Do bilateral procedures further increase the complications for autologous breast reconstruction in obese patients?

BACKGROUND: Obesity is known to be associated with high complication rates. The aim of this study was to evaluate the effect of bilateral procedures on complication rates in obese patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flaps. METHODS: Medical records of patients undergoing autologous breast reconstruction between January 2017 and December 2019 were retrospectively reviewed. Patients were divided into two groups according to their body mass index (BMI): Group 1 (BMI > 30) and Group 2 (BMI < 30). Group 1 was further divided into 3 subgroups: Group 1a (bilateral reconstruction), Group 1b (unilateral reconstruction), and Group 1c (unilateral reconstruction and contralateral symmetrization). Outcomes and complication rates were compared between groups. RESULTS: Ninety-one patients (with 119 free flaps) were followed up between 6 and 12 months. Length of hospital stay, smoking rates, and age were similar in all groups. Group 1 had significantly more rates of wound dehiscence (p = 0.024), mastectomy skin flap necrosis (p = 0.019), and re-operation (p = 0.033). The operation time was significantly higher in group 1 (p = 0.003). There was no significant difference between group 1 and group 2 in terms of hematoma-seroma formation, flap loss, and pulmonary thromboembolism rates. When obese subgroups were compared, no significant difference was observed in terms of complications. CONCLUSION: In our series, microvascular breast reconstruction was associated with more complication rates in obese patients. However, bilateral procedures in the obese patient group did not significantly increase risk of complications as compared to unilateral procedures. By taking appropriate measures bilateral procedures can be performed in obese patients without additional risks.

Modified endoscopic strip craniectomy technique for sagittal craniosynostosis: provides comparable results and avoids bony defects.

PURPOSE: This study describes a modified technique addressing bony defects and incomplete ossification after endoscopic strip craniectomy (ESC) for SC followed by postoperative helmet therapy (PHT). The study aims to delineate quantitative and qualitative outcomes of this modified ESC technique followed by PHT and discern the optimal duration of PHT following ESC. A secondary aim is to address the effects of the technique on bony defects. METHODS: Patients undergoing ESC followed by PHT between 2017 and 2021 were included. Patient sex, age at surgery, duration of surgery, red blood cell transfusion, length of hospital stay, PHT duration, cephalic index (CI) at multiple time points, and bony defect information were collected. Descriptive and correlative analysis was done. RESULTS: Thirty-one patients (25 male, 6 female) were operated in study period. Mean age at surgery was 12.81 weeks, mean duration of surgery was 57.50 min, average transfused RBC volume was 32 cc, mean length of hospital stay was 1.84 days, mean PHT duration was 33.16 weeks, and mean follow-up time was 63.42 weeks. Mean preoperative CI was 70.6, and mean CI at the end of PHT was significantly higher, being 77.1. Maximum improvement in CI (CImax) took place at week 22.97. PHT duration did not have a correlation with CI at last follow up. There were no bony defects. CONCLUSION: Modified ESC technique is effective in successful correction of sagittal craniosynostosis. CImax already takes place, while PHT is continuing, but there is no certain time point for dishelmeting. The technique avoided bony defects and incomplete ossification.

Continuous hemoglobin measurement during frontal advancement operations can improve patient outcomes.

