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Dornseifer U, Pfeiler PP, Kargl L, Moog P, Schilling AF, Ninkovic M. Negative Pressure Wound Therapy in Free Muscle Flaps-Risk or Benefit? J Reconstr Microsurg 2024; 40:197-204. [PMID: 37315931 DOI: 10.1055/a-2110-0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Application of negative pressure wound therapy (NPWT) on free flaps not only reduces edema but also increases the pressure from outside. The impact of these opposite effects on flap perfusion remains elusive. This study evaluates the NPWT system's influence on macro- and microcirculation of free flaps and edema reduction to better assess the clinical value of this therapy in microsurgical reconstructions. METHODS In this open-label, prospective cohort study, a total of 26 patients with free gracilis muscle flaps for distal lower extremity reconstruction were included. Flaps were covered with an NPWT (13 patients) or a conventional, fatty gauze dressing (13 patients) for 5 postoperative days (PODs). Changes in flap perfusion were analyzed by laser Doppler flowmetry, remission spectroscopy, and an implanted Doppler probe. Flap volume as a surrogate parameter for flap edema was evaluated by three-dimensional (3D) scans. RESULTS No flap showed clinical evidence of circulatory disturbances. The groups showed significant differences in the dynamic of macrocirculatory blood flow velocity with an increase in the NPWT group and a decelerated flow in the control group from PODs 0 to 3 and PODs 3 to 5. No significant differences in microcirculation parameters were observed. 3D scans for estimation of edema development demonstrated significant differences in volume dynamics between the groups. Flap volume of the controls increased, while the volume in the NPWT group decreased during the first 5 PODs. The volume of NPWT-treated flaps decreased even further after NPWT removal from PODs 5 to 14 and significantly more than the flap volume in the control group. CONCLUSION NPWT is a safe form of dressing for free muscle flaps that enhances blood flow and results in a sustainable edema reduction. The use of NPWT dressings for free flaps should therefore be considered not only as a pure wound covering but also as a supportive therapy for free tissue transfer.
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Affiliation(s)
- Ulf Dornseifer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Isar Klinikum, Munich, Germany
| | - Peter Paul Pfeiler
- Department of Plastic, Reconstructive and Aesthetic Surgery, Isar Klinikum, Munich, Germany
| | - Lukas Kargl
- Department of Plastic, Reconstructive and Aesthetic Surgery, Isar Klinikum, Munich, Germany
| | - Philipp Moog
- Clinic for Plastic, Reconstructive and Hand Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
| | - Arndt F Schilling
- Department of Trauma Surgery, Orthopedics and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
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Kuenlen A, Waked K, Eisenburger M, Oramary A, Alsherawi A, Ninkovic M. Influence of VAC Therapy on Perfusion and Edema of Gracilis Flaps: Prospective Case-control Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4964. [PMID: 37124381 PMCID: PMC10145892 DOI: 10.1097/gox.0000000000004964] [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: 01/25/2023] [Accepted: 03/09/2023] [Indexed: 05/02/2023]
Abstract
The gracilis muscle flap is a popular choice in reconstructive surgery to repair soft tissue defects or for functional restoration. Little is known on the influence of postoperative application of VAC (vacuum-assisted closure; Kinetic Concepts Inc., San Antonio, Tex.) therapy on perfusion and postoperative flap edema of free gracilis muscle flaps. Methods In total, 26 patients with soft tissue defects of lower extremity underwent gracilis muscle flap reconstruction. The study group (VAC, n = 13) was supplied with postoperative negative pressure therapy as a dressing; the control group (NVAC, n = 13) was supplied with conventional fat gauze dressing. Postoperative measurements of micro- and macroperfusion were performed intraoperatively, on postoperative day (POD) 3 and POD 5. Flap edema measurement was performed intraoperatively, on POD 5 and 2 weeks after operation. Results The VAC group showed significantly better macroflow during intraoperative VAC treatment, as well on POD 3 and POD 5. Venous outflow was also better with lower hemoglobin levels. Microflow was better in the NVAC group with higher measured oxygen levels. All gracilis muscle flaps of the VAC group showed significantly less flap edema compared with the control group. Conclusions VAC application on free gracilis muscle flaps leads to significantly less postoperative flap edema, improved arterial macroflow, and improved venous outflow. VAC therapy can be used without any danger for patient's safety, as flap survival is not endangered, and presents an easy to handle and pleasant dressing regimen for nursing staff and patients.
