Seminars in Plastic Surgery最新文献

Total laryngopharyngectomy for advanced hypopharyngeal and laryngeal cancers results in complex defects that compromise both swallowing and phonation. Restoration of these functions is critical for quality of life, yet reconstructive options present unique challenges. This study evaluates the outcomes of free ileocolon flaps and J-designed anterolateral thigh (J-ALT) flaps for simultaneous reconstruction of the pharyngoesophagus and voice conduit in patients undergoing total laryngopharyngectomy. Between 1988 and 2025, 231 patients underwent ileocolon flap reconstruction, and from 2014 to 2025, 124 patients underwent J-ALT flap reconstruction. Technical refinements, including plication of the ileocecal valve and precise flap inset, were implemented to optimize swallowing and phonation. In the ileocolon cohort, overall flap survival was 97%, with low rates of fistula and anastomotic complications; 78% of patients achieved good swallowing function, and 64% demonstrated satisfactory speech outcomes. The J-ALT flap demonstrated comparable swallowing outcomes, with 97% of patients resuming oral intake and 50% achieving fluent speech through the neophonation tube. Both techniques avoided the complications associated with tracheoesophageal prostheses, including obstruction, infection, and mechanical failure. These findings highlight that meticulous surgical planning and a multidisciplinary approach can achieve reliable long-term restoration of alimentary and vocal function. Both ileocolon and J-ALT flaps represent viable reconstructive options for patients with a favorable life expectancy.

Secondary reconstruction in head and neck cancer refers to surgical procedures performed following the initial primary reconstruction to address complications, residual defects, or recurrent or second primary tumors. The timing of secondary reconstruction can be categorized as either immediate or delayed. Immediate reconstruction is typically required in cases of flap failure or acute complications such as fistula or great vessel exposure. In contrast, delayed reconstruction addresses long-term sequelae such as trismus, oral incompetence, and mandibular or maxillary defects, as well as late complications including plate exposure and osteoradionecrosis (ORN). The interval between initial treatment and secondary reconstruction may range from several months to several years, depending on the clinical condition and patient preference. Thorough planning and appropriate patient selection are critical for optimal functional and aesthetic outcomes. This article focuses on conditions commonly encountered in delayed secondary reconstruction; immediate reconstruction is covered elsewhere.

Free tissue transfer has become the gold standard for reconstructing complex head and neck defects, achieving success rates exceeding 95% in experienced centers. Despite these advances, vascular compromise remains the leading cause of flap failure, most commonly occurring within the first 24 to 72 hours postoperatively. Early detection of arterial or venous thrombosis is therefore critical to maximize flap salvage and optimize patient outcomes. Conventional clinical monitoring, including assessing flap color, temperature, capillary refill, tissue turgor, and bleeding on pinprick, remains the cornerstone of postoperative surveillance due to its simplicity, noninvasiveness, and universal applicability. However, its accuracy depends heavily on clinical experience and is limited in cases such as buried or intraoral flaps where direct observation is restricted. To improve diagnostic sensitivity and objectivity, various adjunctive technologies have been introduced, including handheld and implantable Doppler ultrasonography, laser Doppler flowmetry, thermography, and near-infrared (indocyanine green) angiography. These modalities can provide quantitative or continuous perfusion data, facilitating earlier recognition of vascular compromise. Nonetheless, each technique carries limitations related to cost, invasiveness, and susceptibility to artifacts, and no single method has proven superior to clinical evaluation alone. Effective monitoring requires structured protocols, multidisciplinary coordination, and prompt surgical re-exploration when perfusion deficits are suspected. Integration of multimodal strategies tailored to flap type and patients offer the best balance between sensitivity and practicality. This paper aims to standardize monitoring algorithms, evaluate cost-effectiveness, and explore novel technologies such as artificial intelligence-assisted systems to further enhance early detection, improve flap salvage rates, and optimize reconstructive outcomes.

Osteoradionecrosis of the mandible refers to necrosis of bone and often with surrounding tissues after radiotherapy. This is often compounded by chronic infection, leading to debilitating outcomes on the patient's quality of life. In this article, we discuss the incidence, risk factors, diagnosis, staging, pathophysiology, and management of this condition. We discuss our experience in managing this condition, which can vary depending on severity and patient factors, when taking into account approaches ranging from conservative to surgical resection and free flap reconstruction.

Developing several backup strategies for high-risk reconstruction cases is crucial to patient outcomes in head and neck cancer patients. Free tissue transfer always carries the risk of flap failure, and often, surgeons can be caught out with difficult-to-close wounds over crucial areas. In this article, we discuss several difficult cases after failed free flap reconstruction with crucial structures exposed. The backup reconstruction options need to be robust and reliable. The article focuses on defects in the head and neck area, including the cranium, oropharyngeal defects, and other defects on the external area of the head and neck. Often, a repeat free flap may be required, but if possible or if local or regional options are available, they would be preferable, given the morbidity already presented within this group of patients.

Oncologic ablation in the head and neck region frequently results in the sacrifice of peripheral nerves and their target organs. This inevitably can compromise facial expression, ocular protection, oral competence, speech, swallowing, and cutaneous sensation, causing functional and aesthetic impairment. The application of principles from peripheral nerve surgery in these instances provides the opportunity to minimize these morbidities. For facial reanimation, targeted nerve transfers, cross-facial nerve grafting, and nuances for functioning free muscle transplantation are delineated to restore smile and spontaneous blink function. Dynamic tongue reconstruction is described for hypoglossal nerve innervated muscle flaps combined with conventional fasciocutaneous flaps for improved swallow function, bulk, and lining. Sensory reconstruction includes interposition and cross-face sural grafts to supraorbital/supratrochlear, infraorbital, lingual, and mental nerves, including corneal and lacrimal gland neurotization as potentially vision-saving procedures.

Complex head and neck defects requiring double free flap reconstruction present unique challenges in vascular design. Flow-through configurations, where one flap's arterial supply feeds a second flap, offer theoretical advantages but create inherent vulnerabilities. This seminar examines the hemodynamic and geometric principles underlying flow-through reconstruction, analyzes common failure mechanisms, and provides practical guidelines for surgical decision-making. Key concepts include retrograde thrombus propagation, cumulative pressure drops in series circuits, and the non-Newtonian properties of blood that complicate theoretical predictions. Understanding these principles is essential for appropriate patient selection and technical execution in complex reconstructive cases.

Microsurgical free flaps have become the cornerstone for soft tissue reconstruction in the head and neck following tumor resection, offering improved functional and aesthetic outcomes with reduced donor site morbidity compared to traditional techniques. This retrospective review of over 14,000 cases from Chang Gung Memorial Hospital spanning 40 years highlights evolving trends in flap selection and their associated microsurgical outcomes. The anterolateral thigh (ALT) flap remains the dominant workhorse, with increased usage in recent years due to its versatility and reliability. The profunda artery perforator (PAP) flap has emerged as the second most commonly used flap, effectively replacing the radial forearm flap (RFF), whose use has largely declined because of donor site concerns and limited tissue bulk. While the medial sural artery perforator (MSAP) flap offers a pliable alternative, it carries a higher complication rate, underscoring the importance of surgical experience in its application. Our findings emphasize the importance of individualized flap selection based on defect characteristics, donor site considerations, and long-term reconstructive planning to optimize patient outcomes in head and neck microsurgical reconstruction.