Safe Free Tissue Transfer in Patients Older than 90 Years

Objective This study aimed to evaluate the safety of microvascular free tissue transfer in the elderly patient population. Methods We performed a 20-year retrospective review at a tertiary care private practice of patients of ≥ 90 years of age who underwent microvascular free tissue transfer and had at least 6 months of follow-up. Similarly, we reviewed patients aged 70 to 89 years who underwent free tissue transfer between 2018 and 2020 as a control group. Records were examined for type of flap, defect site, pathology, and occurrence of complications. Results Overall 77 patients of 90 years or older met the inclusion criteria and 77 sequential patients aged 70 to 89 years were identified to serve as a control group. The overall complication rate among patients of ≥ 90 years of age was 18%, with flap-related complications in 4% (two partial flap loss and one total loss). The mortality rate was 1.3%. All patients of ≥ 90 years of age undergoing osteocutaneous reconstruction for osteoradionecrosis experienced complications, but only one was a flap complication (partial loss). Among patients aged 70 to 89 years, the overall complication rate was also 18%, with flap-related complications in 4% (two complete flap failures and one partial loss). The mortality rate in the control group was 2.6%. Conclusion Soft tissue free flaps are a safe option in the elderly patient population and should be offered to patients who are medically optimized prior to surgery, regardless of age. Osteocutaneous reconstruction for osteoradionecrosis must be undertaken with caution. This study reflects level of evidence 4.

Use of Groin Neurectomies for Noniatrogenic Testicular and Groin Pain

Background Chronic groin neuralgia is a life-debilitating condition that plagues patients worldwide. While groin neuralgia is usually traced to iatrogenic causes (inguinal hernia repairs, vasectomy, and hysterectomy), there is a unique subset of patients that present with noniatrogenic groin neuralgia. The diagnosis and treatment of these patients present a particular challenge. Methods A total of 30 patients (current mean age, 46.5 [range: 19–72] years) who presented with noniatrogenic groin neuralgia and received neurectomies on the iliohypogastric, ilioinguinal, and genitofemoral nerves between 2008 and 2017 were identified. A retrospective review of preoperative and immediate postoperative pain scores was compared with prospectively collected current pain on a Likert's scale (0–10). Additionally, patients were asked to complete a Short Form (SF)-20 and identify current pain medications. A two-sided Wilcoxon–Mann–Whitney test was used to analyze the data. Results Of the 30 patients identified, 16 could participate (mean follow-up = 61 months). The average pain reduction for the entire group was 62.7%. When using an established 30% reduction pain as a marker for clinical significance, 12 successful and 4 unsuccessful patients had an average reduction of 81.1 and 7.68%, respectively (success rate of 75%). Patients with successful group showed a statistically significant increased social functioning (p = 0.012) and near-significant increase in mental health (p = 0.063). Improvements, albeit nonsignificant, in mean scaled scores for every other SF-20 quality of life (QoL) category were observed when comparing both groups. Conclusion Neurectomy is a potentially beneficial surgery that can assuage pain and improve quality of life for patients with noniatrogenic groin neuralgia.

Oncologic Head and Neck Reconstructive Microsurgery during the COVID-19 Pandemic in Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia

Background Head and neck cancer is one of the leading cancers worldwide. Complex head and neck procedures are potentially aerosol-generating and considered high risk for coronavirus disease 2019 (COVID-19) transmission between the patients, surgeons, and other health-care workers (HCWs). Several adjustments in the microsurgery procedure were needed. The COVID-19 protocol was developed and applied to minimize the COVID-19 transmission. The study objectives were to describe the preoperative, intraoperative, and postoperative protocols applied and the characteristics of patients who underwent head and neck reconstructive microsurgery during the COVID-19 pandemic in Dharmais Cancer Hospital-National Cancer Center. Methods This study was a retrospective descriptive study of patients who underwent head and neck reconstructive microsurgery between March 2020 and December 2020 in the plastic surgery department and surgical oncology department, Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia. The patients' characteristics including sex, age, location of the defects, the flap type, flap survival, and complications were obtained from medical records and analyzed using SPSS version 23. Results There were 55 patients, 30 (54.54%) patients were female, and 25 (45.45%) patients were male. The mean age at the time of surgery was 51.32 ± 1.85 years. The most common cancer type was squamous cell carcinoma for 49.09% (n = 27/55). The most frequent location was tongue for 25.45% (n = 14/55). Anterolateral thigh flap was also the most used flap in this study for 50.91% (n = 14/55). The overall survival rate of this study was 83.64% (n = 46/55). There were nine patients (16.36%) who were found with postoperative complications. There was no nosocomial infection with COVID-19 for patients, surgeons, and other HCWs. Conclusion Microsurgery can be performed even in the COVID-19 pandemic as the gold standard for oncologic head and neck reconstruction by applying protocols to protect the patients, surgeons, and other HCWs.

