Indian Subcontinent's First Bilateral Supracondylar Level Upper Limb Transplantation.

Introduction This is the first case of supracondylar level transplant from the Indian subcontinent, performed for a bilateral below elbow amputee. It has a completely different set of challenges for the transplant team, with a relatively shorter ischemia time window. The technical considerations for the same have been discussed in detail in this article. Materials and Methods The patient was a 19-year-old female who lost her both upper limbs at proximal forearm level due to severe crush injury following a road traffic accident. Insufficient bone length on either side necessitated a supracondylar level transplant. The preoperative workup included detailed clinical evaluation, biochemical, and psychological evaluation. The donor was a young brain-dead, male patient from a hospital, 30 minutes away. The donor and recipient preparations in this case were unique. The recipient's own elbow flexors and extensors were used while the elbow joint was from the donor. The specific challenges we faced during this procedure have been described in detail. Results The transplantation has been a complete technical success, with the patient rehabilitated back to her independent life style. This article describes only the technical considerations. The functional recovery aspect is part of an another soon to be published manuscript. Conclusion Supracondylar level arm-transplant requires a highly coordinated team effort with precise preoperative planning, along with meticulous attention to detail to achieve a successful outcome. In properly selected patients, it could be a life-changing procedure, worth all the effort.

Outcomes following pharyngeal reconstruction in total laryngectomy - Institutional experience and review of literature.

BACKGROUND: Pharyngeal reconstruction is a challenging aspect of reconstruction after resections for head-and-neck cancer. The goals of reconstruction are to restore the continuity of the pharyngeal passage to enable oral alimentation and rehabilitation of speech wherever possible. This study was performed to determine the outcomes following pharyngeal reconstruction in total laryngectomy (TL) using different reconstructive options and to determine the predictors of pharyngocutaneous fistula (PCF) and swallowing dysfunction. MATERIALS AND METHODS: Retrospective analysis of patient data between 2003 and 2010 of patients undergoing TL with partial or total pharyngectomy. Demographic and treatment details were collected and analysed. Univariate analysis was performed to determine predictors of PCF and swallowing dysfunction. RESULTS: Fifty-seven patients underwent pharyngeal reconstruction following TL, 31 of whom had received prior treatment. Following tumour resection, 31 patients had circumferential defects and 26 patients had partial pharyngeal defects. The flaps used include pectoralis major myocutaneous flap (n = 29), anterolateral thigh flap (n = 8), gastric pull-up (n = 13) and free jejunal flap (n = 7). PCF was seen in 20 patients, of which 15 (75%) were managed conservatively and 5 required another surgery. At last follow-up, 99 patients (68%) were on full oral alimentation. Tracheo-oesophageal puncture and prosthesis insertion was done in 20 patients, of whom 17 (85%) developed satisfactory speech. Partial pharyngeal defects were associated with a higher risk of PCF on univariate analysis (P = 0.006) but were not significant on multivariate analysis. Post-operative swallowing dysfunction was significantly higher with hypopharyngeal involvement by tumour (P = 0.003). CONCLUSION: Pharyngeal reconstruction in TL is feasible with good results. Majority of the patients swallow and regain acceptable swallowing function within 3 months.

First two bilateral hand transplantations in India (Part 2): Technical details.

INTRODUCTION: This article deals with two patients who underwent bilateral hand transplantation following amputation of both upper limbs at the distal third of the foream. MATERIALS AND METHODS: The first patient had a history of loss of hands in a train accident , with possiblity of a run over element during the injury. The second patient lost his both hands in a mine blast. The preoperative work up included detailed clinical and psychological evaluation. The donor retrieval was similar in both the cases and the donors were housed in our own instittution. The donor preparation, recipient preparation and the transplant procedure was similar except for the need of primary tendon transfers in the left hand of the first patient. RESULTS: The first patient needed a free flap transfer to cover compromised skin flap on the left hand on the second day. The second hand transplant was uneventful. Both the recipients are now back to their normal daily routines. CONCLUSIONS: Hand transplantation is a potentially life altering procedure, but to optimise the results, it is imperative that there is a meticulous planning and diligent execution with utmost importance to the detail coupled with a synchronised team effort.

First two bilateral hand transplantations in India (Part 4): Immediate post-operative care, immunosuppression protocol and monitoring.

