Durability and versatility of free lattismus dorsi muscle flap in leg defects in tertiary care hospital

Reconstruction of the legs and feet is challenging. Because of the composite tissue defects, inadequate and tight local tissues and poor circulation, soft tissue scarcity around the lower portion of the leg presents a significant challenge to the reconstructive surgeon. The aim of this study was to assess the outcome of free Lattismus dorsi (LD) muscle flap used for soft tissue reconstruction of leg defects. This prospective non-randomized study was conducted on 13 patients with leg defects of different causes attended emergency unit and outpatient clinic of plastic surgery department of plastic surgery and burn unit, Dhaka medical college hospital (DMCH) in the period between July 2017 and June 2018. Durability of coverage, flap success, infection and overall satisfaction were studied. The age distribution of the study population highest number of patients (46.15%) were in middle (31-40 years) age group whereas lowest are in older group (>51 years). Highest number of patients (84.61%) were standard myocutanous type of flap whereas lowest were in (15.31%) were chimeric flap and partial latissimus muscle flap. There were one case of total flap loss. Two patients had seroma formation among them one patient had partial necrosis. The outcome of reconstruction of n=13 patients 76.92% patients discharged with excellent recovery, (15.38%) patients discharged with good outcome, 1 (7.69%) patients had total flap loss. Flap is easy to dissect, anatomical variation is rare, long pedicle length which allow to anastomose with suitable recipient artery and finally donor morbidity is negligible.

Microvascular free flap for head and neck reconstruction: our experiences with 218 free flaps for head and neck reconstructions

<p class="abstract"><strong>Background:</strong> Defect following radical resection for advance head and neck cancers are complex and without doubt microvascular free flap offer the best reconstructive option. The purpose of this study is to investigate the flap survival rate and review each vascular compromised flaps.</p><p class="abstract"><strong>Methods:</strong> This is a reviewed of 218 microvascular free flaps done for reconstruction of 204 head and neck patients. There were 112 (51.3%) radial forearm flaps (RFF), 82 (37.6%) fibula flaps (FF) and 24 (11%) anterior lateral thigh (ALT) flaps. </p><p class="abstract"><strong>Results:</strong> There were 16 complete flap loss and 3 partial flap loss, giving an overall flap survival rate 91.8% (19/218) and flap survival in turn of complete loss 92.7% (16/218). In RFF, there were 7 complete and 1 partial flap loss, giving an overall flap survival rate 92.9% (8/112) and flap survival in turn of complete loss 93.8% (7/112). In FF, there were 6 complete flap loss, giving a flap survival rate 92.7% (6/82). In ALT flap, there were 3 complete and 2 partial flaps loss, giving an overall flap survival rate 79.2% (5/24) and flap survival in turn of flap complete loss 87.5% (3/24). In our series vascular flaps complications rate was 12.3% (27/218), with a salvageable rate of 29.6% (8/27). The most salvageable flap was RFF 46.6% (7/15).</p><p><strong>Conclusions:</strong> The study re-enforce the learning curve in microvascular free flap and RFF is a good flap for a beginner. </p>

Management of Flap Failure After Head and Neck Reconstruction: A Systematic Review and Meta-analysis

Objective To systematically review management of flap loss in head and neck construction with free tissue transfer as compared with locoregional flap or conservative management. Data Sources Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov were searched up to October 2019. Review Methods Candidate articles were independently reviewed by 2 authors. Articles were considered eligible if they included adequate reporting of flap management after flap loss and outcomes for survival of reconstruction, length of hospitalization, and perioperative complications. Results A total of 429 patients had acute flap failure in the perioperative period. The overall success with a secondary free flap was 93% (95% CI, 0.89-0.97; n = 26 studies, I2 = 12.8%). There was no difference in hospitalization length after secondary reconstruction between free tissue transfer and locoregional flaps or conservative management (relative risk of hospitalization ≥2 weeks, 96%; 95% CI, 0.80-1.14; n = 3 studies, I2 = 0). The pooled relative risk of perioperative complications following free tissue transfer was 0.60 when compared with locoregional flap or conservative management (95% CI, 0.40-0.92; n = 5 studies, I2 = 0). Conclusion Salvage reconstruction with free tissue transfer has a high success rate. Second free flaps following flap failure had a similar length of hospitalization and lower overall complication rate than locoregional reconstruction or conservative management. A second free tissue transfer, when feasible, is likely a more reliable and effective procedure for salvage reconstruction.

