Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery:A case report

BACKGROUND Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence.They require immediate and appropriate management before they progress to an irreversible condition.Although negative pressure wound therapy(NPWT)can prevent wound progression by increasing microcirculation,the inappropriate application of NPWT on complicationthreatened transferred and replanted tissues can induce an adverse effect.CASE SUMMARY A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap.While applying a heating pad directly to the flap site,she sustained a deep second to third-degree contact burn over 30%of the transferred flap on postoperative 7 d.As the necrotic changes had progressed,we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d.After 4 d of NPWT application,the exposed fatty tissues of the flap changed to dry and browncolored necrotic tissues.Upon further debridement,we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.CONCLUSION Although NPWT has been shown to be successful for treating various wound types,the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

Salvage anastomosis in free PAP-flap breast reconstruction:What about free flap neovascularization?

Since the emergence of microsurgery in reconstructive surgery, free flaps have become a key tool in the management of patients with breast cancer. One such flap is the profunda artery perforator(PAP) flap. To date,there is no scientific consensus on whether voluminous free flaps remain dependent on their vascular pedicle throughout their lifespan. Therefore, the pedicle should always be carefully protected during revision surgery.In this article, we review the case of a middle-aged woman who suffered a pedicle transection needing reanastomosis during revision surgery six months after free-flap breast reconstruction. A 52-year-old woman who noticed a firm nodule in her right breast and armpit was referred to our department for surgical management. The Caucasian woman presented with no significant medical history or symptoms at the first consultation. Ultrasound-guided biopsy confirmed an invasive grade Ⅲ lobular carcinoma. Following staging,the patient underwent neoadjuvant chemotherapy before a right mastectomy with a complete homolateral axillary lymph node dissection and postoperative radiotherapy. One year after completing radiotherapy, free flap reconstruction with a PAP flap was performed, and six months later, revision surgery was required to enhance the volume of the reconstructed breast with a tissue expander and later an implant. Unfortunately,pedicle transection occurred during revision surgery, causing complete devascularization of the flap, which was confirmed by intraoperative Indocyanine Green imaging. The authors elected to perform salvage reanastomosis during the surgery. In keeping with the author’s 23-year experience with free flaps, the vascular pedicle should always be preserved in voluminous free flaps, as neovascularization alone may not ensure whole flap survival. The authors suggest always attempting re-anastomosis if vessels are compromised during revision surgery.

Does the advantage of transcutaneous oximetry measurements in diabetic foot ulcer apply equally to free flap reconstruction?

BACKGROUND Transcutaneous oxygen pressure(TcpO2)is a precise method for determining oxygen perfusion in wounded tissues.The device uses either electrochemical or optical sensors.AIM To evaluate the usefulness of TcpO2 measurements on free flaps(FFs)in diabetic foot ulcers(DFUs).METHODS TcpO2 was measured in 17 patients with DFUs who underwent anterolateral thigh(ALT)-FF surgery and compared with 30 patients with DFU without FF surgery.RESULTS Significant differences were observed in the ankle-brachial index;duration of diabetes;and haemoglobin,creatinine,and C-reactive protein levels between the two groups.TcpO2 values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained<30 mmHg and did not increase>50 mmHg.CONCLUSION Even if the flap is clinically stable,sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO2 values in the ALT-FF owing to its thick fat tissues,which is supported by the slow recovery of the sympathetic tone following FF.Therefore,TcpO2 measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

Oral and maxillofacial-head and neck reconstruction with soft tissue free flaps of 41 cases: A single team's experience

Objective To retrospectively review the single team's experience of oral and maxillofacialhead and neck reconstruction involving 41 soft tissue free flap procedures.Methods From 1994 to 2012,41 patients who underwent oral and maxillofacial-head and neck soft tissue free flap reconstruction at the Department of Oral and Maxillofacial-Head and Neck Surgical Oncology,Hospital and College of Stomatology,Xi'an Jiaotong University,were reviewed with clinicopathologic data.Results The 41 patients included 24 men and 17 women with a mean age of 54 years.A total of 41 soft tissue free flaps were performed to reconstruct different anatomical structures in the head and neck region including oral mucosa,facial bone,head and neck skin.Two types of soft tissue free flaps were used to reconstruct surgical defects,including radial forearm flap and latissimus dorsi myocutaneous flap.Radial forearm flaps were used for 37cases and latissimus dorsi-myocutaneous flaps were 4 cases.Of 41 cases,39 were successful,with an overall success rate of 95.1%.There were 2 free flap failures,including one radial forearm flap and one latissimus dorsi-myocutaneous flap(partial flap necrosis);hence,the flap success rates for radial forearm flap and latissimus dorsimyocutaneous were,respectively,97.3% and 87.5%.Conclusions Radial forearm flap and latissimus dorsi-myocutaneous flap are reliable soft tissue free flaps to repair oral and maxillofacial-head and neck area with high success rate,which resulted in good functionally and cosmetically with fewer complications both donor and recipient sites.

