BACKGROUND: In microvascular head and neck reconstruction, ischemia of the free flap tissue is inevitable during microsurgical anastomosis and may affect microvascular free flap perfusion, which is a prerequisite for flap viability and a parameter commonly used for flap monitoring. The aim of this study was to investigate the influence of the number of ischemia intervals and ischemia duration on flap perfusion.
METHODS: Intraoperative and postoperative flap blood flow, hemoglobin concentration, and hemoglobin oxygen saturation at 2 and 8 mm tissue depths, as measured with the O2C tissue oxygen analysis system, were retrospectively analyzed for 330 patients who underwent microvascular head and neck reconstruction between 2011 and 2020. Perfusion values were compared between patients without (control patients) and with a second ischemia interval (early or late) and examined with regard to ischemia duration.
RESULTS: Intraoperative and postoperative flap blood flow at 8 mm tissue depth were lower in patients with early second ischemia intervals than in control patients [102.0 arbitrary units (AU) vs 122.0 AU, P = .030; 107.0 AU vs 128.0 AU, P = .023]. Both differences persisted in multivariable analysis. Intraoperative and postoperative flap blood flow at 8 mm tissue depth correlated weakly negatively with ischemia duration in control patients (r = -.145, P = .020; r = -.124, P = .048). Both associations did not persist in multivariable analysis.
CONCLUSIONS: The observed decrease in microvascular flap blood flow after early second ischemia intervals may reflect ischemia-related vascular flap tissue damage and should be considered as a confounding variable in flap perfusion monitoring.

The maxilla plays a crucial role in maintaining midfacial contour, supporting the globe and dentition and separating the oral and nasal cavity. Reconstruction of total maxillectomy defects has always been a challenge in head and neck surgery. In recent years, on the basis of existing methods, we have used the coronoid-temporalis pedicled flap combined with personalized titanium mesh and free flap to reconstruct total maxillectomy defects. This combination of multiple methods can restore the functional subunits of the maxilla. In this report, we introduce our surgical procedures in detail and assess the postoperative effects. Postoperative facial aesthetic outcomes were satisfactory in all 8 patients. None of the patients showed diplopia, oral-nasal reflux, hypernasality, titanium mesh exposure, or trismus. This new surgical procedure may be a simple and feasible option for the reconstruction of total maxillectomy defects.

To explore the effect of early swallowing training on postoperative outcomes of patients who had undergone oral cancer surgery plus free flap reconstruction.
In this prospective, randomized controlled trial, 121 patients who had undergone oral cancer surgery plus free flap reconstruction were randomly assigned to the control (n = 59) or intervention group (n = 62). The control group underwent routine nursing measures. The intervention group received swallowing training on the sixth postoperative day. On the 15th day and 1 month after surgery, the swallowing function (Mann Assessment of Swallowing Ability-Oral Cancer [MASA-OC] score), weight loss rate, time of nasogastric tube removal, and quality of life were evaluated.
Patients in the intervention group had higher MASA-OC scores and better weight loss rates than those in the control group on the 15th day (MASA-OC: p = 0.014, weight loss: p < 0.001) and 1 month (both p < 0.001) after surgery. The time of nasogastric tube removal and the quality of life was statistically significant between groups (p < 0.001).
Early swallowing training improves the swallowing function, nutritional status, and quality of life and shortens the indwelling time of nasogastric tube of patients who have undergone oral cancer surgery plus free flap reconstruction.