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Background Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. Methods In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008–2018 were reviewed. Results 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear. Conclusion The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.

Partial Flap Loss in Gender Affirming Phalloplasty

Background Flaps used in phalloplasty are larger than described for other indications, with a design that is tubularized up to two times. While the incidence of partial flap loss (PFL) is well described, current literature lacks granularity comparing donor sites and techniques with minimal discussion of etiology and management. The purpose of this study was to review our experience with PFL in phalloplasty. Methods This was a retrospective cohort study of patients who underwent phalloplasty by a single surgeon at a single institution between 2016 and 2020. PFL was defined as any patient requiring sharp excision of necrotic tissue and reconstruction. Patient variables (demographics, body mass index, American Society of Anesthesiologists physical status classification, comorbidities), flap variables (donor site, design, dimensions, perforator number) and intraoperative variables (use of vasopressors, intraoperative fluid volume) were collected. Results Of 76 phalloplasties, 6 patients suffered PFL (7.9%). 5/6 patients were radial forearm free flap tube-within-tube (TWT) and 1/5 patients were pedicled anterolateral thigh TWT. 4/6 cases involved the shaft only and were treated with excision ± Integra and full-thickness skin grafting. 2 cases of PFL involved the urethral extension requiring excision of the necrotic segment. Conclusion PFL occurred in 7.9% of cases and was solely found in the TWT cohort. The majority of cases involved the shaft, sparing the urethral segment. Cases in the acute postoperative period appeared to be related to macrovascular venous congestion, while cases in the subacute period appeared to be due to microvascular arterial ischemia.

The use of machine learning for predicating complications of free flap head and neck reconstruction.

e18633 Background: The use of machine learning (ML) in plastic and reconstructive surgery has increased over the last decade. However, its use to predict surgical outcomes in head and neck reconstruction has not been well studied. The goal of this study is to assess the performance of ML algorithms trained to predict surgical outcomes of head and neck free flap reconstruction. Methods: Our study cohort included routinely collected data from 4000 patients who underwent free flaps for reconstruction of head and neck defects between January 2005 and December 2018. We developed and tested nine supervised ML algorithms to predict three outcomes of a.) any complication, b.) any major recipient-site complication, and c.) total flap loss. Results: In our sample, 33.7% of patients experienced any complication, 26.5% experienced a major complication at the recipient site and 1.7% experienced total flap loss. The k-nearest neighbors algorithm demonstrated the best overall performance for predicting any complication (AUROC = .61, sensitivity = .60). Regularized regression had the best performance for predicting major recipient site complication (AUROC=.68, sensitivity = .66), and decision trees were the best predictors of total flap loss (AUROC = .66, sensitivity = .50). Conclusions: We demonstrated that ML models trained using routinely collected data can make clinical useful predictions about who will experience complications. Our models correctly identified between half and two-thirds of patients who experienced post-surgical complications including total flap loss. These models can be applied to readily available clinical and perioperative data to facilitate decision making. Further performance improvements are likely possible with the inclusion of additional variables related to patient health and behavior.

Mechanical Anastomotic Coupling Device versus Hand-sewn Venous Anastomosis in Head and Neck Reconstruction—An Analysis of 1694 Venous Anastomoses

Background There is a steep learning curve to attain a consistently good result in microvascular surgery. The venous anastomosis is a critical step in free-tissue transfer. The margin of error is less and the outcome depends on the surgeon’s skill and technique. Mechanical anastomotic coupling device (MACD) has been proven to be an effective alternative to hand-sewn (HS) technique for venous anastomosis, as it requires lesser skill. However, its feasibility of application in emerging economy countries is yet to be established. Material and Method We retrospectively analyzed the data of patients who underwent free-tissue transfer for head and neck reconstruction between July 2015 and October 2020. Based on the technique used for the venous anastomosis, the patients were divided into an HS technique and MACD group. Patient characteristics and outcomes were measured. Result A total of 1694 venous anastomoses were performed during the study period. There were 966 patients in the HS technique group and 719 in the MACD group. There was no statistically significant difference between the two groups in terms of age, sex, prior radiotherapy, prior surgery, and comorbidities. Venous thrombosis was noted in 62 (6.4%) patients in the HS technique group and 7 (0.97%) in the MACD group (p = 0.000). The mean time taken for venous anastomosis in the HS group was 17 ± 4 minutes, and in the MACD group, it was 5 ± 2 minutes (p = 0.0001). Twenty-five (2.56%) patients in the HS group and 4 (0.55%) patients in MACD group had flap loss (p = 0.001). Conclusion MACD is an effective alternative for HS technique for venous anastomosis. There is a significant reduction in anastomosis time, flap loss, and return to operation theater due to venous thrombosis. MACD reduces the surgeon’s strain, especially in a high-volume center. Prospective randomized studies including economic analysis are required to prove the cost-effectiveness of coupler devices.

