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Christensen JM, Ahn L, Meulendijks MZ, Iskhakov D, Wong F, Winograd J, Valerio IL, Cetrulo CL, Helliwell LA, Eberlin KR. Technical Variables in Lower Extremity Free Flap Reconstruction. J Reconstr Microsurg 2024; 40:78-86. [PMID: 37040875 DOI: 10.1055/a-2071-3250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2023]
Abstract
BACKGROUND Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.
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Affiliation(s)
- Joani M Christensen
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Leah Ahn
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mara Z Meulendijks
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David Iskhakov
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frankie Wong
- Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Massachusetts
| | - Jonathan Winograd
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Curtis L Cetrulo
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lydia A Helliwell
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Hasegawa H, Kawamura K, Kawai A, Miyamoto T, Nakayama S, Minami N, Okada H, Tanaka Y. Ankle Skin Defects with Vascular Ehlers-Danlos Syndromes Treated by Posterior Tibial Artery Perforator Flap: A Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00011. [PMID: 37856617 DOI: 10.2106/jbjs.cc.23.00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
CASE A 46-year-old man with vascular Ehlers-Danlos syndrome (EDS) had an open ankle fracture with a 10 × 5-cm skin defect on the medial side of the ankle. The patient underwent open reduction and internal fixation, as well as coverage of the skin defect with a posterior tibial artery perforator flap, which led to successful outcomes. CONCLUSION We present the successful implementation of a posterior tibial artery perforator flap for the reconstruction of skin defects in a patient with vascular EDS. Despite the fragility of soft tissues, favorable surgical outcomes were observed.
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Affiliation(s)
- Hideo Hasegawa
- Orthopedic Department, Nara Medical University, Nara, Japan
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Meiwandi A, Kamper L, Küenzlen L, Rieger UM, Bozkurt A. The Great Saphenous Vein-An Underrated Recipient Vein in Free Flap Plasty for Lower Extremity Reconstruction: A Retrospective Monocenter Study. Arch Plast Surg 2022; 49:683-688. [PMID: 36159377 PMCID: PMC9507579 DOI: 10.1055/s-0042-1756346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2022] [Indexed: 11/09/2022] Open
Abstract
Background
Reconstruction of large soft tissue defects of the lower extremity often requires the use of free flaps. The main limiting factor and potential for complications lie in the selection of proper donor and recipient vessels for microvascular anastomosis. While the superficial veins of the lower leg are easier to dissect, they are thought to be more vulnerable to trauma and lead to a higher complication rate when using them instead of the deep accompanying veins as recipient vessels. No clear evidence exists that proves this concept.
Methods
We retrospectively studied the outcomes of 97 patients who underwent free flap plasty to reconstruct predominantly traumatic defects of the lower extremity at our institute. The most used flap was the gracilis muscle flap. We divided the population into three groups based on the recipient veins that were used for microvascular anastomosis and compared their outcomes. The primary outcome was the major complication rate.
Results
Overall flap survivability was 93.81%. The complication rates were not higher when using the great saphenous vein as a recipient vessel when comparing to utilizing the deep concomitant veins alone or the great saphenous vein in combination to the concomitant veins.
Conclusions
In free flap surgery of the lower extremity, the selection of the recipient veins should not be restricted to the deep accompanying veins of the main vessels. The superficial veins, especially the great saphenous vein, offer an underrated option when performing free flap reconstruction.
