The value of microvascular breast reconstruction: Cost equivalence of TRAM and DIEP flaps implications in the era of CMS reforms.

BACKGROUND: Recent CMS billing changes have raised concerns about insurance coverage for deep inferior epigastric perforator (DIEP) flap breast reconstruction. This study compared the costs and utilization of transverse rectus abdominis myocutaneous (TRAM), DIEP, and latissimus dorsi (LD) flaps in breast reconstruction. METHOD: The study utilized the National Inpatient Sample database to identify female patients who underwent DIEP, TRAM, and LD flap procedures from 2016 to 2019. Key data such as patient demographics, length of stay, complications, and costs (adjusted to 2021 USD) were analyzed, focusing on differences across the flap types. RESULTS: A total of 17,770 weighted patient encounters were identified, with the median age being 51. The majority underwent DIEP flaps (73.5%), followed by TRAM (14.2%) and LD (12.1%) flaps. The findings revealed that DIEP and TRAM flaps had a similar length of stay (LOS), while LD flaps typically had a shorter LOS. The total hospital charges to costs using cost-to-charge ratio were also comparable between DIEP and TRAM flaps, whereas LD flaps were significantly less expensive. Factors such as income quartile, primary payer of hospitalization, and geographic region significantly influenced flap choice. CONCLUSION: The study's results appear to contradict the prevailing notion that TRAM flaps are more cost-effective than DIEP flaps. The total hospital charges to costs using cost-to-charge ratio and hospital stays associated with TRAM and DIEP flaps were found to be similar. These findings suggest that changes in the insurance landscape, which may limit the use of DIEP flaps, could undermine patient autonomy while not necessarily reducing healthcare costs. Such policy shifts could favor less costly options like the LD flap, potentially altering the landscape of microvascular breast reconstruction.

Continuing Insurance Coverage for Flap-Based Breast Reconstruction: Is There a Reservation Cost Related to a Woman's Abdominal Flap Choice?

BACKGROUND: The recent proposed alterations to the Centers for Medicare and Medicaid Services regulations, although subsequently reversed on August 21, 2023, have engendered persistent concerns regarding the impact of insurance policies on breast reconstruction procedures coverage. This study aimed to identify factors that would influence women's preferences regarding autologous breast reconstruction to better understand the possible consequences of these coverage changes. METHODS: A survey of adult women in the United States was conducted via Amazon Mechanical Turk to assess patient preferences for breast reconstruction options, specifically deep inferior epigastric perforator (DIEP) and transverse rectus abdominis myocutaneous (TRAM) flap surgery. The Cochrane-Armitage test evaluated trends in flap preferences concerning incremental out-of-pocket payment increases. RESULTS: Of 500 total responses, 485 were completed and correctly answered a verification question to ensure adequate attention to the survey, with respondents having a median (interquartile range) age of 26 (25-39) years. When presented with the advantages and disadvantages of DIEP versus TRAM flaps, 78% of respondents preferred DIEP; however, as DIEP's out-of-pocket price incrementally rose, more respondents favored the cheaper TRAM option, with $3804 being the "indifference point" where preferences for both procedures converged (P < 0.001). Notably, respondents with a personal history of breast reconstruction showed a higher preference for DIEP, even at a $10,000 out-of-pocket cost (P = 0.04). CONCLUSIONS: Out-of-pocket cost can significantly influence women's choices for breast reconstruction. These findings encourage a reevaluation of emergent insurance practices that could potentially increase out-of-pocket costs associated with DIEP flaps, to prevent cost from decreasing equitable patient access to most current reconstructive options.

Practicality and Hemodynamic Advantage of Microvascularly Augmented Pectoralis Major Musculocutaneous Flap: Technical Approach and Evidence Based on Indocyanine Green Angiography.

ABSTRACT: We have recently shown that including the blood flow from the lateral thoracic artery (LTA) in addition to the thoracoacromial artery in the pectoralis major muscle musculocutaneous (PMMC) flap (bipedicle PMMC flap) can increase the perfusion of the flap. We also developed the concept of the supercharged PMMC flap, in which the LTA included in the flap was once cut and anastomosed to a cervical artery under a microscope. It is an effective solution to maintain the additional blood flow from the LTA, when the length of the LTA is compromised for reconstruction. The mandibular reconstruction of an oral cancer patient was performed with a supercharged PMMC flap. Intraoperative indocyanine green angiography was performed in a single pedicle, bipedicle, and supercharged conditions, and the videos were analyzed with a quantitative assessment system of perfusion using some parameters. As a result, blood supply from the LTA was essential for flap survival in this patient, and supercharging from the cervical artery improved flap perfusion compared with the perfusion in the bipedicle condition. The supercharged PMMC flap can resolve the compromise of pedicle length and be also hemodynamically advantageous, thus making the reconstruction more reliable than the conventional technique.

