There is little debate regarding the workhorse flaps for soft-tissue defects in head and neck reconstruction. However, in certain circumstances, the workhorse flaps are not available or suitable, and ...an alternate flap is needed.
The author performed a retrospective review of a single-surgeon experience with alternate soft-tissue flaps performed over a 10-year period.
Overall, 156 alternate soft-tissue free flaps were performed in 155 patients. The distribution of free flaps was 60 ulnar artery perforator (UAP), 28 lateral arm perforator (LAP), 33 medial sural artery perforator (MSAP), and 35 profunda artery perforator (PAP) flaps, with one patient receiving two PAP flaps. Defects included glossectomy, facial defects following parotidectomy or resection of cutaneous malignancies, and other intraoral defects. Eleven patients had donor-site complications: two patients with UAP flap with partial skin graft loss, two patients with delayed wound healing in the MSAP donor-site group and one who developed compartment syndrome with primary closure of the MSAP donor site, one patient with a radial nerve palsy following an LAP flap, and six patients with delayed wound healing in the PAP donor site, which healed secondarily with conservative management. There was one total flap loss each of an LAP and MSAP flap.
Reconstructive microsurgeons performing high-volume head and neck reconstruction may need to incorporate alternate donor sites into their armamentarium when the primary workhorse flaps are not suitable or available.
Therapeutic, IV.
After studying this article, the participant should be able to: 1. Understand the available donor sites for autologous breast reconstruction. 2. Describe the advantages and limitations of each donor ...site. 3. Provide a rational, algorithmic preoperative evaluation and approach for patients seeking autologous breast reconstruction. 4. Develop an effective postoperative monitoring system to minimize complications and maximize salvage of microvascular thromboses.
Breast reconstruction remains at the heart of the field of plastic and reconstructive surgery, and it is continuously evolving. Tremendous advances in breast implant technology and supplemental products, particularly acellular dermal matrices, have revolutionized breast reconstruction in the modern era. However, microvascular free flap breast reconstruction has also witnessed profound advancements with exceptionally high success rates, with the ability to provide the most durable and natural breast reconstruction. Although the pendulum oscillates between prosthesis-based reconstruction and autologous tissue, the present synopsis will focus on autologous free flap breast reconstruction from an historical perspective, recent advancements in microsurgery, and the future of autologous breast reconstruction.
The forearm is a common donor site, providing thin, pliable workhorse flaps for head and neck reconstruction. There are no prospective studies comparing the donor-site morbidity of the radial forearm ...flap to the ulnar artery perforator flap.
All patients undergoing forearm free flaps were included for analysis and followed for a minimum of 1 year. Grip strength, sensation to light touch, temperature sensation, and wound healing were assessed.
A total of 98 patients were enrolled (radial forearm flap, n = 50; ulnar artery perforator flap, n = 48). There were three osteocutaneous radial forearm flaps performed. The donor site was closed primarily in one radial forearm flap patient and four ulnar artery perforator flap patients. The majority of donor sites were resurfaced with full-thickness skin grafts (radial forearm flap, n = 40; ulnar artery perforator flap, n = 44), and the remaining were closed with split-thickness skin grafts. Average grip strength compared to baseline measured at 1, 3, 6, and 12 months after surgery demonstrated no significant differences. All patients returned to baseline sensation to light touch with no long-term sensory deficits at 1 year. No patients suffered significant changes in temperature sensation or cold intolerance. Seven patients suffered partial skin graft loss (radial forearm flap, n = 5; ulnar artery perforator flap, n = 2); all of them healed secondarily with local wound care. There were no flap losses in the study.
The radial forearm and ulnar artery perforator flaps are equivalent in terms of success and donor-site morbidity. Selection of flap should be based on need for pedicle length, flap bulk, concerns with radial or ulnar dominance, and surgeon comfort.
Therapeutic, II.
BACKGROUND:Obesity has been viewed as a relative contraindication against autologous free flap breast reconstruction because of increased risks of complications, including flap loss.
METHODS:The ...authors conducted a prospective analysis of obese patients undergoing autologous breast reconstruction.
