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Asakura T, Shimokawatoko H, Nakazawa Y. Characterization and promotion of endothelialization of Bombyx mori silk fibroin functionalized with REDV peptide. Int J Biol Macromol 2024; 261:129746. [PMID: 38302025 DOI: 10.1016/j.ijbiomac.2024.129746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/03/2024]
Abstract
In the development of small-diameter vascular grafts, it is crucial to achieve early-stage endothelialization to prevent thrombus formation and intimal hyperplasia. Silk fibroin (SF) from Bombyx mori is commonly used for such grafts. However, there is a need to expedite endothelialization post-implantation. In this study, we functionalized SF with Arg-Glu-Asp-Val (REDV) (SF + REDV) using cyanuric chloride to enhance endothelialization. The immobilization of REDV onto SF was confirmed and the amount of immobilized REDV could be calculated by 1H NMR. Furthermore, the conformational changes in Tyr, Ser, and Ala residues in [3-13C]Tyr- and [3-13C]Ser-SF due to REDV immobilization were monitored using 13C solid-state NMR. The REDV immobilized onto the SF film was found to be exposed on the film's surface, as confirmed by biotin-avidin system. Cell culture experiments, including adhesiveness, proliferation, and extensibility, were conducted using normal human umbilical vein endothelial cells (HUVEC) and normal human aortic smooth muscle cells (HAoSMC) on both SF and SF + REDV films to evaluate the impact of REDV on endothelialization. The results indicated a trend towards promoting HUVEC proliferation while inhibiting HAoSMC proliferation. Therefore, these findings suggest that SF + REDV may be more suitable than SF alone for coating small-diameter SF knitted tubes made of SF threads.
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Affiliation(s)
- Tetsuo Asakura
- Department of Biotechnology, Tokyo University of Agriculture and Technology, 2-24-16 Nakacho, Koganei, Tokyo 184-8588, Japan.
| | - Haruka Shimokawatoko
- Department of Biotechnology, Tokyo University of Agriculture and Technology, 2-24-16 Nakacho, Koganei, Tokyo 184-8588, Japan
| | - Yasumoto Nakazawa
- Department of Biotechnology, Tokyo University of Agriculture and Technology, 2-24-16 Nakacho, Koganei, Tokyo 184-8588, Japan
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Coriddi M, Kim L, Haglich K, Nelson J, Shahzad F, Dayan J, Disa J, Mehrara B, Cordeiro P, McCarthy C. Comparisons of Impact of Vein Grafting with Different Indications on Outcomes of Reconstruction with Free Flaps. J Reconstr Microsurg 2024. [PMID: 38190987 DOI: 10.1055/a-2240-1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
BACKGROUND Prior studies have shown an increased risk of complications and flap loss with the use of vein grafts in microsurgery. We hypothesize that indication for use of a vein graft can affect flap complications and loss rates. METHODS We performed a retrospective review of all patients at our institution from 2010 to 2020 who underwent free flap reconstruction and required use of a vein graft. Indications for vein grafting included: salvage of flap during primary operation after microvascular compromise, augmentation of flow during primary operation, lengthening of the flap pedicle during the primary operation, and salvage of the flap during a secondary salvage operation after microvascular compromise. RESULTS A total of 79 patients met the study inclusion criteria. There were significant differences among the vein graft indication groups and the following: area of reconstruction (p = 0.002), vein graft length (p = 0.018), vessels grafted (p = 0.001), vein graft donor site (p = 0.011), and total flap loss (p = 0.047). Of the four indications for vein grafting, salvage of the flap during secondary salvage operation after microvascular compromise had the highest rate of total flap loss (26.7%). There were no significant associations between other flap complications and vein graft indications. CONCLUSION Vein graft use in the primary reconstructive setting is efficacious, with low risk of thrombosis. Use in secondary procedures, however, is associated with higher rates of total flap loss, likely due to the thrombotic process, which was initiated prior to the use of the graft resulting in the salvage procedure and not secondary to the graft itself.
