A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach.

INTRODUCTION: Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle. MATERIALS AND METHODS: All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS: From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25 years, the mean weight was 76.6 kg, and the average BMI was 28.1 kg/m2. The average operating time was 102 min, and the mean weight excised was 459.5 g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4 days. No major complications were reported, and there were no cases of reintervention or recurrence. CONCLUSIONS: Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of subtotal pharyngolaryngectomy using a fasciocutaneous free flap with cartilage graft: A case series of 17 patients.

INTRODUCTION: Subcricoid-hemilaryngopharyngectomy (SCHLP) with a reconstruction using a fasciocutaneous free flap armed with cartilage graft (FFACG) aims to avoid permanent tracheostomy while still maintaining the laryngopharyngeal functions. The purpose of this study is to report the outcome of this surgical approach. MATERIALS AND METHODS: Retrospective study including 17 men operated between 2001 and 2019. Specific survival rate included death caused by cancer or SCHLP complications. Complications, functional and oncological outcomes were evaluated retrospectively. RESULTS: There were no locoregional recurrences. One patient died due to inhalation pneumonia 3 years after surgery. Tracheostomy was closed in 13 patients (76.5%). Mean decannulation time was at six [1-14] months after surgery. CONCLUSION: SCHPL with FFACG could avoid total pharyngolaryngectomy with good oncologic results. However, tracheotomy is extended and deglutition recovery is long with high risk of aspirations. These complications justify that such surgery should be realized only on selected patients by experienced surgical teams. Expertise of the surgical team is critical.

Outcomes of mandibular reconstruction using three-dimensional custom-made porous titanium prostheses.

BACKGROUND: Our aim was to report the long-term outcomes of mandibular reconstruction using CAD-CAM-designed 3D-printed porous titanium implants in patients not amenable to a free vascularized fibula flap reconstruction. METHODS: The implants were designed with ProPlan CMF® 2.2 software and manufactured with a Selective Laser Melting (SLM) "layer-by-layer" 3D-printing of pure porous titanium powder beds. Primary endpoints were implant exposure and implant removal calculated using Gray's tests. Secondary endpoints were predictive factors of implant exposure and implant removal, and rates of dental rehabilitation. RESULTS: Thirty-six patients were operated between 2015 and 2017 and were included in this study. Reconstruction using a porous titanium 3D-printed implant was proposed due to medical contraindication for a fibula free flap (n = 13), due to the failure of a previous fibula free flap reconstruction (n = 7), or due to refusal of a fibula free flap reconstruction by the patient (n = 16). The medical indications for mandibular reconstruction were a primary tumor requiring mandibulectomy in nine patients, mandibular osteoradionecrosis requiring mandibulectomy in nineteen patients, and secondary reconstruction in eight patients. The 2-year rates of implant exposure and implant removal were 69.4% and 52.8%. Reconstruction of the symphysis was a high-risk exposure variable (OR 30; p = 0.0003). Only one patient underwent a successful dental rehabilitation. CONCLUSION: The use of a porous titanium 3D- implant for mandibular reconstruction in head and neck cancer patients resulted in high rates of implant exposure and of implant removal, notably when symphysis involvement.

Head and neck Ewing sarcoma: French surgical practice analysis pleads for surgery centralization.

This study aimed to analyze surgical procedures for head and neck Ewing sarcoma (HNES) with regard to oncological, functional, and esthetic outcomes. A blinded multidisciplinary retrospective chart review of operated French HNES patients (Euro-EWING 99 trial, 1999-2014) was performed to assess patient/tumor characteristics, treatment details, and outcomes. Primary surgery without reconstruction was undertaken in 13 patients (emergency context/misdiagnosis). However, because of contaminated surgical margins, all patients had to undergo systematic postoperative radiotherapy. Twenty-six patients underwent multidisciplinary evaluation and were scheduled to undergo postchemotherapy surgery, with 19 patients scheduled for immediate reconstruction. All cases showed R0 margins after postchemotherapy surgery of the initial tumor bed by multidisciplinary surgical teams, while n = 3/4 of local relapses (very poor prognosis) had R1a margins after surgery of the residual tumor volume following chemotherapy. Only three surgical expertise centers operated on ≥ 4 patients over the 15-year period. Thirty patients developed long-term sequelae, with increased complications following radiotherapy. Referring patients to surgical expertise centers following a suspected diagnosis, with planned postchemotherapy surgery of the initial tumor bed at these centers, might limit the need for intralesional resections, allowing radical R0 resections and thus reducing long-term sequelae as well as the risk of secondary radio-induced malignancy by limiting the need for postoperative radiotherapy.

Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction.

We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.

The Chimeric Scapulodorsal Vascularized Latissimus Dorsi Nerve Flap for Immediate Reconstruction of Total Parotidectomy Defects With Facial Nerve Sacrifice: Building a New Program and Preliminary Results From 25 Cases.

BACKGROUND: Total parotidectomy with facial nerve sacrifice creates 2 challenging reconstructive problems: restoration of facial contour and facial nerve rehabilitation. Strong evidence suggesting that vascularized nerve grafts are superior to nonvascularized nerve grafts motivated our team to develop a chimeric scapulodorsal flap combining the usual harvestable local tissues with the vascularized latissimus dorsi motor nerve (SD-LDVxN). We present our experiences developing a new program at University of California, San Diego, highlighting our first case here, and present preliminary retrospective results focusing on the functional outcomes of facial nerve reanimation. MATERIALS AND METHODS: The first case performed in the United States was a 57-year-old woman with stage IVA left parotid adenoid cystic carcinoma and House-Brackmann grade 6 facial palsy. She underwent total parotidectomy with facial nerve sacrifice and a free chimeric SD-LDVxN flap reconstruction. She had an unremarkable postoperative course, and 3- and 6-month follow-up functional results are reported. Preliminary functional results from our total series of 25 patients were reported. RESULTS: At her 3-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 37, dynamic eFACE score of 31, and smile eFACE score of 48. At her 6-month follow-up, she was a House-Brackmann 5 with a static eFACE score of 50, dynamic eFACE score of 27, and smile eFACE score of 53. Preliminary results from our total series of 25 patients with an average of 5 years of follow-up were a House-Brackmann 2.5 and eFACE scores of 83.1 for static facial symmetry, 67.5 for dynamic facial symmetry, and 77.7 for smile score. Twenty of the 25 patients had postoperative radiotherapy. No local tumor recurrence had been reported. The average reinnervation time was 9 months and ranged from 3 to 15 months. CONCLUSIONS: The SD-LDVxN flap is a highly resourceful solution to reconstruct complex parotid defects, especially those that sacrifice the facial nerve. The vascularized nerve graft allows for primary facial reanimation. Nerve recovery may be superior to what could be expected with a conventional nerve graft.

Thin submental artery perforator flap for upper lip reconstruction: A case report.

Reconstruction of upper lip defects can be challenging even for experienced surgeons. In order to restore both function and morphology, the use of quality soft tissue is essential. To this effect, the most common solution is the use of local flaps, or, in extreme situations, a free flap. However, a thin cutaneous upper lip defect may require a different approach. Perforator flaps are versatile and may allow an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. We present the case of a 41-year-old female with a 1 × 1.5 cm basal cell carcinoma of the right-side upper lip, initially treated with a full thickness skin graft. Due to poor aesthetic and functional result, a thin submental artery perforator (SMAP) flap reconstruction was performed. Flaps' dimensions were 6 cm long and 4 cm wide and it was based on a perforator arising from the submental artery. Dissection was conducted above the platysma muscle, and the SMAP flap was transferred into the defect through a subcutaneous tunnel created below the mandible and posterior to the anterior belly of digastric muscle. The pedicle length of 6.5 cm was adequate for a tension free inset of the flap. Postoperative course was uneventful and the patient was discharged after 2 days. The 4-month follow-up showed a satisfying functional and aesthetic outcome with a concealed donor site scar. This report points out the coverage potential of the thin SMAP flap, which can be successfully used for a harmonious reconstruction in both color and texture of the upper lip.

Three-Dimensional Custom-Made Surgical Guides in Facial Feminization Surgery: Prospective Study on Safety and Accuracy.

