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Mandal P, Moshammer M, Hecker A, Smolle C, Carnieletto M, Mayrhofer M, Schintler M, Winter R, Kamolz LP. The Use of Fibrinolytic Agents in the Salvage of Free Flaps: A Systematic Review. J Pers Med 2024; 14:800. [PMID: 39201992 PMCID: PMC11355706 DOI: 10.3390/jpm14080800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 09/03/2024] Open
Abstract
BACKGROUND Microvascular thrombosis following free tissue transfer presents a complex challenge for surgeons and carries the potential risk of flap failure. The application of fibrinolytic agents represents a robust therapeutic option. The aim of this systematic review is to provide a comprehensive overview of the clinical use of fibrinolytic drugs in the rescue of compromised free flaps. METHODS A systematic literature search for clinical studies detailing the utilization of fibrinolytic agents for salvaging free flaps was conducted using the PubMed and Web of Science databases. The inclusion criteria encompassed English-language publications that specifically addressed the clinical application of fibrinolytic agents for free-flap salvage. RESULTS A total of 331 articles were screened after excluding duplicates, with 56 meeting the inclusion criteria. Among these, 21 were clinical trials (evidence level III), and 35 were case studies (evidence level IV/V). In total, 459 flaps underwent treatment with fibrinolytic agents. CONCLUSION The application of fibrinolytic agents appears to be a valuable intervention for rescuing compromised free flaps attributable to microvascular compromise. Notably, no prospective randomized trials have been published on this subject, and the evidence within the existing literature is characterized by its limited and heterogeneous nature. Further research is imperative to gather data on the efficacy, dosage, and safety profile of fibrinolytic agents.
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Affiliation(s)
- Patrick Mandal
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Maximilian Moshammer
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
- COREMED—Centre for Regenerative Medicine and Precisions Medicine, Neue Stiftingtalstrasse 2, 8010 Graz, Austria
| | - Andrzej Hecker
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
- COREMED—Centre for Regenerative Medicine and Precisions Medicine, Neue Stiftingtalstrasse 2, 8010 Graz, Austria
| | - Christian Smolle
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Martina Carnieletto
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Marcel Mayrhofer
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Michael Schintler
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Raimund Winter
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
| | - Lars Peter Kamolz
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 34/4, 8010 Graz, Austria; (M.M.); (C.S.); (M.C.); (M.M.); (M.S.); (R.W.); (L.P.K.)
- COREMED—Centre for Regenerative Medicine and Precisions Medicine, Neue Stiftingtalstrasse 2, 8010 Graz, Austria
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Hathorn T, Nickel C, Sharma A, Shabani S, Padhya T, Mifsud M. How do i salvage that flap?; An evidence-based primer on salvage techniques for head & neck microvascular free flaps. Oral Oncol 2023; 136:106246. [PMID: 36402054 DOI: 10.1016/j.oraloncology.2022.106246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 11/07/2022] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Travis Hathorn
- USF Health Morsani College of Medicine, 560, Channelside Dr, Tampa, FL 33602, United States
| | - Christopher Nickel
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Abhay Sharma
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Sepehr Shabani
- The University of Texas Medical Branch, Department of Otolaryngology - Head & Neck Surgery, 301 University Blvd., Galveston, TX 77555, United States
| | - Tapan Padhya
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States
| | - Matthew Mifsud
- USF Health Morsani College of Medicine, Department of Otolaryngology - Head & Neck Surgery, 12901 Bruce B Downs Blvd., MDC 73, Tampa, FL 33612, United States.
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Abstract
PURPOSE OF REVIEW To highlight three clinical arenas in which head and neck free-flap compromise is encountered and acted upon: nonoperative, operative and postoperative realms. RECENT FINDINGS Time to identification and intervention is paramount to successful free-flap salvage. Surgical microvascular revision remains chief amongst strategies to revert vascular compromise of a free-flap. Adjuncts, such as thrombolytics and systemic anticoagulation have an important role in the complex work of microvascular free tissue care. Venous congestion of free flaps holds favorable for salvage when compared with arterial insufficiency. SUMMARY Vascular compromise of head and neck free flaps is a rare and feared event for microvascular surgeons, with successful transfers rates approaching above 95%. Success in salvage is dependent on prompt identification of tissue compromise and timely, directed interventions to re-establish tissue perfusion.
