Free Flap Survival Following Failure of the Vascular Pedicle.

BACKGROUND: Controversy exists regarding whether or not, or, if so, how quickly free flaps can achieve neovascularization from the surrounding tissue bed and independence from the vascular pedicle. In this paper, we document the survival of free flaps despite early vascular pedicle thrombosis and review the literature regarding the period of time believed to be required for flap autonomy to occur. DESIGN: Case series SETTING: Harbor-UCLA Medical Center PATIENTS: We report 3 cases in which pedicle failures occurred within 2 weeks of free flap transfer. The first patient suffered repeated leaks from the vascular anastomosis with hematoma formation occurring on postoperative days 4, 6, and 17, ultimately requiring ligation of the pedicle. The second patient developed a salivary leak and accumulation of saliva around the pedicle, which was found thrombosed on postoperative day 11. The third patient lost Doppler signals from the pedicle on postoperative day 7 and 8, each occasion necessitating a return to the operating room for anastomotic revision. However, on postoperative day 9, the signal was lost yet again and no further revisions were attempted. RESULTS: Two of the 3 flaps survived completely and the third was noted to have near complete survival. CONCLUSION: Microvascular free flaps can survive despite complete pedicle failure as early as 10 days after surgery. The mechanism behind this may involve the process of neovascularization. We conclude that early free flap pedicle failure does not necessarily equate to complete flap loss.

Use of Dual, Tubularized Supraclavicular Artery Island Flaps in Series to Restore Gastrointestinal Continuity After a Failed Ileocolic Esophageal Reconstruction.

The supraclavicular artery island flap (SCAIF) is a versatile pedicled flap that can be an excellent alternative to free flap reconstruction in complex head and neck defects. We use the SCAIF routinely as a first-line option for many of our soft tissue head and neck reconstructions. Here we describe a novel application of dual SCAIFs used in series for proximal esophageal reconstruction. This followed esophagectomy for neoplastic disease and failed gastric pull-up and colonic interposition procedures.

Post-Mastectomy Patients in an Urban Safety-Net Hospital: How Do Safety-Net Hospital Breast Reconstruction Rates Compare to National Breast Reconstruction Rates?

BACKGROUND: Breast reconstruction (BR) has documented psychological benefits following mastectomy. Yet, racial/ethnic minority groups have lower reported rates of BR. We sought to evaluate the rate, type, and outcome of BR in a racially and ethnically diverse population within a safety-net hospital system. METHODS: All patients who underwent mastectomy between October 2015 and July 2019 at Harbor-UCLA Medical Center were retrospectively examined. Rates and type of BR were analyzed according to patient characteristics (race/ethnicity, age, and body mass index), smoking status, cancer stage, and presence of diabetes mellitus. Breast reconstruction outcomes were also assessed. RESULTS: Of the 259 patients that underwent mastectomy, 87 (33.6%) received BR. Immediate BR was performed in 79 (30.5%) patients and delayed BR in 8 (3.1%). Of the 79 patients with immediate BR, 58 (73.4%) received implant-based BR and 21 (26.5%) autologous tissue. The BR failure rate was 10%, all implant-based. Increasing age and smoking negatively impacted BR rates. Black (P =.331) and Hispanic (P =.132) ethnicity were not independent predictors of decreased breast reconstruction. CONCLUSION: This study demonstrated that the rate, type, and quality of BR in this integrated safety-net hospital within a diverse population are comparable to national rates. When made available, historically underrepresented minority patients of Black and Hispanic ethnicity utilize BR.

A Randomized Study Comparing Closed-Incision Negative-Pressure Wound Therapy with Standard Care in Immediate Breast Reconstruction.

