Reduction Mammoplasty Approach to Oncoplasty-Zone-Wise Planning in Indian Patients.

Introduction This article is an attempt to formulate certain guidelines for planning of zone-wise reconstruction after breast conservation surgery. The planning involves applying reduction mammoplasty principles with certain modifications to address the defect. Patients and Methods This is a retrospective study of 61 patients with breast cancer who underwent breast conservation surgery and reconstruction of partial breast defects with oncoplastic techniques between January 2014 to March 2019. Patients having low tumor to breast ratio and thus good candidates for volume displacement techniques were included in the study. Results A total of 61 breast cancer cases were included; 22 cases were located in zone 1, nine in zone 2, seven in zone 3, three in zone 4, four in zone 5, one in zone 6, 12 in zone 7, two in zone 8, and three in zone 9. The most common pedicle design used was superomedial in 38 cases, followed by inferior in 19 and medial in 6 cases. Vertical short scar technique was used in 33 cases and Wise pattern skin incision in 30 cases. Follow-up period ranged from 4 months to 65 months, with a mean of 31 months. Four patients had partial skin necrosis, three had suture line dehiscence, two had wound infection, one had seroma, and eight patients had fat necrosis. All patients were satisfied with the cosmetic outcome. Conclusion Breast oncoplastic techniques are effective, reliable, oncologically safe, and conducted with minimal complications in patients with moderately large ptotic breasts, thereby making planning easier and more reproducible by following the reconstruction procedures described in the article. We believe that these techniques should be incorporated in the armamentarium of every plastic surgeon to manage the defects created after breast conservation surgery, in order to achieve the best cosmetic outcomes.

Free fibula flap for lower limb salvage after tumour resection.

CONTEXT: Post-tumour resection lower limb salvage. AIM/INTRODUCTION: Resection of tumours of the femur and tibia around the knee and ankle joints results in large bony defects. Often arthrodesis is an alternative; in case, adequate functional motors cannot be preserved or due to economic constraints. Thus, in an immunocompromised patient, the vascularised fibula is the best form of reconstruction. The vascularised fibular flap (pedicled/free) can be used in combination with an allograft. We refer to such a combination reconstruction as 'allocombo'. The vascularised fibular graft hypertrophies in due course of time, and till that period, the allograft provides the required mechanical strength to allow early ambulation. SUBJECTS AND METHODS: A retrospective study of 24 cases of vascularised fibular graft for lower limb reconstruction was conducted from February 2003 to March 2014. The average defect size was 15.5 cm and the average length of fibula harvested was 24.35 cm. A total of 19 free fibular flaps and 5 pedicled fibula were done. Mean age was 26 years. Fibula was nestled in the allograft obtained from the tissue bank. RESULTS: The mean follow-up time was 52 months. Free flap success rate was 96%. Successful healing was achieved at 45 ends (97.8%). Radiological evidence of union at osteotomy sites occurred at an average of 6.8 months. Eight patients eventually succumbed to disease. At the final follow-up, the mean Musculoskeletal Tumour Society functional score of the evaluable patients was 26 (range 20-30). CONCLUSIONS: Pedicled fibula is a good option if the defect is within 14 cm of the knee joint at the femoral end. The vessels have to curve around the fibular head, thus its removal improves the reach of the pedicle. The flap is easy to harvest with predictable vascular anatomy and it can provide a large amount of vascularised bone and skin paddle. It results in early ambulation, rehabilitation and reduced morbidity. We realised that fixation is easier and chances of vascular injury are less in free as compared to pedicled fibula.

Implant-retained dental rehabilitation in head and neck cancer patients: an assessment of success and failure.

BACKGROUND: This study aimed to evaluate the rate of osseointegration (ROI) and overall success rate (OSR) of implants placed in native and grafted jaws with or without radiotherapy at a 5-year follow-up in Indian head and neck cancer patients. MATERIAL AND METHODS: Thirty head and neck cancer patients from various socioeconomic strata were accrued. Eighty-five implants were inserted in 17 native and 13 grafted jaws. Nineteen patients received radiation therapy. A 5-year follow-up ROI and OSR of implants were reported. RESULTS: The 5-year ROI and OSR were 88% and 77%, respectively. ROI was 93% for grafted, 85% for native, 83% for irradiated, and 100% for nonirradiated jaws. OSR was 73% for grafted, 80% for native, 71% for irradiated, and 89% for nonirradiated jaws. Patients from higher socioeconomic strata had higher OSR (92%) as compared with those belonging to lower socioeconomic strata (65%). CONCLUSION: The failure rate observed in this study was 24% for implants placed in head and neck cancer patients at a 5-year follow-up.

