Versatility of Islanded Nasolabial Flap Based on Facial Artery and Vein for Reconstruction of Oral Cancer Defects, Experience in a Tertiary Care Center.

Introduction: Conventional nasolabial flap has been widely used for reconstruction for head and neck defects. Recent decades witnessed modification of this flap like islanded version based on subcutaneous pedicle or facial artery and vein. The later modification obviated a need for pedicle division, secondary procedures and facilitates reach of the flap to distant sites. Especially, the islanded nasolabial flap pedicled on facial artery and vein can have a long pedicle to conveniently reach the tongue, floor of mouth when the flap is routed through retromandibular area. Methods: A retrospective analysis was done on 14 patients analyzing the functional outcome like deglutition, speech, and aesthetic outcome of flap donor area, recruiting patients in which islanded nasolabial flap was done based on facial vessels for early stages of cancer tongue and lip. Results: In our series of 14 operated cases, all flaps survived. All the flaps were islanded over the skeletonized facial artery and vein. Tip necrosis occurred in one case. The donor site was closed primarily in all cases. The average speech scoring was grade five, Vancouver scar score of the flap donor area was 2.5 and intelligible speech was difficult in only three cases in follow up. Conclusion: We found this flap useful for reconstruction of small to moderate size defects of oral malignancy following excision with acceptable aesthetic and functional outcome in most of the patients.

In Search of Optimal Practice: A Retrospective Comparative Study of Single- Versus Dual-Venous Anastomosis in Microvascular Flaps.

Background In the current era of reconstructive surgery, microvascular free flap transfers are the most popular reconstructive procedures performed. The main reason for the failure of the flap and re-exploration is venous thrombosis. Traditionally, most surgeons prefer performing two-vein anastomoses. There is insufficient literature to support that dual-venous anastomosis is better than single-venous anastomosis. In this study, we compared the success rate of single-venous anastomosis with dual-venous anastomosis of different free flap reconstructions. Methodology The retrospective cohort study was conducted with a total of 101 patients. Eighty-three were in the one-vein group, and the remaining 18 were in the two-vein group. Outcomes were compared between the two groups regarding re-exploration and flap failure. Results The overall success rate of free flap reconstruction was 96%. Among the 101 free flaps, 16 flaps had signs of venous compromise and were re-explored. Out of the 16 flaps, 11 flaps (13.2%) were in the one-vein group, and 5 flaps (27.7%) were in the two-vein group. In the two-vein group, 100% of the flaps were salvaged, and in the one-vein group, only 63% of the flaps were salvaged after re-exploration. There was no statistically significant difference between the one-vein group and the two-vein group concerning re-exploration.  Conclusions The rate of re-exploration was lower in the one-vein group when compared to the two-vein group. However, this difference was not statistically significant. Hence, a single-vein anastomosis is sufficient for a successful microvascular free flap. However, the rate of flap salvage is better with two-vein anastomosis if there is venous congestion.

Optimising oral cancer reconstruction: a retrospective cohort study on the modified radial forearm free flap technique to eliminate the need for a secondary donor site.

The radial forearm free flap (RFFF) is commonly used in the reconstruction of oral cancer patients. Traditional RFFF (TRFFF) techniques, which often require a secondary donor site to repair the forearm defect, may result in a scar extending to the dorsal hand. This can lead to significant functional and aesthetic concerns in the forearm. We designed a modified RFFF (MRFFF) that incorporates a glasses-shaped flap and features deep venous drainage. To evaluate its effectiveness we conducted a retrospective chart review of 105 patients with oral squamous cell carcinoma who underwent reconstructive surgery between 2018 and 2022. These patients were treated either with a TRFFF (n = 60) or the newly developed MRFFF (n = 45). Our inclusion criteria, guided by preliminary surgical experience prior to initiating the study, stipulated that single oral defects should be no larger than 6 × 6 cm2, and adjacent double defects no larger than 3 × 6 cm2. Flap size, pedicle length, harvesting duration, and anastomosis during the surgical procedure were compared between the two techniques. Preoperative and postoperative oral function, recurrence, mortality, and dorsal scarring were recorded. One-week, one-month, and six-month postoperative subjective aesthetics assessments, and self-reported postoperative donor hand function, were measured using the Michigan hand questionnaire (MHQ). There were no significant differences between the groups in terms of flap size, pedicle length, harvesting time, anastomosis time, postoperative oral function, recurrence, and mortality. However, patients with a MRFFF did not require a second donor graft site and did not have scars extending to the dorsal forearm. They also had significantly improved postoperative aesthetic outcomes (1 week: 70.6%, 1 month: 62.2%) and donor hand function (1 week: 54.6%, 1 month: 40.4%) compared with the TRFFF group (p < 0.001). The MRFFF eliminates the need for secondary donor sites and improves primary donor site outcomes. It is versatile and can be employed for either single or composite oral defects. Through extensive case studies, we have defined its specific scope: it is suitable for single defects measuring no more than 6 × 6 cm2, or for composite defects no larger than 3 × 6 cm2. Furthermore, it does not compromise the functional recovery of the recipient site, and should be widely adopted for all qualifying patients.