BACKGROUND: Breast cancer remains the most common nonskin cancer among women. Prophylactic methods for reducing surgical-site complications after immediate breast reconstruction (IBR) are crucial to prevent acellular dermal matrices or prosthesis exposure and loss. The authors assessed the impact of closed-incision negative-pressure wound therapy (ciNPWT) versus standard dressings (ST) after IBR on surgical-site complications, superficial skin temperature (SST), skin elasticity, and subjective scar quality, to determine the potential benefit of prophylactic ciNPWT application. METHODS: A multicenter randomized controlled study of 60 adult female patients was conducted between January of 2019 and July of 2021. All patients had oncologic indications for IBR using implants or expanders. RESULTS: Application of ciNPWT correlated with a significant decrease in surgical-site complications within 1 year of surgery (total, 40%; ST, 60%; ciNPWT, 20%; P = 0.003) and resulted in more elastic scar tissue as measured with a Cutometer (average coefficient of elasticity, 0.74; ST, 0.7; ciNPWT, 0.9; P < 0.001). The SST of each scar 1 week after surgery was significantly higher in the ciNPWT group (average SST, 31.5; ST SST, 31.2; ciNPWT SST, 32.3; P = 0.006). According to the Patient and Observer Scar Assessment Scale v2.0, subjective scar outcomes in both groups were comparable. CONCLUSIONS: This is the first randomized controlled study that demonstrated a significant decrease in surgical-site wound complications within 1 year of surgery in IBR patients receiving ciNPWT. A high probability of postoperative radiotherapy should be a relative indication for the use of ciNPWT. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Gunshot wounds to the face: level I urban trauma center: a 10-year level I urban trauma center experience.

INTRODUCTION: Gunshot wounds (GSWs) to the face are an infrequent occurrence outside of a war zone. However, when they occur, they constitute a significant reconstructive challenge. We present our 10-year experience at an urban level I trauma center to define the patterns of injury, assess the morbidity and mortality, and estimate the cost to the health care system. METHODS: A retrospective review was performed on all patients admitted to Harbor-UCLA Medical Center with GSWs to the head and neck region between January 1997 and January 2007. Those who had sustained GSWs to the face requiring operative intervention were closely reviewed. RESULTS: Between 1997 and 2007, a total of 702 patients were admitted to the Harbor UCLA Emergency Department having sustained GSWs to the head and neck region, of which 501 patients survived. Of the survivors, 28 patients (26 male, 2 female) sustained GSWs to their face requiring operative intervention. The mean age of these patients was 28 (±8.3) years. They generally presented within a few hours of the injury, but 1 individual arrived over 24 hours later. Low-velocity single gunshots (from handguns) were predominantly involved, with facial fractures occurring in all cases. Fractures were of a localized shattering type without the major displacement of bony complexes seen in motor vehicle accidents. Most required wound debridement and fracture fixation. A few patients (14.2%) underwent free tissue transfer for reconstruction (3 fibular flaps, 1 TRAM). Tracheostomy was performed in 35.7% of patients. Mean length of hospital stay was 8.3 (±7.1) days, with 50% of cases requiring admission to the intensive care unit. Mean length of intensive care unit stay was 5.2 (±5.7) days. The average cost per patient exceeded $100,000.

Outcomes of complex gunshot wounds to the hand and wrist: a 10-year level I urban trauma center experience.

PURPOSE: To assess the consequences of gunshot wounds (GSWs) to the hand, we reviewed our 10-year experience at an urban level I trauma center. METHOD: A retrospective review was performed on patients admitted with GSWs to the extremities between January 1, 1997 and January 1, 2007. Those with GSWs to the hand and wrist needing surgery were studied. A telephone survey supplemented the data. RESULTS: Of 1358 patients admitted with GSWs involving the upper extremities, 62 patients with complex hand and wrist injuries requiring operative intervention were identified. Most patients sustained low-velocity handgun injuries and presented within 12 hours of injury. In many individuals (97%), the gunshot injury to the hand or wrist was only part of a multiple gunshot assault. All patients underwent surgical debridement and repair followed by an early aggressive rehabilitation program. Mean length of hospital stay was 5.0 (±5.1) days, with 9.7% of patients requiring ICU care for 3.3 (±1.4) days, with an average cost of $47,819 (±$53,548) per patient. Although 65% of the individuals subsequently reported being "disabled from work" due to pain, the quality of life, and ultimate function was good in 61%, fair in 26.1%, and bad in 13%. CONCLUSION: GSWs to the hand and wrist are often part of multiple handgun wounds in one individual. Most produce comminuted fractures, seldom requiring bone grafts, fusion, or amputation. Vascular injuries, though rare, necessitate vein grafts due to loss of length. Few patients require free flaps, and few sustain nerve or tendon injuries. Most complain of pain or numbness. However, a good quality of life and a return to the activities of daily living occurred in two-third individuals.

