Assuntos
Neoplasias Bucais , Terapia Neoadjuvante , Humanos , Neoplasias Bucais/tratamento farmacológico , Neoplasias Bucais/patologia , Neoplasias Bucais/cirurgia , Terapia Neoadjuvante/métodos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia Adjuvante/métodos , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgiaRESUMO
BACKGROUND: Individual outcomes may not accurately reflect the quality of perioperative care. Textbook outcomes (TOs) are composite metrics that provide a comprehensive evaluation of hospital performance and surgical quality. This study aimed to investigate the prevalence and predictors of TOs in a multi-institutional cohort of patients who underwent breast reconstruction with deep inferior epigastric artery perforator flaps. METHODS: For autologous reconstruction, a TO was previously defined as a procedure without intraoperative complications, reoperation, infection requiring intravenous antibiotics, readmission, mortality, systemic complications, operative duration ≤12 hours for bilateral and ≤10 hours for unilateral/stacked reconstruction, and length of stay (LOS) ≤5 days. We investigated associations between patient-level factors and achieving a TO using multivariable regression analysis. RESULTS: Of 1000 patients, most (73.2%) met a TO. The most common reasons for deviation from a TO were reoperation (9.6%), prolonged operative time (9.5%), and prolonged LOS (9.2%). On univariate analysis, tobacco use, obesity, widowed/divorced marital status, and contralateral prophylactic mastectomy or bilateral reconstruction were associated with a lower likelihood of TOs (P < 0.05). After adjustment, bilateral prophylactic mastectomy (odds ratio [OR], 5.71; P = 0.029) and hormonal therapy (OR, 1.53; P = 0.050) were associated with a higher likelihood of TOs; higher body mass index (OR, 0.91; P = <0.001) was associated with a lower likelihood. CONCLUSION: Approximately 30% of patients did not achieve a TO, and the likelihood of achieving a TO was influenced by patient and procedural factors. Future studies should investigate how this metric may be used to evaluate patient and hospital-level performance to improve the quality of care in reconstructive surgery.
Assuntos
Mamoplastia , Retalho Perfurante , Humanos , Feminino , Mamoplastia/métodos , Pessoa de Meia-Idade , Retalho Perfurante/irrigação sanguínea , Retalho Perfurante/transplante , Adulto , Estudos Retrospectivos , Neoplasias da Mama/cirurgia , Artérias Epigástricas/transplante , Microcirurgia/métodos , Resultado do Tratamento , Complicações Pós-Operatórias/epidemiologia , Mastectomia/métodos , Tempo de Internação/estatística & dados numéricosRESUMO
BACKGROUND: In appropriately selected patients, it may be possible to fully bury breast free flaps deep to the mastectomy skin flaps. Because this practice forgoes the incorporation of a monitoring skin paddle for the flap, and thus limits the ability for physical exam, it may be associated with an increased risk of flap loss or other perfusion-related complications, such as fat necrosis. We hypothesized that fully de-epithelialized breast free flaps were not associated with an increased complication rate and reduced the need for future revision surgery. METHODS: A single-institution retrospective review of 206 deep inferior epigastric artery (DIEP) flaps in 142 patients was performed between June 2016 and September 2021. Flaps were grouped into buried or nonburied categories based on the absence or presence of a monitoring paddle. Patient-reported outcomes were assessed postoperatively using the BREAST-Q breast reconstruction module. Electronic medical record data included demographics, comorbidities, flap characteristics, complications, and revision surgery. RESULTS: The buried flap patients (N = 46) had a lower median body mass index (26.9 vs 30.3, p = 0.04) and a lower rate of hypertension (19.5 vs. 37.5%, p = 0.04) compared with nonburied flap patients (N = 160). Burying flaps was more likely to be adopted in skin-sparing mastectomy or nipple-sparing mastectomy (p = 0.001) and in an immediate or a delayed-immediate fashion (p = 0.009). There was one flap loss in the nonburied group; complication rates were similar. There was a significantly greater revision rate in the nonburied flap patients (92 vs. 70%; p = 0.002). Buried flap patients exhibited a greater satisfaction with breasts (84.5 ± 13.4 vs. 73.9 ± 21.4; p = 0.04) and sexual satisfaction (73.1 ± 22.4 vs. 53.7 ± 29.7; p = 0.01) compared with nonburied flap patients. CONCLUSION: Burying breast free flaps in appropriately selected patients does not appear to have a higher complication rate when compared with flaps with an externalized monitoring paddle. Furthermore, this modification may be associated with a better immediate aesthetic outcome and improved patient satisfaction, as evidenced by a lower rate of revision surgery and superior BREAST-Q scores among buried DIEP flaps.
