Cheng, Hsu-Tang

Major pretibial degloving injuries are complex wounds, which can be challenging to treat. Despite recent advances in reconstructive options, most of these injuries still require a prolonged healing period and may result in amputation. Few reports have been published on the management of these complex traumatic injuries. In this article, we present a case of an octogenarian, frail patient with a major pretibial degloving injury. Treatment included serial surgical debridements in combination with negative pressure wound therapy aimed at salvaging the avulsed tissue. Subsequently, a fenestrated-type artificial dermis and negative pressure wound therapy were used as combined therapy so as to obtain adequate soft tissue coverage. The patient made an unremarkable recovery and was discharged on day 22 after injury. The wound healed by secondary intention without need for skin grafting.

Objective: The aim of this systematic review is to analyze the 30-day postoperative mortality in patients undergoing free flap reconstruction for head and neck cancer published in literature and to identify associated factors. Methods: The authors performed a literature search between January 1950 and February 2020 in PubMed, EMBASE, and Scopus, using a combination of Medical Subject Headings headings and text keywords related to head and neck cancer; microsurgery or free flap reconstruction; and 30-day mortality. Inclusion criteria were: original studies in English reporting on 30-day mortality after head and neck free flap reconstruction in adult population. Results: Thirty-one publications reported on a total of 13,447 patients who underwent head and neck free flap reconstruction. The published 30-day postoperative mortality ranged from 0% to 6.3%, with an average of 1.21%. A number of studies examined the association between mortality and body mass index, American Society of Anesthesiologists, and comorbidity score and age. One study found that underweight patients had significantly higher mortality. Two studies found no association between the American Society of Anesthesiologists score and 30-day postoperative mortality; however, 1 study reported significantly higher mortality with increased comorbidity score. Regarding association with age, 3 studies found significant higher mortality in older patients, while 5 studies found no difference. Conclusions: The average 30-day postoperative mortality in patients undergoing head and neck free flap reconstruction is 1.21% and is; therefore, not negligible. Careful patient selection and preoperative optimization are essential in order to reduce mortality in head neck free flap reconstruction.

Background Complications from prosthetic breast reconstruction are distressing for patients, and their management is challenging. For decades, negative-pressure wound therapy (NPWT) has been successfully used for the closure of complex wounds. This study analyzes the outcomes of NPWT use in the prevention and management of complications from prosthetic breast reconstruction. Method A systematic search of studies published until August 2020 was conducted using the PubMed/MEDLINE, EMBASE, and Ebscohost/CINAHL databases and using the following key words: “negative-pressure wound therapy,” “breast reconstruction,” and “prosthesis” (including breast implants and tissue expanders). Analyzed endpoints were outcomes of NPWT use in prosthetic breast reconstruction compared with conventional dressings. The methodological quality of included studies was assessed independently. Comparative studies were further meta-analyzed to obtain pooled odds ratios (ORs) describing the effectiveness of NPWT in prosthetic breast reconstruction. Results/Discussion Ten studies were included with a total of 787 patients (1230 breasts) undergoing prosthetic breast reconstruction with breast implants or tissue expanders. Three case-control studies focused on preventing breast wound complications. The meta-analysis of the 3 studies included 502 breasts receiving NPWT and 698 breasts receiving conventional wound care. The meta-analysis favored NPWT for less mastectomy flap necrosis (5.6% vs 14.3%; OR, 0.46; 95% confidence interval, 0.27 –0.77; P = 0.004; I 2 = 0%) and less overall wound complications (10.6% vs 21.1%; OR, 0.49; 95% confidence interval, 0.35–0.70; P < 0.00001; I 2 = 0%). In the management of nipple-areolar complex venous congestion, 1 case report demonstrated 85% rescue of nipple-areolar complex after using NPWT (−75 mm Hg) for a total of 12 days. In the management of periprosthetic infections, 2 case series used NPWT with instillation. It accelerated the treatment of infection and maintained the breast cavity for future reconstruction. Conventional NPWT also showed good salvage outcome in four studies. Conclusions Current evidence suggests that prophylactic use of NPWT in prosthetic breast reconstruction reduces the rate of overall wound complications and mastectomy flap necrosis. In the management of complications from prosthetic breast reconstructions, NPWT may be a promising option showing beneficial results. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

