Free gastroepiploic lymph nodes and omentum flap for treatment of lower limb ulcers in severe lymphedema: Killing two birds with one stone.

BACKGROUND AND OBJECTIVES: In patients with lymphedema, the disruption of the lymphatic network increases skin turgor and fibrosis of subcutaneous tissue, delays wound healing, causing recurrent ulcerations and infections. In these cases, management of ulcers can be challenging. METHODS: Between January 2016 and June 2018, patients presenting with lymphedema were enrolled at our Institution. We selected patients with severe lymphedema and ulcers of lower limbs and we performed a surgical approach, involving free gastroepiploic lymph nodes and omentum flap, harvested through laparoscopy. RESULTS: We enrolled 135 patients presenting for lymphedema. Among them, 10 eligible cases underwent excision of the ulcer and reconstruction with omentum flap. Mean age was 57.8 years and average follow-up 24.1 months. Circumferences and skin tonicity significantly decreased from the preoperative period. Lymphoscintigraphy showed improvement of the lymphatic drainage and restoration of lymphatic network. No episodes of infection were recorded in the postoperative period. CONCLUSIONS: Our combined procedure merges free flap techniques and lymphedema surgery: omentum covers the defect while providing a new source of lymph nodes, improving the lymphatic networks of the affected limb. This technique can highly increase the quality of life of the patient in a single-stage operation with fast recovery and low donor site morbidity.

Free Flap Transfer for Head and Neck Reconstruction Using Local Anesthesia in Elderly Patients.

BACKGROUND: The incidence of skin cancer appearing on the head and neck areas is higher in elderly patients. Although free flap reconstruction is the mainstay after tumor excision, it is challenging to complete in elderly patients, owing to the high risk of complications and/or mortality rates associated with the use of general anesthesia. In this study, we used only local anesthesia in free tissue reconstruction of the head and neck in five elderly patients. MATERIALS AND METHODS: From 2013 to 2016, 5 elderly patients with high risk of general anesthesia underwent reconstruction with either anterolateral thigh free flaps or groin free flap under local anesthesia, after wide excision of malignant tumors at head and neck. For each patient, the following information was collected: age, gender, body weight, anesthesia agents, intravenous fluid, blood loss, site of lesion, flap size, operation time, complications, and follow-up time. RESULTS: All flaps survived completely. The mean age of 5 patients (3 male patients and 2 female patients) was 84 years (range, 68-100 years), and mean flap size was 199.6 cm (range, 120-330 cm). The mean follow-up period was 26.6 months (range, 5-38 months). No complications were found. CONCLUSIONS: With proper local anesthesia, successful head and neck reconstruction with free flap was possible, and patient prognosis was positive. There are numerous advantages, including: (1) a safer and inexpensive operation; (2) no complications from general anesthesia; (3) the fact that free flap transfer can be performed in elderly patients, even if they cannot tolerate general anesthesia; and (4) allowance of the performance of free tissue transferring in countries without adequate medical resources.

Repair of a critical-size segmental rabbit femur defect using bioglass-ß-TCP monoblock, a vascularized periosteal flap and BMP-2.

Various synthetic bone substitutes are not suitable for reconstructing critical-size bone defects. This study tested whether a bioglass-ß-tricalcium phosphate (ß-TCP) monoblock is effective for repairing critical-size segmental bone defects if combined with a vascularized periosteal flap and bone morphogenetic protein (BMP)-2. A femoral osteotomy with a gap size of 20 mm was created and stabilized using a plate in 40 rabbits.The defect was left untreated (group A) or repaired using a monoblock (group B), a monoblock with a vascularized periosteal flap (group C), or a monoblock with a vascularized periosteal flap and BMP-2 (group D). Bone regeneration, vascularization and monoblock degradation were analyzed after four and eight weeks using x-ray, hematoxylin-eosin, CD34 immunohistochemical and Masson's trichrome staining observation and histometric evaluation. The radiographic grading score showed a time-dependent increase from weeks 4 to 8. At 8-week postoperative, the total new regenerated bone in groups C and D was 20.0 ± 0.3 and 55.5 ± 8.0 mm2 , respectively, which was significantly greater than in group B. Conversely, group D showed less residual monoblock than did group C. An increase in microvessel density was also observed in groups C and D compared with group B at 4 and 8 weeks postoperative, respectively. This study suggests that bioglass-ß-TCP monoblock alone exhibits poor potential to repair a 20-mm femoral defect. However, supplementation with a vascularized periosteal flap and BMP-2 led to effective vascularization and reliable bone regeneration throughout the monoblock, with concordant material degradation in a timely manner. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 2148-2156, 2018.

Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema.