RESUMO
PURPOSE: Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction. METHODS: A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of ≥ 70% agreement among respondents established consensus among the tested statements. RESULTS: Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration ≤ 12 h for bilateral and ≤ 10 h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay < 5 days. Exclusion criteria for medical and surgical characteristics (e.g., BMI > 40, HgbA1c > 7) and case-volume cut-offs for providers (≥ 21) and institutions (≥ 44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%). CONCLUSION: This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.
Assuntos
Neoplasias da Mama , Mamoplastia , Retalho Perfurante , Humanos , Feminino , Mastectomia/efeitos adversos , Consenso , Técnica Delphi , Neoplasias da Mama/cirurgia , Neoplasias da Mama/complicações , Mamoplastia/efeitos adversos , Mamoplastia/métodos , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do TratamentoRESUMO
BACKGROUND: Skin-preserving, staged, microvascular, breast reconstruction often is preferred in patients requiring postmastectomy radiotherapy (PMRT) but may lead to complications. We compared the long-term surgical and patient-reported outcomes between skin-preserving and delayed microvascular breast reconstruction with and without PMRT. METHODS: We conducted a retrospective, cohort study of consecutive patients who underwent mastectomy and microvascular breast reconstruction between January 2016 and April 2022. The primary outcome was any flap-related complication. The secondary outcomes were patient-reported outcomes and tissue-expander complications. RESULTS: We identified 1002 reconstructions (672 delayed; 330 skin-preserving) in 812 patients. Mean follow-up was 24.2 ± 19.3 months. PMRT was required in 564 reconstructions (56.3%). In the non-PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 0.32, p = 0.045) and lower odds of 30-days readmission (odds ratio [OR] 0.44, p = 0.042), seroma (OR 0.42, p = 0.036), and hematoma (OR 0.24, p = 0.011) compared with delayed reconstruction. In the PMRT group, skin-preserving reconstruction was independently associated with shorter hospital stay (ß - 1.15, p < 0.001) and operative time (ß - 97.0, p < 0.001) and lower odds of 30-days readmission (OR 0.29, p = 0.005) and infection (OR 0.33, p = 0.023) compared with delayed reconstruction. Skin-preserving reconstruction had a 10.6% tissue expander loss rate and did not differ from delayed reconstruction in terms of patient-reported satisfaction with breast, psychosocial well-being, or sexual well-being. CONCLUSIONS: Skin-preserving, staged, microvascular, breast reconstruction is safe regardless of the need for PMRT, with an acceptable tissue expander loss rate, and is associated with improved flap outcomes and similar patient-reported quality of life to that of delayed reconstruction.
