Michael Wagels

Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 consecutive cases.

BACKGROUND The Jejunal Free Flap (JFF) was first described by Seidenberg in 1957 for the reconstruction of pharyngolryngectomy defects. Historically, its outcome profile has been better than alternative reconstructions. Recently, the use of tubed Fasciocutaneous Free Flaps (FCFF) has been increasing as series reporting outcomes superior or equivalent to JFF are published. Our experience with JFF has been more positive than recently published reports suggest. This study aims to provide an accurate and up-to-date assessment of outcomes in JFF reconstruction of pharyngolaryngectomy defects and to compare these results to those of contemporary alternative techniques. METHODS 368 Consecutive free jejunum reconstructions were performed for pharyngolaryngectomy defects between 1977 and 2010. All patients had been assessed by a multidisciplinary Head and Neck Clinic prior to surgery. A systematic review of recent literature pertaining to pharyngolaryngectomy reconstruction outcomes was undertaken for comparison with our dataset. RESULTS 70.9% of tumours in this series were T-grade 3 or 4. Perioperative mortality was 3.8% and flap failure occurred in 2.98%. The incidence of anastomotic leak was 8.2% and stricture occurred in 10.9%. A full oral diet was maintained by 91.6% of patients by day 12 on average. 70.6% underwent primary tracheo-oesophageal puncture and of these 78.1% had effective speech. CONCLUSIONS Overall, our data compares favourably with other series. The strengths of the JFF reconstruction are the capacity to maintain an oral diet, low stricture and leak rates and the versatility to reconstruct long segment defects. We have observed variability in leak rates throughout the study period, which may be operator dependant. The gap between outcomes for FCFF and JFF reconstructions has narrowed but the latter remains our reconstruction of choice for pharyngolaryngectomy defects.

Muscle versus Fasciocutaneous Free Flaps in Heel Reconstruction: Systematic Review and Meta-Analysis

BACKGROUND Management of soft tissue injuries of the heel is challenging and the composition of free tissue transfer that provides optimal aesthetic and functional outcomes in heel reconstruction is not clear. While fasciocutaneous flaps may result in shear planes that cause instability with mobilization, insensate muscle flaps may not be able to withstand the pressures of weight bearing and thus ulcerate. METHODS A systematic literature search was performed using Medline and PubMed databases. Primary outcome measures were time to mobilize, ulceration, revision or debulking surgery, and the requirement for specialized footwear. Analysis of pooled outcomes was undertaken using fixed-effects meta-analysis, calculating the incidence rate ratio for included articles. RESULTS Overall 576 articles were identified; out of which 11 articles met the final inclusion criteria, detailing 168 free tissue transfers in 163 patients. The study size ranged from 4 to 72 cases. There was a trend toward higher rates of ulceration (17 vs. 26%), requirement for revision (23 vs. 31%), and the requirement for specialized footwear (35 vs. 56%) in muscle flaps, but these differences were not statistically significant. CONCLUSION The current review provided a summary of reported outcomes of free heel reconstruction in the literature till date. With the current evidence largely limited to small cohort studies (level IV evidence), there were no significant differences found between reconstructive options. These findings serve as a call to action for more reconstructive surgeons to collaborate on multi-institutional prospective studies with robust outcomes assessment. As such, an ideal flap for reconstruction of the weight-bearing heel has not yet been made clear.

History of lower limb reconstruction after trauma

The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important.

Poland's syndrome: an alternative to the 'vascular hypothesis'.

