Pharyngeal reconstruction with a modified free alt flap with parastomal fascial wings.

AIM: Previous reports have demonstrated good outcomes with the use of the Anterolateral Thigh Flap (ALT) in pharyngeal reconstruction. We report a new modification of free ALT flap pharyngeal reconstruction utilizing vascularised fascial wings or extensions placed in the parastomal gutters to cover the major neck vessels. PATIENTS AND METHODS: This was a single-center retrospective case review. Between November 2017 and January 2019, 8 patients (6 male, 2 female mean age 61, range 35 to 74) underwent near circumferential pharyngeal reconstruction by the modified technique. 3 patients had laryngopharyngectomy for radiorecurrent larynx SCC, 2 for primary, advanced laryngeal SCC, and 3 for primary hypopharyngeal SCC. RESULTS: All eight patients regained adequate swallow to maintain nutrition without tube-feeding. Two of the patients have been assessed as appropriate for tracheo-esophageal puncture and are awaiting placement. One patient uses an electrolarynx for speech and 5 patients aphonic only. One patient died 2 months after the procedure from chest infection. There were no flap failures, no fistulas and no strictures at one year. One patient who underwent a salvage laryngopharyngectomy experienced parastomal wound dehiscence, but critically there was no return to theater for exposed major vessels and the wound healed within 6 weeks requiring dressings only. CONCLUSION: Here we report outcomes of pharyngeal reconstruction with a modified single perforator free ALT flap using fascial extensions to line the parastomal gutters. In the event of parastomal dehiscence, the placement of vascularized tissue parastomally may facilitate spontaneous healing and prevent major vessel exposure.

Safety of major reconstructive surgery during the peak of the COVID-19 pandemic in the United Kingdom and Ireland - multicentre national cohort study.

BACKGROUND: The safety of surgery during and after the coronavirus disease-2019 (COVID-19) pandemic is paramount. Early reports of excessive perioperative mortality in COVID-positive patients promoted the widespread avoidance of operations. However, cancelling or delaying operations for cancer, trauma, or functional restitution has resulted in increased morbidity and mortality. METHODS: A national multicentre cohort study of all major reconstructive operations carried out over a 12-week period of the 'COVID-19 surge' in the United Kingdom and Ireland was performed. Primary outcome was 30-day mortality and secondary outcome measures were major complications (Clavien-Dindo grade ≥3) and COVID-19 status of patients and healthcare professionals before and after surgery. RESULTS: A total of 418 patients underwent major reconstructive surgery with a mean operating time of 7.5 hours and 12 days' inpatient stay. Cancer (59.8%) and trauma (29.4%) were the most common indications. COVID-19 infection was present in 4.5% of patients. The 30-day post-operative mortality was 0.2%, reflecting the death of one patient who was COVID-negative. Overall complication rate was 20.8%. COVID status did not correlate with major or minor complications. Eight healthcare professionals developed post-operative COVID-19 infection, seven of which occurred within the first three weeks. CONCLUSIONS: Major reconstructive operations performed during the COVID-19 crisis have been mostly urgent cases involving all surgical specialties. This cohort is a surrogate for all major operations across all surgical specialties. Patient safety and surgical outcomes have been the same as in the pre-COVID era. With adequate precautions, major reconstructive surgery is safe for patients and staff. This study helps counsel patients of COVID-19 risks in the perioperative period.

The surgical management of sarcomas of the chest wall: A 13-year single institution experience.

