Abdominal-Based Microsurgical Breast Reconstruction: How to Inset the Flap to Maximize the Aesthetic Result-A Systematic Review.

Nowadays, the ultimate goal of microsurgical breast reconstruction is not merely the effective transfer of vascularized tissue but the achievement of a natural, symmetric appearance. The aim of this present study was to systematically summarize the published evidence on abdominal-based free flap inset for breast reconstruction in order to provide principles and classification that could guide the surgeon in choosing the most appropriate inset technique based on patient and flap characteristics. A comprehensive review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, looking for articles on the insetting technique for free flap breast reconstruction. After screening 306 publications, 24 papers (published from 1994 to 2020) were included in the study. We identified four main breast anatomical features on which the papers reviewed focused when describing their insetting technique: breast width, breast ptosis, breast projection, and upper pole fullness. Patient body type, type of mastectomy, and reported complications are also discussed. Flap shaping and inset during breast reconstruction are fundamental steps in any reconstructive procedure. Despite the low evidence in the current literature, this systematic review provides a framework to guide the surgeon's decision-making and optimize the aesthetic outcomes of abdominal-based free flap breast reconstruction.

Survival analysis of segmental mandibulectomy with immediate vascularized fibula flap reconstruction in stage IV oral squamous cell carcinoma patients.

PURPOSE: This study aims to assess the survival rate of oral squamous cell carcinoma (OSCC) patients following immediate mandibular reconstruction with vascularized fibula flap (VFF) and to identify risk factors influencing the overall survival rate and postoperative outcomes. PATIENTS AND METHODS: Patients suitable for the inclusion criterion diagnosed and treated between January 1996 till June 2019 for OSCC were retrospectively reviewed (n = 74). Potential risk factors and postoperative outcomes were recorded and analyzed. RESULTS: The overall cumulative survival rate of patients was 0.52 at the end of 5th year. Overall, advanced pN stage (p = 0.0422), poor tumor differentiation (p < 0.0001), positive/close surgical margins (p = 0.0209), vascular invasion (p = 0.0395), perineural invasion (p = 0.0022) and tumor recurrence (p = 0.0232) were significantly related to a decreased cumulative survival. Tumor recurrence was significantly correlated with involvement of positive/close surgical margins, moderate (p = 0.0488), poor-differentiated tumors (p = 0.202), extracapsular spread (p = 0.0465), computer-assisted surgery (p = 0.0014) and early complications (p = 0.0224). Pain was significantly associated with the extracapsular spread (p = 0.0353) and early complications (p = 0.0127). CONCLUSION: The five-year survival rate of advanced OSCC patients after segmental mandibulectomy with fibula free-flap reconstruction was 52.4%. Clinical/pathological risk factors such as the pN stage, tumor differentiation, surgical margins, vascular invasion, perineural invasion, tumor recurrence significantly influenced the overall cumulative survival rate.

Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity.

BACKGROUND: The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15 cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease. METHODS: Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included in the study. Each patient received a periumbilical electromyogram (EMG) preoperatively, at 6 and 14 weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009 and May 2011. RESULTS: In our LFI-technique, one vertical (4 cm) incision is made where the pedicle exits the muscle. A second, oblique (3 cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at, respectively, 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group. CONCLUSION: This study shows the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function are less endangered using small segmental fascia incisions. We believe that our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.

Fibula Free Flap in Head and Neck Reconstruction: Identifying Risk Factors for Flap Failure and Analysis of Postoperative Complications in a Low Volume Setting.

The fibula free flap (FFF) has been a workhorse in maxillofacial reconstruction. High success rates of this technique are reported. However, identifying risk factors for flap failure and analyzing complications can open the way to better patient care. A retrospective analysis was conducted of all FFFs performed over a 20-year period at a low-volume single tertiary center to identify risk factors and postoperative complications. A total of 129 FFFs were included (122 mandible, 7 maxilla). Complete flap failure occurred in 12.4% and partial flap failure in 7.8% of patients. A significant relation was found between younger age and flap failure, and most failures were associated with venous thrombosis. In-hospital surgical complications occurred in 60.5%, in-hospital medical complications in 49.6%, and out-of-hospital complications in 77.5% of patients. The in-hospital reintervention rate was 27.1%, and including salvaged flaps, flap survival rate was 87.6%. Osteomyocutaneous FFF failure (complete 12.4%; partial 7.8%) is an important clinical reality in a low-volume head and neck reconstruction center resulting in an in-hospital reintervention rate of 27.1%. Postoperative complications are frequent, both surgical and out-hospital complications. These results provide a better understanding of the limitations of the FFF in a low-volume center and can be used to optimize care in this kind of setting.

