Functional outcomes of reconstructive flap surgery for soft tissue sarcoma: Long-term outcomes of functional restoration using innervated muscle transplantation.

Functional outcomes associated with prognostic factors and innervated muscle transplantation after wide soft tissue sarcoma resection remain unclear. We retrospectively examined the functional outcomes of reconstructive flap surgery for soft tissue sarcoma. Twenty patients underwent innervated muscle transplantation with pedicled or free flaps for functional reconstruction of resected muscles. Thirteen latissimus dorsi muscles and one vastus lateralis muscle combined with an anterolateral thigh flap were transferred as free flaps using the epi-perineural suture technique. Six latissimus dorsi muscles were transferred as pedicled flaps with neural continuity. Postoperative functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) scores for the upper and lower extremities of 22 and 24 patients, respectively. The mean MSTS score for all patients was 82.3 at 12 months postoperatively. The mean scores for patients who underwent reconstruction with pedicled and free flaps were 89.2 and 77.1, respectively. The MSTS scores for the lower extremity, tumor size ≥5 cm, and free flap reconstruction were significantly lower than those for the upper extremity, tumor size <5 cm, and pedicled flap reconstruction (P = 0.02, 0.37, and 0.008, respectively). The postoperative MSTS score for innervated muscle transplantation was 76.7 at 12 months and was significantly higher (83.7) at 24 months (P = 0.003). Functional outcomes were significantly associated with tumor location, tumor size, and reconstructive flap type based on the MSTS scores. Innervated muscle transplantation improved functional outcomes at 24 months postoperatively via sufficient recovery of the innervated muscle, not the compensatory recovery of the remaining muscle.

A retrospective propensity score-matched analysis of oncological and functional outcomes of submental island flap versus radial forearm free flap for oral cavity cancer reconstruction.

BACKGROUND: This retrospective study aims to compare the oncological and functional outcomes of the submental island flap versus the radial forearm free flap used for oral cavity cancer reconstruction after minimizing differences in baseline characteristics. METHODS: Propensity scores for each oral cavity cancer patient who underwent surgical resection and immediate reconstruction with a submental island flap or a radial forearm free flap with a flap size ≤ 60 cm2 between October 2008 and December 2021 were generated based on the likelihood of being selected given their baseline characteristics. Patients were matched using a 1:1 nearest-neighbor approach. RESULTS: The final matched-pair analysis included 51 patients in each group. The 5-year overall survival, disease-specific survival, and locoregional control rates were 70.1% and 64.8% (p = 0.612), 77.3% and 83.7% (p = 0.857), and 76.1% and 73.3% (p = 0.664), respectively, for the submental island flap group and the radial forearm free flap group. Speech and swallowing functions were comparable between groups. However, there were significantly lower rates of complication associated with both donor and recipient sites in the submental island flap group, and also the duration of hospital stays and hospital costs were significantly lower in these patients. A subgroup analysis of patients in which the reconstruction was carried out using the submental island flap procedure revealed that in selected cases, the presence of clinically and pathologically positive level I lymph nodes did not affect survival or locoregional control rates. CONCLUSIONS: Although this study was not randomized, the matched-pair analysis of surgically treated oral cavity cancer patients showed that submental island flap reconstruction is as effective as radial forearm free flap reconstruction with regard to oncological and functional outcomes with lower complication rates, hospital stay, and hospital costs. This flap can be safely and effectively performed in selected cases with a clinical level I lymph node smaller than 1.5 cm and no signs of extranodal extension.

Surgical Treatment of Malignant Peripheral Nerve Sheath Tumor of the Scalp With Intracranial and Extracranial Extension: A Rare Case Report.

ABSTRACT: Malignant peripheral nerve sheath tumors of the scalp are rare neoplasms of the peripheral nervous system. Here, we describe an unusual malignant peripheral nerve sheath tumor of the scalp in an 84-year-old Asian man. The tumor was associated with bony destruction, intracranial, and extracranial extension. Trans-arterial embolization was done twice preoperatively. En block excision was performed and the dura and soft tissue defect were reconstructed by anterolateral thigh free fasciocutaneous flap. There is no recurrence and the wound healed well during follow-up.

Tandem Reconstruction of the Femoral Diaphysis Using an Intercalary Prosthesis and a Fibular Free Flap.

