Single-Stage Continent Reconstruction of Composite Pericommissural Defects Using a Combination of Pacman-Style Free Radial Forearm Flaps and Modified Elastic Musculomucosal Flaps

Introduction  Based on the cross-innervation of buccal and marginal mandibular branches of the facial nerve, oblique elastic musculomucosal flaps (OEMMFs) can be harvested and used for continent neo-commissure and modiolus reconstructions. The composite pericommissural defects can then be reconstructed with double cutaneous paddles in Pacman-style free radial forearm flap (PFRFF). This novel single-stage continent reconstruction of composite post-excisional commissure and pericommissural (CPECPC) defects is evaluated in this study. Patients and Methods  This retrospective cohort study was conducted from April 2016 to March 2019. Forty-two patients underwent this type of reconstruction using a combination of PFRFF and OEMMF for the CPECPC defects. They were followed for an average period of 11.5 months. At the end of the follow-up period, they were assessed using the objective institutional scoring system by two independent observers and final score was computed for each patient. Results  The average score obtained at the end of the follow-up period was 11.5 ( p  = 0.035) using the institutional assessment scoring system, which evaluated both the overall aesthesis and function of the neo-commissure and modiolus. Conclusions  The combination of OEMMF and PFRRF for the single-stage reconstruction of CPECPC defects is a useful addendum for re-establishing the aesthesis and continence at the reconstructed site.     

Reconstruction Using Locoregional Flaps for Large Skull Base Defects

We present a modified locoregional flap for the reconstruction of large anterior skull base defects that should be reconstructed with a free flap according to Yano''s algorithm. No classification of skull base defects had been proposed for a long time. Yano et al suggested a new classification in 2012. The lb defect of Yano''s classification extends horizontally from the cribriform plate to the orbital roof. According to Yano''s algorithm for subsequent skull base reconstructive procedures, a lb defect should be reconstructed with a free flap such as an anterolateral thigh free flap or rectus abdominis myocutaneous free flap. However, our modified locoregional flap has also enabled reconstruction of lb defects. In this case series, we used a locoregional flap for lb defects. No major postoperative complications occurred. We present our modified locoregional flap that enables reconstruction of lb defects.     

COMPARTMENT SYNDROME IN A PATIENT WITH X-LINKED AGAMMAGLOBULINAEMIA AND ECTHYMA GANGRENOSUM

Compartment syndrome is a surgical emergency that requires immediate decompression. We know of no documented cases that describe ecthyma gangrenosum as a primary cause of compartment syndrome. We present a case of a baby with x-linked agammaglobulinaemia who developed compartment syndrome associated with systemic Pseudomonas aeruginosa infection and ecthyma gangrenosum of the leg. He was treated by debridement and fasciotomies followed by primary closure and skin grafting and made an uneventful recovery.     

Reconstruction with radial forearm flaps after ablative surgery for hypopharyngeal cancer

BACKGROUND: Patients afflicted with advanced hypopharyngeal cancer must contend with both potentially poor survival prognosis and a compromised quality of remaining life. After extensive ablative surgery, it is imperative to use a reliable, low morbidity reconstructive strategy that will allow for an expedient reconstitution of speech and swallowing. METHODS: Retrospective review of the records of 28 patients who underwent pharyngoesophageal reconstruction with radial forearm free flaps (RFFF) between 1996 and 2001 by a single surgeon (RE). Analysis was confined to patients requiring complete tubulation of the RFFF. Perioperative mortality, morbidity, and functional evaluation based on the parameters of speech and swallowing were analyzed. RESULTS: Completely tubulated RFFF were required in 25 patients. There was 100% RFFF survival with no perioperative mortalities. The median hospital stay was 8.0 days. All patients acquired a reconstitution of oral alimentation; median time to swallowing was 18.0 days. Fourteen of 16 patients (93%) were able to rely on TEP speech as their main modality of communication. Two patients (8%) had early fistulas develop, and 5 (20%) had late fistulas develop. Nine patients (36%) required mechanical dilatation; five of the nine patients required only one dilatation. CONCLUSION: Review of our experience has confirmed the reliability and excellent functional outcome associated with this flap.     

Outcomes following Microvascular Free Tissue Transfer in Reconstructing Skull Base Defects

Objective Successful resection of complex tumors involving the skull base (SB) depends on the ability to reconstruct the resulting defects. The objective of this study was to assess the outcomes of patients undergoing reconstruction after resection of SB tumors with free flaps.Methods From 1995 to 2010 a retrospective review of cases was undertaken. Demographics, histology, surgical management, complications, locoregional control, and survival were analyzed.Results We performed 62 flaps in 57 patients. There was a preponderance of sinonasal malignancies (45%), and most lesions involved the anterior SB (81%). A total of 94% of patients underwent radiotherapy. Reconstruction was undertaken mainly with anterolateral thigh (37%) or radial forearm (34%) flaps. Complications occurred in 17% of patients, and the flap''s success rate was 94%.Conclusion Free flaps are versatile and highly reliable for reconstructing defects resulting from resections of the SB. They should be considered for SB reconstruction of large three-dimensional defects as well as defects involving an irradiated field. Successful reconstruction of the SB can be performed using a small number of highly dependable flaps.     