Immediate versus delayed autologous breast reconstruction: A retrospective matched cohort study of irradiated patients.

BACKGROUND: The impact of radiotherapy on breast reconstructions is not completely understood. The purpose of this study was to evaluate long-term effects of radiation therapy in relation to timing of autologous breast reconstruction. METHODS: A total of 1247 patients undergoing autologous breast reconstruction at the University Hospitals of Leuven between August 1997 and October 2013 were subjected to a retrospective matched cohort study. Each patient who underwent immediate breast reconstruction (IBR) and received post mastectomy radiotherapy (PMRT) were matched with two patients receiving PMRT and delayed breast reconstruction (DBR), according to age and body mass index. Early and late complications were compared between both groups after a minimum follow-up of 3 years. The need for corrective procedures on the reconstructed and contralateral breast was also evaluated. Data were collected using patients' medical records. RESULTS: A total of 20 patients who underwent IR with PMRT were identified and matched to 40 patients who underwent DBR. There were two revisions in the DR group, both due to venous occlusion. Both revisions were successful and no flap failures occurred in either group. The rate of early complications did not differ significantly between the two groups. Among late complications were both the rates of fat necrosis (p < 0.001) and skin contracture (p < 0.001) higher in the IBR group than in the DBR group. Neither corrective procedures to the reconstructed breast nor symmetrizing operations in the contralateral breast, differed between the groups. CONCLUSION: The current study indicates that radiotherapy may contribute to adverse long-term flap-related outcome after IBR. We therefore recommend reconstructions to be delayed whenever possible in patients who will require PMRT.

Regions of ilium and fibula providing clinically usable bone for mandible reconstruction: "A different approach to bone comparison".

A variety of donor sites are available for mandibular reconstruction. We present here a different way of comparing two commonly-used bone flaps. The lengths of the usable parts in a total of 241 coxal bones, 91 mandibles and 60 fibulas were measured. The mandible was measured from condyle-to-condyle and the harvestable bone length (HBL) and usable (UBL) bone lengths in fibula and ilium were also measured. The bone thickness (BT) in 60 iliac crests was measured in two parallel lines from the anterior superior iliac spine (ASIS) along the iliac crest. The mandible was 32.17 mm shorter in females than in males. The total ilium UBL was 171.12 mm in females and 178.80 mm in males. The mean HBL of the fibula was 22.6 mm shorter in females than in males. However, in some fibulas in both females and males, only 4.2% and 21.1% of the HBL respectively could be used if the ultimate goal was to insert dental implants. We found significant correlations between BT and gender in both fibula and ilium (P≤ 0.05). The ilium offers constant BT throughout the usable bone area with a similar bone length to the fibula. In contrast, the fibula showed variable bone dimensions, so not all of it is clinically usable. This should especially be considered in females when a mandibular reconstruction is planned with the goal of occlusal rehabilitation. Clin. Anat. 29:773-778, 2016. © 2016 Wiley Periodicals, Inc.

Histopathological Differences of the Pedicle Artery in Commonly Used Free Flaps: The Influence of Age, Gender, and Side.

PURPOSE: The increasing use of vascularized free flaps has increased the demand for a specified flap selection. This study investigated histologic differences in the arterial wall of the pedicle for commonly used free flaps and the effect of age, gender, and anatomic side on these differences. MATERIALS AND METHODS: Light microscopic examinations of vessel walls were performed on 245 specimens of the nourishing artery of commonly used free vascularized flaps in preserved cadavers. The peroneal artery (PA), radial artery (RA), inferior epigastric artery (IEA), deep circumflex iliac artery (DCIA), and circumflex scapular artery (CSA) were examined. Differences of histologic changes in the arterial wall and the effect of age, gender, and body side were investigated. RESULTS: All examined vessel specimens (age range, 62 to 98 yr; mean age, 83 yr; 15 female and 12 male) displayed mostly Class II changes. PA showed the greatest atherosclerotic changes, followed by the RA, IEA, DCIA, and CSA. Age had a meaningful effect on PA and RA. Anatomic side was important for PA and DCIA, whereas gender had a minor influence on vessel condition. CONCLUSION: The vessel wall of different flaps showed different atherosclerotic changes depending on age, anatomic side, and gender. These differences should be considered in flap selection.