RESULTS:Overall, 72 patients (average age, 48.5 years; average body mass index, 35.7 kg/m) underwent abdominal free flap breast reconstruction. There were 43 bilateral reconstructions and the remainder were unilateral (n = 115 flaps). There were 67 muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps (58.3 percent), 44 deep inferior epigastric perforator (DIEP) flaps (38.2 percent), two free bipedicle DIEP flaps, one superficial inferior epigastric perforator flap, and one free TRAM flap. Forty-two patients (58.3 percent) had prior radiation, and 51 (70.8 percent) had prior chemotherapy. Forty-three patients (59.7 percent) underwent delayed reconstruction and 21 (29.2 percent) underwent immediate reconstruction. Eight patients (11.1 percent) had bilateral reconstruction, with one breast reconstructed in an immediate and the other in a delayed fashion. Half of the patients (n = 36) had mesh placed in an underlay fashion to reinforce the donor site. Regarding breast complications, there were 11 wound dehiscences, one hematoma, one infection, and two patients with mastectomy skin flap necrosis. Twelve patients had donor-site wound healing complications, there were four infections, and three patients developed a bulge/hernia. There were no flap losses. Comparison to historic controls demonstrated no significant differences in overall flap loss rates (p = 0.061) or donor-site bulge/hernia (p = 0.86).
CONCLUSION:Autologous abdominal free flaps can be performed safely in obese patients without increased risks for donor-site bulge/hernia or flap loss compared to nonobese patients; however, patients should be counseled carefully regarding the potential risks of complications.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV
Background
Lymphedema is a common, progressive, and often debilitating condition that can occur after breast cancer treatment. Preliminary reports on vascularized lymph node transfer (VLNT) have been ...promising. We propose an algorithmic approach to simultaneous VLNT with microvascular breast reconstruction (MBR) and provide early results.
Methods
All patients who underwent simultaneous VLNT with MBR were included. Postoperative evaluation was performed at standardized time points and included qualitative assessment and quantitative volumetric analysis.
Results
Between 2011 and 2013, 29 consecutive patients with refractory lymphedema secondary to breast cancer treatment underwent simultaneous VLNT with MBR. Mean follow-up was 11 months. On average, patients had experienced 3.3 years of lymphedema symptoms with 21 % increased volume in the affected arm compared with the unaffected arm. Using our algorithmic approach, all patients underwent successful breast reconstruction. There were no flap losses, and no patients developed donor site lymphedema. Six patients (21 %) experienced donor site wound complications that resolved with conservative measures; 23 patients (79 %) reported sustained symptomatic improvement after reconstruction. The mean volume differential volumes improved to 20, 19, 14, and 10 % at 1, 3, 6, and 12 months after reconstruction, respectively.
Conclusions
Our algorithm provides a reliable approach to optimizing simultaneous abdominal free flap breast reconstruction and VLNT and demonstrates promising results. Long-term studies are warranted to further delineate and improve the safety and efficacy of lymph node transfers.
Introduction
Covid‐19 has ushered in drastic changes to the healthcare system in order to “flatten the curve”; in particular, surgical operations that can consume vital, limited resources, not to ...mention the risk to staff, anesthesiologists, and surgeons. However, under unique circumstances with diligent preparation, vital oncologic operations can be performed safely.
Methods
Prospective comparison of surgical cases during the pandemic from December 2019 to May 2020 to the correlating time frame from December 2018 to May 2019.
Results
A significant decline in case volume was not appreciated until the United States declared a national state of emergency, allowing patients with cancer to continue to undergo curative tumor resection until then (428.3 ± 51.5 vs 166.6 ± 59.8 cases/week; P < .001). The decrease was consistent with the mean case volume during the holidays (213.8 ± 76.8 vs 166.6 ± 59.8 case/week; P = .648). Evaluation of surgical subspecialties demonstrated a significant decrease for all subspecialties with the greatest decline in sarcoma (P = .002) and endocrine (P = .001) surgeries, while vascular (P = .004) and thoracic (P = .011) surgeries had the least.
Conclusions
The novel coronavirus has drastically reduced oncologic operations, but with proper evaluation of patients and allocation of resources, surgery can be performed safely without compromising the aim to flatten the curve and control the coronavirus pandemic.
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