Three-Dimensional Multi-Modality Registration for Orthopaedics and Cardiovascular Settings: State-of-the-Art and Clinical Applications.

The multimodal and multidomain registration of medical images have gained increasing recognition in clinical practice as a powerful tool for fusing and leveraging useful information from different imaging techniques and in different medical fields such as cardiology and orthopedics. Image registration could be a challenging process, and it strongly depends on the correct tuning of registration parameters. In this paper, the robustness and accuracy of a landmarks-based approach have been presented for five cardiac multimodal image datasets. The study is based on 3D Slicer software and it is focused on the registration of a computed tomography (CT) and 3D ultrasound time-series of post-operative mitral valve repair. The accuracy of the method, as a function of the number of landmarks used, was performed by analysing root mean square error (RMSE) and fiducial registration error (FRE) metrics. The validation of the number of landmarks resulted in an optimal number of 10 landmarks. The mean RMSE and FRE values were 5.26 ± 3.17 and 2.98 ± 1.68 mm, respectively, showing comparable performances with respect to the literature. The developed registration process was also tested on a CT orthopaedic dataset to assess the possibility of reconstructing the damaged jaw portion for a pre-operative planning setting. Overall, the proposed work shows how 3D Slicer and registration by landmarks can provide a useful environment for multimodal/unimodal registration.

Orbital Extenteration Defects: Ablative and Reconstructive Flowchart Proposal.

ABSTRACT: Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol. LEVEL OF EVIDENCE: Level III.

Acupuncture for radiation-induced toxicity in head and neck squamous cell carcinoma: a systematic review based on PICO criteria.

PURPOSE: In head and neck squamous cell carcinoma (HNSCC), the potential mitigating effect of complementary medicine interventions such as acupuncture for radiation-induced toxicity is unknown. This study aimed to assess the impact of acupuncture on the incidence and degree of severity of common radiation-induced side effects. METHODS: In accordance with pre-specified PICO criteria, a systematic review was performed. Two electronic databases (Medline and Embase) were searched over a 10-year time frame (01/01/10 to 30/09/20). Patients undergoing a curatively intended, radiation-based treatment for histologically confirmed squamous cell carcinoma of the nasopharynx, oropharynx, larynx, hypopharynx and oral cavity represented the target population of our study. Accurate information on the acupuncture methodology was reported. All included articles were evaluated to identify any potential source of bias RESULTS: Five papers were included in our qualitative analysis, for a total of 633 subjects. Compliance to per-protocol defined schedule of acupuncture sessions was high, ranging from 82 to 95.9%. Most patients (70.6%) were randomly allocated to receive acupuncture for its potential preventive effect on xerostomia. The large heterogeneity in study settings and clinical outcomes prevented from performing a cumulative quantitative analysis, thus no definitive recommendations can be provided. CONCLUSIONS: Although shown to be feasible and safe, no firm evidence currently supports the use of acupuncture for the routine management of radiation-induced toxicity in HNSCC.

Salvage neck dissection for isolated neck recurrences in head and neck tumors: Intra and postoperative complications.

BACKGROUND AND OBJECTIVES: The current evidence regarding complications after salvage neck dissection (ND) for isolated regional recurrences (IRRs) in head and neck cancers is poor. The aim of this study is to evaluate the incidence and differences in complication rates of salvage ND after primary surgery, radiotherapy, chemoradiotherapy, or combined treatments. METHODS: This was a multicentric retrospective study on 64 patients who underwent salvage ND for IRR in three Italian institutes between 2008 and May 2020. RESULTS: Complications were detected in 7 of the 34 patients (20.8%) and surgeons described difficult dissection in 20 patients (58.82%). Accidental vascular ligations or nervous injury during surgery were never detected. None of the variables analyzed were statistically significant in predicting the risk of complications, disease-free survival, or overall survival. CONCLUSIONS: IRR represents a rare entity among total relapses. The incidence of complications after salvage ND for IRR is higher than after primary surgery but at an acceptable rate in experienced hands. However, an adequate balance between functional and oncological outcomes is mandatory.

Pediatric Malignant Mandibular Tumors: Personal Experience and Literature Options Discussion.