OBJECTIVE: Endoscopic total mastectomy (ETM) is predominantly performed with reconstruction using prostheses, lipofilling, omental flaps, latissimus dorsi flaps, or a combination of these techniques. Common approaches include minimal incisions, e.g., periareolar, inframammary, axillary, or mid-axillary line, which limit the technical ability to perform autologous flap insets and microvascular anastomoses, as such the ETM with free abdominal-based perforator flap reconstruction has not been robustly explored.
METHODS: We studied female patients with breast cancer who underwent ETM and abdominal-based flap reconstruction. Clinical-radiological-pathological characteristics, surgery, complications, recurrence rates, and aesthetic outcomes were reviewed.
RESULTS: Twelve patients underwent ETM with abdominal-based flap reconstruction. The mean age was 53.4 years (range 36-65). Of the patients, 33.3% were surgically treated for stage I, 58.4% for stage II, and 8.3% for stage III cancer. Mean tumor size was 35.4 mm (range 1-67). Mean specimen weight was 458.75 g (range 242-800). Of the patients, 92.3% successfully received endoscopic nipple-sparing mastectomy and 7.7% underwent intraoperative conversion to skin-sparing mastectomy after carcinoma was reported on frozen section of the nipple base. Mean operative time for ETM was 139 minutes (92-198), and the average ischemic time was 37.3 minutes (range 22-50). Fifty percent of patients underwent deep inferior epigastric perforator, 33.4% underwent MS-2 transverse rectus abdominis musculocutaneous (TRAM), 8.3% underwent MS-1 TRAM, and 8.3% underwent pedicled TRAM flap reconstruction. No cases required re-exploration, no flap failure occurred, margins were clear, and no skin or nipple-areolar complex ischemia/necrosis developed. In the aesthetic outcome evaluation, 16.7% were excellent, 75% good, 8.3% fair, and none were unsatisfactory. No recurrences were observed.
CONCLUSIONS: ETM through a minimal-access inferior mammary or mid-axillary line approach, followed by immediate pedicled TRAM or free abdominal-based perforator flap reconstruction, can be a safe means of achieving an \"aesthetically scarless\" mastectomy and reconstruction through minimal incisions.

Facial gunshots injuries remain challenging and present functional and aesthetic problems. Such defects generally require composite tissue flaps for reconstruction. Rebuilding the palate and the maxilla is especially delicate because it requires reconstitution of the facial buttresses, and replacement of bony hard palate, based on occlusion, as well as the restoration of the thin intraoral and intranasal lining which normally constitute the soft palate. Various methods of reconstruction have been applied to this area in search of an ideal soft tissue and bone flap to restore the bony framework of the maxilla and palate while providing an internal lining. The scapula dorsal perforator flap is used in the case of a patient to successfully reconstruct the palate, the maxilla and the nasal pyramid in one stage. Free tissue transfer using thoracodorsal perforator flaps and scapula bone free flap have been already described in literature but never to perform the nasal pyramid reconstruction at the same time. Good functional and aesthetic results have been obtained in this case. This article also reviews, through the authors experience and literature, anatomical landmarks, indications, technical surgical tricks, advantages and disadvantages of this flap for palatal, maxillary and nose reconstruction.

The mandible (lower jaw) bone is aesthetically responsible for shaping the lower face, physiologically in charge of the masticatory movements, and phonetically accountable for the articulation of different phonemes. Thus, pathologies that result in great damage to the mandible severely impact the lives of patients. Mandibular reconstruction techniques are mainly based on the use of flaps, most notably free vascularized fibula flaps. However, the mandible is a craniofacial bone with unique characteristics. Its morphogenesis, morphology, physiology, biomechanics, genetic profile, and osteoimmune environment are different from any other non-craniofacial bone. This fact is especially important to consider during mandibular reconstruction, as all these differences result in unique clinical traits of the mandible that can impact the results of jaw reconstructions. Furthermore, overall changes in the mandible and the flap post-reconstruction may be dissimilar, and the replacement process of the bone graft tissue during healing can take years, which in some cases can result in postsurgical complications. Therefore, the present review highlights the uniqueness of the jaw and how this factor can influence the outcome of its reconstruction while using an exemplary clinical case of pseudoarthrosis in a free vascularized fibula flap.

Interventional strategies for dealing with microvascular free flap failure are varied among institutions and even individual surgeons. This systematic review aims to identify the published methods for salvaging a failing free flap and provide surgeons with a comprehensive toolset for successful intervention. A title and abstract search of the PubMed, Embase, and Web of Science databases was performed. 1694 abstracts were screened by three reviewers according to Prisma guidelines. 62 full text articles meeting inclusion criteria detailed techniques which were separated into the categories of thrombectomy, thrombolysis, leech therapy, vascular fistula, and an \"other\" category outlining techniques which did not fit into the prior framework. Assessment of the efficacy of individual salvage techniques is limited due to limited empirical data, however, the approach to successful salvage should be based on timely identification of flap compromise, followed by the implementation of one or several of the aforementioned techniques.