Massive hemorrhage in pediatric cranioplasty operations may necessitate blood transfusion, which may cause many complications. Radical-7 Pulse CO-Oximeter (Massimo Corporation, Irvine, CA) can provide continuous hemoglobin concentration (SpHb) measurements noninvasively. In this study, we aimed to evaluate the effects of SpHb measurement on perioperative transfusion management and postoperative patient outcomes. For this retrospective case-control study, we collected the data of pediatric patients undergoing fronto-orbital advancement surgery for plagiocephaly and trigonocephaly between 2018 and 2021. Perioperative SpHb monitoring was performed for patients in the SpHb Group. Other patients that were managed conventionally were considered as the control group (C Group). The data on patients' demographic and clinical characteristics, intraoperative hemodynamic and laboratory variables such as blood gases, intraoperative blood losses, the amount of the transfused blood products, the length of postoperative intensive care unit (ICU) stay, and the duration of hospital stay were collected. The data of 42 patients were collected, and 29 of these patients were males (69%). In 16 of the patients, SpHb monitoring was performed. The demographic, clinical, and perioperative hemodynamic characteristics of the patients were comparable between the groups. Compared to the C Group, the SpHb Group had significantly lower perioperative packed red blood cell (PRBC) transfusion (136.3 ± 40.1 vs. 181.5 ± 74.8 mL, P = 0.015), less postoperative drainage (125.3 ± 47.7 vs. 185.8 ± 97.6 mL, P = 0.013), and shorter ICU stay (37.1 ± 12.0 vs. 64.8 ± 24.9 h, P < 0.001). There was a positive correlation between the amount of PRBC transfusion and the length of ICU stay (r = 0.459, P = 0.003). Patients with perioperative continuous SpHb measurement have lower intraoperative PRBC transfusion, less postoperative bleeding, and shorter ICU stay. When necessary, SpHb, together with clinical judgment and laboratory confirmation, can be used in decision-making for perioperative PRBC transfusion.

Optimizing survival of large fibula osteocutaneous flaps for extensive full-thickness oromandibular defects: A two-stage approach with temporary orocutaneous fistula.

INTRODUCTION: Composite and large head and neck defects requiring extensive skin-mucosa coverage are often reconstructed by combining flaps. Herein, we present a simple and reliable two-stage fibula osteocutaneous (FOC) flap technique to improve the survival of a large skin paddle for oromandibular reconstructions. METHODS: From October 2011 to September 2016, 47 patients with through-and-through oromandibular defects were reconstructed using FOC flaps with large skin paddles. To ensure optimum survival of skin paddles, temporary orocutaneous fistula were left in place and closed during the second stage operation via de-epithelialization of the skin paddle and suturing of mucosa. Demographic data, operative details, and postoperative complications were recorded. RESULTS: The skin paddle dimensions ranged from 20 to 31.5 cm in length and 12 to 17 cm in width with an average area of 430.4 cm2 (range 300-504). The average time between the two stages and hospital stay were 10 days and 14 days, respectively. Complications at the donor site included wound dehiscence (n = 3, 6.4%), partial skin graft loss (n = 3, 6.4%) and hematoma (n = 2, 4.3%). Recipient site complications included two (4.3%) early postoperative venous congestions that resolved after elevation and three (6.4%) partial skin flap necrosis (less than 5% surface area). All complications resolved with bedside conservative management. There was only one take-back for evacuation of recipient site hematoma (2.1%) but no flap loss. CONCLUSION: Two-staged large skin paddle FOC flaps can simplify reconstruction of extensive oromandibular defects by improving the reliability of the sizable skin paddle and negating the need for a second flap.

Use of abdominal negative pressure wound therapy in different indications: a case series.

Negative pressure wound therapy (NPWT) is a widely used wound management system. Several articles have been published on the advantages and complications of this system. Abdominal dressing negative pressure system (abdominal NPWT) is a newer technology, developed and used in open abdomen cases. The adherence of the sponge to the intra-abdominal organs is prevented by a polyurethane foam. This study presents a number of case series where an abdominal NPWT (ABThera, KCI, US) has been used to treat other vital organs, helping to prevent complications such as organ rupture and fatal bleeding.

Alternative vascular constructs of lymph node flap transfer.

Vascularized lymph node transfer is a quite innovative physiological surgical procedure for the lymphedema treatment. Although is gaining more popularity due to its promising results, there are some concerns regarding difficult to harvest it and the potential risk of iatrogenic lymphedema. Here, we present alternative vascular constructs of lymph node flap for the treatment of lymphedema, which provide the benefits of a technically easier dissection and physiological reconstruction of the damaged lymphatics. Furthermore, we introduce a classification based on the flap vascular supply including six types of flaps and we provide the details of the surgical technique.