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Affiliation(s)
- Abdulwares Meiwandi
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios University Hospital Wuppertal, Witten-Herdecke University, Wuppertal, Germany
| | - Lars Kamper
- Department of Radiology, Radiology, Helios University Hospital Wuppertal, University Witten/Herdecke, Wuppertal, Germany
| | - Lara Küenzlen
- Department of Plastic and Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Frankfurt/Main, Germany
| | - Ulrich M Rieger
- Department of Plastic and Aesthetic, Reconstructive & Hand Surgery, AGAPLESION Markus Hospital Frankfurt, Frankfurt/Main, Germany
| | - Ahmet Bozkurt
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Helios University Hospital Wuppertal, Witten-Herdecke University, Wuppertal, Germany
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Kim DY, Kim Y, Moon SH. Overcoming severe calcified lower extremity artery in lower limb salvage operation by using the Fogarty catheter and vein graft. Microsurgery 2021; 41:734-742. [PMID: 34636068 DOI: 10.1002/micr.30816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/15/2021] [Accepted: 09/17/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND With severe vascular calcifications, vascular clamp application and utilizing the vessel for free flap recipient vessel becomes impossible. These obstacles can be overcome with the Fogarty catheter and vein graft. PATIENTS AND METHODS When unclampable artery was encountered intraoperatively, a vein graft was used to make a clampable recipient site for six diabetic foot patients (ages from 42 to 80). The end of the Fogarty catheter was inserted into the proximal end of the vein graft and the transected calcified vessel in sequence, and the balloon of the catheter was used as an intraluminal tourniquet. The remaining end of the vein graft was connected to the distal vessel with a vascular clamp. RESULTS Five short vein graft revascularization for segmental arterial occlusion, one long vein graft for recipient artery elongation was done (lengths from 2 to 13.8 cm). Three delayed, and two immediate anterolateral thigh flaps (sizes from 15 to 150 cm2 ) were performed, and one patient received vein graft revascularization surgery only. Postoperative vascular sonography of all six patients showed well-maintained patency. Minor flap marginal disruption occurred at two patients but healed with conservative care. Postoperative follow-up was done for 1-18 months (average 7.17). Limb salvage was achieved for five patients and all five free flaps survived. However, for one patient, arterial restenosis at popliteal artery a month later lead to major amputation. CONCLUSION Using a Fogarty catheter and a vein graft may obtain perfect hemostasis during micro-anastomosis and achieve successful microvascular reconstruction in patients with severely calcified vessels.
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Affiliation(s)
- Dong Yeon Kim
- Department of Plastic and Reconstructive Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yesol Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Yoshimatsu H, Karakawa R, Fuse Y, Tanakura K, Yamamoto T, Okada A, Daniel BW, Yano T. Use of the superficial circumflex iliac artery perforator flap for reconstruction after sarcoma resection. J Surg Oncol 2021; 123:1067-1080. [PMID: 33428783 DOI: 10.1002/jso.26364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/05/2020] [Accepted: 12/21/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative complications after flap-coverage in sarcoma treatment can postpone postoperative adjunct treatments. Here, we present our experience with the use of the superficial circumflex iliac artery perforator (SCIP) flap after sarcoma resection. PATIENTS AND METHODS Patients undergoing immediate reconstruction surgery with a flap after sarcoma resection at a single institution from February 2017 to April 2020 were identified. Patient demographics, tumor characteristics, surgical characteristics, and complications were examined. RESULTS Thirty-five consecutive patients underwent reconstructions using a SCIP flap (34 free and one pedicled SCIP flaps). We also identified 47 consecutive patients who underwent reconstruction with other pedicled or free flaps over the same time period. No significant differences were found in patient age, gender, defect size, or operative time between these two groups. The incidences of overall complications (20/47 [42.6%] vs. 3/35 [8.5%], p < .001), flap dehiscence (7/47 [14.8%] vs. 0/35 [0%], p = .018), and total flap complications (15/47 [31.9%] vs. 2/35 [5.7%], p = .005) were statistically greater in the control group than in the SCIP group. CONCLUSION With its minimal postoperative complication rate both in the reconstruction site and the donor site, the SCIP flap can be considered an optimal reconstruction option after sarcoma resection.
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Affiliation(s)
- Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Ryo Karakawa
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuma Fuse
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenta Tanakura
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine Plastic and Reconstructive Surgery, Tokyo, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Bassem W Daniel
- Department of Plastic and Reconstructive Surgery, Center Hospital of National Center for Global Health and Medicine Plastic and Reconstructive Surgery, Tokyo, Japan
| | - Tomoyuki Yano
- Department of Plastic and Reconstructive Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Momeni A, Lanni MA, Levin LS, Kovach SJ. Does the use of arteriovenous loops increase complications rates in posttraumatic microsurgical lower extremity reconstruction?-A matched-pair analysis. Microsurgery 2017; 38:605-610. [DOI: 10.1002/micr.30197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/22/2017] [Accepted: 06/09/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery; Stanford University Medical Center; Palo Alto California
| | - Michael A. Lanni
- Division of Plastic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
| | - Lawrence S. Levin
- Department of Orthopedic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
| | - Stephen J. Kovach
- Division of Plastic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
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Heidekrueger PI, Ehrl D, Heine-Geldern A, Ninkovic M, Broer PN. One versus two venous anastomoses in microvascular lower extremity reconstruction using gracilis muscle or anterolateral thigh flaps. Injury 2016; 47:2828-2832. [PMID: 27771041 DOI: 10.1016/j.injury.2016.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/09/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. PATIENTS AND METHODS Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients' demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. RESULTS Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p>0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p>0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). CONCLUSION This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible.