BACKGROUND: Femoral diaphyseal reconstructions with metal prostheses have mediocre results because of high mechanical forces that result in eventual implant failure. Biological alternatives require prolonged restrictions on weight-bearing and have high rates of infection, nonunion, and fracture. A novel method of utilizing a vascularized fibula in combination with an intercalary prosthesis was developed to complement the immediate stability of the prosthesis with the long-term biological fixation of a vascularized fibular graft. METHODS: A prospectively maintained database was retrospectively reviewed to identify patients who underwent reconstruction of an oncological intercalary femoral defect using an intercalary prosthesis and an inline fibular free flap (FFF). They were compared with patients who underwent femoral reconstruction using an intercalary allograft and an FFF. RESULTS: Femoral reconstruction with an intercalary metal prosthesis and an FFF was performed in 8 patients, and reconstruction with an allograft and an FFF was performed in 16 patients. The mean follow-up was 5.3 years and 8.5 years, respectively (p = 0.02). In the bioprosthetic group, radiographic union of the fibula occurred in 7 (88%) of 8 patients, whereas in the allograft group, 13 (81%) of 16 patients had allograft union (p = 1.00) and all 16 patients had fibular union (p = 0.33). The mean time to fibular union in the bioprosthetic group was 9.0 months, whereas in the allograft group, the mean time to allograft union was 15.3 months (p = 0.03) and the mean time to fibular union was 12.5 months (p = 0.42). Unrestricted weight-bearing occurred at a mean of 3.7 months in the prosthesis group and 16.5 months in the allograft group (p < 0.01). Complications were observed in 2 (25%) of 8 patients in the prosthesis group and in 13 (81%) of 16 patients in the allograft group (p = 0.02). Neither chemotherapy nor radiation affected fibular or allograft union rates. Musculoskeletal Tumor Society scores did not differ significantly between the groups (mean, 26 versus 28; p = 0.10). CONCLUSIONS: Bioprosthetic intercalary femoral reconstruction with a metal prosthesis and an FFF resulted in earlier weight-bearing, a shorter time to union, fewer operations needed for union, and lower complication rates than reconstruction with an allograft and an FFF. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Second primary carcinoma arising on a flap: a new primary or a relapse?

BACKGROUND AND AIM: Free flaps or pedicle flaps are the mainstay of cancer surgery in the head and neck area. However, their long-term sequelae are still poorly understood. Among these, the development of a secondary primary tumor on a flap is a rare and uncertain reported event.   Methods: A computer-aided systematic literature search was performed by using the PubMed, EMBASE and Cochrane Library databases. A systematic review of the literature, following the PRISMA checklist, was carried out with the aim of analyzing all the citations reporting this second primary, with attention to risk factors, behavior, etiological causes.   Results: Overall, 27 cases of second primary squamous cell carcinoma arising on a pedicle or free flap were identified. In addition, other three cases were discussed.   Conclusions: Persistent exposure to oral stimuli such saliva, oral microbiome, smoke or a colonization by the adjacent mucosa were considered as a possible cause of second primary carcinoma. Although rare, a new neoplasm onset should know and considered as a new concept in the follow-up of patients undergoing reconstruction with free or pedicle flaps.

Complications and Peri-operative Characteristics of Flaps for Reconstruction of Defects after Ablation of Squamous Cell Carcinoma of the Floor of the Mouth.

OBJECTIVE: To determine the appropriate method to use to repair defects after ablation of squamous cell carcinoma (SCC) of the floor of the mouth (FOM). METHODS: A retrospective review of 119 patients who underwent surgical resections of SCC of the FOM and flap reconstructions was conducted. A Student t test was used to examine the statistical differences in operative time, length of hospital stay and complications among groups with different reconstructions. RESULTS: Advanced-stage patients were repaired with more free flaps than local pedicled flaps that provided more reconstructions for small-to-medium defects. The most common recipient complication was wound dehiscence, and patients in the anterolateral thigh flap group developed a greater number of overall recipient site complications compared with those in other groups. Patients undergoing local flap reconstructions had shorter operative times compared with those with free flap reconstructions. CONCLUSION: In contrast to a radial forearm free flap as a more appropriate reconstruction for defects involving the tongue, an anterolateral thigh flap was better suited for defects with dead spaces. A fibular flap was appropriate for massive complex defects involving the mandible, FOM and tongue. A pectoralis major musculocutaneous flap provided the last line of reconstruction for patients with relapsed SCC or high-risk factors for microsurgical reconstructions.

