Fasciocutaneous and jejunal free flaps for circumferential hypopharyngeal defect reconstruction: A 22-year multicenter cohort study.

BACKGROUND: It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects. METHODS: All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications. RESULTS: In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007). CONCLUSIONS: The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.

Assessment of deep inferior epigastric perforator flap perfusion with near-infrared fluorescence: A pilot study and description of a standardized working protocol.

Fat necrosis (FN) is a common complication after autologous breast reconstruction (ABR) using a free flap, which can influence reconstruction outcome and patient satisfaction. Intraoperative near-infrared fluorescence imaging using indocyanine green (ICG) permits the visualization of flap perfusion. The aim of this study was to assess the effect of near-infrared fluorescence on FN incidence in patients undergoing an ABR with a deep inferior epigastric perforator flap (DIEP) and to propose a standard working protocol for this technique. In this prospective study, patients undergoing one-sided ABR with a DIEP were included. The standard DIEP procedure was complemented with near-infrared fluorescence imaging using the fluorescent tracer ICG to evaluate flap perfusion. This cohort was compared to a retrospective cohort of DIEP procedures without near-infrared fluorescence imaging. Patients and surgery characteristics, as well as postoperative complications, were registered and compared. In both cohorts, 24 patients were included. No significant differences were present between patients and surgery characteristics, including no difference in duration of surgery. In the prospective and retrospective group, the incidence of FN was 4.2% and 33%, respectively (p-value = 0.023). Moreover, microsurgeons were positive about using near-infrared fluorescence as it either provided additional information about perfusion or confirmed the clinical assessment. Our pilot study showed a significant decrease of FN in patients undergoing an ABR with a DIEP when near-infrared fluorescence imaging was used to assess flap perfusion. This study provides a standardized working protocol for near-infrared fluorescence imaging. In the future, large multicenter studies should focus on the quantification of near-infrared fluorescence imaging.

Implant Loss and Associated Risk Factors following Implant-based Breast Reconstructions.

Implant loss is the most severe complication of implant-based breast reconstructions. This study aimed to evaluate the incidence of implant loss and other complications, identify associated risk factors, and create a risk model for implant loss. METHODS: This was a retrospective cohort study of all patients who underwent a mastectomy, followed by either a two-stage or a direct-to-implant breast reconstruction. Patient variables, operative characteristics, and postoperative complications were obtained from the patient records. A multivariate mixed-effects logistic regression model was used to create a risk model for implant loss. RESULTS: A total of 297 implant-based breast reconstructions were evaluated. Overall, the incidence of implant loss was 11.8%. Six risk factors were significantly associated with implant loss: obesity, a bra cup size larger than C, active smoking status, a nipple-preserving procedure, a direct-to-implant reconstruction, and a lower surgeon's volume. A risk model for implant loss was created, showing a predicted risk of 8.4%-13% in the presence of one risk factor, 21.9%-32.5% in the presence of two, 47.5%-59.3% in the presence of three, and over 78.2% in the presence of four risk factors. CONCLUSIONS: The incidence of implant loss in this study was 11.8%. Six associated significant risk factors were identified. Our risk model for implant loss revealed that the predicted risk increased over 78.2% when four risk factors were present. This risk model can be used to better inform patients and decrease the risk of implant loss by optimizing surgery using personalized therapy.

Perfusion Parameters in Near-Infrared Fluorescence Imaging with Indocyanine Green: A Systematic Review of the Literature.

(1) Background: Near-infrared fluorescence imaging is a technique capable of assessing tissue perfusion and has been adopted in various fields including plastic surgery, vascular surgery, coronary arterial disease, and gastrointestinal surgery. While the usefulness of this technique has been broadly explored, there is a large variety in the calculation of perfusion parameters. In this systematic review, we aim to provide a detailed overview of current perfusion parameters, and determine the perfusion parameters with the most potential for application in near-infrared fluorescence imaging. (2) Methods: A comprehensive search of the literature was performed in Pubmed, Embase, Medline, and Cochrane Review. We included all clinical studies referencing near-infrared perfusion parameters. (3) Results: A total of 1511 articles were found, of which, 113 were suitable for review, with a final selection of 59 articles. Near-infrared fluorescence imaging parameters are heterogeneous in their correlation to perfusion. Time-related parameters appear superior to absolute intensity parameters in a clinical setting. (4) Conclusions: This literature review demonstrates the variety of parameters selected for the quantification of perfusion in near-infrared fluorescence imaging.

Starting an autologous breast reconstruction program after plastic surgical training. Is it as good as it gets?

BACKGROUND: Today, the deep inferior epigastric perforator (DIEP) flap is considered to be the gold standard in microvascular breast reconstruction. Although this procedure is known as technically demanding, novice plastic surgeons must be able to perform these procedures to meet the rising demand. The purpose of this study was to evaluate if the young junior professional is trained adequately to set up and safely perform microsurgical breast reconstructions. METHODS: We compared outcomes of three identically trained novice plastic surgeons who introduced the DIEP flap in their working environment. Their hospitals differed in size and experience in microsurgery. Outcomes were compared between all start-ups and a center of excellence (EMC). RESULTS: A total of 152 DIEP flaps were performed in 123 patients among all start-ups together. Baseline characteristics and major complications were comparable between all groups. The total flap loss rate was 2% in the start-ups versus 3.9% in the control group (p = 0.5). Although there seems to be a trend in a longer operating time in both training and nontraining academic centers, no statistical significance was found between start-ups (p = 0.13) and the control group (p = 0.17). However, a learning curve seems to be present when it comes to duration of surgery and is greatest in the community centers with zero experience in microsurgery (ZGT p = 0.002, Amphia p = 0.065). The same accounts for hospital stay. CONCLUSION: Although there seems to be a learning curve in terms of duration of surgery in hospitals with no experience in microsurgery, it is safe to perform microvascular breast reconstructions as a novice plastic surgeon.

A simple, reliable, and validated method for measuring brow position.

PURPOSE: To establish outcome of brow suspension techniques, a reliable and clinically suitable measurement tool is required. Most of the published methods lack statistical validation, and in none of the reviewed studies, the standardized photograph protocols were validated. METHODS AND TECHNIQUES: Fifteen subjects were independently photographed by 2 different professional medical photographers. Adobe Photoshop CS5 software (San Jose, Calif) was used to perform the measurements based on interpupillary distance and medial, midpupil, and lateral reference points on the brow. To establish intrarater reliability, the photos of both photographers of the same subject were analyzed by the same researcher. To establish interrater reliability, the photos of 1 photographer were analyzed by 1 researcher, whereas the photos of the second photographer were analyzed by a second researcher. Reliability was assessed using the intraclass correlation coefficients (ICCs) and the smallest detectable differences. RESULTS: The ICCs indicated good to excellent interrater and intrarater reliability. The ICCs of the interrater reliability were lower compared with those of the intrarater reliability, although they could still be categorized as good to excellent. We found that the lateral measurements had the highest reliability, and the medial measurements, the lowest reliability. CONCLUSIONS: The current study supports that the "en face" photographs in our database are truly standardized. The good to excellent interrater and intrarater reliability of the present method makes it a valid measuring tool.