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Affiliation(s)
- Anian Kuenlen
- Department of Plastic, Reconstructive, Hand and Burn Surgery - Bogenhausen Academic Hospital, Munich, Germany
| | - Karl Waked
- Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Michael Eisenburger
- Department of Plastic, Reconstructive, Hand and Burn Surgery - Bogenhausen Academic Hospital, Munich, Germany
| | - Alan Oramary
- Department of Plastic, Reconstructive, Hand and Burn Surgery - Bogenhausen Academic Hospital, Munich, Germany
| | - Abeer Alsherawi
- Department of Plastic, Reconstructive, Hand and Burn Surgery - Bogenhausen Academic Hospital, Munich, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery - Bogenhausen Academic Hospital, Munich, Germany
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Bonapace-Potvin M, Govshievich A, Tessier L, Karunanayake M, Tremblay D, Chollet A. Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction. Plast Surg (Oakv) 2023; 31:70-77. [PMID: 36755829 PMCID: PMC9900030 DOI: 10.1177/22925503211019602] [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: 01/03/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.
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Affiliation(s)
| | | | - Laurent Tessier
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
| | | | - Dominique Tremblay
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
| | - André Chollet
- Université de Montréal Plastic Surgery Program,
Montréal, Quebec, Canada
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Brandl A, Egner C, Reisser U, Lingenfelder C, Schleip R. Influence of high-energy laser therapy to the patellar tendon on its ligamentous microcirculation: An experimental intervention study. PLoS One 2023; 18:e0275883. [PMID: 36972259 PMCID: PMC10042339 DOI: 10.1371/journal.pone.0275883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/07/2023] [Indexed: 03/29/2023] Open
Abstract
Laser therapeutic applications, such as the use of high energy lasers (HILT), are widely used in physical therapy, but basic studies on the mechanisms of action of HILT on tendinous/ligamentous tissue are largely lacking. The aim of this study was to investigate microcirculatory changes of the patellar tendon by HILT. 21 healthy volunteers were included in the present investigation. Before and after HILT, as well as 10 minutes later, the microcirculation was measured by noninvasive laser Doppler and white light spectroscopy (O2C device). Tissue temperature was recorded at the measurement time points using thermography. Blood flow increased significantly by 86.38 arbitrary units (AU; p < 0.001) after the intervention and by 25.76 AU (p < 0.001) at follow-up. Oxygen saturation increased by 20.14% (p < 0.001) and 13.48%, respectively (p < 0.001), whereas relative hemoglobin decreased by 6.67 AU and 7.90 AU, respectively. Tendon temperature increased by 9.45° and 1.94° Celsius, respectively. Acceleration of blood flow by improving the flow properties of erythrocytes and platelets may have caused the results. HILT could be a therapeutic perspective for tendon pathologies with impaired microcirculation, although further studies are needed to validate the experimental results.
