Definitive Closure of the Tracheoesophageal Puncture Site after Oncologic Laryngectomy: A Systematic Review and Meta-Analysis.

Tracheoesophageal puncture (TEP) and voice prosthesis insertion following laryngectomy may fail to form an adequate seal. When spontaneous closure of the fistula tract does not occur after conservative measures, surgical closure is required. The purpose of this study was to summarize the available evidence on surgical methods for TEP site closure. A comprehensive search across PubMed, Web of Science, SCOPUS, and Cochrane was performed to identify studies describing surgical techniques, outcomes, and complications for TEP closure. We evaluated the rate of unsuccessful TEP closure after surgical management. A meta-analysis with a random-effect method was performed. Thirty-four studies reporting on 144 patients satisfied inclusion criteria. The overall incidence of an unsuccessful TEP surgical closure was 6% (95% confidence interval [CI] 1-13%). Subgroup analysis showed an unsuccessful TEP closure rate for silicone button of 8% (95% CI < 1-43%), 7% (95% CI < 1-34%) for dermal graft interposition, < 1% (95% CI < 1-37%) for radial forearm free flap, < 1% (95% CI < 1-52%) for ligation of the fistula, 17% (95% CI < 1-64%) for interposition of a deltopectoral flap, 9% (95% CI < 1-28%) for primary closure, and 2% (95% CI < 1-20%) for interposition of a sternocleidomastoid muscle flap. Critical assessment of the reconstructive modality should take into consideration previous history of surgery or radiotherapy. Nonirradiated fields and small defects may benefit from fistula excision and tracheal and esophageal multilayer closure. In cases of previous radiotherapy, local flaps or free tissue transfer yield high successful TEP closure rates. Depending on the defect size, sternocleidomastoid muscle flap or fasciocutaneous free flaps are optimal alternatives.

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes.

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.

Evolution and Transformation of Uterine Transplantation: A Systematic Review of Surgical Techniques and Outcomes.

BACKGROUND: Uterine transplantation (UTx) is acknowledged to be on the second (2A) of five steps of development in accordance with the staging system for the evaluation of surgical innovations. Accordingly, we aimed to systematically review the available evidence of the surgical techniques and outcomes of UTx in terms of graft survival. METHODS: A comprehensive search was conducted across PubMed Medline, Cochrane-EBMR, Scopus, Web of Science, and CENTRAL through November 2020. RESULTS: Forty studies, reporting 64 recipients and 64 donors, satisfied inclusion criteria. The surgical time and the estimated blood loss were 515 minutes and 679 mL for graft procurement via laparotomy, 210 minutes and 100 mL for laparoscopic-assisted graft harvest, and 660 minutes and 173 mL for robotic-assisted procedures, respectively. Urinary tract infections (n = 8) and injury to the urinary system (n = 6) were the most common donor complications. Using the donor's internal iliac system, two arterial anastomoses were performed in all cases. Venous outflow was accomplished through the uterine veins (UVs) in 13 cases, a combination of the UVs and the ovarian/uteroovarian veins (OVs/UOVs) in 36 cases, and solely through the OVs/UOVs in 13 cases. Ischemia time was 161 and 258 minutes when using living donors (LD) and deceased donors (DD), respectively. Forty-eight uteri were successfully transplanted or fulfilled the purpose of transplantation, 41 from LDs and 7 from DDs. Twenty-five and four live childbirths from LDs and DDs have been reported, respectively. CONCLUSION: UTx is still experimental. Further series are required to recommend specific surgical techniques that best yield a successful transplant and reduce complications for donors and recipients.

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.

Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review.

BACKGROUND: Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes. METHODS: This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted. RESULTS: A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy. CONCLUSION: AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.

Master Series Microsurgery for Residents: Results from a Comprehensive Survey of a Multitudinous Online Course during COVID-19 Pandemic.

BACKGROUND: Since COVID-19 emerged, it has significantly affected medical education. Surgical training has been blocked and the learning curve flattened. However, COVID-19 led to the outbreak of multitudinous online courses. Master series: microsurgery for residents (MSMR) has been the most extensive and accessible online nonfee course transmitted so far regarding reconstructive microsurgery. The primary aim of this study was to assess the impact of the MSMR in the surgical community as an international educational tool during pandemic confinement. METHODS: A retrospective, observational, analytic, and transversal study was designed. An 11-item survey was sent to all the 1,513 attendees who completed at least 60% of course attendance during 2 days. Descriptive and analytic statistics were performed. The impact was measured by considering answers to questions 6 to 9 and 11 (course usefulness, microsurgery interest increase, desire to pursue a microsurgical career, attendance to in-person conferences, and overall score, respectively). RESULTS: A total of 1,111 (73.4%) of eligible subjects were included. In total, 55.8% were plastic surgery residents. After the course, 98.9% would pursue a career in reconstructive microsurgery, and 45% would stop attending in-person conferences. The overall score of the event was 9.06 ± 0.9 (from 0 to 10) regardless of the current training status. CONCLUSION: The MSMR was a high impact course and has established a paradigm shift that will lead to an evolution in plastic surgery learning.