INTRODUCTION: Chest wall sarcomas are rare. Resection and reconstruction pose significant anatomical and functional challenges. We present our experience of managing these tumours as plastic surgeons working within a specialist sarcoma MDT. METHODS: All cases of chest wall sarcoma in which a plastic surgeon took part were analysed (2003-2016). Tumours of the breast, abdomen and groin were excluded. Demographics, surgical details and outcomes were analysed. RESULTS: Forty-seven patients were identified. Median age at presentation was 61 years (range 7-91). Thirty-three were male and 14 were female. Chondrosarcoma (n = 16) was the most frequently occurring tumour, followed by myxofibrosarcoma (n = 6), leiomyosarcoma (n = 5) and unclassified sarcomas (n = 5). The majority of tumours were of high (n = 16) or intermediate grade (n = 17) histologically. Wide local excision was carried out in all cases. Twenty-two cases required a mesh and cement reconstruction of the chest wall. Soft tissue reconstruction involved pedicled LD flap +-skin graft (n = 17), direct closure (n = 13), pedicled VRAM (n = 7), free ALT flap (n = 6), and others (n = 4). Clear resection margins were achieved in 32 patients (68%). Fourteen patients underwent adjuvant radiotherapy and four adjuvant chemotherapy. Nine patients (19%) developed a local recurrence, and the median duration from resection to recurrence was 17 months (range 3-72). Nine patients (19%) developed metastasis. Eleven patients died (23.4%), and the median duration of survival 30 months (range 3-92). Thirty-six patients remain well, with a median duration of follow up 57.5 months (range 6-141). Estimated 5 year disease specific survival is 74.2%. CONCLUSION: Plastic surgeons have a vital role in the management of chest wall sarcomas. We present a reconstructive algorithm, which has enabled us to achieve good oncological and functional outcomes and a low complication profile .

Advances in image enhancement for sarcoma surgery.

The recurrence rate of soft tissue and bone sarcomas strongly correlates to the status of the surgical margin after excision, yet excessive removal of tissue may lead to distinct, otherwise avoidable morbidity. Therefore, adequate margination of sarcomas both pre- and intra-operatively is a clinical necessity that has not yet fully been met. Current guidance for soft-tissue sarcomas recommends an ultrasound scan followed by magnetic resonance imaging (MRI). For bone sarcomas, two plane radiographs are required, followed similarly by an MRI scan. The introduction of more precise imaging modalities may reduce the morbidity associated with sarcoma surgery; the PET-CT and PET-MRI approaches in particular demonstrating high clinical efficacy. Despite advancements in the accuracy in pre-operative imaging, translation of an image to surgical margins is difficult, regularly resulting in wider resection margins than required. For soft tissue sarcomas there is currently no standard technique for image guided resections, while for bone sarcomas fluoroscopy may be used, however margins are not easily discernible during the surgical procedure. Near infra-red (NIR) fluorescence guided surgery offers an intra-operative modality through which complete tumour resection with adequate tumour-free margins may be achieved, while simultaneously minimising surgical morbidity. NIR imaging presents a potentially valuable adjunct to sarcoma surgery. Early reports indicate that it may be able to provide the surgeon with helpful information on anatomy, perfusion, lymphatic drainage, tumour margins and metastases. The use of NIR fluorochromes have also been demonstrated to be well tolerated by patients. However, prior to widespread implementation, studies related to cost-effectiveness and the development of protocols are essential. Nevertheless, NIR imaging may become ubiquitous in the future, carrying the potential to transform the surgical management of sarcoma.

Soft Tissue Sarcoma of the Hand and Wrist: Epidemiology and Management Challenges.

Soft tissue sarcomas (STSs) of the hand and wrist are rare and confer a unique set of management challenges. We present a 15-year review and discussion of the epidemiology, tumor characteristics, treatment, and reconstructive strategies for such cases presenting to our regional sarcoma service. Three case examples are described. Of 218 STSs of the upper limb, 17 involved the hand or wrist. Alveolar rhabdomyosarcoma, synovial, and myxofibrosarcoma were the most common ones. Two patients required amputation for recurrence. Eight patients required flap reconstruction, of which five were free flaps with no failures or wound healing complications. Two-year overall survival rate was 92%. Local recurrence occurred in 12%. Limb-sparing surgery is possible in most patients, although there is often a degree of functional loss due to the surgical resection, and complex multistage reconstruction may be required. These lesions are still often incidental or unexpected findings when patients are treated for a presumed benign swelling. Clinicians treating localized swellings of the hand and wrist should maintain vigilance toward the possibility of a sarcoma diagnosis, to avoid delays in definitive treatment.

