The Versatility of the DCIA Free Flap: A Forgotten Flap? Systematic Review and Meta-Analysis.

BACKGROUND: Studies reporting on the deep circumflex iliac artery (DCIA) free flap are restricted to a limited number of patients and areas of application. The aim of this review was to assess the reliability and versatility of the DCIA free flap during reconstruction. METHODS: A comprehensive review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines using PubMed, Web of Science, Cochrane CENTRAL, and SCOPUS. A critical analysis of pooled data was performed to assess outcomes employing the DCIA free flap. RESULTS: A total of 445 DCIA free flaps were included. The main recipient sites were head and neck (72.35%), lower extremity (20.67%), and upper extremity (6.74%). The main indications for reconstruction were tumor resection (73.8%) and trauma (17.43%). Fifty non-DCIA flaps were required to finalize the reconstruction of several defects. The pooled flap failure rate using the DCIA free flap was 4% (95% confidence interval: 1-8%). No significant heterogeneity was present across studies (Q statistic 22.12, p = 0.14; I 2 = 27.68%, p = 0.139). Complication rates for head and neck and limb reconstruction were 57.37 and 40.16%, respectively. The average length and surface area of bone flaps were 7.79 cm and 22.8 cm2, respectively. The area of the skin paddles was 117 cm2. CONCLUSION: The DCIA free flap has shown to be a versatile reconstructive alternative for head and neck and short-medium size limb defects. However, the complexity of functions, the recipient site location, and a potential large defect can detract from the use of the DCIA free flap as an initial reconstructive option for head and neck and extensive limb defects.

The Value of a Co-surgeon in Microvascular Breast Reconstruction: A Systematic Review and Meta-analysis.

Using a co-surgeon model has been suggested to improve perioperative outcomes and reduce the risk of complications. Therefore, we evaluated if a co-surgeon model compared with a single microsurgeon model could decrease the surgical time, length of stay, rate of complications, and healthcare-associated costs in adult patients undergoing microvascular breast reconstruction (MBR). A comprehensive search was performed across PubMed MEDLINE, Embase, and Web of Science. Studies evaluating the perioperative outcomes and complications of MBR using a single-surgeon model and co-surgeon model were included. A random-effects model was fitted to the data. Seven retrospective comparative studies were included. Ultimately, 1411 patients (48.23%) underwent MBR using a single-surgeon model, representing 2339 flaps (48.42%). On the other hand, 1514 patients (51.77%) underwent MBR using a co-surgeon model, representing 2492 flaps (51.58%). The surgical time was significantly reduced using a co-surgeon model in all studies compared with a single-surgeon model. The length of stay was reduced using a co-surgeon model compared with a single-surgeon model in all but one study. The log odds ratio (log-OR) of recipient site infection (log-OR = -0.227; P = 0.6509), wound disruption (log-OR = -0.012; P = 0.9735), hematoma (log-OR = 0.061; P = 0.8683), and seroma (log-OR = -0.742; P = 0.1106) did not significantly decrease with the incorporation of a co-surgeon compared with a single-surgeon model. Incorporating a co-surgeon model for MBR has minimal impact on the rates of surgical site complications compared with a single-surgeon model. However, a co-surgeon optimized efficacy and reduced the surgical time and length of stay.

Case Report of Gas Gangrene after Reconstructive Surgery with Anterolateral Thigh Flap for Resection of Oral Cancer.

