Free flaps for head and neck reconstruction in non-oncological patients: experience of 200 cases

Two hundred free flaps for reconstructing the head and neck regions in 192 patients with non-oncological pathology were studied. Pathological entities included Romberg's disease, hemifacial microsomia, acquired facial palsy, trauma, and burn sequelae. Indications for selecting a specific free flap for reconstructing each case, details of anastomoses, reexploration, flap success, operative time, length of hospitalization, and complications were studied. The long-term results of cosmetic and function were also obtained. Patient age ranged from 6 to 40 years. The most common diagnosis was Romberg's disease 39% (n = 75), followed by hemifacial microsomia 20% (n = 40). The free flap most frequently used was the scapular 32% (n = 64), followed by the groin free flap 21% (n = 42). A total of 190 flaps (95%) were successful, whereas only 10 (5%) were lost. The mean operative time was 5:30 h and the average hospital stay was only 6 days. There were no major complications and no deaths in the study group. The patients were followed for at least 1 year in all cases. It is concluded that free flaps are safe and reliable procedures for reconstructing complex head and neck non-oncological defects.     

Microvascular surgery as an adjunct to craniomaxillofacial reconstruction

Fifteen patients (8 female and 7 male) age 4 to 57 years underwent microsurgical free tissue transfers as a component of a craniomaxillofacial reconstruction. In 12 patients the free flap was performed simultaneously with the bony procedure and in three it was a secondary procedure. The patients included two craniosynostosis, four craniofacial tumours, five hemicraniofacial microsomias, one facial and skull base arteriovenous malformation, one orbitofacial neurofibromatosis and two hemifacial atrophies with extensive facial skeletal involvement. The rectus abdominis free flap was used in 9 patients, the latissimus dorsi in two, the omentum in three, and the first web-space in one. The choice of tissue varied according to the size of the defect and its location. The rectus abdominis musculofasciocutaneous flap was the most frequent source of tissue for contour restoration, and the omentum was used to fill intracranial spaces. One flap failed intraoperatively in a patient with hemifacial microsomia and inadequate and abnormal recipient vessels. One patient had an injury to the temporal branch of the facial nerve, with spontaneous recovery. In 13 patients the free tissue transfer was for soft tissue fill with cover of facial bone or skull base; secondary procedures were frequently required in these patients. In two patients with intracranial free flaps, no further procedures were necessary. In selected cases the association of microvascular techniques with craniomaxillofacial surgery can facilitate reconstruction and improve results.     

Marriage of hard and soft tissues of the face revisited: when distraction meets microsurgery

BACKGROUND: Patients with craniofacial anomalies can have hard and soft tissue deficiencies. In some cases, distraction osteogenesis can restore the bony deficiencies, but the soft tissue contour defect remains problematic. For these patients, the union of distraction osteogenesis and microvascular free flaps (MVFF) can restore bone and soft tissue form and function. PATIENTS AND METHODS: A retrospective review of all patients treated with mandibular distraction osteogenesis between 1989 and 2005 was performed. A similar review of all patients treated with MVFFs was performed. These 2 cohorts were cross-referenced to identify all patients treated with both procedures. The indications, choices, safety, and efficacy of MVFF reconstruction of facial soft tissues following mandibular reconstruction are reviewed. RESULTS: Over a 16-year period, 141 patients underwent mandibular distraction osteogenesis; 8 patients treated with mandibular distraction osteogenesis subsequently underwent 12 MVFFs. Patient diagnoses included unilateral craniofacial microsomia (n = 2), bilateral craniofacial microsomia (n = 3), Goldenhar syndrome (n = 1), Nager syndrome (n = 1), and Treacher-Collins syndrome (n = 1). Free flap choices included 10 parascapular fasciocutaneous, 1 parascapular osteofasciocutaneous, and 1 fibular osteocutaneous flap. Four patients underwent staged bilateral free flaps. A single case of partial flap loss was the only complication. In all cases, facial contour was improved following MVFF transfer. CONCLUSIONS: In certain circumstances, facial rehabilitation may require the marriage of craniofacial and microsurgical techniques to restore both form and function. In these cases, mandibular distraction osteogenesis and MVFFs can be safely and effectively combined.     