Assuntos
Neoplasias da Mama , Mamoplastia , Humanos , Feminino , Mastectomia/efeitos adversos , Neoplasias da Mama/cirurgia , Neoplasias da Mama/complicações , Estudos de Coortes , Estudos Retrospectivos , Qualidade de Vida , Complicações Pós-Operatórias/etiologia , Mamoplastia/efeitos adversos , Radioterapia Adjuvante/efeitos adversos , Medidas de Resultados Relatados pelo Paciente , Resultado do TratamentoRESUMO
BACKGROUND: The use of virtual surgical planning and computer-assisted design and computer-assisted manufacturing (CAD/CAM) has become widespread for mandible reconstruction with the free fibula flap. However, the cost utility of this technology remains unknown. METHODS: The authors used a decision tree model to evaluate the cost utility, from the perspective of a hospital or insurer, of mandible reconstruction using CAD/CAM relative to the conventional (non-CAD/CAM) technique for the free fibula flap. Health state probabilities were obtained from a published meta-analysis. Costs were estimated using 2018 Centers for Medicare and Medicaid Services data. Overall expected cost and quality-adjusted life-years (QALYs) were assessed using a Monte Carlo simulation and sensitivity analyses. Cost effectiveness was defined as an incremental cost utility ratio (ICUR) less than the empirically accepted willingness-to-pay value of $50,000 per QALY. RESULTS: Although CAD/CAM reconstruction had a higher expected cost compared with the conventional technique ($36,487 vs. $26,086), the expected QALYs were higher (17.25 vs. 16.93), resulting in an ICUR = $32,503/QALY; therefore, the use of CAD/CAM in free fibula flap mandible reconstruction was cost-effective relative to conventional technique. Monte Carlo sensitivity analysis confirmed CAD/CAM's superior cost utility, demonstrating that it was the preferred and more cost-effective option in the majority of simulations. Sensitivity analyses also illustrated that CAD/CAM remains cost effective at an amount less than $42,903 or flap loss rate less than 4.5%. CONCLUSION: This cost utility analysis suggests that mandible reconstruction with the free fibula osteocutaneous flap using CAD/CAM is more cost effective than the conventional technique.
Assuntos
Retalhos de Tecido Biológico , Reconstrução Mandibular , Cirurgia Assistida por Computador , Desenho Assistido por Computador , Fíbula , Mandíbula/cirurgia , Medicare , Cirurgia Assistida por Computador/métodos , Estados UnidosRESUMO
BACKGROUND: Following implant-based breast reconstruction (IBR) infection and explantation, autologous reconstruction is a common option for patients who desire further reconstruction. However, few data exist about the outcomes of secondary autologous reconstruction (i.e., free flap breast reconstruction) in this population. We hypothesized that autologous reconstruction following infected device explantation is safe and has comparable surgical outcomes to delayed-immediate reconstruction. METHODS: We conducted a retrospective analysis of patients who underwent IBR explantation due to infection from 2006 through 2019, followed by secondary autologous reconstruction. The control cohort comprised patients who underwent planned primary delayed-immediate reconstruction (tissue expander followed by autologous flap) in 2018. RESULTS: We identified 38 secondary autologous reconstructions after failed primary IBR and 52 primary delayed-immediate reconstructions. Between secondary autologous and delayed-immediate reconstructions, there were no significant differences in overall complications (29 and 37%, respectively, p = 0.45), any breast-related complications (18 and 21%, respectively, p = 0.75), or any major breast-related complications (13 and10%, respectively, p = 0.74). Two flap losses were identified in the secondary autologous reconstruction group while no flap losses were reported in the delayed-immediate reconstruction group (p = 0.18). CONCLUSION: Autologous reconstruction is a reasonable and safe option for patients who require explantation of an infected prosthetic device. Failure of primary IBR did not confer significantly higher risk of complications after secondary autologous flap reconstruction compared with primary delayed-immediate reconstruction. This information can help plastic surgeons with shared decision-making and counseling for patients who desire reconstruction after infected device removal.
Assuntos
Implantes de Mama , Neoplasias da Mama , Retalhos de Tecido Biológico , Mamoplastia , Humanos , Feminino , Implantes de Mama/efeitos adversos , Remoção de Dispositivo/efeitos adversos , Estudos Retrospectivos , Retalhos de Tecido Biológico/cirurgia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/cirurgia , Complicações Pós-Operatórias/etiologia , Neoplasias da Mama/cirurgia , Neoplasias da Mama/complicaçõesRESUMO
Reconstruction of the midface represents a challenge for reconstructive microsurgeons given the formidable task of restoring both aesthetics and functionality. In particular, preservation of proper globe positioning and maintaining normal vision are as important as restoring the proper projection of the midface and enabling a patient to speak and eat as normally as possible. The introduction of virtual surgical planning (VSP) and medical modeling has revolutionized bony reconstruction of the craniofacial skeleton; however, the overwhelming majority of studies have focused on mandibular reconstruction. Here, we introduce some novel advances in utilizing VSP for bony reconstruction of the midface. The present review aims (1) to provide a review of the literature on the use of VSP in midface reconstruction and (2) to provide some insights from the authors' early experience.
