Late partial failure of a free ALT flap

Clinical applications of vascularized fascia lata in head and neck reconstruction: A systematic review

BACKGROUND

Given limitations in the current literature, the precise indications, techniques, and outcomes relevant to vascularized fascia lata free flap reconstruction remain uncertain. The objective of this study was to perform a systematic review of published literature to evaluate indications, methods, and complications for vascularized fascia lata free flap reconstruction.

METHODS

A systematic review of the literature was performed using a set of search criteria to identify patients who underwent free flap reconstruction of the head and neck region using vascularized fascia lata. Articles were reviewed based on relevance, with the primary outcome being surgical complications and surgical indications.

RESULTS

A comprehensive search revealed 783 articles and 5 articles were ultimately found to be appropriate to this review- 55 patients undergoing free flap reconstruction were identified. Overall complication rates were 10.9 % for major complications and 18.1 % for minor complications. Follow-up spanned 1 to 95 months with a median of 48 months.

CONCLUSIONS

Microvascular reconstruction of the head and neck with vascularized fascia lata is achievable with high adaptability and reliability reported in the literature.

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

Autonomization is a physiological process allowing a flap to develop neo-vascularization from the reconstructed wound bed. This phenomenon has been used since the early application of flap surgeries but still remains poorly understood. Reconstructive strategies have greatly evolved since, and fasciocutaneous flaps have progressively replaced muscle-based reconstructions, ensuring better functional outcomes with great reliability. However, plastic surgeons still encounter challenges in complex cases where conventional flap reconstruction reaches its limitations. Furthermore, emerging bioengineering applications, such as decellularized scaffolds allowing a complex extracellular matrix to be repopulated with autologous cells, also face the complexity of revascularization. The objective of this article is to gather evidence of autonomization phenomena. A systematic review of flap autonomization is then performed to document the minimum delay allowing this process. Finally, past and potential applications in bio- and tissue-engineering approaches are discussed, highlighting the potential for in vivo revascularization of acellular scaffolds.

Pharmacological thrombolysis: the last choice for salvaging free flaps

Microvascular free flap transfer has become a prevailing surgery with a failure rate of <5%. However, pedicle thrombosis occurs more frequently than indicated by the failure rate. This difference is due to the successful salvage of failing flaps. During exploration, thrombi are often encountered at anastomotic sites, whereas these causes could not explain vascular compromise in other patients. Thus, we hypothesized that thrombogenic processes might occur at remote sites, specifically within microvessels of the transferred flap. This study retrospectively evaluated 323 patients who underwent microvascular free flap transfer between March 2012 and October 2016 at Korea University Guro Hospital. All patients requiring emergency exploration within 7 days after surgery were retrospectively reviewed. Of patients, 15 required explorative surgery for suspected circulatory compromise. Eight were diagnosed with thrombosis at the perianastomotic site and salvaged in accordance with our protocol. There was no detectable thrombosis at the anastomotic site in seven patients, including one patient in whom thrombosis resolved with topical papaverine application and heparinization. The remaining six patients were diagnosed with intra-flap microthrombosis without discernable thrombosis at the anastomotic site. All patients were treated following our urokinase administration protocol and salvaged without complications. Possible external causes should first be evaluated when salvaging free flaps; in the absence of such evidence, urokinase administration may be utilized as a last resort. This study is the first report describing the effectiveness of pharmacological thrombolysis in resolving intra-flap microthrombosis. Furthermore, a safe and efficient urokinase administration protocol is suggested for perianastomotic thrombosis and intra-flap microthrombosis.

Preserving a patent DIEP pedicle to facilitate salvage breast reconstruction with a second free flap: A case report

Surgeons performing free flap breast reconstruction need to have a range of techniques in their armamentarium to successfully salvage cases of flap failure. We present a case of 47-year-old patient who suffered near-total right breast deep inferior epigastric perforator (DIEP) flap failure 3 days post-bilateral immediate breast reconstruction with DIEP flaps. At debridement, the DIEP pedicle was noted to be patent with preserved perfusion to a small segment of tissue around the origin of the pedicle. This tissue and the DIEP pedicle itself were therefore preserved to facilitate subsequent breast reconstruction using stacked transverse upper gracilis flaps anastomosed end-to-end to the original DIEP pedicle. Post-operatively, both flaps remained viable with no further complications and symmetrical aesthetic result maintained at 2 months follow-up post-salvage procedure. This case emphasizes the importance of exercising caution during initial debridement for free flap failure to preserve viable tissue in the flap and pedicle, particularly in circumstances where vascular flow in the pedicle is maintained, to facilitate successful salvage reconstruction.

Is long-term post-operative monitoring of microsurgical flaps still necessary?

Autologous microsurgical flap reconstruction has become commonplace in most plastic surgery units, and the success rates of this procedure have markedly increased over recent years. However, the possibility of flap failure still needs to be considered. A review of the literature reveals that the critical period for flap-threatening complications is the first 24-48 post-operative hours; however, the window for the onset of these complications remains open for up to 7 days post-operatively. In this study, we focus on the timing of flap complications, aiming to elucidate the time period over which meticulous flap monitoring can positively contribute to flap salvage rates. The relevant literature on the study topic was collated and reviewed in conjunction with the senior author's case series, which consisted of a total of 335 free flaps used during a 2-year period for breast and head and neck reconstruction or limb trauma. Patients' series were then divided into groups according to the complications timing. The correlation between the timing of complications and the flap salvage rate was investigated among the groups. Overall analysis of both the literature and our own data on 335 free flaps showed a progressive reduction in flap salvage rate during post-operative days; the correlations between the times of complication onset and the flap salvage rates in all groups were significant up to the third post-operative day. The correlations between salvage rates and later complications were not significant. Our results suggest that hourly flap monitoring should be compulsory during the first 48 post-operative hours, but clinical monitoring four times daily should be sufficient thereafter.