INTRODUCTION: Being able to counter immune-mediated rejection has for decades been the single largest obstacle for the progress of vascular composite allotransplantation (VCA). The human immune system performs the key role of differentiating the 'self ' from the 'non-self '. This, although is quintessential to eliminate or resist infections, also resists the acceptance of an allograft which it promptly recognises as 'non-self'. MATERIALS AND METHODS: Pre-operative evaluation of the recipient evaluation included immunological assessment in the form of panel reactive antibodies (PRA), human leucocyte antigen (HLA) typing, donor-specific antibody detection assays (DSA) and complement-dependent cytotoxicity assays (CDC). Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. RESULTS: Both the recipients were managed by the standard triple drug therapy and have had only minor episodes of rejections thus far which have been managed appropriately. DISCUSSION: Induction immunosuppression was by thymoglobulin and the maintenance by the standard triple-drug therapy. Various groups have tried various other formulations and regimes as well. CONCLUSION: A comprehensive plan has to be drawn up for immunological screening, selection and the post-operative immunosuppressant usage. The ultimate goal of these immunosuppression modalities is to achieve a state of donor-specific tolerance.

First two bilateral hand transplantations in India (Part 1): From vision to reality.

INTRODUCTION: Vascularized composite tissue allotransplantation is a relatively new concept, which was unavailable in the Indian subcontinent till a bilateral hand transplant was carried out successfully in January 2015. MATERIALS AND METHODS: The setting up of the transplant programme involved obtaining legal clearances, creating public awareness, harnessing the institutional facilities, drawing up protocols, assembling the surgical team, managing immunological issues, rehabilitation and preparing the ancillary services. RESULTS: Both, the first and second bilateral hand transplants were resounding successes with both the recipients getting back to their original daily routines. CONCLUSIONS: The organisation of the hand transplant programme was a large task, which necessitated intensive planning, and cooperation from various teams within and outside the institution. Exemplary team-work was the key to the phenomenal success of these path breaking endeavors in the subcontinent.

First two bilateral hand transplantations in India (Part 3): Rehabilitation and immediate outcome.

INTRODUCTION: This report covers the strategies adopted for rehabilitation for the first and second dual hand transplants performed in India. MATERIALS AND METHODS: The team, under a trained physiatrist, including physiotherapy and occupational therapy personnel, was involved in the management of both these patients. The management protocol was developed considering previous reports as well as our management strategies in the rehabilitation of the replanted hands. The involvement of the team with the patients started in the 1st week itself and continued on a daily basis for the entire year. RESULTS: Outcome analysis was performed at 6 months and 1 year using the disability of shoulder and hand evaluation and hand transplant scoring system. Functional magnetic resonance imaging was done at the end of 1 year to assess the cortical integration of the transplanted hand. CONCLUSION: Despite more than 110 hands being transplanted worldwide, hand transplant remains an experimental procedure. It is still not considered the "standard of care" for hand amputees. Outcome analyses performed worldwide do indicate that the procedure can provide a substantial improvement in the quality of life for the hand amputee, especially the bilateral amputees.

Effect of external volume expansion on the survival of fat grafts.

INTRODUCTION: External volume expansion (EVE) is one method, which has been utilised for increasing the survival of adipose tissue grafts. EVE releases positive pressure from the graft and also induces intense levels of edema that decreases diffusion of metabolites essential for graft survival initially. The ideal timing of external volume expansion in relation to the injection of the fat to facilitate survival is not yet clear. AIMS AND OBJECTIVES: This study was undertaken to evaluate and compare the efficacy of external volume expansion applied at variable time points in relation to the injection of the fat. MATERIALS AND METHODS: Athymic mouse was the animal model and human lipo-aspirate mixed with PRP was used as graft. An indigenous dome shaped silicone device was fabricated to deliver a negative pressure of -30 mm of Hg. The EVE was applied at variable time intervals. At the end of 4 weeks visual, histological and radiological features of the injected fat were compared. The adipose tissue was stained with human vimentin to ascertain the origin of the retained fat. RESULTS: All the grafts, which had EVE, had significantly better volume retention and vascularity. The groups which underwent a delayed EVE or prior expansion followed by concomitant graft injection and expansion showed the most optimal vascularity and graft retention. CONCLUSIONS: A delayed EVE or prior expansion followed by concomitant graft injection and expansion may be the most ideal combinations to optimize graft take. However, on account of the relatively small sample size, there was a limitation in drawing statistically significant conclusions for certain variables.

Challenges in the reconstruction of bilateral maxillectomy defects.