PurposeFree flap reconstruction in head and neck cancer patients with prior tumor resection, neck dissection, and irradiation is clinically challenging. The purpose of this study was to investigate the reliability and outcome of using the anterolateral thigh (ALT) flap and transverse cervical recipient vessels for microvascular reconstruction in patients with depleted vessels in the head and neck region caused by previous surgery and irradiation.MethodsBetween January 2015 and December 2017, microsurgical head and neck reconstruction was performed using the ALT flap and transverse cervical artery (TCA) as the recipient vessel in 15 patients who had undergone previous neck dissections and irradiation for cancer treatment. All patients had a “vessel-depleted neck” resulting from severe scarring and radiation fibrosis. Clinical data of each patient were recorded.ResultsAll ipsilateral TCAs were found to be damage free. Subsequently, free ALT flaps were revascularized using the TCAs. One patient developed venous thrombosis, and another patient developed arterial thrombosis. They were both salvaged within 6 hours postoperatively. No flap failure or mortalities were reported within the 30-day postoperative period. Two patients developed orocutaneous fistula and were further managed with wound care. The mean follow-up time was 11.9 ± 6.0 months (range, 5–23 months). Five patients died during the follow-up period from cancer progression.ConclusionsThe use of the free ALT flap and TCA as the recipient vessel provides favorable microsurgical outcomes in patients with depleted recipient vessels in the head and neck region caused by previous neck dissections and radiation therapy.

Background Patients diagnosed with end-stage renal disease (ESRD) are increasing at around 5% annually. Some of these patients will require free tissue transfers to reconstruct their body after trauma or cancer resection. Comorbidities can increase the level of complexity during reconstruction. Aim Our goal is to describe the outcomes of ESRD patients under dialysis who underwent free tissue transfer for head and neck reconstruction. Methods Two cohorts were analyzed: ESRD group on dialysis and a non-ESRD control group after free tissue transfer for head and neck reconstruction. Postoperative complications and mortality were recorded. For coexisting comorbidities, we determine the presence of diabetes mellitus (DM) and peripheral vascular disease (PVD). Results In this study, 85 cases with ESRD on dialysis and 841 controls were analyzed. Most patients were aged ≤ 65 years (82.5%) and nearly 92.9% of them were men. Types of head and neck cancer were neoplasm of other and unspecified parts of the mouth followed by neoplasm of tongue, the gingiva, hypopharynx, and floor of mouth. Patients with ESRD tended to have higher rates of DM and PVD (p < 0.001) and were significantly associated with an increased risk of stroke and increased risk of 30-day mortality. However, there was no significant difference regarding flap failure among groups. Conclusion Despite greater preoperative risk factors, patients with renal failure on hemodialysis do not appear to have a higher rate of free flap failure following head and neck reconstruction. However, other complications can be minimized by optimizing patient's medical condition to succeed with this reconstructive effort.

AbstractVascularized lymph node transfer has demonstrated promising results for the treatment of extremity lymphedema. In an attempt to find the ideal donor site, several vascularized lymph nodes have been described. Each has a common goal of decreasing morbidity and avoiding iatrogenic lymphedema while obtaining good clinical results. Herein, we present the preliminary clinical outcomes of an intra‐abdominal lymph node flap option based on the appendicular artery and vein used for the treatment of extremity lymphedema. A 62 year‐old woman with moderate lower extremity lymphedema, on chronic antibiotics because of recurrent infections and unsatisfactory outcomes after conservative treatment underwent a vascularized appendicular lymph node (VALN) transfer. At a follow‐up of 6 months, the reduction rate of the limb circumference was 17.4%, 15.1%, 12.0% and 9% above the knee, below the knee, above the ankle and foot respectively. In addition, no further episodes of infection or other complications were reported after VALN transfer. Postoperative lymphoscintigraphy demonstrated that the VALN flap was able to improve the lymphatic drainage of the affected limb. According to our findings, the use of VALN transfer minimizes donor‐site morbidity, avoids iatrogenic lymphedema and may provide a strong clearance of infection because of the strong immunologic properties of the appendiceal lymphatic tissue in selected patients. Despite these promising results, further research with larger number of patients and longer follow‐ up is needed.