Recurrent basal cell carcinoma of lower lid invading the orbit and whole hemiface reconstructed by rectus abdominis free flap

Dear Sir, I am Dong Hyun Ji, from the Department of Ophthalmology of St. Vincent’s Hospital, Suwon, Korea. I write to present a very severely recurrent basal cell carcinoma (BCC) in lower lid invading left orbit and whole hemiface,

Vessel selection and free flap monitoring in head and neck microvascular reconstruction

Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgical technique as well as technological refinement in vessel selection and flap monitoring. Few papers have studied the factors that influence success or failure rates of free flap reconstructions, particularly with an eye towards the technologic advancements that have refined the procedure in the last several decades. Here we present a comprehensive review of perioperative and intraoperative considerations that influence free flap outcomes as well methods of vessel selection and flap monitoring important during microvascular reconstruction of the head and neck.

Current evidence on the use of near-infrared spectroscopy for postoperative free flap monitoring: A systematic review

Background: Although the surgical outcomes of free flap reconstruction have improved over time, vascular compromise remains a devastating complication. Near-infrared spectroscopy(NIRS) is a promising new free flap monitoring technique with the potential for better outcomes than clinical monitoring(CM). This systematic review aims to provide a comprehensive review of the current evidence regarding the use of NIRS for free flap monitoring.Methods: A systematic literature review was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, on existing NRIS studies, including the clinical outcomes of NIRS monitoring, speed of detection, diagnostic accuracy, variables affecting NIRS accuracy, and cost-effectiveness.Results: A total of 24 articles were included in this analysis. In most instances of flap compromise, NIRS enabled earlier detection of compromise than did CM, by an average of 8.1(0.5±32.0) h. The flap salvage rate of flaps monitored with CM and NIRS(87.2%) was significantly higher than that of flaps monitored with CM alone(50.0%)(P<0.01). The overall survival rate for flaps monitored with CM and NIRS(98.1%) was also significantly higher than that for flaps monitored with CM alone(96.3%)(P=0.02). Blood oxygen saturation was the only variable with a significant effect on NIRS results.Conclusion: NIRS is an objective and reliable flap monitoring technique that provides superior flap salvage and survival rates compared with CM, which translates to cost savings and a reduction in workload for healthcare staff. Further large-scale studies are needed to standardize flap compromise criterion values and efficacy for different flap types.

Effect of Pentoxifyiline on necrosis rate and hemorrheology of free flap

Objective To investigate effect of Pentoxifylline on free flap. Methods Forty Wistar rats were chosen as experimental models and free flaps were harvested from the back of rats,which as pect ratio was 3: 1. Then they were divided into two groups randomly. Group A was as the experimental group,receiving drug treatment.

Experimental study of the effects of Ulinastatin on reducing MDA in free flaps

Free flap transplantation is the most important plastic surgery treatment.Although free flap is an important tissue repair tool for plastic surgery,it is easy to happen due to the anastomotic stenosis or thrombosis,as well as the inflammatory reaction caused by ischemia-reperfusion injury of the flap and the inflammation caused by these inflammatory reactions.Microcirculation contracture or occlusion will lead to partial or complete flap necrosis,thus affecting the repair effect.Numerous studies show that neutrophils are closely involved in the process of ischemic injury of free flaps.The purpose of this experiment is to investigate the use of ulinastatin to inhibit the inflammatory infiltration of free flaps to improve the survival of the flap.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves ＂untreated＂. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Anatomy of Free Flap Failures: Dissection of a Series

Introduction: Free flap success rates have remained stable in recent years ranging 93% to 98%. Historically, the causes of free flap failures were attributed to the surgeon’s inexperience and technique. However, there are factors beyond the surgical anastomosis that contribute to flap failure. The purpose of this study is to review each case of total flap loss in detail to develop a better understanding of complications. Methods: A retrospective study was performed over eleven years in a single surgeon’s practice, a predominantly head and neck reconstructive practice. All charts were independently reviewed. In patients who sustained total flap loss, a review was conducted of patient comorbidites, anesthesia records, perioperative and follow-up notes. Results: A total of 514 free flaps were performed. 76% (392) of these flaps were for head and neck reconstruction. There were 22 total flap losses (4%) and 26 partial flap losses (5%). Of the 22 total flap losses, four flaps were avulsed, five flaps were in patients later found to have coagulation disorders (homozygous mutations of the MTHFR gene and factor V Leiden), four patients were exposed to neosynephrine, two patients remained hypotensive perioperatively, and four delayed flap losses were attributed to pseudomonal infection. Five losses were technical or related to flap inexperience. Several representative case scenarios are illustrated. Conclusion: Careful review of free flap failures indicates that a thorough workup (particularly coagulation disorders), flap selection, surgeon to anesthesia communication, proper securing of the flap, and postoperative patient blood pressure and infection control have a greater part to play in this new era of anastomotic success.