BACKGROUND: Facial feminization surgery (FFS) includes several osseous modifications of the forehead, mandible, and chin, procedures that require precision to provide the patient with a satisfactory result. Mispositioned osteotomies can lead to serious complications and poor aesthetic outcomes. Surgical cutting guides are commonly employed in plastic and maxillofacial surgery to improve safety and accuracy. Yet, to our knowledge, there is no report in the literature on the clinical application of cutting guides in FFS. OBJECTIVES: The authors sought to assess the safety and accuracy of custom surgical cutting guides in FFS procedures. METHODS: A prospective follow-up of 45 patients regarding FFS with preoperative virtual planning and 3-dimensional custom-made surgical guides for anterior frontal sinus wall setback, mandibular angle reduction, and/or osseous genioplasty was conducted. Accuracy (superimposing preoperative data on postoperative data by global registration with a 1-mm margin of error), safety (intradural intrusion for the forehead procedures and injury of the infra alveolar nerve for chin and mandibular angles), and patient satisfaction were assessed. RESULTS: A total 133 procedures were documented. There was no cerebrospinal fluid leak on the forehead procedures or any infra alveolar nerve or tooth root injury on both chin and mandibular angle operations (safety, 100%). Accuracy was 90.80% on the forehead (n = 25), 85.72% on the mandibular angles (n = 44), and 96.20% on the chin (n = 26). Overall satisfaction was 94.40%. CONCLUSIONS: Custom-made surgical cutting guides could be a safe and accurate tool for forehead, mandibular angles, and chin procedures for FFS.

Reconstruction of Extensive Composite Parotid Region Oncologic Defects with Immediate Facial Nerve Reconstruction Using a Chimeric Scapulodorsal Vascularized Nerve Free Flap.

BACKGROUND: Cancer involving the parotid gland region may originates from parotid parenchyma itself or from locoregional organs and in rare cases, the facial nerve (FN) has to be sacrificed during tumor resection. In these cases, cancer extension often goes beyond the parotid compartment and requires extensive local resection responsible for complex multitissular defects. The goals of reconstruction may be summarized in the following two components: (1) restoration of the volumetric tissue defect and (2) FN reconstruction. The aim of this study is to describe our surgical technique and our cosmetic results using the chimeric scapulodorsal vascularized nerve (SDVN) flap to reconstruct extensive maxillofacial defects associated with FN sacrifice. METHODS: All patients undergone an extensive maxillofacial resection with FN sacrifice and primarily reconstructed with a SDVN flap were included. We classified the maxillofacial defects into six groups based on the type of resection. Intraoperative data including flap composition, topography of FN injury, length of nerve gap, and number of nervous anastomosis were recorded. RESULTS: Twenty-nine patients were included. Mean follow-up was 38.7 months. The harvested flaps included the SDVN combined with different components according to the defect group. A satisfactory volumetric restoration was obtained in 93% of cases. The mean number of distal nervous anastomosis was 4.5. The length of the vascularized grafted nerve ranged from 7 to 10 cm. CONCLUSION: This is largest series presented in literature on primary FN reconstruction utilizing a vascularized nerve graft. We believe that the chimeric SDVN flap should be highly considered for these cases due to its versatility. The surgeon is able to use single donor site available soft and hard tissues components along with a vascular motor nerve graft, which offers a great length and number of distal branches, and easily matches with the extracranial FN trunk and its peripheral ramifications.

Revisiting the temporal artery posterior auricular skin flap with an anatomical basis stepwise pedicle dissection for use in targeted facial subunit reconstruction.

BACKGROUND: This study demonstrates the anatomy of the pedicled temporal artery posterior auricular skin (TAPAS) flap, its variable arc of rotation based on stepwise dissection, and case reports demonstrating clinical use. This flap provides excellent color match and ultrathin tissue for targeted reconstruction of small- to medium-sized facial subunit defects. METHODS: Twenty-six cadaver dissections were performed. The authors measured the reach and rotation limits of the flap in a pedicled fashion depending on a stepwise approach for vascular pedicle dissection. Two clinical cases demonstrating maximum arc of rotation are seen. RESULTS: The pedicled TAPAS flap maximal rotation limits allow for reconstruction of facial subunits encompassing nearly the entire ipsilateral face. No venous congestion, wound complications, or partial/total flap loss were encountered with extreme clinical applications. CONCLUSION: The pedicled TAPAS flap has extensive versatility for reconstruction of a variety of facial subunit defects. The flap also has, in theory, multiple applications for intraoral reconstruction.

Bipedicled dorsal intercostal artery propeller flaps for reconstruction of extensive cervicothoracic midline defects.

