Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review.

BACKGROUND: Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. METHODS: A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. RESULTS: A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). CONCLUSION: Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

Applying plastic surgery principles to ovarian tissue transplantation.

Ovarian tissue cryopreservation (OTC) and transplantation is an innovative procedure increasingly utilized to help preserve fertility after gonadotoxic treatments especially in cancer patients. Approximately 30% of autotransplanted patients are able to achieve live birth, typically with the help of in-vitro fertilization. Numerous techniques and grafting sites have been described to continue to increase this figure. In the field of plastic surgery, tissue grafting has been successful performed for thousands of years and knowledge in this area has been significantly refined. A qualitative review of the literature using PubMed, Cochrane, SCOPUS and Medline databases was performed to look for articles relating to ovarian tissue transplantation (OTT) and comparisons made to plastic surgery tissue grafting. Many parallels were found between the principles of grafting in plastic surgery and the principles of OTT, including pre-operative patient optimization, suitable donor site selection, tissue harvest and preparation, graft site choice, immobilization of the graft and post-operative care. Consideration of the benefits and risks of using orthotopic versus heterotopic recipient sites is also highly important with regards to graft take, morbidity and ease of access of oocyte collection. We believe that ongoing discussion between disciplines can have the potential to improve knowledge, surgical techniques and patient outcomes.

Efficacy and adverse effects of topical chloramphenicol ointment use for surgical wounds: a systematic review.

BACKGROUND: Chloramphenicol ointment is often used in plastic and dermatologic surgery as a topical antibiotic for surgical wounds, but evidence regarding its efficacy and side effects is lacking. In addition, anecdotal fear of aplastic anaemia exists from the oral use of this drug. We performed a systematic review of the literature to assess the efficacy and side effect profile of topical chloramphenicol ointment on non-ocular surgical wounds. METHODS: A systematic search of MEDLINE, EMBASE and the Cochrane Library from inception until 4 September 2017 was undertaken. Clinical studies of topical chloramphenicol ointment use on surgical wounds were included. Studies looking only at ocular use or those not available in full text or English were excluded. The review was conducted adhering to PRISMA guidelines. RESULTS: After full-text review, five articles were included. Two were randomized controlled trials, one was retrospective case control and two were case studies. There was evidence that chloramphenicol ointment use on surgical wounds produced a non-statistically significant reduction in infection rates. Delayed hypersensitivity and acute oesophagitis were noted as potential side effects of non-ocular topical use. Aplastic anaemia was not reported. CONCLUSION: There is a paucity of clinical data regarding the use of topical chloramphenicol ointment on surgical wounds. Further randomized controlled trials may be beneficial in order to support or refute its use in this setting.