Early postoperative complications and their measures after skull base reconstruction: A study from the standpoint of plastic and reconstructive surgeons.

OBJECTIVE: In skull base surgery, postoperative complications may be lethal and it is important to know how to deal with these. There are several reports on complications after skull base reconstruction, but it is difficult to understand which are important for plastic surgeons in charge of reconstruction. The objective of this study is to clarify the early postoperative survival-related complications after skull base reconstruction of which plastic surgeons should participate in treatment. METHODS: One hundred and seventy-seven patients who underwent skull base reconstruction at our department over the last 12 years were retrospectively surveyed. The cases of early complications in which plastic surgeons were actively involved in treatment were investigated and the preventive measures actually taken at our facility are examined in addition to treatment methods after development. RESULTS: Plastic surgical complications were wound infection in seven patients, impaired blood flow in transplanted tissue in two patients, cerebrospinal fluid leakage in five patients, and intracranial compression in three patients. Total number of postoperative complications were seventeen and the total complication rate was 9.6%. Complication rates tended to be higher in anterior-middle skull base cases than in anterior or middle alone cases and higher with free tissue transfer than with locoregional flap. Multivariate analysis revealed that operation time was a significantly higher risk factor (p=0.012) and preoperative chemotherapy was a significantly lower risk factor (p=0.033) for the development of complications. It was also found that the hospitalization length was significantly longer when complications occurred (p<0.0001). Wound infection was treated with removal of the cause, sufficient drainage, and irrigation. Regarding preventive measures, it is necessary to pay attention especially to intracranial contamination with epithelial components. Rapid surgical measures were necessary when blood flow of the transplanted tissue was impaired. For pedicle flaps, conservation of the feeding vessel is needed, and for free flaps, reliable vascular anastomosis is needed as preventive measures. Plastic surgeons play a role in reducing the risk of cerebrospinal fluid leakage through covering the repaired dura mater with tissue with favorable blood flow, especially in reoperation after development of leakage. Skull base reconstruction with soft tissue may cause intracranial compression, and sometimes, it is not resolved by conservative treatment and reoperation is selected. CONCLUSION: Plastic surgical postoperative complications were clarified, and treatment methods and preventive measures for them were examined. Careful consideration of blood flow, placement, and volume of the transplanted flap is important to prevent complications.

Breast Shape Evaluation After Free Flap Breast Reconstruction After More Than 10 Years Follow-up Using 3-Dimensional Imaging Device.

BACKGROUND: Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up. METHODS: The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items. RESULTS: The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old). CONCLUSION: We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

The different concepts of surgical managements between anterior and lateral skull base reconstructions based on surgical purposes.

OBJECTIVE: Anterior and middle cranial fossa defects require different strategies, depending on their anatomical location. The aim of this study was to elucidate the surgical managements for the defects based on surgical purposes and to clarify the conceptional differences relating to anterior and lateral skull base reconstructions. METHODS: This study included patients who had undergone reconstructive surgery for anterior or middle cranial fossa defects in our institution between July 2008 and June 2019. It consisted of 66 patients who had been subject to anterior skull base reconstructions, and 84 patients who had experienced lateral skull base reconstructions. The medical records were examined retrospectively, and the surgical purposes and procedures performed were reviewed. The surgical purposes were divided into four groups: Separation, Restoration, Augmentation, and Coverage. RESULTS: Regarding anterior skull base reconstructions, the Separation group included 65 patients, who represented 98% of this category. There were 26 cases in the Separation-only group, 20 of which were reconstructed with locoregional flaps, and 6 of which with free tissue transfers. A Combination group, which consisted of Separation and Other purposes, consisted of 40 cases. Within this group, 5 cases were reconstructed with locoregional flaps, and 35 with free tissue transfers. Regarding lateral skull base reconstructions, the Separation group included 34 patients, who represented 40% of this category. The rate of the Other purposes represented the majority. In the Separation-only group of 24 patients, 16 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In the Combination group of 10 patients, 2 cases were reconstructed with locoregional flaps and 8 cases with free tissue transfers. In groups other than the Separation group, 27 cases were reconstructed with locoregional flaps and 23 cases with free tissue transfers. CONCLUSION: In most anterior cranial fossa defect cases, the surgical purpose is separation. In middle cranial fossa defect cases, there are many cases in which the surgical purpose is not separation. In the Separation groups, relating to both anterior and lateral skull base reconstructions, the use of locoregional flaps was an effective measure. Free tissue transfers were required in many cases of the Combination group. Outside of the Separation group associated with lateral skull base reconstructions, the use of locoregional flaps and free tissue transfers were almost equal in proportion, and the selection of reconstructive procedures tended to change from locoregional flaps to large free flaps with increase in the numbers of surgical purposes.