Mind the gap! Interdisciplinary approach to anterior chest wall reconstruction after total sternectomy.

BACKGROUND: There are various reconstructive methods after total sternectomy. Reproducibility is scarce due to overall small patient numbers. Therefore we present a standardized, interdisciplinary approach for thoracic and plastic surgery. METHODS: Four patients underwent interdisciplinary chest wall reconstruction with STRATOS® titanium bars and myocutaneous vastus lateralis muscle free flap in our center. RESULTS: All patients reported chest wall stability after reconstruction. They reported good quality of life, no dyspnea, prolonged pain or impairment in lung function from rigid reconstruction. FEV1/FVC was overall better after surgery. Secondary wound healing was not impaired and there was no implant defect in follow up. CONCLUSIONS: We recommend an interdisciplinary surgical approach in chest wall reconstruction after total sternectomy. The combination of rigid reconstruction with titanium bars and a myocutaneous vastus lateralis muscle free flap renders excellent results in patient satisfaction and is objectifiable via spirometry.

[Clinical effects of flaps or myocutaneous flaps transplantation after titanium mesh-retaining debridement in repairing the wounds with exposed titanium mesh after cranioplasty].

Objective: To explore the clinical effects of flaps or myocutaneous flaps transplantation after debridement to repair the wounds with exposed titanium mesh after cranioplasty on the premise of retaining the titanium mesh. Methods: This study was a retrospective observational study. From February 2017 to October 2022, 22 patients with titanium mesh exposure after cranioplasty who met the inclusion criteria were admitted to the Department of Plastic, Aesthetic & Maxillofacial Surgery of the First Affiliated Hospital of Xi'an Jiaotong University, including 15 males and 7 females, aged from 19 to 68 years. After admission, treatments such as bacterial culture of wound exudate sample, anti-infection, and dressing change were carried out. Thorough surgical debridement was performed when the wound improved, and the wound area was 3.0 cm×2.0 cm to 11.0 cm×8.0 cm after debridement. The wound was repaired with local flaps, expanded flaps, or free latissimus dorsi myocutaneous flaps according to the size, location, severity of infection, and surrounding tissue condition of the wounds, and the areas of flaps or myocutaneous flaps were 5.5 cm×4.0 cm to 18.0 cm×15.0 cm. The donor areas of flaps were sutured directly or repaired by split-thickness skin grafts from head. The wound repair method was recorded. The survivals of flaps or myocutaneous flaps after surgery and wound healing in 2 weeks after surgery were recorded. During postoperative follow-up, recurrence of infection or titanium mesh exposure in the implanted area of titanium mesh was observed; the head shapes of patients, scar formation of the operative incision, and baldness were observed. At the last follow-up, the satisfaction of patients with the treatment effect (dividing into three levels: satisfied, basically satisfied, and dissatisfied) was evaluated. The total treatment costs of patients during their hospitalization were calculated. Results: The wounds in 11 cases were repaired with local flaps, the wounds in 5 cases were repaired with expanded flaps, and the wounds in 6 cases were repaired with free latissimus dorsi myocutaneous flaps. All flaps or myocutaneous flaps survived completely after surgery, and all wounds healed well in 2 weeks after surgery. Follow up for 6 to 48 months after operation, only one patient with local flap grafting experienced a recurrence of infection in the titanium mesh implanted area at more than one month after surgery, and the titanium mesh was removed because of ineffective treatment. Except for one patient who had a local depression in the head after removing the titanium mesh, the rest of the patients had a full head shape. Except for myocutaneous flap grafting areas in 6 cases and skin grafting area in 1 case with local flaps grafting had no hair growth, the other patients had no baldness. All the scars in surgical incision were concealed. At the last follow-up, 19 cases were satisfied with the treatment effects, 2 cases were basically satisfied, and 1 case was dissatisfied. The total treatment cost for patients in this group during hospitalization was 11 764-36 452 (22 304±6 955) yuan. Conclusions: For patients with titanium mesh exposure after cranioplasty, on the premise of adequate preoperative preparation and thorough debridement, the wound can be repaired with appropriate flaps or myocutaneous flaps according to the wound condition. The surgery can preserve all or part of the titanium mesh. The postoperative wound healing is good and the recurrence of infection or titanium mesh exposure in the titanium mesh implanted area is reduced, leading to good head shape, reduced surgical frequency, and decreased treatment costs.

