Peirong Yu

Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction

The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction.

A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients.

Background: The anterolateral thigh free flap may be harvested as a fasciocutaneous perforator flap or as a myocutaneous flap by including variable amounts of the vastus lateralis muscle. The authors sought to determine the donor-site morbidity associated with both types of flap dissection. Methods: Between 2005 and 2008, the authors performed 220 reconstructive operations using the anterolateral thigh free flap. Complications and donor-site function were evaluated prospectively. Results: Variable amounts of vastus lateralis muscle were harvested with the flap in this series: 25 percent included no muscle, 38 percent included minimal muscle, 33 percent included the superficial half of the muscle, and 4 percent included the entire muscle. The motor nerve to the vastus lateralis muscle was spared during dissection of the flap pedicle in 78 percent but required division in 22 percent. Complications included seroma (5 percent), wound dehiscence (2 percent), hematoma (1 percent), infection (1 percent), neuroma (1 percent), and partial skin graft loss (1 percent). Eighty-four percent of patients reported a sensory loss in the distribution of the lateral femoral cutaneous nerve. Weakness or instability was reported by 8 percent of patients at their initial postoperative visit but resolved in all patients within 6 months. All patients regained their postoperative level of activity. Conclusions: The anterolateral thigh free flap is associated with a low rate of complications and functional morbidity. Even when the motor nerve to the vastus lateralis is divided, or substantial amounts of thigh fascia or vastus lateralis muscle are included in the flap design, all patients return to their preoperative level of function.

Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flap versus the jejunal flap.

Background: Pharyngoesophageal defects are commonly reconstructed with free jejunal or fasciocutaneous flaps, with various outcomes, and a direct comparison is lacking. Methods: Fifty-seven circumferential pharyngoesophageal reconstructions with an anterolateral thigh flap (n = 26 patients) performed by a single surgeon or jejunal flap (n = 31 patients) performed by six experienced surgeons between 1998 and 2004 were reviewed and outcomes were compared. Results: Total flap loss occurred in one (4 percent) and two (6 percent) patients, fistula rates were 8 percent and 3 percent, and stricture rates were 15 percent and 19 percent in the anterolateral thigh and jejunal flap groups, respectively (p > 0.5). A completely oral diet was achieved in 95 percent and 65 percent, and fluent tracheoesophageal speech was achieved in 89 percent and 22 percent of patients with the anterolateral thigh and jejunal flaps, respectively (p < 0.01). The mean lengths of postoperative ventilator support, intensive care unit stay, and hospital stay were 1.0 ± 0.2, 1.7 ± 1.0, and 8.0 ± 3.7 days for the anterolateral thigh flap group and 2.2 ± 3.0, 3.0 ± 3.2, and 12.6 ± 7.9 days for the jejunal flap group (p < 0.001 for all), respectively. Mean hospital charges per patient were

Pharyngoesophageal reconstruction with the anterolateral thigh flap: a clinical and functional outcomes study.

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Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy

12,651 for the anterolateral thigh and jejunal flap groups, respectively (p = 0.02). Conclusions: With the limitations of comparing a single surgeons results with those of multiple surgeons, the anterolateral thigh flap appears to offer better speech and swallowing functions and quicker recovery and to be more cost-effective than the jejunal flap for pharyngoesophageal reconstruction. The complication rates were similar.

Free flap reconstruction of osteoradionecrosis of the mandible: a 10-year review and defect classification.

Background: Functional outcomes and morbidities of pharyngoesophageal reconstruction have not been satisfactory. The purpose of the present study was to evaluate such outcomes following pharyngoesophageal reconstruction with the anterolateral thigh flap. Methods: Reconstruction of pharyngoesophageal defects was performed in 41 consecutive patients with the anterolateral thigh flap. There were 31 circumferential and 10 near-circumferential defects. In the initial nine patients, a portion of the flap was externalized for monitoring by deepithelializing a strip of skin at the distal anastomosis. This technique resulted in a 33-percent fistula rate and was thus modified for the subsequent 32 patients, in whom a true end-to-end, spatulated anastomosis was performed. Results: Total flap loss occurred in one patient, and one patient had partial flap necrosis due to ischemic bowel and sepsis. The mean hospital stay was 6.7 ± 1.9 days. With the modified technique, fistulas occurred in two out of 25 patients (8 percent) and two out of seven patients (29 percent) with circumferential and near-circumferential defects, respectively, for an overall fistula rate of 13 percent. Strictures occurred in three out of 25 (12 percent) of patients with circumferential defects only. Fluent speech was achieved in all 13 patients who had successful tracheoesophageal prosthesis placement. Among the 34 patients available for diet assessment, two patients (6 percent) required partial tube feeding owing to extensive tongue resection; all other patients tolerated a regular (88 percent) or pureed (6 percent) diet. Conclusion: The anterolateral thigh flap offers comparable complication rates, superior speech and swallowing functions, minimal donor-site morbidity, a quick recovery, and a short hospital stay.