Plastic Surgery and the Malpractice Industry.

SUMMARY: The current status of the plastic surgeon in the medical liability spectrum and ways to avoid litigation are explored by using pooled national data from the Medical Professional Liability Association, private information from Applied Medico-Legal Solutions RRG, and a detailed literature search. The medical liability system in the United States costs $55.6 billion, or 2.4 percent of total health care spending. Plastic surgery accounts for 3.31 percent of reported claims and 3.16 percent of paid claims. Total payments for plastic surgeons represent 1.75 percent of the total paid for all specialties. Malpractice awards are relatively light for plastic surgeons. Nevertheless, they still have a 15 percent chance per year of being sued. However, 93 percent of cases will close with a dismissal or a settlement, and only 7 percent will go to trial. Of these, the plastic surgeon will prevail in 79 percent. Most importantly, 75 percent of all cases will result in no payment. To minimize the chances of a lawsuit, plastic surgeons should maintain excellent communication with their patients and participate in shared decision-making. They should take a leadership role and buy in to the performance of perioperative checklists, embrace patient education, and actively participate in Maintenance of Certification. They should be transparent in their dealings with patients by preoperatively declaring their policies on revisions, refunds, complications, and payments. Plastic surgeons must maintain complete and accurate medical records and participate in hospital-based programs of prophylaxis. They should be aware that postoperative infection is the single costliest adverse outcome and proactively deal with it.

Reconstruction of total laryngopharyngectomy defects with deep inferior epigastric perforator flaps.

Laryngopharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh, radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. We present a novel approach for total laryngopharyngectomy reconstruction using deep inferior epigastric perforator (DIEP) flaps. A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006 to 2007 was performed. Those undergoing DIEP flaps were identified; management and postoperative course were analyzed. Two patients underwent successful reconstruction of total laryngopharyngectomy defects using DIEP flaps. Flaps up to 10 x 30 cm were harvested. Average donor vessel diameters were 2.5 cm and 3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent reexplorations. There were no postoperative bulges or hernias, and no leaks were detected on postoperative swallow evaluation. The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngopharyngectomy defects. Pedicle length is abundant, and donor vessel caliber is excellent. Large surface-area flaps can be harvested; excess flap can be deepithelialized or utilized for external skin. Primary closure of the donor site can be routinely achieved, negating the need for skin grafts.

Supraclavicular artery island flap (SCAIF) vs free fasciocutaneous flaps for head and neck reconstruction.

OBJECTIVE: At our institution, the supraclavicular artery island flap (SCAIF) has become a reliable option for fasciocutaneous coverage of complex head and neck (H&N) defects. We directly compare the outcomes of reconstructions performed with SCAIFs and free fasciocutaneous flaps (FFFs), which have not been reported previously. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: Retrospective review of consecutive single-surgeon H&N reconstructions using fasciocutaneous flaps over 5 years. Reconstructions were divided into 2 groups: SCAIFs and FFFs. Patient demographics, surgical parameters, and outcomes were compared statistically between groups. RESULTS: Thirty-four flaps were used in H&N reconstruction (18 SCAIFs and 16 FFFs). There was no difference in patient demographics, distribution of defects, or follow-up (SCAIF 9.2 vs FFF 15.13 months, P = .65) between the 2 groups. The SCAIFs were larger than the FFFs (164.6 ± 60 vs 111 ± 68 cm(2), P < .05) and had shorter total operative times (588 ± 131 vs 816 ± 149 minutes, P < .05). Intensive care unit (ICU) length of stay was shorter for the SCAIF vs the FFF group (1.8 vs 5.6 days, P < .05). Overall morbidity was not significantly different (SCAIF 39% vs FFF 44%, P = NS). CONCLUSION: The SCAIF is a technically simpler and equally reliable sensate fasciocutaneous flap for H&N reconstruction with comparable outcomes, shorter operative time, less ICU stay, and no need for postoperative monitoring when compared with using FFFs. It should be considered a first-choice reconstructive option for complex H&N defects.

