Elongation of intercostal nerve cutaneous branches for breast and nipple neurotization during breast reconstruction after mastectomy for breast cancer: case-control study.

BACKGROUND: To restore sensation after breast reconstruction, a modified surgical approach was employed by identifying the cut fourth intercostal lateral cutaneous branch, elongating it with intercostal nerve grafts, and coapting it to the innervating nerve of the flap or by using direct neurotization of the spared nipple/skin. METHODS: This was a retrospective case-control study including 56 patients who underwent breast neurotization surgery. Breast operations included immediate reconstruction after nipple-sparing mastectomy (36 patients), skin-sparing mastectomy (8 patients), and delayed reconstruction with nipple preservation (7 patients) or without nipple preservation (5 patients). Patients who underwent breast reconstruction without neurotization were included as the non-neurotization negative control group. The contralateral normal breasts were included as positive controls. RESULTS: The mean(s.d.) monofilament test values were 0.07(0.10) g for the positive control breasts and 179.13(143.31) g for the breasts operated on in the non-neurotization group. Breasts that underwent neurotization had significantly better sensation after surgery, with a mean(s.d.) value of 35.61(92.63) g (P < 0.001). The mean(s.d.) sensory return after neurotization was gradual; 138.17(143.65) g in the first 6 months, 59.55(116.46) g at 7-12 months, 14.54(62.27) g at 13-18 months, and 0.37(0.50) g at 19-24 months after surgery. Two patients had accidental rupture of the pleura, which was repaired uneventfully. One patient underwent re-exploration due to a lack of improvement 1.5 years after neurotization. CONCLUSION: Using the lateral cutaneous branch of the intercostal nerve as the innervating stump and elongating it with intercostal nerve grafts is a suitable technique to restore sensation after mastectomy. This method effectively innervates reconstructed breasts and spares the nipple/skin with minimal morbidity.

"Submarine-Shaped" Radial Forearm Flap for Simultaneous Reconstruction of Oral and Lower Lip Defects".

BACKGROUND: Reconstruction of the oral cavity commonly results in trismus and lip incompetence. AIM AND OBJECTIVES: In this study, we aim to describe an innovative design of a radial forearm free flap for resurfacing bilateral buccal defects and simultaneous functional lower lip reconstruction in a single stage. MATERIALS AND METHODS: Between January 2010 and December 2019, 6 males underwent simultaneous buccal and lower lip reconstruction with a radial forearm free flap. The mean age of the patients was 57.3 years (range, 50-68 years). The defects were caused by trismus release and due to previous treatments. The mean size of the defects was 17.9 cm in length and 3.25 cm in width. Flaps were harvested, including the proximal perforators of the radial vessels, and the inset began in the buccal area opposite the anastomosis side. RESULTS: Flap size ranged from 16 to 21 × 2 to 4 cm. The recipient vessels used were the superficial temporal (4) and facial (2). All flaps survived. Lip infection was seen in 2 cases and managed conservatively. The mean follow-up was 19.2 months (range, 12-28 months). The mean increase in the interincisal distance was 10.7 mm. Oral continence was good in all patients. Speech intelligibility was considered total in 4 patients and partial in the remaining 2. CONCLUSION: The radial forearm flap constitutes an option for simultaneous lower lip reconstruction and resurfacing of bilateral buccal areas after trismus release. The procedure provides a thin and pliable reconstruction using only 1 donor site and 1 set of recipient vessels.

DIEP Donor Site Satisfaction between Patients with and without History of Pregnancy.

