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Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction
British Journal of Oral and Maxillofacial Surgery (2004) 42, 36—37
SHORT COMMUNICATION
Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction D.R. Ashworth*, N.M. Whear, V. Fan The Black Country Head and Neck Oncology Unit, Oral and Maxillofacial Surgery, New Cross Hospital, Wolverhampton WV10 0QP, UK Accepted 8 September 2003
KEYWORDS Oropharyngeal reconstruction; Surgical anastomosis; Operative techniques
Summary We present a retrospective audit of radial fasciocutaneous vascularised free flaps performed over a decade. These have all been done with binocular loupe magnification, allowing comparison of free flap success with conventional microscope vessel anastomosis. The results are similar to other reported series. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Free tissue transfer is routinely used for reconstruction of defects in the head and neck. The ablative operation is usually for resection of malignant tumours of the oropharynx, but benign conditions and trauma occasionally require vascularised tissue. Microvascular reconstruction has been done in our unit since 1993 by the same lead surgeon under binocular loupe magnification. From the outset, an electronic record of patients and operations was maintained, which has allowed this lengthy audit of free flaps to be completed.
Materials and methods Details of every free flap operation done by the Black Country Head and Neck Oncology Team were recorded on a portable computer, and transferred to new machines as the technology was updated. This has allowed a comprehensive search of med*Corresponding author. Tel.: +44-7870-468-205; fax: +44-1743-261-366. E-mail address: dan [email protected] (D.R. Ashworth).
ical records even though the reconstructions were done in four theatres in two Trusts during that time. We present a retrospective analysis of radial free flaps alone to enable conclusions to be drawn about a standard technique of loupe magnification. Microvascular anastomoses have been done throughout with 2.5 or 3 times binocular loupe magnification. Free approximation of the vessels is the rule and approximating clamps are not used. The arterial anastomosis is usually end-to-end with the facial artery, while the venous configuration is an end-to-side anastomosis of a single vena commitans on to the internal jugular vein. All anastomoses are sutured with 8/0 monofilament polyamide (Ethilon).1 As few sutures are used as are compatible with leak-free closure.
Results The audit was from August 1993 to September 2002. A total of 97 radial fasciocutaneous flaps were inserted, none of which included bone. Ninety-one of the lesions excised were squamous cell carcinoma, although the series includes other neoplasms, a keratocyst, and an oronasal fistula.
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00189-X
Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction The commonest pathological sites involved were tongue (32) and floor of mouth (29), reflecting the distribution of oral squamous carcinoma. Eight radial free flaps were reoperated, in one case twice. The indications were seven venous thromboses, and one bleeding pedicle. All reoperations were done within 5 days. All flaps were salvaged, with the exception of one, the skin of which sloughed. A further flap failed on day 16. The remaining 95 (98%) radial flaps were successful.
Discussion Binocular loupe and microscope magnification are equally effective. Previous audits have shown that both techniques can achieve excellent rates of survival of free flaps.2–5 We disagree with those who suggest that to operate without a microscope somehow deprives our specialty of an essential tool.6 Binocular loupes are within the budget of surgical trainees, and a useful adjunct to many surgical procedures. Their simplicity dispels the mystique that
37
has long surrounded this type of surgery, and in our view, the teaching of surgical trainees is facilitated by the good depth of field, variety of viewing angles, and bright clear illumination.
References 1. Whear NM, Zaki GA. Reconstructive surgery-free transfer flaps. In: Langdon JD, Patel MF, editors. Operative maxillofacial surgery. London, 1998. p. 115–24. 2. Vaughan ED. The radial forearm free flap in orofacial reconstruction. Personal experience in 120 consecutive cases. J Craniomaxillofac Surg 1990;18:2—7. 3. Shenaq MS, Klebuc MJA, Vargo D. Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures. Plast Reconstr Surg 1995;95:261—9. 4. Serletti JM, Deuber MA, Guidera PM, et al. Comparison of the operating microscope and loupes for free microvascular tissue transfer. Plast Reconstr Surg 1995;95:270—6. 5. Ross DA, Ariyan S, Restifo R, Sasaki CT. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer. A retrospective comparison. Arch Otolaryngol Head Neck Surg 2003;129:189—93. 6. Tomaino MM. Routine use of loupe magnification for microvascular anastomoses: at what price? Plast Reconstr Surg 1996;97:248—9.
