Indications, outcomes, and complications of neoumbilical reconstruction: A systematic review.

BACKGROUND AND OBJECTIVES: Neoumbilicoplasty aims to reconstruct an aesthetically pleasing new umbilicus following agenesis, malignancy, anatomical distortion, or umbilicus loss. Despite the wide variety of surgical techniques described, literature is scarce when it comes to standardized categorization of these as well as the clear definition of patients' selections, specific indications, final outcomes, and possible complications. According to available literature, this work aims to evaluate different surgical approaches, and correlate them to specific surgical needs, to simplify the surgical choice and patient management. METHODS: A systematic review was performed in December 2020 in PubMed, Web of Science, and MedLine Ovid databases according to the PRISMA guidelines. RESULTS: A total of 41 studies and 588 patients were finally included. On the basis of the evidence of the literature collected, we divided the studies into four groups according to the neoumbilicoplasty techniques: single suture or purse-string suture, single flap, multiple flap, and skin graft. Patients' surgical comorbidities, neoumbilicoplasty indications, and aesthetic and surgical outcomes were investigated. Direct suture and single and multiple flap techniques assured overall, satisfactory cosmetic outcomes with a low rate of surgical complications. Whereas suture-only techniques were chosen mostly by general surgeons/urologists in laparoscopic surgery, the single flap was the preferred method to reconstruct the umbilicus in open abdominal surgery or combined abdominoplasty with herniorrhaphy. Multiple flap and skin grafts were adopted in abdominoplasty-related umbilicus reconstruction, although the latter option showed impactful aesthetic and surgical complications. CONCLUSIONS: Umbilicoplasty can assure generally pleasant aesthetic outcomes with relatively low complication rates. Indications for specific techniques correspond to different patient populations and surgical scenarios.

Systematic reappraisal of the reverse-flow medial plantar flap: From vascular anatomical concepts to surgical applications.

INTRODUCTION: The medial plantar artery (MPA) flap in its anterograde form is considered the gold standard for heel reconstruction. This flap can be also raised distally for the reconstruction of the weight-bearing forefoot. However, terminal branches of the MPA, together with their connection with distal and dorsal systems, can be variable. Our objective was to provide a comprehensive anatomic description that could match all technical possibilities in raising the distally based MPA flap. A systematic review of indication outcomes and complications of the distally based MPA flap is provided. METHODS: According to PRISMA criteria, we systematically reviewed previous literature using the MEDLINE database concerning the MPA flap from 1977 to November 2018 using the keywords « Medial plantar flap ¼ OR « Medial Plantar Artery ¼. Anatomic variations, techniques, indications, outcomes, and complications were analyzed. RESULTS: All different vascular pedicles that may be used for the vascularization of the MPA flap were classified. Apart from the flap with a proximal flow, there may be five anastomotic connections from the superficial MPA to the plantar arterial network. Four dorso-plantar links supply the plantar network thanks to dorsal vascularization. Literature analysis of outcomes showed how the retrograde MPA flap may be unreliable with 14% of venous congestion rate and 9.3% of average flap loss, for a total average flap complication of 18.6%. CONCLUSION: This review provides the ultimate, clear picture of the complex anastomosis of the forefoot, with direct referral to surgical flap raising techniques, guiding surgeons during challenging reconstructions.

The "nugget design": A modified segmental gracilis free flap for small-sized defect reconstruction on the lower extremity.

BACKGROUND: Little attention has been given to the segmental free gracilis muscle flap supplied by secondary proximal pedicles. We introduce a technical refinement for small-sized three-dimensional defect reconstruction on the foot. METHODS: Between November 2013 and August 2016, three patients with a mean age of 66 years (range 47-70 years) were included. A segmental gracilis free flap supplied by the most proximal secondary pedicle was harvested according to a modified "nugget design" to treat small-sized defects on the lower extremity requiring dead space reconstruction. Minor and major complications, sensitivity with Semmes-Weinstein monofilament test, soft tissue stability and patient satisfaction at final follow-up were recorded. RESULTS: In one case, a segmental gracilis muscle was used for dorsal foot reconstruction after debridement of metatarsal phalanx I with osteomyelitis. In two cases, the segmental gracilis free muscle was harvested for defect reconstruction on the right plantar foot after excision of a melanoma. The first patient required revision after partial failure of the initial segmental gracilis free muscle flap. Overall, good results in foot function and a high degree of patient satisfaction was achieved (Likert scale 9.7, range 9-10) after a mean follow-up of 13 months (range 3-24 months). CONCLUSIONS: Taken from the very proximal dorsal part of the gracilis muscle supplied by the most proximal secondary pedicle and leaving the vast majority of the muscle intact preserves the option to harvest a normal gracilis flap. This technique is especially suitable for small, three-dimensional defects on the lower extremity.

Vascular pedicle ossification of free fibular flap: is it a rare phenomenon? Is it possible to avoid this risk?

Free fibula flap is the most common free tissue transfer for maxillary and mandibular reconstructions. The distal part of the harvested bone is transferred, while the proximal part is removed by sub-periosteum dissection. The vascularized periosteum attached to the vascular pedicle has osteogenic potential. 61 patients reconstructed with free fibula flaps were divided in 2 groups: 41 flaps performed with a standard technique and 20 flaps performed by dissecting the periosteum from the pedicle. Patients were followed up with orthopantomography and CT scan at 6, 12, 18 and 24 months after surgery. The minimum follow-up time was 18 months. With retrospective analysis of the first group we diagnosed 7 pedicle ossifications on 41 reconstructions (17%). In the second group, no pedicle ossification was observed (p < 0.05). The dissection of periosteum from the vascular pedicle of free fibula flaps avoids the risk of ossification.

Head and neck cancer in elderly patients: is microsurgical free-tissue transfer a safe procedure?

The safety and success of microvascular transfer have been well documented in the general population, but the good results achieved with the use of free flaps in elderly patients have received little attention. This study sought to identify differences in complications, morbidity and functional outcomes between elderly (≥ 75 years) and younger (< 75 years) patients treated surgically for advanced head and neck cancer using the Head and Neck 35 module of the European Organisation for Research and Treatment of Cancer quality of life questionnaire. Patient treatment consisted of composite resection, including excision of the primary tumour with ipsilateral or bilateral neck dissection and microvascular reconstruction. Eighty-five microvascular tissue transfers were performed to reconstruct major surgical defects. Postoperative radiation therapy was performed when indicated. Total flap loss occurred in three cases in elderly patients and two cases in younger patients. The rates of major surgical complication were 9% in young patients and 11% in elderly patients. No significant difference was observed between the two groups in the rates of major and minor flap complications, morbidity or long-term functional outcome. The results of the present analysis indicate that free-flap microvascular reconstruction can be considered a safe procedure in elderly patients with head and neck cancer.