BACKGROUND: With the success of free autologous breast reconstruction, the abdominal donor site is now an important consideration, especially in patients of childbearing age. In our institution, there are increasing patients who have successfully undergone the deep inferior epigastric artery perforator (DIEP) flap despite previous pregnancy. This study aims to answer questions on the effect of the donor site on pregnancy and vice versa. METHODS: A retrospective cohort study was conducted to identify breast cancer patients who received a free DIEP flap for breast reconstruction from January 2018 to August 2020. Patients were allocated to two groups according to whether they had prior pregnancies with successful deliveries. Demographics, flap-related parameters, surgical outcomes on breast and abdomen, and patient-reported outcome (Breast-Q questionnaire) were analyzed. Patients were excluded if follow-up time was less than 1 year, or if there was incomplete medical records or Breast-Q replies. RESULTS: Ninety-nine of 116 patients had had successful pregnancies with delivery, 17 of them remained nulliparous. No statistically significant differences existed between groups regarding demographic data, flap-related parameters, surgical outcomes on breast and abdomen. Nulliparous patients exhibited significantly lower score in physical well-being in the abdomen domain compared with delivery-experienced patients (62.1 vs. 73.4, p = 0.025). Significantly, nulliparous patients felt more tightness and pulling of the abdominal wall than the delivery-experienced patients (2.9 vs. 3.7; p = 0.05 and 3.5 vs. 4.0; p = 0.04). CONCLUSION: Free DIEP flap can be transferred safely in nulliparous patients despite a slight increase in abdominal tightness and abdominal pulling. Precise flap design and surgical approaches may help to minimize the abdominal discomfort especially on young, normal body mass index, and nonchildbearing patients.

Small flaps in microsurgical breast reconstruction: Selection between the profunda artery perforator and small deep inferior epigastric artery perforator flaps and associated outcomes and complications.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is widely used in breast reconstruction and the profunda artery perforator (PAP) flap as alternative. However, the difference between the two flaps in smaller breast reconstruction remains lacking, in particular, the donor site complications. In this case series, the results of small breast reconstruction (≤300 g) using PAP or small DIEP flaps were explored. METHODS: Unilateral immediate breast reconstruction using a free PAP flap or small DIEP flap (≤300 g) from 2011 to 2021 were reviewed retrospectively. Excluding patients with delayed reconstruction, 28 patients, including 17 PAP flaps and 11 small DIEP flaps were enrolled. Flap characteristics, breast and donor site complications, and revision surgeries were reviewed. BREAST-Q™ was used for quality-of-life assessment. RESULTS: Compared with a small DIEP flap, a PAP flap was narrow (7.5 ± 1.1 vs. 10.6 ± 0.7 cm, p < .001), short (20.0 ± 2.6 vs. 25.5 ± 1.8 cm, p < .001) and had a shorter pedicle (5.9 ± 1.6 vs. 9.1 ± 1.0 cm, p < .001). There were no significant differences in acute and late complications of wound healing and fat necrosis, but the average number of revisions in the PAP group was significantly higher (1.9 ± 1.3 vs. 0.8 ± 1.4, p = .041). Patient-reported outcomes using BREAST-Q™ displayed no significant difference between the two groups. CONCLUSION: The outcomes of PAP and small DIEP flaps at the breasts and donor sites are satisfactory, despite that a higher tendency of donor site complications in PAP flap and more aesthetic refinement required in the PAP group. The overall outcomes are acceptable.

Six steps for a successful aesthetic free flap reconstruction after minimally invasive mastectomy: a retrospective case-control study.

OBJECTIVE: Breast cancer treatment has evolved to the modern skin-sparing mastectomy and nipple-sparing mastectomy. To better perform these surgeries, minimally invasive techniques using the endoscope, or Da Vinci Robotic Surgery platform have been developed. The deep inferior epigastric perforator (DIEP) flap is the gold standard in breast reconstruction, but it is still not commonly performed after minimally invasive mastectomy due technical difficulty. Here the authors introduced six key steps to a successful aesthetic autologous free flap reconstruction in in minimally invasive mastectomies. METHODS: There are six main steps to our technique: placement of mastectomy incision, precise flap design after angiography studies, trial of shaping, transcutaneous medial suture, footprint recreation and postoperative shaping with bra. Between November 2018 and July 2022, a total of 67 immediate breast reconstructions using free perforator flaps were performed in 63 patients after minimally invasive nipple-sparing mastectomy. RESULTS: The results from the minimally invasive mastectomy group were compared with a group of conventional mastectomy patients ( n= 41) performed during the same period. There were no significant differences in flap exploration rates. One hundred percent of the flaps survived. In the minimally invasive group, the final scar was placed in the lateral region, where it would be hidden from the anterior view. Only 70.7% of the conventional mastectomy group could achieve a hidden lateral scar ( P <0.001). The aesthetic revision rates were similar between two groups. CONCLUSION: With attention to the six steps above, autologous free flap reconstruction can be offered reliably in the setting of minimally invasive mastectomy.