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Affiliation(s)
- Paul I Heidekrueger
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany.
| | - Denis Ehrl
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - Albrecht Heine-Geldern
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital Technical University Munich, Germany
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Hwang K, Lee JP, Yoo SY, Kim H. Relationships of comorbidities and old age with postoperative complications of head and neck free flaps: A review. J Plast Reconstr Aesthet Surg 2016; 69:1627-1635. [PMID: 27697538 DOI: 10.1016/j.bjps.2016.08.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 07/29/2016] [Accepted: 08/31/2016] [Indexed: 11/16/2022]
Abstract
The aim of this study was to determine the relationships between free flap complications and old age or comorbidities. In a PubMed and Scopus search, the search terms (1) free flap OR microvascular anastomosis AND (2) elderly OR old age AND (3) complications OR comorbidity OR co-morbidity were used. Among the 62 full-text articles from 241 abstracts, 31 papers without sufficient content were excluded and 10 mined papers were added. Subsequently, 41 papers were reviewed. Overall complication rates of free flap increased significantly with age (p < 0.001; y = 0.457x + 13.464; 40.9% at 60 years, 45.5% at 70 years, and 50.0% at 80 years). Flap survival rates increased significantly (p < 0.001; y = 0.025x + 93.876). Donor site complication rates also increased significantly with age (p < 0.001; y = 1.238x - 63.700; 10.9% at 60 years, 23.0% at 70 years, and 35.3% at 80 years). The Kaplan-Feinstein index (KFI, OR = 7.944, 9.563), the Adult Comorbidity Evaluation-27 (ACE-27, OR = 5.854), the American Society of Anesthesiologists score (ASA, OR = 4.397), and the Index of Coexistent Diseases score (ICED, OR = 3.584) had statistically significant impacts on flap survival (p < 0.05). Diabetes (OR = 4.562) and chronic obstructive pulmonary disease (OR = 2.300) had statistically significant negative impacts on the flap survival rate (p < 0.05). Elderly patients had significantly higher Charlson Comorbidity Index (CCI) and ASA scores (p < 0.001). Similarly, elderly patients exhibited a significantly higher prevalence of dementia (p < 0.001) and use of aspirin at the time of surgery (p < 0.001). On the basis of these results, we suggest that the incidence of complications is directly related to the preoperative medical condition of an individual patient rather than to age.
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Affiliation(s)
- Kun Hwang
- Department of Plastic Surgery, Inha University School of Medicine, Incheon, South Korea.
| | - Jin Pyo Lee
- Inha University School of Medicine, Incheon, South Korea.
| | - Si Yoon Yoo
- Inha University School of Medicine, Incheon, South Korea.
| | - Hun Kim
- Department of Plastic Surgery, Inha University School of Medicine, Incheon, South Korea.
