To Örebro University

INTRODUCTION: The free fibula flap is a workhorse flap for bony reconstruction of the craniofacial skeleton. The aim of the study was to conduct a systematic review to investigate the postoperative donor site complications and functional outcomes, specifically ankle instability (AI) and gait disturbances (GD), for patients who have received a free fibula flap (FFF) for head and neck cancer reconstruction.

METHODS: We designed a PRISMA-compliant systematic review, which was registered prospectively in PROSPERO. Searches were designed with a health science librarian and included MEDLINE, EMBASE, CINAHL and PEDro. Risk of bias assessment was conducted for each included study, with an assessment of quality using GRADE.

RESULTS: Following exclusion of duplicate entries, a total of 1940 abstracts were identified. After parallel blinded eligibility assessment, 32 studies were included in the analysis. The total number of included participants was 1163, with the total number of FFF being 955. The mean time for functional assessment was 35 months postoperatively (range 8-81 months). The subjective and objective assessment modalities varied considerably. The primary result for AI were 3.3 % and 5.5 % for GD. The results demonstrate heterogeneity in the literature regarding the reporting of AI and GD following FFF.

CONCLUSION: According to this review, the risk of developing these complications appears to be limited but underreporting may be a limitation. Consensus on methods for standardized outcomes assessment of FFF-reconstruction is needed to establish the impact of free fibula flap on AS and GD.

Generative artificial intelligence (AI) large language models are an emerging technology, with ChatGPT and Gemini being 2 well-known examples. The current literature discusses clinical applications and limitations of AI, but its role in research has not yet been extensively evaluated. This study aimed to assess the role of ChatGPT and Gemini in developing novel and clinically relevant research ideas (RIs) for systematic reviews (SRs) in head and neck reconstruction. ChatGPT and Gemini were prompted to provide 10 novel and clinically relevant RIs for SRs in the following domains: head and neck reconstruction in general, microsurgery, and complications in reconstructive head and neck procedures. A comprehensive search was then performed for SRs in MEDLINE, Cochrane Library, and Embase to determine the novelty of the RIs generated. A total of 60 RIs were generated, with half created by ChatGPT and the other half by Gemini. Overall, 3613 entries were found through the literature search. After deduplication and screening, a total of 50 studies that partially addressed the AI-generated RIs were identified and were included in the present review. Out of the 60 AI-generated RIs, 42 had not been previously studied and were therefore considered novel. No statistically significant differences were found between the outputs generated by Gemini and ChatGPT. Both ChatGPT and Gemini were able to effectively generate novel and clinically relevant RIs for SRs, although their suggestions were generally broad. This study demonstrated that AI could potentially aid in the process of conducting novel SRs.

INTRODUCTION: As breast cancer survival rates improve, the long-term quality of life (QoL) has become increasingly important. With a significant number of patients still undergoing mastectomy and experiencing its well-known negative impacts on QoL, breast reconstruction aims to mitigate this by restoring body integrity. This study aimed to evaluate the changes in QoL and satisfaction in patients after breast reconstruction and influence of various patient-related factors.

METHODS: Patients who underwent delayed unilateral deep inferior epigastric perforator (DIEP) breast reconstruction at a single institution between January 2016 and April 2019 were surveyed. QoL was assessed using the BREAST-Q questionnaire preoperatively and one year postoperatively. Scores were compared between the time points, and regression analysis was conducted to identify the influence of age, body mass index, economic status, education level, and relationship status on QoL.

RESULTS: Among the 93 patients, 55 completed the preoperative and one-year postoperative BREAST-Q questionnaires (response rate: 59%). Postoperative QoL scores significantly increased for the domains "satisfaction with breasts," physical well-being chest," "sexual well-being," and "psychosocial well-being" (p<0.001). The scores for the domain "physical well-being abdomen" remained unchanged one year postoperatively. Higher education correlated with greater satisfaction with the breasts. Lack of an intimate partnership was identified as a significant negative factor for poorer psychosocial well-being.

CONCLUSIONS: Delayed unilateral DIEP breast reconstruction significantly enhances QoL and breast satisfaction one year postoperatively without causing long-term physical discomfort at the donor site. Education level and relationship status significantly affect the postoperative outcomes. Tailored preoperative counseling and psychosocial support are essential to maximize patient satisfaction and well-being following reconstruction.