Necrotizing fasciitis (NF) type I is an acute subcutaneous tissue infection that can promptly disseminate generating crepitus. If not accurately diagnosed and expeditiously treated, it becomes a life-threatening infection. In this report, we present a 65-year-old man who developed a case of NF after a hemiglossectomy resecting a tumor in the dorsal surface of the tongue. A biopsy was performed, and he was pathologically diagnosed with squamous cell carcinoma (T2N1M0). The patient underwent preoperative oral cleaning. Right hemiglossectomy was performed by cervical dissection, pull-through style, with tooth removal on the right mandible and a left anterolateral femoral flap reconstruction. Routine intraoperative lavage was performed with 2000 mL of saline solution. Cefazolin 1gr was administered two times per day postoperatively. Four days after primary surgery, the flap circulation was inadequate; therefore, a computed tomography scan was taken, which indicated gas in the ventral neck area. Tooth extraction was the suspected etiology. Debridement was performed; the abscess was drained and cultured, indicating the presence of Staphylococcus haemolyticus and Escherichia coli. It seems that the abscess was not formed by NF, but rather by leachate reservoir associated with the head and neck tumor. After debridement, re-reconstruction was performed with a deltopectoral flap and pectoralis major myocutaneous flap. When NF is present after a neck dissection, there is a risk of disruption due to the direct invasion and inflammation into the carotid artery. Therefore, it is important to provide adequate oral cleaning care before the surgery and early suspicion of the diagnosis.

Surgical management of breast cancer-related lymphedema: a narrative review of contemporary practices.

Background and Objective: Breast cancer-related lymphedema (BCRL) represents a colossal burden in terms of health and patient-reported outcomes. Surgical management plays a prominent role in the psychological and physical well-being of women suffering from BCRL. Therefore, we performed a narrative review of the current surgical management of BCRL and analyzed the postoperative results. Methods: A literature search was conducted across PubMed MEDLINE, Scopus, and Web of Science from database inception through January 2, 2023. We included English-written studies evaluating postoperative outcomes of lymphatic surgery for the management of BCRL. Key Content and Findings: The surgical management of lymphedema can be classified into two approaches: (I) physiologic procedures and (II) debulking or ablative procedures. While ablative procedures are intended to lessen the symptomatic burden of lymphedema via the removal of pathological tissues, physiologic procedures are performed to restore the abnormal lymphatic flow by creating bypasses into the venous or lymphatic circulation, or by creating new lymphatic connections by means of lymphangiogenesis. Physiologic procedures generate better outcomes in the early stages of lymphedema as there is some residual physiologic flow and vessels are less fibrotic, while ablative procedures are regarded to be the best alternative in very advanced lymphedema stages. A combination of physiologic and ablative procedures provides more comprehensive surgical management to BCRL. Conclusions: Lymphedema is a common complication of breast cancer treatment with an extensive incidence range. Postoperative outcomes of the surgical management of BCRL are heterogeneous despite most studies indicating favorable results after lymphatic surgery.

Prepectoral versus subpectoral two-stage implant-based breast reconstruction: U.S. medical center experience and narrative review.

Background and Objective: With the incorporation of autologous fat grafting, acellular dermal matrix (ADM) products, and nipple-sparing mastectomy, prepectoral device placement has become more popular in selected patients when compared to partial submuscular (dual plane) or complete submuscular device placement. In this article, we aimed to present a review of the current state-of-the-art for implant-based breast reconstruction (IBBR) using expanders. Additionally, we present a case series of our experience with IBBR evaluating perioperative outcomes, complications, and patient-reported outcomes (PRO). Methods: For our series, we retrospectively evaluated adult female patients undergoing 2-stage immediate IBBR after total mastectomy between 2011 and 2021. We performed a systematic search across PubMed MEDLINE for articles evaluating outcomes of prepectoral versus subpectoral two-stage IBBR with expanders published from database inception through February 28th, 2023. Key Content and Findings: Both prepectoral and subpectoral are safe alternatives for two-stage IBBR. Due to current advancements in the field of breast reconstruction, prepectoral IBBR has gained popularity and has a comparable rate of complications compared to a subpectoral approach in selected patients according to high-quality articles. In patients with several comorbidities, current tobacco use, history of preoperative radiation, and limited perfusion of the mastectomy flaps, subpectoral device placement should be given special consideration as a layer of vascularized tissue can decrease the risk of major complications or unplanned procedures. As prepectoral device placement does not require dissection of the pectoral muscles, faster recovery, better implant position, decreased pain, and a shorter time to complete expansion is expected. The plane of reconstruction does not seem to significantly affect the time for expander-to-implant exchange or PRO for quality-of-life (QOL) according to most studies. Conclusions: Prepectoral and subpectoral IBBR demonstrated a comparable rate of complications in selected patients. Nonetheless, perioperative outcomes seem to be improved using a prepectoral approach in terms of reduced pain, reduced time to conclude outpatient expansions, and less animation deformity.