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Affiliation(s)
- Andreas Brandl
- Faculty for Psychology and Human Movement Science, Department of Sports Medicine, Institute for Human Movement Science, University of Hamburg, Hamburg, Germany
- DIPLOMA Hochschule, Bad Sooden-Allendorf, Germany
| | | | | | | | - Robert Schleip
- DIPLOMA Hochschule, Bad Sooden-Allendorf, Germany
- Department of Sport and Health Sciences, Conservative and Rehabilitative Orthopedics, Technical University of Munich, Munich, Germany
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Analysis of Factors Determining Patient Survival after Receiving Free-Flap Reconstruction at a Single Center-A Retrospective Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12112877. [PMID: 36428937 PMCID: PMC9689428 DOI: 10.3390/diagnostics12112877] [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: 10/20/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Microsurgical tissue transfer revolutionized reconstructive surgery after extensive trauma, oncological resections, and severe infections. Complex soft tissue reconstructions are increasingly performed in multimorbid and elderly patients. Therefore, it is crucial to investigate whether these patients benefit from these complex procedures. OBJECTIVE To evaluate the outcome for multimorbid patients who underwent microsurgical soft tissue reconstruction and to identify potential risk factors that may increase mortality. METHODS This single-center study retrospectively analyzed prospectively collected data of patients receiving free gracilis (GM) or latissimus dorsi muscle (LDM) flap reconstruction between September 2017 and December 2021. Cases were divided into two groups (dead vs. alive), depending on patient survival. Patient demographics, comorbidities and medication, perioperative details, free flap outcome, as well as microcirculation were determined. RESULTS A total of 151 flaps (LDM, n = 67; GM, n = 84) performed in 147 patients with a mean age of 61.15 ± 17.5 (range 19-94) years were included. A total of 33 patients (22.45%) passed away during the study period. Deceased patients were significantly older (Alive: 58.28 ± 17.91 vs. Dead: 71.39 ± 11.13; p = 0.001), were hospitalized significantly longer (Alive: 29.66 ± 26.97 vs. Dead: 36.88 ± 15.04 days; p = 0.046) and suffered from cardiovascular (Alive: 36.40% vs. Dead: 66.70%; p = 0.002) and metabolic diseases (Alive: 33.90% vs. Dead: 54.50%; p = 0.031) more frequently, which corresponded to a significantly higher ASA Score (p = 0.004). Revision rates (Alive: 11.00% vs. Dead: 18.20%; p = 0.371) and flap loss (Alive: 3.39% vs. Dead: 12.12%; p = 0.069) were higher in patients that died by the end of the study period. CONCLUSIONS Free flap transfer is safe and effective, even in multimorbid patients. However, patient age, comorbidities, preoperative ASA status, and medication significantly impact postoperative patient survival in the short- and mid-term and must, therefore, be taken into account in preoperative decision-making and informed consent.
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Schiefer JL, Andreae J, Fuchs PC, Lefering R, Heidekrueger PI, Schulz A, Bagheri M. Evaluation of Scar Quality after Treatment of Superficial Burns with Dressilk ® and Suprathel ®-In an Intraindividual Clinical Setting. J Clin Med 2022; 11:jcm11102857. [PMID: 35628983 PMCID: PMC9144963 DOI: 10.3390/jcm11102857] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/12/2022] [Accepted: 05/16/2022] [Indexed: 01/27/2023] Open
Abstract
Background: Various synthetic and biological wound dressings are available for the treatment of superficial burns, and standard care differs among hospitals. Nevertheless, the search for an ideal wound dressing offering a safe healing environment as well as optimal scar quality while being economically attractive is a continuing process. In recent years, Dressilk®, which consists of pure silk, has become the standard of care for the treatment of superficial burns in our hospital. However, no long-term scar-evaluation studies have been performed to compare Dressilk® with the often-used and more expensive Suprathel® in the treatment of superficial burns. Methods: Subjective and objective scar evaluations were performed three, six, and twelve months after treatment in patients who received simultaneous treatment of 20 superficial burn wounds with both Suprathel® and Dressilk®. The evaluations were performed using the Vancouver Scar Scale, the Cutometer®, Mexameter®, Tewameter®, and the O2C®. Results: Both dressings showed mostly equivalent results in subjective scar evaluations. In the objective scar evaluations, the wounds treated with Dressilk® showed a faster return to the qualities of non-injured skin. Wound areas treated with the two dressings showed no significant differences in elasticity and transepidermal water loss after 12 months. Only oxygen saturation was significantly lower in wound areas treated with Suprathel® (p = 0.008). Subjectively, wound areas treated with Dressilk® showed significantly higher pigmentation after six months, which was not apparent after 12 months. Conclusion: Both wound dressings led to esthetically satisfying scar recovery without significant differences from normal uninjured skin after 12 months. Therefore, Dressilk® remains an economically and clinically interesting alternative to Suprathel® for the treatment of superficial burns.