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Percutaneous Transluminal Ballooning Angioplasty for Flap Salvage in a Complex Lower Extremity Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3077. [PMID: 33133936 PMCID: PMC7544395 DOI: 10.1097/gox.0000000000003077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
The treatment of lower extremity trauma with extensive soft tissue defects requires a multidisciplinary approach. Following precise bone fixation, appropriate soft tissue reconstruction is a major requisite. We present a case of a severe lower extremity injury caused by an excavator bucket that fell on the patient’s foot, which was reconstructed with multiple perforator flaps after concise bone fixation. During the treatment, we repeatedly experienced threatened flaps, which could not be recovered with emergent re-explorations. Although vascular occlusion after a free flap surgery may be rare, it poses a major challenge. It necessitates urgent re-exploration, but there are logistical challenges with providing sufficient resources for endovascular revascularization. We attempted an immediate postoperative angioplasty after the failure of surgical re-exploration as a salvage option and achieved successful flap survival. As the flap completely survived without complications, the patient could walk, with bearing his full weight without the use of any orthosis. Despite the development of new techniques for flap revision, which have increased the possibility of limb salvage, immediate postoperative endovascular revascularization can be considered as a salvage option in cases of a compromised flap.
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Hsu SY, Cheng HT, Manrique O, Hsu YC. Anterograde injection of low-dose urokinase salvages free anterolateral thigh flap: A case report of safe and effective treatment. Medicine (Baltimore) 2017; 96:e7932. [PMID: 29019875 PMCID: PMC5662298 DOI: 10.1097/md.0000000000007932] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE A 54-year-old Taiwanese male came to our hospital presented with right retromolar mucoepidermoid carcinoma. Composite resection and right modified radical neck dissection were performed. We then use free anteral lateral thigh flap to reconstruct the defect. However, venous congestion was found 32 h after the surgery. PATIENT CONCERNS The main concerns of the patient is complete salvage of the free flap, and avoiding the secondary free flap harvesting and reconstruction surgeries. DIAGNOSES Right retromolar mucoepidermoid carcinoma. INTERVENTIONS We report the case of a patient with an anterolateral thigh flap with venous perianastomosis thrombosis and intraflap microvascular thrombosis successfully salvaged using anterograde intra-arterial injection of low-dose urokinase (60,000 U), without administering intravenous anticoagulation heparin during the postoperative period. OUTCOMES The flap was completely salvaged 3 days after treatment. No other flap-associated or bleeding complications were noted. The intra-oral wounds around the flap completely healed without any post-ischemic complications. LESSONS SUBSECTIONS Although the ideal urokinase doses and delivery procedures for free flap salvage have not been developed thus far, our method maximizes the urokinase gradient in the flap, minimizes the total dose required for flap salvage, and ensures no systemic spread. Thus, compared with other thrombolytic agents, urokinase may be more effective and safe for free flap salvage. With more experience, a standardized dosage and procedure can be developed.
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Free tissue flaps in head and neck reconstruction: clinical application and analysis of 93 patients of a single institution. Braz J Otorhinolaryngol 2017; 84:416-425. [PMID: 28571928 PMCID: PMC9449187 DOI: 10.1016/j.bjorl.2017.04.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/25/2017] [Accepted: 04/15/2017] [Indexed: 11/24/2022] Open
Abstract
Introduction Reconstruction with a free flap is routine in head and neck surgery because of better functional outcomes, improved esthetics, and generally higher success rates. Objective To evaluate the clinical outcomes in patients undergoing different microvascular free flap reconstructions. Methods This was a retrospective study of 93 patients undergoing reconstructions with free flaps from 2007 to 2015. Four types of free flap were performed: anterolateral thigh (76.3%), radial forearm (16.1%), fibula (4.3%) and jejunum (3.3%). Patients’ demographic data were collected, and the outcomes measured included flap survival and complications. Postoperative functional and oncological outcome were also analyzed. Results The patients included 73 men and 20 women, with a mean age of 56.1 years. The most common tumor location was the tongue. Squamous cell carcinoma represented the vast majority of the diagnosed tumors (89.2%). The most common recipient vessels were the superior thyroid artery (77.4%) and the internal jugular vein (91.4%). Nine patients required emergency surgical re-exploration and the overall flap success rate was 90.3%. Venous thrombosis was the most common cause for re-exploration. Other complications included wound infection (5.4%), wound dehiscence (1.1%), partial flap necrosis (9.7%), fistula formation (10.8%), and 1 bleeding (1.1%). The majority of patients had satisfactory cosmetic and functional results of both donor site and recipient site after 46.7 months of mean follow-up. Conclusion Microsurgical free flap is shown to be a valuable and reliable method in head and neck surgery. It can be used safely and effectively with minimal morbidity in selected patients. The reconstruction can be performed by appropriately skilled surgeons with acceptable outcomes. Success rate appears to increase as clinical experience is gained.