INTRODUCTION: Mandibular defects reconstruction could result challenging in childhood, due to facial and mandibular growth patterns. For these reasons, the choice of the most suitable reconstructive option in pediatric patients, affected by mandibular malignancies, still objects of debate. OBJECTIVE: The aim of our study was to compare our reconstructive schedules to the existing literature in order to give a personal contribute to the present panorama. METHODS: We performed, in October 2019, a retrospective evaluation of pediatric patients treated for biopsy-proven mandibular malignancies at our Institute between January 2013 and December 2016. All of them received multimodal therapy in accordance with standard guidelines and their demographic, clinical, treatment, and outcome parameters were collected and analyzed. RESULTS: We observed a shorter duration of surgery, a faster tracheostomy tube and feeding-tube removal, and a minor hospitalization in patients who received grafts transfer compared to those who underwent microsurgical mandibular reconstruction. After a 36-month period of follow-up, osteochondral grafts showed a pattern of growth similar to the mandibular epiphysis (condilylion-gonion linear and vertical ratio ranging to 0.96-1.03 and 1-1.02 at orthopantomogram, respectively). No bone consolidation delays and functional impairment were recorded. CONCLUSIONS: Free flaps mandibular reconstruction in children needs to be better assessed and proximal fibular epiphyseal free flap indication might deserve further studies. Osteochondral grafts find indication for lateral defects, 50-55 mm in maximum length and located in the mandibular ramus, without massive teeth or soft tissue defect. Condyle involvement does not represent an absolute contraindication to rib graft use.

A model to predict postoperative complications for otorhinolaryngology and maxillofacial surgery procedures in elderly patients.

PURPOSE: All kinds of ear, nose, and throat and maxillofacial surgery (ENT/MFS) procedures are being increasingly performed in the elderly although old age is a major risk factor for increased postoperative complications. With only scarce evidence on the topic, surgeons are asked to critically evaluate their procedures' indications and outcomes to balance the treatment risks and benefits. Our primary aim was to identify predictive factors for surgical outcomes in this setting and to create a predictive model for a tailored risk assessment. METHODS: We analyzed a case series of 435 patients from an institutional clinical database at our academic tertiary care center. Multivariate logistic regression was used to identify all possible covariates and nomograms using stepwise backward method were generated. The performance was assessed by calibration curves and c-index. RESULTS: Overall complication rate was 18.3% within the first 30 days and the need for re-intervention was 5.9%. For those under general anesthesia, we identified specific risk factors and developed three risk-predicting models of overall, early, and late complications. All of the nomograms showed satisfactory accuracy with a c-index of 0.83, 0.75, 0.86, and 0.82, respectively. CONCLUSION: Using clinical preoperative variables, we constructed a model for predicting major adverse events in ENT/MFS patients. In our experience, patients over 65 showed a non-negligible risk for postoperative complications depending on several factors. Such tools might help in decision-making, by increasing the risk-awareness of clinicians, to better address peri-operative and post-operative care of these patients.

The PERSONS score: A new tool for cancer patients' symptom assessment in simultaneous care and home care settings.

BACKGROUND: Scientific societies recommend early interaction between oncologic and supportive care, but there is still a lack of systematic evaluations regarding symptoms from the perspective of oncologists. PATIENTS AND METHODS: The aim of this prospective study was to evaluate the PERSONS score, in both "simultaneous care" and "supportive care" settings using the Edmonton Symptom Assessment Scale (ESAS) as a comparator. RESULTS: From November 2017 to April 2018, 67 and 110 consecutive patients were enrolled in outpatient and home care cohorts, respectively. The final study population comprised 163 patients. There were no significant changes over time in the total PERSONS scores and total ESAS scale. The intra-interviewer reliability (ICC2,1) and inter-interviewer reliability (ICC2,k) showed good reproducibility (test-retest) in each group of patients: 0.60 (0.49-0.70) and 0.82 (0.75-0.87), respectively, for the home care patients and 0.73 (0.62-0.81) and 0.89 (0.83-0.93), respectively, for the outpatient cohort. There were high correlations between PERSONS and ESAS, both at the baseline and final assessments. The mean PERSONS and ESAS scores between the home care patients and outpatients were not different at the baseline and final assessments. Receiver operating characteristics (ROC) curve for the PERSONS total score revealed good diagnostic ability. Area under the curve (AUC) was 0.825 and 0.805 for improvement and deterioration, respectively. CONCLUSIONS: The PERSONS score is an easy to apply tool for symptom assessment. Importantly, the PERSONS score showed high concordance with the established ESAS scale and, therefore, provides an alternative for everyday use in supportive care assessment.

Subclavicular flap: A valid reconstructive option among anterior chest flaps in oral cancer patients.

