vascular compromise.

Cirugía plástica, reconstructiva y estética: una visión global para el médico general / Plastic, reconstructive and esthetical surgery: a global view by general psysicians

Existe poco material que oriente lo que debe conocer un médico general respecto a esta especialidad.Quizás el sólo nombre de Cirugía Plástica, conlleva una connotación estética o de ultraespecialidad. El propósito del presente trabajo es dar una visión global de lo que es la Cirugía Plástica y algunos conceptos generales que creemos que debe adquirir el médico general en su formación

A classification of the island grafts.

The techniques for the use of island grafts in the closure of surgical wounds after the excision of cutaneous malignancies are quite simple and yield good cosmetic results. At present, the main configurations of island grafts are described with a diverse and confusing terminology. This article presents a logical classification of the island grafts based upon the shape of the primary defect, the shape of the partial closure, and whether the graft or grafts are distant or contiguous. By use of this classification, it is possible to develop a simplified approach to wound closure for almost all cutaneous surgical defects.