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BACKGROUND: In reconstructive surgery, improvements are needed in the effective teaching of free flap surgery. There is a need for easily accessible and widely available training without high financial costs or ethical concerns while still providing a realistic experience. Our aim was to develop an appropriate training model for microvascular flaps. METHODS: We identified pig head halves as most appropriate regarding availability, cost, and realism. These accrue largely by the food industry, so no animals need to be sacrificed, making it more ethical from an animal welfare perspective. We evaluated the suitability as flap donor site and analyzed the vascular anatomy of 51 specimens. RESULTS: Anatomical evaluation revealed a reliable and constant vascular anatomy, allowing the design of a flap model that can effectively illustrate the entire process of microvascular flap surgery. The process was divided into 6 key steps. The flap can be harvested after marking the vascular pedicle 5.3 cm from the lateral corner of the mouth. Skin island design and subsequent tissue dissection follow until a fasciocutaneous flap is raised, similar to a radial flap. Upon completion of flap harvesting, it can be freely transferred for defect reconstruction. Microvascular anastomosis can be performed on recipient vessels in the cervical region, and the difficulty can be individually adjusted. CONCLUSIONS: The developed training model is a reasonable compromise in terms of surgical realism, availability, didactic value, and cost/time effectiveness. We believe it is a powerful and effective tool with high potential for improving surgical education and training.

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BACKGROUND: In the surgical treatment of head and neck locally advanced malignancies, microvascular free flaps represent the most valuable solution to reconstruct the tissue defect after resection of the primary neoplasm. In particular, microvascular free flaps allow to restore the functional and aesthetical features of the head and neck compartments. The superficial circumflex iliac perforator (SCIP) flap represents, as an evolution of the groin flap, a valid alternative to the radial fasciocutaneous free (RFFF) flap or the anterolateral thigh (ALT) flap. METHODS: This systematic review adhered to the recommendations of the Preferred Reporting Items of Systematic Reviews and Meta-analysis (PRISMA) 2009 guidelines. A computerized MEDLINE search was performed using the PubMed service of the U.S. National Library of Medicine ( www.pubmed.org ) and Scopus database ( www.scopus.com ). Two authors screened the articles, then selected and extracted data on malignancies characteristics, reconstructive techniques, outcomes, and complications. RESULTS: A total of 25 articles were selected and reviewed among the 39 identified through the search string. Six out of the selected 25 articles were case reports, while the remaining 19 articles were retrospective case series. The whole study population was represented by 174 oncologic patients undergoing ablation of a head and neck tumor and reconstruction with a SCIP flap. The site of reconstruction was the oral cavity in 125 (71.0%) patients, being the tongue the most common subsite in 73 (41.5%) patients, the pharynx in 10 (5.7%) cases, the larynx in 3 (1.7%) and head and neck skin in 36 (20.4%) patients. Only two cases of total flap loss were reported. Partial flap loss or shrinkage requiring minor surgical revisions was observed in 11 patients (6.32%). Primary closure of the donor site was achieved in the whole study population, according to the available data. CONCLUSIONS: In head and neck postoncological reconstruction, despite the caliber and the length of the pedicle, SCIP flap offers a pliable and thin skin paddle, allowing single-stage resurfacing, medium to large skin paddle, possibility of composite-fashion harvest and a well-concealed donor site.

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Scapula tip flaps have been introduced in the literature as an ideal surgical treatment option for large defects in the horizontal plane of the maxilla. This article aims to present a unique step by step protocol for a near total maxillectomy with a pterygoid bone resection and consecutive microvascular reconstruction with a harvested scapula tip flap. The protocol includes immediate placement of extra-short implants in donor bone with the aid of Virtual Surgical Planning (VSP), and an in-house 3D printing of medical 3D models and surgical guides. So far, there has been no presented surgical technique combining immediate implant placement in the scapula region with simultaneous microvascular repair. This technique allows: tumour resection; flap harvesting; extra-short implant placements and reconstruction to be performed in one simultaneous procedure. The technique is presented with illustrations, VSP (presented on videos), radiographs, and surgical findings. We discovered that this refinement of the scapula tip surgery has enabled reconstructive procedures to be performed at the same time as implant placements, providing expedited functional and aesthetic outcomes in selected cases. Moreover, modification of the surgical technique could enhance the competence of the oropharyngeal edge. In conclusion, this new surgical protocol utilizing VSP, 3D models and simultaneous extra-short implant placement provides indispensable advantages for such a complicated surgical procedures, while significantly shortening the duration of surgery.

