The Ischemic Tolerance up to Four Hours of Free Jejunum Flap: A Retrospective Cohort Study.

BACKGROUND: While free jejunum transfer (FJT) following total pharyngo-laryngo-esophagectomy (TPLE) is a reliable reconstruction technique, the jejunum flap is viewed as more susceptible to ischemia than a standard free flap. Animal studies have indicated that the jejunum can tolerate ischemia for as little as 2 to 3 hours. Clinical studies also reported increased complications after the FJT with more than 3 hours of ischemia. Traditionally, our institution has carried out FJT with an initial intestinal anastomosis, followed by a vascular anastomosis, which often results in extended jejunal ischemia time. In this study, we retrospectively examined the actual tolerance of the jejunum to ischemia, considering perioperative complications and postoperative dysphagia. METHODS: We retrospectively studied 402 consecutive cases involving TPLE + FJT. Patients were divided into five groups based on jejunum ischemia time (∼119 minutes, 120∼149 minutes, 150∼179 minutes, 180∼209 minutes, 210 minutes∼), with each variable and result item compared between the groups. Univariate and multivariate analyses were conducted to identify independent factors influencing the four results: three perioperative complications (pedicle thrombosis, anastomotic leak, surgical site infection) and dysphagia at 6 months postoperatively. RESULTS: The mean jejunal ischemia time was 164.6 ± 28.4 (90-259) minutes. When comparing groups divided by jejunal ischemia time, we found no significant differences in overall outcomes or complications. Our multivariate analyses indicated that jejunal ischemia time did not impact the three perioperative complications and postoperative dysphagia. CONCLUSION: In TPLE + FJT, a jejunal ischemia time of up to 4 hours had no effect on perioperative complications or postoperative dysphagia. The TPLE + FJT technique, involving a jejunal anastomosis first followed by vascular anastomosis, benefits from an easier jejunal anastomosis but suffers from a longer jejunal ischemia time. However, we found that ischemia time does not pose significant problems, although we have not evaluated the effects of jejunal ischemia extending beyond 4 hours.

Two stages of salvaging an extensively necrotic foot with chronic limb-threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report.

Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.

Free Flap Reconstruction of Oncologic Gluteal Defects.

ABSTRACT: A number of studies have already examined gluteal reconstruction with free flaps. Thus, the aim of this study was to investigate the reliability of free flap reconstruction for oncologic gluteal defects. This retrospective cohort study included 23 patients who underwent immediate soft tissue reconstruction for an oncologic gluteal defect. Fifteen patients underwent reconstruction with a free flap and 8 with a regional flap. The postoperative results were compared between the free and regional flaps. In the free flap group, the latissimus dorsi musculocutaneous flap was used in 12 patients, the thoracodorsal artery perforator flap in 2 patients, and the anterolateral thigh flap in 1 patient. Recipient vessels were the inferior gluteal vessels or their branches in 8 patients and the superior gluteal vessels or their branches in 7 patients. All flaps have fully survived in both groups without vascular compromise. Dehiscence of the gluteal wound tended to be more common in the regional flap group; however, the difference between the groups was not statistically significant. The use of free flap reconstruction for large oncologic defects in the gluteal region is a feasible and reliable option. Tension-free wound closure and simplified suture lines can provide reliable wound coverage irrespective of the postoperative patient's position or movement. Because of the risk of postoperative compression on the vascular pedicle, selecting the appropriate recipient vessel and type of microvascular anastomosis is key for the success of free flap transfer in this region.

Association between anti-complement factor H antibodies and renal outcome in primary membranous nephropathy.

