Inherited Thrombophilias in Thrombosis Advancement in Microvascular Flap Surgery

Microvascular flap surgery is a reliable method for reconstructive surgery. To avoid and foresee free flap thrombosis advancement after microvascular flap surgery, patient assessment, flawless surgical technique, and eligible perioperative care are pivotal. In this prospective observational study, we aimed to elucidate the most common inherited single nucleotide polymorphisms (SNPs) attributable to free flap thrombosis. A total of 152 patients undergoing microvascular flap surgery during the study period of 2016–2019 were analysed for five SNPs: rs6025 in Factor V Leiden (FVL) gene, rs1799963 in Factor II (FII) gene, rs2066865 in Fibrinogen Gamma Chain gene (FGG), rs2227589 in SERPINC 1 gene and rs1801133 in Methylene Tetrahydrofolate Reductase (MTHFR) gene. Activated protein C resistance (aPCR), prothrombin, antithrombin (AT), fibrinogen and homocysteine plasma levels were measured to determine association with the analysed SNPs and with free flap thrombosis advancement. Our preliminary results show that carriers of FVL mutation were associated with aPCR, as we observed significantly lower aPCR plasma levels in carriers of genotype C/T, as compared to C/C; p = 0.006 (CI 95%, 0.44 to 1.19). Additionally, mean fibrinogen plasma levels were higher in carriers of FGC gene rs2066865 genotype A/A (5.6 ± 1.81 g/l), as compared to G/A and G/G; p = 0.04 (CI 95%, 0.007 to 1.09); p = 0.004 (CI 95%, 0.48 to 2.49), respectively. The study group included 12 patients (7.9%) with free flap thrombosis. For one patient free flap thrombosis advancement might have been related to the rs6025T – FVL mutation with a PCR plasma level 1.21. Lower aPCR levels was associated with carriers of FVL rs6025 C/T and higher fibrinogen plasma levels with carriers of FGG rs2066865 A/A, suggesting that these genotypes might predict higher free flap thrombosis risk, but we found no significant association between analysed SNPs and free flap thrombosis advancement.

Handheld Near-Infrared Fluorescence Imaging Device Using Modified Action Cameras for Peri-Operative Guidance of Microvascular Flap Surgery

Indocyanine green near-infrared fluorescence (ICG-NIRF) imaging has recently come into use as a novel method in peri-operative microvascular flap assessment. However, a majority of the many commercial devices launched for clinical use lack mobility, portability, and cost-efficiency and are thus unsuitable for intra-oral applications. This study introduces a cost-effective, customized, handheld NIRF device following principles of ICG-NIRF imaging. Moreover, the novel characteristics of our prototype, considered in conjunction with a literature review highlighting the significance of fluorescence devices in microvascular surgery, point to a new generation of devices for use in microvascular flap surgery.

Craniectomy with microvascular flap reconstruction in a patient taking infliximab for vasculitis

For patients whose vasculitis is managed with biologic medications, no reports or evidence-based guidance exists regarding the perioperative management of microvascular flaps. We present a case of a 78-year-old patient with Takayasu’s arteritis (TA) and diabetes mellitus who was taking infliximab and underwent wide local excision of squamous cell carcinoma, craniectomy and reconstruction with a latissimus dorsi flap. TA, an immune-mediated large cell vasculitis characterised by granuloma formation, tends to affect larger vessels and aortic branches. The typical localisation of this condition raises concerns about potentially compromised pedicle and recipient vessels (ie, superficial temporal arteries), which could hinder postoperative flap success. Discontinuation of infliximab 4 weeks before surgery and resumption 6 weeks after led to favourable results. This case addresses the gap in the literature concerning stopping and restarting biologic drugs in the perioperative setting and documents a successful course of a microvascular procedure in a patient with vasculitis.

Wide Excision with Immediate Reconstruction of the Mandible Using Free Fibular Flap in Ameloblastoma of the Mandible—A Need of Time: Our Experience of 37 Cases

Background Ameloblastoma is a benign yet locally aggressive odontogenic tumor of the jaw with high recurrence rates. Despite many studies, the search is still on for the treatment approach which can render the acceptable recurrence rates with good functional and esthetic results. Methods In this prospective study, we operated on 37 patients of mandibular ameloblastoma between 2009 and 2018. Two patients were treated with curettage and chemical sterilization of the cavity. Resection of a tumor with a 2-cm margin was performed in the rest of 35 patients. The mandibular defect was primarily reconstructed with the microvascular free fibular flap in 29 patients. Results The follow-up ranged from 6 months to 7.7 years with a mean of 5.1 years. A tumor recurred within a year in all two patients (100%) treated with curettage. Out of 35 radical excisions, only one patient (2.85%) developed recurrence 3 years after the disease-free interval. Good mouth opening, intelligible speech, satisfactory lower jaw shape, and facial profiles were achieved in all 29 patients who were treated with primary free fibular flap. Conclusion We prefer wide excision with 2-cm margins on each side of a tumor with the primary reconstruction of the mandible in all cases of mandibular ameloblastoma. The free fibular microvascular flap is our treatment of choice as all defects of the mandible can be reconstructed with the free fibular flap. Wide excision is the key to prevent a recurrence.

VERSATILITY OF PARAUMBILICAL PERFORATOR FLAP FOR UPPER LIMB RECONSTRUCTION

Background Microvascular flap and groin flap are the most commonly used flaps for upper limb reconstruction. Microvascular flap can not be done in certain situations and groin flap is not convenient for coverage of forearm defect and elbow defect. Paraumbilical perforator (pup) flaps can provide a large amount of tissue for coverage of forearm , elbow defects and mitigates the side effects of groin flap. Material and method A retrospective study was conducted for reconstruction of soft tissue defects from finger tip to elbow between January 2016 to December 2019 with PUP flaps .Demographic data, size of the defect, etiology ,flap design and flap complication were analysed . Result The age of the patients ranged from 12 years to 56 year with mean age of 29.85 years and SD = 11.073. Male to female ratio was 1.5 : 1 (M=12 , F= 8). Size of the defect varied between 20 cm2 to 288cm2 with mean of 88.1 cm 2 and SD = 29.69 .No of cases with flap dimension < 100 cm 2 (n= 13), and > 100 cm2 (n= 7) . Aetiology of injury included vehicular accidents in 10 patients, machine injury in 2 patients, electrical burns in 6 patients post snake bite ulcer 2 patients. The location of the defect included hands, forearm and the elbow, and fingers.Flap was directed Superolaterally in 18 patients , inferolaterally in one case , and combined medially and laterally in one case. There was no case of complete flap failure. Conclusion Paraumbilical perforator flap can be a safe and reliable option for soft tissue reconstruction in varied areas of upper limb.