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Affiliation(s)
- Jennifer Lynn Schiefer
- Clinic of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, 58448 Witten, Germany; (J.A.); (P.C.F.); (A.S.); (M.B.)
- Correspondence: ; Tel.: +49-221-8907-0
| | - Janine Andreae
- Clinic of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, 58448 Witten, Germany; (J.A.); (P.C.F.); (A.S.); (M.B.)
| | - Paul Christian Fuchs
- Clinic of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, 58448 Witten, Germany; (J.A.); (P.C.F.); (A.S.); (M.B.)
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten-Herdecke, 50933 Cologne, Germany;
| | - Paul Immanuel Heidekrueger
- Center of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, 93053 Regensburg, Germany;
| | - Alexandra Schulz
- Clinic of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, 58448 Witten, Germany; (J.A.); (P.C.F.); (A.S.); (M.B.)
| | - Mahsa Bagheri
- Clinic of Plastic, Reconstructive, Hand and Burn Surgery, Hospital Cologne Merheim, University of Witten-Herdecke, 58448 Witten, Germany; (J.A.); (P.C.F.); (A.S.); (M.B.)
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Lee ZH, Ramly EP, Alfonso AR, Daar DA, Kaoutzanis C, Kantar RS, Thanik V, Saadeh PB, Levine JP. Dangle Protocols in Lower Extremity Reconstruction. J Surg Res 2021; 266:77-87. [PMID: 33989891 DOI: 10.1016/j.jss.2021.03.028] [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: 01/06/2021] [Accepted: 03/03/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Dangling protocols are known to vary by surgeon and center, and their specific regimen is often largely based on single surgeon or institutional experience. A systematic review was conducted to derive evidence-based recommendations for dangling protocols according to patient-specific and flap-specific considerations. METHODS A systematic review was performed using PubMed, Embase-OVID and Cochrane-CENTRAL. Study design, patient and flap characteristics, protocol details, dangling-related complications, and flap success rate were recorded. Studies were graded using the Oxford Center for Evidence-Based Medicine Levels of Evidence Scale. Data heterogeneity precluded quantitative analysis. RESULTS Eleven articles were included (level of evidence (range):IIb-IV; N (range):8-150; age (range):6-89). Dangling initiation, time, and frequency varied considerably. Flap success rate ranged from 94 to 100%. Active smoking, diabetes, and hypertension are associated with characteristic physiologic changes that require vigilance and potential protocol modification. Early dangling appears to be safe across a variety of free flap locations, sizes, and indications. Axial fasciocutaneous flaps may tolerate more aggressive protocols than muscular flaps. While flaps with single venous anastomosis tolerate dangling, double venous or flow-through anastomoses may provide additional benefit. Major limitations included small sample sizes, uncontrolled study designs, and heterogeneous patient selection, dangling practices, monitoring methods, and outcome measures. CONCLUSIONS Significant heterogeneity persists in postoperative dangling protocols after lower extremity microvascular reconstruction. Patient comorbidities and flap characteristics appear to affect tolerance to dangling. We propose two different standardized pathways based on risk factors. Clinical vigilance should be exercised in tailoring lower extremity protocols to patients' individual characteristics and postoperative course.
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Affiliation(s)
- Z-Hye Lee
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - David A Daar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Vishal Thanik
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Pierre B Saadeh
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY.