Quantization of extraoral free flap monitoring for venous congestion with deep learning integrated iOS applications on smartphones: a diagnostic study.

BACKGROUND: Free flap monitoring is essential for postmicrosurgical management and outcomes but traditionally relies on human observers; the process is subjective and qualitative and imposes a heavy burden on staffing. To scientifically monitor and quantify the condition of free flaps in a clinical scenario, we developed and validated a successful clinical transitional deep learning (DL) model integrated application. MATERIAL AND METHODS: Patients from a single microsurgical intensive care unit between 1 April 2021 and 31 March 2022, were retrospectively analyzed for DL model development, validation, clinical transition, and quantification of free flap monitoring. An iOS application that predicted the probability of flap congestion based on computer vision was developed. The application calculated probability distribution that indicates the flap congestion risks. Accuracy, discrimination, and calibration tests were assessed for model performance evaluations. RESULTS: From a total of 1761 photographs of 642 patients, 122 patients were included during the clinical application period. Development (photographs =328), external validation (photographs =512), and clinical application (photographs =921) cohorts were assigned to corresponding time periods. The performance measurements of the DL model indicate a 92.2% training and a 92.3% validation accuracy. The discrimination (area under the receiver operating characteristic curve) was 0.99 (95% CI: 0.98-1.0) during internal validation and 0.98 (95% CI: 0.97-0.99) under external validation. Among clinical application periods, the application demonstrates 95.3% accuracy, 95.2% sensitivity, and 95.3% specificity. The probabilities of flap congestion were significantly higher in the congested group than in the normal group (78.3 (17.1)% versus 13.2 (18.1)%; 0.8%; 95% CI, P <0.001). CONCLUSION: The DL integrated smartphone application can accurately reflect and quantify flap condition; it is a convenient, accurate, and economical device that can improve patient safety and management and assist in monitoring flap physiology.

Microsurgical Reconstruction of Extensive Lower Lip Defects: An Algorithm for Free Flap Selection and Functional Outcomes.

BACKGROUND: Large defects of the lower lip pose a difficult challenge for any reconstructive surgeon. When there is limited local tissue available to resurface the defects, free flaps are the preferred option. AIM AND OBJECTIVES: We reported our experience in the reconstruction of extensive lower lip defects. The authors propose a new algorithm for microsurgical technique selection and assessment of the functional outcomes obtained. MATERIALS AND METHODS: A retrospective review of all microsurgical reconstructions of extensive lower lip defects by the senior author for 10 years was performed. The functional outcomes assessed included speech, feeding, and oral continence. Patients were stratified according to their status of simultaneous mandible resection (none, marginal, segmental). RESULTS: Fifty-one patients were included in this study. Almost all patients (96.1%) achieved intelligible speech. Only 1 patient experienced severe drooling. Most patients could eat a solid or soft diet (72.5%). Mandible resection was associated with the worst feeding outcomes. CONCLUSIONS: Microsurgical reconstruction of extensive lip defects is safe and provides good results. Free flap selection should take into account the location of the defect, the resected structures, and the body mass index of the patient. Feeding status seems to be inversely correlated with the amount of mandibular resection.

Novel Port Placement in Robot-Assisted DIEP Flap Harvest Improves Visibility and Bilateral DIEP Access: Early Controlled Cohort Study.

SUMMARY: To minimize donor-site damage, robot-assisted (RA) deep inferior epigastric perforator (DIEP) flap harvest has been suggested. Current robotic approaches favor port placement, which either does not allow a bilateral DIEP flap harvest through the same ports or necessitates additional scars. In this article, the authors propose a modification of port configuration. In a retrospective controlled cohort study, RA-DIEP and conventional DIEP surgery were compared. The perforator and pedicle were visualized conventionally until the level behind the rectus abdominis muscle. Next, the robotic system was installed to dissect the retromuscular pedicle. The authors assessed patient age; body mass index; history of smoking, diabetes mellitus, and hypertension; and additional surgical time. The length of the anterior rectus sheath (ARS) incision was measured. Pain was quantified using the visual analogue scale. Donor-site complications were assessed. Thirteen RA-DIEP flaps (11 unilateral and two bilateral) and 87 conventional DIEP flaps were harvested without flap loss. The bilateral DIEP flaps were raised without readjustments of the ports. The mean time for pedicle dissection was 53.2 ± 13.4 minutes. The length of the ARS incision was significantly shorter in the RA-DIEP group (2.67 ± 1.13 cm versus 8.14 ± 1.69 cm; 304.87% difference; P < 0.0001). There was no statistical difference in postoperative pain (day 1: 1.9 ± 0.9 versus 2.9 ± 1.6, P = 0.094; day 2: 1.8 ± 1.2 versus 2.3 ± 1.5, P = 0.319; day 3: 1.6 ± 0.9 versus 2.0 ± 1.3, P = 0.444). Preliminary results show that the authors' RA-DIEP approach is safe and allows dissection of bilateral RA-DIEP flaps with short ARS incision lengths. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A Comparison Study of Outcomes and Complications Between Marginal Mandibulectomy With or Without Additional Mandibulotomy in Tongue Cancers.