BACKGROUND: Vascularized lymph node (VLN) transfer for lymphedema treatment has shown promising results. Optimal donor and recipient sites remain a matter of debate. We describe the technique and outcomes of a laparoscopically harvested extended gastroepiploic VLN flap with two levels of inset. PATIENTS AND METHODS: Between 2014 and 2015, four-patients with upper limb breast cancer-related lymphedema and three-patients with lower limb pelvic cancer-related lymphedema who underwent VLN transfers were included. After harvest, the gastroepiploic VLN flap was divided into two halves that were separately inset at the level of elbow and wrist (upper limb) or knee and ankle (lower limb). The mean patient age was 53.1 years (range, 42-65 years). RESULTS: The average flap size after division was 6.3 cm in length (range, 5-7 cm) and 3.4 cm in width (range, 3-4 cm). The mean pedicle length was 3.2 cm (range, 2.5-4 cm). All flaps survived completely. No donor or recepient site complication was noted. At a mean follow-up of 9.7 months (range, 8-11 months), the mean circumference reduction rate was 43.7 ± 2.5% along the entire limb (P < 0.05). No episode of infection was noted postoperatively. CONCLUSIONS: Double gastroepiploic VLN transfers to middle and distal limb are a safe approach with very promising results. This technique may be used to improve clinical outcomes by enhancing the lymphatic drainage of the entire affected limb in a uniform fashion. In addition, the laparoscopic harvest can provide decreased donor site morbidity with a faster recovery.

Low-Level Laser Therapy in Enhancing Wound Healing and Preserving Tissue Thickness at Free Gingival Graft Donor Sites: A Randomized, Controlled Clinical Study.

OBJECTIVE: The aim of this study was to determine the effects of low-level laser therapy (LLLT) on wound healing at free gingival graft (FGG) donor sites. MATERIALS AND METHODS: Forty patients requiring FGG were selected for this randomized, controlled, and double-blinded prospective clinical trial. The FGG donor sites were treated with LLLT and compared with an untreated control group. The Wound-Healing Index (WHI), tissue consistency, color match, and H2O2 bubbling test for the evaluation of complete wound epithelialization were recorded on the 3rd, 7th, 14th and 21st days. The pain-burning level, number of analgesics, and bleeding were recorded for 7 days. Donor area soft tissue thickness (TT) was measured at baseline and at the first month. RESULTS: The prevalence of Complete Wound Epithelization was higher in the LLLT group than in the control group on the 14th day (p < 0.001). The bleeding was lower in the test group than in the control group during the first 2 days (p ≤ 0.001). Higher WHI Scores were observed in the test group relative to the control group at all visits (p ≤ 0.001). Color match scores were higher in the test group than in the control group at the first 3 visits (p < 0.05). The TT changed from 4.62 ± 0.79 to 4.71 ± 0.82 mm in the LLLT group and from 4.23 ± 0.62 to 4.01 ± 0.68 mm in the control group. CONCLUSIONS: It can be concluded that LLLT enhances FGG donor site wound healing and preserves TT at palatinal donor sites.

[Reconstruction with supraclavicular island flaps : An option in oncological treatment of head and neck carcinomas]. / Rekonstruktion mit dem supraklavikulären Insellappen : Eine Alternative in der onkologischen Therapie von Kopf-Hals-Karzinomen.

BACKGROUND: Reconstruction of defects after extirpation of head and neck cancer is a highly challenging and complex surgical undertaking. Commonly used techniques, e.g., the radial forearm flap, the anterior lateral thigh flap, or flaps harvested from the chest-deltopectoral or pectoralis major-share numerous disadvantages, such as donor-site morbidity, poor color matching for cutaneous reconstruction, and excessive tissue bulk. The use of a supraclavicular artery island flap is a long-forgotten but increasingly popular option for reconstruction in the head and neck area. MATERIALS AND METHODS: In the period 03/2013-02/2016, a total of 12 patients were treated with a supraclavicular island flap after surgical resection of carcinoma of the oral cavity, pharynx, parotid, or facial skin. RESULTS: Using examples, reconstruction of the lateral tongue and tongue base following resection of a squamous cell carcinoma, and reconstruction of the parotideal region after total parotidectomy and neck dissection for a skin spinalioma that had infiltrated the parotid are reported. In both patients, the flap healed without problems and led to very good functional and cosmetic outcomes. CONCLUSION: The supraclavicular island flap is a reliable and versatile flap for reconstruction in the head and neck region. Minimal donor-site morbidity, excellent cosmetic properties, and the relative ease of preparation and use compared to other distant flaps render it an excellent reconstructive tool for ENT surgeons.

Health-related quality of life after segmental resection of the lateral mandible: Free fibula flap versus plate reconstruction.