The supraclavicular artery island flap (SCAIF) for head and neck reconstruction: surgical technique and refinements.

OBJECTIVE: We have found the supraclavicular artery island flap (SCAIF) to be a reliable, first-line tool for the reconstruction of complex head and neck defects. Here, we review our technique of flap elevation and summarize the current literature citing important contributions in the evolution of this flap. DATA SOURCES: Medline literature review of supraclavicular artery island flap or shoulder flap in head and neck reconstruction with particular emphasis on developments within the past 5 years. REVIEW METHODS: Literature review of technique, indications, anatomy, modification, and outcomes of the supraclavicular artery island flap. CONCLUSION: The supraclavicular artery island flap is an important and reliable option in head and neck reconstruction. We use the flap routinely in our practice as a first-line technique when fasciocutaneous soft-tissue reconstruction is required, and we provide a detailed summary of the flap elevation and inset. IMPLICATIONS FOR PRACTICE: The supraclavicular artery island flap is a safe, reliable, technically simple, sensate, thin, pliable fasciocutaneous regional flap option that has low morbidity. It provides sensate, single-stage reconstruction for a variety of head and neck defects and should be considered as a first-line option in head and neck reconstruction.

Introducing the tibial-dorsalis pedis osteocutaneous shin flap: a new option for oromandibular reconstruction.

BACKGROUND: The authors investigated the possibility of incorporating a well-vascularized, partial corticotomy of the anterolateral aspect of the tibia "in-series" with a dorsalis pedis fasciocutaneous free flap for oromandibular reconstruction. METHODS: A cadaveric injection study was performed to characterize the vascular territory of the anterior tibial artery with regard to the surrounding osseous and soft tissue. The two-point breaking strength of the tibia (twist) was examined with fracture strain gauge analysis to determine the threshold of tibia corticotomy that would lead to a pathologic fracture. Finally, the authors performed an in vivo prospective clinical examination of the tibial-dorsalis pedis osteocutaneous shin flap. RESULTS: The perfusion study revealed that the anterior tibial artery provided a rich matrix of musculofascial periosteal blood supply to the anterolateral cortex of the tibia that could potentially support free osseous tibial transfer. Two-point osteotomy fracture strain gauge analysis demonstrated that the threshold of tibia corticotomy that would lead to pathologic fracture of the remaining tibia was greater than 30 percent. The osteocutaneous shin flap was performed in eight patients. The mean follow-up was 61 months. There were no cases of flap loss, salivary fistula, nonunion, or tibia pathologic fracture. All patients achieved ambulation. CONCLUSIONS: The authors introduce the osteocutaneous tibial-dorsalis pedis free vascularized flap as a viable option for oromandibular reconstruction. Its most notable advantage is the independent mobility of the skin paddle, in combination with bone stock that replicates mandibular bone dimensions, facilitating primary osseointegration or denture rehabilitation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Bipedicled flaps in posttraumatic lower-extremity reconstruction.

