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1.  Pectoralis major myocutaneous flap in head and neck reconstruction: An experience in 100 consecutive cases 
The pectoralis major myocutaneous (PMMC) flap has been used as a versatile and reliable flap since its first description by Ariyan in 1979. In India head and neck cancer patients usually present in the advanced stage making PMMC flap a viable option for reconstruction. Although free flap using microvascular technique is the standard of care, its use is limited by the availability of expertise and resources in developing world. The aim of this study is to identify the outcomes associated with PMMC flap reconstruction.
Patients and Methods:
After ethical approval we retrospectively analyzed 100 PMMC flap at a tertiary care hospital from 2006 to 2013. A total of 137 PMMC flap reconstructions were performed out of which follow-up data of 100 cases were available in our record.
A total of 100 patients were reviewed of these 86% were of oral cavity and oropharyngeal lesions, 8% were of hypopharyngeal, 3% were of laryngeal malignancies and 3 cases were of salivary gland tumor. Most tumors (83%) were advanced (T3 or T4 lesion). 95 PMMC flap reconstruction were done as a primary procedure, and 5 were salvage procedure. PMMC flap was used to cover mucosal defect in 84 patients, skin defects in 10 patient and both in 6 patients. Overall flap related complications were 40% with a major complication in 10% and minor complications in 30%. No total flap loss occurred in any patient, major flap occurred in 6% and minor flap loss in 12%. In minor flap loss patients, necrotic changes were mostly limited to skin. Orocutaneous and pharyngocutaneous fistula developed in 12 patients. 10% patients required re-surgery after developing various flap related complications Pleural empyema developed in 3 patients. Other minor complications such as neck skin dehiscence and intra-oral flap dehiscence developed in 26 patients.
PMMC flap is a versatile flap with an excellent reach to face oral cavity and neck region. With limited expertise and resources, it is still a workhorse flap in head and neck reconstruction.
PMCID: PMC4668731  PMID: 26668451
Head and neck cancers; head and neck reconstruction; pectoralis major myocutaneous flap; pedicled flap
2.  The value of postoperative anticoagulants to improve flap survival in the free radial forearm flap 
Free radial forearm flap (FRFF) reconstruction is a valuable technique in head and neck surgery, that allows closure of large defects while striving to maintain functionality. Anticoagulative drugs are often administered to improve flap survival, although evidence regarding effectiveness is lacking.
Objective of review
To investigate the effectiveness of postoperative anticoagulants to improve survival of the FRFF in head and neck reconstruction.
Type of review
Systematic review and multicenter, individual patient data meta-analysis.
Search strategy
MEDLINE, EMBASE, Web of Science and CINAHL were searched for synonyms of ‘anticoagulants’ and ‘free flap reconstruction’.
Evaluation method
Studies were critically appraised for directness of evidence and risk of bias. Authors of the highest quality publications were invited to submit their original data for meta-analysis.
Five studies were of adequate quality and data from four studies (80%) were available for meta-analysis, describing 759 FRFF procedures. Anticoagulants used were: aspirin (12%), low-molecular weight dextran (18.3%), unfractioned heparin (28.1%), low-molecular weight heparin (49%) and prostaglandin-E1 (2.1%). Thirty-one percent did not receive anticoagulants. Flap failure occurred in 40 of 759 patients (5.3%) On univariate analysis, use of unfractioned heparin was associated with a higher rate of flap failure. However, these regimens were often administered to patients who had revision surgery of the anastomosis. In multivariate logistic regression analysis, anticoagulant use was not associated with improved flap survival or flap-related complications.
The studied anticoagulative drugs did not improve FRFF survival or lower the rate of flap-related complications. In addition some anticoagulants may cause systemic complications.
PMCID: PMC5023143  PMID: 25823832
Free radial forearm flap; free flap reconstruction; anticoagulants; head and neck cancer; meta-analysis
3.  My First 100 Consecutive Microvascular Free Flaps: Pearls and Lessons Learned in First Year of Practice 
Microvascular reconstruction for oncologic defects is a challenging and rewarding endeavor, and successful outcomes are dependent on a multitude of factors. This study represents lessons learned from a personal prospective experience with 100 consecutive free flaps.
All patients’ medical records were reviewed for demographics, operative notes, and complications.
Overall 100 flaps were performed in 84 consecutive patients for reconstruction of breast, head and neck, trunk, and extremity defects. Nineteen patients underwent free flap breast reconstruction with 10 patients undergoing bilateral reconstruction and 2 patients receiving a bipedicle flap for reconstruction of a unilateral breast defect. Sixty-five free flaps were performed in 61 patients with 3 patients receiving 2 free flaps for reconstruction of extensive head and neck defects and 1 patient who required a second flap for partial flap loss. Trunk and extremity reconstruction was less common with 2 free flaps performed in each group. Overall, 19 patients (22.6%) developed complications and 14 required a return to the operating room. There were no flap losses in this cohort. Thorough preoperative evaluation and workup, meticulous surgical technique and intraoperative planning, and diligent postoperative monitoring and prompt intervention are critical for flap success.
