Use of Flow-through Free Flaps in Head and Neck Reconstruction.

Background: Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. Methods: To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. Results: We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. Conclusion: In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Total Autologous Breast Reconstruction.

BACKGROUND: When abdomen-based free flap reconstruction is contraindicated, the muscle-sparing thoracodorsal artery perforator (TDAP) flap may be considered for total autologous breast reconstruction. The TDAP flap is often limited by volume and is prone to distal flap necrosis. We aim to demonstrate our experience combining the delay phenomenon with TDAP flaps for total autologous breast reconstruction. METHODS: Patients presenting for autologous breast reconstruction between April 2021 and August 2023 were recruited for surgically delayed TDAP flap reconstruction when abdominally based free flap reconstruction was contraindicated because of previous abdominal surgery or poor perforator anatomy. We dissected the TDAP flap except for a distal skin bridge and then reconstructed the breast 1 to 7 days later. Data included flap dimensions (in centimeters × centimeters), delay time (in days), predelay and postdelay perforator caliber (in millimeters) and flow (in centimeters per second), operative time (in minutes), hospital length of stay (in days), complications/revisions, and follow-up time (in days). RESULTS: Fourteen patients and 16 flaps were included in this study. Mean age and body mass index of patients were 55.9 ± 9.6 years and 30.1 ± 4.3 kg/m2, respectively. Average flap skin island length and width were 32.1 ± 3.3 cm (n = 8 flaps) and 8.8 ± 0.7 cm (n = 5 flaps), respectively. Beveled flap width reached 16.0 ± 2.2 cm (n = 3 flaps). Average time between surgical delay and reconstruction was 2.9 days, ranging from 1 to 7 days (n = 18 flaps). Mean predelay and postdelay TDAP vessel caliber and flow measured by Doppler ultrasound increased from 1.4 ± 0.3 to 1.8 ± 0.3 mm (P = 0.03) and 13.3 ± 5.2 to 43.4 ± 18.8 cm/s (P = 0.03), respectively (n = 4 flaps). Complications included 1 donor site seroma and 1 mastectomy skin flap necrosis. Follow-up ranged from 4 to 476 days (n = 17 operations). CONCLUSIONS: We demonstrate surgically delayed TDAP flaps as a viable option for total autologous breast reconstruction. Our series of flaps demonstrated increased perforator caliber and flow and enlarged volume capabilities and had no incidences of flap necrosis.

A Rare Presentation of Scurvy in a Well-Nourished Patient.

Vitamin C deficiency, otherwise known as scurvy, is a rare diagnosis among populations with adequate nutritional resources. We present a 37-year-old female patient with bilateral lower extremity edema, episodic anasarca, petechiae, and easy bruising who was diagnosed with scurvy. Given the clinical presentation, a broad differential was investigated with no findings suggestive of hematologic or cardiovascular pathology. Initial laboratory studies were unremarkable. Progression of cutaneous symptoms and subsequent laboratory findings demonstrating low vitamin C levels supported a diagnosis of scurvy. Classical symptoms of scurvy include mucocutaneous petechiae, poor wound healing, ecchymosis, hyperkeratosis, corkscrew hair, gingival swelling, and bleeding gums. Following standard enteral supplementation of vitamin C, repeat vitamin C levels failed to adequately respond with the patient remaining to be symptomatic. Given a lack of insufficient nutritional intake or known systemic illness, gastrointestinal malabsorptive etiology was suspected. Though rare in the United States, scurvy should be considered in patients with manifestations of a bleeding disorder. A gastrointestinal workup may be indicated if other nutritional deficiencies are identified, or a source of inadequate intake cannot be established.

Surgical Delay of Thoracodorsal Artery Perforator Flaps for Bilateral Autologous Breast Reconstruction.