Arteriovenous Vascular Loops in Latissimus Free Flap Reconstruction of Cervical and Cervicothoracic Spine Wounds

Introduction Wound dehiscence is the most common complication after spinal fusion procedures, resulting in an increase in mortality rate and hospital length of stay. Reconstruction of these wounds presents a challenge, as the spine is dependent on these implants for stability and must be maintained throughout the wound dehiscence treatment protocol. We describe a method for extending the thoracodorsal pedicle with an arteriovenous loop to permit an increased excursion of the latissimus dorsi muscle in patients with exposed implants and present the results of this procedure. Materials and Methods A retrospective review of patients treated with a latissimus free flap with saphenous vein pedicle extension for posterior spinal wounds from 2010 to 2020 were reviewed. Patient charts were reviewed for demographic information including comorbidities, previous spine operations, wound size and location, and postoperative complications including total flap loss, flap dehiscence, and need for secondary surgery. Results Six patients were identified who underwent a total of eight extended pedicle free flaps. Mean age was 64.8 years with a mean follow-up of 12.3 months (range, 6–20 months). Four wounds were in the cervicothoracic region with two wounds in the cervical region. Mean number of previous spine surgeries was 3.5 (range, 2–4). Mean wound size was 189 cm2 with a mean vein graft length of 28 cm. Wound coverage was successful in five of six patients. Major complications occurred in five of six patients. Total flap loss occurred in two patients (33%) and both underwent a second extended latissimus flap from the contralateral side. Three patients developed postoperative flap dehiscence which resolved with regular dressing changes. Conclusion Extended pedicle latissimus flaps are an effective treatment for posterior spine wounds but are associated with a high complication rate, secondary to medically complex patients with multiple prior surgeries. Careful patient selection is critical for success.

Use of Perforator Propeller Flaps for Coverage of Soft issue Defects Around The Distal Leg and Ankle

Introduction: Perforator propeller flap is a suitable option to cover soft tissue defects in the distal leg and ankle which preserves the main vascular arteries of the lower extremity and muscle function. The aim of this study is to evaluate the use of perforator propeller flaps for coverage of soft tissue defects around the distal leg and ankle. Methods: This prospective study was donebetween December 2018 to November 2019in the Department of Burn & Plastic Surgery of National Institute of Traumatology and Orthopedic Rehabilitation ( NITOR), Dhaka. Total 32 patients with small to medium sized soft tissue defect over distal leg and ankle underwent reconstruction with perforator propeller flaps. Sixteen patients had defect over tendo achilles area, 6 had defect over lateral malleolus,7 over medial malleolus and medial aspect of distal third leg and only 3 had defect in front of ankle. Average Flap length and width were 12.72 (+4.19) & 5.63 (+1.78) cm respectively. Flap rotation was measured 180 degrees in 84.37% of the cases. The propeller flaps were based on a single perforator and it was observed from the posterior tibial artery in 62.5% and peroneal artery in 37.5% of the cases. Results: 81.25% of the flaps completely survived. Total flap loss was observed in one case (3%) while partial flap loss occurred in 6.2% cases. Marginal flap necrosis and epidermolysis were observed in 6.2% and 3% cases respectively. Conclusions: Propeller flapshavereliable vascular pedicle as well as greater freedom in design and arc of rotation that extend the possibility ofreconstructing difficult wounds with local tissues and minimal donor-site morbidity. J Bangladesh Coll Phys Surg 2021; 39(2): 87-93