Twelve Years of Establishing the Strategies for Tongue Reconstruction.

BACKGROUND: Reconstruction after resection of malignant tongue tumors remains one of the most difficult problems in head and neck oncology. Recent trends in tongue reconstruction have focused on optimizing speech and swallowing functions and maximizing quality of life. In the recent literature, several reconstructive strategies including regional flaps and free flaps have been described. PATIENTS AND METHODS: A case series of 328 patients underwent oral tongue reconstruction between March 2011 and March 2022. Functional evaluation was performed in all patients 3 months after reconstruction (where the patients required no adjuvant radiotherapy) or after radiotherapy. RESULTS: Total flap necrosis was seen in 5 patients with free flap reconstruction (2 radial forearm flaps, 1 lateral arm flap, and 2 anterolateral thigh flaps), 5 patients with infrahyoid myocutaneous flap, and 1 patient reconstructed with a supraclavicular flap. Our success rate is 96.6%; partial flap necrosis was observed in 11 patients with infrahyoid myocutaneous flap and 2 patients with a supraclavicular flap. Most patients with subtotal glossectomy or smaller defects (type II-IVA defects) could communicate on the phone and had the near-normal capacity for an oral diet. The remaining patients (type IVB-V defects) had significantly lower speech scores. The majority of patients could eat liquid and semiliquid foods. CONCLUSION: Tongue cancer surgery and subsequent reconstruction posed exciting challenges for the surgeon to optimize tongue function and quality of life for patients. Attention to the principles of tongue reconstruction and choosing appropriate flap for each defect achieve better functional results.

Effect of Peritoneal Fixation (PerFix) on Lymphocele Formation in Robot-assisted Radical Prostatectomy with Pelvic Lymphadenectomy: Results of a Randomized Prospective Trial.

BACKGROUND: Symptomatic lymphoceles present the most common complication of robot-assisted radical prostatectomy (RARP) with extended pelvic lymph node dissection (ePLND). No surgical technique has so far shown success in reducing the incidence rate, but several retrospective studies have shown the beneficial effect of the fixation of the peritoneum. OBJECTIVE: To introduce a modification in the technique of fixing the peritoneum to the pubic bone and to confirm whether this intervention reduces the incidence of lymphoceles. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized (1:1) single-center one-sided blind study was conducted in patients with localized prostate cancer (cT1-2cN0M0) indicated for RARP with ePLND operated between December 2019 and June 2021. In the intervention group, the free flap of the peritoneum was fixed to the pubic bone. In the control group, the peritoneal flap was left free without fixation. SURGICAL PROCEDURE: In the intervention group, the free flap of the peritoneum was fixed to the pubic bone (PerFix) so that lateral holes were left, allowing drainage of lymph from the pelvis into the abdominal cavity, where it would be resorbed. The iliac vessels and obturator fossa remained uncovered by the peritoneum and the bladder. MEASUREMENTS: The primary objective was to evaluate the frequency of symptomatic lymphoceles during follow-up. The secondary endpoints were the radiological presence of lymphoceles on computed tomography of the pelvis carried out 6 wk after surgery, the volume of the lymphoceles, and the degree of severe (Clavien-Dindo ≥3) complications. RESULTS AND LIMITATIONS: Of the 260 randomized patients, 245 were evaluated in the final analysis-123 in the intervention and 122 in the control group. The median follow-up was 595 d. There were no differences between the groups regarding clinical and pathological variables. The median of 17 nodes removed was the same in both groups (p = 0.961). Symptomatic lymphoceles occurred in 17 patients (6.9%), while in the intervention group these were found in three (2.4%) versus 14 (11.5%) in the control group (p = 0.011). The number of radiologically detected asymptomatic lymphoceles did not differ (p = 0.095). There was no significant difference in lymphocele volume between the two groups (p = 0.118). The rate of serious complications (Clavien 3a and 3b) was 4.8% in the intervention group and 9.1% in the control group (p = 0.587). A multivariate logistic regression model of symptomatic lymphocele occurrence was created with significant factors: body mass index (odds ratio [OR] = 1.1, 95% confidence interval [CI] = [1.03, 1.26], p = 0.012) and intervention (OR = 4.6, 95% CI = [1.28, 16.82], p = 0.02). CONCLUSIONS: Fixation of the peritoneum (PerFix) reduced the incidence of symptomatic lymphoceles in RARP with ePLND. We found no difference in the frequency of asymptomatic lymphocele development. The volume of the detected lymphoceles was similar. PATIENT SUMMARY: In this study, we compared the rate of development of postoperative complications using the peritoneal fixation technique with that of a nonfixation control group for robot-assisted radical prostatectomy with extended pelvic lymphadenectomy. Fixation of the peritoneum should obviate the development of severe complications in the postoperative period.