Risk Factors of Anastomotic Thrombosis in 200 Head and Neck Free Flaps among Asian Patients

Background: Despite excellent results from free flap transfers, postoperative thrombosis does occur and, although infrequent, causes total loss of the flap. We investigate the risk factors of anastomotic thrombosis in head and neck free flaps. Study design, Subjects and Methods: A retrospective analysis was carried out on 200 consecutive free flaps applied to patients who underwent head and neck reconstruction. Multiple logistic regression analysis was conducted to identify risk factors of anastomotic thrombosis, taking into account twelve factors: diabetes, obesity, hypertension, hypertriglyceridemia, proteinuria, age, gender, smoking habit, habitual alcohol intake, previous chemotherapy and radiation, and hypercholesterolemia. Results: Hypertension, female gender, aging, and drinking habit were statistically significant risk factors of postoperative thrombosis. Conclusions: Our data suggest that four factors mentioned above are possible predictors of anastomotic thrombosis in free flaps used for head and neck.

Secondary Reconstruction of Recurrent Primary Intraosseous Meningioma of the Calvarium Using a Fasciocutaneous Anterolateral Thigh Free Flap

We present a patient with a primary intraosseous meningioma of the calvarium that recurred three years after initial resection and reconstruction with a free anterolateral thigh (ALT) flap. The patient re-presented with progressive swelling in the same area. Imaging confirmed aggressive tumour recurrence with both intra- and extra-cranial diseases and also extension to the ipsilateral orbit. The original anterolateral free flap was raised on anterior pedicle and further debulking of the tumour was performed. Histology confirmed widely infiltrative atypical meningioma (WHO grade II). This case highlights the benefit of using a fasciocutaneous free flap for reconstruction given the potential for tumour recurrence.

The Use of Fibula Free Flap for Reconstruction of Anterior Chest Wall Full-Thickness Defects

Reconstructions of the sternum remain a formidable challenge for the operating team. Reconstruction of the sternumdefect, regardless of the reason, should ensure the stability of the anterior chest wall, the return of acceptable respiratory parameters and the control of wounds. Stability of the chest wall can be provided by autogenous tissues or prosthetic materials. In our experience, the fibula free osteocutaneous flaps are harvested for reconstruction of the bone defect in two patients after full-thickness defect of the sternum and anterior chest wall.

A retrospective analysis of pain and opioid usage in head and neck free flap reconstruction

Objectives:Investigate opioid usage and postoperative pain in patients undergoing head and neck free flap surgery.Methods:A retrospective review of 100 consecutive patients undergoing head and neck free flap reconstruction at two academic centers was performed.Data captured included demographics,postoperative inpatient pain,pain at postoperative visits,morphine equivalent doses(MEDs)administration,medication history,and comorbidities.Data were analyzed using regression models,χ2 tests,and student’’st-tests.Results:Seventy-three percent of patients were discharged with opioid medication,with over half(53.4%)continuing to take opioids at their second postoperative visit,and over one-third(34.2%)continuing to take them around 4-month postoperatively.One out of every five(20.3%)opioid-na?ve patients chronically took opioids postoperatively.There was a poor association between inpatient postoperative pain scores and daily MEDs administered(R2=0.13,0.17,and 0.22 in postoperative Days 3,5,and 7,respectively).Neither preoperative radiotherapy nor postoperative complications were associated with an increase in opioid usage.Conclusions:For patients undergoing head and neck free flap operations,opioid medications are commonly used for postoperative analgesia.This practice may increase the chance an opioid-na?ve patient uses opioids chronically.We found a poor association between MEDs administered and patient-reported pain scores,which suggests that standardized protocols aimed at optimizing analgesia while reducing opioid administration may be warranted.Level of Evidence:3(Retrospective cohort study).

Comparison of outcomes between early and delayed weight bearing following lower limb free flaps:an 18-month single-center study

Aim:Post-operative protocols following lower limb free flap surgery are not well defined,with a lack of consensus in the literature around limb dependency and weight bearing.The aim was to compare the complication rate for lower limb free flaps before and after the introduction of an enhanced lower limb free flap protocol with earlier dangling(day 3 vs.day 4)and weight bearing(day 5 vs.day 14)post lower limb free flap surgery.Methods:All lower limb free flaps between June 2020-January 2022 were identified from a departmental flap database.Patient data were collected from the comprehensive lower limb free flap database,medical notes,and electronic records.Patients prescribed an extended non-weight-bearing period due to the method of bone fixation were excluded.Results:A total of 37 patients,15 pre-and 22 post-enhanced protocol,were identified for comparison.The mean age was 43(17-72)with a M:F of 3:1.There was no difference in the type of flap reconstruction between groups,with the anterolateral thigh flap being the most common in both groups.No differences were identified in the number of complications related to dependency/weight bearing before and after the introduction of the enhanced protocol,with the mean length of stay reduced from 12.1 to 10.6 days(P=0.34).Conclusion:The new enhanced protocol remains the standard of care in our unit,as we demonstrated a reduction in length of stay with no difference in complication rates following early weight bearing after lower limb free flap surgery.