Donor-Site Morbidity Following Free Fibula Flap Harvest for Mandibular or Maxillary Reconstruction in Pediatric Patients.

INTRO AND AIM: The morbidity at the donor-site in the free fibula flap is a well-studied fact in the adult population, but in children, there are few reports of the long-term adverse effects at the donor site. In this study, we evaluate donor-site morbidity, complications, and functional outcome in pediatric patients undergoing free fibula flap harvest for mandibular or maxillary reconstruction, and the relation between pain and walking abilities. METHODS: A retrospective study of 22 pediatric patients undergoing free fibula flap harvest for mandibular and maxillary reconstruction between 2003 and 2014 was conducted. A certified point evaluation system was used, analyzing several factors like pain, walking ability, restriction in activities, gait alteration, paresthesia, and cosmetic appearance, and the relationship between variables. RESULTS: Mean age follow up of patient was 8.5 years (range 2-13 years). Pain was reported in 27% (n = 6), paresthesia and numbness 9% (n = 2), walking ability alteration in 50% (n = 11), restriction in activities in 18% (n = 4), gait alteration in 23% (n = 5), and cosmetic appearance alteration in the 14% (n = 3). We compare the pain and the gait alteration and did not find any relation between pain and gait alteration (P = 0.6016) and there was no relation between restriction in activities and walking ability (P = 0.1455). CONCLUSION: Free fibula flap is the gold standard for head and neck reconstruction, but the morbidity at the donor site, especially in a growing child, should not be ignored or minimized when counseling patients and their families.More studies, with more population and with a long-term follow-up should be carried out to determine the impact on the daily activities on the pediatric population.

Lessons Learned from Delayed Versus Immediate Microsurgical Reconstruction of Complex Maxillectomy and Midfacial Defects: Experience in a Tertiary Center in Mexico.

Microsurgical reconstruction of complex midfacial and maxillectomy defects is among the most challenging procedures in plastic surgery, and it often requires composite flaps to improve functional and aesthetic results. Various factors have been identified as having influence in the outcome of microsurgical reconstruction. In this article, the authors present their experience with immediate and delayed reconstruction of complex maxillectomy defects in a tertiary center in Mexico. The authors present a total of 37 patients with microsurgical reconstruction of a complex maxillectomy defect; 13 patients had immediate and 24 had delayed reconstructions. The authors recommend doing immediate reconstruction when feasible.

Standardized templates for shaping the fibula free flap in mandible reconstruction.

Conversion of the straight fibula bone flap into the parabolic mandible shape can be performed using customized acrylic templates made from a 1:1 mandible computed tomography scan and lateral cephalogram. The premise of the current study is to objectively quantify the variability in a series of acrylic templates used for mandible reconstruction to assess the feasibility of creating a standardized template.In this study acrylic templates of 48 consecutive adult dentate patients who underwent fibula flap mandible reconstruction from 1994 to 1999 were evaluated. Osteotomy angles for the mandibular angle, midbody and parasymphysis, and length of each bony segment were determined using a metric ruler and protractor. Values were reported as means ± standard deviation.The mean mandibular angle measured 122.6 ± 6.4 degrees, while the midbody and parasymphysis angles were 153 ± 4.5 degrees and 130 ± 4.2 degrees, respectively. Mean bone segment lengths were: ramus 64.5 ± 9.8 mm, distal body 47.6 ± 4.2 mm, mesial body 40.6 ± 3.2 mm, and symphysis 18.5 ± 2.2 mm.It was concluded that the evaluation of patient acrylic templates used in a series of mandible reconstructions demonstrates osteotomy angles vary minimally (3-5%). Bone segment lengths vary from 10 to 15%, suggesting heterogeneity in mandible size. A standard template can be used to shape the fibula in most mandible reconstructions eliminating the need for routine preoperative imaging or costly fabricated computer-aided design/computer-aided manufacturing cutting guides.

A shift from the osteocutaneous fibula flap to the prelaminated osteomucosal fibula flap for maxillary reconstruction.

BACKGROUND: Reconstruction of the maxilla with the fibula free flap is a popular and well-described technique. The ideal intraoral lining would be mucosa, which is moist, thin, and non-hair-bearing. Prelamination of the fibula with buccal mucosa replaces like tissue with like tissue, obviates the need for a skin paddle, and facilitates placement of osseointegrated implants in a single stage. For central maxillary defects, the authors have shifted from using an osteocutaneous to a prelaminated free fibula flap. In this article, the authors report their experience using the prelaminated osteomucosal fibula for maxillary reconstruction. METHODS: From 2003 to 2011, 24 patients underwent reconstruction of a central maxillary defect using a free fibula flap. The first 10 patients had osteoseptocutaneous flaps, and the other 14 patients had prelaminated flaps. Data collected included patient age, cause of defect, type and number of operations, complications at both the donor and recipient sites, and placement of osseointegrated implants. RESULTS: The majority of patients in the series (n = 21) had central maxillary defects caused by loss of the premaxilla during early repair of bilateral cleft lip-cleft palate. There was one flap failure in the nonprelaminated flap group and one in the prelaminated group. Repeated debulking to thin the skin paddle was required in all of the patients with osteocutaneous flaps. CONCLUSIONS: Prelamination delivers like tissue to the recipient site, obviates the need for debulking, and may reduce donor-site wound problems. To the authors' knowledge, this is the largest series of prelaminated fibulas for maxillary reconstruction in the literature. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Reconstruction of the premaxilla: an option for mutilated bilateral clefts.