SHORT COMMUNICATION
Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction D.R. Ashworth*, N.M. Whear, V. Fan The Black Country Head and Neck Oncology Unit, Oral and Maxillofacial Surgery, New Cross Hospital, Wolverhampton WV10 0QP, UK Accepted 8 September 2003
KEYWORDS Oropharyngeal reconstruction; Surgical anastomosis; Operative techniques
Summary We present a retrospective audit of radial fasciocutaneous vascularised free flaps performed over a decade. These have all been done with binocular loupe magnification, allowing comparison of free flap success with conventional microscope vessel anastomosis. The results are similar to other reported series. © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction Free tissue transfer is routinely used for reconstruction of defects in the head and neck. The ablative operation is usually for resection of malignant tumours of the oropharynx, but benign conditions and trauma occasionally require vascularised tissue. Microvascular reconstruction has been done in our unit since 1993 by the same lead surgeon under binocular loupe magnification. From the outset, an electronic record of patients and operations was maintained, which has allowed this lengthy audit of free flaps to be completed.
Materials and methods Details of every free flap operation done by the Black Country Head and Neck Oncology Team were recorded on a portable computer, and transferred to new machines as the technology was updated. This has allowed a comprehensive search of med*Corresponding author. Tel.: +44-7870-468-205; fax: +44-1743-261-366. E-mail address: dan [email protected] (D.R. Ashworth).
ical records even though the reconstructions were done in four theatres in two Trusts during that time. We present a retrospective analysis of radial free flaps alone to enable conclusions to be drawn about a standard technique of loupe magnification. Microvascular anastomoses have been done throughout with 2.5 or 3 times binocular loupe magnification. Free approximation of the vessels is the rule and approximating clamps are not used. The arterial anastomosis is usually end-to-end with the facial artery, while the venous configuration is an end-to-side anastomosis of a single vena commitans on to the internal jugular vein. All anastomoses are sutured with 8/0 monofilament polyamide (Ethilon).1 As few sutures are used as are compatible with leak-free closure.
Results The audit was from August 1993 to September 2002. A total of 97 radial fasciocutaneous flaps were inserted, none of which included bone. Ninety-one of the lesions excised were squamous cell carcinoma, although the series includes other neoplasms, a keratocyst, and an oronasal fistula.
0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/S0266-4356(03)00189-X
Radial free flaps using loupe magnification: audit of 97 cases of orofacial reconstruction The commonest pathological sites involved were tongue (32) and floor of mouth (29), reflecting the distribution of oral squamous carcinoma. Eight radial free flaps were reoperated, in one case twice. The indications were seven venous thromboses, and one bleeding pedicle. All reoperations were done within 5 days. All flaps were salvaged, with the exception of one, the skin of which sloughed. A further flap failed on day 16. The remaining 95 (98%) radial flaps were successful.
Discussion Binocular loupe and microscope magnification are equally effective. Previous audits have shown that both techniques can achieve excellent rates of survival of free flaps.2–5 We disagree with those who suggest that to operate without a microscope somehow deprives our specialty of an essential tool.6 Binocular loupes are within the budget of surgical trainees, and a useful adjunct to many surgical procedures. Their simplicity dispels the mystique that
37
has long surrounded this type of surgery, and in our view, the teaching of surgical trainees is facilitated by the good depth of field, variety of viewing angles, and bright clear illumination.
References 1. Whear NM, Zaki GA. Reconstructive surgery-free transfer flaps. In: Langdon JD, Patel MF, editors. Operative maxillofacial surgery. London, 1998. p. 115–24. 2. Vaughan ED. The radial forearm free flap in orofacial reconstruction. Personal experience in 120 consecutive cases. J Craniomaxillofac Surg 1990;18:2—7. 3. Shenaq MS, Klebuc MJA, Vargo D. Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures. Plast Reconstr Surg 1995;95:261—9. 4. Serletti JM, Deuber MA, Guidera PM, et al. Comparison of the operating microscope and loupes for free microvascular tissue transfer. Plast Reconstr Surg 1995;95:270—6. 5. Ross DA, Ariyan S, Restifo R, Sasaki CT. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer. A retrospective comparison. Arch Otolaryngol Head Neck Surg 2003;129:189—93. 6. Tomaino MM. Routine use of loupe magnification for microvascular anastomoses: at what price? Plast Reconstr Surg 1996;97:248—9.