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Microvascular flap surgery is a widely acknowledged procedure for significant defect reconstruction. Multiple flap complication risk factors have been identified, yet there are limited data on laboratory biomarkers for the prediction of flap loss. The controlling nutritional status (CONUT) score has demonstrated good postoperative outcome assessment ability in diverse surgical populations. We aim to assess the predictive value of the CONUT score for complications in microvascular flap surgery. This prospective cohort study includes 72 adult patients undergoing elective microvascular flap surgery. Preoperative blood draws for analysis of full blood count, total plasma cholesterol, and albumin concentrations were collected on the day of surgery before crystalloid infusion. Postoperative data on flap complications and duration of hospitalization were obtained. The overall complication rate was 15.2%. True flap loss with vascular compromise occurred in 5.6%. No differences in flap complications were found between different areas of reconstruction, anatomical flap types, or indications for surgery. Obesity was more common in patients with flap complications (p = 0.01). The CONUT score had an AUC of 0.813 (0.659-0.967, p = 0.012) for predicting complications other than true flap loss due to vascular compromise. A CONUT score > 2 was indicated as optimal during cut-off analysis (p = 0.022). Patients with flap complications had a longer duration of hospitalization (13.55, 10.99-16.11 vs. 25.38, 14.82-35.93; p = 0.004). Our findings indicate that the CONUT score has considerable predictive value in microvascular flap surgery.

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Rationale: Fibula free flap has become the workhorse for head and neck reconstruction. In this retrospective study we aimed at determining the outcomes of mandibular reconstruction with fibula free flaps. Methods: Any patient who underwent a mandibulectomy and reconstructed with vascularised fibula flap was included in the study. The predictor variables were age, sex, type of lesion, tobacco and alcohol use, tracheostomy, neck dissection, post operative radio and chemotherapy. Flap failure, fistulas, dehiscence, bone exposure and hardware complications were the outcomes. A P value of < 0.05 was considered statistically significant. Results: 242 patient records were selected for evaluation. PORT, CRT, neck dissection, no. of segments were the factors significantly associated with every complication. Malignant lesion was significantly associated with every complication except for plate fracture. Plate fracture although occurred more frequently with malignant diseases, the association was insignificant. Tobacco consumption was significantly associated with increased incidence of post -operative complications. Alcohol consumption was significantly associated with plate fracture, screw loosening, fistulas, bone exposure and flap failure. Conclusion: Overall the fibula free flap has a success rate of 90.0% with fistulas being the most significant complication. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03344-2.

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The authors would like to present the possibilities of reconstructive surgery using free microvascular flaps with bone elements in the treatment of cavities in the head and neck area. The cavities in the presented article resulted both from resection of tumors in the head and neck area as well as congenital defects and radiation damage. The authors would like to discuss the difficulties that may arise during the postoperative period, including the maintenance of the graft's viability, the healing of the donor site and systemic problems. The article presents 33 reconstruction surgeries performed on 31 patients using different flaps, briefly describing their advantages and technical difficulties that may arise during the microvascular anastomoses. The authors emphasise the importance of a well-conducted qualification for the surgery as well as the need to discuss the course of the surgery and recovery and other possible treatment options with patients and their families. The complications that happened in the presented group and how they were treated are described. The authors discuss in details the 3 cases with different types of reconstructive procedures and draw attention to the importance of postoperative care consisting of the constant monitoring of the viability of the graft carried out by qualified personnel of the Otolaryngology Department and appropriately conducted anticoagulant therapy.