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Flap management following orthotopic heart transplantation: A single institution's review of 66 sternal wound complications.

BACKGROUND: Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population. METHODS: A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure. RESULTS: The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes. CONCLUSIONS: Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results.

Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019.

INTRODUCTION: Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States. METHODS: Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling. RESULTS: A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242). CONCLUSIONS: As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor.

BACKGROUND: The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome. METHODS: A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups. RESULTS: Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001). CONCLUSIONS: This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

Outcome of modified fleur-de-lis latissimus dorsi myocutaneous flap for breast reconstruction.

BACKGROUND: Reconstruction of breast following mastectomy is important in terms of rehabilitating patients of breast cancer. Numerous approaches have been used in the reconstruction process. A procedure that has gained interest of the patients is reconstruction of breast using the autologous form. Main objective of this study is to determine the outcomes of modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction. METHODOLOGY: This is a retrospective case series which was conducted at the Department of Plastic Surgery, SIMS/Services Hospital, Lahore, from January 2020 till December 2022. 184 patients age 25-60 years and Females with a history of mastectomy, who had to undergo creation of breast shape using a tissue flap from another part of the body at the site of breast following mastectomy were included. All patients were subjected to standard procedure of breast reconstruction with latissimus dorsi flap using modified fleur-de-lis technique and postoperatively weekly assessment in the first month and then monthly until 3 months was carried out and outcome of the study was analysed. RESULTS: The mean age and VAS score of the patients was 49.7 ± 9.17 and 6 ± 2.21, respectively. 57.1 % patients have DCIS, benign in 38 % patients and other tumours were present in 4.9 % patients. Immediate versus delayed reconstruction was done in 63.6 % versus 36.4 % patients respectively. Good aesthetic outcome was achieved in 80.3 % patients CONCLUSION: Modified fleur-de-lis latissimus dorsi flap in patients undergoing breast reconstruction yielded a good aesthetic outcome in the majority of the patients.

Anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle.

INTRODUCTION: We conducted an anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle to cover soft tissue defects of the knee region. HYPOTHESIS: A recent anatomic study by Mojalla showed that the sartorius muscle had 2 distinct pedicles, making it possible to isolate this muscle on its distal pedicle and harvest it with a skin paddle. MATERIALS AND METHODS: This anatomic study was conducted on 10 lower limbs. The 2 criteria assessed were (1) the viability of our proximal skin paddle and (2) the arc of rotation and coverage obtained with this myocutaneous flap. RESULTS: We identified 7 proximal skin paddles after the injection of India ink into the distal pedicle of the sartorius muscle. In all cases, the arc of rotation of the flap allowed coverage of the knee region. The mean distance between the inferior edge of the skin paddle and the proximal border of the patella (DBAP) was measured at 13cm, and the mean distance between the superior edge of the flap paddle and the anterior superior iliac spine (DASIS) at 16cm. The average skin paddle size was 14 by 7cm. DISCUSSION: Our anatomic study demonstrated the feasibility of our sartorius flap with a distally based pedicle and proximal skin paddle. This technique may be a viable alternative when using gastrocnemius flaps is not feasible, or the surgeon lacks the microsurgical skills to perform free flaps. LEVEL OF EVIDENCE: IV; descriptive anatomic study.

[Clinical effect of modified vertical rectus abdominis myocutaneous flap in repairing skin and soft tissue defects after abdominoperineal resection for rectal cancer].