A 3-Dimensional Analysis of Flap Volume Change in Hemi-Tongue Reconstruction.

BACKGROUND: An adequate volume of the tongue flap is essential to preserve speech and swallowing functions. However, it is generally known that the volume of the free flap tends to decrease over time because of various reasons. Especially in hemi-tongue reconstruction, as half of the normal tongue is retained, some functions are maintained; consequently, there are few studies related to the volume of the flap and function. This study investigated the relationship between flap volume change and function after hemi-tongue reconstruction. METHODS: A retrospective chart review of 26 patients who underwent hemi-tongue reconstruction between 2003 and 2020 was performed. Patient demographic data, postoperative radiotherapy (RT), and data on flap types were collected. The volume of the flap was measured by converting the computed tomography and magnetic resonance images into 3 dimensions using the Mimics software. In addition, speech scores and feeding scores were collected. RESULTS: The first follow-up computed tomography or magnetic resonance imaging (T1) was performed after an average of 2.09 months, and the second follow-up imaging study (T2) was performed at 16.58 months on average. On average, the T2 volume was 64% of the T1 volume (range, 45.75%-90.54%). Factors including speech and swallowing functions were compared by dividing the group into a group with a more than average decrease in volume (group 1) and a group with a less than average decrease in volume (group 2). In group 1, there were significantly more cases of postoperative RT than in group 2 (85.7%, 50.0%, in group 1 and group 2, respectively; P = 0.049). However, there was no difference in the functional aspects between the 2 groups. CONCLUSIONS: The present study revealed that the flap volume decreased more when RT was performed. However, there was no association between the degree of volume loss and speech and swallowing functions. Regardless of the group, the loss of function was not severe, probably because the remaining half of the tongue was functioning.

Primary Cutaneous Cribriform Carcinoma of the Heel: A Rare Case Report.

Primary cutaneous cribriform carcinoma (PCCC) is an extremely rare carcinoma of the sweat glands. In this case report, we present a 41-year-old man with PCCC in the heel. The patient had heel pain for 10 months, and his complaints had increased in the past 2 months. Physical examination revealed a firm nonmobile mass at his heel. The PCCC in the heel was excised by wide resection after biopsy, and the defect that occurred after resection was reconstructed with a vascularized free anterolateral thigh flap. There were no complications during or after the surgery. No recurrence or metastasis was encountered during 48 months of follow-up. The patient continues his daily life activities without any problems or pain. In the heel, PCCC can be effectively treated by extensive resection and reconstruction of the defect with a skin graft/vascularized flap. Cribriform carcinomas of visceral organs and primary cutaneous adenoid cystic carcinoma should be included in the differential diagnosis, which should be made carefully, histopathologically, and immunohistochemically.

The impact of dynamic tongue reconstruction using functional muscle transfer: A retrospective review of 94 cases with functional outcome analysis for various glossectomy defects.