Perforator patterns of the anteromedial thigh flap

Pharyngoesophageal defects traditionally have been reconstructed using a jejunal or radial forearm flap. In 2002, the authors began using the anterolateral thigh flap for pharyngoesophageal reconstruction, and it has become our preferred method. The purpose of this study was to analyze the clinical and functional outcomes achieved using this technique.

Design of a reliable skin paddle for the fibula osteocutaneous flap: perforator anatomy revisited.

The purpose of this study was to evaluate outcomes of free flap reconstruction for advanced osteoradionecrosis (ORN) defects and develop an algorithm to guide surgical planning.

Reconstruction of extensive head and neck defects with multiple simultaneous free flaps.

Background: The vascular anatomy of the anteromedial thigh flap has not been well defined. The purpose of this study was to determine the perforator patterns and vascular anatomy of this flap. Methods: The perforators of the anteromedial thigh flaps and their origins were prospectively explored, documented, and mapped. Results: Twenty-one of 100 thighs had no anteromedial thigh perforators. For the remaining thighs, there were two sources of perforators: the rectus femoris branch of the descending branch of the lateral circumflex femoris artery, and the superficial femoral artery. Perforators from the latter were short and small and thus less useful. Anteromedial thigh flaps based on rectus femoris branch perforators shared the same vascular pedicle as the anterolateral thigh flap and were thus clinically useful. These rectus femoris branch perforators, however, were present in only 51 percent of the patients. Their surface locations follow a similar pattern as the anterolateral thigh flap, with the majority of perforators near the midpoint, but an average of 3.2 cm medial to a line connecting the anterior superior iliac spine and the superolateral patella. Forty-three thighs had a single rectus femoris branch perforator and eight had two perforators. Sixty-six percent were septocutaneous and the rest traversed a thin layer of the rectus femoris muscle. Conclusions: The perforator patterns of the anteromedial thigh flap were examined and defined. It is best to plan the anteromedial thigh flap to complement the anterolateral thigh rather than to be the primary flap.

Decellularized tracheal matrix scaffold for tissue engineering

Background: Designing a reliable fibula flap skin paddle can be challenging because of the lack of information on precise perforator locations. The purpose of this study was to precisely map the perforators and provide a simple and reliable method for skin paddle design. Methods: Eighty consecutive patients undergoing free fibula flap reconstruction were included in this prospectively designed study. The location, size, and type of perforators were recorded intraoperatively and mapped on the line connecting the fibular head and lateral malleolus. Results: There were 46 male and 34 female patients with a total of 202 perforators. The average length of the fibular head and lateral malleolus line was 36.1 ± 3.4 cm (male patients, 38.2 ± 2.2 cm; female patients, 34.1 ± 2.7 cm). Two discrete groups of perforators could be identified. The proximal perforator was consistently found one-third the length and 1.5 cm posterior to the line. The majority of these perforators (84 percent) were musculocutaneous. The more clinically useful perforators to support a skin paddle are the distal ones over the third quarter of the fibula. One to three distal perforators were consistently present, grouped as perforators A, B, and C at points 0.51, 0.62, and 0.73 along the line, respectively. Perforators were approximately 3.5 cm apart and 2 cm posterior to the line, and the majority (96 percent) were septocutaneous. Conclusions: Using common anatomical landmarks, a reliable skin paddle can be designed with simplicity and confidence over the third quarter of the fibula. The proximal perforator can be useful as a second skin paddle for through-and-through reconstruction.