As a young plastic surgeon embarking in reconstructive plastic surgery at an academic institution, the challenges and dilemmas presented in the first year of practice have been daunting but also represent opportunities for learning and improvement. Skills and knowledge acquired from time, experience, and mentors are invaluable in optimizing outcomes in microvascular free flap reconstruction.
PMCID: PMC4173838  PMID: 25289221
4.  Robot-Assisted Free Flap in Head and Neck Reconstruction 
Archives of Plastic Surgery  2013;40(4):353-358.
Robots have allowed head and neck surgeons to extirpate oropharyngeal tumors safely without the need for lip-split incision or mandibulotomy. Using robots in oropharyngeal reconstruction is new but essential for oropharyngeal defects that result from robotic tumor excision. We report our experience with robotic free-flap reconstruction of head and neck defects to exemplify the necessity for robotic reconstruction.
We investigated head and neck cancer patients who underwent ablation surgery and free-flap reconstruction by robot. Between July 1, 2011 and March 31, 2012, 5 cases were performed and patient demographics, location of tumor, pathologic stage, reconstruction methods, flap size, recipient vessel, necessary pedicle length, and operation time were investigated.
Among five free-flap reconstructions, four were radial forearm free flaps and one was an anterolateral thigh free-flap. Four flaps used the superior thyroid artery and one flap used a facial artery as the recipient vessel. The average pedicle length was 8.8 cm. Flap insetting and microanastomosis were achieved using a specially manufactured robotic instrument. The total operation time was 1,041.0 minutes (range, 814 to 1,132 minutes), and complications including flap necrosis, hematoma, and wound dehiscence did not occur.
This study demonstrates the clinically applicable use of robots in oropharyngeal reconstruction, especially using a free flap. A robot can assist the operator in insetting the flap at a deep portion of the oropharynx without the need to perform a traditional mandibulotomy. Robot-assisted reconstruction may substitute for existing surgical methods and is accepted as the most up-to-date method.
PMCID: PMC3723995  PMID: 23898431
Robotics; Free tissue flaps; Head and neck neoplasms
5.  Head and neck reconstruction with pedicled flaps in the free flap era 
Nowadays, the transposition of microvascular free flaps is the most popular method for management of head and neck defects. However, not all patients are suitable candidates for free flap reconstruction. In addition, not every defect requires a free flap transfer to achieve good functional results. The aim of this study was to assess whether pedicled flap reconstruction of head and neck defects is inferior to microvascular free flap reconstruction in terms of complications, functionality and prognosis. The records of consecutive patients who underwent free flap or pedicled flap reconstruction after head and neck cancer ablation from 2006 to 2015, from a single surgeon, in the AOUC Hospital, Florence Italy were analysed. A total of 93 patients, the majority with oral cancer (n = 59), were included, of which 64 were pedicled flap reconstructions (69%). The results showed no significant differences in terms of functional outcome, flap necrosis and complications in each type of reconstruction. Multivariate regression analysis of flap necrosis and functional impairments showed no associated factors. Multivariate regression analysis of complicated flap healing showed that only comorbidities remained an explaining factor (p = 0.019). Survival analysis and proportional hazard regression analysis regarding cancer relapse or distant metastasis, showed no significant differences in prognosis of patients concerning both types of reconstruction. In this retrospective, non-randomised study cohort, pedicled flaps were not significantly inferior to free flaps for reconstruction of head and neck defects, considering functionality, complications and prognosis.
PMCID: PMC5317124  PMID: 28177328
Head and neck reconstruction; Oral cavity reconstruction; Pedicled flap; Free flap; Head and neck cancer
6.  Free anteromedial thigh perforator flap: Complementing and completing the anterolateral thigh flap 
Theobjective of this study was to determine the indications, utility, advantages and surgical approach for the anteromedial thigh (AMT) flap.
Materials and Methods:
We reviewed the records of the patients in whom the AMT flap was used for head and neck reconstruction. We use an anterior approach to harvest the anterolateral thigh (ALT) flap with a non-committal straight line incision. This preserves both ALT and AMT flap territories intact, and further decision is based on the intraoperative anatomy of perforator and pedicle. The ALT flap was usually used as the first choice when available and suitable.
Free AMT skin flaps were harvested in 24 patients. All flaps were used for the head and neck reconstruction. Two flaps had marginal flap necrosis. One flap was lost due to venous thrombosis.
The thigh is an excellent donor site as it has large available skin territory, expendable lateral circumflex femoral artery system and low donorsite morbidity. The ALT flap is the most commonly used flap for reconstruction of soft-tissue defects. However, it is characterised by variable vascular pedicle and perforator anatomy. The AMT flap is an excellent alternative when the ALT flap is not available due to variable perforator anatomy, injury to perforator, when an intermediate thickness is needed between distal and proximal thigh or a chimeric flap is needed.
The AMT flap offers all the advantages of the ALT flap without increasing donor-site morbidity. The anterior non-committal approach keeps both the ALT and the AMT flap options viable.
