Albert H. Chao

The effect of neoadjuvant versus adjuvant irradiation on microvascular free flap reconstruction in sarcoma patients.

Background: Sarcoma patients often require radiation therapy in addition to surgical resection. Although neoadjuvant irradiation possesses advantages over adjuvant irradiation related to smaller doses and field sizes, existing studies suggest adverse effects on wound healing and possibly microvascular free flap success. Conversely, microvascular reconstruction may counteract some of the negative effects of irradiation by replacing irradiated tissue with well-vascularized unirradiated tissue from a distant site. Methods: A review of sarcoma patients who underwent resection, microsurgical reconstruction, and either neoadjuvant or adjuvant irradiation was performed. Results: A total of 119 patients met inclusion criteria, of which 73 underwent neoadjuvant irradiation and 46 underwent adjuvant irradiation. Sarcomas were located in the head and neck (n = 47), trunk (n = 7), upper extremity (n = 15), and lower extremity (n = 50). The rate of perioperative (⩽30 days) complications was 26.9 percent, whereas the rate of late recipient-site complications was 14.3 percent. No significant differences in perioperative recipient-site (p = 0.19), donor-site (p = 1.00), or medical complications (p = 0.30) were observed between patients undergoing neoadjuvant and adjuvant irradiation. Free flap loss rates were lower in patients undergoing neoadjuvant irradiation (0 percent versus 8.7 percent, respectively; p = 0.02). Late recipient-site complications occurred less often in patients undergoing neoadjuvant radiation (6.8 percent versus 26.1 percent, respectively; p = 0.006). Conclusions: Neoadjuvant irradiation does not increase the risk of acute wound or microvascular complications when combined with free flap reconstruction, and is associated with fewer late recipient-site complications than adjuvant irradiation. These factors should be considered when determining the timing of radiation therapy in sarcoma patients undergoing oncologic resections and microsurgical reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10-year experience.

In scalp reconstruction, soft tissue and osseous defects frequently coexist. The purpose of this study was to compare outcomes of simultaneous scalp and calvarial reconstruction to scalp only reconstruction.

Proximal vascular pedicle preservation for sartorius muscle flap transposition.

Background: A variety of muscle flaps have been described to treat complex groin wounds associated with infected and/or exposed femoral vessels or vascular grafts and persistent lymphatic leaks, and for prophylaxis against wound breakdown following inguinal lymphadenectomy. The sartorius muscle flap has several advantages over other muscle flaps: it is immediately adjacent to the groin, it is easy to prepare, and the harvest causes no functional morbidity. Despite these advantages, the flap’s reliability has been questioned because of the segmental blood supply to the muscle and the flap’s limited arc of rotation. To improve the reliability of the flap, the authors defined the proximal vascular anatomy of the sartorius muscle in 20 human cadavers and assessed the correlation with 20 clinical cases. They describe a technique for the harvest of the sartorius muscle transposition flap that preserves the most proximal pedicle. Methods: From July of 2000 to January of 2004, 40 sartorius muscles were dissected in 20 human preserved cadavers. During the same time period, 21 sartorius muscle transposition flap procedures were performed in 19 patients for a variety of complex groin wound complications, including infection (n = 10), lymphadenectomy (n = 4), lymphatic leak (n = 3), exposed femoral vessels (n = 3), and high-risk wound (n = 1). The location of the most proximal vascular pedicle with respect to the anterior superior iliac spine was measured in each cadaveric dissection as well as in each clinical case. Outcomes were assessed in the clinical cases with respect to wound healing. Results: The distance between the anterior superior iliac spine and the proximal vessels in the cadaver specimens was 6.6 ± 1.3 cm (range, 5.0 to 9.5 cm). The distance between the anterior superior iliac spine and the proximal vessels in the clinical patients was 6.2 ± 0.6 cm (range, 5.5 to 7.5 cm). Patients were followed for an average period of 30 months (range, 5 to 45 months). There were no incidences of partial or total flap necrosis. All wounds healed to completion. Conclusions: The proximal pedicle of the sartorius muscle is consistently located at 6.5 cm from the anterior superior iliac spine. Preservation of the proximal pedicle during dissection ensures the viability of the sartorius muscle transposition flap for the treatment of complex groin wounds.