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Affiliation(s)
- Michelle Coriddi
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Leslie Kim
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kathryn Haglich
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonas Nelson
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Farooq Shahzad
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Dayan
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Disa
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Babak Mehrara
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter Cordeiro
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Colleen McCarthy
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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3
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lai CS, Chang YT, Shen CH, Tsai YC, Lu CT, Yen JH, Chen IC, Lin YL. The role of vein grafts in reconstructive head and neck microsurgery. Braz J Otorhinolaryngol 2022; 88 Suppl 4:S81-S88. [PMID: 34802968 DOI: 10.1016/j.bjorl.2021.09.004] [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: 05/09/2021] [Revised: 08/25/2021] [Accepted: 09/05/2021] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Free tissue transfer is widely used for head and neck reconstruction. In certain circumstances, vein grafting is required to elongate free flap pedicles to connect them to appropriate recipient vessels. Because of controversy regarding the use of interposition vein grafts in free tissue reconstruction, this paper reports vein graft indications, techniques, safety, and outcomes for head and neck microvascular surgery. METHODS Twenty-six patients (23 men and 3 women) who underwent interposition vein grafting concurrent with free tissue transfer were included in this study. The most common reason for head and neck reconstruction with vein graft was tumor recurrence, followed by flap salvage. The interposition vein grafts were applied in two manners as temporary arteriovenous (A-V) loop and conduit to extend the length of the free flap for venous drainage. RESULTS The most common reconstructions were anterolateral thigh flaps (15 cases), followed by vastus lateralis myocutaneous (3 cases) and radial forearm (2 cases) flaps. The common recipient vessels were superior thyroid artery, superficial temporal artery and external jugular vein. The free flap loss rate was 7.7% with vein grafts and 4.9 without vein grafts (p = 0.380). The free flap complication rate was 50.0% and 16.8% in patients with and without vein grafts, respectively (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, and prior free flap transfer were more common in the vein graft group (all p < 0.001). The hospital stay was significantly longer for the vein graft group than for the non-vein graft group (29.5 vs. 19.0 days; p = 0.001). CONCLUSION Overall free flap survival rates of 92.3% and 95.1% in the vein and non-vein graft groups, respectively - indicating the reliability of the vein grafts in challenging head and neck reconstructions, particularly in salvage cases and patients with multiple reconstructions. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Chih-Sheng Lai
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China
| | - Yi-Ting Chang
- Taichung Veterans General Hospital, Department of Anesthesiology, Taichung, Taiwan, Republic of China
| | - Ching-Hui Shen
- Taichung Veterans General Hospital, Department of Anesthesiology, Taichung, Taiwan, Republic of China; National Yang Ming Chiao Tung University, Faculty of Medicine, School of Medicine, Taipei, Taiwan
| | - Yueh-Chi Tsai
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China; HungKuang University, Department of Nursing, Taichung, Taiwan, Republic of China
| | - Chen-Te Lu
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China
| | - Jung-Hsing Yen
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China
| | - I-Chen Chen
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China
| | - Yi-Ling Lin
- National Chung Hsing University, Department of Post-Baccalaureate Medicine, Taichung, Taiwan, Republic of China; HungKuang University, Department of Nursing, Taichung, Taiwan, Republic of China; Taichung Veterans General Hospital, Department of Emergency, Division of Trauma and Critical Care Medicine, Taichung, Taiwan, Republic of China.
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Moltaji S, El Khatib A, Rogers AD. Delayed axial flaps for coverage of a fourth degree scalp burn. J Surg Case Rep 2022; 2022:rjac468. [PMID: 36299910 PMCID: PMC9586711 DOI: 10.1093/jscr/rjac468] [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: 08/22/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Although free tissue transfers may be required to cover wounds of the head and neck with bone involvement and exposure, options lower on the reconstructive ladder should still be considered during the planning process. We present a case of an elderly gentleman with a history of cardiovascular comorbidity and neck radiotherapy, who sustained a deep flame burn injury to his scalp. Two delayed axial flaps, based on the superficial temporal and supraorbital arteries respectively, were used to obtain durable coverage of this complex wound.
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Affiliation(s)
- S Moltaji
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - A El Khatib
- Centre Hospitalier de l’Universite de Montreal, Montreal, Canada
| | - A D Rogers
- Correspondence address. D718, Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, M4N 3M5, Toronto, Canada. Tel: +4164806100 ext 3769; Fax: +4164804531; E-mail:
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Saphenous Vein Interposition Grafts in Lower Extremity Reconstruction: Appraisal of Technique and Case Series. Plast Reconstr Surg Glob Open 2022; 10:e4536. [PMID: 36168606 PMCID: PMC9509154 DOI: 10.1097/gox.0000000000004536] [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: 08/31/2021] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Vascular microanastomosis is technically challenging in patients with calcified recipient and donor vessels. Inside-to-outside suturing can prevent plaque rupture and ensure full-thickness intimal approximation. Although this is the preferred technique for anastomosis of atherosclerotic vessels, direct connection of calcified arteries necessitates outside-to-inside suturing on one side of the anastomosis. Furthermore, it is difficult to achieve optimal vessel wall approximation in the setting of luminal size mismatch and rigid vasculature. We previously reported on the use of a saphenous vein interposition graft as a novel technique to achieve a flow-sparing anastomosis in patients with diffuse atherosclerosis who are undergoing free tissue transfer. This study further assesses outcomes of this technique in a series of patients and demonstrates a flap success rate of over 93% in patients with calcified recipient and donor microvasculature.
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Stiles ZE, Lohman RF, Mann GN. Plastic Surgery Reconstruction of Sarcoma Resection Defects. Surg Clin North Am 2022; 102:583-599. [DOI: 10.1016/j.suc.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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8
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Zhang Y, Liu Y, Wang T, Dong J, Dong L, Xu H. A split flap technique shifting the location of perforator entry point to lengthen the pedicle of a multiple perforator based free flap. Acta Chir Belg 2022; 122:215-221. [PMID: 35499197 DOI: 10.1080/00015458.2022.2066273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Pedicle length deficiency in microsurgical procedure is a challenging issue. The aim of this report is to present a case series of a flap-splitting technique for pedicle lengthening of large multiple perforator-based (MPB) free flaps. METHODS In this retrospective case series, we reviewed the medical records of patients who underwent free flap repair with "split flap" pedicle-lengthening technique between August 2017 and December 2021. Main outcome measures included patient demographics, indications, defect size, flap type, additional vascular pedicle length, and flap survival. RESULTS Data from 16 patients (age 38-78 years) were reviewed. Indications included breast reconstruction, repair of scalp malignancy or titanium mesh implant exposure, and repair of burn scar contracture. Flaps included ALT flap, LD flap and DIEP flap. The mean added pedicle length was 3.8 cm. Fifteen flaps survived completely and one flap was necrotic distally. No major complications occurred. CONCLUSIONS The 'split flap' technique could be an effective remedy for unexpected pedicle length deficiencies in large MPB free flaps.