Objective: To investigate the clinical effect of the modified vertical rectus abdominis myocutaneous flap in repairing the skin and soft tissue defect after abdominoperineal resection for rectal cancer. Methods: This study was a retrospective observational study. From June 2019 to July 2022, five male patients with low rectal cancer who were conformed to the inclusion criteria were admitted to the Department of Basic Surgery of Xiangya Hospital of Central South University, with ages ranging from 65 to 70 years and the sizes of the perianal skin ulcers ranging from 5 cm×4 cm to 11 cm×9 cm, and all of them underwent abdominoperineal resection. The secondary skin and soft tissue defects in the perineum with an area of 8 cm×6 cm-14 cm×12 cm (with the depth of pelvic floor dead space being 10-15 cm) were repaired intraoperatively with transplantation of modified vertical rectus abdominis myocutaneous flaps with the skin area being 9 cm×7 cm-16 cm×12 cm, the volume of the muscle being 18 cm×10 cm×5 cm-20 cm×12 cm×5 cm, and the vessel pedicle being 18-20 cm in length. During the operation, most of the anterior sheath of the rectus abdominis muscle was retained, the flap was transferred to the recipient area through the abdominal cavity, the remaining anterior sheaths of the rectus abdominis muscle on both sides of the donor area were repeatedly folded and sutured, the free edge of the transverse fascia of the abdomen was sutured with the anterior sheath of the rectus abdominis muscle, and the donor area skin was directly sutured. After the operation, the survival of the transplanted myocutaneous flap was observed. The occurrence of complications in the perineal recipient area was recorded within 2 weeks after the operation. The recovery of the perineal recipient area and the abdominal donor area was observed during follow-up, and the occurrence of complications in the donor area of the abdomen as well as the recurrence of tumors and metastasis were recorded. Results: All transplanted myocutaneous flaps in 5 patients survived after surgery. One patient had dehiscence of the incision in the perineal recipient area 2 days after surgery, which healed after 7 d with intermittent dressing changes and routine vacuum sealing drainage treatment. In the other 4 patients, no complications such as incisional rupture, incisional infection, or fat liquefaction occurred in the perineal recipient area within 2 weeks after surgery. Follow-up for 6-12 months after discharge showed that the skin of the perineal recipient area had good color, texture, and elasticity, and was not bloated in appearance; linear scars were left in the perineal recipient area and the abdominal donor area without obvious scar hyperplasia or hyperpigmentation; no complications such as incisional rupture, incisional infection, intestinal adhesion, intestinal obstruction, or weakening of the abdominal wall strength occurred in the abdominal donor area, and the abdominal appearance was good with no localized bulge or formation of abdominal hernia; there was no local recurrence of tumor or metastasis in any patient. Conclusions: The surgical approach of using the modified vertical rectus abdominis myocutaneous flap to repair the skin and soft tissue defects after abdominoperineal resection for rectal cancer is relatively simple in operation, can achieve good postoperative appearances of the donor and recipient areas with few complications, and is worthy of clinical promotion.

[Preliminary application of foldable pedicled latissimus dorsi myocutaneous flap for repairing soft tissue defects in shoulder and back].

Objective: To explore the feasibility and effectiveness of a foldable pedicled latissimus dorsi myocutaneous flap to repair soft tissue defects in the shoulder and back. Methods: Between August 2018 and January 2023, the foldable pedicled latissimus dorsi myocutaneous flaps were used to repair soft tissue defects in the shoulder and back of 8 patients. There were 5 males and 3 females with the age ranged from 21 to 56 years (mean, 35.4 years). Wounds were located in the shoulder in 2 cases and in the shoulder and back in 6 cases. The causes of injury were chronic infection of skin and bone exposure in 2 cases, secondary wound after extensive resection of skin and soft tissue tumor in 4 cases, and wound formation caused by traffic accident in 2 cases. Skin defect areas ranged from 14 cm×13 cm to 20 cm×16 cm. The disease duration ranged from 12 days to 1 year (median, 6.6 months). A pedicled latissimus dorsi myocutaneous flap was designed and harvested. The flap was divided into A/B flap and then were folded to repair the wound, with the donor area of the flap being pulled and sutured in one stage. Results: All 7 flaps survived, with primary wound healing. One patient suffered from distal flap necrosis and delayed healing was achieved after dressing change. The incisions of all donor sites healed by first intention. All patients were followed up 6 months to 4 years (mean, 24.7 months). The skin flap has a good appearance with no swelling in the pedicle. At last follow-up, 6 patients had no significant difference in bilateral shoulder joint motion, and 2 patients had a slight decrease in abduction range of motion compared with the healthy side. The patients' daily life were not affected, and linear scar was left in the donor site. Conclusion: The foldable pedicled latissimus dorsi myocutaneous flap is an ideal method to repair the soft tissue defect of shoulder and back with simple operation, less damage to the donor site, and quick recovery after operation.

