Evaluation of aesthetic outcomes of mandibular reconstruction using artificial intelligence.

BACKGROUND: Although vascularized bone graft (VBG) transfer is the current standard for mandibular reconstruction, reconstruction with a mandibular reconstruction plate (MRP) and with a soft-tissue flap (STF) alone remain crucial options for patients with poor general conditions. However, objective aesthetic outcome evaluations for these methods are limited. METHODS: In a retrospective analysis of 65 patients (VBG, 33; MRP, 19; and STF, 13), mandibular asymmetry value was calculated for each patient's photograph using facial recognition AI, with a higher value indicating worse asymmetry. RESULTS: The MRP group had a value comparable to the VBG group regardless of mandibular defect types. The STF group had a significantly higher value than the VBG group. CONCLUSIONS: Regarding cosmesis, STF was inferior to VBG, whereas MRP was comparable to VBG, even for anterior defects for which rigid reconstruction is mandatory. However, MRP's risks of plate-related complications limit its use to cases where VBG is contraindicated or with poor prognosis.

Scapula harvest in the supine position for immediate mandibular reconstruction.

PURPOSE: The scapula is the second most popular donor site for mandibular reconstruction after the fibula. Scapula harvest is generally performed in the lateral decubitus position and the requirement of positional changes hamper the widespread use of the scapula. This study compared scapula harvest for immediate mandibular reconstruction between the supine and lateral decubitus positions. METHODS: We reviewed the outcomes of 16 patients who underwent segmental mandibulectomy and immediate reconstruction of the scapula based on the angular branch of the thoracodorsal artery. The scapula was harvested in the lateral decubitus (lateral decubitus group) or supine position (supine group) in eight patients each. Several perioperative parameters were compared between the two groups. RESULTS: One scapula was lost because of inadvertent injury of the angular branch in the supine group. The operative time was significantly shorter in the supine group than in the lateral decubitus group. CONCLUSION: Harvesting of the scapula in the supine position is a feasible option for immediate mandibular reconstruction. Although deep anatomic knowledge and technical expertise are necessary, this strategy can eliminate positional change and significantly reduce the operative time.

Clinical assessment of early mobilization after head and neck free flap reconstruction: A retrospective case-control study.

PURPOSE: We examined whether there were any differences in perioperative complications between patients who mobilized on the first postoperative day (early mobilization) and those who mobilized on the second postoperative day after head and neck reconstruction using free tissue transfer. METHODS: In the control group (n = 74), patients were instructed to mobilize on the second postoperative day (April 2019-March 2020), while in the early mobilization group (n = 101), patients were instructed to mobilize on the first postoperative day (April 2020-March 2021). Mobilization was defined as maintaining a standing position or walking. Clinical data were collected from medical records and retrospectively analyzed. RESULTS: There were no significant differences in clinical background factors, with the exception of intraoperative blood loss volume. The proportion of patients who successfully mobilized on the day of instruction was significantly lower in the early mobilization group (89.1% vs. 98.7%). One case of total flap loss and four cases of partial flap loss occurred in the control group, and three cases of partial flap loss occurred in the early mobilization group. There was no significant difference in partial or total flap loss between the two groups. There were no significant differences in other perioperative complications (wound infection, postoperative bleeding, and delirium) between the two groups. The median postoperative hospital stay was 24.5 and 25.0 days in the control and early mobilization groups, respectively. CONCLUSION: In this study, early mobilization on the first day after head and neck free flap reconstruction was safe and feasible.

Crescent-shaped skin paddle for a fibular flap: Avoiding skin grafting at the donor site.

A fibular osteocutaneous flap is the mainstay of oromandibular reconstruction. This report aimed to present a crescent-shaped skin paddle, a novel fibular skin paddle designed to achieve both sufficient intraoral lining and primary closure of the donor site. A 3-5-cm-wide crescent-shaped skin paddle was harvested according to the locations of the distal septocutaneous perforators on preoperative color Doppler sonography. This narrow skin paddle fits well morphologically into the mucosal defect, enabling a reliable intraoral lining. This advantage becomes more evident when the mandibular defect crosses the midline or extends posteriorly to the maxillary tuberosity as the shape of the mucosal defect becomes arcuate. Primary closure of the donor site is easier to achieve because the required width of the crescent-shaped skin paddle is minimized. This method reduces donor-site morbidity associated with skin grafting while ensuring safe intraoral closure with a fibular osteocutaneous flap.

Surgical Outcome of Pharyngocutaneous Fistula After Total Laryngectomy: A Retrospective Study.