Assuntos
Reconstrução Mandibular , Neoplasias , Procedimentos de Cirurgia Plástica , Humanos , Impressão Tridimensional , Face , FíbulaRESUMO
Autologous fat grafting (AFG) serves as an effective method to address volume defects, contour irregularities, and asymmetry in both aesthetic and reconstructive procedures. In recent years, there has been growing concern about the potential of cancer recurrence and interference with cancer surveillance in oncologic patients receiving AFG. The adipose tissue contains adipose-derived stem cells (ASCs), a specific type of mesenchymal stem cells, that facilitate secretion of numerous growth factors which in turn stimulate tissue regeneration and angiogenesis. As such, it has been theorized that ASCs may also have the potential to stimulate cancer cell proliferation and growth when used in oncologic patients. Multiple research studies have demonstrated the ability of ACSs to facilitate tumor proliferation in animal models. However, clinical research in oncologic patients has yielded contradictory findings. Although the literature pertaining to oncologic safety in head and neck, as well as sarcoma, cancer patients remains limited, studies demonstrate no increased risk of tumor recurrence in these patient populations receiving AFG. Similarly, both the efficacy and safety of AFG have been well established in breast cancer patients through numerous clinical studies. More recently, preclinical research in animal models has shown that AFG has the potential to facilitate tissue regeneration and improve joint contracture following irradiation. Ultimately, further research is needed to elucidate the safety of AFG in a variety of oncologic patients, as well as explore its use in tissue regeneration, particularly in the setting of radiotherapy. Level of Evidence: 4.
Assuntos
Neoplasias da Mama , Mamoplastia , Tecido Adiposo , Neoplasias da Mama/cirurgia , Humanos , Recidiva Local de Neoplasia , Transplante AutólogoRESUMO
PURPOSE: The identification of patient-specific risk factors, which predict morbidity following abdominally based microvascular breast reconstruction is difficult. Sarcopenia is a proxy for patient frailty and is an independent predictor of complications in a myriad of surgical disciplines. We predict that sarcopenic patients will be at higher risk for surgical complications following abdominally based microvascular breast reconstruction. METHODS: A retrospective study of all patients who underwent delayed abdominally based autologous breast reconstruction following postmastectomy radiation therapy from 2007 to 2013 at a single institution was conducted. Univariate and multiple logistic regression models were used to assess the effect of sarcopenia on postoperative outcomes. RESULTS: Two hundred and eight patients met the inclusion criteria, of which 30 met criteria for sarcopenia (14.1%). There were no significant differences in demographics between groups. There were no significant differences in minor (36.7% vs 44.4%; P = .43) or major (16.7% vs 25.3%; P = .36) complications between groups as well as hospital length of stay. Multivariable logistic regression demonstrated that a staged reconstruction with the use of a tissue expander was the only consistent variable, which predicted major complications (OR, 2.24; 95% CI, 1.18-4.64; P = .015). CONCLUSIONS: Sarcopenia does not predispose to minor or major surgical complications in patients who undergo abdominally based microsurgical breast reconstruction.