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Xiong L, Gazyakan E, Kremer T, Hernekamp FJ, Harhaus L, Saint-Cyr M, Kneser U, Hirche C. Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36:511-24. [DOI: 10.1002/micr.30020] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 10/31/2015] [Accepted: 12/08/2015] [Indexed: 12/17/2022]
Affiliation(s)
- Lingyun Xiong
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
- Department of Plastic and Reconstructive Surgery; Aesthetic Surgery Center, Union Hospital, Huazhong University of Science and Technology; 430022 Wuhan P.R. China
| | - Emre Gazyakan
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
| | - Thomas Kremer
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
| | - Frederick J. Hernekamp
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
| | - Leila Harhaus
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
| | - Michel Saint-Cyr
- Division of Plastic Surgery, Department of Surgery; Mayo Clinic; Rochester MN 55905
| | - Ulrich Kneser
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
| | - Christoph Hirche
- Department of Hand-, Plastic and Reconstructive Surgery; Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg; Ludwigshafen 67071 Germany
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Postoperative Venous Insufficiency in Microsurgical Lower Extremity Reconstruction and Deep Vein Thrombosis Potential as Assessed by a Caprini Risk Assessment Model. Plast Reconstr Surg 2015; 136:1094-1102. [DOI: 10.1097/prs.0000000000001701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Fujiki M, Miyamoto S, Sakuraba M. Flow-through anastomosis for both the artery and vein in leg free flap transfer. Microsurgery 2015; 35:536-40. [DOI: 10.1002/micr.22476] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Masahide Fujiki
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital; 5-1-1 Tsukiji, Chuo-Ku Tokyo Japan
| | - Shimpei Miyamoto
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital; 5-1-1 Tsukiji, Chuo-Ku Tokyo Japan
| | - Minoru Sakuraba
- Division of Plastic and Reconstructive Surgery; National Cancer Center Hospital East; 6-5-1 Kashiwanoha Kashiwa, Chiba Japan
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Free and pedicle flaps in lower extremity trauma. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-014-1056-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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A retrospective study of end-to-side venous anastomosis for free flap in extremity reconstruction. Int J Surg 2015; 17:72-8. [DOI: 10.1016/j.ijsu.2015.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 01/20/2015] [Accepted: 03/16/2015] [Indexed: 11/19/2022]
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Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2010; 64:649-55. [PMID: 20727842 DOI: 10.1016/j.bjps.2010.07.028] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Revised: 07/20/2010] [Accepted: 07/27/2010] [Indexed: 11/22/2022]
Abstract
Venous insufficiency is the most common cause of re-exploration in free-tissue transfers to the lower extremity. There is currently no consensus regarding the best approach to recipient vein selection. This study was designed to evaluate whether the type of venous system or the number of recipient veins would impact flap outcomes after microsurgical lower-extremity reconstruction. A retrospective study was conducted in 362 free-tissue transfers for lower-extremity reconstruction between 2003 and 2008. Flap outcomes were evaluated according to the selection of recipient vein system and number of veins. The deep venous system (80.4%) was more frequently selected than the superficial venous system (12.1%) or the combination of both systems (7.5%). In addition, one vein (65.5%) was more commonly used for anastomosis than two veins (34.5%). A total of 26 flaps (7.2%) presented with postoperative venous insufficiency. Male patients, composite defects including bones and the use of bone flaps presented higher rates of venous insufficiency with statistical significance. However, no significant differences were found among the different groups related to the age of patients, co-morbidities, aetiology, location of the defects or timing of reconstruction after trauma. The superficial venous system group was associated with a higher rate of venous insufficiency and partial flap loss compared with the deep venous system group (p = 0.036 and 0.018, respectively). One-vein-anastomosis flaps were associated with statistically significant fewer complete flap failure in comparison with two-vein-anastomosis flaps (p = 0.014). In conclusion, the assessment of recipient vein parameters by surgeon's experience is the best predictor of flap outcome in lower-extremity reconstruction. In our cohort of patients, the deep venous system was more reliable than the superficial venous system, but the use of more than one vein for anastomosis did not correlate with better flap outcomes.
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The Use of Supermicrosurgery in Lower Extremity Reconstruction: The Next Step in Evolution. Plast Reconstr Surg 2009; 123:230-235. [PMID: 19116557 DOI: 10.1097/prs.0b013e3181904dc4] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels. Plast Reconstr Surg 2007; 120:1568-1575. [PMID: 18040190 DOI: 10.1097/01.prs.0000282102.19951.6f] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. METHODS Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). RESULTS Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher's exact test did not indicate a significant difference between a simultaneous or staged flap transfer. CONCLUSIONS Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.
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Spector JA, Levine S, Levine JP. Free Tissue Transfer to the Lower Extremity Distal to the Zone of Injury: Indications and Outcomes over a 25-Year Experience. Plast Reconstr Surg 2007; 120:952-959. [PMID: 17805125 DOI: 10.1097/01.prs.0000255175.92201.c7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Microvascular free flap anastomoses performed for lower extremity reconstruction are traditionally proximal to the zone of injury. The authors assessed the feasibility and outcomes of microvascular free flaps with anastomoses performed distal to the zone of injury. METHODS The authors retrospectively reviewed all microvascular free flaps performed at their institution over the past 10 years for lower extremity reconstruction and compared this group with their previously published experience (January of 1979 through August of 1995). Between September of 1995 and May of 2005, 119 flap procedures were performed for lower extremity reconstruction. Twenty-eight flaps (24 percent) were anastomosed distal to the zone of injury and 87 (76 percent) were anastomosed proximally. There were insufficient data on the location of the anastomosis for four free flaps (all successful). RESULTS Twenty-seven of 28 distal microvascular free flaps were successful (96 percent); two (7 percent) required emergent postoperative reexploration of the anastomosis. Of the 87 proximal flaps, 79 (91 percent) were successful and eight (9 percent) failed. There was no statistically significant difference in the success rate of microvascular free flaps between the proximal and distal anastomosis groups (p = 0.30, Fisher's exact test). Combined with the data from the authors' previous series (January of 1979 to August of 1995), there were 63 free flaps with anastomosis performed distal to the zone of injury; 61 (97 percent) were successful. CONCLUSION The authors' extensive 25-year experience with lower extremity reconstruction demonstrates that in appropriately selected patients, free tissue transfer to recipient vessels distal to the zone of injury is reliable and in certain cases preferable.