BACKGROUND: Marginal mandibulectomy with or without additional mandibulotomy could represent the alternatives to avoid segmental mandibulectomy in carefully selected tongue cancers. AIM AND OBJECTIVES: This study investigated a subgroup of tongue cancers with suspected involvement to the alveolar bone because of the shallow and deformed mouth floor. We aimed to compare the functional outcomes, postoperative complications, and disease control efficacy between the 2 different marginal mandibulectomy approaches, with or without additional mandibulotomy. MATERIALS AND METHODS: A retrospective study of 29 marginal mandibulectomies and 26 combined mandibulotomies for tongue cancer wide excisions and flap reconstruction at Chang Gung Memorial Hospital Linkou Branch during 2014 to 2019 was performed. RESULTS: The combined mandibulotomy group had more advanced T-status ( P < 0.001) and greater tumor diameters ( P < 0.001) but not increased preexisting trismus, bone invasions, or positive margins. The additional mandibulotomy increased flap necrosis ( P = 0.044), late infections ( P = 0.004), and tongue movement limitations ( P = 0.044) but not osteoradionecrosis. Osteoradionecrosis was unrelated to the resected mandibular length or the mandibulotomy sites. Feeding tube dependence was greater in the combined group at discharge ( P = 0.014), but no long-term differences were noted. Kaplan-Meier overall survival ( P = 0.052) and disease-free survival ( P = 0.670) were both comparable between the 2 groups. CONCLUSIONS: The combined procedure of mandibulotomy and marginal mandibulectomy in large tongue cancers without bone invasions is associated with increased soft tissue-related complications but not bone-related complications. However, comparable disease control, survival, and long-term tube feeding outcomes were noted.

Current Concepts for Reconstruction of Oral Tissues Following Ablative Surgery: A Comprehensive Approach.

Appropriate concepts of reconstruction can eliminate contraindications, reduce the incidence of complications, increase the success rates, and promote the outcomes. Besides, appropriate concepts can also help economical use of expensive technology or assistant tools on the patients who are necessary and beneficial. This paper provides a comprehensive approach to select reconstructive methods for oral defects following ablative surgery. A comprehensive approach should have a thorough understanding of the reconstructive goals, the patient's information, the surgeon's ability, and the hospital's support. To achieve a basic structural and functional restoration of oral cavity, "reconstruction ladder" could be skipped to free flap transfer. Goal-oriented thinking process with rethinking the feasibility assessment can help the surgeon to find the most appropriate method of reconstruction. Appropriate methods can mostly achieve the above-average results and rarely lead to inadequate results. Current concepts for reconstruction of oral tissue are the balance between maximal outcome and minimal complication, maximal accuracy and minimal cost, maximal efficacy and minimal investment. A comprehensive approach to select flap, a reliable method to harvest flap, and a customized flap design/inset are keystones to achieve a relatively better outcome. The awesome of limitations from the surgeon's ability, hospital's support, and the patient's condition can minimize the complications.

Venous Size Discrepancy Is a Critical Factor When Using Superficial Temporal Vessels as Recipient Vessels for Free Flaps.