BACKGROUND: Complex, lower-extremity, soft-tissue defects pose a significant challenge to the reconstructive surgeon and often require the use of free flaps, which puts significant demands on the patient, the surgeon and the health-care system. Bipedicled flaps are random but receive a blood supply from two pedicles, allowing the surgeon to use local tissue with an augmented nutrient blood flow. They are simple to elevate and economical in operating time. This study describes our experience with lower-extremity wound reconstruction using the bipedicled flap as an alternative to pedicled flaps and free flaps. METHODS: Ten patients with lower-extremity defects underwent bipedicled flap reconstruction. Operative times, length of stay following flap procedure and postoperative complications were documented. Data were collected in a prospective fashion. RESULTS: Two patients had minimal areas of flap necrosis, both of which resolved with conservative local wound care and one patient developed a postoperative wound infection remedied with a course of oral antibiotics. We experienced one major complication involving wound dehiscence requiring an additional flap. CONCLUSIONS: Bipedicled flaps provide a safe, fast and relatively easy alternative for coverage of certain complex open wounds in the lower extremities. Their use does not preclude the use of more traditional options of pedicled muscle or free flap coverage at a later time should they be required. CLINICAL QUESTIONS ADDRESSED/LEVEL OF EVIDENCE: What are alternative strategies for lower-extremity wound reconstruction. Level of Evidence V.

The sensate fibula osteocutaneous flap: neurosomal anatomy.

BACKGROUND: Rapid return of oral sensation enhances quality of life following oromandibular reconstruction. For predictable reinnervation of flaps, a detailed knowledge of their nerve supply is required. This study was designed to investigate the cutaneous nerve supply of the fibula osteocutaneous flap. METHODS: We dissected thirty-seven fresh cadaveric specimens to better understand the cutaneous innervation of the typical fibula flap that would be used in oromandibular reconstruction. In addition, ten volunteers were enlisted for nerve blocks testing the cutaneous innervation of the lateral aspect of the lower leg. RESULTS: The lateral sural cutaneous nerve (LSCN) is generally considered to be sole cutaneous innervation to the lateral aspect of the lower leg; however, our analysis of the cadaveric specimens revealed dual innervation to this region. We identified a previously unnamed distal branch of the superficial peroneal nerve, which we have termed the recurrent superficial peroneal nerve (RSPN). Given the cadaveric findings, both the LSCN and the RSPN were tested using sequential nerve blocks in 10 volunteers. An overlapping pattern of innervation was demonstrated. CONCLUSIONS: The lateral aspect of the lower leg has an overlapping innervation from the LSCN and the newly described RSPN. The overlap zone lies in the region of the skin paddle of the fibula flap. The exact position of the neurosomal overlap zone (N.O.Z.E.) may be an important factor in reestablishing sensation in the fibula's skin paddle following free tissue transfer.

The sensate fibular osteoneurocutaneous flap in oromandibular reconstruction: clinical outcomes in 31 cases.

Thirty-one patients requiring composite mandibular resection were reconstructed with sensate fibula osteocutaneous flaps. Preoperatively, all patients underwent lower extremity sensory testing at the location of the proposed flap site. Intraoperatively, either the Lateral Sural Cutaneous Nerve (LSCN) or the Recurrent Superficial Peroneal Nerve (RSPN) was chosen as donor. It was then joined to either the lingual or the greater auricular nerve. Both end-to-end and end-to-side neurorrhaphies were used. At least six months postoperatively, the intraoral flaps were tested for sensory function. Twenty-eight patients achieved sensory return, including hot/cold and pinprick sensation. Both the LSCN and RSPN groups demonstrated improved two-point discrimination in static and moving studies. Better results were obtained when the lingual rather than the greater auricular nerve was the recipient. Only three patients underwent end-to-side repair, with improved two-point discrimination in two patients. The average follow-up for all patients was 11.7 months. The most dramatic return of sensory function was seen in the end-to-end lingual nerve neurorrhaphies, followed by end-to-side lingual nerve neurorrhaphies. Of the five repairs using the greater auricular nerve, only three demonstrated any measurable postoperative sensory return. Functional outcomes of postoperative patients were measured via analysis of speech, type of food consumption, and oral continence. The majority of patients exhibited normal or easily intelligible speech, was able to consume a soft food or normal diet, and could maintain normal to manageable oral continence. A subset of patients enrolled in the study went on to pursue dental rehabilitation.

Experiential learning in aesthetic surgery training: a quantitative comparison among surgical subspecialties.