Assuntos
Abdome/cirurgia , Neoplasias da Mama/cirurgia , Retalhos de Tecido Biológico/efeitos adversos , Mamoplastia/efeitos adversos , Mastectomia/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Sarcopenia/fisiopatologia , Neoplasias da Mama/patologia , Feminino , Seguimentos , Retalhos de Tecido Biológico/transplante , Humanos , Pessoa de Meia-Idade , Assistência Perioperatória , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Transplante AutólogoRESUMO
PURPOSE: Enhanced recovery after surgery (ERAS) pathways are increasingly promoted in post-mastectomy reconstruction, with several articles reporting their benefits and safety. This meta-analysis appraises the evidence for ERAS pathways in breast reconstruction. METHODS: A systematic search of Medline, EMBASE, and Cochrane databases was performed to identify reports of ERAS protocols in post-mastectomy breast reconstruction. Two reviewers screened studies using predetermined inclusion criteria. Studies evaluated at least one of the following end-points of interest: length of stay (LOS), opioid use, or major complications. Risk of bias was assessed for each study. Meta-analysis was performed via a mixed-effects model to compare outcomes for ERAS versus traditional standard of care. Surgical techniques were assessed through subgroup analysis. RESULTS: A total of 260 articles were identified; 9 (3.46%) met inclusion criteria with a total of 1191 patients. Most studies had "fair" methodological quality and incomplete implementation of ERAS society recommendations was noted. Autologous flaps comprised the majority of cases. In autologous breast reconstruction, ERAS significantly reduces opioid use [Mean difference (MD) = - 183.96, 95% CI - 340.27 to 27.64, p = 0.02) and LOS (MD) = - 1.58, 95% CI - 1.99 to 1.18, p < 0.00001] versus traditional care. There is no significant difference in the incidence of complications (major complications, readmission, hematoma, and infection). CONCLUSION: ERAS pathways significantly reduce opioid use and length of hospital stay following autologous breast reconstruction without increasing complication rates. This is salient given the current US healthcare climate of rising expenditures and an opioid crisis.
Assuntos
Mamoplastia/métodos , Analgésicos Opioides/uso terapêutico , Neoplasias da Mama/cirurgia , Feminino , Humanos , Tempo de Internação , Mastectomia , Manejo da Dor/métodos , Cuidados Pós-Operatórios , Retalhos CirúrgicosRESUMO
OBJECTIVE. The objective of this video article is to discuss the use of the scapular osteocutaneous free flap in reconstructive procedures. We attempt to discuss normal and variant vascular anatomy, image acquisition via CT angiography, and image interpretation as well as computer-assisted design and manufacturing. CONCLUSION. The scapular osteocutaneous free flap is commonly used for maxillary and mandibular reconstructive surgery. The complex vasculature supplying the scapular region allows flap versatility. There are anatomic variations in the origin of the circumflex scapular and angular arteries. Our method of performing and reporting CT angiography for patients scheduled to undergo scapular osteocutaneous free flap procedures provides a reliable and reproducible means of communicating important elements of vasculature to surgeons. This in turn can facilitate the manufacturing of custom scapular cutting guides and improve surgical outcomes.
Assuntos
Transplante Ósseo/métodos , Angiografia por Tomografia Computadorizada , Retalhos de Tecido Biológico/irrigação sanguínea , Retalhos de Tecido Biológico/transplante , Procedimentos de Cirurgia Plástica , Escápula/irrigação sanguínea , Escápula/diagnóstico por imagem , Escápula/transplante , HumanosRESUMO
BACKGROUND: For organ transplant recipients, cancer secondary to immunosuppressive therapy threatens long-term survival. The associated multiple comorbidities make major free flap reconstruction following cancer surgery a complicated event. This study evaluates the outcomes of free flap reconstruction in this population. METHODS: A retrospective chart review of all head and neck free flap cases in patients with a history of organ transplantation receiving systemic immunosuppressive therapy between 2005 and 2017 at a single-institution was conducted. RESULTS: Of 57 organ transplant patients, 25 patients (28 flaps) were included. Flaps used included the anterolateral thigh (n = 17), radial forearm (n = 4), latissimus dorsi (n = 3), fibula (n = 2), lateral arm (n = 1), and thoracodorsal artery perforator (n = 1) flaps. The most common organ transplant was kidney, then lung, liver, and heart. Mean inpatient stay was 8.2 days (range, 4-28). Complications occurred in 15 patients, with no total or partial flap losses. CONCLUSION: Major head and neck free flap reconstructive surgery can be performed safely in organ transplant patients receiving immunosuppressive therapy. Meticulous multidisciplinary care is required to achieve consistently successful outcomes.