BACKGROUND: The subclavicular pedicled flap is based on the thoracic branch of the supraclavicular artery, and it represents a versatile reconstructive option for low-middle third face defects. Since its use in head and neck surgical oncology has not been popularized yet, we propose its application for oral cavity reconstruction after cancer resection by showing favorable results. METHODS: Eighteen subclavicular pedicled flaps were used to treat intraoral defects after oral squamous-cell cancer resection between June 2015 and December 2018. Tumor dissection type, complications, donor and reconstructed area results, and functional and aesthetic outcomes were assessed. RESULTS: No major complications were observed and all of the flaps survived. Adjuvant therapy was administered without delay when needed, and all of the patients had normal functional outcomes and good aesthetic results. CONCLUSIONS: The subclavicular flap is an excellent choice for the reconstruction of oral cavity defects. Selection of patients should exclude positive lower-third neck node and include appropriate informed consent for women due to the possibility of deformity of the breast. In our opinion, this flap has the potential for common application given its consistent anatomy and donor site advantages, including long pedicle, high pivot point, and relatively unlimited flap width.

What cancer patients actually know regarding medical cannabis? A cross-sectional survey with a critical analysis of the current attitudes.

BACKGROUND: In Italy medical cannabis is a prescription drug since 1998. Even though it could not be considered a therapy as such, it is indicated as a symptomatic treatment also in cancer patients, to cure iatrogenic nausea/vomiting and chronic pain. PATIENTS AND METHODS: We conducted a knowledge survey about medical cannabis among cancer patients referred to two outpatient cancer care centers and a home care service. RESULTS: From February to April 2018, 232 patient were enrolled; 210 patients were on active disease-oriented treatment (90.5%), while 22 (9.5%) not. Eighty-one percent of the patients have heard about medical cannabis, but only 2% from healthcare professionals. Thirty-four percent of responders thought about using cannabis to treat one or more of their own health problems, especially pain (55%). Despite that, 18% of the participants believe that medical cannabis could have negative effects on their own symptoms. Patients with high educational level better knew cannabis (odds ratio = 3.52; 95% confidence interval: 1.07-11.53), and medical cannabis (odds ratio = 3.21; 95% confidence interval: 1.48-6.98), when compared to patient with low educational level. Patients who were on active disease-oriented treatment better knew medical cannabis (odds ratio = 3.91; 95% confidence interval: 1.26-12.11) compared to "out of treatment" patients. Metastatic patients were less informed about medical cannabis compared to patients on adjuvant treatment. CONCLUSIONS: Our survey shows that most of Italian cancer patients know medical cannabis and a third of them have considered using cannabis to treat one (or more) of their own health problems. In the same time, they are poorly informed and do not tend to ask for information about medical cannabis to healthcare professionals.

Buccal Fat Pad: Report of 24 Cases and Literature Review of 1,635 Cases of Oral Defect Reconstruction.

OBJECTIVE: The buccal fat pad (BFP) has been progressively introduced into clinical practice for oral defect reconstruction. This study describes our experience with this technique and compares indications in the literature and outcomes. METHODS: We prospectively enrolled 24 patients presenting oral surgical defects and treated between January 2012 and January 2015 at our institution. They all were eligible for BFP defect reconstruction. A comprehensive literature review was performed from 1977 onwards and surgical indications and results were compared. RESULTS: All 24 BFP procedures showed excellent recovery and uneventful follow-up. Literature review confirmed a global success rate of 96.2% for a reported number of 1,635 patients with multiple surgical indications. BFP showed very low morbidity and failure rates in accordance with the outcomes reported in the literature, and the high patient compliance together with the easy harvesting of this surgical technique make it a good reconstructive option in cases of small-to-medium size oral defects in patients with a high rate of comorbidities or as salvage/second option. CONCLUSION: The BFP is worthy of consideration for the reconstruction of selected mouth defects, due to its easy mobilization, excellent blood supply, and minimal donor-site morbidity, where shape and size represent its main limitations, and a defect's location influences its pliability.

Classification of tongue cancer resection and treatment algorithm.