Soft tissue reconstruction of the trunk with pedicled perforator and musculocutaneous flaps: A single-center comparative retrospective study.

BACKGROUND: Soft tissue trunk reconstruction is often challenging. Although free microvascular flaps are a feasible option in case of extensive defects involving deep structures, pedicled flaps represent a good alternative, especially if harvested and dissected with a "microsurgical" approach. The aim of this study is to evaluate the feasibility of trunk reconstruction with the use of pedicled flaps, according to the application of our reconstructive algorithm, and to compare it to other reconstructive methods. PATIENTS AND METHODS: From January 2017 to December 2021, we retrospectively analyzed patients who underwent soft tissue reconstruction of the trunk with pedicled flaps at the authors' institution. Patient's demographic, clinical and surgical characteristics and postoperative complications were recorded and analyzed by descriptive statistics. A comparative analysis was made between the study group and two other groups who underwent reconstruction of trunk defects with free flaps and skin grafts, respectively, at the authors' institution. RESULTS: Forty-seven patients were included in the study. Patients' age ranged between 36 and 82 years (mean: 57.8 years). Twenty-eight patients were male, while 19 patients were female. In 76.6% of patients (36 out of 47), reconstructive procedures were performed to repair defects resulting from cancer resection. Reconstruction of superficial defects was always achieved with perforator flaps (n = 25). In case of full-thickness defects, reconstruction was carried out with musculocutaneous flaps (n = 22); latissimus dorsi and vastus lateralis were the most used flaps for chest and abdominal wall reconstruction, respectively. In our series, we observed only one case of total flap loss requiring re-operation under general anesthesia. Minor complications occurred in 8.5% of cases (4 out of 47 patients). We observed two cases of partial flap necrosis and two cases of wound dehiscence. In the skin grafts group (n = 53), the mean age was 54.5 years (range 39-85) and 56% of patients were male (n = 30). In 66% of cases (n = 30) the defect resulted from oncological resection. The overall complication rate was 18.8% (n = 10). In the free flaps group (n = 10), the mean age was 49.0 years (range 29-77) and 60% of patients (n = 6) were male. In 70% of cases (n = 7) the defect was caused by oncological resection. Complications occurred in two patients (20%). No statistically significant differences were found in terms of overall complication rate between the study group and the two comparative groups (p = .48). A significant correlation was found between the reconstructive method and the type and size of the defect, with reconstruction through free flaps being associated with larger (344.0 vs. 220.4 cm2 ) (p = .04) and full-thickness defects (80.0% vs. 46.8%) (p < .01) if compared to pedicled flaps. CONCLUSIONS: In the new era of microsurgery, pedicled flaps represent a valid alternative to free flaps for the majority of soft tissue defects of the trunk. In our series, no statistically significant differences in terms of complications were found between reconstructions of similar defects achieved with pedicled and free flaps, and free flap use was limited to extensive full-thickness defects. In addition, the rate of postoperative complications with pedicled flaps found in our cohort was lower than the rate reported in the literature.

Soft tissue Reconstruction Using Pedicled Trapezius Musculocutaneous Flap for Cranial Bone Flap Infection in the Occipital Region.

When managing cranial bone flap infections, infected bone flaps are typically removed and subsequently replaced with artificial bones 6 to 12 months after the inflammation subsides. However, defects in the occipital region pose challenges due to concerns regarding brain protection when patients lie in the supine position. Herein, the authors report the case of a 73-year-old woman with an occipital bone flap infection, which was successfully managed by reconstruction with a trapezius musculocutaneous flap immediately after removing the infected bone flap. One year and 2 months postoperatively, the wound had fully healed, and the patient remained symptom-free without any complications, such as sunken flap syndrome. Soft tissue reconstruction using pedicled trapezius musculocutaneous flap is a viable strategy for managing occipital bone flap infections. This flap ensures stable blood flow and requires minimal vascular manipulation, thereby reducing operation time as the patient does not need to change position.

Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q.

BACKGROUND: The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale. METHODS: In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted. RESULTS: Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated. 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 .

Favourable swallowing outcomes after subtotal glossectomy with laryngeal suspension.