PMCID: PMC5469229
Anteromedial thigh perforator flap; chimeric flaps; freestyle perforator flap
7.  Improved Head and Neck Free Flap Outcome—Effects of a Treatment Protocol Adjustment from Pre- to Postoperative Radiotherapy 
The impact of preoperative radiotherapy on microvascular reconstructive surgery outcome has been a subject of debate. However, data are conflicting and often dependent on local treatment protocols. We have studied the effects of radiotherapy in a unique, single-center setting where a treatment protocol change was undertaken from pre- to postoperative radiotherapy administration for microsurgical head and neck reconstructions.
A cohort study was conducted for 200 consecutive head and neck free flap cases, where 100 were operated on before and 100 after the treatment protocol adjustment in 2006. Only direct cancer reconstructions were included. Complication rates of anastomosis-related (flap necrosis) and flap bed–related (infection, fistula, and wound dehiscence) complications were compared between irradiated and nonirradiated patients. A multivariate analysis was performed to correct for treatment period.
One hundred twenty-six patients had received radiotherapy before reconstruction due to cases of cancer recurrence. There were no significant differences in demographic data or risk factors between irradiated and nonirradiated cases. Irradiated cases had a higher rate of both flap loss (9.5% versus 1.4%; P = 0.034) and flap bed–related complications (29% versus 13%; P = 0.014). However, after multivariate analysis, there was only a significant relationship between preoperative irradiation and infection (odds ratio = 2.51; P = 0.033) and fistula formation (odds ratio = 3.13; P = 0.034).
The current single-center study clearly indicates that preoperative radiotherapy is a risk factor for both infection and fistula formation, most likely related to an impaired flap bed. We suggest postoperative radiotherapy administration whenever possible for oncological reasons, otherwise proper antibiotic cover and meticulous flap insetting to prevent radiation-related infection and fistula formation.
PMCID: PMC5404438
8.  Supraclavicular artery perforator flap in management of post-burn neck reconstruction: clinical experience 
Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques, including chimeric flaps, supercharged flap, pre-expanded flaps, “superthin” flaps and perforator flaps. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Between January 2013 and March 2015, 20 patients suffering from postburn neck contracture underwent reconstruction with 20 unilateral supraclavicular artery perforator flaps. Nineteen patients had post-burn neck contractures (9 cases type Іc, 10 cases type Пc) while only one had post-burn granulation tissue in the neck. We harvested fifteen flaps from the right side and five from the left. Size of the reconstructed defect ranged from 23x10 to14x6, and flap size varied from 25/11 to 16/7cm. Period of follow up ranged from 27-2months (average 12.3). Nineteen flaps survived well (95% survival rate): only one was lost due to iatrogenic extensive dissection over the pedicle. Five cases showed distal superficial epidermolysis, and 2 cases showed 2 cm complete distal necrosis. All patients were managed conservatively. Our results coincide with other literature results confirming the efficacy and rich vascularity of this flap. In all cases with distal partial necrosis, flaps were 23 cm or more. We recommend that supraclavicular flaps of more than 22 cm in length are not harvested immediately and that flaps are expanded before harvesting. Expanding the supraclavicular flap increases its surface area and decreases donor site morbidity.
PMCID: PMC5266240  PMID: 28149252
supraclavicular flap; post-burn neck contracture; pedicled supraclavicular perforator flap; fasciocutaneous flap
9.  Free Flap Reconstruction of Head and Neck Defects after Oncologic Ablation: One Surgeon's Outcomes in 42 Cases 
Archives of Plastic Surgery  2014;41(2):148-152.
Free flap surgery for head and neck defects has gained popularity as an advanced microvascular surgical technique. The aims of this study are first, to determine whether the known risk factors such as comorbidity, tobacco use, obesity, and radiation increase the complications of a free flap transfer, and second, to identify the incidence of complications in a radial forearm free flap and an anterolateral thigh perforator flap.
We reviewed the medical records of patients with head and neck cancer who underwent reconstruction with free flap between May 1994 and May 2012 at our department of plastic and reconstructive surgery.
The patients included 36 men and 6 women, with a mean age of 59.38 years. The most common primary tumor site was the tongue (38%). The most commonly used free flap was the radial forearm free flap (57%), followed by the anterolateral thigh perforator free flap (22%). There was no occurrence of free flap failure. In this study, risk factors of the patients did not increase the occurrence of complications. In addition, no statistically significant differences in complications were observed between the radial forearm free flap and anterolateral thigh perforator free flap.
We could conclude that the risk factors of the patient did not increase the complications of a free flap transfer. Therefore, the risk factors of patients are no longer a negative factor for a free flap transfer.
PMCID: PMC3961612  PMID: 24665423
Free tissue flaps; Postoperative complication; Risk factors
10.  Versatility of the Anterolateral Thigh Free Flap: The Four Seasons Flap 
Eplasty  2012;12:e21.