PURPOSE: Bilateral maxillectomy defects, if not adequately reconstructed, can result in grave esthetic and functional problems. The purpose of this study was to investigate the outcome of reconstruction of such defects. MATERIALS AND METHODS: This is a retrospective case series. The defects were analyzed for their components and the flaps used for reconstruction. Outcomes for flap loss and functional indices, including oral diet, speech, and dental rehabilitation, also were evaluated. RESULTS: Ten consecutive patients who underwent bilateral maxillectomy reconstruction received 14 flaps. Six patients had malignancies of the maxilla, and 4 patients had nonmalignant indications. Ten bony free flaps were used. Four soft tissue flaps were used. The fibula free flap was the most common flap used. Three patients had total flap loss. Seven patients were alive and available for functional evaluation. Of these, 4 were taking an oral diet with altered consistency and 2 were on a regular diet. Speech was intelligible in all patients. Only 2 patients opted for dental rehabilitation with removable dentures. CONCLUSIONS: Reconstruction after bilateral maxillectomy is essential to prevent esthetic and functional problems. Bony reconstruction is ideal. The fibula bone free flap is commonly used. The complexity of the defect makes reconstruction difficult and the initial success rate of free flaps is low. Secondary reconstructions after the initial flap failures were successful. A satisfactory functional outcome can be achieved.

Anatomic basis for an algorithmic approach for free fibula flap donor side selection in composite oro-mandibular defects.

INTRODUCTION: Head and neck oncological resections may result in composite oro-mandibular defects involving the oral mucosa (lining), mandibular bone and the skin (cover). Reconstructive options for such defects have evolved over a period. Free fibula flap reconstruction is currently accepted the world over as the gold standard for oro-mandibular defect reconstruction. Existing literature provides conflicting views about the use of a particular side and orientation of the fibula flap for achieving the optimal outcome. The purpose of this study is to confirm anatomically the effect of bone, soft tissue and vessel orientation on the ease of doing reconstruction. MATERIALS AND METHODS: This is a cadaveric study. A mandibular model with a defect was used. This was pre plated to maintain continuity. Composite fibula flaps of the same dimension were harvested from both legs of a fresh cadaver. The harvested flaps were used to reconstruct the mandibular defect in different orientations and the best configuration for each reconstructive requirement was assessed. RESULTS: Keeping the peroneal surface for plating, that is, facing outwards, four different configurations of the fibula flap are possible for a given mandibular defect. With a posterior vascular pedicle ipsilateral fibula is suitable for skin cover and contralateral for mucosal lining and the reverse for an anteriorly placed pedicle. CONCLUSION: The algorithm based selection of appropriate sided fibula flap facilitates complex mandibular reconstruction by placing the right kind of tissue at the right place and helps in reducing the donor site morbidity by allowing the surgeon to harvest only the required amount of skin.

Objective analysis of microtia reconstruction in Indian patients and modifications in management protocol.

INTRODUCTION: An ideal ear, with representation of all anatomic landmarks, is the aim of any reconstructive surgeon embarking on reconstructing the ear in a microtia patient. The literature is abundant with the description of techniques, but these have been reported mainly in Caucasian and Oriental population. There have been very few publications on results in the population belonging to the Indian subcontinent. In spite of strictly adhering to the recommended techniques of reconstruction, the results obtained in these patients have often been marred by problems that are not reported with the Oriental or Caucasian populations. This may necessitate a relook into the management strategy of these cases. Hindering the assessment of the results, their reporting and auditing the improvement obtained by such change in the management strategy, is the lack of a standardized method for assessment of the outcome. Hence, an attempt was made in a series of patients who underwent microtia reconstruction to assess the outcome using a new tool based on the attained definition of anatomical components of the reconstructed pinna. Further effort was made to document the modifications in the technical execution of the reconstruction during the period of the study. MATERIALS AND METHODS: A retrospective review of 44 patients and a prospective analysis of 11 patients, who underwent ear reconstruction for microtia from December 2003 to September 2014 at a tertiary care teaching hospital, was undertaken. Taking a cue from Nagata's description of an 'ideal reconstructed ear' which should show all the anatomical components, we developed an objective grading system to assess our results. The technique had undergone several changes during these years combining the principles of three universally accepted methods, that is, those described by Nagata, Brent, and Firmin. These changes, as well as the reasons behind them, were documented. RESULTS: On objectively measuring and analysing the replication of normal morphologic characteristics of the reconstructed ears, we documented progressive improvement of our results. Good or excellent results could be achieved in 70% of cases in the second group compared to a poor outcome in more than 2/3(rd) of the cases carried out during the initial period. Based on these results and the changes adopted in our practice we propose suggestions for management of microtia cases in the Indian population. CONCLUSIONS: An objective, weighted grading system has further enabled us to critically evaluate the outcomes and to further improve upon the existing results. Our amalgamation of the salient features of the established techniques as well as changes made based on our experience has enabled us to get good results more consistently in our attempts at microtia reconstruction. We believe that the adoption of such amalgamated methods will be more suitable in Indian patients.