AIMS: The complement factor H (CFH) is a regulator for the alternative complement pathway. The prevalence and roles of anti-CFH antibodies in the clinical outcome of primary membranous nephropathy (MN) patients remain unclear. MATERIALS AND METHODS: A total of 106 biopsy-proven kidney disease patients and 18 healthy controls were retrospectively investigated in this study. 36 patients had primary MN and 70 patients were diseased controls (31 minimal change nephrotic syndrome (MCNS), 19 rapidly progressive glomerulonephritis (RPGN), and 20 IgA glomerulonephritis (IgAGN)). Serum anti-CFH antibody titers were measured by enzyme-linked immunosorbent assay. RESULTS: 77.8% of MN patients were positive for anti-CFH antibodies. However, only 27.1% of diseased control patients and 5.6% of healthy controls were positive for anti-CFH antibodies. Moreover, median anti-CFH antibody titers were significantly higher in MN patients (4.69 AU/mL) than in diseased control patients (MCNS patients (0 AU/mL, p < 0.01), RPGN patients (0 AU/mL, p < 0.05), IgAGN patients (0 AU/mL, p < 0.01)), and healthy controls (0 AU/mL, p < 0.01). Anti-CFH antibody titer was selected as an independent unfavorable predictor of renal dysfunction by Cox proportional hazards analysis. CONCLUSION: These data suggest that anti-CFH antibodies may be involved in the deterioration of renal function in primary MN.

Retrospective single-arm cohort study of steroid-dependent minimal change nephrotic syndrome treated with very low-dose rituximab.

AIM: Conclusions regarding the best rituximab (RTX) dose to maintain remission and reduce immunosuppressant dependence in adult patients with steroid-dependent minimal change nephrotic syndrome (MCNS) are inconsistent. We report the first low-dose (< 375 mg/m2 BSA) RTX therapy, administered once every 6 months. MATERIALS AND METHODS: In this retrospective single-arm cohort study, we investigated the safety and efficacy of low-dose RTX therapy to reduce and ultimately stop prednisolone (PSL) and cyclosporine (CyA) treatment. 13 patients (8 men and 5 women; aged 16 - 65 years; 8-year median treatment history; 12 patients concurrently taking CyA) with steroid-dependent MCNS were chosen to maintain remission following low-dose RTX (200 mg/body) administration. RESULTS: The median period of subject observation following the first RTX dosing was 34 months (cumulative RTX dose: 400 - 1,400 mg). RTX significantly reduced PSL and CyA doses during the final observation in each subject (median dose: PSL 15→0 mg/day, p = 0.0002; CyA 80→0 mg/day, p = 0.0005). All patients maintained complete remission after discontinuing both drugs for a median complete remission (CR) maintenance period of 25 months. One patient showed relapse following the first RTX dose, but a temporary increase in PSL and CyA dose restored the remission. No serious RTX-related adverse effects were observed. Even with MCNS remission, peripheral CD19-positive cell count was not depleted in 90.5% of all cases. CONCLUSION: Low-dose RTX therapy appears to be effective in maintaining remission and reducing immunosuppressant doses in patients with steroid-dependent MCNS, which might involve a B-cell-independent mechanism.

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.

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.

The use of lower abdominal perforator flaps in soft-tissue reconstruction after sarcoma resection.

BACKGROUND: Historically, conventional musculocutaneous flaps have been commonly used for reconstruction after soft tissue sarcoma resection, and the use of lower abdominal perforator flaps has not been popular. This report examined the current role of lower abdominal perforator flaps in sarcoma treatment. METHODS: We reviewed the outcomes of 14 patients (mean age: 46.3 years, range: 18-79 years) who underwent immediate reconstruction with a deep inferior epigastric artery perforator (DIEP) flap or a superficial inferior epigastric artery (SIEA) flap after sarcoma resection. The defects ranged in size from 7 × 6 cm2 to 25 × 22 cm2 (mean: 16.5 × 12.1 cm2 ). An oblique design was used for pedicled DIEP flaps and a transverse design for free DIEP flaps. RESULTS: Free SIEA flaps were used in six patients, pedicled DIEP flaps in five, and free DIEP flaps in three. The flaps ranged in size from 13 × 8 cm2 to 36 × 12.5 cm2 (mean: 23.1 × 9.2 cm2 ). All DIEP flaps except one were harvested based on one dominant perforator. All flaps survived without vascular compromise. Surgical site infection and seroma occurred at the recipient site in one patient each. No donor-site complications occurred. CONCLUSIONS: Lower abdominal perforator flaps can serve as a versatile donor site for reconstruction after sarcoma resection.

Nipple-Areolar Complex Position in Female-to-Male Transsexuals After Non-skin-excisional Mastectomy: A Case-Control Study in Japan.