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Affiliation(s)
- Yi Zhang
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Ying Liu
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Tingliang Wang
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Jiasheng Dong
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Liping Dong
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
| | - Hua Xu
- Plastic and Reconstructive Surgery, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, Shanghai, China
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9
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Hallock GG. Perforator and Perforator Flap Spinoffs: A Historical Journey. Plast Reconstr Surg 2022; 149:287e-296e. [PMID: 35077428 DOI: 10.1097/prs.0000000000008795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY The concept of the perforator has now become a fundamental topic well known in every training program. However, that has not always been so. The mere definition of the word has historically been argued relentlessly; nevertheless, its major derivative, the perforator flap, has become accepted as a basic consideration whenever flaps need be selected. However, this has not been the only spinoff derived from the author's investigations of the perforator, a point that should be stressed in addition to some reiterations of pertinent and perhaps confusing nomenclature that deserve to be reemphasized. Truly, it has been amazing to see how our ideas and innovations arise simultaneously and independently throughout the world of reconstructive surgery. A final plea is made to sustain the future-each of us must continue to contribute our passion and our knowledge to all others by means of that technology now globally so instantaneously available.
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Affiliation(s)
- Geoffrey G Hallock
- From the Division of Plastic Surgery, St. Luke's Hospital, Sacred Heart Division
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10
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Coriddi M, Myers P, Mehrara B, Nelson J, Cordeiro PG, Disa J, Matros E, Dayan J, Allen R, McCarthy C. Management of postoperative microvascular compromise and ischemia reperfusion injury in breast reconstruction using autologous tissue transfer: Retrospective review of 2103 flaps. Microsurgery 2022; 42:109-116. [PMID: 34854501 PMCID: PMC8810672 DOI: 10.1002/micr.30845] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 10/22/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion. METHODS We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded. RESULTS Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n = 29, 61.7%) or partially salvaged (n = 5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n = 33, 70.2%), thrombectomy (n = 27, 57.4%), tissue plasminogen activator administration (n = 26, 55.3%), and vein grafts (n = 18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n = 33, 70.2%), postoperative steroids (n = 17, 38.6%), and postoperative therapeutic anticoagulation (n = 27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years. CONCLUSIONS Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.
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Affiliation(s)
- Michelle Coriddi
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paige Myers
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Babak Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonas Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter G Cordeiro
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Disa
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Evan Matros
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph Dayan
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Robert Allen
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Colleen McCarthy
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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11
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Reconstruction of Complex Scalp Defects in Different Locations: Suggestions for Puzzle. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2021; 55:349-358. [PMID: 34712077 PMCID: PMC8526234 DOI: 10.14744/semb.2020.98475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/05/2020] [Indexed: 11/20/2022]
Abstract
Objective Scalp defects may occur following trauma, radiotherapy, oncologic resection, and recurrent surgeries. The hair-bearing scalp has a dual role, which consists of protecting the calvarium and contributing to aesthetic appearance. While the "reconstructive ladder" approach may be used to close small and medium-sized scalp defects, it is not the case for larger ones involving the calvarium or with a radiation therapy history. The aim of this study is to present cases operated due to complex scalp defects, analyze complications, and discuss the choice of reconstruction. Material and Methods The study consists of 14 patients who were operated between December 2017 and August 2019 due to a complex scalp defect. Patient were evaluated according to age, gender, etiology, radiation therapy history, defect size and location, reconstruction steps, cranioplasty and duraplasty options, type of free flap, recipient artery, vein graft requirement, and complications. Results The mean age of patients, which consists of 11 men and three women, was 56.7 years. The etiology for scalp defects included basosquamous carcinoma, squamous cell carcinoma, giant basal cell carcinoma, atypical meningioma, glioblastoma multiforme, angiosarcoma, and anaplastic oligodendroglioma. The defect involved the full thickness of calvarium in nine cases and pericranium in five cases. Cranioplasties were made with rib graft (n=1), bone graft (n=1), and titanium mesh (n=7). Free flaps used for reconstruction were musculocutaneous latissimus dorsi (LD) (n=4), LD muscle (n=3), anterolateral thigh (ALT) (n=4), musculocutaneous ALT (n=1), vastus lateralis muscle (1), and rectus abdominis muscle (n=1). Flap loss was not observed. Complications occurred in four of the patients; include a partial graft loss, a wound dehiscence, seroma, and an unsatisfactory esthetic result. Conclusion Free tissue transfers rather than local flaps should be opted to reconstruct complex scalp defects, as failure of the latter, could create much greater defects, and worse consequences. There are many options for proper reconstruction, and it is essential to select the appropriate one, taking into account the comorbid conditions of each case.