The aim of this study was to evaluate the functional outcomes of dynamic tongue reconstruction in various types of glossectomy defects. A retrospective review of patients who underwent tongue reconstruction following cancer resection was performed. Patients were divided into two groups by the type of procedure: dynamic reconstruction using motor-innervated free flaps and conventional reconstruction with fasciocutaneous free flaps. Demographics, including patient and tumor characteristics, and surgical factors, including the type of glossectomy and flap, were investigated. Functional outcomes were compared through quantitative assessment of tongue movement, speech capacity, videofluoroscopic barium swallow, and percutaneous endoscopic gastrostomy (PEG) tube dependency. 94 patients were enrolled in this study. The conventional reconstruction was performed in 52 patients and dynamic reconstruction was performed in 42 patients. Overall, the dynamic group showed improved swallowing capacity (videofluoroscopic swallowing scale, mean ± standard deviation, dynamic group, 3.24 ± 0.79, versus conventional group, 2.88 ± 1.08; p = 0.07). No significant differences in tongue motion and speech outcomes were noted between the groups. In multivariate logistic analysis controlling of various confounders, the dynamic reconstruction was significantly related to improved swallowing outcomes (adjusted odds ratio, 0.148; 95% confidence interval 0.03-0.725; p = 0.018). Dynamic reconstruction was not significantly related to the rate of PEG tube dependency. Within the limitations of the study, it seems that the dynamic tongue reconstruction using motor innervated free flaps can improve swallowing outcome by reproducing the original sling action of tongue musculature and preserving the tongue volume.

Efficacy of free anterolateral thigh flap and free jejunum in reconstruction for hypopharyngeal and cervical esophagus. / æ¸¸ç¦»è‚¡å‰å¤–ä¾§çš®ç“£å’Œæ¸¸ç¦»ç©ºè‚ é‡å»ºä¸‹å’½é¢ˆæ®µé£Ÿç®¡çš„ç–—æ•ˆ.

OBJECTIVES: Because of its peculiar anatomical location, most patients with hypopharyngeal and cervical esophageal cancer are at advanced stage when they visit the hospital. At present, the treatment for hypopharyngeal and cervical esophageal cancer is primarily surgical resection and radiotherapy. However, due to the wide range of surgical resection, it can often lead to a large range of annular defects. Therefore, the upper digestive tract reconstruction after tumor resection is very important. We use the free anterolateral thigh flap (ALT) and free jejunum (FJ) transfer to reconstruct the hypopharyngeal and cervical esophagus, and to investigate the effect of both reconstruction methods on upper gastrointestinal tract defects. METHODS: A retrospective analysis was conducted to investigate the clinical data of 42 patients with hypopharyngeal and cervical esophageal cancer (Clinical Stage IV) from Jan. 2004 to Jan. 2016 in the Second Xiangya Hospital of Central South University. All patients underwent total laryngopharyngectomy and cervical esophageal resection. The hypopharyngeal circumferential and cervical esophageal defects were reconstructed with free ALT (n=22) or FJ (n=20). Four patients who underwent radiotherapy and chemotherapy before surgery did not receive radiotherapy or chemotherapy after surgery. The remaining 38 patients underwent postoperative radiotherapy and chemotherapy. All patients were followed up by telephone or outpatient review, with a follow-up deadline in Jan. 2021. We compared the differences between the 2 groups in postoperative complications, radiotherapy complications, and survival rate. The differences in individual characteristics between 2 groups were analyzed using Fisher test. The differences in postoperative and radiotherapy complications between two groups were analyzed using χ² test. The 3- and 5-year overall survival rates were calculated using Kaplan-Meier survival curve method. RESULTS: In the ALT group, the postoperative complications mainly included anastomotic fistula, chylous fistula and subcutaneous hematoma of the donor site. The radiotherapy complication was anastomotic stenosis. However, in the FJ group, the postoperative complications mainly included chylous fistula, intestinal obstruction, and intestinal fistula. The radiotherapy complications mainly contained anastomotic fistula and tissue flap necrosis. The cases of postoperative complications in the ALT group and the FJ group were 7 and 5, respectively (P=0.625), and the cases of radiotherapy complications were 3 and 4, respectively (P=0.563). The 3-year overall survival rates in the ALT group and the FJ group were 52.9% and 46.7%, respectively, and the 5-year total survival rates were 35.1% and 31.9%, respectively (P=0.53). The cases of anastomotic stenosis after radiotherapy in the ALT group were more than those in the FJ group (P=0.097). However, the cases of jejunal necrosis and anastomotic fistula after radiotherapy in the FJ group were more than those in the ALT group (P=0.066). CONCLUSIONS: There are no significant differences in postoperative and radiotherapy complications and 3-and 5-year survival rates between the ALT group and the FJ group. The reconstruction with ALT is prone to develop anastomotic stricture. The reconstruction with FJ cannot withstand high-dose radiotherapy. The ALT and FJ are effective methods in the reconstruction of hypopharynx and cervical esophagus. The treatment protocol should be carefully chosen based on its advantages and disadvantages of these 2 methods.