Autologous reconstruction accounts for nearly one-quarter of all breast reconstruction cases in the United States, with the abdomen functioning as the most popular donor site. This case describes a 62-year-old woman who presented to our clinic with a remote history of estrogen receptor+/progesterone+ breast cancer and bilateral implant-based reconstruction. After grade IV capsular contracture of her left breast, she presented for autologous reconstruction. Due to her body habitus and prior belt lipectomy, deep inferior epigastric perforator flap reconstruction was contra-indicated. The thoracodorsal artery perforator (TDAP) flap is well described in the literature, and was chosen as an alternative salvage procedure to avoid latissimus harvest and the need for implants. The TDAP flap is often limited in volume and prone to distal tip necrosis, limiting its use in breast reconstruction. We have previously demonstrated the utility of the surgical delay phenomenon in improving the reliability of superficial inferior epigastric artery free flap breast reconstruction. In this case, we demonstrate the surgically delayed TDAP flap as a viable alternative to the latissimus flap with implants for bilateral total autologous breast reconstruction.

Severity of Chronic Venous Insufficiency on Primary Total Knee Arthroplasty Outcomes.

BACKGROUND: More than 700,000 people in the United States undergo total knee arthroplasty (TKA) each year. Chronic venous insufficiency (CVI) affects 5% to 30% of adults, sometimes resulting in leg ulceration. These CVI cases in TKAs have been associated with worse outcomes; however, we found no study differentiating CVI severity. METHODS: This retrospective study analyzed TKA outcomes at one institution from 2011 to 2021 using patient-specific codes. Analyses included short-term complications (< 90 days postoperative), long-term complications (< 2 years), and CVI status (yes/no; simple/complex/unclassified). Complex CVI consisted of pain, ulceration, inflammation, and/or other complications. Revisions within 2 years and readmissions within 90 days post-TKA were assessed. Composite complications included short-term and long-term complications, revisions, and readmissions. Multivariable logistic regressions predicted complication (any/long/short) as a function of CVI status (yes/no; simple/complex) and potential confounding variables. Of 7,665 patients, 741 (9.7%) had CVI. Among CVI patients, 247 (33.3%) had simple CVI, 233 (31.4%) had complex CVI, and 261 (35.2%) had unclassified CVI. RESULTS: There was no difference in CVI versus control in composite complications (P = .722), short-term complications (P = .786), long-term complications (P = .15), revisions (P = .964), or readmissions (P = .438) postadjustment. Composite complication rates were 14.0% without CVI, 16.7% with complex CVI, and 9.3% with simple CVI. Complication rates differed between simple and complex CVI (P = .035). CONCLUSION: Overall, CVI did not affect postoperative complications versus control. Patients who have complex CVI are at higher risk for post-TKA complications compared to those who have simple CVI.

Autologous Breast Reconstruction with Bilateral Stacked Free Flaps in Massive Weight Loss Patients.

Patients with a history of massive weight loss who are undergoing autologous breast reconstruction after mastectomy represent a unique surgical challenge. Although these patients often have an abundance of excess skin, it may be difficult to acquire sufficient tissue volume for adequate reconstruction of bilateral breasts using single flap techniques due to the paucity of subcutaneous fat. Stacked flap techniques have emerged as an effective method in thinner patients with suboptimal fat distribution who desire autologous breast reconstruction. This can serve as an ideal strategy, specifically in this patient population, when it serves the dual function of providing adequate volume for bilateral breast reconstruction and the secondary benefit of removing the excess skin present after massive weight loss. In this article, we discuss surgical techniques used during two cases of bilateral stacked flap breast reconstruction in cancer patients subsequent to massive weight loss.

Autologous Mandible Reconstruction in a Hypercoagulable Patient following Multiple Failed Free Flaps.

Coagulopathies affect 3% of free flap patients and are among the leading causes of free flap failure. This report describes the case of a head and neck cancer patient that experienced two remote free flap failures before successful autologous mandibular reconstruction. Following identification of an unrecognized thrombophilic state, a focused anticoagulation strategy was executed, including an intraoperative heparin drip, stringent postoperative maintenance of Factor Xa levels between 0.3 and 0.5 IU per mL, and transition to an outpatient enoxaparin regimen of 1 mg per kg twice daily for 1.5 months following surgery. Here, we demonstrate that free tissue transfer following multiple previous failed attempts in the setting of hypercoagulability remains a viable reconstructive option with close interdisciplinary collaboration, close clinical monitoring, and patient-specific antithrombotic protocols.