BACKGROUND AND OBJECTIVES: Reconstruction of tongue cancer defects is challenging due to the complex anatomy and physiology of the tongue. Here, we classify patterns of tongue tissue loss and describe a treatment algorithm for achieving good functional and oncologic outcomes. METHODS: We retrospectively reviewed 50 tongue squamous-cell carcinomas surgically treated between January 2010-June 2015. Cancer resection and tongue reconstruction were stratified according to the missing anatomical subunits. RESULTS: A type 1 defect is a unilateral and marginal defect, not crossing the midline, and not extending to the posterior-third of the tongue. Type 2 involves the two-anterior-thirds of the mobile body, not crossing the midline, without posterior-third evolvement. Type 3 involves the two-anterior-thirds of the mobile body of the tongue with contralateral extension. Type 4 extends to the tongue base. Type 5 defect comprises any of the previous defects along with involvement of the floor of the mouth. Type 2 and 3 defects were the most common. Microvascular reconstruction was performed in 23 out of 50 patients. Complications included infection, partial necrosis, dehiscence, and microvascular thrombosis. CONCLUSIONS: Our classification system and treatment algorithm represent a reliable method of addressing management of tongue defects.

A low-cost, user-friendly electroencephalographic recording system for the assessment of hepatic encephalopathy.

UNLABELLED: Electroencephalography (EEG) is useful to objectively diagnose/grade hepatic encephalopathy (HE) across its spectrum of severity. However, it requires expensive equipment, and hepatogastroenterologists are generally unfamiliar with its acquisition/interpretation. Recent technological advances have led to the development of low-cost, user-friendly EEG systems, allowing EEG acquisition also in settings with limited neurophysiological experience. The aim of this study was to assess the relationship between EEG parameters obtained from a standard-EEG system and from a commercial, low-cost wireless headset (light-EEG) in patients with cirrhosis and varying degrees of HE. Seventy-two patients (58 males, 61 ± 9 years) underwent clinical evaluation, the Psychometric Hepatic Encephalopathy Score (PHES), and EEG recording with both systems. Automated EEG parameters were calculated on two derivations. Strong correlations were observed between automated parameters obtained from the two EEG systems. Bland and Altman analysis indicated that the two systems provided comparable automated parameters, and agreement between classifications (normal versus abnormal EEG) based on standard-EEG and light-EEG was good (0.6 < κ < 0.8). Automated parameters such as the mean dominant frequency obtained from the light-EEG correlated significantly with the Model for End-Stage Liver Disease score (r = -0.39, P < 0.05), fasting venous ammonia levels (r = -0.41, P < 0.01), and PHES (r = -0.49, P < 0.001). Finally, significant differences in light-EEG parameters were observed in patients with varying degrees of HE. CONCLUSION: Reliable EEG parameters for HE diagnosing/grading can be obtained from a cheap, commercial, wireless headset; this may lead to more widespread use of this patient-independent tool both in routine liver practice and in the research setting. (

Cognitive reserve is a resilience factor for cognitive dysfunction in hepatic encephalopathy.

Cognitive Reserve (CR) modulates symptoms of brain disease. The aim of this study was: to evaluate the effect of CR on cognition in cirrhosis and on the mismatch between cognitive and neurophysiologic assessment of hepatic encephalopathy (HE). Eighty-two outpatient patients with cirrhosis without overt HE were studied [73% males; age: 62 (54-68) (median, interq. range) yrs.; education: 8 (6-13) yrs.]. The Psychometric Hepatic Encephalopathy Score (PHES) was used as cognitive measure of HE. The spectral analysis of the electroencephalogram (EEG) was used as neurophysiologic measure of HE. The CR was assessed by the CR Index (CRI), which was measured by the CRI questionnaire (CRIq) ( http://cri.psy.unipd.it ). The PHES was altered in 28% of patients and the EEG in 41%. Altered PHES was related to the severity of cirrhosis as assessed by Child-Pugh classification (R = 0.31, p < 0.005). Patients with maintained PHES had higher CRI than those with altered PHES (CRI = 100 ± 20 vs. 88 ± 12 vs., p < 0.01), but not the ones with normal EEG compared to those with abnormal EEG (CRI = 96 ± 17 vs. 98 ± 17 vs. p: n.s.).The PHES, but not the EEG, was found to be related to the CRI (r = 0.35, p < 0.01). The mismatch between cognitive and neurophysiologic evaluation of non-overt HE (the ratio between PHES and the mean dominant frequency -MDF- of the EEG i.e., cognitive performance normalized by EEG speed) was found to be correlated to the CRI (r = 0.36, p < 0.005). CR is a resilience factor for cognitive dysfunction in cirrhosis, and is easily measurable by CRIq.

Vigilance and wake EEG architecture in simulated hyperammonaemia: a pilot study on the effects of L-Ornithine-L-Aspartate (LOLA) and caffeine.