BACKGROUND: Head and neck cancer (HNC) is the seventh most prevalent cancer worldwide, usually requiring a multidisciplinary approach. The National Surgical Quality Improvement Program (NSQIP) risk calculator is a tool for predicting postoperative complications that possibly can help in decision-making, support patient education, and guide the choice between surgical and nonsurgical treatment options. The aim of this study was to assess the reliability of the NSQIP risk calculator as a predictor of postoperative complications following head and neck surgery with microvascular reconstruction.

METHODS: This retrospective study included 99 patients diagnosed with HNC who underwent microvascular reconstruction from January 2016 to February 2021. The observed complications were compared with those predicted by the NSQIP calculator. To assess the discriminatory power of the NSQIP estimates, receiver operating characteristic statistics, logistic regression, and the overall Brier score were used.

RESULTS: Forty-four percent of the patients experienced at least 1 postoperative complication, and 27.2% developed serious complications. The receiver operating characteristic analysis for any complications revealed an area under the curve (AUC) of 0.62 (95% confidence interval 0.51-0.73, P = 0.046). For serious complications, the AUC was 0.65 (95% confidence interval, 0.52-0.79, P = 0.021). Both AUC values fell short of the threshold for "acceptable discrimination" (0.7-0.8). The overall Brier score was 0.32, with scores less than 0.09 considered to have good accuracy.

CONCLUSIONS: The results suggest that the NSQIP risk calculator tends to underestimate the likelihood of postoperative complications in patients who are undergoing resection for HNC accompanied by microvascular reconstruction.

Nitrous oxide has a wide range of medical applications, such as being used as an analgesic in general anesthesia, dental procedures, childbirth and sedation. Lately, it has also been employed as an inhalant recreational drug to induce brief euphoria. Recent studies indicate a worldwide rise in the incidence of skin frostbites associated with nitrous oxide use. A scoping review was conducted to synthesize and summarize the existing literature published in English regarding frostbite injuries associated with the recreational use of nitrous oxide. The literature search was carried out in July 2024 using databases such as Embase, Web of Science and PubMed®. From an initial pool of 83 publications, 8 studies were ultimately selected for full-text review as they met our inclusion criteria for analysis. Additionally, we provide a representative clinical case involving a 21-year-old male who experienced frostbite following skin exposure to nitrous oxide. Most publications on nitrous oxide induced frostbites are from recent years, primarily between 2022 and 2024, with the first case documented in 1996. These injuries are mostly observed in young adults, with a female dominance, and are typically localized to the inner thighs. According to the existing literature, the predominant treatment approach is conservative management, with excision and split-thickness skin grafting (STSG) in the second place. This study represents the first literature review summarizing frostbite injuries to the skin from nitrous oxide misuse. There is a need for enhanced preventive measures to raise public awareness and reduce the incidence of frostbite injuries associated with the recreational use of nitrous oxide.

The most common cited cause of split-thickness skin graft failure is infection and due to the association between bacterial findings in wound beds an attempt to decrease the bacterial burden before skin-grafting evolved. Thus, pre-operative microbiology swabs of the wound bed became routine at some institutions prior to grafting. This is not standard practice in the Pietermaritzburg burn service. Emphasis is instead placed on a strict protocol of intra-operative wound bed preparation to promote adequate graft take. This pilot study aims to evaluate whether pre-operative wound swabs are appropriate. We performed a prospective observational study to determine if positive wound cultures were associated with graft failure. All patients with a burn surface area of less than 10 %, where delayed grafting (later than 28 days from time of burn injury) was performed, from March to December 2021 were analyzed. Patient demographics, days from burn to graft, %TBSA burn, %TBSA grafted, whether sharp debridement prior to grafting in the same procedure was performed or not, use of topical gentamicin intra-operatively, graft outcome (% graft loss), need for regraft, and organism grown were recorded into an excel spread sheet for analysis. The sample included 52 patients. Of these, 17 (31.5%) were female. The median %TBSA grafted was 8% (IQR 4-13%) and similar in both groups. The median days from burn to grafting was 35 days. Thirty-nine patients (75%) had graft Take and 13 (25%) had graft Failure. In the failed group, median % graft failure was 50% (30 - 70%). Of the group with successful graft take, 90% were noted to have had a positive wound culture prior to grafting. A positive wound culture was not found to be a risk factor for graft failure (p=0.993). Despite the positive wound cultures graft take was more than 90 % in 75% of grafts performed and only 2/52 patients required supplementary grafting. We believe that this demonstrates that our local protocol is reasonable in this setting and that waiting for negative wound swabs prior to grafting should not be a reason to delay grafting.