BACKGROUND: Mastectomy is performed in female-to-male transsexual (FTM TS) patients as a surgical treatment to make a female thorax resemble a male thorax; however, no studies have examined the nipple-areolar complex (NAC) position in FTM TS patients after mastectomy. PATIENTS AND METHODS: The NAC position in 41 FTM TS patients before and after non-skin-excisional mastectomy was examined and compared with that in 50 age- and BMI-matched biologically male subjects as controls. The factors affecting the NAC position after the operation were also examined and verified by multiple regression analysis. RESULTS AND CONCLUSIONS: After non-skin-excisional mastectomy, the NAC in the FTM TS patients was positioned significantly more medially (horizontal NAC position ratio {('internipple distance'/'width of thorax') × 100} [HNPR]: preoperatively, 70.07% ± 4.19%; postoperatively, 63.28% ± 3.79%) and cranially (vertical NAC position ratio {('distance from sternal notch to nipple height'/'distance from sternal notch to umbilicus') × 100} [VNPR]: preoperatively, 43.87% ± 3.68%; postoperatively, 41.37% ± 3.15%). Postoperatively, the NAC in the FTM TS patients was located significantly more medially than that in the control subjects (HNPR: 63.28% ± 3.79% to 66.79% ± 4.82%), although the height of the NAC was the same. Multiple regression analysis revealed that the NAC position on breasts characterized by ptosis, a high projection, and lateral leaning (low skin elasticity and a substantial amount of skin between the nipples) tended to be positioned more medially after non-skin-excisional mastectomy. Laterally deviated eccentric circular type mastectomy may be a good option for FTM TS patients who have moderately sized breasts with such features. 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 .

Soft silicone foam dressing is more effective than polyurethane film dressing for preventing intraoperatively acquired pressure ulcers in spinal surgery patients: the Border Operating room Spinal Surgery (BOSS) trial in Japan.

Preventing intraoperatively acquired pressure ulcers (IAPUs) in patients undergoing spinal surgery in the prone position using a Relton-Hall frame is challenging. We investigated the efficacy of soft silicone foam dressings in preventing IAPUs. A prospective dual-center sham study was conducted among patients undergoing elective spinal surgery in a general hospital and a university hospital in Japan. The incidence of IAPUs that developed when soft silicone foam dressings and polyurethane film dressings were used was compared on two sides in the same patient. IAPUs developed on the chest in 11 of 100 patients (11%). Polyurethane film dressings were associated with a significantly higher rate of IAPUs than soft silicone foam dressings (11 versus 3, P = 0·027). A multivariate logistic regression analysis revealed that a diastolic blood pressure of <50 mmHg (P = 0·025, OR 3·74, 95% confidence interval [CI] 1·18-13·08) and the length of surgery (by 1 hour: P = 0·038, OR 1·61, 95% CI 1·03-2·64) were independently associated with the development of IAPUs. The use of soft silicone foam dressings reduced the risk of IAPUs (P = 0·019, OR 0·23, 95% CI 0·05-0·79) and was more effective than film dressings for preventing IAPUs in spinal surgery patients.

Drug-Induced Atrial Fibrillation Complicates the Results of Flap Surgery in a Rat Model.

The relationship between atrial fibrillation (AF) and flap survival has not been fully characterized. Therefore, the goal of this study was to investigate the effect of AF on survival areas of pedicled flap and survival rates of free flap in an experimental rat AF model. An aconitine-induced rat AF model was established without intubation anesthesia. Survival areas of the pedicled rectangular epigastric flap were compared between AF rats (n = 7) and control rats (n = 7), and survival rates of the free epigastric flap were compared between AF rats (n = 10) and control rats (n = 10). Animals that died during the study or in which AF was not induced were excluded from study. A total of 64 rats were assessed in this study. Atrial fibrillation was induced with a success rate of 77.8% (21/27) throughout the study. Pedicled flap survival area was significantly higher in controls (75.1 ± 9.0%; n = 7) than that in AF animals (55.7 ± 13.0%; n = 7) (P < 0.01, nonpaired Student t test). Free flap survival rates were 80% in controls and 40% in AF animals (P = 0.07, χ² test). This is the first study to develop an aconitine-induced model of AF in rats. Atrial fibrillation has a detrimental effect on survival areas of the pedicled flap and survival rates of the free flap.