Incidentaloma at Radial Artery Forearm Free Flap Harvest: An Occult Volar Wrist Ganglion

Occult volar wrist ganglion originating from radioscaphoid interval and having adherence to flexor carpi radialis tendon [Fcr] and radial artery is an uncommon occurrence. We report such a case which was occult and asymptomatic during pre-operative assessment and presented as an incidentaloma during radial artery forearm free flap harvest for oral cancer reconstruction.     

The First Case of Free Radial Forearm Skin Flap: A 40-Year Follow-Up Study

BackgroundThe radial forearm skin flap (RFSF) was first introduced by the Chinese scholar Guofan Yang and has since been used for nearly 40 years. The many advantages of RFSF have been investigated in this study.Case presentationIn this case, a female patient underwent RFSF surgery in 1979. In 2016 and 2018, two interviews were held to evaluate her subjective postoperative experience. In addition, overall donor site evaluation was conducted based on general health checkups and tests; tests for appearance, tactile sensitivity, muscle strength, and motor function; and CTA.ResultsThe flap survived well, and the donor site recovered without hand necrosis in the 1970s. In 2018, the patient was in good health condition and expressed her satisfaction with the surgery. The patient did not suffer from any postoperative complications such as diminished sensation of the donor site or donor site dysfunction; in the evaluation of hand and finger function, there was no point where functional reduction of the donor site was noted. CTA revealed compensatory blood supply with enlargement in the diameter of the ulnar and interosseous artery.ConclusionAfter a nearly 40-year follow-up, the patient who underwent the first free radial forearm flap transplantation expressed satisfaction with the operative outcomes. The examination showed good results at the recipient site with little donor site deformities and good compensatory blood supply.     

Extended Inferior Turbinate Flap for Endoscopic Reconstruction of Skull Base Defects

Objective When the use of the nasoseptal flap for endoscopic skull base reconstruction has been precluded, the posterior pedicle inferior turbinate flap is a viable option for small midclival defects. Limitations of the inferior turbinate flap include its small surface area and limited arc of rotation. We describe a novel extended inferior turbinate flap that expands the reconstructive applications of this flap. Design Cadaveric anatomical study. Participants Cadaveric specimens. Main Outcome Measures Flap size, arc of rotation, and reconstructive applications were assessed. Results The average width of the flap was 5.46 ± 0.58 cm (7.32 ± 0.59 cm with septal mucosa). The average length of the flap was 5.01 ± 0.58 cm (5.28 ± 0.37 cm with septal mucosa). The average surface area of the flap was ∼ 27.26 ± 3.65 cm² (40.53 ± 6.45 cm² with septal mucosa). The extended inferior turbinate flap was sufficient to cover clival defects extending between the paraclival internal carotid arteries. The use of the flap in 22 cadavers and 5 clinical patients is described. Conclusion The extended inferior turbinate flap presents an additional option for reconstruction of skull base defects when the nasoseptal flap is unavailable.     

钛网支架结合前臂游离皮瓣在颌面部肿瘤切除术后软组织缺损修复中的应用

目的:研究钛网支架结合前臂游离皮瓣修复颌面部肿瘤切除术后面部组织缺损的价值。方法:选取笔者医院60例颌面部肿瘤切除术后面部组织缺损修复患者为研究对象,抽签随机分为观察组和对照组,均30例。观察组采取钛网支架结合前臂游离皮瓣进行修复,对照组采取钛网支架结合股前外侧皮瓣进行修复。比较两组患者修复后匹配形态情况(POSAS量表)、面部修复重建疗效(华盛顿大学生存质量评分)和术后并发症发生率及皮瓣存活率。结果:观察组疼痛或瘙痒程度、硬度、厚度以及平整度评分低于对照组,差异有统计学意义(P<0.05),观察组颜色评分与对照组比较差异无统计学意义(P>0.05)。观察组充血程度、厚度及柔软度评分均低于对照组,差异有统计学意义(P<0.05),观察组色泽和顺应度评分与对照组比较差异无统计学意义(P>0.05)。观察组术后张口度和口腔容水量与对照组比较差异无统计学意义(P>0.05),而工作状况、饮食、口腔闭合、咀嚼、咬合、吞咽、语言表达功能的恢复评分均高于对照组,差异有统计学意义(P<0.05)。观察组术后并发症率为6.67%低于对照组26.67%,皮瓣存活率100.00%高于对照组86.67%,差异有统计学意义(P<0.05)。结论:钛网支架结合前臂游离皮瓣修复颌面部肿瘤术后面部组织缺损具有较高价值,能较好地恢复患者的生理功能和面部形态,术后并发症发生率低,皮瓣存活率高,值得临床推广和应用。     