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Microvascular procedures require visual magnification of the surgical field, e.g. by a microscope. This can be accompanied by an unergonomic posture with musculoskeletal pain or long-term degenerative changes as the eye is bound to the ocular throughout the whole procedure. The presented study describes the advantages and drawbacks of a 3D exoscope camera system. The RoboticScope®-system (BHS Technologies®, Innsbruck, Austria) features a high-resolution 3D-camera that is placed over the surgical field and a head-mounted-display (HMD) that the camera pictures are transferred to. A motion sensor in the HMD allows for hands-free change of the exoscope position via head movements. For general evaluation of the system functions coronary artery anastomoses of ex-vivo pig hearts were performed. Second, the system was evaluated for anastomosis of a radial-forearm-free-flap in a clinical setting/in vivo. The system positioning was possible entirely hands-free using head movements. Camera control was intuitive; visualization of the operation site was adequate and independent from head or body position. Besides technical instructions of the providing company, there was no special surgical training of the surgeons or involved staff upfront performing the procedures necessary. An ergonomic assessment questionnaire showed a favorable ergonomic position in comparison to surgery with a microscope. The outcome of the operated patient was good. There were no intra- or postoperative complications. The exoscope facilitates a change of head and body position without losing focus of the operation site and an ergonomic working position. Repeated applications have to clarify if the system benefits in clinical routine.

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BACKGROUND: Vascular events are a major cause of flap failure and identifying patients who are at risk is of paramount importance. In the past, many studies have been conducted to investigate the effect of blood count parameters for ischemic events such as peripheral vascular diseases. AIMS: This study aimed to evaluate whether blood count parameters can have predictive value for vascular events in microvascular flap surgery. METHODS: Elective cases with free flap microsurgery performed in a single center were reviewed from 2015 to 2019. Demographic data, comorbidities, flap types, perioperative complications, and preoperative blood count parameters from the hospital records were screened. RESULTS: A total of 147 patients were included in the study, taken from the 163 patients undergoing free tissue transfer. The rate of thrombosis and partial necrosis was 8.8%, was 8.2%, respectively, and the total flap loss due to these complications was 5.4%. Only patient age, gender, and length of hospital stay were correlated with flap loss. According to the preoperative blood count results, there were significant differences between vascular events and leucocyte, and neutrophil counts. CONCLUSION: The findings of this preliminary study suggest that these parameters may be used in predicting vascular events in flap surgery.

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Introduction This is a retrospective therapeutic series of eight cases of facial mucormycosis treated over a 15-year period to determine the safety of simultaneous debridement and free-flap reconstruction in facial mucormycosis. Methods Surgical debridement was done for three cases that presented acutely with systemic manifestations (group 1) and five cases that presented in the subacute phase without systemic manifestations (group 2). The debridement involved total maxillectomy with orbital exenteration in three cases, total maxillectomy with orbital preservation in two, and subtotal maxillectomy in three cases. A total of seven out of eight patients underwent reconstruction with free flap for defect closure; in one patient, only primary closure of mucosa was done. Results The mean follow-up was 20.5 months. Two patients with acute disease, where reconstruction was done, died in the postop period (on the 27th and 6th day post reconstruction, respectively) due to continuing infection and septic shock. One of the three (group 1), who presented acutely and underwent debridement alone, survived. Four of five patients in group 2 underwent successful free-flap reconstruction. The patient with free-flap loss was salvaged with an extracorporeal radial forearm flap. All except one patient had a soft-tissue free-flap reconstruction. Three of the six living patients reported for secondary surgery. The inability to achieve clear nonnecrotic surgical margins due to extensive disease was the reason for mortality in two patients in group 1. There was no mortality in any of the group 2 patients, even when debridement and free-flap coverage was done simultaneously. Conclusion Simultaneous debridement and free flap can be successfully implemented in select cases of facial mucormycosis.

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Surgical treatment for patients with actinomycosis with head and neck reconstruction should be considered as a reliable treatment option with a good long-term effect.