Examination of tissue oxygen saturation (StO2) changes associated with vascular pedicle occlusion in a rat Island flap model using near-Infrared spectroscopy.

PURPOSE: The purpose of this study was to perform continuous StO(2) monitoring of rat island flaps during pedicle vessel occlusion using near-infrared spectroscopy (NIRS) in order to collect experimental data for StO(2) flap monitoring under optimized conditions. MATERIALS AND METHODS: Twenty rats were used in this study. The 3 × 3 cm(2) epigastric skin island flaps were elevated on either side. The animals were randomly assigned to two groups; an arterial occlusion group (n = 10) and a venous occlusion group (n = 10). The StO(2) values of the flaps were observed for over 30 min for the pedicle artery or venous occlusion, followed by an additional 30 min release. RESULTS: The baseline StO(2) value was 78.4% ± 3.2% in the arterial occlusion group, compared to 78.5% ± 5.8% in the venous occlusion group, with no significant differences (P > 0.05). The StO(2) values decreased immediately after arterial occlusion, whereas a temporal StO(2) increase was initially observed after venous occlusion, followed by a StO(2) decrease. The StO(2) values decreased 27.3% ± 7.1% after arterial occlusion and 28.4% ± 19.1% after venous occlusion at 30 min after pedicle vessel clamping (P > 0.05). The StO(2) values were 0.4% ± 5.8% lower than baseline 30 min after arterial release (P > 0.05), while 18.9% ± 11.3% lower than baseline 30 min after venous release (P < 0.01). CONCLUSION: NIRS can be used to indicate StO(2) changes in flaps with the pedicle vessel occlusion and differentiate between pedicle artery and vein occlusion. Further investigations are needed to obtain definitive evidence associated with predicting the degree of flap viability and determine the practical use of this technique.

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.

Bidirectional pressure-induced penetrating necrotizing compartment syndrome in the forearm and surgical reconstruction using a two-lobed latissimus dorsi musculocutaneous flap in nonfunctional hand scenarios: a report of two cases.

This report describes two similar cases in which the distal forearm was compressed between the rib cage and floor for a prolonged period owing to immobility, resulting in severe compartment syndrome and extensive penetrating necrosis in the forearm. The cases were a 59-year-old man with cervical spondylolisthesis and a 65-year-old man suspected of having Parkinson's disease. A distinctive necrotic pattern characterized by necrosis in the volar and dorsal compartments, preservation of the lateral compartment, and retention of the radial artery was commonly observed in both cases. Despite the anticipated nonfunctional outcome of the salvaged limb, a two-lobed free latissimus dorsi musculocutaneous flap transfer with interposition of the thoracodorsal nerve in the median nerve defect was performed in both cases. Although the salvaged limbs were nonfunctional, the patients were able to use it for activities such as getting up and other daily tasks.

Evidence of nutritional vascular formation from the "nutrient flap" in a patient with no-option chronic limb-threatening ischemia: An indocyanine green fluorescence imaging study.

The concept of a "nutrient flap," in which ischemic tissue is nourished by a transferred well-perfused flap, has been advocated for use since the early days of free flap procedures. Several studies have reported cases of no-option chronic limb-threatening ischemia salvaged by nutrient free flap transfer. However, it has been difficult to prove the actual dynamic flow and nutritional vascular formation. Thus, the existence of a nutrient flap has remained unproved. In the present report, we have described the case of free flap transfer for a patient with no-option chronic limb-threatening ischemia in whom we detected evidence of a nutrient flap using indocyanine green fluorescence imaging.

Superficial Temporal Vein and Alternative Middle Temporal Vein as Recipient Veins for Free-flap Reconstruction.