UNLABELLED: Hyperammonaemia/mild hepatic encephalopathy (HE) can be simulated by the oral administration of a so-called amino acid challenge (AAC). This study sought to assess the effects of the AAC alone and in combination with either ammonia-lowering [L-ornithine-L-aspartate (LOLA)] or vigilance-enhancing medication (caffeine). Six patients with cirrhosis (5 males; 61.3 ± 9.2 years; 5 Child A, 1 Child B) and six healthy volunteers (5 males; 49.8 ± 10.6 years) were studied between 08:00 and 19:00 on Monday of three consecutive weeks. The following indices were obtained: hourly capillary ammonia, hourly subjective sleepiness, paper & pencil/computerized psychometry and wake electroencephalography (EEG) at 12:00, i.e. at the time of the maximum expected effect of the AAC. RESULTS: On average, patients had worse neuropsychological performance and slower EEG than healthy volunteers in all conditions but differences did not reach significance. In healthy volunteers, the post-AAC increase in capillary ammonia levels was contained by both the administration of LOLA and of caffeine (significant differences between 10:00 and 14:00 h). The administration of caffeine also resulted in a reduction in subjective sleepiness and in the amplitude of the EEG on several frontal/temporal-occipital sites (p < 0.05; paired t-test). Changes in ammonia levels, subjective sleepiness and the EEG in the three conditions were less obvious in patients. In conclusion, both LOLA and caffeine contained the AAC-induced increase in capillary ammonia, especially in healthy volunteers. Caffeine also counteracted the AAC effects on sleepiness/EEG amplitude. The association of ammonia-lowering and vigilance-enhancing medication in the management of HE is worthy of further study.

Analysis of Lipoasiprated Following Centrifugation: Wet Versus Dry Harvesting Technique.

BACKGROUND: The success of lipotransfer strongly depends on the harvesting, processing, and placement of the lipoaspirated samples. This study was designed to assess the histomorphometric characteristics and viability of fat harvested using different techniques (wet and dry) following centrifugation, as described by Coleman. METHODS: The study enrolled 85 consecutive, nonrandomized, healthy patients from March 2010 to December 2014 (45 males and 40 females). The mean age was 40 years (range, 18-59 years), and the mean body mass index was 25.8 (range, 24-32). The authors performed a histological analysis (hematoxylin/eosin), morphometry (ImageJ 1.33 free-share image analysis software), and a viability assessment (Trypan Blue exclusion test; Sigma-Aldrich, Milan, Italy) of the lipoaspirated samples. RESULTS: The hematoxylin and eosin-stained sections exhibited similar features; in particular, clear-cut morphological signs of adipocyte disruption, apoptosis, or necrosis were not detected in the examined samples. Morphometry confirmed the visual findings, and the values of the mean surface area of the adipocyte vacuoles were not significantly different. Additionally, the adipocyte viability was not significantly different in the analyzed fat tissue samples. CONCLUSIONS: The results from this study showed, for the first time, that there is not a reduction in the viability of fat grafts harvested with the dry or wet technique following centrifugation according to Coleman technique. Both methods of fat harvesting collect viable cells, which are not influenced by standard centrifugation. The fat grafts harvested and processed by this technique could be used in clinical settings without increasing the reabsorption rate. LEVEL OF EVIDENCE: V.

Curative Transvenous Onyx Embolization of a Maxillary Arteriovenous Malformation in a Child: Report of a New Technique.

Endovascular management of maxillary arteriovenous malformation (AVMs) can be complex. Transarterial, transvenous, and direct puncture embolization has been described. The authors report the case of a 9-year-old girl with a hemorrhagic maxillary AVM, which has been treated by transvenous embolization after failure of transarterial embolization. The venous pouch was catheterized with a detachable tip microcatheter and occluded by slow Onyx injection. Onyx filled the pouch and retrogradely reached some arterial feeders, achieving complete occlusion. Bleeding episode ceased and at 6 months follow-up no recurrence was found. Maxillary AVMs can be successfully treated by transvenous Onyx embolization.

Three-dimensional airways reconstruction in syndromic pedriatric patients following mandibular distraction osteogenesis.