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Denzinger M, Held M, Amr A, Krauß S, Bender D, Daigeler A, Wenger A. The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects. J Reconstr Microsurg 2021; 37:694-703. [PMID: 33792003 DOI: 10.1055/s-0041-1726028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Venous thrombosis is the most common cause of flap failure in the first days after surgery. Although heparin is one of the most important antithrombotic substances and is implemented in the therapy of various diseases, there are only a few studies addressing its topical administration in the field of flap surgery. Especially, very little is known about the effects of topical heparin and its impact on microcirculation. In this study we evaluated to what extent topically administered heparin influences skin microcirculation (capillary venous oxygen saturation SO2, blood filling of microvessels, blood flow, and velocity) in healthy subjects. METHODS Skin perfusion parameters on the forearm were measured with the O2C device in a double-blinded, controlled, and randomized study with 50 healthy subjects after administration of heparin ointment in three different concentrations and a control ointment (dexpanthenol). RESULTS Topically administrated heparin slightly increased SO2 (max. 187 ± 285 SD or standard deviation % vs. 145 ± 129 SD %), flow (max. 264 ± 427 SD % vs. 151.74 ± 111 SD %), and velocity (max. 153 ± 149 SD % vs. 122 ± 56 SD %) after an incubation time of 60 minutes in comparison to control. No statistically significant difference could be detected regarding heparin concentration. CONCLUSION As a first important step in possible future implementing of heparin as a topical administration in flap surgery, our data-although not statistically significant-indicate that heparin can improve microcirculation (SO2, flow) in healthy subjects. Nevertheless, further research in subjects with impaired microcirculation is necessary.
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Affiliation(s)
- Markus Denzinger
- Department of Pediatric Surgery and Orthopedics, St. Hedwig, University Medical Center Regensburg, Regensburg, Germany
| | - Manuel Held
- Clinic for Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Tuebingen, Germany
| | - Amro Amr
- Department of Plastic Surgery, Microsurgery and Reconstructive Breast Surgery, Marien Hospital, Stuttgart, Germany
| | - Sabrina Krauß
- Clinic for Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Tuebingen, Germany
| | - Dominik Bender
- Clinic for Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Tuebingen, Germany
| | - Adrien Daigeler
- Clinic for Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Tuebingen, Germany
| | - Andrea Wenger
- Clinic for Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Klinikum Traunstein, Traunstein, Germany
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Trull B, Zhang Z, Boyd K, Allen M, Zhang J. Canadian Postoperative Dependency Protocols Following Lower Limb Microvascular Reconstruction: A National Survey and Literature Review. Plast Surg (Oakv) 2020; 29:122-127. [PMID: 34026676 DOI: 10.1177/2292550320954093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons. Methods Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions. Results All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days. Conclusion While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.
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Affiliation(s)
- Brent Trull
- Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Zach Zhang
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Kirsty Boyd
- Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Murray Allen
- Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Jing Zhang
- Division of Plastic Surgery, Department of Surgery, University of Ottawa, Ontario, Canada
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10
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Berner JE, Will P, Geoghegan L, Troisi L, Nanchahal J, Jain A. Safety and effectiveness of early compression of free flaps following lower limb reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2020; 73:1604-1611. [PMID: 32563669 DOI: 10.1016/j.bjps.2020.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/25/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Early postoperative compression of free flaps for lower limb reconstruction remains controversial. It may reduce venous congestion and promote the resolution of oedema. However, concerns remain regarding inadvertent pedicle compression, which may lead to flap failure. The aim of this systematic review was to determine the safety and effectiveness of this intervention. METHODS A systematic review was designed in compliance with PRISMA. MEDLINE and EMBASE databases were searched. Parallel screening, selection of eligible studies, and data gathering were carried out by two independent authors. A formal risk of bias assessment was included along with the appraisal of outcomes. RESULTS A total of 847 abstracts were retrieved and 262 free flaps for lower limb reconstruction were identified in ten eligible articles. The overall flap failure rate for patients who underwent early postoperative compression was 1.6%. Apart from flap failure rates, there were no other outcomes consistently reported and none of the studies included a no-compression group for comparison. DISCUSSION All included studies had methodological flaws, resulting in a high risk of bias. Nevertheless, there was consistent reporting of flap failure as a postoperative outcome. Compression of free flaps in the context of lower limb reconstruction does not appear to be associated with a higher flap failure rate compared with other series. Compression bandages may reduce the pain associated with dangling regimes. However, there is no evidence to support that free flap compression in the context of lower limb reconstruction is associated with any other clinical benefit.