The surgical management of head and neck sarcoma: The Newcastle experience.

INTRODUCTION: Head and neck sarcomas are rare and difficult to manage surgically. Factors that influence the prognosis include the type and grade of tumour, resection margins, the anatomical site and patient-specific parameters. We review our experience as plastic surgeons working in a bone and soft-tissue tumour multidisciplinary team (MDT) in managing these tumours surgically. METHODS: Data on all patients with sarcoma of the head or neck managed surgically from 2004 to 2015 was reviewed. Demographics, surgical details and outcomes were analysed. RESULTS: Forty-nine patients underwent surgery for sarcoma of the head or neck. The mean age at presentation was 53.1 years (range 0.5-92). Histological diagnosis was varied. Leiomyosarcoma (n = 6), angiosarcoma (n = 9), synovial sarcoma (n = 4), sarcoma of no specific type (n = 5) and rhabdomyosarcoma (n = 5) were the most frequently seen tumours. All sarcomas were treated by wide excision. Excision margins were histologically complete in the vast majority (n = 43). Reconstruction was undertaken as follows: direct closure (n = 12), local flap ± skin graft (n = 12), free tissue transfer (n = 21), pedicled flap ± skin graft (n = 3) and skin graft (n = 1). Twelve patients received adjuvant chemotherapy and fifteen patients received adjuvant radiotherapy. Eleven patients developed local recurrence and 10 patients developed metastasis. Twelve patients died of their disease: mean survival period was 17 months (range 8-28 months). The mean duration of follow-up was 78 months (range 18-137 months). Estimated 5-year disease-specific survival for this cohort was 72% and overall estimated survival was 61% (Kaplan-Meier equation). CONCLUSION: Head and neck sarcomas are rare and challenging to manage. Successful outcomes can be achieved by early, aggressive resection and appropriate reconstruction within the specialist MDT setting.

Reconstructive considerations in head and neck surgical oncology: United Kingdom National Multidisciplinary Guidelines.

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The reconstructive needs following ablative surgery for head and neck cancer are unique and require close attention to both form and function. The vast experience accrued with microvascular reconstructive surgery has meant a significant expansion in the options available. This paper discusses the options for reconstruction available following ablative surgery for head and neck cancer and offers recommendations for reconstruction in the various settings. Recommendations • Microsurgical free flap reconstruction should be the primary reconstructive option for most defects of the head and neck that need tissue transfer. (R) • Free flaps should be offered as first choice of reconstruction for all patients needing circumferential pharyngoesophageal reconstruction. (R) • Free flap reconstruction should be offered for patients with class III or higher defects of the maxilla. (R) • Composite free tissue transfer should be offered as first choice to all patients needing mandibular reconstruction. (R) • Patients undergoing salvage total laryngectomy should be offered vascularised flap reconstruction to reduce pharyngocutaneous fistula rates. (R).

The medial sural artery perforator flap in intra-oral reconstruction: A Northeast experience.

BACKGROUND: The medial sural artery perforator (MSAP) flap is a fasciocutaneous flap that is gaining popularity for intra-oral reconstructions. The aim of this two-centre review was to evaluate the use of the MSAP flap in intra-oral reconstructions and report our experiences. METHODS: Data were collected prospectively on 35 consecutive intra-oral reconstructions using the free MSAP flap. Patient details and intraoperative flap details were recorded. RESULTS: Thirty-five patients underwent intra-oral reconstruction with a free MSAP flap (26 males and nine females). The average flap dimensions were a length of 8.03 cm, a width of 5.0 cm and a thickness of 7.1 mm. Twenty-two flaps had two perforators, and the average pedicle length was 11.1 cm. There were no flap losses. Ninety-one per cent of donor sites were closed primarily. There were two minor complications related to donor-site wound dehiscence, which required delayed skin grafting. The overall complication rate was 5.7%. CONCLUSIONS: The MSAP flap is a good choice for intra-oral reconstruction. It has reliable anatomy and provides thin, pliable skin with a long pedicle. In addition, donor morbidity is low as the donor site can be closed directly in most cases. It is currently our flap of choice for small intra-oral soft tissue defects.