Presented at the following academic meetings:
○ 56th Meeting of the Italian Society of Plastic, Reconstructive and Aesthetic Surgery (SICPRE) Fasano (Brindisi), Italy, September 26-29, 2007
○ 42nd Meeting of the European Society for Surgical Research (ESSR), Warsaw, Poland, May 21-24, 2008
○ Winter Meeting, British Association of Plastic, Reconstructive and Aesthetic Surgeons, (BAPRAS) London, December 1-3, 2009
Background: The anterolateral free flap has become increasingly popular at our institution year on year. We decided to review our experience with this flap and study the reasons for this trend. Methods: A retrospective review of all anterolateral thigh free flaps performed at Addenbrooke's University Hospital from the available charts was carried out. This chart review included patients' demographics, indications, flap size, recipient vessels used, ischemia time, flap, and donor site outcomes. All flap perforator vessels were located preoperatively using a handheld Doppler ultrasound probe. Results: From October 1999 to December 2008, 55 anterolateral thigh flaps were performed in 55 patients to reconstruct a variety of soft-tissue defects (upper and lower limbs, chest wall, skull base, head and neck). Flap size ranged 12 to 35 cm in length and 4 to 11 cm in width. During flap elevation, the main supply to the flap was found to be a direct septocutaneous perforator in 41% (n = 23) of the cases as opposed to a musculocutaneous perforator, which was found in 59% (n = 32). The mean ischemia time was 82 minutes (range, 62-103). The overall flap success rate was 100%. Two flaps were successfully salvaged after reexploration for venous congestion. The donor site morbidity was minimal. The mean follow-up time was 18 months (range, 2-48). Discussion and Conclusion: The anterolateral thigh free flap was found to be a very reliable flap (100% success) across a wide range of clinical indications. It facilitates microvascular anastomoses as evidenced by the short ischemia time. It provided ample skin with volume that could be tailored to the defect. These advantages have led to its widespread use by different consultants and trainees in our department.
PMCID: PMC3343765  PMID: 22582118
11.  Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India 
Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India.
Materials and Methods:
This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed.
We performed 22 cases of free flaps in a six-month period (2008-2009). Majority (17) of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9) and anterolateral thigh flap (ALT: 9) were the most commonly used flaps. A fibula flap (1) was done for an anterior mandible defect, whereas a jejunum free flap (1) was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps.
Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.
PMCID: PMC3745127  PMID: 23960310
Free flap; head and neck cancer; microvascular surgery; reconstruction; resource constrained; reconstruction of head and neck
12.  Submental island flap reconstruction reduces cost in oral cancer reconstruction compared to radial forearm free flap reconstruction: a case series and cost analysis 
In Canada, 4,400 cases of oral cancer are diagnosed yearly. Surgical resection is a key component of treatment in many of these cancers. Reconstruction of defects, with the goal of preserving function, is of utmost importance. Several choices are possible for reconstruction of larger defects, including both free and pedicled flaps. Free flap reconstruction is reliable and effective, but requires additional personnel and peri-operative resources. Pedicled flaps remain an important alternative to free flaps, and are less resource intensive. This paper reviews our inaugural experience with the submental island flap (SIF) and compares costs incurred to a matched cohort of oral cancer patients reconstructed with forearm free flaps.
Charts of patients who underwent SIF and RFFF reconstruction from January 1st 2013 to April 1st 2015 were retrospectively examined. Associated costs were obtained via online database and previously reported costs at the study institution.
Mean length of ICU stay in glossectomy RFFF reconstruction was 4.7 days. Only one patient required ICU stay for one night in the SIF group. Mean length of hospital stay was not significantly different in SIF patients vs RFFF patients (12.4 vs 15.4 days, p > 0.05). Mean operative time was significantly lower in the SIF group compared to the RFFF group (347 vs 552 min, p < 0.05). Total mean intraoperative costs were found to be $4780.59 for RFFF operations, versus $2307.94 for SIF. Total mean cost of post-operative stay was $18158.40 in the SIF group and $43617.60 in the RFFF group. Total cost savings were therefore $27931.85 per patient for the SIF group.
We have demonstrated the use of the submental island flap as an alternative to radial forearm free flaps, showing both decreased hospital costs and comparable patient outcomes. Pedicled flaps are making a resurgence in head and neck reconstruction, and the submental island flap offers an excellent alternative to more labour intensive and costly free flap alternatives.