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Johal KS, Chen HC. Interpositional vein grafting for significant size discrepancy: The important role for short, sequential grafts in step-up and step-down microvascular anastomoses. J Plast Reconstr Aesthet Surg 2021; 75:659-664. [PMID: 34764041 DOI: 10.1016/j.bjps.2021.09.012] [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: 06/15/2020] [Revised: 03/26/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Anastomotic vessel size discrepancy may be addressed by numerous techniques, including the end-to-side. Most of these conventional methods are less suited with larger flap vessels relative to recipients, such as the vessel-depleted oncological neck with prior radiotherapy or in supermicrosurgical techniques with perforator recipients. We describe how short segment (single or double) interpositional vein grafts can be used to safely graduate this discrepancy in a 'step-up' or 'step-down' manner. METHODS We conducted a retrospective review of all cases where interpositional vein grafts had been utilised. Furthermore, the technique for harvest, vessel preparation and anastomotic sequence is described. RESULTS Over fifteen years, 116 short segment interpositional vein grafts (in 83 patients) were employed to address vessel discrepancy. Concerning patient demographics, there were 81 male:2 female, mean age 51 years (range 27-68 years), and aetiology was oral cancer (75), trauma(7) and congenital(1). Single (50) and double (33) grafts were used for 65 arterial anastomoses (8 step-down: 57 step-up) and 18 for venous anastomoses (12 step-down: 6 step-up). Flaps employed were osteocutaneous fibula (28), anterolateral thigh (24), free ileocolon (11), radial forearm (11), SCIP (7) and others (2). Six flaps (of 83) were lost (5 arterial and 1 venous thrombosis). CONCLUSION Short segment interpositional vein grafts may be safely utilised for 'step-up' and 'step-down' anastomoses. Planned use in the primary case, minimum required length and meticulous preparation are fundamental for success and to dispel traditional concerns over poorer outcomes when vein grafts are used.
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Affiliation(s)
- Kavan S Johal
- Department of Plastic Surgery, China Medical University Hospital, 2 Yuh-Der Road, Taichung 40447, Taiwan; Department of Plastic Surgery, St Thomas' Hospital, London, United Kingdom
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, 2 Yuh-Der Road, Taichung 40447, Taiwan.
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Yamanaka H, Mahara A, Morimoto N, Yamaoka T. REDV-modified decellularized microvascular grafts for arterial and venous reconstruction. J Biomed Mater Res A 2021; 110:547-558. [PMID: 34486215 DOI: 10.1002/jbm.a.37305] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 11/09/2022]
Abstract
Recently, a decellularized microvascular graft (inner diameter: 0.6 mm) modified with the integrin α4β1 ligand, REDV, was developed to provide an alternative to autologous-vein grafting in reconstructive microsurgery, showing good early-stage patency under arterial flow in rats. This consecutive study evaluated its potential utility not only as an arterial substitute, but also as a venous substitute, using a rat-tail replantation model. Graft remodeling depending on hemodynamic status was also investigated. ACI rat tail arteries were decellularized via ultra-high-hydrostatic pressure treatment and modified with REDV to induce antithrombogenic interfaces and promote endothelialization after implantation. Grafts were implanted into the tail artery and vein to re-establish blood circulation in amputated Lewis rat tails (n = 12). The primary endpoint was the survival of replants. Secondary endpoints were graft patency, remodeling, and regeneration for 6 months. In all but three cases with technical errors or postoperative self-mutilation, tails survived without any evidence of ischemia or congestion. Six-month Kaplan-Meier patency was 100% for tail-artery implanted grafts and 62% for tail-vein implanted grafts. At 6 months, the neo-tunica media (thickness: 95.0 μm in tail-artery implanted grafts, 9.3 μm in tail-vein implanted grafts) was regenerated inside the neo-intima. In conclusion, the microvascular grafts functioned well both as arterial and venous paths of replanted-rat tails, with different remodeling under arterial and venous conditions.
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Affiliation(s)
- Hiroki Yamanaka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan.,Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Atsushi Mahara
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| | - Naoki Morimoto
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine and Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Tetsuji Yamaoka
- Department of Biomedical Engineering, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
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Effects of endothelial defects and venous interposition grafts on the acute incidence of thrombus formation within microvascular procedures. Sci Rep 2021; 11:8767. [PMID: 33888838 PMCID: PMC8062688 DOI: 10.1038/s41598-021-88324-2] [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: 01/23/2021] [Accepted: 03/30/2021] [Indexed: 11/14/2022] Open
Abstract
Endothelial defects (ED) and the usage of interposition vein grafts (IVG) are known risk factors for free flap failure. This experimental study aimed to compare both situations of thrombus formation and fluorescence angiographic behavior. Indocyanine green videoangiography (ICGVA) with the FLOW 800 tool was systematically performed in groups I = ED, II = IVG, and III = ED and IVG (each n = 11). ICGVA was able to detect thrombosis in five animals and safely ruled it out in 26 with two false-positive cases (sensitivity, specificity, and positive and negative predictive values were 100%, 90%, 62%, and 100%, respectively). The difference between visually and ICGVA-assisted ED measurements was significant (p = 0.04). The areas of thrombosis showed no significant difference. Moreover, ICGVA detected a decrease of all parameters at the ED area and/or within the IVG section in all groups. The presence of an endothelial defect had a higher impact on thrombus formation than the IVG usage. ICGVA is qualitatively able to detect endothelial defects and clinically evident thrombosis. However, the quantitative values are not yet attributable to one of the clinical scenarios that may jeopardize free flap transfer.