Myxofibrosarcoma of the extremity and trunk: a multidisciplinary approach leads to good local rates of LOCAL control.

AIMS: Myxofibrosarcomas (MFSs) are malignant soft-tissue sarcomas characteristically presenting as painless slowly growing masses in the extremities. Locally infiltrative growth means that the risk of local recurrence is high. We reviewed our experience to make recommendations about resection strategies and the role of the multidisciplinary team in the management of these tumours. PATIENTS AND METHODS: Patients with a primary or recurrent MFS who were treated surgically in our unit between 1997 and 2012 were included in the study. Clinical records and imaging were reviewed. A total of 50 patients with a median age of 68.4 years (interquartile range 61.6 to 81.8) were included. There were 35 men; 49 underwent surgery in our unit. RESULTS: The lower limb was the most common site (32/50, 64%). The mean size of the tumours was 8.95 cm (1.5 to 27.0); 26 (52%) were French Fédération Nationale des Centres de Lutte Contre le Cancer grade III. A total of 21 (43%) had positive margins after the initial excision; 11 underwent further excision. Histology showed microscopic spread of up to 29 mm beyond macroscopic tumour. Local recurrence occurred in seven patients (14%) at a mean of 21 months (3 to 33) and 15 (30%) developed metastases at a mean of 17 months (3 to 30) post-operatively. CONCLUSION: High rates of positive margins and the need for further excision makes this tumour particularly suited to management by multidisciplinary surgical teams. Microscopic tumour can be present up to 29 mm from the macroscopic tumour in fascially-based tumours. Cite this article: Bone Joint J 2016;98-B:1682-8.

Head and neck skin involvement by non-cutaneous head and neck cancers: free flap reconstruction.

INTRODUCTION: Patients with skin involvement from head and neck cancer have a poor prognosis, with a median survival time of 2 months. METHOD AND RESULTS: During a 9 year period, 31 patients with skin involvement above the clavicle by non-cutaneous malignant tumours of the head and neck were treated. In 19 males and 12 females with a mean age of 62 years, the parotid gland (32%) and the oral cavity (29%) were the commonest sites of primary disease and 77% of the cases were squamous cell carcinomas. Twenty-six had recurrent disease, 20 had received previous radiotherapy and all underwent surgical resection with free flap reconstruction, the commonest being the radial forearm (78%). Complete histological clearance was achieved in 53% of the cases, and adjuvant post-operative irradiation was given to 60%. With this form of management, palliation was extended to a mean survival of 23 months. Six patients are currently alive and disease free at a mean follow up of 4.5 years. CONCLUSIONS: Patients with head and neck skin involvement by non-cutaneous head and neck malignancies have a very poor prognosis, but surgical resection combined with free microvascular flap reconstruction and planned post-operative radiotherapy, can offer good long-term palliation.

Latissimus dorsi muscle flap based on arterial branch to serratus anterior as salvage of a failed bipedicled transverse rectus abdominis muscle flap. A case report.

We present a case of a failed bipedicled (unilateral rectus flap with superior epigastric pedicle preserved and inferior epigastric vessels anastomosed to the thoracodorsal trunk as the second pedicle) transverse rectus abdominis muscle flap that had compromised the dominant pedicle of the latissimus dorsi muscle. A salvage procedure was possible using this muscle as a pedicle flap based on the back-flow from the serratus anterior arterial branch with success. The use of the reconstructive ladder is highlighted.

A case report of post-traumatic facial reconstruction in the West Indies.