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Current concepts in salvage procedures for failing microvascular flaps: is there a superior technique? Insights from a systematic review of the literature. Int J Oral Maxillofac Surg 2016; 45:1378-1387. [DOI: 10.1016/j.ijom.2016.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/14/2016] [Accepted: 06/29/2016] [Indexed: 12/27/2022]
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Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: Systematic review and practical recommendations. ANN CHIR PLAST ESTH 2016; 62:e1-e13. [PMID: 27427444 DOI: 10.1016/j.anplas.2016.06.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 06/12/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Medicinal leeches have been part of the therapeutic armamenterium of plastic surgeons for more than 50 years. While their use in hand surgery is a matter of course, their use in salvage of flaps with venous congestion remains facultative depending on teams. MATERIALS AND METHODS We conducted a systematic review of leech therapy for flap salvage between 1960 and 2015, analyzing 121 articles and subsequently taking into consideration 41 studies. In parallel, we collected data from 43 patients for whom leach therapy had recently been applied in treatment of venous insufficiency in pedicled or free flaps after revision surgery had failed to improve flap vascularization, or in cases where flap revision was not appropriate. The data collected pertained to relevant indications, treatment procedure, efficacy, adjuvant therapies, side effects and complications. RESULTS For this indication, the success rate of leech therapy ranged from 65 to 85% (83.7% in our series) according to the situations encountered. Optimal frequency of application ranged from 2 to 8hours, while average overall duration ranged from 4 to 10 days. The number of leeches to be applied can be determined depending on volume of the flap. In 50% of the cases reported in the literature, the patients required transfusion. Antibiotic prophylaxis against Aeromonas is highly advisable. A ciprofloxacin and trimethoprim-sulfametoxazole combination currently appears as the most relevant prophylactic antibiotherapy. CONCLUSION Hirudotherapy is a reliable treatment in cases of patent venous insufficiency of pedicled or free flaps (or when revision surgery is not recommended). Even though the relevant literature is highly heterogeneous, we have attempted to put forward a specific protocol bringing together dosage, delivery route, frequency of administration and appropriate prophylactic antibiotherapy. An algorithm for treatment and management of venous congestion and a practical information sheet have been placed at the disposal of plastic surgery teams.
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Affiliation(s)
- C Herlin
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France.
| | - N Bertheuil
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rennes, 35000 Rennes, France
| | - F Bekara
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France
| | - F Boissiere
- Service de chirurgie plastique et reconstructrice, centre des brûlés, CHRU Lapeyronie, 325, avenue du doyen-Gaston-Giraud, 34295 Montpellier cedex 5, France; Service de chirurgie plastique et craniofaciale pédiatrique, CHRU Lapeyronie, 34295 Montpellier, France; Unité de plaies et cicatrisation, CHRU Lapeyronie, 34295 Montpellier, France
| | - R Sinna
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Picardie, 80080 Amiens, France
| | - B Chaput
- Service de chirurgie plastique, reconstructrice et esthétique, CHRU de Rangueil, 31400 Toulouse, France
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Henderson PW, Fernandez JG, Cemal Y, Mehrara BJ, Pusic AL, McCarthy CM, Matros E, Cordeiro PG, Disa JJ. Successful Salvage of Late Anastomotic Thrombosis after Free Tissue Transfer. J Reconstr Microsurg 2016; 32:316-24. [PMID: 26872023 DOI: 10.1055/s-0036-1571359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Anastomotic thrombosis following free tissue transfer (FTT) on or after day 5 ("late thrombosis") is reported to have extremely low rates of salvage. Analysis of our institution's experience with FTT was performed to make recommendations about the optimal management of late thrombosis, and to identify any variables that are correlated with increased salvage rates. Methods The study included patients who underwent FTT between 1986 and 2014, then suffered anastomotic thrombosis on or after postoperative day 5. Twenty-six variables involving demographic information, flap characteristics, circumstances of the thrombotic event, and details of any salvage attempt were analyzed. Patients whose FTT were successfully salvaged and those whose were not were statistically compared. Results Of the 3,212 patients who underwent FTT, 23 suffered late thrombosis (0.7%), and the salvage rate was 60.8% (14 of 23). The salvage rate for reconstruction of the head and neck was 53.3%, breast was 66.7%, and extremity was 100%. There was a statistically significantly greater salvage rate in flaps performed after 1998 than in those performed before 1998 (p = 0.023). There was a nonstatistically significant trend toward increased salvage rates in patients who had no anastomotic thrombotic risk factors, reconstruction using fasciocutaneous flaps, and anastomotic revision using new recipient vessels. Conclusion Our data demonstrate that flap survival after episodes of late thrombosis can be higher than what the literature has previously reported. This underscores the importance of rigorous postoperative monitoring, as well as the importance of exploration at the earliest instance of concern for threatened flap viability.