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Gazyakan E, Xiong L, Sun J, Kneser U, Hirche C. Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures. J Reconstr Microsurg 2021; 37:608-616. [PMID: 33592633 DOI: 10.1055/s-0041-1723823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. METHODS A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. RESULTS A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). CONCLUSION In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.
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Affiliation(s)
- Emre Gazyakan
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Lingyun Xiong
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany.,Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiaming Sun
- Department of Plastic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Prince ADP, Broderick MT, Neal MEH, Spector ME. Head and Neck Reconstruction in the Vessel Depleted Neck. FRONTIERS OF ORAL AND MAXILLOFACIAL MEDICINE 2020; 2. [PMID: 33236000 DOI: 10.21037/fomm-20-38] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Microvascular free tissue transfer has revolutionized reconstruction and subsequently functional outcomes in the head and neck, but requires suitable recipient vessels for successful results. Recipient vessels can be significantly compromised by prior surgery, radiation therapy, or existing and/or underlying vascular disease in the neck. When further microvascular reconstruction is required in the vessel-depleted neck, identification of appropriate vessels for anastomosis can be difficult and can present complex decisions for the surgeon as well as the patient. In this article, we review the available literature on the vessel depleted neck and the possible vessel options. We present critical strategies for preoperative treatment planning and vessel selection in these patients. We also discuss the benefits and limitations of arterial and venous options while commenting on our unique institution's experiences. The external carotid branches as well as the available subclavian artery branches are presented in detail. The venous anatomy is also described, with particular focus on the accompanying veins and cephalic vein. We provide guidance on the selection and modification of free flaps to achieve the greatest function and cosmetic outcomes in the vessel depleted neck. Our collection of advanced management techniques will provide surgeons with more options to manage the complexity of the vessel depleted neck, and to further help patients understand the risk and benefits of these selections.
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Affiliation(s)
| | | | - Molly E Heft Neal
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Matthew E Spector
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan
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17
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Kapila AK, Wakure A, Morgan M, Belgaumwala T, Ramakrishnan V. Characteristics and outcomes of primary interposition vascular grafts in free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:2142-2149. [PMID: 32565135 DOI: 10.1016/j.bjps.2020.05.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/10/2020] [Accepted: 05/16/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION There is paucity of data on primary interposition vascular grafts (IVG) use in microsurgery. Our study examines the characteristics, indications and outcomes of IVG in free flap breast reconstruction. METHODS All cases of breast reconstruction with free flaps between January 2013 and June 2018 were examined and cases with primary IVG were included. Data were collected on patient, flap and graft characteristics, indications and outcomes. RESULTS A total of 76 IVG, specifically 65 vein grafts and 11 arterial grafts, were used for 49 (of 1547) flaps in 48 (of 1346) cases. Of these, 52 grafts were primarily used to lengthen the pedicle and aid flap inset and 24 grafts to augment venous flow; 49 grafts were harvested from the flap harvest site, 7 from the anastomosis recipient site and 20 from a separate site. Of the total, 16.7% (8/49 flaps) required salvage procedures - seven cases for venous congestion and one for ischaemic compromise - in comparison to 4.3% in cases without IVG (65/1498) (p<0.0001). Out of 49 IVG flaps, three (6.1%) failed in comparison to 1.7% (26/1498), where IVG flaps were not used (p<0.05). Two were transverse upper gracilis flaps with vessel calibre mismatch, and one lumbar artery perforator (LAP) flap with past infected implant and failed deep inferior epigastric artery (DIEP). CONCLUSION We present the largest number of primary vascular grafts for free flap breast reconstruction in the literature. Primary IVG were used for at-risk flaps and had a success rate of 93.9%. This shows that IVG are a viable option to prevent venous congestion and lengthen the pedicle to aid inset and shaping; they are associated with higher complication rates bearing in mind the high-risk profile of the flaps these are used for.