BACKGROUND: Propeller flaps have been reported to cover cervicothoracic midline defects with lower donor site morbidity compared to muscle flaps. When these defects are extensive, we propose a propeller flap technique that we have named dorsal intercostal artery perforator plus (DICAP+) flap based on two perforator pedicles, to secure the large skin paddle. In this article, we present our experience. METHODS: Six propeller DICAP+ flap procedures were performed on five patients, to reconstruct cervicothoracic midline defects. Three of them were caused by tumors and two were secondary to hardware exposure after spinal surgery. Defect sizes ranged from 16 × 5 to 24 × 9 cm. Every propeller flap was harvested on two perforators including one DICAP, and rotated from 80° to 180°. RESULTS: Skin ellipse size ranged from 15 × 7 cm or 82.4 cm2 to 25 × 12 cm or 235.5 cm2 , equal to a mean surface area of 160 cm2 . The donor site was closed by primary suturing in four of the six procedures, by a contralateral propeller DICAP flap in one patient, and was left to heal by secondary intention in another one. All six flaps successfully covered the underlying defects with no evidence of partial or complete necrosis. No other complications were observed at recipient and donor sites. The follow-up period ranged from 9 months to 2 years. CONCLUSIONS: Propeller flaps based on two dorsal perforators including one dorsal intercostal artery perforator, DICAP+, are a reliable means of reconstructing extensive cervicothoracic midline defects.

Facial functional outcomes analysis after reconstruction by vascularized thoracodorsal nerve free flap following radical parotidectomy with facial nerve sacrifice.

BACKGROUND: Parotid spread tumor may occasion wide defect with facial nerve sacrifice. We report our one time reconstruction experience of this defect using a thoracodorsal artery perforator and nerve flap (TAPN). METHODS: Eight patients underwent a radical parotidectomy with facial nerve sacrifice between February 2010 and June 2016. A single time reconstruction was performed using a thoracodorsal artery perforator and nerve flap, with skin or fat paddle. The thoracodorsal nerve vascularized was harvested and used to reconstruct the facial nerve from the trunk to four until six distal branches. Patients underwent physiotherapy for 3 months at least. Facial outcomes were assessed using House-Brackmann scale and eFACE application. OUTCOMES: Mean follow-up was 30 months. No complication occurred on donor site. All patients recovered a complete soft eye closure. No Frey syndrome occurred. CONCLUSION: TAPN is adapted to wide and complex parotid defects.

Predictive value of the milking patency test when performing the arterial microanastomosis in head and neck surgery.

BACKGROUND: The milking patency test (MPT) is widely used to assess the patency of microanastomosis, despite it being proven to be a traumatic test. METHODS: We performed microanastomoses with intentional two-wall stitches and asked senior microsurgeons to evaluate the permeability of the anastomoses by looking first at the results of the MPT, then according to artery pulsation. RESULTS: Microsurgeons were all accurate in evaluating normal or clamped anastomoses. But in anastomoses with defects, the MPT was considered normal 94%, 85%, and 73%. MPT has a positive predictive value of 100% but with a negative predictive value of 27.5%. Observation of the artery pulsation distal to the anastomosis gave similar results. CONCLUSIONS: Our experiment shows that the two-wall stitches on arterial anastomoses are hardly detected by an MPT. The observed pulsation of the artery gives the same results and could be used instead, without damaging the vessels.

The infraorbital artery: From descriptive anatomy to mucosal perforator flap design.

BACKGROUND: The terminal and perforating branches of the infraorbital artery (IOA) are poorly described. Its anatomical situation and mucosal component could provide an interesting donor site for mucosal reconstruction. The aims of the following study were to establish an anatomical description and to assess the feasibility of mucosal perforator flaps for eyelid and nasal reconstruction. METHODS: Twenty-three fresh cadaver hemifaces were studied in order to perform an IOA anatomical classification by recording the artery's characteristics, its course, number, type, and diameter of terminal branches. We also examined the feasibility of local flaps for facial reconstruction. RESULTS: We highlighted five different types of courses. All cadavers had at least one superior vestibular branch with a caliber of ≥0.4 mm. A pedicled flap arising from the vestibular branch was raised in all dissections. CONCLUSION: The vestibular perforator flap based on the IOA seems to be a reliable flap in reconstruction of mucosal defects.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer.