Reconstruction of Axillary Defect due to Necrotizing Fasciitis and Debridement Using a Free-Flap Transfer: A Report of Three Cases

Background Necrotizing fasciitis is a well-known disease that causes extensive tissue infection and requires radical debridement of the infected tissue. It can occur in all parts of the body, but there are few reports of necrotizing fasciitis in the axilla. We treated three patients with axillary necrotizing fasciitis. Methods In all cases, patients were referred to us after radical debridement of the infected soft tissue in the emergency department. At the first visit to our department, there were fist-sized soft tissue defects in the axilla. Moreover, the ipsilateral pectoralis major and latissimus dorsi muscles were partially resected because of the debridement of necrotizing fasciitis. In all cases, the ipsilateral thoracodorsal vessels were severely damaged and free-flap transfer was performed to close the axillary wound. Results All free flaps survived without complications. The patient's range of motion for shoulder abduction on the affected side was maintained postoperatively. Conclusion If necrotizing fasciitis occurs in the axilla, tissue infection can spread beyond it. In such a case, free-flap transfer can be an optimal treatment. Radical resection of the infected tissue results in the absence of recipient vessels in the axilla. Surgeons should bear in mind that, because of radical resection of the infected tissue, they may need to seek recipient vessels for free-flap transfer far from the axilla.

Flap Selection Algorithm Based on the Body Mass Index for Phalloplasty in Female-to-Male Transgender: Techniques and Outcomes

Background Various phalloplasty methods have been reported; however, a consensus has not been reached. Therefore, we suggest an alternative algorithm for an ideal phalloplasty considering the factors that affect flap selection. Methods We retrospectively examined 32 phalloplasty cases of female-to-male transgender. Flaps used for phalloplasty were classified into three groups as follows: (1) radial forearm (RF) group, (2) anterolateral thigh (ALT) group, and (3) flap combination (FC) group. Statistical analyses were performed to determine the significance of age and body mass index (BMI) as well as differences in the rates of postoperative complication, reoperation, esthetic acceptability, tactile or erogenous sensibility, and the ability to urinate while standing. Results Ten cases were included in the RF group and 7 and 15 cases in the ALT and FC groups, respectively. With respect to BMI, the RF group (mean [standard deviation (SD)] = 25.9 [3.3]) showed significantly higher BMI than the ALT (21.7 [0.9]) or FC group (22.2 [4.5]). The RF (mean [SD] = 3.7 [0.4]) and ALT groups (3.5 [0.9]) had significantly higher esthetic acceptability evaluation scores (from 1 to 4) than the FC group (2.5 [1.2]). Moreover, the RF and ALT groups were superior than the FC group in terms of tactile or erogenous sensibility rates. Conclusion BMI effected flap choices for phalloplasty because of the correlation between BMI and skin thickness. FC becomes an option between ALT flap and RF flap in terms of flap choice based on BMI. Our alternative algorithm for an ideal phalloplasty based on BMI will be useful for objective flap choices.

Free Tissue Transfer in Pressure Ulcer Reconstruction: A Systematic Review

Background Pressure ulcers (PUs) affect 2.5 million people in the United States annually and incur health-care costs of 11 billion dollars annually. Stage III/IV PU often require local flap reconstruction. Unfortunately, PU recurrence is common following reconstruction; recurrence rates as high as 82% have been reported. When local flap options are inadequate, free tissue transfer may be indicated but the indications have yet to be delineated. To develop evidence-based guidelines for the use of free flaps in PU reconstruction, we performed a systematic review. Methods A systematic review of the available English-language, peer-reviewed literature was conducted using PubMed/MEDLINE, Google Scholar, Scopus, EMBASE, and the Cochrane Database of Systematic Reviews. Articles were manually reviewed for relevance. Results Out of 272 articles identified, 10 articles were included in the final analysis. Overall, this systematic review suggests that free-flap PU reconstruction yields fewer recurrences compared with local flaps (0–20 vs. 13–82%). Further, several types of free flaps for PU reconstruction were identified in this review, along with their indications. Conclusion Free tissue transfer should be considered for recurrent PU. We offer specific recommendations for their use in PU reconstruction.