PMCID: PMC4743171  PMID: 26846792
Oral cancer; Reconstruction; Submental Island Flap; Radial Forearm Free Flap; Cost; Pedicle Flap; Free Flap
13.  Utility of arteriovenous loops before free tissue transfer for post-traumatic leg defects 
Crush injuries of severe magnitude involving lower limbs require complex bone and soft tissue reconstructions in the form of microvascular free tissue transfers. However, satisfactory recipient vessels are often unavailable in the leg due to their vulnerability to trauma and post traumatic vessel disease (PTVD), which extends well beyond the site of original injury. In such situations, healthy recipient vessels for free flap anastomosis can be made available by constructing temporary arteriovenous loops with saphenous vein grafts, anastomosed to corresponding free flap vessels. Our study included 7 patients with severe crush injuries of leg due to rail and road traffic accidents. Long and short saphenous vein grafts were anastomosed to Femoral artery in the subsartorial canal in 2 cases and to large muscular branches and accompanying veins in rest of the cases. Free flap transfers were performed in the same sitting in 6 cases. One case showed insufficient dilatation of the vein loop and hence free flap transfer was staged. Free Latissimus dorsi, Gracilis and Rectus abdominis flaps were performed. There were two cases of flap necrosis – one in the case of a pathologic vein graft with staged flap transfer which showed vein thrombosis on re exploration. The other case of flap failure was caused by a hematoma underneath the flap. In another patient, secondary haemorrhage occurred on day 18, without any consequence to the flap. All the other cases had complete free flap survival. We consider the use of single stage arteriovenous loops, a valuable tool to increase the applications of free flap, whenever healthy recipient vessels are not available in the periphery of the trauma.
PMCID: PMC4413487  PMID: 25991884
Arteriovenous loops; staged free flaps; vein grafts
14.  Autonomized flaps in secondary head and neck reconstructions 
Free flaps, with their very high rates of success and low donor site morbidity, are considered the gold standard in head and neck reconstruction, allowing the transfer of ideal tissues for head and neck reconstruction. Nonetheless, under certain circumstances they may be contraindicated or cannot be utilized. We describe four subjects in which delayed locoregional flaps were used to reconstruct head and neck defects after a previous flap failure. Due to adverse anatomic and systemic conditions these patients were not suitable for a free flap, and thus one delayed prelaminated temporalis fasciocutaneous flap placement and three delayed supraclavicular flap (one of which was prelaminated) placements to reconstruct large defects of the cheek and commissural region needed to be performed. All flaps and grafts were viable. All patients in this case series had acceptable functional and aesthetic outcomes. Donor-site morbidity was negligible. Delayed locoregional flap placement required a total of three surgical sessions. Although limited, our experience suggests that in cases in which a free flap is contraindicated or not ideal, locoregional flaps may be a valid and safe alternative. Limitations of these procedures include increased duration of hospitalization and, foremost, the need for three-step surgery.
PMCID: PMC3546399  PMID: 23326014
Delayed flap; Locoregional flap; Free flap failure
15.  Results of Free Flap Reconstruction After Ablative Surgery in the Head and Neck 
Due to the complex anatomy and function of the head and neck region, the reconstruction of ablative defects in this area is challenging. In addition, an increasing interest in improving the quality of life of patients and achieving good functional results has highlighted the importance of free flaps. The aim of this study was to summarize the results of free flap reconstruction and salvage of free flaps in a single institute, and to analyze differences in the results by the flap donor site, recipient site, and learning curve.
The medical records of patients who underwent free flap reconstruction from 2004-2012 were reviewed retrospectively. One hundred and fifty free flaps were used in 134 patients, who had an average age of 57.7 years. The types of flaps applied, primary defect sites, success rates, results of salvage operations for compromised flap, and the learning curve were analyzed.
The anterolateral thigh flap was preferred for the reconstruction of head and neck defects. The overall success rate was 90.7%, with 14 cases of failure. A total of 19 salvage operations (12.7%) for compromised flap were performed, and 12 flaps (63.2%) were salvaged successfully. Dependency on the facial vessels as recipient vessels was statistically different when oral and oropharyngeal defects were compared to hypopharyngeal and laryngeal defects. The learning curve for microvascular surgery showed decrease in the failure rate after 50 cases.
The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.
PMCID: PMC4451543  PMID: 26045917
Free Tissue Flaps; Head and Neck Neoplasms; Reoperation
16.  Near-Infrared Laser-Assisted Indocyanine Green Imaging for Optimizing the Design of the Anterolateral Thigh Flap 
Eplasty  2012;12:e30.
Objective: The anterolateral thigh flap is a versatile flap that can be used in a free or pedicled fashion. Because of the large amount of potential soft tissue, low donor site morbidity, and long pedicle lengths, many researchers consider it to be the perfect free flap. However, dissection of this and other perforator flaps can become an arduous experience with learning curves to overcome. Near-infrared laser angiography using indocyanine green provides a useful adjunctive tool to more predictably assess direct perforator perfusion zones. Laser-assisted angiography with SPY-Q analysis gives live localization of the flap's dominant perforator perfusion zones while quantifying the relative tissue perfusion for immediate skin paddle design. Methods: Fifteen patients with head and neck cancer defects were reconstructed with a free anterolateral thigh flap using laser-assisted near-infrared indocyanine green perforator mapping. The mid-point of a line between the anterior superior iliac spine and the patella was determined and the laser was centered over this. Indocyanine green (12.5 mg) was injected intravenously and fluorescence patterns were recorded. Optimal perforators were chosen using real-time imaging and SPY-Q analysis software. The anterolateral thigh skin paddle was centered over perforators based on best relative perfusion values. The hand-held Doppler was not used to identify perforators. All flaps were elevated in standard fashion. Patient demographics, defect characteristics, reconstructive techniques, and clinical outcomes were assessed. Results: All 15 free flaps were raised with the assistance of laser-assisted angiography. Cutaneous Doppler did not aid in the design of the skin paddle. There was only 1 flap loss due to venous congestion. All donor defects were closed primarily without the need for a skin graft. Conclusions: Laser-assisted indocyanine green angiography using SPY-Q analysis software provides robust, intraoperative, objective data to optimize anterolateral thigh skin paddle design while potentially minimizing patient morbidity. Future studies will be needed to further evaluate the use of this new technology.