Soft tissue augmentation for restoration of facial contour deformities using the free SCIA/SIEA flap

Reconstruction for facial contour deformities is still a challenging process and treatment for most cases is achieved only by soft tissue augmentation. The use of free tissue transfer offers the advantage of one step vascularized soft tissue augmentation. This article summarized the authors' use of de-epithelialized free superficial circumflex iliac artery/superficial inferior epigastric artery flap for facial contour deformities. Of these patients, two had hemifacial microsomia, one depressed scar, and one had hemifacial progressive atrophy. Stable restoration of the facial contour was achieved in all patients. The advantages of this flap are numerous. Two surgical teams may work at the same time for flap harvesting and recipient area preparation. A wide flap may be planned for large contour deformity to achieve one single stage augmentation. Pedicle course of this flap allows primary de-fating without disturbing distal flap circulation when in need of a thin flap for mild contour deformity. Donor site may be closed with bikini (abdominoplasty) incision, which has excellent esthetic outcome compared to other flaps.     

Facial contouring with parascapular free flap: A case series of 22 cases

Background:

The facial asymmetry correction in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Progressive hemifacial atrophy (HFA) and hemifacial microsomia (HFM) can manifest in different grades of severity. Most patients require only soft-tissue augmentation. Free flaps are the best option for correction of severe facial soft-tissue deficiency.

Materials and Methods:

Twenty-two patients of HFM and HFA were included in this study from January 2006 to March 2009 in the Department of Plastic and Reconstructive Surgery, SMS Medical College and Hospital. In all cases, atrophy correction was done using de-epithelialised parascapular free flap with the de-epithelialised surface was placed under the skin. A small skin paddle was taken for monitoring.

Results:

All cases were reconstructed with de-epithelialised parascapular free flap. There was no flap loss in this series. Hematoma was noted in five cases. Debulking and removal of skin paddle were done in all cases after 6 months. Atrophy recurrence was not observed in any of the cases on follow-up.

Conclusion:

Contouring of face in cases of HMF and HFA is satisfactorily done with the parascapular free flap. It gives better cosmetic results with minimal donor site morbidity. Facial vessels are better recipient vessels for anastomosis. Keeping de-epithelialised surface of flap under the skin helped in preventing sagging.KEY WORDS: Hemifacial atrophy, hemifacial microsomia, parascapular flap     

Microsurgical anterolateral thigh fasciocutaneous flap for facial contour correction in patients with hemifacial microsomia

The correction of facial asymmetry in complex hemifacial microsomia presents a challenging problem for reconstructive surgeons. Numerous microsurgical flaps have been introduced for reconstruction of facial asymmetry. This article reports our experience in facial soft tissue reconstruction with microsurgical anterolateral thigh fasciocutaneous flap transfer in six patients with hemifacial microsomia. This flap, which has a reliable vascular pedicle and relatively thin pliable soft tissue, can provide an ideal treatment for facial asymmetry in hemifacial microsomia.     

Microsurgical correction of facial asymmetry in hemifaclal microsomia

Facial asymmetry in hemifacial microsomia presents reconstructive problems of bone and soft tissue. In most cases, this is managed by skeletal reconstruction followed by microvascular free tissue transfer for patients requiring soft tissue augmentation. We present here our experience using customized parascapular free flaps with extensions of dorsal thoracic fascia, which yields esthetically satisfying results.     

Reconstruction of foot defects with free lateral arm fasciocutaneous flaps: analysis of fifty patients

In this article, long-term outcomes of foot reconstruction with free lateral arm fasciocutaneous flaps were retrospectively analyzed in 50 patients. The patients, 38 men and 12 women, ranged in age from 7-73 years (mean, 43.5 years). Indications for surgery included trauma (32 patients), diabetes mellitus (7 patients), burns (7 patients), chronic ulcers (3 patients), and tumor (1 patient). The locations of defects were the dorsum (n=21), ankle (n=12), medial (n=6), lateral (n=6), posterior heel (n=2), and distal sole (n=3) Concomitant bone injury occurred in 5 cases, and the weight-bearing surface of the foot was involved in 5 patients. Defects ranged in size from 27-76 cm(2) (mean, 36.4 cm(2)). Successful reconstructions were accomplished in 46 cases (92%). Flap complications included total flap loss and below-knee amputation (1 patient) and partial flap loss (3 patients); 75% (3/4) of these cases had diabetes as a comorbid factor, and 25% (1/4) had a concomitant bone injury. Six patients with dorsum defects required debulking of the flap (11.1%). None of the patients required modified shoes. In the majority of cases, flaps provided stable coverage and a gain in protective deep-pressure sensation. In long-term follow-up (up to 4 years), patients regained their ambulation, free of pain. Even in weight-bearing areas, none of the cases experienced ulceration or skin breakdown. Free lateral arm flaps provided excellent durability, with solid bony union and successful restoration of the contour of the foot in moderate-sized foot defects.     