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PURPOSE: Early persistent/recurrent hypopharyngeal tumours represent a challenge for surgeons who have to balance the need for oncological radicality and the desire to maintain a functioning larynx with preservation of the patient's quality of life. The aim of this study was primarily to understand the technical feasibility, functional outcomes, and the possibility of obtaining oncological radicality using lateral hypopharyngectomy with laryngeal preservation in early recurrent post-radio/(chemo)therapy hypopharyngeal tumours. METHODS: Patients with recurrent T1 hypopharyngeal squamous cell carcinoma were retrospectively selected from our institutional database. The external lateral approach according to Spriano and a modified lateral hypopharyngectomy with laryngeal preservation were used to resect tumours of the lateral pyriform sinus wall. Reconstruction was obtained by direct approximation of the posterior border of the sectioned thyroid cartilage to the posterior hypopharyngeal wall, and this was reinforced with a second layer of vascularised and non-irradiated tissue that was provided by a microvascular fascial anterobrachial flap. Swallowing was assessed 3 weeks after surgery using videoendoscopic evaluation. RESULTS: The surgical procedure was technically feasible, and complete resection was obtained in all patients. None of the patients experienced major post-operative complications (salivary fistula, bleeding, aspiration pneumonia). Mild dysphagia was observed in one patient who underwent swallowing rehabilitation. Tracheostomy was closed in all patients. No recurrence was recorded after a median follow-up of 20 months. CONCLUSION: The reported experience shows that, in selected cases, it is possible to radically remove lateral hypopharyngeal cancer with acceptable functional results.

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In the present study, the reproducibility and postoperative stability of a 3D printed surgical guide were evaluated in mandibular reconstruction with an osteocutaneous free flap (OCFF), including a fibular free flap (FFF) and deep circumflex iliac artery free flap (DCIA). Fifteen patients were enrolled, and a 3D surgical guide was fabricated by simulation surgery using preoperative (T0) Computed tomography (CT) images. Mandibular reconstruction was performed with OCFF using the 3D surgical guide. Postoperative CTs were taken immediately, 1 week (T1), and 6 months (T2) after surgery, to evaluate the reproducibility of the 3D surgical guide and condyle stability. Error of the 3D surgical guide ranged from 0.85 to 2.56 mm. There were no differences in reproducibility according to flap type. Condylar error and error at mandible midpoint were significantly different in FFF. However, there was no difference in DCIA error between the condyle and mandible midpoint. Regarding condyle stability 6 months after surgery, condyles moved more than 2 mm (up to 2.85 mm) in FFF, whereas there were no significant movement in DCIA. Careful intraoperative flap fixation and closed postoperative observation should be considered for stable clinical outcome, especially in the case of FFF.

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INTRODUCTION: Commercial CAD/CAM planning of free osteocutaneous microvascular fibula flap does not support integration of soft tissue structures including perforator vessel anatomy. Therefore, in a clinical trial, a method for such a combined hard- and soft tissue 3D-fibula planning was assessed. MATERIALS AND METHODS: In a clinical study on 24 patients needing reconstruction with osteocutaneous fibula graft, skin perforators of the respective leg were detected via Doppler sonography and documented on a measurement device. Each of the perforators' localization was transferred to a CAD/CAM planning software and included in each planning step as well as in the surgical cutting guide. A comparison between sonography and clinical localization, damage to perforator vessels during surgery as well as a subjective evaluation of feasibility and usefulness of the procedure was carried out. RESULTS: In total, 19 skin paddles were placed orally, 2 extraorally and 3 at both sites at once. Survival rate was 92% (22/24). In addition, 3 skin paddles were lost complete and 2 partially. Anatomical sites of perforator vessels were never < 1 cm from planned positions and not damaged at all (n = 75). Planning was judged useful for skin paddle design and positioning of osteotomies. In accordance, surgical guides were always implemented successfully without the need of changing planned procedures during surgery. CONCLUSION: Integration of skin perforators into 3D planning of microvascular fibular graft is feasible and may even decrease involuntary dissection of perforator vessels. Even so, clinical studies for comparison are needed.