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Affiliation(s)
- Ayush K Kapila
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom; Department of Plastic and Reconstructive Surgery, University Hospital Brussels (UZ Brussel), Belgium.
| | - Abhijeet Wakure
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
| | - Mary Morgan
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
| | - Tasneem Belgaumwala
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
| | - Venkat Ramakrishnan
- St. Andrew's Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, United Kingdom
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Survival after Digit Replantation and Revascularization Is Not Affected by the Use of Interpositional Grafts during Arterial Repair. Plast Reconstr Surg 2019; 143:551e-557e. [DOI: 10.1097/prs.0000000000005343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Henn D, Bigdeli AK, Horsch M, Weiß C, Kühner C, Hirche C, Schmidt VJ, Kneser U. Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: A matched‐pair analysis. Microsurgery 2019; 40:12-18. [DOI: 10.1002/micr.30428] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/29/2018] [Accepted: 01/04/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Dominic Henn
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Amir K. Bigdeli
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Miriam Horsch
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Christel Weiß
- Department of Medical StatisticsUniversity Medicine Mannheim, University of Heidelberg, Theodor‐Kutzer‐Ufer 1 Mannheim Germany
| | - Clemens Kühner
- Department of Vascular SurgeryLudwigshafen Hospital, Bremser Str. 79 Ludwigshafen Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Volker J. Schmidt
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, BG Trauma Center LudwigshafenUniversity of Heidelberg, Ludwig‐Guttmann‐Str. 13 Ludwigshafen Germany
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Strategies for Complex Scalp Reconstruction in Patients With Poor Recipient Vessels. J Craniofac Surg 2018; 30:e12-e14. [PMID: 30376503 DOI: 10.1097/scs.0000000000004876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Complex scalp defects with poor recipient vessels represent a challenge for plastic surgeons. In these cases, free flaps are the last resort for solving the problem. The authors present 5 difficult cases with complex large scalp and calvarium defects with unsuitable small recipient vessels for anastomoses. For these cases, the lesser saphenous vein was harvested and used as an interposition graft between the external carotid artery, the jugular vein, and the flap. Latissimus Dorsi, Anterolateral Thigh, and serratus anterior were the flaps used for reconstruction. Cranioplasty was simultaneously performed in 4 cases. The scalp defects varied from 83 to 288 cm. All flaps survived. In 1 case (extended Latissimus Dorsi) there was local infection and wound dehiscence with marginal flap necrosis that required flap readvancement. In conclusion, end-to-end anastomosis to the external carotid artery offers strong outflow through the vein graft and flap. A large vein graft allows good outflow and is more resistant to the pressure of the skin envelope. Anastomosis to large neck vessels (internal or external jugular) facilitates drainage since there is also an aspiration effect due to the venous flow circulation through it.
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21
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Azzi AJ, Zhou S, Safran T, Xu L, Alnaif N, Zadeh T. Vascularized Tissue Reconstruction in Previously Irradiated Sarcoma Defects. Ann Plast Surg 2018; 82:89-92. [PMID: 30325838 DOI: 10.1097/sap.0000000000001652] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Radiation therapy (RT) is recommended for appropriately selected sarcoma patients to minimize the risk of local recurrence and to maximize outcomes of disease-free survival and function. The purpose of this study was to confirm the safety of vascularized tissue reconstruction in recently irradiated sarcoma defects. METHODS A retrospective review of all patients treated by the senior author for sarcoma reconstruction from January 2005 to July 2017 was performed. Two independent reviewers collected data from both electronic and paper medical records. Patients were included if they underwent flap reconstruction (pedicled or free) following sarcoma resection. The safety of neoadjuvant RT was compared with a control group with no previous irradiation using χ(2) analysis. RESULTS Fifty-seven patients were included in the study; 35 patients were included in the preoperative RT group, and 22 patients were included in the control group (no previous irradiation). There was no significant difference in wound complications between the 2 groups (infection, dehiscence, hematoma, and seroma). Microvascular complications (arterial thrombosis, venous thrombosis, partial/total flap loss) were also comparable in the free tissue transfer subgroup. CONCLUSIONS The current study demonstrates the safety of both pedicled and free flap reconstruction in previously irradiated sarcoma defects. Judicious selection of reconstructive technique and recipient vessels is crucial in obtaining optimal outcomes given the devastating effects of RT on native tissues.
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Affiliation(s)
| | - Sarah Zhou
- McGill University, Faculty of Medicine, Montreal, Quebec, Canada
| | - Tyler Safran
- McGill University, Faculty of Medicine, Montreal, Quebec, Canada
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Higginson J, McMillan K, Mustafa E, Grew N. Use of the superficial inferior epigastric vein as an unusual interpositional vein graft. Br J Oral Maxillofac Surg 2018; 56:761-762. [DOI: 10.1016/j.bjoms.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 07/01/2018] [Indexed: 10/28/2022]
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23
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Tissue-engineered submillimeter-diameter vascular grafts for free flap survival in rat model. Biomaterials 2018; 179:156-163. [DOI: 10.1016/j.biomaterials.2018.06.022] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 06/11/2018] [Accepted: 06/14/2018] [Indexed: 01/27/2023]
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25
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Reissis M, Reissis D, Bottini GB, Messiha A, Davies DC. A morphometric analysis of the suitability of the transverse cervical artery as a recipient artery in head and neck free flap microvascular reconstruction. Surg Radiol Anat 2018; 40:891-897. [PMID: 29632965 DOI: 10.1007/s00276-018-2019-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 04/05/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE Gold standard recipient arteries in head and neck free flap microvascular reconstruction are currently branches of the external carotid. However, these arteries can be compromised by neck dissection or radiotherapy, resulting in 'vessel-depleted neck' and 'frozen neck' respectively. In such cases, the transverse cervical artery (TCA) may be a suitable recipient artery. METHODS The origin, course and diameter of the TCA were determined in 46 sides of neck from 23 cadavers. The distances from the origin of the TCA to the angle of the mandible, floor of the mouth and mandibular symphysis were measured to determine the pedicle length required for free flap anastomosis. RESULTS The TCA was present bilaterally in all subjects investigated and its course across the posterior triangle of the neck was constant between individuals. The mean distances from the origin of the TCA to the angle of mandible, floor of mouth and mandibular symphysis were 10.0, 9.2 and 12.6 cm, respectively. There were no significant differences in these distances between the left and right sides of the neck (p > 0.05 for all comparisons). The distances from the TCA origin to the angle of the mandible and floor of the mouth were significantly longer in males than in females (p = 0.004) and correlated directly with the greater height of males compared to females (p = 0.0004). The mean diameter of the TCA measured 2 cm from its origin was 2.2 mm. CONCLUSION The TCA is a suitable and reliable recipient artery for free flap microvascular reconstruction, when branches of the external carotid artery are unavailable.
