Reconstruction in the head and neck regions with free radial forearm flaps and split-rib bone grafts

Fifty patients with wound defects in the head and neck region underwent reconstruction with the free radial forearm flap. Mandible defects in 17 patients were reconstructed by split-rib bone grafts. Radiotherapy was administered to 44 patients preoperatively. The free flap was successful in 49 patients, and there was one case of partial flap necrosis. The free flap is soft, thin, and movable. The split-rib bone graft was successful in 15 patients, and there was one case of partial graft necrosis and one case of complete necrosis. Postoperative complications were decreased by 50 percent when compared with the complication rate when split ribs were covered by forehead flaps, deltopectoral flaps, or oral mucosa. Finally, the functional and cosmetic results were excellent.     

Free flaps for type III complex pharyngoesophageal defects after enlarged ablative surgery for advanced cancer of larynx and hypopharynx

Free tissue transfer has become a useful technique for reconstruction of type III complex pharyngoesophageal defects after enlarged laryngectomy and partial or total pharyngoesophageal resection. We present a retrospective analysis of our experience with 36 patients who received free flaps for reconstruction of complex pharyngoesophageal defects associated with skin and soft-tissue defects. Free fasciocutaneous flaps and jejunum combined with a deltopectoral flap and musculocutaneous pectoralis major flap, gastro-omental flap, and combined latissimus dorsi musculocutaneous and cutaneous scapular flaps were used for reconstruction. Adjuvant therapy included preoperative or postoperative radiotherapy. Free flap failure occurred in 2 of 36 patients. Twenty-eight patients had good swallowing function. Better results with fewer complications in reconstruction of type III complex pharyngoesophageal defects were obtained with the use of a combined latissimus dorsi and scapular flap.     

Complications after laryngectomy

The charts of 100 consecutive patients who underwent laryngectomy at Memorial Hospital were reviewed to assess those factors that contribute to postoperative complications. Laryngectomy was performed for epidermoid carcinoma in 94 patients and for laryngeal incompetence in 6. Total laryngectomy was performed in 48 patients and partial and circumferential pharyngectomies in addition to laryngectomy in 40 and 12 patients, respectively. Significant complications, which delayed discharge, occurred in 13 patients (27 percent) who had simple laryngectomy, including the formation of two fistulas (4 percent). After laryngopharyngectomy, the complication rate was 77 percent (40 of 52 patients) with pharyngocutaneous fistulas in 19 patients (37 percent). The fistula rate of formation was not increased in irradiated patients; however, the duration of time to closure of a pharyngocutaneous fistula, if it occurred, was longer. Planned pharyngostomy or staged deltopectoral flap reconstruction after extended laryngopharyngectomy was associated with excessive morbidity. Newer techniques of reconstruction utilizing flaps or gastric transposition offer the prospect of reduced morbidity after laryngopharyngectomy.     

Reconstructive experience with the medially based deltopectoral flap

One hundred and five deltopectoral flaps were raised in 100 patients. Fifty-four were delayed prior to use and 51 flaps were used immediately without delay. Delay was used whenever there was a high probability of impaired healing or a modification of a portion of the flap was necessary. In patients with delayed flaps there was major loss in 16.6 per cent and minor loss in 9.2 per cent. In immediate reconstruction of the flap, major loss occurred in 15.7 per cent and minor loss in 17.6 per cent. The most frequent major flap losses occurred during attempts to reconstruct the palate.Placement of the flap into a previously radiated tissue bed, diabetes, and wound infections were the major contributing factors to major flap loss in both groups of patients.     

