Progress in flap surgery: Greater anatomical understanding and increased sophistication in application

Flaps for lower limb diabetic wound reconstruction: A systematic review and meta-analysis

Differential visualization of arterial and venous flow in deep inferior epigastric perforator imaging with vector-flow perforator Phase Contrast Angiography (pPCA)

The most common complication in flap surgery is of a circulatory nature. Impeded blood flow leads to altered metabolism in the tissue. Possible metabolic differences between different zones of the transverse rectus abdominis muscle (TRAM) flap were studied and the metabolism of pedicled and free TRAM flaps was compared intraoperatively and postoperatively. The method used was microdialysis, which is a useful technique for following local metabolic changes continuously in various tissues.Twenty-two patients with a pedicled or free TRAM flap were monitored using the microdialysis technique. Two microdialysis catheters were placed subcutaneously in the flap (zone I and zone II), and a third one was placed subcutaneously in the flank to serve as a control. The flaps were monitored intraoperatively and postoperatively for 3 days with repeated analyses of extracellular glucose, lactate, and glycerol concentrations. An additional analysis of pyruvate was performed in some patients to calculate the lactate-to-pyruvate ratio. This study showed that glucose, lactate, and glycerol change in a characteristic way when complete ischemia (i.e., complete inhibition of the blood circulation) is present. A slower stabilization with prolonged metabolic signs of ischemia, such as lower glucose and higher lactate and glycerol concentrations, was seen in zone II compared with zone I, and more pronounced metabolic signs of ischemia, but with a faster recovery, were detected in the free TRAM flap group than in the pedicled TRAM flap group. The fact that the metabolites returned to normal earlier in free flaps than in pedicled flaps may indicate that free TRAM flaps sustain less ischemic damage because of better and more vigorous perfusion.

Introduction: Skin flap application in the clinical practice is restricted due to the ischemic damage and flap necrosis. Rosmarinus oil has been shown to improve a skin flap survival. In the present work we studied the role of mammalian target of rapamycin (mTOR) signaling on rosmarinus-induced flap protection. Methods: A flap surgery was performed on Sprauge-Dawley rats (8 cm in by 3 cm). A week before and a week after the surgery the flaps were treated with topical rosmarinus oil (twice per day). Rapamycin (m-TOR inhibitor) was administered 30 minutes before the flap surgery in rosmarinus-treated or not treated groups. A week after the surgery the malondialdehyde (MDA) contents, myeloperoxidase (MPO) and superoxide dismutase (SOD) activities, expression of Bax, Bcl-2, mTOR and p-mTOR were measured in the flap tissue. Results: Topical application of the rosmarinus increased the flap survival (p<0.05), anti-oxidative enzyme activity (SOD, p<0.05) and anti-apoptotic protein Bcl-2 expression. Rosmarinus treatment decreased the flap MDA content, MPO activity, and pro-apoptotic protein Bax expression (p<0.05). Rosmarinus topical application did not change mTOR expression and phosphorylation in the flap tissue. Expression of p-mTOR in rosmarinus treated group was suppressed by rapamycin pre-treatment, which also abolished rosmarinus effects on the flap survival (p<0.05). Conclusion: These data suggested p-mTOR dependent mechanism in rosmarinus-induced flap survival.

Satellite cell proliferation, reinnervation, and revascularization in human free microvascular muscle flaps 1