Outcomes of calvarial reconstruction in cancer patients.

Background: Limited data exist on outcomes of calvarial reconstruction in cancer patients, including the relative efficacy of various cranioplasty materials, and risk factors for complications. Methods: A retrospective review was performed of cancer patients who underwent calvarial reconstruction over a 12-year period. Results: A total of 269 patients underwent 289 calvarial reconstructions. Materials used for cranioplasty included titanium mesh (49.8 percent), methylmethacrylate (16.3 percent), porous polyethylene (4.8 percent), polyetheretherketone (4.5 percent), calcium phosphate cement (3.8 percent), autologous bone grafts (2.1 percent), or a combination of materials (18.3 percent). Perioperative (⩽30 days after surgery) complications occurred in 42 cases (14.5 percent), of which 29 (10.0 percent) were at the recipient site, most commonly infection (2.8 percent) and cerebrospinal fluid leak (2.4 percent). Risk factors for perioperative complications included radiation therapy (p = 0.012), prior surgery (p = 0.003), and prior infection (p = 0.014). Late recipient-site complications (>30 days after surgery) occurred in 20 cases (6.9 percent), including infection (3.8 percent) and wound dehiscence (3.1 percent), and for which radiation therapy was identified as a risk factor (p = 0.011). The use of calcium phosphate cement in combination with titanium mesh was associated with a higher long-term complication rate (p < 0.001). Twenty-five cases (8.7 percent) required cranioplasty removal, with infection and dehiscence being risk factors for implant loss (p < 0.001 for both). Conclusions: Alloplastic cranioplasty is effective in cancer patients with calvarial defects. Commonly used materials have similar complication profiles, with the possible exception of calcium phosphate cement, which is associated with a higher rate of complications when combined with titanium mesh and used to reconstruct larger defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Lower extremity reconstruction with the anterolateral thigh flap

The versatility and location of the anterolateral thigh (ALT) flap make it well suited for lower extremity reconstruction. The purpose of this study was to evaluate surgical and functional outcomes by specific anatomic regions in the lower extremity to better define the role of the ALT flap in lower extremity reconstruction. A retrospective review of patients undergoing lower extremity reconstruction with an ALT flap between July 2002 and December 2010 was performed. Total 46 patients underwent lower extremity reconstruction with an ALT flap, of whom 29 (63%) had a pedicled flap and 17 (37%) a microvascular free flap. Defects were located in the hip/buttocks (n = 8), groin (n = 13), thigh (n = 8), knee (n = 5), leg (n = 6), and foot/ankle (n = 6). The mean postoperative follow-up was 4 months. Total flap loss occurred in two patients (4%). There were 11 recipient site complications (24%). The most common complication was recipient site seroma, which occurred in five patients (11%), all of whom had hip/buttock or groin defects. Overall, 38 patients (83%) returned to their preoperative functional status. The ALT flap is an effective method of lower extremity reconstruction. It can be performed as a pedicled or free flap, with good surgical and functional outcomes.

Obturator nerve transfer for femoral nerve reconstruction: anatomic study and clinical application.

Background: Femoral nerve lesion causes significant disability. In many cases, the availability of the proximal stump is in question and further complicates surgical management by severely limiting reconstructive options and precluding nerve graft reconstruction. The purpose of this report is to describe the successful restoration of quadriceps function by distal nerve transfer at the level of the thigh without functional donor morbidity and the findings of cadaveric dissections of the obturator and femoral nerve branches. Methods: Eight fresh frozen cadaveric lower limbs were dissected at the region of the groin and thigh. Two patients were referred to us with complete femoral nerve palsy and unavailability of the proximal femoral nerve for reconstruction by conventional methods. Distal nerve transfers were performed using the anterior branch of the obturator nerve and in one case, the motor branch to the tensor fasciae latae to reinnervate the rectus femoris and vastus medialis muscles. Results: As measured in cadaveric specimens, the transferable lengths of each donor nerve branch when used to innervate any combination of quadriceps muscles provide plenty of length for tension-free end-to-end coaptations. One patient recovered 3 to 4/5 Medical Research Council grade knee extension and the other 4+/5 knee extension. The latter patient is able to walk, run, and use stairs normally, whereas the former still has difficulty with fast ambulation, running, and stairs. Conclusion: The authors present a novel reconstructive approach that yields good clinical outcomes, as well as an anatomic study that demonstrates the feasibility of this technique.