The use of frozen autogenous bone flaps in delayed cranioplasty revisited

OBJECTIVE: To reevaluate the use of frozen autogenous bone flaps for patients undergoing delayed cranioplasty. METHODS: In the past 12 years, 49 patients have undergone delayed cranioplasty using frozen autogenous bone flaps. Bone flaps removed during the initial operation were sealed in three sterilized vinyl bags and stored at -35 degrees C (n = 37) or -84 degrees C (n = 12) for 4 to 168 days (mean, 50.6 d). The bone flaps were thawed at room temperature and replaced in their original positions. After cranioplasty, we monitored resorption of the bone flaps with computed tomography and evaluated the clinical and aesthetic results. Follow-up periods ranged from 14 to 147 months (mean, 59.2 mo). RESULTS: For 47 patients (95.9%), there were no complications during the follow-up period; there was slight thinning of the bone flap in some cases, but clinical and aesthetic results were highly satisfactory. Resorption was observed for a 12-year-old boy who had undergone cranioplasty, using two pieces of bone flap, 66 days after the initial operation. A 14-year-old boy with a cerebral contusion experienced a bone flap infection. Both patients underwent a second cranioplasty procedure, with ceramic plates. CONCLUSION: The clinical and aesthetic results of delayed cranioplasty using frozen autogenous bone flaps were satisfactory. The most important factor for success was excellent contiguity between the flap and the bone edge.     

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.     

A critical review of perioperative complications in 175 free deep inferior epigastric perforator flap breast reconstructions

BACKGROUND: The purpose of this study was to critically evaluate the perioperative complications for deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: From February 2002 until February 2006, 175 consecutive abdominal free tissue breast reconstructions were performed in 131 patients. Perioperative risk factors and complications were evaluated for the entire group. Data analysis was performed to compare subsequent chronologic groups for a learning curve effect. RESULTS: In 159 cases (90.9%) a DIEP flap could be raised. In 13 cases (7.4%), a mini-TRAM flap and in 3 cases (1.7%) a regular free TRAM flap was harvested. A learning curve was found showing a risk for flap complications in the first 30 DIEP flaps of 40% and in flaps 31 to 175 of 13.8% (P < 0.012). Microsurgical revision rate was 4% (n = 7), with a total flap failure rate of 0.6% (n = 1). Partial flap failure rate was 8.6% (n = 15), which was solved by debridement, medial advancement, and direct closure in 6.8% (n = 12) and latissimus dorsi flap transposition in 1.8% (n = 3). Multivariate analysis showed no significant influence of risk factors on development of postoperative flap complications. CONCLUSION: DIEP flap breast reconstruction is an excellent method, with limited donor-site morbidity. A definite learning curve was reflected in a larger number of flap complications in the beginning of our series.     

Oromandibular reconstruction with vascularized free flaps: a review of 50 cases

Fifty cases of oromandibular reconstruction using vascularized free flaps to evaluate functional parameters of results were evaluated. There were 23 iliac crest flaps, 17 fibula flaps, 30 ulnar forearm flaps, and 3 radial forearm flaps with bone. Thirteen female and 37 male patients comprised the study, with a mean age of 57.66 years. Squamous-cell carcinoma (SCC) constituted 86% of cases, of which 60% were T4 lesions and 13.9% were recurrent. Anterolateral mandibular defects constituted 48.7%, and the mean bone gap was 8.13 cm. Functional evaluation was based on the University of Washington Questionnaire (UWQ) through phone calls and personal communication. The mean hospital stay was 12.42 days. The external carotid (75%) and facial (18.3%) were the main recipient arteries. The internal jugular (47.05%) was the main recipient vein. Overall flap survival was 95.9%. Three flaps were lost due to unsalvageable venous thrombosis. Major local complications such as partial flap loss, hematoma, and orocervical fistula constituted 10% of cases. Speech was classified as "excellent" and "good" in 43.3% of cases. Swallowing was identified as "excellent" and "good" in 53.3% of cases. Cosmetic acceptance was rated "good" in 63.3% of cases. Vascularized free flap reconstruction of oromandibular defects provides excellent functional and aesthetic results. The majority of patients are able to tolerate a regular diet. Intelligible speech and acceptable appearance are restored, providing patient satisfaction.     