BACKGROUND: The management of pharyngocutaneous fistula is challenging. We typically treat postlaryngectomy pharyngocutaneous fistulas with a pedicled pectoralis major flap transfer. This study analyzed the outcomes of our surgical treatments for pharyngocutaneous fistula to propose considerations for surgical strategies. METHODS: This retrospective review included all patients who underwent surgical repair of a postlaryngectomy pharyngocutaneous fistula at the National Cancer Center Hospital East in Kashiwa, Japan, from January 2005 to December 2019. RESULTS: The final analysis included 33 cases (median age, 71 years). Twenty-two cases had a history of radiotherapy to the head and neck region. Wound closures were performed with a pedicled pectoralis major musculocutaneous flap (n = 26) or pedicled pectoralis major muscle flap (n = 7). In 1 case, a deltopectoral flap was combined with the pectoralis major musculocutaneous flap. The median total operation time was 236 minutes, the median blood loss during surgery was 144 mL, and the median hospital stay after the reconstructive surgery was 39 days. Minor leakage occurred in 19 cases, and major leakage occurred in 2 cases. The fistula was finally cured successfully in 31 cases. We compared the outcomes in patients with leakage after surgical repair to those in patients without leakage after surgical repair to determine the risk factors for leakage after surgical repair of a pharyngocutaneous fistula. Five patients in the nonleakage group and 17 in the leakage group had a history of preoperative radiation (P = 0.052). The median preoperative blood values in the nonleakage and leakage groups were as follows: albumin, 3.6 and 3.2 g/dL (P = 0.061), and C-reactive protein, 2.36 and 6.77 mg/dL (P = 0.031), respectively. The time between the occurrence of the fistula and reconstructive surgery was 32 and 9 days in the nonleakage and leakage groups, respectively (P = 0.009). CONCLUSIONS: Our surgical treatment for postlaryngectomy pharyngocutaneous fistula succeeded in 31 of 33 cases (94%). This study demonstrated that pedicled pectoralis major flap transfer is useful for the treatment of postlaryngectomy pharyngocutaneous fistula.

Surgical outcome for colorectal or urinary tract-related fistula: Usefulness of vascularized tissue transfer-a retrospective study⁎.

BACKGROUND: It is challenging to manage colorectal or urinary tract-related fistula. We typically treat colorectal or urinary tract-related fistula with a vascularized tissue transfer. This study aimed to analyze the outcomes of our surgical treatments for colorectal or urinary tract-related fistula. METHODS: This retrospective review included all patients who underwent surgical repair of a colorectal or urinary tract-related fistula at our institution from October 2004 to September 2019. Patients whose surgical outcomes could not be evaluated were excluded. The primary outcome was the overall cure rate. We also evaluated the complication rate and compared the outcomes for rectovaginal fistula with those for urorectal fistula. RESULTS: The final analysis included 38 cases, of which 17 were rectovaginal fistula and 16 were urorectal fistula. The transperineal approach was used in 28 cases and transperineal and transabdominal combined in nine cases. A gracilis muscle flap was used in 19 cases and a gluteal fold flap in 13 cases. Although a major leak occurred in nine cases, the fistula was finally cured successfully in 31 cases. A comparison of the outcomes for rectovaginal fistula and urorectal fistula showed that complications occurred in 5/17 cases of rectovaginal fistula and 10/16 cases of urorectal fistula (p = 0.056). Fistulae were cured successfully in 13/17 cases of rectovaginal fistula and 14/16 cases of urorectal fistula (p = 0.656). CONCLUSION: Our surgical treatment for colorectal or urinary tract-related fistula succeeded in 31 of 38 cases. Thus, vascularized tissue transfer is useful for refractory colorectal or urinary tract-related fistula.

Combined use of ipsilateral latissimus dorsi flap and anterolateral thigh flap to reconstruct extensive trunk defects.

Reconstruction of a full-thickness trunk defect is challenging because of the complex nature of such defects, which include the chest wall, abdominal wall, and diaphragm. We herein describe three patients in whom extensive trunk defects after sarcoma resection were reconstructed with a latissimus dorsi flap and an anterolateral thigh flap. In two patients, the defect included both the chest wall and the abdominal wall. The other patient had an extensive full-thickness chest wall defect. The size of the anterolateral thigh flap for each patient was 34 × 10 cm, 26 × 15 cm, and 23 × 5 cm, respectively. Although one patient required take-back for additional venous drainage, all wounds healed with no other complications. No respiratory dysfunction or abdominal wall hernia occurred in any patients. The combined use of a latissimus dorsi flap and an anterolateral thigh flap may provide reliable coverage of an extensive trunk defect and robust support of the chest and abdominal walls. Additionally, the availability of a two-team approach without a positional change makes this combination a versatile reconstructive option.