PMCID: PMC3392148  PMID: 22876337
17.  Head and neck cancer in elderly patients: is microsurgical free-tissue transfer a safe procedure? 
The safety and success of microvascular transfer have been well documented in the general population, but the good results achieved with the use of free flaps in elderly patients have received little attention. This study sought to identify differences in complications, morbidity and functional outcomes between elderly (≥ 75 years) and younger (< 75 years) patients treated surgically for advanced head and neck cancer using the Head and Neck 35 module of the European Organisation for Research and Treatment of Cancer quality of life questionnaire. Patient treatment consisted of composite resection, including excision of the primary tumour with ipsilateral or bilateral neck dissection and microvascular reconstruction. Eighty-five microvascular tissue transfers were performed to reconstruct major surgical defects. Postoperative radiation therapy was performed when indicated. Total flap loss occurred in three cases in elderly patients and two cases in younger patients. The rates of major surgical complication were 9% in young patients and 11% in elderly patients. No significant difference was observed between the two groups in the rates of major and minor flap complications, morbidity or long-term functional outcome. The results of the present analysis indicate that free-flap microvascular reconstruction can be considered a safe procedure in elderly patients with head and neck cancer.
PMCID: PMC3552542  PMID: 23349555
Head and neck cancer; Elderly patient; Microvascular free flap; Complication; Functional outcome
18.  Postoperative monitoring of free flap reconstruction: A comparison of external Doppler ultrasonography and the implantable Doppler probe 
Plastic Surgery  2016;24(1):11-19.
Despite the significant versatility and success of microvascular free flap reconstruction for repairing large tissue defects, flap-related complications, often presenting in the postoperative course, still occur. Given that shorter times to detection of flap defects due to vascular compromise lead to higher successful salvage rates, reliable monitoring techniques – clinical observation or otherwise – are vital. This retrospective study compared the effectiveness of two devices that have emerged as potentially useful adjunctive monitoring modalities.
The time to detection of vascular compromise and the postoperative time to re-exploration are shorter using the implantable Doppler (ID) probe, thereby resulting in earlier surgical re-exploration and a higher flap salvage rate.
A single-centre experience with 176 consecutive free flap reconstructions in 167 patients from 2000 to 2008 in a university-based teaching hospital by retrospective chart review is presented.
There was a significant difference in overall flap survival (ID 98.0%, external Doppler [ED] 89.3%) and total flap loss (ID 2.0%, ED 10.7%) between the two groups (P=0.03). The difference in flap salvage rate was not significant (ID 90.9%, ED 63.6%; P=0.068). The false-positive (ID 0%, ED 3%; P=0.18) and false-negative rates (ID 0.0%, ED 4.5%; P=1.0) were not significantly different. There was also a lower median postoperative time to re-exploration for the ID group, from 48 h to one week after initial surgery (ID 74.5 h, ED 136.8 h; P=0.05).
The present analysis revealed a potential benefit for the ID probe in the postoperative monitoring of free tissue transfers.
PMCID: PMC4806750  PMID: 27054132
Complications; Doppler; External; Free flap; Handheld; Implantable; Internal; Monitoring; Reconstruction
19.  Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy 
The purpose of this study was to investigate the reliability and outcome of using the transverse cervical vessel (TCV) as a recipient vessel for microvascular reconstruction in patients whose vessels in the neck region are unavailable because of previous surgery or radiotherapy.
Between January 2012 and August 2014, secondary head and neck reconstruction was performed using the TCV as a recipient vessel in eight patients who had undergone previous neck dissection and radiation therapy (n = 5). Five patients had a recurrent carcinoma, one had undergone an operation for scar release and two had been treated surgically for a second primary cancer. The anterolateral thigh flap (ALT), anteromedial thigh flap (AMT), and fibular flap were used for the reconstruction. Clinical data were recorded for each patient.
All of the ipsilateral transverse cervical arteries were found to be free of disease. The second free flap was revascularized using the TCVs (n = 6) or the external (n = 1) or internal (n = 1) jugular vein. The free flaps used for the reconstruction included the ALT flap (n = 6), AMT flap (n = 2), and fibular flap (n = 1). All of the flaps survived without vascular events, and the patients healed without major complications. The mean follow-up time was 11 months. One patient died of distant metastases during follow-up.