A Comparative Clinical Study of Flap Thickness: Medial Sural Artery Perforator Flap Versus Anterolateral Thigh Flap.

INTRODUCTION: The purpose of this study is to measure flap thicknesses of anterolateral thigh (ALT) and medial sural artery perforator (MSAP) flaps in healthy subjects by Doppler ultrasonography and compare the results in relation to sex and body mass index (BMI). METHOD: The perforators of ALT and MSAP flaps were marked on 30 healthy subjects. The thickness of skin and subcutaneous tissue was measured in millimeters at the site of the perforator using Doppler ultrasonography. RESULTS: The mean ± SD age of the participants was 36.4 ± 10.5, the mean ± SD BMI was 25.2 ± 3.9 (19.4-32.5). The mean ± SD flap thickness was 11.55 ± 4.38 mm for ALT and 8.31 ± 3.6 mm mm for MSAP (P < 0.01). Anterolateral thigh flap was significantly thicker than MSAP in both males (9.02 vs 6.11 mm) and females (14.07 vs 10.52 mm) (P < 0.05). The thickness of both MSAP and ALT flap had a positive correlation with BMI. The relationship was stronger for ALT in males (r = 0.66 for ALT, r = 0.59 for MSAP) and for MSAP in females (r = 0.70 for ALT, r = 0.83 for MSAP). DISCUSSION: This study confirms that MSAP flap is thinner than ALT and the results correlate with BMI. Therefore, MSAP flap can be considered a good alternative to ALT, to avoid bulk, in reconstruction of shallower soft tissue defects.

A head-to-head comparison among donor site morbidity after vascularized lymph node transfer: Pearls and pitfalls of a 6-year single center experience.

Between 2010 and 2016, 110 patients with extremity lymphedema underwent vascularized lymph node (VLN) transfer: groin (G-VLN = 20), supraclavicular (SC-VLN = 54), and right gastroepiploic (RGE-VLN = 36) open and laparoscopic approach. Herein, we discuss the pearls and pitfalls for VLN harvest and compare donor site morbidity and complications. Lymphatic leakage: G-VLN (n = 1) and SC-VLN (n = 1) and one hematoma: SC-VLN were found. Laparoscopic harvest of the RGE-VLN reduces donor site morbidity. However, surgeons experience is imperative to minimize donor site morbidity and complications. J. Surg. Oncol. 2017;115:37-42. © 2016 Wiley Periodicals, Inc.

Back-up procedures following complicated gastric pull-up procedure for esophageal reconstruction: Salvage with intestinal flaps.

BACKGROUND: Gastric pull-up (GPU) is the most common procedure for restoring the continuity of the alimentary tract. Yet, complications because of anastomotic problems are reported to be as high as 25% after this procedure. Managing the neck with anastomotic leakage or stricture following failed GPU and/or radiotherapy is formidable. We report our method, basic algorithm and results with the complicated GPU procedure management with intestinal transfers . PATIENTS AND METHODS: Nineteen cases referred to our department with complicated esophageal reconstruction following GPU procedure were included in this report. Of the19 patients, 18 had undergone GPU procedure for reconstruction after cancer resection (mean age 55 years) and one for idiopathic esophagitis (mean age 45years). Fifteen patients presented with severe stricture formation and 4 patients with leakage from the anastomotic site. Average time between the GPU and salvage procedures was 7.3 months for patients with stricture formation and 15.5 days for patients with leakage. Pedicled colon interposition (n = 8) was used when the upper end of the gastric tube was located below the sternoclavicular junction. A free jejunal flap (n = 11) was utilized when defects were located at the neck (above the sternoclavicular junction). RESULTS: In all patients salvage procedures with intestinal flap transfer were successful with complete flap survival. Post-operative period was uneventful except of two patients with pedicled colon interposition who presented minor leakage post-operatively (10.5%). This was treated with conservative means, leading to spontaneous healing. The average follow-up for the patients with tumor resection was 11.8 months (range: 6 to 30) after the salvage procedure. All patients resumed smooth oral intake eventually. There were 16 patients who could feed with solid diet, whereas three patients were able to tolerate only soft diet. CONCLUSION: Intestinal tissues can be safely and successfully transferred as salvage procedures, with meticulous technique, careful patient selection and individual flap design. While gastric pull-up remains a good procedure for esophageal reconstruction, the methods described in this report are useful as back-up armaments in complicated cases. © 2015 Wiley Periodicals, Inc. Microsurgery 36:567-572, 2016.