Outcome Analysis of Advanced Oral Cancers Requiring Large Composite Fibular Osteocutaneous Flap Reconstruction: Experience From a Tertiary Care Cancer Hospital.

BACKGROUND: Advanced oral cancer entailing extensive resection of large parts of the mucosa, bone, and skin require reconstructions with composite free flaps. Our aim was to analyze the outcomes of those oral squamous cell carcinomas requiring fibular osteocutaneous free flaps with large skin defects. METHODS: Perioperative course and histopathological and survival outcomes of 246 consecutive patients warranting composite fibular flaps from January 2010 to June 2015 at Tata Memorial Hospital, Mumbai, India, were retrospectively analyzed. RESULTS: Despite majority of T4 disease (88.2%) and stage IV disease (92%) patients, the 5-year overall survival was 52.1% and the 5-year recurrence-free survival was 48.6% with a median follow-up of 42 months with minimal complications. CONCLUSIONS: Reconstruction with composite fibular osteocutaneous flaps has comparable outcomes of survival with acceptable complications in mega oral squamous cell carcinomas requiring extensive resection.

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection.

OBJECTIVE: The thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection. METHODS: From April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery-including end-to-end tracheal anastomosis and simple pharynx closure-was performed after thyroid carcinoma resection. The patients' records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed. RESULTS: When our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used. CONCLUSION: Our analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.

Total Pharyngo-Laryngo-Cervical-Esophagectomy with Jejunal Free Flap Reconstruction in a Developing Country: A Case Report from Vietnam.

BACKGROUND Esophageal invasion in hypopharyngeal cancer is an uncommon lesion and has a poor prognosis. Total pharyngo-laryngo-esophagectomy is the most effective treatment option. Reconstruction of the gastrointestinal tract in the same period of surgery is required. There are many different options, such as pedicle flap, gastric pull-up, pedicled transverse colon flaps, and free flap. In cases where only cervical esophagectomy is required, with benefits for patients, jejunal free flap is the first choice to reconstruct the esophagus. However, the extensive surgical resection requires interdisciplinary collaboration among surgical specialities, which is not always available. CASE REPORT A 52-year-old male patient came to us with a chief concern of dysphagia, which first appeared 3 months ago. Rigid fiberoptic and direct laryngoscopes indirectly observed the tumor at the posterior wall; it had passed the esophagus opening and infiltrated to the cervical esophagus, with the rightmost part spread into the right pyriform sinus. Histopathology studies of the tumor showed a squamous cell carcinoma. The patient underwent total pharyngo-laryngo-cervico-esophagectomy, reconstructed with a jejunal free flap, and adjuvant radiation therapy after surgery. At follow-up 1 year after surgery, the patient was significantly recovery with no signs of tumor recurrence, no difficulties of oral intake, and his speech was restored by electrolarynx. CONCLUSIONS We reported the case of a patient with hypopharyngeal cancer who underwent total pharyngo-laryngo-cervico-esophagectomy and esophagus reconstruction using a jejunal free flap, performed for the first time in Vietnam. As expected, with good oncological and functional results, the degree of invasiveness and sequelae of the surgery can be well tolerated.

Blood flow distribution after end-to-side anastomosis with wide arteriotomy in extremity free flap surgery.

PURPOSE: Although many studies have investigated the optimal anastomotic procedure for the end-to-side (ETS) procedure with a free flap, no study has focused on the size of the arteriotomy. Some surgeons have recently described the effectiveness of ETS with wide arteriotomy, but the postoperative haemodynamics remains unclear for free flaps created using this technique. The aim of this study was to use ultrasonography to evaluate the postoperative blood flow distribution after ETS with a wide arteriotomy in extremity free flap surgery. METHODS: We evaluated 20 free flaps in 18 consecutive patients who received an ultrasonographic examination after free flap surgery using the ETS technique with wide arteriotomy for arterial anastomosis. All flaps were examined after surgery and blood flow was calculated for the flap and recipient vessels. RESULTS: All 20 flaps survived, but one flap developed asymptomatic arterial thrombosis and 19 flaps were analysed. For the ETS technique with wide arteriotomy, peripheral circulation was well preserved in all flaps. Comparison of flap types showed that blood flow was significantly higher in myocutaneous flaps than in fasciocutaneous flaps, but there was no significant difference according to the size of the arteriotomy. CONCLUSIONS: Given the range of arteriotomy performed using the ETS with a wide arteriotomy technique, the blood flow volume in the flap depended on the type of flap but not on the size of the arteriotomy. A steal phenomenon related to the creation of a wide window in the receipt artery was not found in the analysed retrospective cohort.