In patients who have previously undergone neck surgery with or without radiotherapy, the TCVs are reliable and easily accessible recipient vessels for microsurgical reconstruction in the oral and maxillofacial region. If the transverse cervical vein is unavailable, the internal or external jugular vein should be dissected carefully to serve as an alternative for microvascular anastomoses.
PMCID: PMC4485336  PMID: 25966959
Transverse cervical vessel; Oral and maxillofacial; Reconstruction
20.  Reconstructive Trends in Post-Ablation Patients with Esophagus and Hypopharynx Defect 
Archives of Craniofacial Surgery  2015;16(3):105-113.
The main challenge in pharyngoesophageal reconstruction is the restoration of swallow and speech functions. The aim of this paper is to review the reconstructive options and associated complications for patients with head and neck cancer. A literature review was performed for pharynoesophagus reconstruction after ablative surgery of head and neck cancer for studies published between January 1980 to July 2015 and listed in the PubMed database. Search queries were made using a combination of 'esophagus' and 'free flap', 'microsurgical', or 'free tissue transfer'. The search query resulted in 123 studies, of which 33 studies were full text publications that met inclusion criteria. Further review into the reference of these 33 studies resulted in 15 additional studies to be included. The pharyngoesophagus reconstruction should be individualized for each patient and clinical context. Fasciocutaneous free flap and pedicled flap are effective for partial phayngoesophageal defect. Fasciocutaneous free flap and jejunal free flap are effective for circumferential defect. Pedicled flaps remain a safe option in the context of high surgical risk patients, presence of fistula. Among free flaps, anterolateral thigh free flap and jejunal free flap were associated with superior outcomes, when compared with radial forearm free flap. Speech function is reported to be better for the fasciocutaneous free flap than for the jejunal free flap.
PMCID: PMC5556778  PMID: 28913234
Esophagus; Reconstruction; Free tissue transfer; Cancer; Review
21.  Impact of flap reconstruction on radiotoxicity after salvage surgery and reirradiation for recurrent head and neck cancer 
Annals of surgical oncology  2016;23(Suppl 5):850-857.
Recurrent head and neck malignancies remain a therapeutic challenge. Tissue transfer, in addition to defect coverage and prevention of wound complications, may potentially decrease radiotoxicity. We evaluated radiation toxicity and survival outcomes of patients who underwent salvage surgery with reirradiation, comparing primary closure to flap reconstruction.
Retrospective outcomes analysis of recurrent head and neck squamous cell carcinoma (HNSCC) patients treated with curative intent by salvage surgery (± flap reconstruction) and reirradiation from 1996–2011. Recurrent stage, reirradiation modality, chemotherapy use, and toxicities were evaluated.
Of 96 patients, 59 had primary closure while 37 underwent flap reconstruction (26 free, 11 pedicled). Median radiation and reirradiation doses were 66Gy and 60Gy, respectively. Comparing non-flap and flap patients, there was no significant difference in acute mild toxicities (100% vs. 100%, p=1.0) or acute severe toxicities (33.9% vs. 37.8%, p=0.83). Non-flap patients experienced significantly greater incidence of both late mild toxicities (81.4% vs 54.1%, p=0.006) and late severe toxicities (47.5% vs 21.6%, p=0.02). Overall survival at 5 years was equivalent (33.1% vs. 34.7%, p=0.88). Free flap patients had greater delays to postoperative reirradiation and treatment package times compared to pedicled flap patients, but no meaningful difference in survival outcomes.
Vascularized tissue potentially helps offset late toxicities associated with a second radiation course in recurrent head and neck cancer patients. In these selected patients, flap coverage may confer functional benefits and improve the long-term radiotoxicity profile.
PMCID: PMC5271365  PMID: 27506662
22.  Modified Incision Design for Submental Flap: An Excellent Design Method for the Reconstruction of a Defect after Head and Neck Tumor Resection 
PLoS ONE  2013;8(9):e74110.
The usage of submental flap is a good method for head and neck reconstruction, but it has some risk also, such as anatomical variations and surgical errors. In this article, we present a modified incision design for the submental flap.
We designed a modified submental flap incision method based on the overlap of the incision outline of the submental flap, platysma myocutaneous flap and infrahyoid myocutaneous flap. If we found that the submental flap was unreliable during the neck dissection at the level III, II and Ib areas, the infrahyoid myocutaneous flap or platysma myocutaneous flap was used to replace it. Between 2004 and 2012, we performed 30 cases using this method. As control, 33 radial forearm free flaps were counted. Significant differences were evaluated using the χ2 test and Mann-Whitney U. Survival and recurrence were analyzed using the Kaplan-Meier method.
Of the 30 patients, 27 finally received a submental flap, 1 patient received an infrahyoid myocutaneous flap, and 2 patients received a platysma myocutaneous flap. In patients who received the submental flap, the average operation time was 5.9 hours, 2.4 hours shorter than the radial forearm free flap group; the average age was 61.8, 6.1 years older than the radial forearm free flap group; the survival time and recurrence time did not significantly differ with those of the forearm free flap group; and the success rate was higher than traditional methods.