Subtotal or total glossectomy for advanced tongue cancer has an adverse impact on swallowing. The purpose of this retrospective study was to analyse postoperative swallowing outcomes and to determine the ideal reconstruction method in these patients. The clinical and swallowing data of patients with tongue cancer who underwent subtotal glossectomy at the study institution between 2005 and 2019 were reviewed retrospectively. Data were available for 101 patients. The most common reconstruction method was a free rectus abdominis musculocutaneous flap (69 cases). The postoperative feeding tube dependency rate was 11.1% at discharge and 9.4% at 1 year. During the study period, laryngeal suspension and/or a cricopharyngeal myotomy was performed in 39 patients (38.6%), with 25 of these operations performed after 2017. Patients treated in 2017-2019 were significantly more able to take thin liquid (P < 0.001) and lost less weight (P = 0.015) compared to those treated in 2005-2016. Multivariate analysis of 61 patients who did not undergo laryngeal suspension and/or cricopharyngeal myotomy showed significant feeding tube dependency in those aged 65 years and older (P = 0.004). Thin liquid intake was significantly improved after subtotal glossectomy with laryngeal suspension, which led to better postoperative swallowing and improved quality of life.

Combined Blepharoplasty and Brow Fat Pad Transfer for the Correction of Dermatochalasis and Sunken Upper Eyelids.

BACKGROUND: Women commonly experience upper eyelid dermatochalasis and upper eyelid depression with advancing age. Blepharoplasty is a suitable method for treating dermatochalasis, but not sunken eyelid. This study proposed a novel technique for eyelid rejuvenation by simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women. METHODS: Forty patients underwent subbrow blepharoplasty combined with brow fat pad transfer. Ellipse-shaped skin and subcutaneous tissue underneath the eyebrow were measured, demarcated, and excised. The orbicularis oculi muscle beneath the subcutaneous tissue was exposed and dissected in the upper-third area. The brow fat pad was turned downward using the lower edge as the pedicle and was fixed in the layer of retro-orbicularis oculi fat to fill the depressed area in the upper eyelid. The lower muscle flap was fixed to the supraorbital rim periosteum and upper musculocutaneous flaps, thereby forming a cross flap for interlocking fixation. The surgical outcomes were evaluated using a three-dimensional imaging device and the Global Aesthetic Improvement Scale. RESULTS: The depth and volume of upper eyelid depression decreased significantly 3 months after the surgery and stabilized within 6 months. Global Aesthetic Improvement Scale scores significantly improved after the surgery, and the postoperative outcomes were acceptable. CONCLUSIONS: The novel technique is simple and effective for simultaneously correcting dermatochalasis and sunken upper eyelids in middle-aged women. The surgical outcomes are predictable and acceptable to most patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. OBJECTIVES: The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. METHODS: All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. RESULTS: Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). CONCLUSIONS: Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

Extended arc of rotation of Latissimus Dorsi Musculocutaneous Flap providing well-vascularized tissue for reconstruction of complete defects of the sternum: An anatomical study of flap pedicle modification.

BACKGROUND: Deep sternal wound infections (DSWI) following cardiothoracic surgery represent a life quality endangering sequelae and may lead to sternal osteomyelitis. Radical debridement followed by Negative Pressure Wound Therapy (NPWT) may achieve infection control, provide angiogenesis, and improve respiratory function. When stable wound conditions have been established a sustainable plastic surgical flap reconstruction should be undertaken. OBJECTIVE: This study analyses a method to simplify defect coverage with a single Latissimus Dorsi Myocutaneous Flap (LDMF). METHODS: Preparation of 20 LDMF in ten fresh frozen cadavers was conducted. Surgical steps to increase pedicle length were evaluated. The common surgical preparation of LDMF was compared with additional transection of the Circumflex Scapular Artery (CSA). RESULTS: Alteration of the surgical preparation of LDMF by sacrificing the CSA may provide highly valuable well-vascularized muscle tissue above the sensitive area of the Xiphisternum. All defects could be completely reconstructed with a single LDMF. The gain in length of flap tissue in the inferior third of the sternum was 3.86±0.9 cm (range 2.2 to 8 cm). CONCLUSIONS: By sacrificing the CSA in harvesting the LDMF a promising gain in length, perfusion and volume may be achieved to cover big sternal defects with a single flap.