The latissimus dorsi-groin-lymph node compound flap: A comprehensive technique with three features including skin coverage, restoration of motor function, and prevention of upper limb lymphedema.

Reconstruction of complex upper extremity defects requires a need for multiple tissue components. The supercharged latissimus dorsi (LD)-groin compound flap is an option that can provide a large skin paddle with simultaneous functional muscle transfer. It is necessary to supercharge the flap with the superficial circumflex iliac pedicle to ensure the viability of its groin extension. In this report, we present a case of a supercharged LD-groin flap in combination with vascularized inguinal lymph nodes, which was used for upper limb reconstruction in a young male patient, following excision of high-grade liposarcoma. Resection resulted in a 28 cm × 15 cm skin defect extending from the upper arm to the proximal forearm, also involving the triceps muscle, a segment of the ulnar nerve and the axillary lymph nodes. Restoration of triceps function was achieved with transfer of the innervated LD muscle. Part of the ulnar nerve was resected and repaired with sural nerve grafts. Post-operatively, the flap survived fully with no partial necrosis, and no complications at both the recipient and donor sites. At 1-year follow up, the patient had a well-healed wound with good elbow extension (against resistance), no tumor recurrence, and no signs of lymphedema. We believe this comprehensive approach may represent a valuable technique, for not only the oncological reconstruction of upper extremity, but also for the prevention of lymphedema. © 2015 Wiley Periodicals, Inc. Microsurgery 36:689-694, 2016.

The innervated gracilis muscle for microsurgical functional lip reconstruction: review of the literature.

Reconstruction of the lower and upper lip should meet both aesthetic and functional requirements, whenever possible. Achievement of these goals presents a major challenge particularly in extensive lip defects requiring microsurgical reconstruction. Successful reconstructive outcomes have been reported using free fasciocutaneous flaps such as composite radial forearm flap or anterolateral thigh flap in conjunction with static tendon slings. In recent years, neurovascular gracilis muscle transfer has been introduced in hopes to overcome noncontractile properties of these flaps and to restore oral competence by muscle contractility. This article reviews the available data on the innervated gracilis muscle transfer for functional lip reconstruction. Tips and techniques gleaned from all of the current literature are discussed.

Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel.

BACKGROUND: Anterolateral thigh (ALT) flap is now a workhorse flap for reconstruction of skin and soft tissue defects. However, there are some drawbacks in its application, and revisions are often needed after surgery. Here, we present the results of the use of a special type of partition for ALT flap based on the concept of perforator flap vascular anatomy for reconstruction around a protruding structure, a cavity or a canal, in patients. PATIENTS AND METHODS: We used the keyhole design for reconstruction with ALT flaps in five patients. Wounds involved circumferential soft tissue defects around the following structures: thumb (two cases), penis, ear canal, and anus. Defects arose following excision of scar contracture, arterio-venous malformation, Paget's disease, squamous cell carcinoma, and Fournier's gangrene, respectively. The ALT flap was raised based on perforators. The flap was partitioned with a keyhole incision performed in a zone between two perforators or distal to them, avoiding complete split of the flap and minimizing disruption of its vascular crossover. The circulation of the flap was well preserved. The closure of the flap had no tension. RESULTS: All the flaps had 100% viability without partial loss. Mean follow-up was of 7.4 months (range 4 - 11 months). Significant functional improvement was achieved in the two thumb cases. Adequate patency of the ear and anal canals was obtained. No contracture around the penis was observed. CONCLUSION: The keyhole design may be a valuable method of partition of the ALT flap for specific reconstructions around protruding organs, cavities, or canals.