The loss of the maxilla is a severe mutilation resulting from inadequate surgery of bilateral clefts of the lip and palate. It is usually associated with palatal fistulae, collapse of the maxillary segments, and limited facial growth.Functional rehabilitation can be achieved by reconstruction of the premaxilla with osteomucosal fibula grafts. Mucosal grafts are fixed to the fibula in a preliminary stage. The composite graft is transplanted to the maxilla 10 to 12 weeks later. Osteointegrated implants are placed 3 months later.The procedure was used in 7 patients, 1 holoprosencephaly and 6 with sequelae of bilateral clefts; mean age, 17.28 years, with a follow-up of 14 to 70 months.The mucosal grafts integrated successfully to the fibula in all the patients. The osteocutaneous graft achieved a solid maxillary arch in all the patients. Normal mastication was achieved with a prosthesis fixed to the osteointegrated implants. Facial proportions were greatly improved.

Mandibular microsurgical reconstruction in patients with hemifacial microsomia.

BACKGROUND: Although hemifacial microsomia is a relatively common craniofacial malformation, there is some debate regarding the ideal treatment of severe mandibular hypoplasia. Traditionally, patients with severe mandibular deficits have been treated with iliac or costochondral bone grafts followed by distraction osteogenesis, with mixed results. The authors present their experience with the use of the fibula osteocutaneous free flap for mandibular reconstruction in severe hemifacial microsomia patients. METHODS: From 1999 to 2006, 10 patients aged 3 to 10 years (mean, 7.2 years) underwent 10 free flap reconstructions. Of the 10 patients, six were girls and four were boys. Data were collected retrospectively from the patients' records, photographs, and radiographs. The authors report the surgical technique used, complications, and long-term outcome. RESULTS: Nine of 10 flaps were successful, for a flap survival rate of 90 percent. Donor bone length was 5 to 10 cm, with a mean of 6.3 cm. Skin paddles ranged from 8 to 36 cm, with a mean size of 18.7 cm. Mean operation time was 412 minutes and mean follow-up was 45.4 months (range, 12 to 94 months). Two patients underwent successful distraction osteogenesis subsequent to their free flap mandible reconstruction. All patients demonstrated stable bony union of the free flap by physical and radiographic examination. One major complication (a failed free flap) and two minor complications were observed. CONCLUSION: The free flap is safe and effective, and should be considered as a first choice in mandibular reconstruction in severe cases of hemifacial microsomia where distraction osteogenesis is not possible.

Reconstruction of maxillectomy and midfacial defects with free tissue transfer.

The maxillary bones are part of the midfacial skeleton and are closely related to the eyeglobe, nasal airway, and oral cavity. Together with the overlying soft tissues, the two maxillae are responsible to a large extent for facial contour. Maxillectomy defects become more complex when critical structures such as the orbit, globe, and cranial base are resected, and reconstruction with distant tissues become essential. In this article, we describe a classification system and algorithm for reconstruction of these complex defects using various pedicled and free flaps. Most defects that involve resection of the maxilla and adjacent soft tissues may be classified into one of the following four types: Type I defects, Limited maxillectomy; Type II defects, Subtotal maxillectomy; Type III defects, Total maxillectomy; and Type IV defects, Orbitomaxillectomy. Using this classification, reconstruction of maxillectomy and midfacial defects may be approached considering the relationship between volume and surface area requirements, that is, addressing the bony defect first, followed by assessment of the associated soft tissue, skin, palate, and cheek-lining deficits. In our experience, most complex maxillectomy defects are best reconstructed using free tissue transfer. The rectus abdominis and radial forearm free flap in combination with immediate bone grafting or as an osteocutaneous flap reliably provide the best aesthetic and functional results. A temporalis muscle pedicled flap is used for reconstruction of maxillectomy defects only in those patients who are not candidates for a microsurgical procedure.

Long-term follow-up and unusual findings after microvascular transfer of hair-bearing skin for pubic hair restoration.

Alopecia in the pubic area can be restored successfully with hair transplantation using minigrafts and micrografts or with free tissue transfer of a hair bearing flap. In this report the authors present the successful transfer of hair bearing tissue from the temporoparietal scalp for the correction of a congenital form of alopecia of the pubic region. In addition, they present long term results of this transfer. Auxiliary procedures such as tissue expansion before or after transferring the flap, hair epilation and minigraft and micrograft transplantation could help to achieve a more natural result. Tissue expansion of the donor site could also be performed to enhance the outcome of the procedure. Of note is the rapid rate of hair growth in the transplanted tissue. This type of reconstruction using a hair bearing temporoparietal flap for restoration of hair to the pubic region is a useful method that can yield good results.