Anatomy of the arterial and venous systems of the superficial inferior epigastric artery flap: A retrospective study based on computed tomographic angiography.

BACKGROUND: This study was performed to investigate the arterial and venous anatomy of superficial inferior epigastric artery (SIEA) flaps using multidetector-row computed tomography angiography (MDCTA). We hypothesized that applicability of the SIEA flap has been underestimated in previous studies. METHODS: We retrospectively analyzed the results of preoperative MDCTA of the bilateral lower abdominal walls in 72 consecutive patients. We assessed the presence and branching pattern of the superficial inferior epigastric artery, superficial inferior epigastric vein (SIEV), superficial circumflex iliac vein, and venae comitantes (VC) of the superficial inferior epigastric artery. We also assessed the internal diameter of the SIEA at its origin. RESULTS: The SIEA was present on 133 sides (92.4%), and the mean internal diameter was 2.0 mm. The internal diameter of the SIEA was ≥2.0 mm on 102 sides (70.8%). The VC drained into the superficial circumflex iliac vein on 68 sides (47.2%) and to the SIEV on 30 sides (20.8%). CONCLUSIONS: An internal diameter of the SIEA of ≥2.0 mm at its origin on preoperative imaging can be a good criterion for exploring the artery during lower abdominal flap harvest. The VC is the dominant drainage vein over the SIEV in some patients, and it communicates with the superficial circumflex iliac vein in almost half of patients. These findings can increase the safety of breast reconstruction with an SIEA flap.

Large-to-Small End-to-Side Venous Anastomosis in Free Flap Transfer.

BACKGROUND: Vessel size discrepancy is one of the major risk factors for anastomotic failure in free flap transfer. The situation becomes challenging for reconstructive microsurgeons when the recipient vein is much smaller than the flap vein. We investigated the feasibility of large-to-small end-to-side venous anastomosis for such cases. MATERIALS AND METHODS: The subjects were 16 consecutive patients who underwent a free flap transfer for oncologic defects with a large-to-small end-to-side venous anastomosis. The larger flap vein was anastomosed to the side slit of the smaller recipient vein under an operating microscope. Surgical details and postoperative outcome were investigated retrospectively. RESULTS: An anterolateral thigh flap was used in five patients, a superficial inferior epigastric artery flap in four, a thoracodorsal artery perforator flap in three, and a latissimus dorsi musculocutaneous flap and a fibular osteocutaneous flap in two patients each. The internal mammary vein and the anterior tibial vein were most frequently used as a recipient vein (four patients each), followed by the deep inferior epigastric vein (three patients). The extent of vessel size discrepancy ranged from 1.3- to 3.3-fold, and the mean discrepancy was 1.9-fold. No anastomotic failure occurred postoperatively, and the flap survived in all patients. CONCLUSIONS: Large-to-small end-to-side venous anastomosis can be a versatile option when only a small vein is available as a recipient vein. Internal mammary, deep inferior epigastric, and anterior tibial veins are good candidates for this technique.

Septocutaneous thoracodorsal artery perforator flaps: a retrospective cohort study.

BACKGROUND: This study aimed to investigate the versatility of septocutaneous thoracodorsal artery perforator (TDAP-sc) flaps in various areas in the body and the running pattern of septocutaneous perforators. METHODS: This retrospective cohort study included 20 consecutive patients who underwent reconstruction of an oncological defect with a TDAP-sc flap from May 2014 to January 2018. Fifteen flaps were free, and the remaining five were pedicled. Surgical details and postoperative complications were investigated. RESULTS: The flap size ranged from 13 × 6.5 to 22 × 15 cm. The defect location was the upper extremity in eight patients, the head and neck in six, the lower extremity in four, and the trunk in two. The septocutaneous perforator arose from the thoracodorsal vessels proximal to the serratus anterior branch in 10 (50.0%) patients, from the thoracodorsal vessels distal to the serratus anterior branch in six (30.0%), and from the serratus anterior branch in four (20.0%). All flaps completely survived, except the one with partial necrosis. The scapula was simultaneously harvested based on the angular branch in three patients who underwent mandibular reconstruction. CONCLUSIONS: The TDAP-sc flap can be a versatile option for various types of reconstruction if a dominant septocutaneous perforator is present. Prevalence of a dominant TDAP-sc is estimated at approximately 50%. However, this flap can be harvested without tedious intramuscular dissection, and the two-team approach is possible during tumor resection. The presence of a dominant septocutaneous perforator can expand indication of the TDAP flap.

