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Background: The scapular free flap has increasingly gained popularity as an alternative to the fibular free flap in osseous head and neck reconstruction. The authors evaluated its use in maxillomandibular reconstruction and examined surgical and patient outcomes.

Methods: Osseous head and neck defects reconstructed with an angular artery-based scapular flap or fibular flap from 2016 to 2022 at 2 Swedish university hospitals were evaluated for their intraoperative execution (osseous and soft-tissue combinations) and postoperative outcomes. Facial quality of life (QoL) was assessed using the FACE-Q Head and Neck Cancer module. Donor-site morbidity was assessed using the Disabilities of the Arm, Hand, and Shoulder (DASH) and Self-Evaluated Foot and Ankle Score (SEFAS) questionnaires for scapular- and fibular-reconstructed cases, respectively.

Results: A total of 120 patients were recruited, 86 with mandibular reconstructions (26 scapulas, 60 fibulas) and 34 with maxillary reconstructions (32 scapulas, 2 fibulas). The concave scapula facilitated fewer osteotomies for curved reconstructions, particularly for lateral mandibular defects (P = 0.039). Intraoral lining was primarily achieved with muscle accompanying the scapula and skin accompanying the fibula. Using the latissimus dorsi muscle instead of only teres major decreased fistulas, plate/bone exposure, and nonunions (P = 0.039) in scapular reconstructions. Both flaps demonstrated comparable facial QoL, but the scapula presented superior donor-site outcomes (P = 0.001). Donor limb outcomes were unaffected by harvesting the latissimus dorsi with the scapula (P = 0.64) or by resuturing the detached muscles to the remaining scapula (P = 0.35).

Conclusion: The scapular free flap can be advantageous in osseous head and neck reconstructions, enabling nonosteotomized and chimeric reconstructions without compromising surgical outcomes or QoL.

INTRODUCTION:The development of post-operative abdominal compartment syndrome is one of the major risks associated with the repair of massive parastomal hernias. Minimizing the occurrence of such post-operative complications is imperative but challenging. Plastic surgery techniques in complex hernia repairs can offer significant advantages in such complex surgeries.CASE PRESENTATION:We present a case of a 26-year-old, obese, non-smoking male with a massive left-sided parastomal hernia extending below the inguinal region. The hernia was confirmed on a pre-operative computed tomography (CT) and seen to include most of the remaining bowel area. Pre-operative optimization of the abdominal wall was performed by ultrasound-guided botulinum toxin injections to all three abdominal wall muscles bilaterally. The surgery was performed in three steps involving the reduction of the hernia, abdominal wall component separation, closure of the abdominal wall with dual mesh placement, de-epithelization and folding of excess abdominal skin, and repositioning of the stoma. Post-operatively, the patient was followed-up for pain, ventilatory problems, and increasing abdominal pressures.CONCLUSION:Massive parastomal hernia repair avoiding post-operative abdominal compartment syndrome can be achieved by application of a multi-dimensional surgical approach. The use of pre-operative Botox represents an innovative approach that may reduce the risk of post-operative complications.

Microsurgical reconstruction constitutes a fundamental part of plastic and reconstructive surgery. It demands high dexterity and intricate technical skills. Its steep learning curve benefits from thorough training throughout residency, where using realistic simulation models in the appropriate sequence of complexity progression is essential in ensuring patient safety prior to progressing to a clinical setting. Commencing training on microvascular-like small diameter vessels could prove unsuitable and ineffective for inexperienced surgeons, however, the larger diameter neurovascular structures in the porcine thigh can provide excellent anastomotic training without compromising the animal tissue training sought after by residents. We present the results from implementing the first vascular anastomotic course in our country, where reconstructive theory was combined with simulated anastomotic training on the porcine thigh. Junior plastic surgery residents described acquiring comprehensive knowledge of reconstructive techniques and could successfully complete anastomoses, despite none to minimal previous experience. Using the porcine thigh should be encouraged as a start-up vascular anastomotic training tool as it provides realistic conditions and tissue handling training, and could improve quality of further training on microvascular structures.

Background

The pectoralis major myocutaneous pedicled (PMMP) flap is still considered by many a workhorse flap in head and neck (H&N) reconstruction, despite free flap surgery advancing. The authors aimed to examine this claim and associated myths and controversies by analyzing literature trends and revealing the role of the PMMP flap in a well-established microsurgery center.

Methods

The senior author’s reconstructive H&N practice between 1995 and 2022 was reviewed to describe and critically judge primary and secondary PMMP flap decisions to provide invaluable lessons learned and debunk common controversies related to complex H&N reconstruction. A literature review from 1978 to 2022 evaluated PMMP flap articles from plastic surgery and allied H&N specialties, with a deeper analysis on publications from 2010 onward.

Results

In 27 years of practice, the senior author performed 2871 major H&N reconstructions, including 27 PMMP flaps. Both primary (13/27) and secondary (14/27) PMMP flaps decreased over time. Indications shifted from external skin compromise (fistulae/metastases) to complex medical morbidity and high-risk neck status. Neck status was increasingly evaluated based on any previous violation, surgical or irradiative, rather than simply number of remaining vessels. A literature review revealed an ongoingly abundant and primary PMMP flap use, largely by non-plastic surgeons.

Conclusion

The PMMP flap can and should be reserved for complex, high-risk or free flap-exhausted cases. Thus, current indications deserve redefinition. Multidisciplinary collaboration in specialized centers with plastic surgeons is imperative to ensure appropriate reconstructive rational and protect patient outcomes, as changing reconstructive hands and starting anew risks reconstructive regression.