Reliability of Temporal Vascular Anastomosis and Techniques for Better Outcomes.

BACKGROUND: Although there are several potential recipient vessels in the neck, those in the temporal region are limited. In skull base reconstruction, there are difficulties associated with the anastomosing recipient vessels in the neck region since long nutrient vessels are needed in the flap. We evaluated the reliability of temporal vascular anastomosis by comparing surgical outcomes between reconstructive methods and examined which surgical procedures may achieve better results. METHODS: We examined the medical records of free tissue transfer cases between April 2007 and March 2018. Seventy-three surgeries were performed in the temporal region, including skull base reconstruction in 48, head and neck reconstruction (without skull base) in 16, and secondary surgery for head deformities in nine cases. In total, 445 neck surgeries were performed. Postoperative complications were retrospectively analyzed. RESULTS: The postoperative complication rates were 8.2 and 2.7% for all temporal and neck surgeries, respectively. There were no arterial complications in the temporal region and all of the six postoperative anastomotic complications were due to venous thrombosis. In contrast, there were 12 cases of vascular anastomotic complications, with six cases each of arterial and venous thrombosis in the neck. In the temporal region, the complication rate was 2.1% for skull base reconstruction, 11% for secondary revision, and 25% in head and neck reconstruction. The corresponding values for middle temporal vein (MTV) usage rates were 54, 22, and 25%. In skull base reconstruction, a coronal incision was made in all cases. A more frequent use of the MTV was associated with a reduced complication rate. CONCLUSION: The low complication rate in the temporal region was attributed to the wide surgical field and low tension of anastomotic vessels. Multiple venous anastomoses, including those of the MTV, are recommended to prevent complications.

Ideal esthetic and functional full-thickness lower eyelid "like with like" reconstruction using a combined Hughes flap and swing skin flap technique.

BACKGROUND: A goal in ideal lower eyelid reconstruction is to achieve not only an esthetic recovery of the shape of the eyelid but also to obtain satisfactory eyelid function without damage to the corneal surface. In this report, we introduce our "Like with Like" reconstruction technique using a combined Hughes flap and swing skin flap. The Hughes flap is a tarsoconjunctival pedicled flap from the upper eyelid, and the swing skin flap is a kind of transposition flap based on the orbicularis muscle pedicle. PATIENTS AND METHODS: Eight patients who had more than 25% of the lower eyelid affected by a full-thickness defect were included. There were five men and three women, and the average age was 68.4years old. All patients had undergone wide tumor excision of the lower eyelid due to a malignant tumor and had also had primary two-stage eyelid reconstruction with a combined Hughes flap and swing skin flap. RESULTS: The average reconstructive time was 1:20, and no postoperative severe complications such as flap necrosis or wound dehiscence were observed. The follow-up period was an average of one year, and there were no functional problems such as ectropion, lower eyelid retraction, lid margin hypertrophy, lacrimation disorder, or corneal problems observed in any cases. Esthetically, no reconstructed eyelid bulging or asymmetry in the lid margin was observed in any of the cases. CONCLUSIONS: Combining the Hughes flap and skin swing flap technique might be the best choice for a full-thickness lower eyelid defect with regard to the esthetic and functional results.

Use of a combined SIEA and SCIP based double pedicled abdominal flap for breast reconstruction.

BACKGROUND: Recently, the deep inferior epigastric perforator (DIEP) flap has become the gold standard for breast reconstruction, but it has some drawbacks such as abdominal bulging and hernia. To overcome these disadvantages, the superficial inferior epigastric artery perforator (SIEA) flap is used as an alternative option, but it has another problem, namely limited vascular territory and risk of vascular thrombosis. To solve these problems, we introduced our new technique, a combined SIEA and superficial circumflex iliac artery perforator (SCIP) based double pedicled abdominal flap. In this report, we present our experience of using this technique. METHODS: The SIEA and SCIP based double pedicled abdominal flap was used in five patients who wanted to have unilateral breast reconstruction after a mastectomy due to breast cancer. The average age was 48.2 (range 38-56) years, and the average BMI was 24.4 (range 19.2-31.4). The SIEA and SCIP based double pedicled abdominal flap was designed as a modified DIEP flap, and all flaps were placed in the vertical setting. The flap pedicles had two different vascular supplies, SIEA and SCIA, and the drainage systems, SIEV and SCIV, anastomosed to the internal mammary artery and vein in all cases. RESULTS: The harvested SIEA and SCIP based double pedicled abdominal flaps were a median volume of 925 g (range 452-1570 g) and average size of 491 cm2 (range 440-611 cm2 ). The average reconstructive time was 7:41 (range 6:31-9:17). In four out of the five cases, the SIEA and SCIA joined together to make a common pedicle artery trunk, and its average size was 1.08 mm. Four out of the five cases had a wide vascular territory crossing the abdominal midline as shown by ICG angiography. One case showed ICG fluorescence for the hemi-side of the abdominal flap. Postoperative course was uneventful, and there were no major perioperative complications, which need extra surgical procedures. Follow-up period averaged 273 days (range 194-312 days). CONCLUSION: The SIEA and SCIP based double pedicled abdominal flap showed viable flap territory across the midline in all cases. The SIEA and SCIP based double pedicled abdominal flap might be another ideal option for breast reconstruction, when appropriate SIEA and SCIA pedicles are identified, and an adequate ICG fluorescence is obtained for the size of flap needed.