Bone-Supported Arch Bars Are Associated With Comparable Outcomes to Erich Arch Bars in the Treatment of Mandibular Fractures With Intermaxillary Fixation

PURPOSE Titanium arch bars that are directly fixated to the maxilla and mandible with self-drilling locking screws combine features of Erich arch bars and bone-supported devices and present an alternative method of intermaxillary fixation (IMF) that possesses potential advantages over existing techniques. The objective of this study was to compare IMF using this device with Erich arch bars secured with circum-dental wires. MATERIALS AND METHODS A retrospective cohort study was performed of patients who were surgically treated for mandibular fractures from 2012 through 2013. The primary predictor variable was fixation technique, which was IMF using Erich arch bars secured with circum-dental wires (group I) or titanium arch bars fixated with maxillary and mandibular screws (group II). The outcome variables were complication rates, time necessary for device application and removal, glove perforation rate, and cost. Statistical analysis was performed with InStat (GraphPad, Inc, La Jolla, CA) using the Fisher, χ(2), or Mann-Whitney test, as appropriate. RESULTS Twenty-five consecutive cases in group I and in group II were reviewed. There were 43 male patients (86%) and 7 female patients (14%) with a mean age of 28.4 years. Mean follow-up was 2.0 months. Overall complication rates for groups I and II were similar (16.0% vs 12.0%, respectively; P = 1.00). In group II, there were 3 instances of delayed wound healing at the sites of gingivobuccal incisions attributed to the close proximity of the arch bar eyelets. The time necessary for device application was faster in group II than in group I (42 vs 62 minutes, respectively; P = .02). CONCLUSIONS Bone-supported arch bars may be a comparable alternative to Erich arch bars secured with circum-dental wires for IMF. Careful planning of transoral incisions in relation to locking screw eyelets may help minimize wound complications.

Current approaches to free flap monitoring.

Postoperative monitoring of free flaps remains an essential component of care in patients undergoing microsurgical reconstructive surgery. Early recognition of vascular problems and prompt surgical intervention improve the chances for flap salvage. Physical examination remains the cornerstone of free flap monitoring, but more recently, additional technologies have been developed for this purpose. In this article, current approaches to free flap monitoring are reviewed.

Surgical management of soft tissue sarcomas: Extremity sarcomas

Wide surgical resection is the recommended treatment for extremity soft tissue sarcomas. Chemotherapy and/or radiotherapy may improve local control, but with marginal effect on overall survival. Advanced reconstructive techniques and multidisciplinary care, including plastic surgery, may allow a higher rate of limb salvage. This report focuses on surgical and reconstructive aspects in the multimodality care of extremity sarcomas. J. Surg. Oncol. 2015 111:540–545.

A review of devices used in the monitoring of microvascular free tissue transfers.

The use of microvascular anastomoses to allow transfer of viable tissue is a fundamental technique of reconstructive surgery, and is used to treat a broad spectrum of clinical problems. The primary threat to this type of reconstructive surgery is anastomotic vascular thrombosis, which can lead to complete loss of tissue with potentially devastating consequences. Monitoring of tissue perfusion postoperatively is critical, since early recognition of vascular compromise and prompt surgical intervention is correlated with the ability for tissue salvage. Traditionally, physical examination was the primary means of monitoring, but possesses several limitations. Medical devices introduced for the purposes of flap monitoring address many of these deficiencies, and have greatly enhanced this critical aspect of the reconstructive surgery process.