腹部皮瓣乳房重建术后并发症及危险因素的研究

目的 探讨腹部皮瓣乳房重建的术后并发症及其相关危险因素.方法 对2001年5月至2008年10月接受腹部皮瓣乳房重建的115例患者的资料和术后并发症情况进行回顾性分析.术后观察指标包括:皮瓣全部坏死、皮瓣部分坏死、脂肪坏死、腹壁疝、腹壁膨出、脂肪液化、感染.并对其术后并发症的相关危险因素进行分析.结果 术后并发症的总发生率为17.4%(20/115),未出现皮瓣全部坏死、腹壁疝、腹壁膨出等严重并发症.皮瓣并发症为脂肪坏死6例(5.2%)、皮瓣部分坏死5例(4.3%)和感染1例(0.9%),供区并发症为脂肪液化8例(7.0%)和感染3例(2.6%).年龄、肥胖和手术时机对于术后并发症的发生率无影响.吸烟者、既往有放疗史者、带蒂横行腹直肌肌皮瓣组术后并发症的发生率较高,但未达到统计学意义.结论 在熟练掌握显微外科技术的情况下,实施腹壁下动脉穿支皮瓣乳房重建更有利于降低术后并发症.术前有吸烟或放疗史的患者应慎重考虑做腹部皮瓣乳房重建,而年龄、肥胖等因素不应成为腹部皮瓣乳房重建的禁忌.     

面颌部洞穿缺损的双皮瓣及肌皮瓣修复

目的为解决由各种原因引起的面颌部洞穿性缺损的修复问题。方法采用两个带蒂的组织瓣搭配使用修复面颌部洞穿缺损45例,共用组织瓣90个。其中胸三角皮瓣58个(占64%),依次是颈阔肌肌皮瓣,胸大肌肌皮瓣,额部皮瓣,胸锁乳突肌肌皮瓣,背阔肌肌皮瓣等。结果45例洞穿性缺损所用90个组织瓣中全部成活及绝大部分成活者87个,成活率达97%,全部或大部分坏死的3个(占3%)。结论面颌部洞穿性缺损即刻修复是可行的。修复洞穿缺损有多种皮瓣、肌皮瓣可供选择;提出胸三角皮瓣、颈阔肌肌皮瓣、胸大肌肌皮瓣等是修复面颌部洞穿性缺损的优质组织瓣。临床应用中取得了功能与外形同时修复的效果。     

Reconstruction of perforating defects of the maxillofacial region with double flaps]

OBJECTIVE: To solve the problems in restoration of perforating (full thickness) defects in the maxillofacial region. METHODS: Double flaps have been used to reconstruct the defects. Forty-five patients with full thickness defects on the maxillofacial region were treated with 90 flaps, including 58 (64%) deltopectoral flaps, the platysma myocutaneous flap, pectoralis major myocutaneous flap, sternomastoid myocutaneous flap, forehead flap and latissimus myocutaneous flap. RESULTS: The operation results were satisfactory. Of the 90 flaps, 87 flaps survived completely or subtotally with a successful rate of 97%. Three flaps sustained total or large necrosis. CONCLUSION: A number of flaps can be used for repairing the full thickness defects of the maxillofacial region, especially the deltopectoral flap, the platysma myocutaneous flap and the pectoralis major myocutaneous flap. They can provide excellent external cover or internal lining. They are well vascularized, hairless and colour-matched.     

面颌部洞穿缺损的双皮瓣及肌皮瓣修复

目的为解决由各种原因引起的面颌部洞穿性缺损的修复问题。方法采用两个带蒂的组织瓣搭配使用修复面颌部洞穿缺损４５例,共用组织瓣９０个。其中胸三角皮瓣５８个（占６４％）,依次是颈阔肌肌皮瓣,胸大肌肌皮瓣,额部皮瓣,胸锁乳突肌肌皮瓣,背阔肌肌皮瓣等。结果４５例洞穿性缺损所用９０个组织瓣中全部成活及绝大部分成活者８７个,成活率达９７％,全部或大部分坏死的３个（占３％）。结论面颌部洞穿性缺损即刻修复是可行的。修复洞穿缺损有多种皮瓣、肌皮瓣可供选择;提出胸三角皮瓣、颈阔肌肌皮瓣、胸大肌肌皮瓣等是修复面颌部洞穿性缺损的优质组织瓣。临床应用中取得了功能与外形同时修复的效果。     

Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection

Microvascular free tissue transfer has gained world-wide acceptance as a means of reconstructing post-oncologic surgical defects in the head and neck region. Since 1977, the authors have introduced this reconstructive procedure to head and neck reconstruction after cancer ablation, and a total of 2372 free flaps were transferred in 2301 patients during a period of over 23 years. The most frequently used flap was the rectus abdominis flap (784 flaps: 33.1 percent), followed by the jejunum (644 flaps: 27.2 percent) and the forearm flap (384 flaps: 16.2 percent). In the reported series, total and partial flap necrosis accounted for 4.2 percent and 2.5 percent of cases, respectively. There was a significant statistical difference ( p < 0.05) in complete flap survival rate between immediate and secondary reconstruction cases. The authors believe that the above-mentioned three flaps have been a major part of the armamentarium for head and neck reconstruction because of a lower rate of flap necrosis, compared to other flaps.     

The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications

Sixty-seven patients underwent 73 pectoralis major myocutaneous flap procedures for the immediate reconstruction of defects after resection of head and neck cancers. Thirty-six patients experienced a total of 50 complications for an overall complication rate of 54 percent. There were 3 instances of total flap necrosis, 9 of partial flap necrosis, 12 orocutaneous fistulas, 9 suture line separations, 8 neck wound complications, 1 donor site complication, and 8 mandibular replacement complications. Most complications were minor and did not require a second procedure for correction; however, 36 percent did require a second operation. Eight of 10 patients in whom a metal appliance was placed to restore mandibular continuity required the removal of that appliance due to either flap necrosis, fistula formation, or exposure. Based on our experience, we conclude that attention to flap design, operative technique, and post-operative management were useful in reducing the incidence of complications. We also conclude that a metal appliance was an unsatisfactory means of restoring mandibular continuity when utilized beneath a pectoralis major myocutaneous flap. Although the overall incidence of complications was high, the actual incidence of flaps failing to accomplish their intended purpose and requiring secondary repair was acceptable. The pectoralis major myocutaneous flap was reliable in the reconstruction of defects in the head and neck region.     

Some observations on 112 pectoralis major myocutaneous flaps

Our results of 112 pectoralis major flaps used alone or in combination have been reviewed. Also, other anatomic studies have been described which led to the development of a true island flap with a more mobile, less bulky pedicle. The use of the flap in full-thickness reconstruction by modification of the flap or bilateral flaps has been discussed. The place of the flap when used in combination with the deltopectoral and forehead flaps in the repair of major postexcisional defects has been illustrated.     

Complications of the pectoralis major osteomyocutaneous flap used for head and neck reconstruction

The analysis of the complications of the pectoralis major osteomyocutaneous flaps used for head and neck reconstruction and how to prevent them is the subject of this report. Ten patients with squamous cell carcinoma of the floor of the mouth who had undergone segmental glossectomy and mandibulectomy, radical uni- or bilateral cervical lymphadenectomy, and immediate reconstruction with the pectoralis major osteomyocutaneous flaps were evaluated. Neither partial nor total necrosis of the myocutaneous segment occurred in any patient but rib necrosis developed in five. An oral fistula occurred in four patients exposing the junction of the rib with the mandible. There were three cases of flap necrosis of the neck dissection. Two patients developed pneumothorax. The overall complication rate was 66.7%. Although this surgery requires major intraoral excision, the tumor is exophytic with previous infection and the patients' general condition debilitated, the incidence of complications is high. Despite the high morbidity, the pectoralis major myocutaneous flap remains a useful adjunct for head and neck reconstruction. The flap is versatile and for many patients repair with a free flap is impossible because of contraindications such as previous irradiation, problems with the vascular anastomoses, advanced age and poor general condition. It also aids in the surgical training of new specialists.     