OBJECTIVE: We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical-transoral robotic oropharyngectomy course with free flap reconstruction. METHODS: Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre-operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery. RESULTS: Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous-cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications. CONCLUSIONS: In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations. LEVEL OF EVIDENCE: 4.

Total nasal reconstruction with 3D custom made porous titanium prosthesis and free thoracodorsal artery perforator flap: A case report.

Total nasal reconstruction is a challenging surgical procedure which usually involves a free flap, forehead flap, and cartilage grafts. In certain failure situations where patients do not accept the idea of anaplastology, possibilities become very limited. We report the case of a patient who underwent several reconstruction steps with multiple failures including free and local flaps and cartilage harvests which showed recurrent episodes of necrosis and infection leading to melting and collapse of reconstructed structures. Furthermore, the patient did not want any anaplastological rehabilitation. We proposed to the patient an innovative method that consists to print a three-dimensional custom-made porous titanium prosthesis, based on the original shape of his nose, to replace the cartilage support. This implant was first inserted in a thoracodorsal artery perforator flap for primary integration before the free transfer of the complete structure, two months later. The free transfer was successful without any complication. A stable reconstruction and satisfying result was obtained. The patient did not want additional surgical improvement 24 months post-operatively, and resumed his professional activities. The possibility of using three-dimensional custom titanium prostheses to replace the bone and cartilage support seems to be an interesting alternative for patients in the failure situation of nasal reconstruction.

Reliability of Color Doppler Ultrasound Imaging for the Assessment of Anterolateral Thigh Flap Perforators: A Prospective Study of 30 Perforators.

Despite numerous advantages, the anterolateral thigh perforator flap suffers from the variable position and nature of its perforators. The aim of the authors' study was to assess the reliability of preoperative color Doppler ultrasound imaging for the exploration of perforator location and course of anterolateral thigh perforator flaps. A prospective cohort study involving patients for whom head and neck reconstruction was planned with thin anterolateral thigh perforator flaps was conducted. Each patient underwent a color Doppler ultrasound exploration of the thighs, in the operating room, immediately before surgery. The sonographer was the surgeon who raised the flaps. Perforators were sought according to surgical needs, and the same location protocol was followed for all of the cases, using an orthonormal coordinate system to report the passages of the perforators through the vastus lateralis aponeurosis. Between January of 2016 and January of 2017, 22 thin anterolateral thigh perforator flaps were successfully harvested. Thirty perforators were located and used. The median distance between the preoperative color Doppler ultrasound planning and the final location of the perforators was 5 mm, statistically smaller than a 10-mm threshold (p = 0.002). Color Doppler ultrasound effectively predicted the nature of the perforators in 90 percent of the cases. The median duration for perforator color Doppler ultrasound location was 3 minutes, statistically shorter than 10 minutes (p = 0.0001). Preoperative color Doppler ultrasound seems to be reliable, accurate, and compatible with a quick routine assessment during patient setup for the elevation of thin anterolateral thigh perforator flaps. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Early assessment of feasibility and technical specificities of transoral robotic surgery using the da Vinci Xi.

The latest generation Da Vinci® Xi™ Surgical System Robot released has not been evaluated to date in transoral surgery for head and neck cancers. We report here the 1-year results of a non-randomized phase II multicentric prospective trial aimed at assessing its feasibility and technical specificities. Our primary objective was to evaluate the feasibility of transoral robotic surgery using the da Vinci® Xi™ Surgical System Robot. The secondary objective was to assess peroperative outcomes. Twenty-seven patients, mean age 62.7 years, were included between May 2015 and June 2016 with tumors affecting the following sites: oropharynx (n = 21), larynx (n = 4), hypopharynx (n = 1), parapharyngeal space (n = 1). Eighteen patients were included for primary treatment, three for a local recurrence, and six for cancer in a previously irradiated field. Three were reconstructed with a FAMM flap and 6 with a free ALT flap. The mean docking time was 12 min. "Chopsticking" of surgical instruments was very rare. During hospitalization following surgery, 3 patients experienced significant bleeding between day 8 and 9 that required surgical transoral hemostasis (n = 1) or endovascular embolization (n = 2). Transoral robotic surgery using the da Vinci® Xi™ Surgical System Robot proved feasible with technological improvements compared to previous generation surgical system robots and with a similar postoperative course. Further technological progress is expected to be of significant benefit to the patients.