Breast reconstruction using the Latissimus Dorsi Flap and Immediate Fat Transfer (LIFT): A systematic review and meta-analysis.

BACKGROUND: Despite several efforts have been made to increase the volume of the latissimus dorsi (LD) flap, few studies have reported the outcomes of LD flap and immediate fat transfer (LIFT) to restore a natural native breast appearance during the initial reconstructive procedure. The aim of this study was to report the different surgical techniques used when implementing LIFT for breast reconstruction and evaluate the postoperative outcomes. METHODS: A systematic search was conducted across PubMed, Embase, Web of Science, Ovid MEDLINE®, and Scopus. We included articles reporting postoperative outcomes of patients who underwent breast reconstruction with LIFT. RESULTS: We included nineteen studies reporting outcomes of 704 breast reconstructions with LIFT (57.09%). The average age and BMI of patients were 51 years and 26.01 kg/m2. The pooled rate of patients requiring additional fat grafting following LIFT was 64.9% (95% CI 43.3%-86.5%). The overall pooled incidence of total flap loss was 3% (95% CI <0%-7.2%), wound-related complications was 14.5% (95% CI 7.3%-21.7%), seroma was 18.2% (95% CI 5.1%-31.2%), and fat necrosis was 14.5% (95% CI 4.5%-24.4%). When compared with abdominal free flaps, we found a significantly lower risk difference of developing wound-related complications favoring LIFT (RD, 0.066; 95%CI 0.004-0.129; p = 0.038). CONCLUSIONS: LIFT offers a totally autologous, less morbid type of reconstruction in breast cancer patients who are not ideal candidates for reconstruction with free tissue transfer. However, immediate fat transfer during reconstruction with the LD flap does not eliminate the need for further fat grafting.

Maximizing Safety and Optimizing Outcomes of Labiaplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: The considerable increase in labiaplasty requires plastic surgeons to be acquainted with the surgical techniques, their respective complications, and satisfaction rates. The authors conducted a systematic review of the available evidence on labia minoraplasty, looking at surgical techniques, clinical outcomes, and patient satisfaction. METHODS: A comprehensive search across PubMed, Web of Science, SCOPUS, and CochraneCENTRAL was performed through October of 2020. A random-effects model meta-analysis was performed to assess satisfaction and complication rates. RESULTS: Forty-six studies including 3804 patients fulfilled the inclusion criteria. The pooled satisfaction rate after labia minoraplasty was 99 percent (95 percent CI, 97 to 99 percent). Substantial heterogeneity was present across studies ( I2 = 63.09 percent; p < 0.001). The highest pooled incidence of dehiscence was reported for laser-assisted labiaplasty (5 percent; 95 percent CI, 2 to 8 percent) and wedge resection (3 percent; 95 percent CI, 1 to 5 perecent). The highest pooled incidence of hematoma formation (8 percent; 95 percent CI, <1 to 23 percent) and postoperative bleeding (2 percent; 95 percent CI, <1 to 15 percent) was reported for W-shape resection. The highest pooled incidence of transient pain or discomfort was reported for de-epithelialization (2 percent; 95 percent CI, <1 to 23 percent) and W-shape resection (2 percent; 95 percent CI, <1 to 15 percent). Three cases of flap necrosis were reported; two occurred using wedge resection labia minoraplasty and one was not specified. The most common causes for revision surgery ( n = 169) were dehiscence and aesthetic concerns. CONCLUSIONS: Labia minoraplasty is a safe procedure, but serious complications requiring surgical management have been reported. Surgical experience, knowledge of female genital anatomy, and thorough technique selection in accordance with the patient characteristics are mandatory.