BACKGROUND: Superficial temporal vessels have been used successfully as recipient vessels for head and neck reconstruction. This study evaluates the impact of several treatment variables on flap failure and take-back rate when using these recipient vessels. METHODS: We conducted a retrospective study of all microsurgical reconstructions using superficial temporal vessels as recipient vessels in a period of 10 years. Variables collected included previous treatments (radiotherapy, chemotherapy, neck dissection, free flap reconstruction), type of flaps used (soft tissue, osteocutaneous), and vessel size discrepancy between donor and recipient vessels. RESULTS: A total of 132 patients were included in the study. The flap success rate was 98.5%. The take-back rate was 10.6%. The most frequent reason for take-back was venous congestion secondary to thrombosis. None of the studied variables was associated with flap failure. Reconstructions using osteocutaneous flaps and vein diameter discrepancy (ratio ≥ 2:1) had significantly higher take-back rates. CONCLUSION: Flaps with a significant size discrepancy between donor and recipient veins (ratio ≥ 2:1) and fibula flaps (compared with soft tissue flaps) were associated with a higher risk of take-back. It is crucial to minimize venous engorgement during flap harvest and anastomosis, and limit vein redundancy during flap in-setting.

Two-Layer Palatal Reconstruction Reduces Postoperative Intraoral Complications in Head and Neck Surgery.

BACKGROUND: Although microvascular free flaps are commonly performed and have high success rates, postoperative oronasal fistulas or infections do occur. The authors hypothesized that a two-layer closure is effective for prevention of intraoral complications. METHODS: Patients who underwent palatal reconstruction with a microvascular free flap were evaluated retrospectively. The cases were divided into two groups (palatal reconstruction with or without a two-layer closure). A two-layer closure involves unilateral reconstruction with a free flap, then reconstruction of the nasal lining with a local flap or folding free flap. The postoperative complication rates between these two groups were compared. RESULTS: One hundred fifty-five cases were evaluated. A two-layer closure was performed in 65 cases (41.9 percent). The incidence of infections, dehiscence of the recipient site, and oronasal fistula were significantly higher in the single-layer closure group than in the two-layer closure group [10.0 percent versus 0 percent (p = 0.011); 15.6 percent versus 4.6 percent (p = 0.036); and 17.8 percent versus 4.6 percent (p = 0.013), respectively]. CONCLUSIONS: A two-layer closure in palatal reconstruction was shown to reduce the rate of infection, intraoral wound dehiscence, and oronasal fistula in the current study. A two-layer closure provides greater support and stability and reduces the risk of failure in reconstruction of the palate with a microvascular free flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Transcutaneous medial fixation sutures for free flap inset after robot-assisted nipple-sparing mastectomy.

The application of minimal invasive mastectomy has allowed surgeons to perform nipplesparing mastectomy via a shorter, inconspicuous incision under clear vision and with more precise hemostasis. However, it poses new challenges in microsurgical breast reconstruction, such as vascular anastomosis and flap insetting, which are considerably more difficult to perform through the shorter incision on the lateral breast border. We propose an innovative technique of transcutaneous medial fixation sutures to help in flap insetting and creating and maintaining the medial breast border. The sutures are placed after mastectomy and before flap transfer. Three 4-0 nylon suture loops are placed transcutaneously and into the pocket at the markings of the preferred lower medial border of the reconstructed breast. After microvascular anastomosis and temporary shaping of the flap on top of the mastectomy skin, the three corresponding points for the sutures are identified. The three nylon loops are then sutured to the dermis of the corresponding medial point of the flap. The flap is placed into the pocket by a simultaneous gentle pull on the three sutures and a combined lateral push. The stitches are then tied and buried after completion of flap inset.

The Effect of Negative Pressure on Wound Healing and Regeneration in Closed Incisions under High Tension: Evidence from Animal Studies and Clinical Experience.

Closed-incision negative-pressure wound therapy (iNPWT) is known to enhance wound healing and tissue regeneration. The main aim of the present study is to investigate its effectiveness on enhancing wound healing under tension. An animal study was designed using a swine model by removing a skin flap to create a wound that could be closed primarily under tension, and iNPWT was applied. The enhancement of angiogenesis, lymphangiogenesis, collagen deposition, and tissue proliferation with reduced inflammation by iNPWT was confirmed by histology. The effect of iNPWT was further verified in patients receiving a profunda artery perforator (PAP) free flap for breast reconstruction. iNPWT was applied on the transversely designed donor site in continuous mode for 7 days, in which the wound was always closed under tension. A significant improvement in off-bed time was noted with the application of iNPWT (4.6 ± 1.1st and 5.5 ± 0.8th postoperative days in the iNPWT and control groups, respectively, p = 0.028). The control group (without iNPWT treatment) presented more cases of poor wound healing in the acute (23.1% vs. 0%) and wound breakdown in the late (23.1% vs. 8.3%) stages. The treatment of closed incisions under tension with iNPWT clinically enhances wound healing and tissue regeneration and with histological evidence.

Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series.

BACKGROUND: The application of robotic-assisted nipple-sparing mastectomy (R-NSM) has allowed mastectomy to be performed via a small incision. Breast reconstruction with free autologous tissue results in the most natural and long-lasting results, however, its application in R-NSM can be difficult via the small incision and haven't been explored in depth. The purpose of the study was to investigate the feasibility and aesthetic outcome of free perforator flap breast reconstruction via small lateral chest wall incision after R-NSM. MATERIALS AND METHODS: A retrospective chart review was conducted to identify patients who received R-NSM and free perforator flap reconstruction as the study group and patients who received conventional nipple-sparing mastectomy (C-NSM) and free perforator flap reconstruction as the control group from January 2018 to August 2020 by single reconstructive surgeon. Patient demographic data, complications from both mastectomy and reconstruction, status of resection margin and oncological outcome were reviewed. Aesthetic outcome was evaluated by 9 plastic surgeons. RESULTS: A total of 63 patients were included of which 22 (34.9%) received R-NSM and 41 (65.1%) received C-NSM. Their demographic data, reconstruction flaps, overall complication rate and follow up time were similar. Unlike C-NSM, majority of the R-NSM groups used the thoracodorsal or lateral thoracic vessels as the recipient vessels. Patients in the R-NSM group has smaller scar and better aesthetic outcome in the symmetry of breast inframammary fold, scar location and visibility, and overall aesthetic outcome. CONCLUSION: Although with difficulty in microvascular anastomosis and flap inset and shaping, R-NSM with perforator flap reconstruction presented with equal surgical and oncological safety with C-NSM and even better aesthetic results.

Direct-to-implant breast reconstruction following nipple-sparing mastectomy: predictive factors of adverse surgical outcomes in Asian patients.

BACKGROUND: Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes. METHODS: Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed. RESULTS: There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025). CONCLUSIONS: Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

The "Safe Index" Considering Body Surface Area for Prolonged Dexamethasone Regimen in Airway Control After Head and Neck Microsurgical Reconstruction.

BACKGROUND: Dexamethasone (Dexa) is frequently administrated to patients receiving head and neck microsurgical reconstruction with nasotracheal intubation postoperatively for airway control. Infection is the greatest concern when prolonging the treatment course. We aimed to find out the relationship between flap infection and the safe dose of Dexa. MATERIALS AND METHODS: A retrospective review of enrolling total 156 patients underwent microsurgical free flap reconstruction for head and neck cancers with nasotracheal intubation from December 2015 to December 2016 was conducted. Among them, 139 patients had received prolonged Dexa treatment course (>2 days). Safe index was then defined as the total amount of used Dexa (in milligrams) over body weight (in kilograms), body mass index (in kilograms per square meter) and body surface area (BSA, in square meter). Statistics were performed for the cutoff level of the safe index and to find out the independent risk factors. RESULTS: The cutoff level of the safe index was 0.76 for body weight group, 2.28 (10-3 m2) for body mass index group, and 33.84 mg/m2 for BSA group. Safe index for BSA group also outweighed other risk factors in multivariant analysis (odds ratio = 6.242, 95% confidence interval = 2.292-17.002, P = 0.000), which is the only independent risk factors for flap infection in our cohort. CONCLUSIONS: Throughout our study, the "safe index" helps clinician easily predict flap infection risk when using Dexa as the medication for airway control after head and neck microsurgical reconstruction.

A constant harvest technique for chimeric anterolateral thigh flaps and patient outcomes following their use in reconstructive head and neck surgery.