BACKGROUND: Airway obstruction, associated with mandibular hypoplasia, is a frequent complication in syndromic pediatric patients. The clinical signs of airway obstruction change from mild positional obstruction to severe respiratory distress with cyanosis. The young age of the patients makes medical management extremely complex. METHODS: The purpose was to evaluate the success of surgery, evaluating the expansion of the respiratory volumes measured by computer tomography analyzed through a software (SimPlant Pro 15). Twelve patients with mandibular hypoplasia and respiratory distress were treated between December 2010 and December 2013. Eleven of them had tracheostomy in the preoperative period. The goal of surgery was to prevent permanent tracheostomy or to remove it, if present. RESULTS: Volume and surface area increased by an average of 279.2% and 89.4%, respectively. Tracheostomy was avoided in 1 patient who underwent surgery precociously, and it was removed in 10 patients. Only 1 case failed in volume airway augmentation, and tracheostomy was not removed. CONCLUSIONS: Computer tomography can calculate the cross-sectional areas of the airway in 3 planes of space: coronal, sagittal, and axial. In most patients, changes in airways have been accompanied by improvements in sleep and breathing, allowing for the removal of tracheostomy with an improved quality of life. Three-dimensional reconstruction of airways revealed a useful tool to better understand the success of surgery. LEVEL OF EVIDENCE: IV.

Bipaddle radial forearm flap for head and neck reconstruction.

BACKGROUND: Although the radial forearm free flap has become a workhorse flap in head and neck reconstruction, the skin grafting of the donor is the main drawback resulting in an unacceptable contour deformity and an unsightly appearance. Several technical modifications have been therefore applied to the radial forearm (RF) flap marking, elevation, and inset to overcome this major shortcoming. In this article, we report our clinical series with the bipaddle RF flap. METHODS: The authors described their 11 cases of head and neck oncologic reconstruction with the bipaddle RF flap. The skin island is designed longer and narrower and split into 2 separate skin paddles each nourished by a proximal and a distal independent perforators raising from the radial artery so that the donor site could be closed directly. The narrow design of the skin paddle and the subsequent splitting in its 2 components applying the "perforator-pedicle propeller flap method" allow for the changing of the flap shape according to the shape of the recipient site defect. RESULTS: From 2007 to 2013, the bipaddle RF flap method was used in 11 patients to restore head and neck defects following cancer ablation. The mean age of the patients was 43 years, ranging from 31 to 50 years. The location of the defects was the tongue (n = 7) and the intraoral region (n = 4). The defect sizes varied from 4 × 5 cm to 5 × 6 cm, and the flap maximum width was 3 cm with mean area of 26.4 cm. The healing was uneventful in all patients with excellent cosmetic and functional results of both donor site and recipient site after 20 months of mean follow-up. CONCLUSIONS: The bipaddle RF free flap is a reliable and versatile option for the reconstruction of a wide range of soft tissue defects of head and neck region. This method allows for a customized resurfacing of the defect because of its large variability in shape and size. The harvesting site is closed primarily, and a second donor site for skin graft is avoided.Clinical Question, Level of Evidence: Therapeutic, IV.

Anterolateral thigh flap thinning: techniques and complications.

BACKGROUND: A thinned anterolateral thigh flap is often necessary to achieve optimal skin resurfacing. In this article, we describe the techniques available for immediate flap thinning and the vascular complications that can follow trimming. MATERIALS AND METHODS: A systematic literature review was performed to identify the different thinning techniques and any possible complications. Data were identified by performing a systematic search on Medline, Ovid, Embase, the Cochrane Database of Systematic Reviews, Current Contents, PubMed, Google, and Google Scholar. We cross-referenced the identified articles and conference abstracts in the English and French languages. RESULTS: The study selection process was adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, and 34 were articles compiled by using the study inclusion criteria. These articles were then reviewed for the author name(s), the publication year, the flap dimensions, the flap thickness (both before and after thinning), the perforator type, the type of flap transfer, the complications that followed the thinning, the thinning technique used, the amount of deep fascia preserved around the perforator, the number of cases in the study, the area of application, and the technique used for donor-site closure. We analyzed the possible vascular complications that stemmed from the flap area site selected, the flap thickness, the thinning technique used, and whether the deep fascia was spared. CONCLUSIONS: The subfascial dissection of anterolateral thigh flaps revealed that the safest method for minimizing vascular complications accounted for a 3.1% probability for marginal necrosis, which can be managed conservatively. The overall breakdown of the vascular-related complications that followed flap thinning totals 13.4% and can be broken down as follows: partial flap loss of 4.1%, partial distal necrosis of 3.5%, marginal necrosis of 3.1%, and total flap loss of 2.5%.