The radial forearm free flap is one of the most commonly used free flaps in reconstructive surgery. It is a recognized option for facial reconstruction internationally, but, to our knowledge, it has not been widely used in the Caribbean. We present a patient who posed a difficult reconstructive problem, for which the radial forearm free flap was the ideal solution, utilizing the flap's features of a long length of pedicle, large area of coverage, minimal tissue bulk, and options for further cosmetic revision.

Pedicled flaps in reconstructive surgery.

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised débridement in trauma and oncological resection.

Free vascularized fibula graft for a cystic femoral head and neck lesion in the West Indies.

A case is presented of an 18-year-old athlete with fibrous dysplasia of the femoral neck and head. The approach was by joint plastic and orthopaedic teams, which minimized operating time and allowed the option of vascular bone grafting. The lesion was curetted through a greater trochanteric window and the defect reconstructed with a free vascularized fibula graft with excellent result. Weight bearing was achieved in six months and there was minimal donor site morbidity. We believe the free vascularized fibula graft to be a reconstructive option, in difficult orthopaedic problems, facilitated by microsurgery and there is immense benefit of a joint effort between the orthopaedic and plastic surgical teams.

Tissue transfer to post-chemoradiation salvage laryngectomy defects to prevent pharyngocutaneous fistula: single-centre experience.

Background: In recent practice, we have used tissue transfer (pedicled or free flap) to augment the pharyngeal circumference of the neopharynx following salvage total laryngectomy, even in patients who have sufficient pharyngeal mucosa for primary closure. In this study, the rates of pharyngocutaneous fistula were compared in soft tissue flap reconstructed patients versus patients who underwent primary closure. Method: A retrospective assessment was carried out of all patients who had undergone a salvage total laryngectomy between 2000 and 2010. The presence or absence of a pharyngocutaneous fistula was compared in those who received reconstruction closure versus those who received primary closure. Results: The reconstruction closure group (n = 7) had no incidence of pharyngocutaneous fistula, whereas the primary closure group (n = 38) had 10 fistulas, giving pharyngocutaneous fistula rates of 0 per cent versus 26 per cent, respectively. Conclusion: The findings revealed a lower rate of pharyngocutaneous fistula with tissue transfer compared with primary closure of the neopharynx.

The superficial circumflex iliac artery perforator flap in intra-oral reconstruction.

INTRODUCTION: The superficial circumflex iliac artery perforator (SCIP) flap is a modification of the groin flap using perforators of the superficial circumflex iliac artery (SCIA). It has mainly been used in lower-limb reconstruction with no descriptions in the literature of its use in intra-oral soft-tissue head and neck reconstruction. This article reports the initial Newcastle experience. METHODS: Data were gathered prospectively for the first five head and neck patients with SCIP flap reconstruction. All patients had a speech and swallowing assessment as part of their post-operative follow-up. RESULTS: An SCIP flap was used following the resection for four intra-oral squamous cell carcinomas (SCCs) and one pharyngeal SCC. There was no flap compromise and excellent functional outcome at 6 months. The donor-site morbidity was minimal with direct closure achieved in each case leaving a scar easily concealed in the groin crease. CONCLUSIONS: Overall, the results at both the primary and donor sites in our first five cases have been aesthetically and functionally excellent. The flap pedicle easily reached the common recipient vessels in the neck. The vessels can be of smaller calibre but well within the scope of the microsurgeon. The SCIP flap appears to offer a thin, pliable, reliable flap with an excellent donor site.

Lipoma or liposarcoma? A cautionary case report.

MERRF syndrome (myoclonic epilepsy with ragged-red fibres) is a mitochondrial encephalomyopathy characterised by a mixed seizure disorder and myoclonus. The condition is associated with multiple large cervical lipomas that often require surgical excision. Comprehensive clinical examination combined with pre-operative radiographic imaging is vital in such cases to help differentiate benign fatty masses from potential liposarcomas. We describe a case in which a lipoma-like liposarcoma was identified following excision of what was expected, on clinical and radiological grounds, to be a lipoma. This case highlights the potential for sarcomatous changes in suspicious lipomas, and the key role that imaging plays in differentiating benign from malignant.