BACKGROUND: Chimeric anterolateral thigh free flaps (ALT) have been commonly used for head and neck defects, which require two epithelial lined surfaces. However, because of unpredictable vascular anatomy, it is a challenge to consistently elevate large chimeric flaps with multiple perforators based on the Lateral Circumflex Femoral Artery (LCFA). Here, we present our method to reliably harvest a chimeric flap from the ALT territory and investigate its long-term outcomes when used in the reconstruction of extensive head and neck defects. METHODS: A prospective review of practice consisting of 27 patients, between January 2011 and April 2019, with extensive through-and-through head and neck defects, which require dual paddle flaps underwent reconstruction with chimeric ALT harvested with a portion of distal vastus lateralis. The age of the patients ranged from 32 to 68 years (mean 53.2 years). RESULTS: Flap length ranged from 17 to 30 cm (mean, 25.6 cm). The mean flap area was 261.6 cm2 (range, from 225 to 340 cm2). The mean ischemia time was 162.9 min (range, from 59 to 269 min). At a mean follow-up time of 33.4 months (range, from 4 to 91 months), four patients died of cancer recurrence. For the other 23 patients, 4 required revision to achieve better cosmetic lip competence. All flaps survived with two recorded returns to theater for pedicle exploration associated with partial flap loss only. CONCLUSION: Harvesting the chimeric ALT with a portion of vastus lateralis distally negates the need for tenuous intramuscular perforator dissection. It is a reliable option for head and neck surgery, which require composite reconstruction. Using this technique produces a good functional cosmetic outcome. It also allows large defects to be reconstructed in a single sitting with free tissue transfer.

The Benefits of the Supercharged Ileocolic Flap in Patients Who Underwent Total Esophagectomy and Gastrectomy.

BACKGROUND: Patients who undergo total esophagectomy and gastrectomy present a challenging scenario for reconstructive surgeons. Several techniques have been described. However, the best choice is still a matter of debate. We aim to report our experience with the supercharged ileocolic flap, then to compare the long-term functional outcomes in cancer and caustic injury patients. We investigate the safest route of transposition and demonstrate the importance of supercharging the flap. Last, we perform a literature review to compare our results with the ones reported in the literature. METHODS: A total of 36 patients underwent the supercharged ileocolic flap procedure. The details reviewed included the type of defect, flap characteristic, route of transposition, complications, patient survival, and swallowing evaluation. Survival and long-term function preservation were considered as the main outcomes. A secondary end-point was the identification of the safest route of transposition. We extracted the pertinent literature on supercharged bowel flaps from 1995 to July 2020 RESULTS: All flaps survived; only two flaps were partially lost. Thirty-three percent of the cohort experienced postoperative complications; the most common was leakage of the cervical anastomosis (17%), followed by neck wound infection (8%). The 5-year dysphagia-free survival rate was 87% in corrosive injury patients and 78% in cancer patients. The mean time to be free from dysphagia after surgery was 25.12 ± 4.55 months for corrosive patients and 39.56 ± 9.45 months for cancer patients (p = 0.118). The safest route of transposition was retrosternal extra-mediastinal. From the literature review, the data from 11 studies were extracted. CONCLUSION: The supercharged ileocolic flap is a robust option for total esophageal replacement when the stomach is not available and the retrosternal route is the safest for transposition. The functional outcomes are excellent, with acceptable morbidity and a good life expectancy, either in cancer and noncancer patients. Supercharging the flap is recommended.

Complication analysis of three different designs of temporary mandibulotomy in tongue cancer treatment.

BACKGROUND: Mandibulotomy helps access posterior oral cavity tumors. If osteotomy designs affect postoperative and postradiotherapy complications, needs to be tested clinically. METHODS: Two hundred and eighteen patients who underwent midline mandibulotomy for primary tongue cancer wide excision and flap reconstruction at Chang Gung Memorial Hospital during 2014-2019. RESULTS: There were 114 straight, 54 notched, and 50 stair-stepped osteotomy cases. Stair-stepped osteotomy had less advanced tumor stages (P = .009) and notched osteotomy more common single-plate fixations (P = .012). The former showed higher mandibular heights (P = .000) and more intact midline teeth (P = .011) than notched and straight ones. Straight osteotomy cases showed lower early infection rates (P = .039). Single-plate fixation was related to more flap dehiscence (P = .001) and oro-cutaneous fistulas (P = .035). CONCLUSIONS: Complex osteotomy does not offer long-term benefits in midline mandibulotomies for primary tongue cancers and has higher early infections. Single-plate fixation increases postoperative complications.