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Affiliation(s)
- Jason A Spector
- New York, N.Y. From the Division of Plastic Surgery, Weill Cornell Medical College, and Institute of Reconstructive Plastic Surgery, Division of Plastic Surgery, New York University School of Medicine
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20
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Srikanth R, Reddy DM, Mosahebi A. A simple classification for standardisation of nomenclature in free flap outcome. J Plast Reconstr Aesthet Surg 2006; 59:1318-24. [PMID: 17113510 DOI: 10.1016/j.bjps.2006.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Accepted: 05/26/2006] [Indexed: 11/30/2022]
Abstract
The numbers of free flap donor site as well as their indications are constantly increasing. Despite increasing popularity of microvascular reconstructive procedures, literature lacks clear and objective outcome criteria. This paper reports on a simple outcome classification that has become a routine part of the unit's large workload of microvascular outcome recording. The classification was formed through a retrospective analysis of 241 consecutive cases from 2000 to 2001 and is a five graded numerical classification. Grade 1 equates to total success without co-morbidity and grade 5 to a major complication such as amputation, etc., whatever the status of the flap itself. From 2002 to 2005 the classification was prospectively used on 527 consecutive cases with ease of integration into routine clinical practice. The Classification would enable a more objective record keeping thus analysis of the outcome. It would allow a more realistic comparison of different techniques or donor types as well set a benchmarking level for further improvement of the results.
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Affiliation(s)
- R Srikanth
- Nizam's Institute of Medical Sciences, Hyderabad, India.
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21
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Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower Extremity Trauma: Trends in the Management of Soft-Tissue Reconstruction of Open Tibia-Fibula Fractures. Plast Reconstr Surg 2006; 117:1315-22; discussion 1323-4. [PMID: 16582806 DOI: 10.1097/01.prs.0000204959.18136.36] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors' institution for these injuries. METHODS Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. RESULTS The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. CONCLUSIONS These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology.
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Affiliation(s)
- Brian M Parrett
- Division of Plastic and Reconstructive Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02478, USA
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Muramatsu K, Shigetomi M, Ihara K, Kawai S. Microvascular anastomosis through the tibial tunnel: a new technique in free-tissue transfer to the leg. Microsurgery 2004; 24:293-7. [PMID: 15274186 DOI: 10.1002/micr.20023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Free-tissue transfer to a severely traumatized leg has a high rate of vascular complications. We present three successful cases using a new technique of microvascular anastomosis through the tibial tunnel. Because of the unavailability of anterior tibial artery due to posttraumatic vascular disease, donor vascular pedicles were passed posterior to the tibia through the tibial tunnel and anastomosed to the posterior tibial artery or its branch in an end-to-end fashion. The flaps survived perfectly, without any vascular complication. This technique represents a safe route, and the shortest route, to an expected anastomosis point. Our technique is indicated especially in cases with a single-vessel leg.
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Affiliation(s)
- Keiichi Muramatsu
- Department of Orthopedic Surgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan.
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Rainer C, Meirer R, Gardetto A, Schwabegger AH, Ninkovic MM. Perforator-pedicled skin island flap for coverage of microvascular anastomoses in myocutaneous flaps in the lower extremity. Plast Reconstr Surg 2003; 112:1362-7. [PMID: 14504521 DOI: 10.1097/01.prs.0000081468.12246.38] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Christian Rainer
- Department of Plastic and Reconstructive Surgery, Univeristy of Innsbruck, and Ludwig-Boltzmann-Institute for Quality Control in Plastic Surgery, Austria
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