Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap

Abstract

The pectoralis major myocutaneous pedicled flap (PMMPF) – the “workhorse” for head and neck reconstruction – is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.     

Forehead reconstruction using a modified dual-plane A to T flap

Forehead defects often present myriad challenges for the reconstructive surgeon. Many options exist for forehead reconstruction, from primary closure to free flaps. To optimally match colour, contour and texture, the best approach replaces ‘like with like’. When primary closure is not possible due to size limitations, and colour or depth is not suitable for grafts, then locoregional flaps become the mainstay of repair. The authors present three cases in which a dual-plane modified A to T flap is used to reconstruct central and lateral forehead defects up to 8 cm in size with excellent aesthetic results. This technique applies principles of the periglabellar flap, with modifications designed to encompass larger defects as well as defects of the lateral forehead.     

Synchronous reconstruction of the floor of mouth and chin with a single skin island fibular free flap

Objectives: The goal this presentation is to: 1) Review the reconstructive options for anterior mandible through‐and‐through composite defects and 2) Instruct the audience in the application of the double‐skin paddle fibular flap in selected patients. Methods: Case presentation with review of the literature. Results: A 70‐year old male with an anterior floor of mouth squamous cell carcinoma underwent composite resection that included resection of a 5‐cm ovoid component of overlying chin skin. The defect was reconstructed with a fibular osteocutaneous flap with a double skin paddle technique. Conclusions: Several reconstructive options have been described in the literature for extended oral cavity defects including the use of multiple free flaps, combinations of regional and distant flaps, and sequential reconstruction. This case report reviews the use of a single flap reconstruction of these defects for selected patients. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.     

Microsurgical reconstruction of maxillectomy defects: experience of 24 cases

Introduction

The defect complexity and reconstructive options make the maxillary reconstruction a controversial theme and in a constant debate. The maxilla is a fundamental aesthetic and functional structure of the face. Microsurgical vascularized flaps replaced the usage of prosthetic material and pedicled flaps as a “gold standard” for the reconstruction of complex defects following maxillectomy.

Methods

The authors report their experience of 24 maxillectomies with immediate microsurgical reconstruction, performed by the senior author (H.C.) between 1998 and 2011. They evaluate and classify the defects and the reconstructive options according to the classification system as proposed by Cordeiro and Santamaria in 2000, by a patient questionnaire and post-operative surgeon follow-up for the functional (diet, speech, and vision) and aesthetic end results.

Results

There were no flap failures. The main etiology was squamous cell carcinoma and the most used flap was rectus abdominis free flap. Classes I and II were responsible for the cases in which the reconstructive algorithm was not followed. Most patients responded as having a normal diet, a nearly normal speech and unaffected vision. In a score of 1 to 5, the mean score in esthetic given by the patient was 3.62, while the mean score given by the surgeons was 4.13.

Conclusions

Microsurgical reconstruction of maxillectomy defects with free flaps is the best reconstructive option, being the osteomyocutaneous flaps as the gold standard. Although with limited rehabilitation, good functional and aesthetic results are to be expected with myocutaneous flaps. The existence of an algorithm facilitates the classification and systematization of maxillary reconstruction. However, due to defect complexity and large number of reconstructive options, a perfect solution does not exist. The individual assessment of the patient and the defect always provides the best method for the reconstructive planning, mainly when choosing free flaps. Level of Evidence: Level IV, therapeutic study.     

Flow‐through omental flap to free anterolateral thigh flap for complex chest wall reconstruction: Case report and review of the literature

Despite the options currently available for chest wall reconstruction, patients with complex composite defects may still pose a significant challenge for the reconstructive surgeon when only using conventional methods. In particular, prior radiotherapy and/or large en bloc resection may leave inadequate regional flaps and recipient vessels for free tissue transfer. Here, we describe a case in which we reconstruct a 14 cm × 18 cm complex chest wall defect, secondary to tumor resection and infected sternum debridement, with a pedicled flow‐through omental flap to a 14 cm × 22 cm free anterolateral thigh flap using the omental gastroepiploic vessels as recipient vessels. Reconstruction was successful with excellent flap viability, and no complications at recipient or donor sites. We review the literature on complex chest wall reconstruction and introduce this valuable option of utilizing a pedicled omental flap as a flow‐through flap to a free flap for patients without viable recipient vessels or local flaps. © 2015 Wiley Periodicals, Inc. Microsurgery 36:70–76, 2016.     