Immediate debridement of road rash injuries with Versajet® hydrosurgery: traumatic tattoo prevention?

UNLABELLED: Traumatic tattoos can result from accidental deposition of foreign particles in the dermis. These pigmented particles become permanently lodged in the dermis after re-epithelialization of the wound and can give rise to irregular black or blue discoloration of the skin. Different methods for tattoo removal exist. The best strategy is to prevent traumatic tattooing by immediate removal of the foreign bodies before the healing process has begun. We present a fine-tuned debridement method to selectively debride the wound and preserve as much viable tissue as possible. LEVEL OF EVIDENCE V: 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 .

Factors influencing the necessity for preoperative vascular imaging before harvesting a vascularized fibular flap.

OBJECTIVE: This study was carried out to identify groups of patients who would benefit from this angiography. The angiographic images of a random group of patients were studied; the correlations between the vascular state of the lower extremities and vessel pathology were investigated; and the possible links of these findings with certain medical conditions were explored. STUDY DESIGN: Three experienced observers independently evaluated the angiograms of 185 patients. The status of all 3 vessels of the lower extremities (anterior tibial artery, posterior tibial artery, and peroneal artery) was evaluated. The patients' gender, age, drinking and smoking habits, and medical conditions were documented. RESULTS: We found a significant correlation between pathology of the arteries of the lower extremity and blood cholesterol level, blood pressure, coronary heart disease, diabetes mellitus, and age. CONCLUSIONS: We suggest that preoperative vascular imaging be carried out in patients with comorbidities to reduce the potential for flap failure and to minimize donor site complications.

Surgical management of auricular defect depending on the size, location, and tissue involved.

PURPOSE: Auricular reconstruction is a challenging surgical intervention that requires perfect surgical skills, exact planning, and esthetic knowledge. It is necessary to use a suitable method of reconstruction for each patient. From 10 years of experience, the authors have developed a general concept for auricular reconstruction. PATIENTS AND METHODS: Seventy-five patients (62 male, 13 female; age range, 8 to 92 yr; mean age, 65.9 yr) underwent partial to total auricular reconstruction. Tissue loss occurred from different causes: 19 cases of squamous cell carcinoma (25.3%), 18 cases of basal cell carcinoma (24%), 14 cases of Bowen disease (18.7), 11 cases of malignant melanoma (14.7%), 7 cases of trauma (9.3%), 3 different malignant tumors (4%), and 3 cases of congenital deformity (4%). RESULTS: Defects smaller than one fourth the vertical auricular size (15 to 20 mm) could be treated by primary closure. A larger defect closed by this method caused visible deformity. In defects larger than one to three fourths the vertical auricular size (40 to 55 mm), a reversed retroauricular flap was used successfully if there was no contraindication or rejection. This flap can be combined with other flaps, depending on the flap location, size, and tissue involved. In defects exceeding three fourths the vertical auricular size, an implant-retained prosthesis was preferred. CONCLUSION: The location and size of a defect, the medical condition of the patient, and the desired esthetic outcome play an important role in choosing the appropriate method. According to the authors' experience, the only contraindications for the reversed retroauricular flap are medical condition, poor prognosis, and patient refusal.

New approach to shaping a ptotic breast in secondary autologous breast reconstruction.

UNLABELLED: Breast ptosis in women is mostly perceived as unattractive. It is associated with aging, breastfeeding, and multiple pregnancies. However, women who undergo radical mastectomy are the exception. They strive for a natural appearance and do not perceive a ptotic breast as unaesthetic. Shaping a ptotic breast from autologous tissue is one of the most challenging and difficult reconstructive procedures, especially because the risk of tissue failure has decreased significantly. The authors present their method of shaping a ptotic breast after a delayed autologous breast reconstruction. The technique, presented in detail, consists of dividing the native breast skin below the mastectomy scar into two dermocutaneous triangular flaps that carry the new breast. The dermocutaneous triangular flaps can be turned outward to decrease upper pole fullness and increase ptosis. Creating a carbon copy of the contralateral breast can be achieved during surgery. This report presents the results of the authors' method and discusses its advantages and disadvantages. In addition to its simplicity, this method gives ptosis up to grade 3 according to Regnault, frequently negating a mastopexy of the contralateral breast to reach symmetry. Equally important, the results have been stable in the long term. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

The unilateral deep inferior epigastric perforator flap: comparing university to community hospital.

The deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard for autologous breast reconstruction. This study evaluates the outcome of unilateral DIEP flap reconstructions, comparing university with a community hospital setting. A total of 77 unilateral DIEP flaps were performed at one university hospital and two community hospitals by the same two surgeons. Outcome parameters were: hospital stay, operating time, wound infection, wound dehiscence, fat necrosis, haematoma, (partial) flap necrosis and the need for surgical intervention. Forty-nine unilateral DIEP flaps were performed in the university hospital and 28 in the community hospitals. Baseline characteristics were equal. No significant difference was found in total complication rate, flap loss or need for surgical intervention. Although wound dehiscence occurred more often in the community hospitals, unilateral DIEP flap breast reconstructions can be performed with a comparable degree of safety and complication risk in both university and community hospital settings.

Fat necrosis in deep inferior epigastric perforator flaps: an ultrasound-based review of 202 cases.

BACKGROUND: In autologous breast reconstruction after mastectomy, fat necrosis is a rather common complication that may lead to secondary corrective surgery. The understanding of fat necrosis until now has been limited because previous studies were based exclusively on physical examination and used diverse definitions. METHODS: The authors retrospectively reviewed the incidence of fat necrosis and the correlation of several risk factors in 202 deep inferior epigastric perforator (DIEP) flaps for breast reconstruction. The incidence of fat necrosis was based on both physical examination and ultrasound imaging. The following risk factors were studied: age, smoking, body mass index, timing of reconstruction, and timing and extent of radiation therapy fields. RESULTS: Physical examination revealed a palpable mass or nodule in 14 percent of the DIEP flaps (28 of 202). Ultrasound examination added another 21 percent of DIEP flaps (42 of 202) with a firm area of scar tissue (diameter >or=5 mm). The overall ultrasound incidence of fat necrosis in this study was 35 percent (71 of 202). Although the overall ultrasound incidence of fat necrosis was very high, only 7 percent of the DIEP flaps (15 of 202) needed to undergo an extra surgical procedure for removal of this area. In contrast to previous studies, none of the risk factors studied was statistically significant for the occurrence of fat necrosis. CONCLUSIONS: These results suggest that there is no significant association between previously suspected risk factors and fat necrosis. The overall incidence of fat necrosis, however, is much higher than previously accepted, even though the need for corrective surgery is limited.

Minimizing limb amputations in meningococcal sepsis by early microsurgical arteriolysis.

PURPOSE: Surgical treatment of children with meningococcal sepsis has mainly involved debridement of necrotic skin and amputation of limbs. This resulted in major functional impairment. On the contrary, when early microsurgical arteriolysis was performed, freeing up the blood vessels, the impaired blood flow could be restored, thereby significantly reducing the amputation levels. METHODS: We prospectively evaluated 14 patients affected by meningococcal sepsis. In 7 patients, microsurgical arteriolysis was performed; standard sepsis treatment was performed on the remaining 7. Ischemia levels on admission were compared with permanent amputation levels after 1 year. RESULTS: Statistically significant decreases (P = .005) in ischemia values were achieved by the arteriolysis, in comparison with final amputation percentages. The functional impairment of the affected limbs was highly reduced compared with the probable loss of function observed on admission. CONCLUSIONS: Our findings show that early microsurgical arteriolysis is a reliable method to reduce the devastating amputations normally found in patients with meningococcal sepsis. This significantly improves the functional outcome in severely ischemic limbs in meningococcal induced septic children.

Initial reconstruction of sustained neck and facial burns.

Approximately 50% of burn injuries involve the neck and head region. Because both appearance and function must be taken into account with burns of this area, several consecutive reconstructions will be performed. With a focus on improving outcome after burn injury, we underline the method of grafting as a very important element in primary surgery. With our special excision and grafting technique, we aim to achieve a reconstruction that deals with mobility and aesthetics. Consequently, necessary reconstructive procedures may be fewer and of less magnitude. We describe this surgical technique in detail. In this study we surgically treated 39 patients with sustained facial and neck burns. For 22 patients this surgical treatment circumvented the need to perform any secondary reconstructions. The proposed treatment involves a special grafting technique after pretreatment with a topical agent in combination with early pressure therapy.