Despite the widespread use of fibula free flap (FFF) surgery for head and neck reconstruction, there are no studies assessing if early weight-bearing (EWB) affects postoperative recovery, and the timing of weight-bearing initiation following FFF surgery varies considerably across institutions. Therefore, it is important to understand the effect of EWB in these patients and whether it could improve postoperative recovery. To assess the association of EWB after FFF surgery with donor-site complications, length of stay, and discharge to home status. This retrospective cohort study took place at Massachusetts Eye and Ear, a single tertiary care institution in Boston, Massachusetts. A total of 152 patients who received head and neck reconstruction with a fibula osteocutaneous free flap between January 11, 2010, and August 11, 2022, were included. EWB on postoperative day 1 vs non-EWB on postoperative day 2 or later. Patient characteristics, including demographic characteristics and comorbidities, surgical characteristics, donor-site complications, length of stay, and discharge disposition, were recorded. Descriptive statistics and multivariate logistic regressions were used to compute effect sizes and 95% CIs to compare postoperative outcomes in EWB and non-EWB groups. A total of 152 patients (median [IQR] age, 63 [55-70] years; 89 [58.6%] male) were included. The median (IQR) time to postoperative weight-bearing was 3 (1-5) days. Among all patients, 14 (9.2%) had donor-site complications. EWB on postoperative day 1 was associated with shorter length of stay (adjusted odds ratio [AOR], 0.10; 95% CI, 0.02-0.60), increased rate of discharge to home (AOR, 7.43; 95% CI, 2.23-24.80), and decreased donor-site complications (AOR, 0.11; 95% CI, 0.01-0.94). Conversely, weight-bearing 3 or more days postoperatively was associated with an increased risk of pneumonia (AOR, 6.82; 95% CI, 1.33-34.99). In this cohort study, EWB after FFF surgery was associated with shorter length of stay, increased rate of discharge to home, and decreased donor-site complications. These findings support the role of early mobilization to optimize postoperative recovery after FFF surgery.

Abstract: Osteoradionecrosis (ORN) following radiation therapy is a much-feared complication of the treatment of head and neck cancer. Free flap reconstruction in the ORN patient has specific challenges for the surgeon. From 2014 to 2020 the Head and Neck Microvascular unit of the Oral and Maxillofacial Surgery Division at Jackson Health/University of Miami treated 149 ORN patients with free flap reconstruction. The fibula free flap (n=65) and anterior lateral thigh free flap (6n=1) were the workhorse flaps in our series comprising 44% and 41% of the total flap surgeries. A total of 13 cases (8.7%) involved performing 2 flaps in the same operation. Thirty cases had recorded complications with one flap loss (0.7%) and one case of partial necrosis (0.7%) of the flap. The most common complications encountered were flap congestion with 8 cases (5%), 5 cases of flap dehiscence,4 cases of neck hematoma (2.6%) and 3 cases of infection of the flap reconstruction site (3%). The average length of stay was 8.2 days. In this paper we present our approach to reconstruction in these patients and the lessons we have learned. Though this surgery is complex and has greater risks than free flap surgery in the “virgin” neck, our experience demonstrates that good outcomes can be achieved consistently with a structured approach.

To What Extent is Each Area of Oral-Maxillofacial Surgery Practiced in the United States Today?

Assessment of the fluorescein dye test for prediction of skin flap viability in pigs

A total of seven patients (six men and one woman) with a defect in the Achilles tendon and overlying soft tissue underwent reconstruction using either a composite radial forearm flap (n = 3) or an anterolateral thigh flap (n = 4). The Achilles tendons were reconstructed using chimeric palmaris longus (n = 2) or tensor fascia lata (n = 2) flaps or transfer of the flexor hallucis longus tendon (n = 3). Surgical parameters such as the rate of complications and the time between the initial repair and flap surgery were analysed. Function was measured objectively by recording the circumference of the calf, the isometric strength of the plantar flexors and the range of movement of the ankle. The Achilles tendon Total Rupture Score (ATRS) questionnaire was used as a patient-reported outcome measure. Most patients had undergone several previous operations to the Achilles tendon prior to flap surgery. The mean time to flap surgery was 14.3 months (2.1 to 40.7). At a mean follow-up of 32.3 months (12.1 to 59.6) the circumference of the calf on the operated lower limb was reduced by a mean of 1.9 cm (sd 0.74) compared with the contralateral limb (p = 0.042). The mean strength of the plantar flexors on the operated lower limb was reduced to 88.9% of that of the contralateral limb (p = 0.043). There was no significant difference in the range of movement between the two sides (p = 0.317). The mean ATRS score was 72 points (sd 20.0). One patient who had an initial successful reconstruction developed a skin defect of the composite flap 12 months after free flap surgery and this resulted in recurrent infections, culminating in transtibial amputation 44 months after reconstruction. These otherwise indicate that reconstruction of the Achilles tendon combined with flap cover results in a successful and functional reconstruction.