Anthropomorphic and perforator analysis of anterolateral thigh flap in Indian population.

BACKGROUND: Anterolateral thigh (ALT) flap is one of the most common flaps in the reconstruction armamentarium of plastic surgeons, but there is no published data about the flap characteristics in the Indian population. The aim of this study is to analyse the anthropomorphic characteristics of the ALT flap and the perforator details in Indian population. MATERIALS AND METHODS: ALT flap details were studied in 65 patients of Indian origin comprising 45 males and 20 females. The study period is from August 2011 to July 2012. A prospective database of the Doppler findings, perforator and pedicle details and the flap morphology were maintained. The variables are analysed by using the SPSS, PASW statistics 18 software IBM(®). RESULTS: In nearly 75% of cases, the perforator was found within 4 cm of the pre-operative Doppler markings. The percentage of musculocutaneous and septocutaneous perforators was 61.8% and 38.2% respectively. The pedicle variation was found in 6 cases (9.23%). The average thickness of the thigh skin in Indians is similar to the western people, but thicker than the other Asian people. Flap thinning was performed in nine patients without any major complications. CONCLUSION: The perforator details and type in the Indian population are similar to the published reports from other parts of the world. We advise pre-operative Doppler examination in possible cases. The variation in pedicle anatomy should not be overlooked to avoid complications. The thickness of subcutaneous tissue of the flap is higher in Indians, but still can be safely thinned. The data of this study will serve as a guide for the ALT flap characteristics in Indian patients.

Free anterolateral thigh flap for reconstruction of complex craniofacial defects after resection of tumors of the fronto-orbitomaxillary complex.

Tumors of the fronto-orbitomaxillary segment are complex and pose a significant challenge for radical resection and subsequent reconstruction. With evolution in surgical reconstructive techniques, better reconstruction of these complex defects is now possible and facilitates more aggressive surgical management. The anterolateral thigh (ALT) flap has features particularly suited for this reconstruction. We review our single institutional experience with this technique. Sixteen consecutive patients with defects of the fronto-orbitomaxillary segment (from radical resection of craniofacial tumors of this region) were reconstructed using the free ALT flap. The demographic features, radiology, histology, and surgical technique as well as the perioperative events were reviewed retrospectively from a prospective database of all craniofacial resections performed. There were 9 males and 7 females with a mean age of 35 years. Eleven had previously undergone surgery. Dura was resected in 6 and inadvertently breached in another 2. Gross total resection was achieved in 14 (87.5%) of the 16 patients, of which 8 had microscopically negative margins. Thirteen musculocutaneous flaps and 3 chimeric flaps were performed. The mean duration of surgery was 9.4 hours. The average total blood loss was 2000 mL. There was no perioperative mortality. Major complications occurred in 2 patients in the form of venous thrombosis on the next day of surgery. These were detected and salvaged promptly by urgent re-exploration and redo of venous anastomosis, ultimately requiring skin grafting for partial flap loss. In our experience, the free ALT flap is a suitable reconstructive choice for complex craniofacial defects and has favorable results.

Two in one: Double free flap from a single free fibula osteocutaneous unit.

In the past two decades, the advancement in the microsurgical techniques has revolutionised the reconstruction of post-oncological head and neck defects. Free fibula osteocutaneous flap (FFOCF) has been considered as the treatment of choice by many for mandible reconstruction. The improvement in the surgical resection and adjuvant treatment has improved the survival rates even in patients with advanced cancer. Simultaneously the reconstruction is addressed towards more functional and aesthetic aspects to improve the quality of life in these patients. In this respect, a double free flap is advocated in certain cases of extensive composite oromandibular defects (COMDs). But in our institute, we have managed two such cases of extensive COMD with a single FFOCF unit - fibula bone with a skin paddle for inner lining and a perforator-based skin paddle from the proximal part of the FFOCF unit, anastomosed separately for outer cover. Compared to two separate free flaps, this method has the advantage of single donor site and reduction in reconstruction time. Though the technique of divided paddle, deepithelisation and supercharging has been mentioned for FFOCF, no such clinical cases of two free flaps from a single FFOCF unit have been mentioned in the literature.