Defect components and reconstructive options in composite orbitomaxillary defects with orbital exenteration.

PURPOSE: The conventional way of reconstructing an orbital exenteration defect associated with a maxillectomy is to cover it with a soft tissue free flap and camouflage it with a spectacle-mounted orbital prosthesis. Also, there are some reports on the use of bone flaps. The objective of this study was to review the reconstructive options for a defect resulting after orbital exenteration and maxillectomy. MATERIALS AND METHODS: This study concerns a retrospective case series of 20 patients. Electronic medical records, including clinical details, operative notes, and follow-up data, were analyzed. Defects were analyzed for their reconstructive components. The reconstructive methods used were studied by the types of flap used, bony versus soft tissue types of reconstruction, and the prosthetic method used to rehabilitate the eye. Outcomes were analyzed for flap success rate. Descriptive methods for data analysis were used. RESULTS: Fourteen patients underwent a soft tissue reconstruction alone and 6 underwent bony reconstruction. The free rectus abdominis was the commonest soft tissue flap used. This article presents the outcome of reconstruction in such patients and the utility of individual flaps for their ability to replace different components of the defect. CONCLUSIONS: Ideal reconstruction should address all individual defect components of facial contour, orbital, palatal, skull base, and skin defects. The free rectus abdominis flap remains the common choice. When a composite socket reconstruction is to be achieved, the innovative free tensor fascia lata flap with the iliac crest bone and internal oblique muscle is an option.

Dilemmas and challenges in the management of a neonate with Adams-Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update.

BACKGROUND: Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects. CASE REPORT: A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age. DISCUSSION: We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination. CONCLUSION: Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.

Propeller flaps in the closure of free fibula flap donor site skin defects.

The free fibula is a versatile and commonly used free flap in microvascular reconstruction. It allows for reconstruction of both bone and soft tissue defects. In head and neck reconstruction, the skin paddle harvested along with the flap allows for the reconstruction of skin or oral mucosal defects. After skin paddle harvest, the donor site can be closed primarily or with skin grafts. Grafting the donor area is the common method used. However, this could lead to delayed healing because of the poor graft over the area of peroneal tendons. Propeller flaps have been extensively reported for closure of leg skin defects. We report a series of 10 patients in whom we used a local propeller flap for the closure of the fibula flap skin donor site. The donor defects could be satisfactorily closed without the need of a skin graft in 9 patients. This method is simple, reliable, and suitable for closing small to medium defects.

Safety and efficacy of low molecular weight dextran (dextran 40) in head and neck free flap reconstruction.

BACKGROUND: Antithrombotic agents have been used in microvascular surgeries. Low molecular weight dextran (dextran 40), though used, is not without complications. METHODS: Retrospective analysis of 172 consecutive flaps. A comparison was made between two groups of patients (86 flaps each) with and without the use of dextran 40, in terms of safety and efficacy. RESULTS: The free flap survival rate was 95.9%. The flap survival rates were comparable between the groups. Total flap loss in Group A (patients who received dextran 40) was 3.5% compared with 2.3% in Group B (patients who did not receive dextran 40) (p = 1.00). There was no statistically significant difference in the incidence of thrombotic flap complications between the groups. None of the patients developed acute respiratory distress syndrome or required prolonged ventilator support. No patient had dextran-related anaphylactoid reactions. Thirty-eight patients (43.7%) in Group A had postoperative atelectasis and 21 (25.6%) patients in Group B had this complication (p = 0.01). Six patients in Group A developed postoperative pneumonia, and five patients in Group B developed this complication (p = 0.93). CONCLUSIONS: Though dextran 40 did not result in any significant adverse local or systemic complications, it is not useful as a postoperative antithrombotic agent in head and neck oncologic reconstruction with free tissue transfer.

Short-term augmentation of venous drainage with extra-corporeal shunt and simultaneous auto-transfusion, for salvaging a congested free flap.