Cephalic Vein-Pedicled Radial Forearm Semi-free Flap: An Alternative When no Suitable Vein in Recipient Site for Free Forearm Flap

The risk of venous thrombosis is the main factor of free forearm flap necrosis. In some cases there is no suitable vein at recipient site to provide venous return of the free flap. In this report, two cephalic vein-pedicled radial forearm semi-free flaps were used as an alternative to resurface soft tissue defects in submaxilla and anterior cervical area. The two flaps survived uneventfully. The cephalic vein-pedicled radial forearm semi-free flap could be harvested with a long cephalic vein pedicle, and could be an alternative when there was no suitable or healthy recipient veins at recipient site.     

Function-Preserving Neurotized Lateral Arm Free Flap in the Reconstruction of Hemiglossectomy Defects

Introduction and Methods  The glabrous, thin, and pliable texture of lateral arm flap with no loss of any axial vessel of the limb renders it a good choice for hemiglossectomy defect reconstruction. The main caveat of this flap harvest is the loss of sensation in the distribution of posterior antebrachial cutaneous nerve (PABCN). In this article, we present two strategic sites and techniques to preserve the integrity of PABCN and at the same time harvesting lateral arm flap with a lengthy lower lateral cutaneous nerve of arm for the neurotization. The outcome of this function-preserving neurotized lateral arm free flap in the reconstruction of hemiglossectomy defects is analyzed and presented in this article. Results  Ninety percent of the patients attained grade 3 score in objective assessment, leading to a significant p -value of 0.02 with this technique. All had preservation of sensation in the distribution of PABCN. Conclusion  Our technique of harvest and neurotization has brought good functional recovery of the oral cavity with preservation of PABCN.     

Reconstruction of Lateral Forefoot Using Reversed Medial Plantar Flap with Free Anterolateral Thigh Flap

Skin defects of the heel have frequently been reconstructed using the medial plantar flap; however, forefoot coverage has remained a challenge, because the alternatives for flap coverage have been very limited. We describe a case of malignant melanoma on the lateral forefoot that was radically removed and reconstructed successfully with a distally based medial plantar flap, together with a free anterolateral thigh flap. The advantages of this flap include that it does not reduce the vascular supply to the foot owing to reconstruction of the medial plantar vascular systems, reduces the risk of flap congestion, minimizes donor site morbidity, and enables the transport of structurally similar tissues to the plantar forefoot. We believe this technique is a reasonable reconstructive option for large lateral plantar forefoot defects.     

股前外侧皮瓣游离移植修复上颌窦癌术后缺损

目的探讨游离股前外侧皮瓣在修复上颌窦术后缺损中的应用。方法采用游离股前外侧皮瓣游离移植,同期修复上颌窦术后缺损17例。结果 17例患者中,2例患者出现血管危象,1例皮瓣部分坏死,5例出现早期局部并发症。术后随访3个月至4年,10例术后头颈部外形及功能基本恢复正常,受区和供区均无严重并发症;2例带瘤生存;5例分别因局部复发、颈淋巴结转移及远处转移而死亡。结论利用吻合血管的游离股前外侧皮瓣,更易于塑形修复,并减少供区并发症的发生,是修复各种头颈肿瘤术后洞穿性缺损的良好方法。     

Functional outcomes after surgical reconstruction of the base of tongue using the radial forearm free flap in patients with oropharyngeal carcinoma

BACKGROUND: Historically, the prevention of functional morbidity after multimodal treatment for squamous cell carcinoma in patients with large base of tongue lesions has been challenging. The purpose of the present research is to report prospectively collected speech and swallowing outcomes for patients with disease that encompassed half or more of the base of tongue. METHODS: Speech and swallowing data were gathered at 4 evaluation times that spanned the first year of treatment for 32 patients treated with surgery and adjuvant radiation therapy. RESULTS: Speech intelligibility remained above 90% for most patients. In the early postoperative period, patients with 100% of their base of tongue resected experienced decreased intelligibility, which improved by the half-way mark of the evaluations. The majority of patients resumed normal oral feeding, with those who lacked dentition needing to puree their food. Modified barium swallow studies revealed that only 3 patients aspirated thin liquid at the final evaluation. Five patients used a feeding tube at some point over the year of evaluation. At the final evaluation, only 3 patients required enteral feeding, with 2 of these using the tube in combination with oral feeding and 1 using the tube for primary nutrition. CONCLUSIONS: The results of this study suggest that surgical reconstruction of the base of tongue using the radial forearm free flap in patients with large base of tongue lesions can lead to functional speech and swallowing results.