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers.

BACKGROUND: Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations. MATERIALS AND METHODS: It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases). RESULTS: All flaps in which cephalic vein was used survived completely. CONCLUSION: Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.

Assessment of quality of life after implant-retained prosthetically reconstructed maxillae and mandibles postcancer treatments.

PURPOSE: The aim of this prospective study was to assess treatment outcome and impact on quality of life with implant-retained prosthesis in reconstructed jaws in head and neck cancer patients. MATERIALS AND METHODS: Twelve patients were rehabilitated with implant-retained dental prosthesis following free fibular graft after segmental resection. These subjects were evaluated by standardized questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 (version 3) and clinical assessment for quality of life. Objective assessment of speech parameters was done with Dr. Speech Software (Tiger DRS Inc., Seattle, WA). The questionnaire consisting of information on evaluation of deglutition, salivation, status of the mandible and teeth in relation to predisease level was used for subjective judgment of speech. RESULTS: Consumption of solid, semisolid, and overcooked food was considerably better with the prosthesis. Drinking ability was not affected. Patients' voice resonance was improved, and they could sustain phonation for longer duration without difficulty. They were able to speak loudly, and their intonation pattern was also slightly better. Failure of the implants to osseointegrate at the end of 18 months was observed in 37% of the patients. This was attributed to radiation before implant insertions and periimplantitis. Despite the observed improvement in some patients, the statistical analysis of speech, swallowing parameters, and quality of life were not significant because of the paucity of numbers in this pilot study. There was no improvement in the symptoms scale scores. CONCLUSION: Reconstruction and rehabilitation of the jaws affected by tumor restores the patient anatomically, esthetically, and functionally to optimum levels. However, a study with larger numbers of patients is necessary to ascertain the benefits of this treatment modality.

Utility of proximally based sural artery flap for lower thigh and knee defects.

The proximally based sural artery flap presents distinct advantages in reconstruction of knee and lower thigh defects including thin sensate flap, reduced donor-site morbidity with good aesthetic outcome. However there are few reports in the literature regarding this flap. This study presents our experience with use of this flap in 37 patients. A retrospective study was performed over a 6-year period (from January 2003 to October 2008) using proximally based islanded sural artery flap for the lower thigh, knee, and upper leg defects following tumor excision defects. There were no complete failures in the series with only one flap requiring additional bipedicled flap for the necrosis of distal margin. All donor sites were closed with split thickness skin graft, with skin paddle sizes ranging up to 23 x 10.5 cm. All patients achieved a good final outcome. The authors found the proximally based islanded sural artery flap to be a simple and reproducible technique to perform and have greater reach up to the lower thigh. It provides thin pliable skin with minimal compromise to either appearance or function. The flap is suitable in the regional reconstruction around the knee as a pedicled flap.

Pedicled anterolateral thigh flap: a versatile flap for difficult regional soft tissue reconstruction.

Reconstruction of extensive oncosurgical defects of lower trunk, perineum and upper thigh, without the complexity of microsurgery, is a reconstructive challenge. Pedicled anterolateral thigh (ALT) flap offers many advantages over other regional flaps for this purpose, such as the large skin and soft tissue availability, the remarkable pedicle length and the reliability. However, there is paucity of literature describing the utility of pedicled ALT flaps for reconstruction of these difficult soft tissue defects. We present our experience of pedicled ALT flaps for various post oncosurgical defects. From January 2005 to August 2008, 85 pedicled ALT flaps were done in 78 patients for post oncological excision defects of lower trunk, groin, perineum, and upper thigh. Majority of patients were males, with locally advanced inguinal disease, underwent wide skin excision and en bloc nodal resection. Age group ranged from 22 to 81 years. The flap size ranged from 10 x 5 cm (50 cm) to 38 x 20 cm (760 cm). The length of the pedicle ranged from 8 to 14 cm. Satisfactory coverage was achieved in all patients, except one, where the flap had to be discarded due to absent artery in the vascular pedicle. Clinically, no functional deficit of knee extensor mechanism was seen in any of these patients during routine activities. Present study has shown the wide arc of rotation, large skin replacement potential, and reliability of pedicled ALT flap.