The free iliac crest and fibula flaps in vascularized oromandibular reconstruction: comparison and long-term evaluation.

BACKGROUND: A variety of free flaps have been successfully used for mandible reconstruction. This study compared the short- and long-term results of using the free iliac crest and fibula flaps. METHODS: We conducted a retrospective analysis of 117 patients who underwent mandibular reconstruction, 59 patients with iliac crest and 58 with free fibula. Accurate long-term functional assessment was possible in 31 cases in the iliac crest group and in 48 patients with fibular reconstruction. Anterior or combined anterolateral defects formed 72% and 64% in the iliac crest and fibula groups, respectively. The remainder were pure lateral defects. In both series, a skin paddle was included to provide either lining, skin cover, or both in 77% of the cases, whereas in 23% bone only was used. RESULTS: Complications included two perioperative deaths and three flap losses in the iliac crest group and five flap losses in the fibula group. Long-term functional and cosmetic assessment showed no statistically significant differences in oral continence (p > 0.9), speech (p = 0.57), and contour results (p = 0.80) between the two groups. However, oral deglutition was statistically significantly better in the fibula free flap group (p = 0.009). CONCLUSION: Although the fibula free flap is the flap of choice, the iliac crest is an excellent and reliable complementary flap for mandibular reconstruction.     

Principles of microvascular reconstruction in burn and electrical burn injuries

Free tissue transplantation is a rarely indicated procedure in burn reconstruction. As the versatility and variability of free flaps have significantly developed during recent years, so have the indications for this procedure expanded. This study reports retrospectively the results of 75 free flaps in 60 severely burned patients using 20 different free flaps. This experience enabled us to establish reconstructive principles pertinent to the type of injury (burn versus high voltage injuries) and the timing of reconstruction procedures. In high voltage injuries (n = 26) early free flap coverage (<21 days after trauma) with muscular flaps was the most frequently used type of reconstruction. Reconstruction site was predominantly the upper extremity and forearm. In burn injuries (flame, contact, fluid), free flap coverage was performed during a later stage of the treatment course (3-6 weeks after trauma), or as a secondary procedure. Reconstruction with cutaneous flaps was the preferred method. In contrast to high voltage injuries, the trunk and the face were also recipient sites. In the upper extremity, the elbow and dorsum of the hand were the most frequent sites of reconstruction. Overall, the flap failure rate was 13% (n = 10). We were able to show a relationship between flap failure rate and timing of the procedure. Eight out of 10 flap failures occurred within 5-21 days after trauma, all 10-flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. For the reconstruction of complex or large defects (n = 14), we recommended combined 'chimeric' flaps, pre-expansion of free flaps, or the combination of a free and local flap. Our data demonstrate that burn and high voltage injuries are distinct entities, each requiring custom tailored reconstructive solution.     

Free latissimus dorsi perforator flap for reconstruction of hemifacial atrophy: case report

Progressive hemifacial atrophy (PHA) is characterized by slow and progressive atrophy usually of one side of the face. PHA affects primarily the subcutaneous fat and muscle tissues, but may involve the bone. The cause is unknown. The treatment is symptomatic and directed at augmentation of the deficient soft-tissue volume. The reconstructive procedures may combine fat grafts, dermis fat grafts, pedicle flaps, bone grafts, microvascular free flaps, and alloplastic implants. We report a patient with of PHA whose condition was treated with a free latissimus dorsi (LD) perforator flap. The LD perforator flap was suitable for the large defect of the patient. It could easily be tailored and thinned to follow the facial contour. Minor revisions were needed for esthetic reasons. There was neither significant downward gravitation nor wasting of the flap. 23 months later, the natural appearance of the face was maintained.     