Adequate drainage of venous blood is the most critical part of successful free tissue transfer. We report a case of anterolateral thigh flap used for covering open communited tibial fracture. The flap was salvaged with short term augmentation of venous drainage with external shunt. The drainage was continued for six days. It was confirmed that there is no more congestion after blocking the catheter and then the drainage was discontinued on seventh day. The flap was successfully salvaged. This method has potential applications in multiple situations for successful salvage of free tissue transfer.

Reconstruction in Salvage Surgery for Head and Neck Cancers.

Introduction: Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers. Study Design: This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017. Methods: The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported. Results: Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor. Conclusions: Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

Reconstructive indications of simultaneous double free flaps in the head and neck: a case series and literature review.

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo-radiotherapy. Forty-two free flaps were used in these patients. The predominant combination was that of free fibula osteo-cutaneous flap with free anterolateral thigh (ALT) fascio-cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro-mandibular bone and soft tissue defects (n = 13), (b) large oro-mandibular soft tissue defects (n = 4), (c) complex skull-base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow-up period was 11 months. Twelve patients were alive and free of disease at the end of the follow-up. Eighteen of 19 patients with oro-mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro-mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed.

Comparison of health state utility measures and disabilities of arm, shoulder and hand questionnaire scores in bilateral hand amputees.

Bilateral hand amputation (BHA) is a life-changing event that can result in a great degree of loss of function. Prosthetic limb replacement and composite tissue allotransplantation are the treatment options. Understanding the BHA in terms of economic utility will help direct future research and upgrading in healthcare delivery. This is a cross-sectional study in 32 BHA who have completed a minimum of six months after wound healing. The primary objective was to assess the convergent validity of three different health utility (HU) derivation methods, namely the time trade-off (TTO), EuroQol questionnaire (EQ-5D-5L), and EuroQol visual analog scale (EQ-VAS) among BHA. The secondary objective was to correlate the disabilities of arm, shoulder and hand (DASH) scores with the HU scores and see whether the DASH score predicts the HU scores derived by different methods. The mean (SD) HU scores for TTO, VAS, and EQ-5D-5L were 0.34 (0.25), 0.61 (0.25), and 0.46 (0.20), respectively. HU derived by the TTO method displayed a weak correlation with EuroQol-based derivatives (EQ-VAS & EQ-5D-5L). But there was a moderate correlation between values by EQ-VAS & EQ-5D-5L. Hence, the EuroQol HU derivative is preferable to TTO. The mean (SD) of the DASH score was 48.4 (22.9). There was a strong correlation between the DASH scores and HU derived by different methods. Also, the DASH score is seen to be a good predictor of HU scores. This study is the first to derive HU and correlate the DASH with HU scores in the BHA scenario .

Outcomes of Re-exploration Procedures After Head and Neck Free Flap Reconstruction.

This study was conducted to evaluate the outcomes of re-exploration procedures done after head and neck microvascular flap reconstructions. This is a retrospective review of 109 flaps in 106 patients (three patients had two flaps each) that underwent re-exploration procedures in 1001 consecutive free flap surgeries. The outcome was analysed in terms of the type of the flaps, re-exploration rate, flap salvage rate and overall flap success rate. Free radial forearm (RFF) was the commonest flap done (354, 35.3%). One hundred nine flaps underwent re-exploration procedures in 106 patients. Out of this, 79 flaps could be salvaged, and 30 flaps failed. There were also another ten flaps, which failed without any re-exploration. The overall re-exploration rate was 10.8%. The flap salvage rate was 72.4%. The overall flap success rate was 96.1%. Nearly three-fourths of the flaps with vascular compromise can be successfully salvaged with appropriate and timely intervention.

Shape-modified radial forearm free tissue transfer in oral cavity reconstruction: Technique and a prospective comparison with the conventional technique.

BACKGROUND: Donor site morbidity is a significant drawback of the radial forearm flap. The purpose of this study is to describe a new shape-modified technique. The donor site morbidity was compared to that of the conventional technique, in terms of the esthetic, functional outcomes, and quality of life (QOL). METHODS: This is a prospective study of 30 patients with oral cancer who underwent reconstruction using radial forearm flaps, in two groups. RESULTS: Regarding the donor site characteristics, the differences in the time for healing (P = .006), the scar score (P < .0001), and the QOL score (P < .0001) were significant. The number of patients with sensory deficit was 11 in the conventional group and 3 in the shape-modified group (P = .009). CONCLUSIONS: The functional and esthetic outcomes of the donor site were better for the shape-modified technique. It is best suited for small defects. Compromise of the pedicle length is a limitation.