The optimum method for reconstruction of complex lateral oromandibular-cutaneous defects

BACKGROUND: Ablation of large intraoral cancers can create extensive through-and-through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full-thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects. METHODS: A series of 12 patients with large lateral facial-mandibular defects is reviewed. All patients were treated for squamous cell carcinoma except for 1 patient with osteoblastic sarcoma of the mandible. All patients underwent primary reconstruction with various free flap techniques, including 6 scapular free flaps, 2 iliac crest free flaps, 3 free fibula flaps, and 1 radial forearm flap. Attainment of reconstructive goals, free flap survival, and complication rates were assessed. RESULTS: All defects were successfully reconstructed in the primary setting. No flap failures occurred. One venous occlusion was successfully salvaged. No orocutaneous fistulas or postoperative hematomas were noted. CONCLUSION: The reconstructive options for extensive defects of the lateral face and jaw are reviewed with attention to the complex three-dimensional soft tissue requirements. The superiority of the scapular composite flap is emphasized because this single free flap provides two independent and versatile skin paddles of optimal thickness in addition to adequate bone stock.     

Consecutive flap transfer for repairing massive soft tissue defects in the opisthenar with improved donor site closure

Objective：To explore a surgical model of utilizing consecutive free scapular flap and adjacent pedicled flap transfer for repairing massive soft tissue defects on the dorsum of the hand while minimizing the donor site morbidity.Methods：Six patients with massive soft tissue injuries on the opisthenar and forearm were treated with free scapular flaps.Afterwards,a pedicled flap adjacent to the donor site was transferred to cover the donor site defect by direct closure.Results：All six free scapular flaps survived without signs of infection.Three adjacent pedicled flaps presented minor signs of insufficient blood flow on the distal apex,which resolved after six weeks with only conservative therapy.All the incisions healed without other complications.At six-month follow-up,the patients regained full shoulder function.Conclusion：With the assistance of an adjacent pedicled flap,the scapular flap is a highly applicable approach in repairing massive soft tissue defects in the opisthenar.It can achieve positive outcomes in both reconstructive and aesthetic aspects.     

Single-stage maxillary and nasal floor reconstruction with the double-paddle rectus abdominis musculocutaneous free flap

Palatal integrity is essential for useful speech, deglutition, good oral hygiene, and prevention of nasal regurgitation. Maxillary defects after tumor extirpation, therefore, can have serious functional and cosmetic implications. Given the often disappointing results obtained with local and regional pedicled flaps for maxillary reconstruction, a variety of microvascular free flaps have been utilized in recent years, including the rectus abdominis, fibular, radial forearm, and latissimus dorsi flaps. Experience with these techniques has been documented in a limited number of case reports. We describe our single-stage approach to maxillary and nasal floor reconstruction with the double skin-paddle rectus abdominis musculocutaneous free flap. A series of five patients is presented; six of these immediate free flap reconstructions were performed for defects resulting from tumor resection. A vertical rectus abdominis musculocutaneous free flap was used in all cases, designing two separate skin paddles to accommodate the measured maxillary and nasal floor deficiencies. Anastomoses of the deep inferior epigastric artery and vena comitans were performed end-to-end to the facial artery and vein, respectively. In addition, orbital floor reconstruction with calvarial bone grafts or titanium mesh was performed in all five patients. Separation of the oral and nasal cavities was maintained postoperatively. No intraoperative complications, perioperative mortalities, flap losses, instances of skin paddle necrosis, hematomas, or oronasal fistulae were observed. One patient required bedside drainage of a surgical site abscess that resolved without adverse sequelae. Over the past 4 years, the double skin-paddle rectus abdominis musculocutaneous free flap has provided reliable results at our institution for single-stage reconstruction of maxillary and nasal floor defects. This reconstructive technique should be considered a viable method that can alleviate the functional and cosmetic debility associated with these defects.     

Osseocutaneous radial forearm flap with beavertail modification; a case report of a novel,single, reconstructive free flap for the tongue,floor of mouth and mandible

IntroductionComplex hard and soft tissue defects produced as a result of ablative resection of head and neck malignancy can represent a reconstructive challenge, especially when patients are medically compromised. PRESENTATION OF CASE: We present the case of 72-year-old women presenting with an oral squamous cell carcinoma of the right floor of mouth invading the right mandible. Surgical management of the disease required ablative surgery with complex free tissue transfer reconstruction to provide restoration of form and function. Potential reconstructive options were limited by her medical comorbidities and poor vessel patency in the lower limbs, requiring novel thinking and adaptation of established techniques.DiscussionWe describe the first reported use of an osseofasciocutaneous radial forearm flap with a ‘beavertail modification’ to provide a single and combined reconstructive option to reconstruct a complex hard and soft tissue defect.ConclusionThis novel free-flap technique adds to the reconstructive armamentarium of the head and neck surgeon.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