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Affiliation(s)
- Juan Enrique Berner
- Queen Victoria Hospital, NHS Foundation Trust, East Grinstead, United Kingdom; Kellogg College, University of Oxford, Oxford OX2 6PN, United Kingdom.
| | - Patrick Will
- BG Klinik Ludwigshafen, Ludwigshafen am Rhein, Germany; Ruprecht Karl, University of Heidelberg, Heidelberg, Germany
| | - Luke Geoghegan
- Imperial College Healthcare, NHS Trust, London, United Kingdom
| | - Luigi Troisi
- University Department of Hand Surgery and Rehabilitation, San Giuseppe Hospital, IRCCS MultiMedica Group, Milan, Italy
| | - Jagdeep Nanchahal
- The Kennedy Institute of Rheumatology. Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abhilash Jain
- Imperial College Healthcare, NHS Trust, London, United Kingdom; Nuffield Department of Orthopaedic, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
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Investigating Lower Limb Hemodynamics during Flap Training Regimens and Patient-led Isometric Contraction Protocols. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2731. [PMID: 32537372 PMCID: PMC7253290 DOI: 10.1097/gox.0000000000002731] [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: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. The evidence for lower limb flap (LLF) training regimens is equivocal. The commonest cause of LLF failure is venous congestion. The aim of this study was to investigate whether venous congestion could be reduced by patient-led isometric calf contractions during flap training. A prospective clinical study was conducted using photospectroscopy and laser Doppler (Oxygen to See) to assess healthy limbs and LLF characteristics during flap training and isometric calf contractions. Tissue oxygen saturation, venous congestion, and blood flow were measured at rest, as well as during and after limb dangling and calf contraction exercises. In the acute postoperative period following LLF surgery, dependency markedly reduced superficial flow (−55.20% ± 19.17%), with a concurrent increase in venous congestion (33.80% ± 28.80%); supine isometric contractions improved superficial flow and reduced venous congestion from postoperative day 5. Contractions cause a significant increase in blood flow in the outpatient cohort (+84.40% ± 7.86%, P = 0.009), with a mean time since discharge of 14 weeks. Our data suggest patient-led isometric calf exercises are well tolerated and may reduce venous congestion in the acute phase. Progressive changes toward normal physiological function were demonstrated in the outpatient rehabilitation period. Incorporating calf exercises into LLF rehabilitation may allow longer periods of leg dependency, quicker recovery from surgery, and ultimately improve outcomes.
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A systematic review of near-infrared spectroscopy in flap monitoring: Current basic and clinical evidence and prospects. J Plast Reconstr Aesthet Surg 2017; 71:246-257. [PMID: 29175135 DOI: 10.1016/j.bjps.2017.10.020] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 09/09/2017] [Accepted: 10/13/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) has been reported to be a reliable non-invasive modality for free flap monitoring; however, the history of its application in flap monitoring is short, and there is no definite consensus regarding its use at present. OBJECTIVES The aim of this review is to clarify the evidence related to post-operative flap monitoring using NIRS and examine its appropriateness and usability. MATERIALS AND METHODS The PubMed and Web of Science databases were searched using the strings "flap monitoring AND near-infrared spectroscopy" and "flap monitoring AND tissue oxygen saturation," with a study period from inception to December 31, 2016. Two authors independently extracted articles and assessed the quality of the studies. Articles related to NIRS for flap perfusion monitoring were classified and selected regardless of study type. RESULTS A total of 15 clinical studies and 8 animal studies were identified and reviewed. The evidence and information on various aspects of NIRS flap monitoring were summarized. The overall flap success rate was 99.5%, and the flap salvage rate was 91.1%, when measuring StO2 at intervals of every 2 h or sooner. Single StO2 monitoring was able to detect vascular compromise with 99.1% sensitivity and 99.9% specificity, and earlier than other monitoring methods, but additional Hb concentration monitoring was useful for avoiding false negatives and differentiating arterial and venous occlusion. CONCLUSIONS NIRS can be used for flap monitoring and displays high accuracy in various situations; however, further studies are needed to take full advantage of the potential of NIRS.