Assuntos
Retalhos de Tecido Biológico/transplante , Neoplasias de Cabeça e Pescoço/cirurgia , Cabeça/cirurgia , Imunossupressores/efeitos adversos , Pescoço/cirurgia , Transplante de Órgãos/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias , Feminino , Fíbula/irrigação sanguínea , Fíbula/transplante , Seguimentos , Retalhos de Tecido Biológico/irrigação sanguínea , Neoplasias de Cabeça e Pescoço/etiologia , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Coxa da Perna/irrigação sanguíneaRESUMO
The gold standard treatment of large segmental bone defects is autologous bone transfer, which suffers from low availability and additional morbidity. Tissue engineered bone able to engraft orthotopically and a suitable animal model for pre-clinical testing are direly needed. This study aimed to evaluate engraftment of tissue-engineered bone with different prevascularization strategies in a novel segmental defect model in the rabbit humerus. Decellularized bone matrix (Tutobone) seeded with bone marrow mesenchymal stromal cells was used directly orthotopically or combined with a vessel and inserted immediately (1-step) or only after six weeks of subcutaneous "incubation" (2-step). After 12 weeks, histological and radiological assessment was performed. Variable callus formation was observed. No bone formation or remodeling of the graft through TRAP positive osteoclasts could be detected. Instead, a variable amount of necrotic tissue formed. Although necrotic area correlated significantly with amount of vessels and the 2-step strategy had significantly more vessels than the 1-step strategy, no significant reduction of necrotic area was found. In conclusion, the animal model developed here represents a highly challenging situation, for which a suitable engineered bone graft with better prevascularization, better resorbability and higher osteogenicity has yet to be developed.
Assuntos
Transplante Ósseo/métodos , Fêmur/irrigação sanguínea , Fêmur/lesões , Transplante de Células-Tronco Mesenquimais/métodos , Engenharia Tecidual , Animais , Reabsorção Óssea , Células Cultivadas , Modelos Animais de Doenças , Coelhos , Alicerces Teciduais/química , Transplante AutólogoRESUMO
Denervated muscle tissue undergoes morphologic changes that result in atrophy. The amount of muscle atrophy after denervation following free muscle transfer has not been measured so far. Therefore, the amount of muscle atrophy in human free muscle transfer for lower extremity reconstruction was measured in a series of 10 patients. Three-dimensional laser surface scanning was used to measure flap volume changes 2 weeks as well as 6 and 12 months after the operation. None of the muscles transferred was re-innervated.All muscles healed uneventfully without signs of compromised perfusion resulting in partial flap loss. The muscle volume decreased to 30 ± 4% and 19 ± 4% 6 and 12 months, respectively, after the operation, ie, the volume decreased by approximately 80% within a 12-month period.Denervated free muscle flap tissue undergoes massive atrophy of approximately 80%, mostly within the first 6 months.
Assuntos
Lasers , Músculo Esquelético/patologia , Atrofia Muscular/diagnóstico , Procedimentos de Cirurgia Plástica/métodos , Adolescente , Adulto , Idoso , Autoenxertos , Criança , Denervação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atrofia Muscular/etiologia , Cuidados Pós-Operatórios , Adulto JovemRESUMO
We present a salvage procedure to reconstruct the neo-urethra after partial flap necrosis occurring in free radial forearm flap (RFF) phalloplasty for sex reassignment surgery. Two cases of tube-in-tube phalloplasty using a free sensate RFF are described in which partial flap necrosis occurred involving the complete length of the neo-urethra and a strip of the outer lining of the neo-phallus. Neo-urethra-reconstruction was performed with a second RFF from the contralateral side providing well-vascularized tissue. No flap-related complications were observed. Twelve months postoperatively, both patients were able to void while standing. A satisfactory aesthetic appearance of the neo-phallus could be preserved with an excellent tactile and erogenous sensitivity. Using this technique, we successfully salvaged the neo-urethra and reconstructed the outer lining of the neo-phallus
Assuntos
Retalhos de Tecido Biológico , Pênis/cirurgia , Complicações Pós-Operatórias/cirurgia , Cirurgia de Readequação Sexual/métodos , Uretra/cirurgia , Adulto , Antebraço/cirurgia , Retalhos de Tecido Biológico/patologia , Humanos , Masculino , Necrose , Procedimentos Cirúrgicos Urológicos Masculinos/métodosRESUMO
The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized "double-barrel" fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.