口腔口咽肿瘤切除术后较大缺损修复的研究

目的总结口腔口咽肿瘤切除后较大缺损的修复方法，讨论影响组织瓣相关并发症的因素。方法回顾性分析2004年12月～2006年4月我院头颈外科收治的部分口腔口咽肿瘤患者64例，肿瘤切除后出现较大缺损，使用组织瓣66块进行修复，其中带蒂组织瓣39块，游离组织瓣27块。结果27例游离组织瓣中，2例前臂皮瓣坏死，成功率92．6％；39例带蒂组织瓣中，4例胸大肌肌皮瓣出现部分坏死。成功率90％。64例患者中，除1例死亡外，全部恢复经口进食。带蒂或游离组织瓣的选择及术前放疗与否不影响组织瓣相关并发症的发生。结论对口腔口咽部肿瘤切除后的较大缺损，应视缺损的范围、大小及患者的一般情况、术前放疗、颈部手术史等综合考虑，选择最合适的组织瓣进行修复。如果出现皮瓣相关井发症，尤其对术前放疗者应积极处理。     

口腔颌面部缺损的修复重建--1 973例临床分析

目的 口腔颌面部缺损游离组织瓣修复方式的对比研究。方法 2001年1月～2004年6月，收集修复重建患者共1973例，分别对其年龄、性别、病种、缺损部位和修复类型的分布情况，游离组织瓣危象的发生率及成功率进行分类统计。采用SAS6．12医用统计软件包进行数据分析。结果 中年（〉45～≤60岁）患者764例，占38.72％；老年（〉60岁）527例，占26．71％；青壮年（〉28～≤45岁）450例，占22．81％；青年（〉14≤28岁）187例，占9．48％，儿童（≤14岁）45例，占2．28％。男1193例，女780例，男、女之比为1．5：1。良、恶性病变之比为1：1．94。缺损部位依次为舌20．63％、下颌骨17．38％、腮腺13．74％、颊12．72％、上颌骨8．16％、口咽7．60％、口底5.68％、其他占14．09％。血管化游离组织瓣修复904例，占45．82％；带蒂组织瓣753例，占38．17％；随意（皮）瓣201例，占10．19％；非血管化骨移植30例，占1．52％；其它方法85例，占4．30％。其中游离前臂皮瓣594例，腓骨肌（皮）瓣143例，带蒂胸大肌（皮）瓣369例，3种组织瓣共1106例，占修复重建总例数的56．06％。游离组织瓣共940个，发生术后危象47个（5．20％），抢救成功30个（63．83％），游离组织瓣总成功率为98．19％。结论 口腔颌面部缺损修复重建患者以中老年、男性、恶性肿瘤为主；舌的缺损修复约占1／5；游离组织瓣的成功率高，是主要的修复方式；前臂皮瓣、腓骨肌（皮）瓣、带蒂胸大肌（皮）瓣成为口腔颌面部缺损修复的常用组织瓣。     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

A ten-year experience of multiple flaps in head and neck surgery: how successful are they?

Ablative surgery in the head and neck often results in defects that require free flap reconstruction. With improved ablation/reconstructive and adjuvant techniques, improved survival has led to an increase in the number of patients undergoing multiple free flap reconstruction. We retrospectively analyzed a single institution's 10-year experience (August 1993 to August 2003) in free flap reconstruction for malignant tumors of the head and neck. Five hundred eighty-two flaps in 534 patients were identified with full details regarding ablation and reconstruction with a minimum of 6-month follow-up. Of these 584 flaps, 506 were for primary reconstruction, 50 for secondary reconstruction, 12 for tertiary reconstruction, and 8 patients underwent two flaps simultaneously for extensive defects. Overall flap success was 550/584 (94%). For primary free flap surgery, success was 481/506 (95%), compared with 44/50 (88%) for a second free flap reconstruction and 9/12 (75%) for a third free flap reconstruction ( P < 0.05). Eight extensive defects were reconstructed with 16 flaps, all of which were successful. More than one free flap may be required for reconstruction of head and neck defects, although success decreases as the number of reconstructive procedures increases.     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

Instep free flap for plantar soft tissue reconstruction: indications and options

Pedicled instep flaps are frequently used in weight-bearing plantar reconstruction, but may not be available after severe foot injuries. Although free instep flaps offer a viable option, they have scarcely been reported. A posttraumatic plantar forefoot defect was reconstructed with a sensate, instep free flap, because local flaps were not available and defect size did not require a distant free flap, and the current literature was reviewed for therapeutic options. The instep free flap yielded an excellent functional and aesthetic long-term result. In the literature, pedicled instep flaps are advocated for moderate size defects of the weight-bearing heel and sole, while free flaps from distant sites are preferred for large defects. Although skin-grafted muscle flaps and fasciocutaneous flaps yield similar results, reconstruction by like tissues appears favorable. We suggest the instep free flap for weight-bearing plantar foot reconstruction, when pedicled instep flaps are not available and distant free flaps are avoidable.     