OBJECTIVES: Segmental resection of the mandible causes functional, aesthetic and social problems affecting health-related quality of life (HRQoL). It is often assumed that reconstruction with composite free flaps guarantees better function and aesthetics than bridging the defect with reconstruction plates. METHODS: Using the European Organization for Research and Treatment of Cancer questionnaires (EORTC QLQ-C30 version 3.0 and EORTC QLQ-H&N35), we compared HRQoL in patients who received free fibula flaps versus reconstruction plates after segmental resection of the lateral mandible. RESULTS: Thirty-seven completed questionnaires (18 fibula reconstructions and 19 patients with reconstruction plates) were available. Reconstruction with a free fibula flap did not provide clear additional benefit to bridging the defect with a reconstruction plate after segmental resection of the lateral mandible. In particular aspects known to have the most impact on HRQoL like swallowing, speech and chewing were not influenced by the type of reconstruction. CONCLUSIONS: Reconstruction of segmental defects of the lateral mandible with free fibula flap and reconstruction plate resulted in comparable HRQoL. If dental rehabilitation by means of dental implants is not anticipated in the fibula, then plate reconstruction with adequate soft tissue remains a suitable technique for the reconstruction of segmental defects of the lateral mandible.

Evaluation of palatal donor site haemostasis and wound healing after free gingival graft surgery.

AIM: Evaluating effectiveness of a medicinal plant extract (MPE) in achieving haemostasis and early wound healing at free gingival graft (FGG) donor site in a randomized controlled fashion. METHODS: Forty patients requiring FGG at lower anterior area were randomly assigned into two groups. FGG was performed to all patients and following graft procurement; wet gauze (WG) was applied alone (control: WG group) or with MPE (test: MPE + WG group) for haemostasis. Donor site working time, bleeding (BLE), colour match (CM), pain, epithelization (EP) and sensation loss (SL) were evaluated. RESULTS: Thirty-three participants completed a 6-month period study. In the test group, primary BLE was shorter (p < 0.001) and fewer individuals showed secondary BLE during 3 days (p < 0.001). During the 6 days, pain scores were higher in WG patients (p < 0.05). Later on, no inter-group difference was observed. EP was relatively faster (p < 0.001) and CM was slightly better (p < 0.05) in MPE + WG group. CONCLUSION: MPE provided faster and continuous haemostasis that made a positive contribution to the early soft tissue healing to some extent but due to limitations; further trials are needed to demonstrate the efficiency of this material.

Vascularized Partial Free Toe Tissue Transfer Under Local Anesthesia.

BACKGROUND: This study was designed to introduce free toe soft tissue transfer using local infiltration anesthesia in patients not suitable for general anesthesia and local tissue coverage. METHODS: From January 2006 to August 2012, a total of 11 traumatic fingertip defects were reconstructed by toe soft tissue transfer. All procedures except 1 were done as primary reconstructions, with either the lateral side of the great toe (5 cases) or the medial side of the second toe (6 cases) used as a donor. Postoperative follow-up periods were between 8 months to 2 years and 6 months. RESULTS: Flap sizes varied from 1.0 × 2.0 to 2.0 × 3.5 cm. The mean operative times were 4 hours 29 minutes for cases done by a single team and 3 hours 21 minutes for cases done by a 2-team approach. Approximately 5.8 mL of local anesthetic agent was used in each finger and 5.9 mL was used in the toes for a total of 11.7 mL. All flaps survived and were fully taken without complications, except 1 case that presented partial necrosis. CONCLUSIONS: Fingertip soft tissue reconstruction by free toe tissue transfer under local anesthesia uses a more limited operative field, with a shorter operative time, enabling reconstruction in patients not suitable for general anesthesia. This is even more so with a microsurgical 2-team approach, which reduces the volume of anesthetic agent needed, making this method a sufficiently realistic option for fingertip soft tissue reconstruction.

Two cases of prostheses for flap protection after buccal mucosal incision.

Here we describe two patients in whom prostheses were applied for flap protection after buccal mucosal incision. In the first case, the patient was a 65-year-old man with a diagnosis of buccal mucosa squamous cell carcinoma (T2N0M0). Left buccal mucosa squamous cell tumor resection and dermoplasty were performed, followed by alveolar ridge augmentation and buccal mucosal graft in the scar area. The carcinoma recurred, however, and left buccal mucosa carcinoma resection was performed, followed by reconstruction surgery using a free forearm flap. After a 12-week healing period, a molar support was constructed on the unaffected side and a protective prosthesis placed on the affected side. Training in ingestion and swallowing were given postoperatively. The patient in the second case was a 62-year-old woman with a diagnosis of buccal mucosa squamous cell carcinoma (T2N1M0). Right buccal mucosa carcinoma resection and supraomohyoid neck dissection were performed, followed by reconstruction surgery using a free forearm flap. A molar support was constructed on the unaffected side and a protective prosthesis placed on the affected side at 5 months postoperatively. Training was given in ingestion and swallowing postoperatively. The prostheses prevented bite wounds to the flaps in the affected areas due to jaw movement during swallowing or speaking. The postoperative courses were uneventful, and the average masticatory score was 92.5 (85, 100), not affecting daily life. The prostheses were placed after reconstruction surgery using free flaps after buccal mucosa squamous cell carcinoma resection. Dysphasia recovered to the preoperative level by dysphasia and pronunciation training in both cases. The postoperative prognosis was favorable, with the prosthesis preventing damage to the flap.

Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: experience from a regional head and neck unit.

This study is a retrospective review of treatment outcomes of osteoradionecrosis (ORN) of the mandible with specific reference to the evolving role of medical management with pentoxifylline, tocopherol, and doxycycline. We reviewed the presentation and management of 71 patients treated for ORN of the mandible at the regional head and neck unit during a 15-year period to January 2011, and categorised them into three grades using the Notani classification: grade I (n=28), grade II (n=16), and grade III (n=27). Twelve patients with grade I ORN, 3 with grade II, and 10 with grade III, were prescribed medical treatment. Of these, three with grade I, and two with grade II ORN were cured, and progression of the disease had halted and there was satisfactory control of symptoms in eight with grade I and four with grade III disease. Patients who failed to respond to conservative treatment were further analysed for the need for free flap reconstruction. Medical management was introduced as a standard treatment in January 2006. Of the 39 patients diagnosed before this, 20 (51%) required resection and free flap reconstruction compared with only 8/32 (25%) after it had been introduced.

Multidisciplinary approach to lethal bleeding from an arteriovenous malformation in the external auditory canal.

Arteriovenous malformations (AVMs) are composed of abnormally connecting feeding arteries as well as draining veins and lack a regulatory system. Frequent recurrences and unpredictable behavior are their main problems. Potential mortality and morbidity associated with therapeutic procedures must be considered with these patients. Improper treatment often aggravates the condition, potentially rendering therapy more complex. A multidisciplinary approach, including an endovascular approach, surgical excision, and flap reconstruction, is considered to completely eradicate an AVM. This study introduces a complicated case of AVM with massive bleeding through the external auditory canal that was treated with a multidisciplinary approach.

Antibiotic selection for the treatment of infectious complications of implant-based breast reconstruction.

BACKGROUND: Infection requiring explantation remains the most devastating complication associated with implant-based breast reconstruction. There are many treatment algorithms to prevent reconstructive failure in face of infection using both oral and intravenous antibiotics. In the absence of patient-specific culture data, antibiotic selection is generally directed toward broad-spectrum coverage based on historical data. We hypothesize that reviewing our institution's microbiology data obtained from explanted implant-based breast reconstructions would provide a rational basis for antibiotic selection in the future. METHODS: A retrospective review of 902 consecutive immediate implant-based breast reconstructions at a single institution from November 2007 to May 2011 was conducted. Implant reconstructions requiring explantation or drainage by interventional radiology were identified. Patient demographics, implant characteristics, presence of skin necrosis, microbiological data, and outcomes were reviewed. RESULTS: Forty-three (4.76%) implant reconstructions requiring explantation or drainage by interventional radiology met the inclusion criteria for this study. Five patients (11.6%) had round, smooth silicone implants, and 36 (88.4%) had textured tissue expanders. Twenty-six implants were explanted because of infection; 3, because of exposure from skin necrosis; and 11, because of the combination of flap necrosis and infection; and 1, secondarily because of cancer invasion into the skin. Reconstruction was salvaged in 21 breasts (51.2%): 12 (57.1%) by implant reconstruction, 5 (23.8%) by pedicled latissimus dorsi flaps, and 4 (19.1%) with a microvascular free flap. Thirty explants had microbiology data available. The most common organism isolated was Staphylococcus epidermidis (10), followed by methicillin-sensitive Staphylococcus aureus (5), Serratia marcescens (5), Pseudomonas aeruginosa (4), enterococcus (3), Escherichia coli (2), Enterobacter (2), group B streptococcus (1), and Morganella morganii (1). Forty percent of the organisms were resistant to cefazolin; however, 86% were sensitive to gentamicin, 80% were sensitive to Levaquin, and 63% were sensitive to ciprofloxacin. CONCLUSIONS: Infection associated with implant-based breast reconstructions continues to threaten explantation and reconstructive failure. Based on our microbiological data, initial cellulitis amenable to oral antibiotics should be treated with oral fluoroquinolones as a first-line treatment. If this regimen fails, intravenous imipenem or gentamicin and vancomycin should be initiated. Obviously, clinical judgment regarding specific patient risk factors and compliance should play a role in decision making, but these data provide an evidence-based rationale for first-line oral antibiotic selection.