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Affiliation(s)
- M Reissis
- Human Anatomy Unit, Department of Surgery and Cancer, Imperial College London, Charing Cross Campus, St Dunstan's Road, London, W6 8RP, UK
| | - Dimitris Reissis
- Human Anatomy Unit, Department of Surgery and Cancer, Imperial College London, Charing Cross Campus, St Dunstan's Road, London, W6 8RP, UK.
| | - G B Bottini
- Department of Oral and Maxillofacial Surgery, St George's Hospital, London, UK
| | - A Messiha
- Department of Oral and Maxillofacial Surgery, St George's Hospital, London, UK
| | - D C Davies
- Human Anatomy Unit, Department of Surgery and Cancer, Imperial College London, Charing Cross Campus, St Dunstan's Road, London, W6 8RP, UK
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Ciudad P, Agko M, Date S, Chang WL, Manrique OJ, Huang TCT, Lo Torto F, Trignano E, Chen HC. The radial forearm free flap as a "vascular bridge" for secondary microsurgical head and neck reconstruction in a vessel-depleted neck. Microsurgery 2017; 38:651-658. [PMID: 29105820 DOI: 10.1002/micr.30259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 08/13/2017] [Accepted: 10/03/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND In a vessel-depleted neck, distant recipient sites may be the only option for secondary free flap reconstruction. While interposition vein grafts and arteriovenous loops can bridge the gap between the recipient and donor pedicle, they are not without risks. In these scenarios, we examinate the reliablity of a radial forearm free flap (RFFF) as an alternative vascular conduit. PATIENTS AND METHODS A retrospective review of cases between March 2005 and May 2016 was performed. Demographic data, prior surgical history, intraoperative details and outcomes were recorded. A total of ten patients, eight male and two female, with a mean age of 54.2 years (range, 39-74) were identified. The RFFF was initially anastomosed to either the thoracoacromial (n = 6) or internal mammary vessels (n = 4) and subsequently served as the recipient pedicle for the second "main" flap, an anterolateral thigh (n = 4), jejunum (n = 3) or fibula flap (n = 3). RESULTS The average RFFF dimensions were 13.8 cm by 5.8 cm. All twenty flaps, ten RFFF and ten "main' flaps survived completely with only one case of minimal epidermal loss. One patient with esophageal reconstruction with jejunum developed a fistula that required closure with a local falp. At a mean follow-up of 18.4 months (range 8-29), the reconstructive goals had been achieved in all cases. CONCLUSIONS The RFFF serves as a reliable "vascular bridge" that extends the reach of distant recipient sites to free flaps in secondary head and neck reconstruction.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Biological Science and Technology, China Medical University, Taichung, Taiwan
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Wei-Ling Chang
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tony C T Huang
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Emilio Trignano
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Ciudad P, Agko M, Manrique OJ, Date S, Kiranantawat K, Chang WL, Nicoli F, Lo Torto F, Maruccia M, Orfaniotis G, Chen HC. The retrograde transverse cervical artery as a recipient vessel for free tissue transfer in complex head and neck reconstruction with a vessel-depleted neck. Microsurgery 2017; 37:902-909. [PMID: 28753219 DOI: 10.1002/micr.30193] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 05/17/2017] [Accepted: 06/09/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND Reconstruction in a vessel-depleted neck is challenging. The success rates can be markedly decreased because of unavailability of suitable recipient vessels. In order to obtain a reliable flow, recipient vessels away from the zone of fibrosis, radiation, or infection need to be explored. The aim of this report is to present our experience and clinical outcomes using the retrograde flow coming from the distal transverse cervical artery (TCA) as a source for arterial inflow for complex head and neck reconstruction in patients with a vessel-depleted neck. METHODS Between July 2010 and June 2016, nine patients with a vessel-depleted neck underwent secondary head and neck reconstruction using the retrograde TCA as recipient vessel for microanastomosis. The mean age was 49.6 years (range, 36 to 68 years). All patients had previous bilateral neck dissections and all, except one, had also received radiotherapy. Indications included neck contracture release (n = 3), oral (n = 1), mandibular (n = 3) and pharyngoesophageal (n = 2) reconstruction necessitating free anterolateral thigh (n = 3) and medial sural artery (n = 1) perforator flaps, fibula (n = 3) and ileocolon (n = 2) flaps respectively. RESULTS There was 100% flap survival rate with no re-exploration or any partial flap loss. One case of intra-operative arterial vasospasm at the anastomotic suture line was managed intra-operatively with vein graft interposition. There were no other complications or donor site morbidity during the follow-up period. CONCLUSIONS In a vessel-depleted neck, the reverse flow of the TCA may be a reliable option for complex secondary head and neck reconstruction in selected patients.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Department of Biological Science and Technology, China Medical University, Taichung, Taiwan