Complications following laryngectomy

The complications following 100 consecutive laryngectomies performed at our hospital during a recent 18-month period are reviewed. The complication rates for total laryngectomy (63 patients) and extended laryngectomy (37 patients) were 19% and 49%, respectively, while the fistula rates were 8% and 27%, respectively. These rates were influenced primarily by the extent of surgery and the type of reconstruction, which during this interval included primary closure, pectoralis major myocutaneous flap, or gastric transposition. In comparison to our previous study, when the deltopectoral flap was used for patching the pharynx, the fistula rate for extended laryngectomy has decreased as a result of our use of myocutaneous flaps and greater experience with gastric transposition. Currently, we use the pectoralis major myocutaneous flap for pharyngeal repair if the mucosa would otherwise be closed under tension. All circumferential defects are repaired with a gastric transposition.     

Reconstruction of soft-tissue defects of the heel with local fasciocutaneous flaps

Soft tissue heel defects reconstruction represents a challenge for plastic surgeons because of the poor availability of regional tissue to perform the reconstruction. We divide the heel on the anterior or weight-bearing heel and the posterior or non-weight-bearing heel. Our preferences are the fasciocutaneous instep flap for anterior heel defects and the reverse sural flap for posterior heel defects. We have performed 11 reconstructions of the heel. The complications were total necrosis of 1 instep flap in a previously irradiated patient and 1 case of partial tip necrosis in a reverse sural flap. Functional recovery has been very satisfactory for both procedures. Regional island flaps are for us the first therapeutic option because the skin is similar to the lost one and less time consuming than a free-flap reconstruction.     

Bilobed fibula flap for reconstruction of through-and-through oromandibular defects

BACKGROUND: The role of fibula free flaps for reconstruction of through-and-through oromandibular defects is examined. METHODS: Thirty-four patients underwent reconstruction of through-and-through oromandibular defects using fibula free flaps that contain large, bilobed skin paddles for simultaneous reconstruction of intraoral mucosa and external skin. We examined the incidence of wound healing complications, the need for revision reconstructive surgery, and factors affecting the incidence of complications. RESULTS: Wound healing complications occurred in 50% of patients. There was a relatively high incidence of partial flap necrosis (26%) and revision surgery (41%). The area of the flap skin paddle was significantly associated with the risk of partial flap necrosis and the need for revision surgery. CONCLUSIONS: Many through-and-through oromandibular defects can be successfully reconstructed using a fibula free flap that contains a large, bilobed skin paddle. However, wound healing complications are increased when the flap skin paddle area exceeds 300 cm2.     

Der freie ALT-Oberschenkellappen in der traumatologischen und onkologischen Defektdeckung

BACKGROUND: The anterolateral thigh flap (ALT) has become one of the most preferred options for soft tissue defect reconstruction in Asia with an increasing popularity in Europe. The article presents the authors' experience using the ALT flap for various indications in the upper and lower extremities. METHODS: Between January 2005 and March 2007, 60 free ALT flaps were operated for reconstruction of various soft tissue defects. The causes of soft tissue defects included trauma (13), infection (26), and sarcoma resection (21). We operated on 39 male and 19 female patients with an average age of 50.9 years (range: 16-84 years). RESULTS: The flap survival rate was 95.0% percent (57 of 60 flaps); 5% of the flaps died. The donor site was closed primarily in all cases. Donor site complications were minimal. The average operative time was 282 min (69-544 min). Flap-related major complications occurred in 35.0% of patients including reexploration of the anastomoses and partial flap necrosis. Minor complications, e.g., wound infection, hematoma, and swelling were seen in 23 cases. CONCLUSIONS: Our experience indicates that the free ALT flap is a reliable method for soft tissue defect reconstruction. The use of the ALT offers many advantages such as a long and large caliber vascular pedicle, a large skin island as well as minimal donor site morbidity. The surgery can simultaneously performed by two teams with the patient in a supine position.     