The superficial and middle temporal veins (STV and MTV) have been used as recipient veins for free-flap reconstruction; however, the STV is sometimes small and cannot be used, while the MTV is not fully recognized or utilized as a recipient vein. The purpose of the present study was to evaluate the reliability of the STV/MTV as recipient veins and to verify the utility and availability of the MTV by comparing the two veins. Thirty-five consecutive cases of free-flap reconstruction utilizing recipient vessels in the temporal region were retrospectively reviewed. Regarding recipient veins, the STV was the only option in the first 18 cases; the MTV was included among the options in the latter 17 cases. The calibers of the STV/MTV were evaluated at two level points (1: zygomatic arch, 2: palpebral fissure) using the results of preoperative dynamic-enhanced computed tomography (CT). Two cases of severe venous congestion were identified among the first 18 patients. After the adoption of the MTV, the MTV was used in 10 of the 17 cases, and no vascular complication occurred. On CT imaging evaluation, the caliber of the MTV (Point 2) (2.94 ± 0.55 mm) was significantly larger than the calibers of the STV (Point 1) (2.40 ± 0.48 mm) and MTV (Point 1) (2.49 ± 0.43 mm) (both P < 0.001). Regarding the recipient veins in the temporal area, the MTV can offer an option with a larger caliber or for additional venous anastomosis when the condition of the STV is inadequate.

Wearable, wireless, multi-sensor device for monitoring tissue circulation after free-tissue transplantation: a multicentre clinical trial.

Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.

A Quantitative Evaluation of the Flow-Increasing Effect of Flow-Through Arterial Anastomosis in the Vascular Pedicle of Free Flaps: A Prospective Clinical Before-and-After Study.

BACKGROUND: The clinical application of flow-through anastomosis has been reported in various studies; however, no studies have quantitatively evaluated and compared the actual hemodynamics in flow-through anastomosis and end-to-end anastomosis. This study quantitatively evaluated the blood inflow (volumetric flow rate) and vascular resistance (pulsatility index) of flow-through arterial anastomosis using an ultrasonic flowmeter, and compared these values with those of end-to-end anastomosis in actual clinical settings. In addition, factors affecting the outcomes have also been examined. METHODS: Twenty-eight patients who underwent free flap reconstruction after tumor resection were subjected to flow-through arterial anastomosis and flow examination. First, in the end-to-end state, the proximal anastomotic site was measured. This was followed by the opening of the distal arterial clamp, and measurement was then continued (in the flow-through state). RESULTS: In flow-through arterial anastomosis compared with end-to-end anastomosis, the volumetric flow rate was significantly increased (18.9 ± 14.1 ml/minute versus 6.0 ± 6.3 ml/minute) and the pulsatility index was significantly decreased (5.2 ± 3.7 versus 13.6 ± 10.2), when comparing paired data. Multiple regression analyses revealed that a perforator flap (versus a musculocutaneous flap) was independently associated with both reduced volumetric flow rate and increased pulsatility index in end-to-end anastomosis, and that hypertension was independently associated with an increased pulsatility index in end-to-end anastomosis. However, no factors in flow-through anastomosis were significantly associated with those values. CONCLUSION: In terms of blood flow and vascular resistance, flow-through arterial anastomosis was considered to have promising quantitative effects and should be performed when the conditions of both the donor and recipient vessels meet the requirements. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Chronological flap volume and distribution changes after reconstruction of total maxillectomy defect using a rectus abdominis myocutaneous flap.

BACKGROUND/PURPOSE: After total or subtotal maxillectomy, reconstruction using a free rectus abdominis myocutaneous (RAMC) flap is a fundamental and useful option. The purpose of the present study was to clarify the degree of flap volume change and volume distribution change with time after total or subtotal maxillectomy and free RAMC flap reconstruction and to examine the factors affecting the results. METHODS: A total of 20 patients who underwent total or subtotal maxillectomy with free RAMC flap reconstruction were examined, and the flap volume change rate (volume at final evaluation [POD 181-360] / volume at initial evaluation [POD 5-30]) was investigated using the results of imaging tests. Moreover, the flap was divided into four blocks (A-D) in the cranio-caudal direction, and the volume change of each block was individually analyzed. RESULTS: The overall volume change rate of fat/muscle/total was 0.84 ± 0.21/0.36 ± 0.08/0.67 ± 0.15, at the mean follow-up period of 309±35 days after the operation. The multiple regression analysis revealed that weight loss (for fat), postoperative RT (for fat and muscle), and young age (for muscle) were independently associated with flap volume loss. The results also indicated that the fat volume was stable, whereas the muscle volume decreased to <40% over time, assuming there were no influencing factors. Regarding flap volume distribution change, the fat volume tended to gather toward the central-cranial direction, while the muscle volume gathered toward the cranial direction, and total flap volume gathered toward the central direction.