Free latissimus dorsi musculocutaneous flap for external hemipelvectomy reconstruction.

INTRODUCTION: External hemipelvectomy is one of the most extensive surgical procedures for locally advanced pelvic tumors. Stump coverage with the local tissues can be difficult in recurrent cases. Herein, we report our experience with immediate stump coverage using a free latissimus dorsi musculocutaneous (LDMC) flap after external hemipelvectomy for recurrent pelvic malignancies. METHODS: Six patients underwent external hemipelvectomy and immediate reconstruction using a free LDMC flap between November 2012 and June 2017. The mean age of the patients was 65 years (range: 63-69 years). The primary tumors were myxoid liposarcoma, chondrosarcoma, osteosarcoma, squamous cell carcinoma, and pleomorphic liposarcoma. A free LDMC flap was harvested from the ipsilateral back and transferred to the defect. When an intercostal nerve was found at the recipient site, the thoracodorsal nerve was coaptated with the intercostal nerve to reinnervate the muscle. RESULTS: The mean flap size was 23 × 10 cm and the range was 20 × 8-27 × 13.5 cm. The contralateral deep inferior epigastric vessels were used as recipient vessels in all patients. Thoracodorsal-intercostal nerve coaptation was performed in 2 patients. The flap survived in all patients. Three patients had complications of abscess formation. No patient developed postoperative hernia. CONCLUSION: Although it is challenging to do reconstruction after external hemipelvectomy, a free LDMC flap has several advantages, including a large coverage area, stability of circulation, ease of elevation, and preservation of the strength of the remaining abdominal wall. Technical tips for selecting anastomosis vessels are important and nerve coaptation could be effective.

Stripped Mesenteric Flap: A Novel Option for Preventing Anastomotic Leakage in Circumferential Pharyngeal Reconstruction.

Reconstruction of a circumferential pharyngeal defect with a free jejunal flap is a well-established procedure. However, anastomotic leakage often occurs, which can lead to abscess formation, pharyngocutaneous fistula formation, and carotid rupture. Previous reports have described covering the anastomotic site with a mesenteric flap to prevent anastomotic leakage. However, the mesentery is covered by a serosal membrane, which interferes with adhesion and vascular communication. Therefore, we stripped off the serosal membrane to accelerate adhesion to the anastomotic site. We retrospectively studied patients who had a history of radiotherapy and who had received a stripped mesenteric flap in a circumferential pharyngeal reconstruction procedure. We collected the following data: operative time, blood loss, postoperative complications, interval to resumption of oral intake, and duration of hospital stay. We obtained data for 11 patients. The jejunal flap failed in one patient because of arterial thrombosis. One of the other 10 patients developed anastomotic leakage caused by congested mucous membrane necrosis. The patient was treated conservatively and showed no clinical symptoms of infection or inflammation. The 9 remaining patients had no anastomotic leakage. In the present series, although anastomotic leakage was observed in one of 10 patients who underwent circumferential pharyngeal reconstruction using a stripped mesenteric flap, the severity of the leakage was minimized.

Topical application of nitrosonifedipine, a novel radical scavenger, ameliorates ischemic skin flap necrosis in a mouse model.

Ischemic skin flap necrosis can occur in random pattern flaps. An excess amount of reactive oxygen species is generated and causes necrosis in the ischemic tissue. Nitrosonifedipine (NO-NIF) has been demonstrated to possess potent radical scavenging ability. However, there has been no study on the effects of NO-NIF on ischemic skin flap necrosis. Therefore, they evaluated the potential of NO-NIF in ameliorating ischemic skin flap necrosis in a mouse model. A random pattern skin flap (1.0 × 3.0 cm) was elevated on the dorsum of C57BL/6 mice. NO-NIF was administered by topical injection immediately after surgery and every 24 hours thereafter. Flap survival was evaluated on postoperative day 7. Tissue samples from the skin flaps were harvested on postoperative days 1 and 3 to analyze oxidative stress, apoptosis and endothelial dysfunction. The viable area of the flap in the NO-NIF group was significantly increased (78.30 ± 7.041%) compared with that of the control group (47.77 ± 6.549%, p < 0.01). NO-NIF reduced oxidative stress, apoptosis and endothelial dysfunction, which were evidenced by the decrease of malondialdehyde, p22phox protein expression, number of apoptotic cells, phosphorylated p38 MAPK protein expression, and vascular cell adhesion molecule-1 protein expression while endothelial nitric oxide synthase protein expression was increased. In conclusion, they demonstrated that NO-NIF ameliorated ischemic skin flap necrosis by reducing oxidative stress, apoptosis, and endothelial dysfunction. NO-NIF is considered to be a candidate for the treatment of ischemic flap necrosis.