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Affiliation(s)
- Peter W Henderson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John G Fernandez
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yeliz Cemal
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak J Mehrara
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrea L Pusic
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Colleen M McCarthy
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Matros
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter G Cordeiro
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph J Disa
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Salvage of a free flap using postoperative percutaneous angioplasty in patients with diabetic foot ulcers. Arch Plast Surg 2014; 41:788-90. [PMID: 25396201 PMCID: PMC4228231 DOI: 10.5999/aps.2014.41.6.788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 06/22/2014] [Accepted: 07/01/2014] [Indexed: 11/09/2022] Open
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Changes of perfusion of microvascular free flaps in the head and neck: a prospective clinical study. Br J Oral Maxillofac Surg 2014; 52:810-5. [DOI: 10.1016/j.bjoms.2014.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 07/07/2014] [Indexed: 11/20/2022]
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Anterograde intra-arterial urokinase injection for salvaging fibular free flap. Arch Plast Surg 2013; 40:251-5. [PMID: 23730603 PMCID: PMC3665871 DOI: 10.5999/aps.2013.40.3.251] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 03/18/2013] [Accepted: 04/09/2013] [Indexed: 11/23/2022] Open
Abstract
We present a case of a 57-year-old male patient who presented with squamous cell carcinoma on his mouth floor with cervical and mandibular metastases. Wide glossectomy with intergonial mandibular ostectomy, and sequential reconstruction using fibular osteomyocutaneous free flap were planned. When the anastomosis between the peroneal artery of the fibular free flap and the right lingual artery was performed, no venous flow was observed at the vena comitans. Then re-anastomosis followed by topical application of papaverine and lidocaine was attempted. However, the blood supply was not recovered. Warm saline irrigation over 30 minutes was also useless. Microvascular thromboses of donor vessels were clinically suspected, so a solution of 100,000 units of urokinase was infused once through a 26-gauge angiocatheter inserted into the recipient artery just at the arterial anastomotic site, until the solution gushed out through the flap vena comitans. Immediately after the application of urokinase, arterial flow and venous return were restored. There were no complications during the follow-up period of 11 months. We believe that vibrating injuries from the reciprocating saw during osteotomies and flap insetting might be the cause of microvascular thromboses. The use of urokinase may provide a viable option for the treatment of suspicious intraoperative arterial thrombosis.
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Pignatti M, Iwuagwu FC, Browne TF. Late partial failure of a free ALT flap. J Plast Reconstr Aesthet Surg 2012; 65:e124-7. [DOI: 10.1016/j.bjps.2011.11.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 11/26/2011] [Indexed: 11/26/2022]
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Zhong T. Invited commentary. J Plast Reconstr Aesthet Surg 2011; 64:1520-1. [PMID: 21531644 DOI: 10.1016/j.bjps.2011.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 04/05/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Toni Zhong
- University Health Network, Surgery, Surgical Oncology, 200 Elizabeth St, 8N 871 Eaton's Wing, Toronto, ON, Canada.
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