We have identified a case of Poland syndrome in which a patent pectoral branch of the thoraco-acromial artery was present and of near normal caliber. This finding is an alternative to the dominant etiological hypothesis of disruption to the subclavian artery during Carnegie stage 19 (days 42–47 of embryogenesis), creating a sequence of ischaemia followed by aplasia of the pectoral girdle and upper limb musculature [2–4]. An alternative theory has been proposed in which it is suggested that the anomaly results from a failure of the paraxial mesenchyme to develop, as described elsewhere for similar anomalies [1]. The patient, a 57-year-old man with known right-sided Poland syndrome, was undergoing a delay procedure for a right-sided deltopectoral (DP) flap. This was being performed to provide a ‘‘lifeboat’’ for a planned pharyngolaryngectomy and free jejunum flap for recurrent squamous cell carcinoma in a vessel-depleted neck. The normal left pectoralis major had been used in a salvage procedure during surgical management of the primary malignancy 8 years prior. On performing the DP delay, both heads of pectoralis major were absent; however, the pectoral branch of the thoraco-acromial artery was clearly evident during dissection (Fig. 1) and on review of preoperative computed tomography angiography. Importantly, there were two distinct layers of fascia present in the ‘pectoral’ space. This is not consistent with the vascular disruption hypothesis, which would support the absence of the pectoralis major alongside its blood supply and fascial support. It is postulated that the fascia seen represents an embryologic remnant of the somatopleuric mesenchyme which would have directed formation of the muscle. Upper limb and axial musculature is derived from mesenchymal cells during the 5th week of development [5]: (1) somatopleuric mesenchyme gives rise to connective tissue, cartilage, bone and tendon; (2) paraxial mesenchyme from the somites gives rise to myogenic cells of muscle; (3) angiogenic mesenchyme gives rise to the vascular supply of the limb, for derivatives of both somatopleuric and paraxial mesenchyme. Our patient had two distinct layers of fascia binding loose areolar tissue with a clear arterial supply. Our case can be best described by an isolated defect in the paraxial mesenchyme during early limb development, rather than an interruption in the blood Fig. 1 Dissection of the pectoral component to the deltopectoral free flap. Green arrows illustrate the two distinct layers of fascia binding the pectoral branch of the thoracoacromial axis with surrounding areolar tissue (blue arrow) (colour figure online)

Moderators of angiogenesis in muscle flaps: a non-randomised animal study

INTRODUCTION A muscle flap can survive a pedicle injury under favourable conditions. In the reconstruction of compound limb injuries, the wound milieu is variable and may affect the rate and manner of neovascularisation. Our aim is to determine the effect of some key clinical variables on neovascularisation in muscle flaps in an animal model. METHODOLOGY The pectoralis profundus was raised in 60 rats and covered with a skin graft. Fifteen rats were allocated to each of the following groups: separation of the flap from the skin inset (S), inflammation by inoculation with Staphylococcus aureus (I), flap elevation with harmonic scalpel (H) and preservation of the motor nerve (N) as well as compared to controls (C). Graft take and wound complications were assessed five days later, as well as perfusion before and after pedicle ligation, by laser Doppler flowmetry and neovascularisation using barium angiography. RESULTS Flaps with an intact motor nerve had significantly higher graft take than controls (59% vs 29%). Perfusion change was lesser in all study groups than in controls, although the extent of flap necrosis was not significantly different. Only flaps raised with the harmonic scalpel generated more new vessels than controls at the inset (9.6 vs 3.2), particularly at the origin of the muscle (1.10 vs 0.19). CONCLUSIONS All study groups were less dependent on their pedicle for perfusion than controls. The use of the harmonic scalpel and increased inflammation seem pro-angiogenic, although they do not reduce flap necrosis after simulated pedicle injury. Neovascularisation will preferentially bridge to the skin at the inset rather than tissues in the base of the wound. It is likely that flap necrosis is the result of a combination of unfavourable variables rather than one in isolation.

Basal Cell Carcinoma Involving a Ventriculoperitoneal Shunt: Case Report and Literature Review

Ventriculoperitoneal shunts (VPSs) are commonly used for the management of raised intraventricular pressure, especially in the context of hydrocephalus. Malignant invasion involving a VPS is an exc...

Response to Re: History of lower limb reconstruction after trauma

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