Rekonstruktion bei schweren Weichteilverletzungen an der Hand

Background

Severe soft tissue defects of the hand are often caused by occupational trauma and frequently lead to considerable functional impairment.

Objective

Which reconstructive options and what supportive treatment measures are available for severe soft tissue defects of the hand?

Material and methods

A representative summary of treatment measures concerning primary care and further covering of defects as exemplified by selected cases from our own patients and additional recommendations for treatment are presented.

Results

The reconstruction of severe soft tissue defects of the hand usually consists of several steps and is performed according to individual patient needs. For this purpose, different types of local, pedicled and free flaps are available.

Conclusion

Hand surgery provides a wide range of options for the reconstruction of tissue defects of different etiologies. The spectrum of operative procedures encompasses both local and pedicled flaps as well as free flaps taken from other regions of the body with microvascular connection to the recipient region. Free flaps are an essential pillar in the reconstructive treatment and due to the safety in the execution, the application of free flaps should not only be seen as a last resort. Many kinds of free flaps can be harvested with parts from different tissue types or as a combination of several free flaps. As a result individual solutions can be provided depending on patient needs. Supportive measures following free flap surgery can help to improve the postoperative result with respect to blood supply, complaints and function.

     

Reconstruction of lateral through and through oro‐mandibular defects following oncological resections

Background: Resections of oromandibular squamous cell carcinoma involving lateral mandible, oral cavity, and the skin, lead to composite oromandibular defects that can be approached in several ways depending on the extension of the bone defect, of the soft tissue and cutaneous resection, the patient's general status and the prognosis. Purpose of the study is to evaluate retrospectively functional and esthetic outcome obtained with different reconstructive technique employed. Methods: A retrospective evaluation of 42 patients has been performed. The study population consisted of 24 males (57.1%) and 18 females (42.9%), ranging in age from 25 to 81 years (mean, 62.6 years). The primary location of the tumor was the mandibular alveolar crest (18 cases), retromolar trigon (9), floor of the mouth (8), cheek (5), and oral commissure (2). For reconstruction a single free flap technique was used eight times; a double free flap technique, seven times; free and locoregional flap association, 25 times; and a single locoregional flap and two associated locoregional flaps, one time each. Postoperative follow‐up ranged from 12 to 144 months. Final results were evaluated with regards to deglutition, speech, oral competence, and esthetic outcome. Results: When free bone‐containing flaps or two free flaps technique were used, the functional results were better (normal diet, 67%–71%; good oral competence, 100%–71%; good or intelligible speech, 100%–86%). When free and locoregional flap association was chosen, the esthetic results were best (excellent, 76%; acceptable 24%; poor 0%). The worst results were obtained with the use of a single free soft tissue flap and with the use of single or double locoregional flap technique. Conclusion: Bone reconstruction of the lateral mandible is indicated whenever possible. In elderly or poor prognosis patients acceptable results can be achieved with free soft tissue flaps techniques. When the defect involves different structures of the oral cavity, the best results are provided by the association of two free flaps. Finally, the association of free and locoregional flaps is a good option for external coverage reconstruction. © 2010 Wiley‐Liss, Inc. Microsurgery 30:517–525, 2010.     

The free lateral arm flap in reconstructive hand surgery

Microsurgical tissue transplantation has provided a great advance in reconstructive surgery, especially regarding upper limb defects. Compared to conventional pedicled flaps, mobilisation can occur earlier, hospital stay is shorter and no additional interventions for pedicle detachment and flap inset are needed. The lateral arm flap is an exceptionally versatile free flap with straightforward dissection and low donor site morbidity. End-to-side anastomosis preserves blood flow through the main arteries to the hand and reduces the risk of vascular compromise of the hand, which is especially important in case of severe hand injuries. Sixteen patients who underwent hand reconstruction using the lateral arm free flap are reviewed. All arterial anastomoses were conducted in end-to-side-technique either to the radial or the ulnar artery. There was no total- or partial-flap failure and only one revisional procedure due to a haematoma under the anastomosis. Eight flaps required secondary defatting, combined with removal of osteosynthesis material or tenolysis. From our point of view the free lateral arm flap is a very reliable and versatile method to resurface small and medium sized hand defects.