Determine the safety and effectiveness of a nasogastric tube removal plan designed to shorten nasogastric tube indwelling time after oral cancer surgery plus free flap reconstruction.
A parallel randomized clinical trial was conducted from May 2021 to December 2021 at Peking University School of Stomatology. Volunteers (n = 128) were separated into four groups: non-tracheostomy control and intervention groups and tracheostomy control and intervention groups. Control patients received the conventional nasogastric tube removal plan. Non-tracheotomy intervention patients were asked to swallow 5 ml of water on the first postoperative day. If there was no coughing, they were allowed progressively increasing amounts of water for the following 2 days. The nasogastric tube was removed only after ensuring level I/II performance on the Watian water swallowing test, no \"wet voice\" after drinking water, no marked decrease in blood oxygen saturation after drinking, and satisfactory daily oral nutritional intake. Tracheotomy intervention patients received the same protocol plus an additional Watian water swallowing test after tracheal tube removal.
Nasogastric tube removal time was earlier in the intervention subgroups than in control subgroups: 5.0 ± 2.3 days versus 7.8 ± 3.9 days (p = 0.001) in non-tracheostomy patients and 9.8 ± 1.1 days versus 16.2 ± 13.0 days (p = 0.049) in tracheostomy patients. Incidence of wound complications and daily food intake were comparable between the groups. The incidence of pneumonia was lower in the tracheostomy intervention group than in the tracheostomy control group (12.5% vs. 3.1%, p = 0.162). Pharyngeal pain score was lower in tracheotomy intervention patients than in tracheotomy control patients (p = 0.029). Postoperative hospital stay was shorter in tracheotomy intervention patients than in tracheotomy control patients (p = 0.005).
On the basis of ensuring safety and effectiveness, patients undergone free flap reconstruction for oral cancer could be offered oral intake early after surgery, which will not increase the incidence of wound complications and pneumonia or adversely affecting the oral intake of the patients; it can also help minimize pharyngeal pain and shorten postoperative hospital stay of patients with a tracheotomy.
2 Laryngoscope, 133:1382-1387, 2023.

The aim of this study was to explore a new total tongue reconstruction strategy based on the five-point eight-line segment (FIPELS) technique and a palatal speech appliance, and to evaluate the functional and aesthetic outcomes. Twenty patients with tongue squamous cell carcinoma were included in this study. All patients underwent total tongue resection followed by tongue reconstruction with an anterolateral thigh flap. The patients were divided randomly into two groups according to the reconstruction strategy: FIPELS group (10 patients) and traditional flap design group (10 patients). All 10 patients in the FIPELS group received a palatal speech appliance 1 month after the surgery. A Likert scale was used to assess swallowing function, speech articulation, and the aesthetic outcome of the reconstructed tongue in the traditional and FIPELS (with and without the palatal speech appliance) groups. Compared with the traditional group, swallowing function (1 month, P = 0.016; 3 months, P = 0.021) and the aesthetic outcome (1 month, P = 0.016; 3 months, P = 0.020) were significantly better in the FIPELS group (without the palatal speech appliance); however, there was no significant difference in speech articulation (1 month, P = 0.549; 3 months, P = 0.513). Within the FIPELS group, significantly better speech articulation was obtained with the palatal speech appliance than without it (1 month, P = 0.031; 3 months, P = 0.015).

BACKGROUND: Single free flaps are a commonly used reconstructive method for multiple soft tissue defects in digits. We analyzed the flap size, division timing, and degree of necrosis in cases with various types of flap division.
METHODS: We conducted a retrospective review of the medical charts of patients who had undergone single free flap reconstruction for multiple soft tissue defects across their digits from 2011 to 2020. The flap types included were the lateral arm free flap, venous forearm free flap, thenar free flap, hypothenar free flap, anterolateral thigh free flap, medial plantar free flap, and second toe pulp free flap. Flap size, anastomosed vessels, division timing, and occurrence of flap necrosis were retrospectively investigated and then analyzed using the t-test.
RESULTS: In total, 75 patients were included in the analysis. The success rate of the free flaps was 97.3%. All flaps were successfully divided after at least 17 days, with a mean of 47.17 days (range, 17-243 days) for large flaps and 42.81 days (range, 20-130 days) for the medium and small flaps (P=0.596). The mean area of flap necrosis was 2.38% in the large flaps and 2.58% in the medium and small flaps (P=0.935). Severe necrosis of the divided flap developed in two patients who had undergone flap division at week 6 and week 34.
CONCLUSIONS: In cases where blood flow to the flap has been stable for more than 3 weeks, flap division can be safely attempted regardless of the flap size.