BACKGROUND: The specialty of plastic surgery has evolved to encompass a wide breadth of both reconstructive and aesthetic surgery. Practitioners in other specialties have increasingly advanced on procedures and areas that have traditionally been served by plastic surgeons. To date, no evaluation and comparison of the operative experience of graduating residents from various specialties has been performed. METHODS: The authors review the case log statistical reports of the Accreditation Council for Graduate Medical Education. For each specialty, this annual report highlights the average number of cases performed for all graduating residents. The national case log reports were reviewed for dermatology, ophthalmology, otolaryngology, and plastic surgery. Four procedures (i.e., blepharoplasty, face lift, liposuction, and rhinoplasty) were compared for residents graduating in the 2006 to 2010 academic years. The hypothesis that no difference exists between the average numbers of aesthetic procedures performed by various specialty residency training was tested using a two-sample t statistic. RESULTS: For blepharoplasty, face lift, and liposuction, the higher number of cases performed by graduating plastic surgery residents was statistically significant (p < 0.00001) for all years examined. Although plastic surgery trainees graduating from 2006 to 2010 had a higher number of recorded rhinoplasties, this difference in case logs was statistically significant only for plastic surgery residents graduating in 2008. CONCLUSIONS: The quantitative operative experience of graduating plastic surgery residents for selected aesthetic surgery cases exceeds that of other surgical subspecialties. Given the exposure and strength of plastic surgery training, plastic surgeons should remain at the forefront of aesthetic surgery.

Reconstructive surgery training: increased operative volume in plastic surgery residency programs.

BACKGROUND: Practitioners in other surgical specialties have increasingly advanced their volume of reconstructive procedures traditionally served by plastic surgeons. Because there has not been a previous specialty training comparison, the average operative reconstructive volume of graduating plastic surgery residents was formally compared with that of other specialties. METHODS: The authors review the case log statistical reports of the Accreditation Council for Graduate Medical Education. For each specialty, this annual report highlights the average number of cases performed for all graduating residents. The national case log reports were reviewed for orthopedic surgery, otolaryngology, and plastic surgery. Six procedures were compared for residents graduating in the 2006 to 2010 academic years and are reviewed. A two-sample Welch-Satterthwaite t test for independent samples with heterogeneous variance was conducted to compare the average number of procedures performed per graduating resident. RESULTS: Graduates of plastic surgery residencies compared with graduates of other specialties performed more cleft lip and palate repairs, hand amputation, hand fracture, and nasal fracture procedures. This difference showed statistical significance for all years examined (2006 to 2010). For repair of mandible fractures, plastic surgery trainees had significantly more cases for 2006 to 2009 but not 2010. CONCLUSIONS: The quantitative operative experience of graduating plastic surgery residents for selected reconstructive cases is above that of the average graduating trainee outside of plastic surgery. Given the exposure and strength of plastic surgery training, plastic surgeons should remain at the forefront of reconstructive surgery.

Quality of innervation in sensate medial plantar flaps for heel reconstruction.

BACKGROUND: Reconstruction of the heel represents a difficult challenge for surgeons, given the demand for thick, durable skin capable of withstanding both pressure and shear. The authors describe the use of a sensate medial plantar flap for heel reconstruction in three patients and document the long-term retention of sensation compared with the contralateral uninjured heel and corresponding donor site. METHODS: A medial plantar flap was harvested to include the branch of the medial plantar nerve to the instep to preserve innervation. Sharp pain, light and deep pressure, vibration, cold temperature, and static and dynamic two-point discrimination were examined between 6 months and 1 year after surgery. RESULTS: Sharp pain, vibration, and deep pressure sensation were present equally in the medial plantar flap, contralateral heel, and contralateral instep. Cold perception, light pressure, and static two-point and dynamic two-point discrimination were significantly less in the normal contralateral heel when compared with the heel reconstructed by the innervated flap. There were no significant differences in sensation between the medial plantar flap and the contralateral instep. CONCLUSIONS: The medial plantar flap is capable of providing durable, sensate coverage of plantar hindfoot defects with minimal donor-site morbidity. Furthermore, that sensation remains identical to that of the instep donor site and superior to that of the normal heel pad.