Clinical observation of endoscopic skull base reconstruction with an anterolateral thigh free fascia flap

Objective:Radiation osteonecrosis of the skull base after radiotherapy for nasopharyngeal carcinoma is one of the most serious complications,affecting patient survival and quality of life.To date,surgical resection is the main treatment for radiation osteonecrosis.The repair after the operation is very important.Inappropriate repair or lack of repair can easily cause local infection that can even spread to the brain,aggravating osteonecrosis.This study aimed to verify the feasibility and safety of the ante-rolateral thigh free fascia flap in repairing large skull base defects.Methods:From June 2021 to July 2022,a total of 12 patients with a history of radiotherapy for naso-pharyngeal carcinoma received surgical treatment at the Department of Otolaryngology Head&Neck Surgery,Sir Run Run Shaw Hospital,Zhejiang University School of Medicine.All patients were diagnosed with radiation osteonecrosis of the skull base with large skull base defects.During the endoscopic operation,a free anterolateral thigh fascia flap was used to repair the skull base and complete vascular anastomosis reconstruction.The preoperative and postoperative pain scores were retrospectively analyzed,and the dynamic changes in endoscopic surgery sites were observed.Results:The 12 patients had a median age of 58 y,with 8(66.7%)males and 4(33.3%)females.The median headache score for the patients was 5(4-7)before surgery.The patient's headache was significantly relieved postoperatively,with 11 patients having a score of 0 and one patient having a score of 1.The stench was completely resolved after the operation.There were no serious complications during the perioperative period or 12 months after the operation.Conclusion:The application of anterolateral thigh free fascia flap in skull base reconstruction is a safe and reliable reconstruction technique suitable for endoscopic surgical repair of large-scale skull base necrosis.

Multi-Segmental Osteocutaneous Free Fibula Flap for Three-Dimensional Post-Traumatic Thumb and Wrist Reconstruction

Thumb reconstruction following a traumatic injury challenge depends on the extent of the injury. Ideally, reconstruction should restore thumb length and position and retain thumb stability, mobility, and strength, while preserving sensation and aesthetics. Achieving these outcomes can be especially challenging in severe cases of soft tissue and bony loss. The authors present a case of a 20-year-old right-hand dominant female involved in a motor vehicle accident who sustained severe crush injuries and burns to her right hand. Her injuries included soft tissue and bony defects extending from the thumb to the distal radius, namely avulsion of the thumb and significant loss of the distal radial and carpal column, resulting in severe wrist instability. We employed a three-segment vascularized osteocutaneous fibula flap to reconstruct the thumb and wrist to restore bony construct, carpal support, and soft tissue coverage. Thumb motion could not be achieved, but this technique offered a sensate, functional post for opposition and the appearance of an anatomic hand. Because of this surgery, the patient was enabled to graduate from college and pursue full-time employment. The authors hope that this report will add to the fund of knowledge and surgeon armamentarium for similar devastating injuries demanding thumb and wrist reconstruction.

Clinical applications of free medial tibial flap with posterior tibial artery for head and neck reconstruction after tumor resection

Tumor resection causes damage in the head and neck which creates problems in swallowing, chewing, articulation, and vision, all of which seriously affect patients' quality of life. In this work, we evaluated the application of a free medial tibial flap in reconstruction of head and neck defects after tumor resection. We discussed the anatomy, surgical technique, and the advantages and disadvantages of the flap. We found several benefits for the flap, such as, it is especially effective for the defects that require thin-layer epithelium to cover or the separated soft tissue defect; a two-team approach can be used because the donor site is far away from the head and neck; and the flap is easy to integrate because of the subcutaneous fat layer of the free medial tibial flap is thin and the flap is soft. Thus, the medial tibial flap could replace the forearm flap for certain applications.

Aesthetic reconstruction of the severely disfigured burned face:a creative strategy for a"natural"appearance using pre-patterned autogenous free flaps

The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The"keystone"of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the"piece of a puzzle"into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative"sculpting"is employed both"in situ"at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author's approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants;advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the"palette"upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a"natural"facial appearance while preserving fluid motions of facial expression.