Setting up a new microsurgical breast service in a non-tertiary hospital: Is it safe, and do outcomes compare to centres of excellence?

AIMS: Access to autologous reconstruction continues to be limited in some areas of the United Kingdom. This is, in part, due to the perceived difficulty offering this service outside of a large tertiary centre. We present our experience setting up a new microsurgical breast reconstruction service in a district hospital and compare our results to the published outcomes of large volume centres. METHODS: Patient data were collected prospectively from the start of the service to date (July 2018- July 2020) with the capture of demographics, management, and outcomes. The BREAST-Q tool was used preoperatively and at a minimum of 3 months. RESULTS: The first 40 patients undergoing DIEP reconstruction were included. Of these, 70% were immediate, mean age was 49 years (27-68) and BMI was 28.1 kg/m2 (22-32.5). In all, 50% had one or more co-morbidities other than breast cancer. Median length of stay was 3 days (2-6) with 75% of patients discharged on day 2 or 3. Ten patients' stay exceeded 3 days - mostly due to social reasons. Flap loss occurred in 1 patient (2.5%). Twenty-one patients developed complications (52%) within 90 days: seven Clavien-Dindo Grade I, two Grade II and ten Grade IIIb. Fat necrosis and mastectomy flap necrosis were the most common complications. Surgical intervention was higher in those needing adjuvant therapy. Patient-reported outcomes showed post-operative improvement across all domains except abdominal physical well-being at median 11.3 months. CONCLUSIONS: We present the shortest published length of stay for unilateral DIEP reconstructions. We are the first paper to publish patient-reported outcomes following a breast microsurgical enhanced recovery protocol. We demonstrate how a new microsurgical service, utilising an enhanced recovery protocol and careful patient selection can immediately achieve outcomes comparable to well-established centres. There is no reason why all patients should not have access to microsurgical breast reconstruction locally.

Pathological Features of Free Graft and Pedicled Flap in the Nasal Cavity: An Animal Study.

OBJECTIVES/HYPOTHESIS: Recent developments in reconstructive techniques for mucosal defects using mucoperiosteal materials have enabled rapid recovery of physiological function after endoscopic sinus surgery. Clinical trials have described the advantages, disadvantages, and different outcomes of free graft and pedicled flap, which, respectively, sacrifice or preserve blood flow. However, histological changes, that affect the postoperative outcomes after reconstruction, remain unclear. We created an animal model for the reconstruction of mucosal defects using free grafts and pedicled flaps, and evaluated them histologically. STUDY DESIGN: Animal study. METHODS: We created mucosal defects in the left nasal septum of 20 rabbits and performed reconstruction with free grafts and pedicled flaps. The distribution of ciliary and goblet cells at the reconstruction site was evaluated after 7 and 28 days using hematoxylin and eosin-stained sections to calculate the Ciliary Cell Index and Goblet Cell Index. The severity of inflammation was assessed using the Cartilage Inflammatory Cell Score. RESULTS: Crusting and changes in the mucosal morphology at the reconstruction site occurred only in the free graft group. In addition, the pedicled flap group had significantly greater preservation of ciliary and goblet cells and less inflammatory cell infiltration into the septal cartilage (P < .05) than the free graft group. CONCLUSIONS: After reconstruction procedures for mucosal defects, histopathological differences were observed between the free graft and pedicled flap. Reconstruction with pedicled flaps had advantages including preservation of healthy mucosal epithelium and suppression of inflammation on the reconstruction site. This indicated that reconstruction with pedicled flaps might have advantages over that with free grafts. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E428-E433, 2021.