Novel Technique to Increase the PMMC Flap Pedicle Length by Coplanar Rotation Along the Pedicle Axis.

Pectoralis major myocutaneous flap (PMMC) continues to be a prime tool in the armamentarium for the reconstruction of head and neck malignancies even though free flaps have proved their versatility in functional and cosmetic outcomes. It still holds significance in both primary reconstruction and salvage procedures in head and neck malignancies. Inadequate infrastructure and resources make PMMC a preferred choice in many high-volume centres of developing countries. However, the length of the PMMC flap becomes a limiting factor for the distance that flap can be transferred when extensive reconstructions are being planned (Kudva et al. in J Maxillofac Oral Surg 14:481-483, 2015). We propose a modification in the conventional technique that maximises the length of the pedicle in orofacial reconstruction. Our technique allows the rotation of skin paddle along the longitudinal axis of the pedicle at the distal end along the same plane. This technique provides an easily reproducible and reliable technique that enables the surgeon to enhance the reach of the skin paddle and flexibility considerably.

Turned in fasciocutaneous island flap from face and neck based on subdermal microcirculation for reconstruction of the oral cavity following cancer surgery.

BACKGROUND: The skin and soft tissues of the face and neck have a rich plexus of dermal-subdermal vessels, which creates the possibility of raising a fasciocutaneous flap based on this vascular supply. A turned in fasciocutaneous island flap (TIFCIF) from an adjacent area of the defect can provide a simple substitute to many complex reconstructive procedures. MATERIALS AND METHODS: Fifteen patients underwent wide excision for oral cancer and upper neck dissection, maintaining bone framework, between August 2010 and June 2014. The reconstruction was done with a 'turned in fasciocutaneous island flap' (TIFCIF) from the upper neck-lower face based on subdermal superficial adipofascial microvascular network instead of a specific known feeder vessel. The upper cervical flap, the donor site, when raised during the initial incision and the upper neck dissection, was cut off from the facial artery, the submental artery, the superior thyroid and the transverse cervical arteries. The microcirculation depended largely on the rich vascular plexus formed of the branches of the superficial temporal and the maxillary arteries. The donor site was primarily closed in Fourteen of the Fifteen patients. Eight patients received post-surgery irradiation. RESULTS: All the flaps survived and healed and withstood radiation well. Two patients had flap dehiscence from suture line, of which one needed reattachment while other a minor one healed by itself and one patient had occasional drooling. There was no difficulty in eating or swallowing. CONCLUSIONS: A random patterned TIFCIF based on superficial subdermal adipofascial microcirculation, formed of a rich vascular plexus in the face and neck region can provide a simple alternative for intraoral reconstruction.

Incidentaloma at radial artery forearm free flap harvest: an occult volar wrist ganglion.

Occult volar wrist ganglion originating from radioscaphoid interval and having adherence to flexor carpi radialis tendon [Fcr] and radial artery is an uncommon occurrence. We report such a case which was occult and asymptomatic during pre-operative assessment and presented as an incidentaloma during radial artery forearm free flap harvest for oral cancer reconstruction.