Neuroma Prevention and Implantation Effects of NEUROCAP in Rat Sciatic Nerve Model

Introduction Symptomatic neuroma with neuropathic pain can develop following peripheral nerve injury. Current interventions for symptomatic neuroma have unpredictable results. NEUROCAP (Polyganics, Groningen, The Netherlands) is a bioresorbable nerve capping device intended to protect a peripheral nerve end and separate the nerve from the surrounding environment, to prevent the recurrence of a symptomatic neuroma. Materials and Methods This study aims to assess the implantation effects of the NEUROCAP device in a rat sciatic nerve model during 12 months (±2 days). Forty-one adult male Sprague-Dawley rats were used in this study. They were randomly divided into a capping or test group, or a noncapping or control group for different time points of survival (12 weeks, 6 months, and 12 months). The objective of this study was evaluated regarding procedural data, adverse events, clinical observations, and histopathology. Results The overall general health of the animals was adequate throughout the study, with the exception of autotomy during the first 4 months of survival. Eight animals were euthanized early due to autotomy, excluded from the study and seven of them have been replaced. Autotomy was an expected outcome and a known limitation of the animal model, particularly as this was a full sciatic nerve transection model. Neuroma formation was observed in the control group while there was no neuroma formation present in the test group. The control group showed increased nerve outgrowth and more chaotic fascicles in comparison with the test group. The test group also had a higher percentage of myelinated fibers compared to the control group. These results indicate a preventive mode of action of the NEUROCAP with regard to neuroma formation after nerve transection in a rat sciatic nerve model. Conclusion The results indicate that NEUROCAP is safe and effective in preventing the recurrence of neuroma formation and inhibiting nerve outgrowth.

Successful Microsurgical Reconstruction for Limb Salvage in a COVID-19-Positive Patient: A Case Report

Background Although the novel 2019 coronavirus (COVID-19) pandemic delayed elective microsurgical reconstruction cases, traumatic injuries requiring microsurgical reconstruction for limb salvage still presented to our hospital. Recent data suggests a link between COVID-19 and increased venous and arterial thromboembolic events, theoretically increasing the risk of microvascular anastomotic thrombosis and flap failure. Methods We provide a single case report of microsurgical limb salvage in a COVID-19-positive patient with a Gustilo IIIb open tibial-fibular fracture. Results A free latissimus dorsi muscle flap was used to successfully cover a Gustilo IIIb open tibial-fibular fracture with exposed orthopedic hardware and large soft tissue defect, with 5-month follow-up demonstrating a well-healed flap allowing for preserved ambulation. Conclusion Although there is a theoretical increased incidence of venous and arterial thrombotic microvascular failure in COVID-19-positive patients, microsurgical reconstruction is occasionally the lone option for salvage. Microsurgical reconstruction in this population must be carefully considered, meticulously executed, and closely monitored.

Observation of the Absence of Ulnar Artery in a Patient Planned to Free Dorsoulnar Artery Perforator Flap for Finger Defect: Is Preoperative Doppler evaluation of Perforator Alone Sufficient?

Background Volar finger defects where critical structures exposed are always challenging for plastic surgeons. In these types of defects, local flaps, cross finger flaps, abdominal flaps, and free flaps are used. Free dorsoulnar artery perforator (DUAP) flaps and superficial palmar branch of radial artery (SPBRA) flaps are also used. In this case, we present a patient who was scheduled to receive a DUAP flap to address defect on the second finger of right hand; however, we repaired the defect with a SPBRA flap because intraoperative absence of the ulnar artery was observed. Materials and Methods A 34-year-old male patient was admitted with a wound that exposed the tendon and neurovascular bundle on the volar side of the second finger of the right hand. A free DUAP flap was planned for the patient. A perforator was detected during the preoperative Doppler ultrasound examination. While dissecting the perforator, we noted the absence of an ulnar artery proximal to the perforator vessel. The elevated SPBRA flap from same extremity and the defect were closed. Results Postoperative computer tomography showed an absence of the ulnar artery distal to the right antecubital region. No complications were seen in the donor and recipient areas. Long-term motor movements were natural, and the patient's quality of life was good. Conclusion Determining the perforator site using Doppler alone may not be sufficient in preoperative evaluation of patients scheduled to receive DUAP flaps. Performing an Allen test and using advanced imaging methods can prevent surgeons from encountering a bad surprise.

The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model

Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers. Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care. Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019. Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.