Supraclavicular osteocutaneous free flap: clinical application and surgical details for the reconstruction of composite defects of the nose.

The supraclavicular fasciocutaneous flap is a well-recognized flap in head and neck reconstruction. In this report, we describe for the first time a variation of this flap, the osteocutaneous supraclavicular (SOC) free flap, which was used to reconstruct a composite nasal defect. The defect arose after resection of a recurrent squamous cell carcinoma and involved dorsal nasal skin, cartilage, and the entire nasal bone. A 6 cm × 4 cm size flap including skin, subcutaneous tissue, and a vascularized cortico-periosteal segment of the clavicle was raised based on the transverse cervical artery. The flap survived with no complications. A satisfactory aesthetic outcome was achieved following two revision procedures. We believe that the incorporation of bone to the supraclavicular flap may expand its applications in reconstruction of composite nasal and facial defects.

Risk assessment for free tissue transfers: is old age a determining factor?

INTRODUCTION: Free tissue transfers are more often performed in the elderly with the increase in geriatric patient population. The aim of this study was to investigate the effect of advanced age in reconstructive microsurgery procedures and analyze the association of other variables with complications and surgical success. PATIENTS AND METHOD: A retrospective review of 70 consecutive free tissue transfers between January 2012 and June 2013 was performed. Patients were divided into 2 groups: those younger than 60 years and those aged 60 years or older. Besides demographics, the American Society of Anesthesiologists (ASA) risk score, comorbid conditions, and anatomic locations for surgery (head and neck, extremities, trunk), operative time, need for reoperation, intensive care unit (ICU) admission and blood transfusion, length of hospital stay, medical and surgical complications, as well as partial and total flap loss were noted and analyzed. RESULTS: A total of 71.4% of the patients were younger than 60 years (n = 50; average, 37.4 y), and 28.6% of the patients were 60 years or older (n = 20; average, 67.5 y). None of the other collected data showed significant difference between the groups. Although age was not associated with ICU admission, the location of the reconstruction site and the operative time were found to have a significant correlation with ICU referral. In this series, the operative time correlated with medical complications but not with surgical complications. Higher ASA scores did have a negative effect on the incidence of medical complications (P = 0.028). CONCLUSIONS: This retrospective review demonstrates that age alone is not an independent variable for increased risk in microvascular reconstruction. However, operative time, ASA risk score, and location of the reconstruction site are more associated with the overall success of free tissue transfers.

The Effect of Evaluating Perfusion with Infrared Fluorescent Angiography on Flap Survival in Head and Neck Free Flap Reconstruction.

INTRODUCTION: Intraoperative fluid management is one of the most important factors affecting optimal perfusion in the microcirculatory area in patients that undergo flap surgery. While insufficient fluid administration in the intraoperative period leads to flap complications and organ dysfunction, volume load can cause complications such as edema in the denervated flap tissue, the opening of the sutures, or fat necrosis. The Infrared Fluorescent Angiography Perfusion Evaluation Device (SPY) is one of the many noninvasive techniques that evaluate the well-being of microcirculation at the tissue level. This device monitors and scores the perfusion distribution in the flap area. This retrospective study aimed to investigate the effect of fluid resuscitation in head and neck free flap transfer surgery on flap quality and patient outcomes according to the change in SPY scores. MATERIAL AND METHOD: This study included 39 ASA I-II patients who were aged 18-60 years and underwent simultaneous free flap reconstruction of the head and neck between 2015 and 2021. Patients' blood pressure, body temperature, hemoglobin, pH, and lactate values were recorded at both baseline and end of the operation. Also, the SPY "Infrared Fluorescent Angiography Perfusion Evaluation Device" scores, the amount of intraoperative fluid and transfusion, bleeding and urine output, and the duration of mechanical ventilation, anesthesia and surgery, and the duration and amount of drainage, the length of stay in hospital and intensive care unit, and the presence of flap infection, detachment, necrosis and loss, and re-exploration rate were recorded for the patients. RESULTS: The difference between the first and last measured SPY values was observed to be positively correlated with the length of stay in the hospital and intensive care unit and the duration of drainage. There was a positive correlation between the length of stay in the hospital and intensive care unit and the duration of drainage, the amount of drainage, as well as the duration of anesthesia and the duration of surgery (p < 0.001). A positive correlation was found between the amount of drainage and the amount of crystalloid solution administered (r = 0.36, p < 0.05). In patients with flap infection, the difference between SPYfirst and SPYlast, the duration of anesthesia, and the duration of surgery were significantly higher. The amount of crystalloid solution given and bleeding and the duration of anesthesia and surgery were found to be significantly higher in mechanically ventilated patients (p < 0.05). CONCLUSIONS: It has been concluded that SPY-guided fluid management can be beneficial in preventing morbidities, such as extended hospital and intensive care stay, by reducing flap infection, mechanical ventilation duration, and drainage, with early diagnosis of insufficient perfusion.