24例半侧颜面发育不全畸形外科矫治的临床分析

目的 对24例半侧颜面发育不全畸形的外科矫治作回顾性分析,探讨此类畸形综合治疗的效果. 方法 1991年7月至2006年8月,采用正颌外科技术、游离组织瓣法、Medpor植入术、牵引成骨技术综合治疗半侧颜面发育不全畸形24例,对患者年龄、畸形分类、手术时机、治疗方法及术后并发症等情况进行分析. 结果 所有患者术后均顺利完成治疗,术后患侧面部丰满度和面部对称性均得到明显提高,咬合关系均较术前明显改善,咬合平面基本摆正,其中8例血管化游离组织瓣均成活,无一例出现血管危象和组织瓣的坏死. 结论 根据患者年龄及畸形的分类选择合适的手术方案组合,对半侧颜面发育不全畸形的矫治可获得咬合关系和容貌均满意的效果.     

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。     

吻合血管的游离组织瓣修复进行性单侧面萎缩症

目的用游离的股前外侧筋膜脂肪瓣充填修复进行性单侧面萎缩症。方法设计以旋股外侧动脉降支为血管蒂的游离股前外侧筋膜脂肪瓣或旋肩胛血管为血管蒂的肩胛真皮脂肪瓣，切取筋膜脂肪瓣或真皮脂肪瓣后将其转移至面部萎缩处，然后将旋股外侧动脉降支或旋肩胛血管和面动静脉相吻合。结果临床治疗8例，其中应用股前外侧筋膜脂肪瓣7例，肩胛真皮脂肪瓣1例，组织瓣全部成活，矫正的患侧面部形态与健侧基本对称，外形满意。结论游离组织瓣移植，尤其以旋股外侧动脉降支为血管蒂的股前外侧筋膜脂肪瓣能提供足够的组织量，是修复进行性单侧面萎缩症较好的方法。     

Patient benefit from ear reconstruction with porous polyethylene in severe cases of hemifacial microsomia

Background

Ear reconstructions in patients with severe hemifacial microsomia belong to the most challenging cases. When deciding about the best position for the reconstructed ear, the surgeon has to make a compromise out of different given factors, it being impossible to achieve symmetry to the contralateral side. The present study was initiated to analyze if this difficult patient collective with naturally imperfect esthetical results benefits from the operation by an increase in health-related quality of life.

Methods

For ear reconstruction, the authors used frameworks of porous polyethylene (PPE) covered by a temporoparietal fascia flap. Six patients with microtia and hemifacial microsomia type 3 (three adults and three children) received validated questionnaires determining the effects of the ear reconstruction on the patients’ health-related quality of life (Glasgow Benefit Inventory, GBI, or Glasgow Children’s Benefit Inventory, GCBI, respectively). Scores can range from ?100 (maximal negative effect of the intervention) through 0 (no effect) to +100 (maximal positive effect).

Results

All patients achieved positive GBI or GCBI scores suggesting a benefit from the ear reconstruction. For the adults, the mean GBI total score was 27.8. For the children, the mean GCBI total score was 40.3. Scores were higher compared to a control group of microtia patients without additional facial asymmetries.

Conclusions

In severe cases of hemifacial microsomia, ear reconstruction with PPE can significantly increase patients’ health-related quality of life. Furthermore, PPE frameworks offer different surgical advantages compared to autologous cartilage especially in severe hemifacial microsomia. Level of Evidence: Level III, therapeutic study.     

Outcomes of flap salvage with medicinal leech therapy

Medicinal leech therapy (MLT) to salvage venous congestion in native skin and local flaps is commonly practiced. However, the role of MLT in compromised regional and free flaps remains unclear. Leeches were used in 39 patients to treat venous congestion in native skin (n = 5), local flaps (n = 6), regional flaps (n = 14), and free flaps (n = 14). There were no total losses in patients with compromised native skin or local flaps. One patient who had received a radial forearm free flap expired before flap outcome could be assessed, and was excluded from analysis. Of the remaining 27 regional and free flaps, 33.3% were salvaged, 33.3% were partially salvaged, and 33.3% were lost. Means of 38.3 ± 34.0, 101.0 ± 11.2, and 157.9 ± 224.4 leeches and 1.7 ± 3.6, 3.2 ± 4.4, and 5.6 ± 5.2 units of blood were required for the salvaged, partially salvaged, and lost groups, respectively. Twenty-two patients required blood transfusion (57.9%). No patients developed wound infection with Aeromonas hydrophilia. Two patients developed donor site hematomas, and four patients developed recipient site hematomas. MLT is efficacious in congested native skin and local flaps. Some regional and free flaps can be totally or partially salvaged. However, the morbidity of MLT must be weighed against the risks of flap loss.