Assuntos
Articulação do Tornozelo , Fraturas Expostas/cirurgia , Luxações Articulares/cirurgia , Osteomielite/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos , Fraturas Expostas/complicações , Humanos , Luxações Articulares/complicações , Masculino , Osteomielite/etiologia , Osteomielite/microbiologia , Adulto JovemRESUMO
BACKGROUND: Limited data exist regarding the effect of adjuvant radiochemotherapy on free flap volume in head and neck reconstruction. However, an adequate free flap volume is an important predictor of functional and patient-reported outcomes in head and neck reconstruction. METHODS: A systematic review of Medline, Embase, and the Cochrane Central Register of Controlled Trials was conducted using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. A total of 6710 abstracts were screened, and 36 full-text papers were reviewed. Nineteen studies met the inclusion criteria and were used to extract data for this analysis. RESULTS: A meta-analysis of 14 two-arm studies comparing the impact of adjuvant radiotherapy versus no adjuvant radiotherapy was performed. The main analysis revealed that 6 months postoperatively, irradiated flaps showed a significant reduction of volume (average, 9.4%) compared to nonirradiated flaps. The average interpolated pooled flap volumes 6 months postoperatively were 76.4% in irradiated flaps and 81.8% in nonirradiated flaps. After a median postoperative follow-up of 12 months, the total flap volume was 62.6% for irradiated flaps and 76% for nonirradiated flaps. Four studies reported that chemotherapy had no significant impact on free flap volume. CONCLUSIONS: Compared to nonirradiated flaps, irradiated flaps were significantly reduced in volume (range, 5% to 15.5%). Clinicians should take this into account when planning the surgical reconstruction of head and neck defects. Conducting large-scale prospective studies with standardized protocols and well-defined follow-up measurements could contribute to defining the ideal, personalized free flap volume for optimal function and patient-reported outcomes.
Assuntos
Quimiorradioterapia Adjuvante , Retalhos de Tecido Biológico , Neoplasias de Cabeça e Pescoço , Procedimentos de Cirurgia Plástica , Humanos , Neoplasias de Cabeça e Pescoço/terapia , Neoplasias de Cabeça e Pescoço/cirurgia , Procedimentos de Cirurgia Plástica/métodosRESUMO
BACKGROUND: Total or subtotal glossectomy defects cause significant functional deficits in swallowing and speech and subsequently impair patients' quality of life (QOL). Recently, the profunda artery perforator (PAP) flap has emerged as a potential alternative for reconstructing extensive glossectomy defects. While previous studies assessing recovery of neurotized anterolateral thigh (ALT) flaps in head and neck reconstruction reported superior sensory recovery, improved swallow function, and improved overall patient satisfaction in patients with neurotized flaps vs. non-neurotized ALT flap reconstruction, PAP flap neurotization has not been described and systematically assessed in head and neck patients. METHODS: Six patients underwent subtotal tongue reconstruction with neurotized PAP flaps at the authors' institution from May 2022 until August 2023. A branch of the posterior femoral cutaneous nerve of the PAP flap was coaptated to the lingual nerve. Two-point discrimination, Semmes-Weinstein monofilament, pain, and temperature assessments were conducted at 3, 6, and 12 months postoperatively on the neo-tongue. The MD Anderson speech and deglutition scales and the EORTC-QLQ-H&N35 were used to record functional outcomes and QOL. RESULTS: The mean age was 69 ± 4 years, and the mean body mass index was 25 ± 7 kg/m2. Neo-tongue median 2-point discrimination at the tip improved from >10 mm at 3 months to 6 mm at 12 months. All patients had protective pain and temperature perception at the neo-tongue tip at the 6-month follow-up. Speech and swallowing functions were similar at the 12-month follow-up to data on neurotized ALT flaps from literature. No neuropathic pain was reported at the donor site at the 6-month follow-up. CONCLUSIONS: This is the first case series of PAP flap neurotization in head and neck patients, suggesting potential functional advantages with minimal donor-site morbidity. LEVEL OF EVIDENCE: V Case Series.