The role of free flaps in the treatment of persistent scalp osteomyelitis.

OBJECTIVE: To evaluate the efficacy of the combination of an extensive surgical debridement and simultaneous free flap repair in case of troublesome cranial osteomyelitis. METHODS: Five patients with persistent, frontal bone osteomyelitis were treated with surgical debridement of the infected bone and reconstruction with a free flap. In all patients, osteomyelitis occurred after neurosurgical procedures and lasted from 1 to 7 years. A latissimus dorsi muscle flap with a split skin graft has been performed. RESULTS: No flap failure occurred and donor site morbidity was negligible. No signs of osteomyelitis or soft tissue infection were observed during the mean follow-up period of 3.2 years. Furthermore, the contour of the cranium could be preserved without a need for bone grafts or implants. CONCLUSION: In our experience, the combination of an extensive surgical debridement and a free flap transfer is demonstrated to be an effective treatment for "chronic" osteomyelitis of the cranium.

Preservation of rat cremaster muscle microcirculation after prolonged cold storage and transplantation.

BACKGROUND: Microvascular surgery for the reconstruction of complex defects involves an ischemic period, which may cause flap failure as the result of ischemia/reperfusion injury. We assessed the microvascular consequences of rat cremaster muscle transplantation after prolonged periods of cold storage in HTK-Bretschneider solution (HTK). MATERIALS AND METHODS: Cremaster muscle transplantations were performed immediately or after 8 or 24 h of cold storage (4 degrees C) in HTK or saline. Intravital microscopy was used to quantify capillary perfusion and venular leukocyte-endothelium interactions following transplantation. RESULTS: The transplantation procedure itself resulted in 50-65 min of ischemia. After direct transplantation, capillary perfusion was 90% of control. Transplantation after 8 h of cold storage in either HTK or saline did not deteriorate capillary perfusion. When the tissue was stored for 24 h, HTK was superior to saline in preserving capillary perfusion (HTK: 76-83% of control, saline: 30%). Immediate transplantation induced a small increase in leukocyte adhesion. Prolonged cold storage in either fluid resulted in reduced flow velocities (qualitative observations) and edema formation, which hampered quantification of leukocyte-endothelium interactions. CONCLUSIONS: Even after 8 or 24 h of cold storage in HTK, transplantation of rat cremaster muscle was successful with good capillary perfusion. Capillary perfusion was better preserved in HTK than in saline.

Microcirculatory hemodynamics of the rat cremaster muscle flap in reduced blood flow states.

Recent studies revealed that muscle and musculocutaneous flaps have the lowest peripheral resistance and best flap survival. The critical values of flow rates responsible for this survival have not been established. The authors evaluated the effect of prolonged arterial flow reduction on flow hemodynamics and muscle flap survival, independent of neovascularization using the rat cremaster muscle island flap model for microcirculatory studies. Muscle flaps were implanted into a transparent Plexiglas chamber to allow prolonged observation of the microcirculation. Twenty-six male Sprague-Dawley rats were studied in three experimental groups. In group I (control; no occlusion), after flap isolation, the cremaster muscle was implanted into the tissue chamber and microcirculatory measurements were performed from day 0 to day 3. In group II, after flap isolation, flow in the main feeding artery (the iliac) was reduced with a silk suture loop between 47% and 62%. In group III, arterial flow was reduced between 63% and 80%. Vessel diameters, red blood cell velocities, number of perfused capillaries, and number of rolling, sticking, and transmigrating leukocytes were reduced daily for each rat. Immediately after flow reduction, mean arteriolar (A1) diameters were significantly smaller in group II (25%) and group III (29%) compared with the controls (p<0.05). This reduction was confirmed by a drop in red blood cell velocities of 37% and 58% in groups II and III respectively (p<0.05). At day 1, more than 60% of group III flaps had no arterial flow, whereas normal flow was observed in control flaps for as long as 3 days. In addition, the number of perfused capillaries dropped significantly (by 42%) in group II flaps after 3 days (p<0.05). The authors conclude that continuous arterial blood flow reduction exceeding 60% of the normal volume, independent of angiogenesis, is incompatible with flap viability in the rat cremaster muscle model.