Development of Skin Flaps for Reconstructive Surgery: Random Pattern Flap to Perforator Flap.

Flap transplantation has been an important procedure in plastic and reconstructive surgery to cover and fill various defects. Flap necrosis due to blood circulation failure leads to severe complications, especially in a patient undergoing reconstruction concerning the body cavity after tumor ablation. Surgical procedures for flap transplantation have been further improved and developed. We have reviewed from the random pattern flap to the newest procedure, the perforator flap. Perforator vessels were investigated in the process of development of the fasciocutaneous flap and have become important for blood supply of the skin flap. Blood circulation of the flap has become more stable and reliable than ever with the development and findings of the perforator vessels. Further development of a skin flap will be based on the perforasome concept, which involves the study of the territory and linking of perforator vessels. J. Med. Invest. 63: 159-162, August, 2016.

Reduction mammaplasty and mastopexy for the contralateral breast after reconstruction surgery following cancer resection: A report of 3 cases.

BACKGROUND: Breast reconstruction generally involves autologous tissue transplantation and placement of a mammary prosthesis. When the patient's breasts are extremely large and ptotic, breast reconstruction often results in significantly asymmetrical appearance. However, a good aesthetic outcome after reconstruction surgery following cancer resection is an important quality-of-life factor. We evaluated the efficacy of touch-up surgery, either reduction mammaplasty or mastopexy, performed on the contralateral breast for symmetrization. METHODS: Reduction mammaplasty was performed on the contralateral breast in 2 patients and mastopexy was performed on the contralateral breast in 1 patient after reconstruction surgery following cancer resection, between 2008 and 2014. We reviewed each patient's medical record for general clinical information and for the methods of breast cancer resection and breast reconstruction used, wait time between breast cancer resection and touch-up surgery, preservation of the sensitivity of the nipple-areola complex after the touch-up surgery, and aesthetic outcome (based on visual analog scale score). RESULTS: Wait times in the 3 cases were 4, 9, and 18 months. Nipple-areolar sensitivity was well preserved in all 3 cases. Aesthetic outcomes were judged "excellent" or "very good." CONCLUSION: Revision surgery on the contralateral breast 4 to 18 months after breast reconstruction substantially improves the aesthetic outcome. J. Med. Invest. 63: 281-285, August, 2016.

Combined use of anterolateral thigh flap and pharyngeal flap for reconstruction of extensive soft-palate defects.

BACKGROUND: Functional reconstruction of extensive soft-palate defects is challenging for microsurgeons. The versatility of the combination of a free anterolateral thigh flap and a superiorly based pharyngeal flap for oncologic soft-palate reconstruction was investigated. METHODS: The combination of flaps was used for immediate reconstruction after total or subtotal resection of the soft palate in five consecutive patients from 2006 to 2011. RESULTS: All flaps survived completely. Palatal fistula and miniplate infection each developed in one patient but healed conservatively. Follow-up period ranged from 21 to 66 months. All patients tolerated a regular diet without significant aspiration or nasal regurgitation. Speech intelligibility was excellent in all patients, and none required a palatal prosthesis. CONCLUSIONS: The combination of an anterolateral thigh flap and a superiorly based pharyngeal flap is a versatile option for reconstructing extensive soft-plate defects. This method is simple and achieves reproducible results with limited donor-site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:291-296, 2016.

Accompanying artery of sciatic nerve as recipient vessel for free-flap transfer: a computed tomographic angiography study and case reports.

Suitable recipient vessels for free-flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid-thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free-flap transfer in selected patients.

Flow-through divided latissimus dorsi musculocutaneous flap for large extremity defects.

Reconstructing large defects of the extremities is a challenging problem for reconstructive microsurgeons. The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for this purpose, but a skin graft is needed when the defect is wider than available flaps. We used flow-through divided LDMCFs to reconstruct large defects of the extremities in 5 consecutive patients from 2010 through 2012. The semicircular skin island was split longitudinally, and 1 skin island was advanced over the other to close a round or oval defect without a skin graft. Postoperatively, all flaps survived completely, and the mean Enneking score was 90.0%. The flow-through divided LDMCF is a reliable and versatile option for reconstructing large defects of the extremities.