Rare Tumors of Skin: Malignant Cutaneous Adnexal Tumors and Clinicopathological Features.

Background: Cutaneous adnexal tumors (CATs) are a large group of neoplasms of the skin and the pathological diagnosis can be challenging. Objective: The aim of this study was to examine clinicopathological features of malignant cutaneous adnexal tumors (MCATs) and to identify therapeutic and prognostic implications. Materials and Methods: Twenty-six patients diagnosed with MCATs and operated in our center were included. Demographic and clinical characteristics of patients, tumor size, histological subtype, perineural and lymphovascular invasion, re-excision status, lymph node metastasis, distant metastasis, recurrence, follow-up, and treatment choice were recorded. All lesions were excised with 1 to 2-cm surgical margin. Surgical margin was determined according to tumor size. Results: Of 26 patients, 14 were males and 12 were females (median age: 66 years). Median follow-up was 52.08 months. Tumor location was the face in 69.2% (n = 18) patients, followed by scalp and neck region. Four patients had coexisting skin tumors. Majority of MCATs (69.2%, n = 18) originated from sweat glands. Median tumor diameter was 4 (range, 0.8 to 17) cm. There was a statistically significant correlation between presence of perineural invasion and advanced disease (P = 0.036). Majority of the patients had Stage 1-2 disease, while two patients had Stage 4 disease. In six patients (23.1%), re-excision was performed due to surgical margin positivity. Conclusion: Incidence of MCATs has an increasing trend with advanced age and these tumors are more commonly seen in men and in visible sites of the body such as head and neck and scalp. Wide resection according to tumor size is the first-line treatment.

Bare dorsal thoracic fascial flap for esophageal defects: an experimental study with dogs.

BACKGROUND: Reconstruction of esophageal defects has challenged reconstructive surgeons for a long time. Problems that affect the continuity of the orogastic tract influence the patient's quality of life and general health. Bare free fascial flaps are used to restore soft tissue defects of the oral cavity because they provide thin, pliable tissues with a high capacity for epithelialization to preserve the local anatomy. An experimental study was planned to investigate reconstruction of anterior cervical esophageal defects using a pedicled dorsal thoracic fascial flap. METHODS: Eight hybrid dogs were used in the study. All operations were planned in three steps and performed with the animals under general anesthesia. For the two-layered reconstruction, the bare dorsal thoracic fascial flap was harvested and adapted like a patch to the defect. RESULTS: No partial or total flap loss was observed. On postoperative day 20 surgery, a complete epithelial lining on the same plane as the esophageal mucosa was observed over the flap tissue. A 4- to 5-mm longitudinal scar that did not form even a minimal stricture in any dog also was observed. No significant changes from postoperative day 20 to postoperative days 40 and 60 were observed. CONCLUSION: Bare fascial flaps in the oral cavity heal with spontaneous epithelialization and with no need for skin and mucosal grafts. Fascial flaps are easy to harvest and do not cause any functional loss because they are nonfunctional units. Their thin constitution helps the surgeon to shape the tissue and even form tubed flaps.