Second free tissue transfers in head and neck reconstruction

OBJECTIVE: As the era of free tissue transfer for head and neck reconstruction matures, more patients are requiring second resections and reconstructions. Our objective was to evaluate: patient characteristics, reconstructive options, flap survival, perioperative morbidity, and mortality. STUDY DESIGN: Retrospective chart review. SUBJECTS AND METHODS: Sixty-five patients underwent a second free tissue transfer separate from the time of the primary flap. RESULTS: The most common (53%) reason for a second flap was tumor recurrence. The most common flaps used were radial forearm and fibula in both the first and second reconstructions. Larger flaps were used in the second reconstruction. In-hospital mortality was 4.6 percent; medical complications occurred in 5 percent of patients. Flap survival was 97 percent; 13 percent of second flaps returned to the operating room for complications. Eight patients had a third free flap. CONCLUSION: A second free tissue transfer is a viable resource in head and neck reconstruction. Acceptable rates of flap survival and complications are encountered.     

Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps

Coverage of complex perineal wounds resulting from surgical and radiation therapy results in significant morbidity. Acute complications occur in 25% to 60% of patients. Serious complications occur in 25% to 46% of patients. Musculocutaneous or omental flaps are used as primary or salvage procedures for nonhealing perineal wounds. Vertical rectus abdominis flaps are ideally suited to bring nonirradiated tissue into defects associated with radical surgical extirpation procedures and irradiated fields.A retrospective review of 73 cases using a vertical rectus abdominis flap for perineal reconstruction is reported. Acute perineal wound complications occurred in 17.8%, while serious complications requiring reoperation occurred in only 3.5%. There was 1 complete flap failure. Primary healing occurred in 84.9% of patients, with 94.5% of patients obtaining a healed perineal wound within 30 days. These results support the use of the transpelvic vertical rectus flap in difficult perineal wound reconstruction.     

Reconstruction of the chin using an expanded deltopectoral flap following multiple recurrences of oral cancer

An important alternative to free tissue transfer in patients requiring correction of soft tissue chin defects are local and regional flaps, such as the pectoralis major myocutaneous flap and deltopectoral flap. With predictable vascular supply, potential for large size, and good aesthetic match for facial and cervical skin, the deltopectoral flap can offer the reconstructive surgeon additional options in patients who lack vessels suitable for free tissue transfer. The use of an expanded deltopectoral flap for a staged reconstruction of the chin in a patient with cancer recurrences, concomitant resections, radiation and multiple reconstructions is reported.     

Arterialized venous free flaps for soft-tissue reconstruction of digits: a 40-case series

When there is not sufficient local tissue available for reconstruction of one or multiple digital defects, distant flap reconstructions are required. Available thin flaps with defined arterial inflow and venous outflow are limited and require the sacrifice of an arterial pedicle. In addition, a functional limitation can occur at the donor site. During the last decades, experimental and clinical attempts have been made in using venous flaps, based just on the venous network for in- and outflow. A 40-case series of arterialized venous free flaps in soft-tissue reconstruction of the digits and hand is presented. Neovessel formation induced by an intact venous plexus within the flap proved clinically to be the survival mechanism. Postoperative congestion was present in all flaps and subsided within 14 days; 92 percent of all flaps eventually survived. In 57.5 percent of cases, total flap survival was observed; in 17.5 percent of flaps, a superficial epidermolysis occurred, not requiring further surgery; in 17.5 percent of flaps, a full-thickness skin necrosis developed, requiring grafting (minor complication); in 7.5 percent of reconstructions, total flap necrosis was observed. Thus, in the authors' experience, when conventional local flaps are not available, arterialized venous free flaps proved to be a successful solution for soft-tissue reconstruction in digits and hands. The authors present the main indications and advantages of arterialized venous free flaps, emphasizing the essential technical steps and the most frequent pitfalls in treatment.