Introduction: Nicotine consumption is linked to higher perioperative complications. The cellular damage secondary to smoking is due to cellular dysfunction and thrombogenesis following free radical release, tissue hypoxia, microvascular injury, and inhibition of immune cell function by oxidative stress. This has an impact on wound healing as a whole, while increasing risk of infection and wound dehiscence.

Method: A review of the literature was conducted to summarize all studies focusing nicotine-complications in Plastic and Hand surgery. Of 2,186 articles, retrieved from PubMed, Embase and Web of Science databases, 364 publications were included following a blinded parallel screening as per PRISMA.

Result: Numerous peri-operative complications have been attributed to smoking, from undesirable aesthetic outcomes to life threatening sepsis. Some previous studies have illustrated a few of nicotine’s physiological effects as reversible, through a smoking cessation ranging from 3 to 8 weeks, or even longer, while others seem persistent. Available literature has found a correspondence between the amount of nicotine consumption and complication rates. Both pre- and postoperative nicotine cessation has been proven to have favourable outcome.

Discussion: Nicotine abuse is linked to higher complication rates following Plastic and Hand Surgery, according to the published literature. Nicotine consumers are a high-risk patient group that needt o be stratified, evaluated for peri-operative morbidities, and provided risk-specific care and follow-up.

It is important to understand the pathophysiological mechanisms behind the negative effects of nicotine on postoperative recovery. A standardized pre- and postoperative nicotine detox routine should be established to minimize the rate of postoperative complications.

Introduction: In Sweden, approximately 1700 patients are diagnosed with head and neck cancer (HNC) every year. HNC is relatively rare (2,6 % of all cancers). Risk factors for HNC are smoking, high consumption of alcohol, human papilloma virus (HPV) infection and inflammation 1. The Örebro head and neck cancer registry (ÖHNCR) was founded 1988 to register amount of HNC patients, treatment, reconstruction and overall survival.

Method: We performed a retrospective review of all microvascular and local/regional reconstructions in ÖHNCR from 1988 to 2023. It includes in total 4111 patients in the registry to present day.

Result: The majority, approximately 71.8% of the patients, were judged to be tumour-free at the last check-up. The five-year survival rate for all HNC patients has increased from 49.8% in 1988 to 55.1% in 2023, an increase of 5.3%. Overall survival varies between types of cancer within HNC. The number of both free and local/regional flaps has increased over the past two decades. Of all reported patients in ÖHHCR, approximately 44 patients (34%) have been reconstructed each year. The most common free flap for soft tissue reconstruction were, radial free flap (n=331, 49%) and osteocutaneous reconstruction was the fibula free flap (n=210, 31%). The most common local/regional flap were pectoralis major flap (n=242, 33%).

Discussion: The registry data trends correspond with the current literature, with increased incidence of number of cases with HNC and following reconstruction. We speculate that the increased number of reconstructions, permits an increased number of radical HNC resections followed by improved oncological- and functional outcomes.

Flera fall av vårdorsakade brännskador har rapporterats till Ivo och Socialstyrelsen de senaste decennierna.

Alkoholbaserade lösningar för perioperativ steriltvätt i kombination med diatermi kan orsaka brand och brännskador om lösningen inte torkat ordentligt.

Tvättlösningar kan ansamlas i draperingsveck eller i tyger. Det är viktigt att säkerställa att alkoholbaserade tvättlösningar har torkat ordentligt före användning av diatermi.

Majoriteten av incidenter relaterade till intraoperativa brännskador orsakade av diatermi beror på felaktig användning.

Around 36 000 people seek care in Sweden due to burns annually. This usually requires repeated wound care and in some case surgery. Iatrogenic burns are rare but may be deep. One cause could be preparation of a patient with alcohol before surgery, or direct skin contact with a diathermic probe. In this case series we present two patients with this type of burns. These cases highlight the potential harm toward the patient, and it is important to have clear guidelines and take precautions when performing a diathermy