Flap surgery is the commonest procedure in plastic surgery and is the essence of the discipline. Part science, part art, success depends on an understanding of soft tissue’s blood supply, mobility, a keen sense for form and function, and, not least, surgical experience. The principles enunciated here form the fluid and creative foundations of plastic surgery practice. This chapter covers the historical evolutions and basics of clinical practice using flap surgery.

Comparison between Fasciocutaneous and Jejunum Flaps in Pharyngolaryngoesophageal Reconstruction

The fate of the oblique abdominal muscles after free TRAM flap surgery

Toe pulp flap surgery is a viable option for soft tissue defects of the fingertips, effectively addressing patient needs and fingertip characteristics. The preferred anesthesia for lower-extremity surgery includes spinal and regional anesthesia. However, the choice between these methods depends on patient safety and surgical efficacy. In this retrospective study, we aimed to ascertain the optimal anesthetic technique by examining the efficacy, safety, pain control, and potential side effects of spinal and peripheral nerve block anesthetics. We included 40 patients aged 18-60 years who underwent partial second toe pulp free flap surgery for fingertip reconstruction. Twenty patients received spinal anesthesia (SA), while the remaining 20 received peripheral nerve block anesthesia. We conducted a comparative analysis of postoperative pain scores, adverse effects, analgesic usage, and patient satisfaction scores associated with each anesthesia method. Independent t-test, Mann-Whitney U test, and chi-squared test were performed. The SA group exhibited hypotension, bradycardia, urinary retention, and postdural puncture headache rates of 10%, 10%, 5%, and 5%, respectively. A significant difference in the timing of first analgesic use was observed (spinal, 3.7 ± 0.8 vs. peripheral nerve block, 13.2 ± 6.6; P = 0.006). Visual analog scale (VAS) scores of the patients at the 2nd, 4th, and 6th h were significantly lower in the peripheral nerve block group (P < 0.001, P < 0.001, P < 0.001, respectively). VAS scores at 12 and 24 h were similar between the groups (P = 0.07, P = 0.135, respectively). Peripheral nerve block anesthesia is superior to SA for partial second toe pulp free flap surgery, offering lower complication rates, reduced postoperative pain, and improved patient comfort.

The skin is our largest organ and it simultaneously fulfills many functions required in everyday life. The most important function of the skin is to act as a barrier between the body and the external environment. Many immune cells are also present in the skin to provide protection against invading micro-organisms. The skin is in addition an important participant in the physiological water homeostasis and it is one of the main ways the body regulates its temperature. Normal skin has sensation with protective value; a physical tensile capacity allowing for body mobility and it provides the external contour as well as the texture and the color of the exterior. Over the millennia mankind has been fascinated by the body’s ability to heal itself. Throughout history the main goal has always been to cover skin defects and to close wounds in order to protect the human body. Skin grafting and flap surgical procedures have been used in order to facilitate wound healing for thousands of years. Due to the advances in critical care and resuscitation, patients who, in the past, would have died in the acute phase are now surviving. Consequently there is a much greater need for high-quality skin substitutes. The clinical demand has driven newer technologies, building upon principles learned using cadaver and autografts, to the creation of engineered skin substitutes using living allograft cells as well as the combining of technologies to create composites – the most advanced products and at present the closest products to living skin. An autologous split thickness skin graft currently still remains superior to all commercially available skin substitutes with regards to its unique qualities. There are, however, situations where we prefer to use non-autologous substitutes, either because the patient may be too fragile for the added surgical trauma of harvesting split-skin grafts or due to the fact that there is not enough skin which could be harvested, for example, post-burn.