Managing venous discrepancy: simple method.

Microvascular anastomosis is an essential technique for free flap transfer and replantation surgery. Size discrepancy in microvascular anastomosis is a common issue in free flap transfer. Different methods are used by microvascular surgeons to solve the problem of vascular discrepancies. We describe a simple technique using Ligaclips (TM) that effectively narrows the wider vein in such discrepancy.

Successful reconstruction of large oropharyngeal defect with pectoralis major myocutaneous flap in a four-year-old boy with recurrent fibromatosis.

BACKGROUND: Pectoralis major myocutaneous (PMMC) flap continues to be the workhorse in head and neck reconstruction. Although free tissue transfer has revolutionized the reconstruction in cancers of the oral region, PMMC is still considered a readily accessible source of vascularized soft tissue available to the reconstructive surgeon and especially in most developing nations where due to the cost, time, expertise, or infrastructural constraints free flaps cannot be generally offered. Although commonly used in adults, it has been hardly described for reconstruction in children. CASE PRESENTATION: We present a 4-year-old child with recurrent fibromatosis of the oropharyngeal region where the PMMC was used for reconstruction of the surgical defect and to the best of our knowledge is the youngest patient undergoing reconstruction with PMMC for neoplastic lesion of the head and neck. CONCLUSION: The PMMC flap is justifiably a popular flap that continues to command an important place in the head and neck surgeon's reconstructive armamentarium.

Anterolateral Thigh Twin Free Flaps from a Single Donor Site-a Modification Based on the Oblique Branch of the Lateral Circumflex Femoral Artery.

The pedicle of the anterolateral thigh flap is formed by the descending branch of the lateral circumflex femoral artery. Recently, an oblique branch of lateral circumflex femoral artery was described by Wei et al., which can also be used as an alternative to the descending branch. We describe a case in which both the pedicles were used to create two free flaps (twin flaps) from the same thigh for post tumour reconstruction of breast.

Reconstruction of oncological oro-mandibular defects with double skin paddled-free fibula flap: a prudent alternative to double flaps in resource-constrained centres.

OBJECTIVE: The free fibula flap is the choice flap for mandibular reconstruction following extensive tumor resections. While large defects are managed with a second flap [free or pedicle] in advanced centres, a free fibula flap with a large skin paddle that can be de-epithelised to provide outer skin and inner lining is the best alternative in resource- constrained centres. MATERIALS AND METHODS: From January 2005 to December 2009 a total of 386 free fibula flaps were used of which 307 flaps had de-epithelised double skin paddle in reconstructing complex oral and mandibular defects after tumor ablative surgeries. RESULTS: Complete flap survival was seen in 282/307 patients. Complete flap loss was seen in 9/307 patients. Partial flap loss was seen in 16 patients. Re - exploration was done in 30 patients and the flap was salvaged in 21 patients. CONCLUSION: The vascular supply of the free fibula osteo myocutaneous flap is reliable and a flap with a large skin paddle can be used to provide both inner lining and outer cover in resource-constrained centres.

Skin paddle vascularity of free fibula flap - A study of 386 cases and a classification based on contribution from axial vessels of the leg.

OBJECTIVE: The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems. MATERIALS AND METHODS: A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study. RESULTS: The skin paddle of the free fibula flap was classified into four different types (a-d) based on the dominance of vascular contribution by axial vessels of the leg. CONCLUSION: The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.

Chimeric superficial temporal artery based skin and temporal fascia flap plus temporalis muscle flap - An alternative to free flap for suprastructure maxillectomy with external skin defect.

Flaps from temporal region have been used for mid face, orbital and peri-orbital reconstruction. The knowledge of the vascular anatomy of the region helps to dissect and harvest the muscle/fascia/skin/combined tissue flaps from that region depending upon the requirement. Suprastructure maxillectomy defects are usually covered with free flaps to fill the cavity. Here we report an innovative idea in which a patient with a supra structure maxillectomy with external skin defect was covered with chimeric flap based on the parietal and frontal branches of superficial temporal artery and the temporalis muscle flap based on deep temporal artery.