The vertically oriented free myocutaneous gracilis flap in head and neck reconstruction.

Oncologic resections in the head and neck can result in a variety of complex defects. Many free tissue transfers have been described for soft-tissue reconstruction in this area. The pedicled, vertical gracilis myocutaneous flap has been well described for use in the perineum, but is rarely used as a free tissue transfer because of previously documented unreliability of the skin island. The objective of this study was thus to review a single author's experience with reconstruction of complex head and neck defects using the vertically oriented free myocutaneous gracilis flap. A retrospective review of all head and neck reconstructions at a major cancer center from 2003-2006 was performed. Demographic, oncologic and reconstructive data were retrieved from a prospectively maintained clinical database. Ten patients (mean age, 57 years; range, 33-84 years) with complex defects of the head and neck were reconstructed using a gracilis myocutaneous flap with a vertically oriented skin paddle. Seven patients had a malignant skin tumor; 3 patients had a parotid gland tumor. Mean surface area requirements were 88.6 cm. Composite resections were common and included skin, facial nerve, mandibular and/or temporal bone, partial glossectomy, parotidectomy, and/or orbital exenteration. Six patients had a history of prior irradiation; 6 patients received postoperative radiotherapy. Mean follow-up was 8 months (range, 2-20 months). Total flap survival was 100%. There were no partial flap losses. Primary wound healing occurred in all cases. The vertically oriented free myocutaneous gracilis flap is a reliable option for reconstruction of moderate volume and surface area defects in the head and neck. It represents an underutilized flap that should be more commonly considered for soft-tissue reconstruction of complex defects in the head and neck.

The influence of AlloDerm on expander dynamics and complications in the setting of immediate tissue expander/implant reconstruction: a matched-cohort study.

AlloDerm (LifeCell, Branchburg, NJ) is gaining acceptance in tissue expander/implant (TE/I) breast reconstruction. Anecdotal evidence suggests its use limits postoperative musculoskeletal morbidity and allows injection of greater initial fill-volumes and rapid postoperative expansion. The objective of this study was to evaluate AlloDerm's impact on expansion rates in immediate TE/I reconstruction. A matched, retrospective cohort study was performed. Medical records of patients who underwent immediate TE/I reconstruction from 2004 to 2005 were reviewed. Two cohorts were identified: (1) underwent TE/I reconstruction with AlloDerm, and (2) underwent standard TE/I reconstruction. Individuals were matched 1:1 on the basis of: expander size (+/-100 mL), history of irradiation, and indication for mastectomy. Cohorts were compared for intraoperative volume injected (mL), rate of postoperative expansion (mL/ injection), number of expansions, and time to completion of expansion (days). Incidence of complications was evaluated. Pairwise comparisons were performed using the Wilcoxon sign rank test and McNemar test. Ninety immediate TE/I reconstructions were evaluated. Forty-five TE/I-AlloDerm reconstructions were matched to standard TE/I reconstructions. Intraoperatively, expanders in the AlloDerm and non-AlloDerm cohorts were filled to a mean volume of 223.8 and 201.1 mL (P = 0.180). Median number of expansions performed was 5 and 6 in the AlloDerm and non-AlloDerm cohorts (P = 0.117). There was no difference in the mean rate of postoperative tissue expansion (AlloDerm: 97 mL/injection versus non-AlloDerm: 95 mL/injection [P = 0.907]), nor in the incidence of complications (P = 0.289). Minor complications occurred in 13.1% of AlloDerm cases (cellulitis [n = 3], seroma [n = 3], hematoma [n = 1]. Although this study does not address AlloDerm's efficacy in decreasing morbidity or improving esthetic outcomes in TE/I reconstruction, it indicates that AlloDerm does not increase the rate of tissue expansion after immediate TE placement. It does not, however, appear to increase the risk of postoperative complications.

Indications and outcomes for mandibular reconstruction using sequential bilateral fibula flaps.

BACKGROUND: A subset of patients with recurrent or second intraoral tumors undergo both primary and secondary mandibular reconstruction using bilateral fibula flaps. The objective of this report is to describe indications and outcomes for these patients. METHODS: A retrospective analysis of a prospectively collected database was performed. Charts were reviewed to identify demographics, operative features, and functional outcomes. RESULTS: Ten patients underwent mandibular reconstruction with a second fibula flap for recurrent or second oral tumors. Time between flaps averaged 20 months. Bone gap size measured 8 cm after both resections. Eighty percent of secondary resections included the mandibular arch, in contrast to 20 percent of primary resections (p=0.070). Compared with primary resections, secondary soft-tissue defects were larger and more frequently included composite tissues. There were low complication rates and no flap failures after both reconstructions. Functional evaluation showed a greater dependency on supplemental enteral nutrition after the second resection (p=0.033). Five patients died at a median of 12.5 months after the second resection and the remaining patients have survived for a median of 18.6 months. CONCLUSIONS: The principal indication for second fibula flaps in mandibular reconstruction is central segment defects where rigid support is required to prevent sequelae of the Andy Gump deformity. For lateral resections, the large soft-tissue deficits of secondary extirpation may be better served by reconstruction with soft-tissue flaps. Second osseous free flaps can be performed safely, but with a significant decline in postoperative oropharyngeal function. Goals of surgery and quality of life need to be addressed before ablation of recurrent or second oral tumors is performed.

Postmastectomy reconstruction: an approach to patient selection.

SUMMARY: The overriding goal of reconstructive breast surgery is to satisfy the patient with respect to her own self-image and expectations. Ultimately, individualized selection of a reconstructive technique for each patient will be a predominant factor in achieving a reconstructive success. The authors reviewed their institutional experience with postmastectomy reconstruction over the past 2 years and discuss indications, contraindications, advantages, and disadvantages of autogenous tissue and prosthetic breast reconstruction.