| | - Mouchammed Agko
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, United Sates
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Kidakorn Kiranantawat
- Division of Plastic and Maxillofacial Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wei Ling Chang
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Federico Lo Torto
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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Transverse Cervical Artery: Consistent Anatomical Landmarks and Clinical Experience with Its Use as a Recipient Artery in Complex Head and Neck Reconstruction. Plast Reconstr Surg 2017; 139:745e-751e. [PMID: 28234854 DOI: 10.1097/prs.0000000000003085] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many head and neck reconstructions occur in patients with extensive history of surgery or radiation treatment. This leads to complicated free flap reconstructions, especially in choosing recipient vessels in a "frozen neck." The transverse cervical artery is an optimal second-line recipient artery in head and neck reconstruction. METHODS Seventy-two neck sides in 36 cadavers were dissected, looking for the transverse cervical artery and transverse cervical vein. Anatomical location of these vessels, their diameter, and length were documented. A retrospective analysis on 19 patients who had head and neck reconstruction using the transverse cervical artery as a recipient artery was undertaken as well with regard to outcome of procedures, reason for surgery, previous operations, and use of vein grafts during surgery. RESULTS The transverse cervical artery was present in 72 of 72 of cadaveric specimens, and was infraclavicular in two of 72 specimens. Transverse cervical artery length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.65 mm. The transverse cervical vein was present in 61 of 72 cadaveric specimens, the length ranged from 4.0 to 7.0 cm, and the mean diameter was 2.90 mm. The transverse cervical artery averaged 33 mm from midline, and branched off the thyrocervical trunk at an average 17 mm superior to the clavicle. Transverse cervical artery stenosis was markedly less in comparison with external carotid artery stenosis. In a 20-year clinical follow-up study, the transverse cervical artery was the recipient artery in 19 patients. A vein graft was used in one patient, and no flap loss occurred in any of the 19 patients. CONCLUSION The transverse cervical artery is a reliable and robust option as a recipient artery in free flap head and neck reconstruction.
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Baliarsing A, Date S, Ciudad P. Medial sural artery as a salvage recipient vessel for complex post traumatic microvascular lower limb reconstruction. Microsurgery 2017; 38:157-163. [DOI: 10.1002/micr.30158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/20/2016] [Accepted: 01/05/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Amresh Baliarsing
- Department of Plastic and Reconstructive Surgery; T. N. Medical College (TNMC); Mumbai India
| | - Shivprasad Date
- Department of Plastic and Reconstructive Surgery; T. N. Medical College (TNMC); Mumbai India
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Plastic and Reconstructive Surgery; Dr. D. Y. Patil Medical College; Navi Mumbai India
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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Yamamoto T, Yoshimatsu H, Yamamoto N, Yokoyama A, Numahata T, Koshima I. Multisite Lymphaticovenular Anastomosis Using Vein Graft for Uterine Cancer-Related Lymphedema After Pelvic Lymphadenectomy. Vasc Endovascular Surg 2015; 49:195-200. [DOI: 10.1177/1538574415614402] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Lymphaticovenular anastomosis (LVA) is becoming a treatment option for lymphedema. It is challenging to perform LVA when a lymphatic vessel is too far from a vein to anastomose directly. Methods: We applied vein grafting for simultaneous multisite LVA (SM-LVA), when there was a considerable distance between a lymphatic vessel and a vein. Five patients with lower extremity lymphedema (LEL) who underwent SM-LVA were included in this study. Feasibility and treatment effect of the method were evaluated. Results: Simultaneous multisite LVA resulted in 35 anastomoses. Vein grafting was performed in 5 of 35 anastomoses with 100% technical success. All LVAs showed good intraoperative anastomosis patency. At 6 months postoperatively, LEL index was significantly lower than preoperative LEL index (251.0 ± 33.0 vs 271.0 ± 38.5, P < .001). Conclusion: In SM-LVA surgery, a vein can be harvested from another surgical field without additional invasiveness and is useful for bridging a lymphatic vessel and a distant vein.
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Affiliation(s)
- Takumi Yamamoto
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hidehiko Yoshimatsu
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Ai Yokoyama
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Takao Numahata
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Isao Koshima
- Department of Plastic and Reconstructive Surgery, the University of Tokyo, Bunkyo-ku, Tokyo, Japan
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