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OBJECTIVES: Increasingly, aging societies pose a challenge, particularly in the most developed countries. This trend leads to an increasing group of old and very old patients presenting unique requirements and challenges. One of these challenges consists in reassessment and adaption of established treatment strategies for the elderly patients. There is an ongoing discussion taking place among cranio-maxillo-facial surgeons about the appropriate extent of reconstructive flap surgery for old patients. MATERIALS AND METHODS: This monocentric retrospective cohort study investigated 281 reconstructions with microvascular flaps by comparing the risk for a negative outcome, which was defined as revision, flap loss, and patient death, between three subgroups of elderly patients and younger patients. The three subgroups of elderly patients were defined as-1: young old (65-74 years), 2: old (75-84 years), and 3: oldest old (≥ 85 years). The group of the younger patients was defined by age between 50 and 64 years. Data were obtained within a defined period of 42 months. RESULTS: Significant correlations with a negative outcome were found for the variables stay on IMC/ICU, multiple flaps, and radiotherapy prior surgery. Our data showed no significant correlation between age and a higher risk for a negative outcome. CONCLUSION: Defect reconstruction with microvascular flaps in old patients is not related with a higher risk for a negative outcome. CLINICAL RELEVANCE: Independently of age, treatment with microvascular flaps is an option for all operable patients, with an indication for oncologic surgery. For optimal therapy planning, individual patient resources and preferences should be considered instead of chronologic age.

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Objective: Failure rates of microvascular autologous breast reconstruction are reportedly low. When failure of the microvascular anastomoses does occur, it is most likely to be salvaged if detected early. Flap compromise or venous congestion occurring several weeks later is uncommon and with significantly lower salvage rates. Methods: We present a unique case of delayed venous congestion of a single-perforator deep inferior epigastric perforator flap breast reconstruction in which the usual pedicle thrombosis was not identified. Presentation of the flap compromise occurred 72 hours postoperatively and again in the delayed setting 5 weeks after surgery, from suspected compression at the perforator level. Results: The deep inferior epigastric perforator flap was successfully salvaged with conservative measures, and the flap healed without fat necrosis or further complication. Conclusion: This case highlights the higher risk of flap compromise with reconstructions in a radiated field and potentially with single-perforator flaps.

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Background and Objective: Thrombosis due to inherited hypercoagulability is an issue that has been raised in microvascular flap surgery previously. We analyzed the association of a single nucleotide polymorphism (SNP) in rs2066865 in the fibrinogen gamma chain (FGG) gene, alteration in plasma fibrinogen concentration, and presence of microvascular flap thrombosis. Materials and Methods: A total of 104 adult patients with microvascular flap surgery were subjected to an analysis of the presence of SNP rs2066865 in the FGG gene. Alterations in plasma fibrinogen concentration according to genotype were determined as a primary outcome, and flap thrombosis was defined as a secondary outcome. Results: Flap thrombosis was detected in 11.5% of patients (n = 12). Successful revision of anastomosis was performed in four patients, resulting in a microvascular flap survival rate of 92.3%. We observed an increase in plasma fibrinogen concentration in genotype G/A and A/A carriers (G/G, 3.9 (IQR 4.76-3.04); G/A, 4.28 (IQR 5.38-3.18); A/A, 6.87 (IQR 8.25-5.49) (A/A vs. G/A, p = 0.003 and A/A vs. G/G, p = 0.001). Within group differences in microvascular flap thrombosis incidence rates were observed-G/G 6/79 (7.59%); G/A 5/22 (22.7%); A/A 1/3 (33.3%) (OR 0.30 95%; CI 0.044 to 0.57), p = 0.016; RR 3.2-when G/G versus G/A and A/A were analyzed respectively. Conclusions: A/A and G/A genotype carriers of a single nucleotide polymorphism in rs2066865 in the fibrinogen gamma chain gene had a higher plasma fibrinogen concentration, and this might be associated with an increased microvascular flap thrombosis incidence rate. Determined polymorphism could be considered as a genetic marker associated with microvascular flap thrombosis development. To confirm the results of this study, the data should be replicated in a greater sample size.