The Feasibility of Harvesting an Innervated Profunda Artery Perforator Flap for Breast Reconstruction.

The profunda artery perforator (PAP) flap has become an alternative option for breast reconstruction. Reliable perforators arise through the adductor magnus muscle, and dissection of the perforator is straightforward. Recently, we have found that the PAP flap with the sensory nerves can be harvested as an innervated flap. We discuss the feasibility of PAP flap neurotization. We reviewed 13 patients for whom innervated PAP flap harvesting was considered. The average age was 50.7 years. There are 3 different patterns of innervated PAP flap harvesting, Type 1: including a sensory nerve that can be found in the adipose tissue around the PAP flap, Type 2: including a sensory nerve that runs along the medial femoral circumflex system, and Type 3: including a sensory nerve that runs along the profunda artery perforators. The average flap harvest time was 2:11 ± 0:31, and a sensory nerve was identified in 10 of 13 cases (77%). No sensory nerves were found in the other 3 cases. The length of the included sensory nerve was 5.5 ± 1.6 mm on average. Types 1 and 2 were found in 3 patients (30%), Type 3 was found in 2 patients (20%), and combined Types 1 and 3, 2 and 3 were found in one patient each (10%). As sensory nerves run around the PAP flap or close to the perforators, it is easy to perform flap neurotization with the PAP flap. We believe that the PAP flap could be an alternative option to achieve sensate breast reconstruction.

An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report.

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

Esthetic Craniofacial Bony and Skull Base Reconstruction Using Flap Wrapping Technique.

For a safe and esthetic skull base reconstruction combined with repair of craniofacial bone defects, the authors introduce the flap wrapping technique in this study. This technique consists of skull base reconstruction using the vastus lateralis muscle of an anterolateral thigh (ALT) free flap, and structural craniofacial bony reconstruction using an autologous calvarial bone graft. The key to this technique is that all of the grafted autologous bone is wrapped with the vascularized fascia of the ALT free flap to protect the grafted bone from infection and exposure. Two anterior skull base tumors combined with craniofacial bony defects were included in this study. The subjects were a man and a woman, aged 18 and 64. Both patients had preoperative proton beam therapy. First, the skull base defect was filled with vastus lateralis muscle, and then structural reconstruction was performed with an autologous bone graft and a fabricated inner layer of calvarial bone, and then the grafted bone was completely wrapped in the vascularized fascia of the ALT free flap. By applying this technique, there was no intracranial infection or grafted bone exposure in these 2 patients postoperatively, even though both patients had preoperative proton beam therapy. Additionally, the vascularized fascia wrapped bone graft could provide a natural contour and prevent collapse of the craniofacial region, and this gives patients a better facial appearance even though they have had skull base surgery.

Tongue reconstruction with minimal donor site morbidity using a deep inferior epigastric perforator (DIEP) free flap in a 6-year-old girl.

Tongue reconstruction was performed using a deep inferior epigastric perforator (DIEP) free flap in a 6-year-old girl with undifferentiated sarcoma of the tongue. After hemi-glossectomy with upper neck dissection, a 3-lobed DIEP free flap was used for the reconstruction. Donor site was closed primarily with suturing umbilicus in proper position. No flap loss, leakage, or infection occurred. Postoperatively, the patient was able to consume a normal diet without difficulty or aspiration and displayed good speech function. No donor site morbidity, e.g., herniation or bulging, was observed, and the patient was able to perform their normal daily activities. DIEP flaps provide a pliable skin paddle, an adequate amount of adipose tissue, and reduced donor site morbidity, even in children. We did not have any difficulty harvesting the DIEP flap or with the microvascular anastomosis. We consider DIEP free flaps to be the ideal option for pediatric tongue reconstruction.