Early facial nerve reconstruction should be offered in every patient with oncological resections of the facial nerve due to the debilitating functional and psychosocial consequences of facial nerve palsy. Oncologic pathology or oncologic resection accounts for the second most common cause of facial nerve palsy. In the case of these acute injuries, selecting an adequate method for reconstruction to optimize functional and psychosocial well-being is paramount. Authors advocate consideration of the level of injury as a framework for approaching the viable options of reconstruction systematically. Authors breakdown oncologic injuries to the facial nerve in three levels in relation to their nerve reconstruction methods and strategies: Level I (intracranial to intratemporal), Level II (intratemporal to extratemporal and intraparotid), and Level III (extratemporal and extraparotid). Clinical features, common clinical scenarios, donor nerves available, recipient nerve, and reconstruction priorities will be present at each level. Additionally, examples of clinical cases will be shared to illustrate the utility of framing acute facial nerve injuries within injury levels. Selecting donor nerves is critical in successful facial nerve reconstruction in oncological patients. Usually, a combination of facial and nonfacial donor nerves (hybrid) is necessary to achieve maximal reinnervation of the mimetic muscles. Our proposed classification of three levels of facial nerve injuries provides a selection guide, which prioritizes methods for function nerve reconstruction in relation of the injury level in oncologic patients while prioritizing functional outcomes.

The use of virtual surgical planning (VSP) and computer-aided design and manufacturing to assist in osseous reconstruction has become the standard of care in head and neck reconstruction. The use of the free fibula flap with VSP remains the most common flap for osseous reconstruction, and as such, it is well described in the published literature. The scapular free flap (SFF) based on the angular branch has not yet garnered the same attention. The popularity of the SFF osseus head and neck reconstruction is increasing due to the flaps' inherently different properties and indications it can fulfill; the natural curvature of the bone, the reduced incidence of atheroscelerosis in the donor vessels and the earlier postoperative mobilization of the patient. In the preoperative planning process, the SFF presents several unique challenges and considerations that differ from the free fibula flap. It is important for surgeons already using, or considering using the SFF, that VSP is used correctly to achieve optimal outcomes. The authors aim to describe and clarify aspects of VSP use in SFF reconstruction in the head and neck area with a specific focus on: (1) The perforator-like vascular anatomy of the scapula; (2) How to maximize the shape of the scapula to minimize osteotomies; (3) Fine-tuning of scapula osteotomies on side table; (4) How to plan cutting guide placement and fit on the scapula. The authors hope that this article will help reconstructive microsurgeons plan and perform the SFF in conjunction with VSP.

Background This study investigated the outcomes of nipple-sparing mastectomy (NSM) with a deep inferior epigastric perforator (DIEP) flap using delayed primary retention suture (DPRS) to achieve superior breast esthetics.

Methods Between December 2010 and March 2021, patients who underwent NSM with DIEP flap were inset with or without a skin paddle (using DPRS) as Group A or B, respectively. Demographics, operative findings, complications, BREAST-Q questionnaire, and Manchester scar scale were compared between two groups.

Results Twelve patients underwent 12 unilateral reconstructions in Group A, while 12 patients underwent 13 DIEP flaps in Group B. There was no significant difference in demographics, ischemia time, flap-used weight and percentage, complications of hematoma, infection, re-exploration, partial flap loss, and total flap loss (All p > 0.05, respectively). At a mean 9 months of follow-up, the Breast-Q "Satisfaction with surgeon" domain was significant in Group B (p = 0.04). At a mean 12 months of follow-up, the overall Manchester scar scale of 10.3 in Group B was statistically superior to 12.6 in Group A (p = 0.04).

Conclusions The NSM with a DIEP flap using DPRS is a reliable and straightforward technique. It can provide greater cosmesis of the reconstructed breast mound in a single-stage procedure.

Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients.

Methods: Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey.

Results: Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest.

Conclusion: The authors reflect on the causes and propose preventative strategies in each peri-operative stage.

BACKGROUND: Advantages of one-stage implant-based reconstructions include expedited surgery and recovery. This study aimed to investigate clinical and patient-reported outcomes in one-stage implant-based breast reconstructions without acellular dermal matrix (ADM).

METHODS: A prospectively collected database from 2002 to 2018 was retrospectively reviewed. One-stage and two-stage groups were compared for demographics, implant properties, early complications (hematoma, seroma, poor wound healing, implant removal), late complications (skin necrosis, capsular contracture, implant exposure, implant rupture), revision procedures, and Breast-Q questionnaire outcomes.

RESULTS: A total of 223 patients, 187 one-stage (84%) and 36 two-stage (16%) patients were recruited. At a mean follow-up of 124.9 and 92.5 months, respectively (p < .01), there were no differences in early (p = .85) or late (p = .23) complications or revision procedures (p = .12). Eighty patients (36%) returned the Breast-Q questionnaire (60 one-stage, 20 two-stage patients). There were no statistical differences in patient reported outcomes in breast well-being (p = .07), psychosocial well-being (p = .84), or sexual well-being (p = .78).

CONCLUSIONS: One-stage implant-based breast reconstruction without an ADM is a viable reconstruction providing comparable outcomes to two-stage procedures, with the benefit of minimal complications, a shorter reconstructive journey, and satisfactory quality of life.