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RESUMEN: La reconstrucción de la cabeza y el cuello contempla avances importantes a lo largo de los años. Los colgajos microvasculares se han convertido en la primera opción de tratamiento en grandes defectos del territorio maxilofacial, mientras tanto, la tecnología con el uso de microscopía y luego las imágenes como CT, angiografía por tomografía computarizada, dispositivo ultrasónico, RNM o Doppler contribuyen a lograr una predictibilidad excepcional de estos colgajos microvasculares. Por lo general, la técnica de anastomosis consiste en una sutura de 9-0 en 360°, pero existen autores que han descrito diversos métodos que no son de sutura con un rendimiento aceptable. Existe un buen número de diferentes colgajos microvasculares, cuatro de ellos son los más comunes en la reconstrucción maxilofacial: fíbula, ilíaco, antebrazo radial, escápula. Además el colgajo anterolateral, muy útil en defectos de piel y tejidos blandos. La evolución de los colgajos microvasculares implica los colgajos quiméricos, muy útiles en defectos grandes. El objetivo de este artículo es describir y exponer el desarrollo de la microcirugía y las diversas opciones de colgajos microvasculares en la reconstrucción maxilofacial.

ABSTRACT: Head and neck reconstruction have shown important advances over the years. Microvasculars flaps transfer has become the first treatment option in large defects of the maxillofacial area. Meanwhile technology through the use of microscopy and the subsequent use of images such as CT, CT angiography, RNM or Doppler ultrasonic device, and additional new techniques have contributed to an exceptional predictability of these microvascular flaps. Typically, the anastomosis technique consists in 9-0 suture in 360°, but since the vascular flaps exist, authors have described diverse non-suture methods with acceptable performance. There are a number of different microvasculars flaps, four of them are the most common in maxillofacial reconstruction: fibula, iliac, radial forearm, scapula. In addition the anterolateral tight flap, very useful in skin and soft tissues defects. The microvascular flaps evolution involves the chimeric flaps that are useful in large defects. The aim of this article is to describe and expose microsurgery development and the diverse microvascular flap options in maxillofacial reconstruction.

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For the treatment of skin necrosis with exposed tendons in rheumatoid arthritis (RA) foot, we should perform microvascular free flap surgery at an early stage without conservative treatment considering the increased risk of infection and the decreased physical activity.

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Autologous microsurgical flap reconstruction has become commonplace in most plastic surgery units, and the success rates of this procedure have markedly increased over recent years. However, the possibility of flap failure still needs to be considered. A review of the literature reveals that the critical period for flap-threatening complications is the first 24-48 post-operative hours; however, the window for the onset of these complications remains open for up to 7 days post-operatively. In this study, we focus on the timing of flap complications, aiming to elucidate the time period over which meticulous flap monitoring can positively contribute to flap salvage rates. The relevant literature on the study topic was collated and reviewed in conjunction with the senior author's case series, which consisted of a total of 335 free flaps used during a 2-year period for breast and head and neck reconstruction or limb trauma. Patients' series were then divided into groups according to the complications timing. The correlation between the timing of complications and the flap salvage rate was investigated among the groups. Overall analysis of both the literature and our own data on 335 free flaps showed a progressive reduction in flap salvage rate during post-operative days; the correlations between the times of complication onset and the flap salvage rates in all groups were significant up to the third post-operative day. The correlations between salvage rates and later complications were not significant. Our results suggest that hourly flap monitoring should be compulsory during the first 48 post-operative hours, but clinical monitoring four times daily should be sufficient thereafter.

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INTRODUCTION: Major facial defects due to cancer or deformities can be reconstructed through microvascular osteocutaneous flaps. Hereby CAD/CAM workflows offer a possibility to optimize reconstruct and reduce surgical time. We present a retrospectiv observational study regarding the developement of an in-house workflow allowing an accelerated CAD/CAM fibula reconstruction without outsourcing. CASE DESCRIPTION: Workflow includes data acquisition through computertomography of head and legs, segmentation of the data and virtual surgery. The virtual surgery was transferred into surgical guides and prebent osteosynthesis plate. Those were sterilized and used in surgery. EVALUATION: The workflow was used in 30 cases. Minimum planning period took 4 days from CT to surgery, average time was 8 days. Planning could be transferred to surgery every time. Intraoperative complications regarding osteotomy, assembly and fixation did not occur. DISCUSSION/CONCLUSION: An in-house workflow for CAD/CAM fibula reconstruction is feasible within a few days providing an accelerated procedure even in urgent cases.