The wider indications, less required time, the similar low risk of recurrence and death as radial forearm free flap, higher success rate than traditional submental flap harvest methods, and ability to safely harvest a submental flap make the modified incision design a reliable method.
PMCID: PMC3770673  PMID: 24040181
23.  External monitor for buried free flaps in head and neck reconstructions 
Head and neck defects following oncological surgery must often be repaired with soft tissue and/or bone from other areas of the body. Significant loss of soft tissue requires flaps of sufficient bulk to adequately reconstruct the defect. Microvascular free tissue transfer is a good method for reconstructing even large defects following oncological surgery for head and neck cancer. Continuous post-operative monitoring of the perfusion of a free flap is vitally important to achieve not only a favourable outcome but also to decrease morbidity. Microvascular thrombosis occurs in 4% of the flaps and the best chance for flap salvage is offered by the earliest possible revision of the microanastomosis. Use of buried flaps in head and neck reconstruction makes monitoring particularly difficult and exteriorization of a segment of the flap permits a direct visualization.
An original technique is presented for harvesting forearm free flaps with a secondary monitor skin paddle to externally check the status of the paddle and, when modified, can also be used for fibula and rectus abdominis flap.
PMCID: PMC2639957  PMID: 18383750
Head and neck cancer; Reconstruction surgery; Free flaps; Free flap monitoring
24.  Fibular flap for mandible reconstruction in osteoradionecrosis of the jaw: selection criteria of fibula flap 
Osteoradionecrosis is the most dreadful complication after head and neck irradiation. Orocutaneous fistula makes patients difficult to eat food. Fibular free flap is the choice of the flap for mandibular reconstruction. Osteocutaneous flap can reconstruct both hard and soft tissues simultaneously. This study was to investigate the success rate and results of the free fibular flap for osteoradionecrosis of the mandible and which side of the flap should be harvested for better reconstruction.
A total of eight consecutive patients who underwent fibula reconstruction due to jaw necrosis from March 2008 to December 2015 were included in this study. Patients were classified according to stages, primary sites, radiation dose, survival, and quality of life.
Five male and three female patients underwent operation. The mean age of the patients was 60.1 years old. Two male patients died of recurred disease of oral squamous cell carcinoma. The mean dose of radiation was 70.5 Gy. All fibular free flaps were survived. Five patients could eat normal diet after operation; however, three patients could eat only soft diet due to loss of teeth. Five patients reported no change of speech after operation, two reported worse speech ability, and one patient reported improved speech after operation. The ipsilateral side of the fibular flap was used when intraoral soft tissue defect with proximal side of the vascular pedicle is required. The contralateral side of the fibular flap was used when extraoral skin defect with proximal side of the vascular pedicle is required.
Osteonecrosis of the jaw is hard to treat because of poor healing process and lack of vascularity. Free fibular flap is the choice of the surgery for jaw bone reconstruction and soft tissue fistula repair. The design and selection of the right or left fibular is dependent on the available vascular pedicle and soft tissue defect sites.
PMCID: PMC5122601  PMID: 27995119
Osteoradionecrosis; Fibular; Mandible; Free flap; Radiation; Oral neoplasm
25.  Fibular flap for mandible reconstruction in osteoradionecrosis of the jaw: selection criteria of fibula flap 
Osteoradionecrosis is the most dreadful complication after head and neck irradiation. Orocutaneous fistula makes patients difficult to eat food. Fibular free flap is the choice of the flap for mandibular reconstruction. Osteocutaneous flap can reconstruct both hard and soft tissues simultaneously. This study was to investigate the success rate and results of the free fibular flap for osteoradionecrosis of the mandible and which side of the flap should be harvested for better reconstruction.
A total of eight consecutive patients who underwent fibula reconstruction due to jaw necrosis from March 2008 to December 2015 were included in this study. Patients were classified according to stages, primary sites, radiation dose, survival, and quality of life.
Five male and three female patients underwent operation. The mean age of the patients was 60.1 years old. Two male patients died of recurred disease of oral squamous cell carcinoma. The mean dose of radiation was 70.5 Gy. All fibular free flaps were survived. Five patients could eat normal diet after operation; however, three patients could eat only soft diet due to loss of teeth. Five patients reported no change of speech after operation, two reported worse speech ability, and one patient reported improved speech after operation. The ipsilateral side of the fibular flap was used when intraoral soft tissue defect with proximal side of the vascular pedicle is required. The contralateral side of the fibular flap was used when extraoral skin defect with proximal side of the vascular pedicle is required.
Osteonecrosis of the jaw is hard to treat because of poor healing process and lack of vascularity. Free fibular flap is the choice of the surgery for jaw bone reconstruction and soft tissue fistula repair. The design and selection of the right or left fibular is dependent on the available vascular pedicle and soft tissue defect sites.
PMCID: PMC5122601  PMID: 27995119
Osteoradionecrosis; Fibular; Mandible; Free flap; Radiation; Oral neoplasm

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