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McGhee J, Cooper L, Orkar K, Harry L, Cubison T. Systematic review: Early versus late dangling after free flap reconstruction of the lower limb. J Plast Reconstr Aesthet Surg 2017; 70:1017-1027. [DOI: 10.1016/j.bjps.2017.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 03/03/2017] [Accepted: 04/14/2017] [Indexed: 10/19/2022]
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Hotfiel T, Swoboda B, Krinner S, Grim C, Engelhardt M, Uder M, Heiss RU. Acute Effects of Lateral Thigh Foam Rolling on Arterial Tissue Perfusion Determined by Spectral Doppler and Power Doppler Ultrasound. J Strength Cond Res 2017; 31:893-900. [PMID: 27749733 DOI: 10.1519/jsc.0000000000001641] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Hotfiel, T, Swoboda, B, Krinner, S, Grim, C, Engelhardt, M, Uder, M, and Heiss, R. Acute effects of lateral thigh foam rolling on arterial tissue perfusion determined by spectral Doppler and power Doppler ultrasound. J Strength Cond Res 31(4): 893-900, 2017-Foam rolling has been developed as a popular intervention in training and rehabilitation. However, evidence on its effects on the cellular and physiological level is lacking. The aim of this study was to assess the effect of foam rolling on arterial blood flow of the lateral thigh. Twenty-one healthy participants (age, 25 ± 2 years; height, 177 ± 9 cm; body weight, 74 ± 9 kg) were recruited from the medical and sports faculty. Arterial tissue perfusion was determined by spectral Doppler and power Doppler ultrasound, represented as peak flow (Vmax), time average velocity maximum (TAMx), time average velocity mean (TAMn), and resistive index (RI), and with semiquantitative grading that was assessed by 4 blindfolded investigators. Measurement values were assessed under resting conditions and twice after foam rolling exercises of the lateral thigh (0 and 30 minutes after intervention). The trochanteric region, mid portion, and distal tibial insertion of the lateral thigh were representative for data analysis. Arterial blood flow of the lateral thigh increased significantly after foam rolling exercises compared with baseline (p ≤ 0.05). We detected a relative increase in Vmax of 73.6% (0 minutes) and 52.7% (30 minutes) (p < 0.001), in TAMx of 53.2% (p < 0.001) and 38.3% (p = 0.002), and in TAMn of 84.4% (p < 0.001) and 68.2% (p < 0.001). Semiquantitative power Doppler scores at all portions revealed increased average grading of 1.96 after intervention and 2.04 after 30 minutes compared with 0.75 at baseline. Our results may contribute to the understanding of local physiological reactions to self-myofascial release.
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Affiliation(s)
- Thilo Hotfiel
- 1Division of Orthopedic Rheumatology, Department of Orthopedic Surgery, Friedrich-Alexander-University of Erlangen-Nuremberg, Erlangen, Germany; 2Department of Orthopedic Trauma Surgery, University Hospital Erlangen, Erlangen, Germany; 3Department of Trauma and Orthopedic Surgery, Klinikum Osnabrück, Osnabrück, Germany; and 4Department of Radiology, University Hospital Erlangen, Erlangen, Germany
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Medved F, Medesan R, Rothenberger JM, Schaller HE, Schoeller T, Manoli T, Weitgasser L, Naumann A, Weitgasser L. Analysis of the microcirculation after soft tissue reconstruction of the outer ear with burns in patients with severe burn injuries. J Plast Reconstr Aesthet Surg 2016; 69:988-93. [PMID: 26997326 DOI: 10.1016/j.bjps.2016.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/04/2016] [Accepted: 02/18/2016] [Indexed: 11/28/2022]
Abstract
Reconstruction of soft tissue defects of the ear with burns remains one of the most difficult tasks for the reconstructive surgeon. Although numerous reconstructive options are available, the results are often unpredictable and worse than expected. Besides full and split skin grafting, local random pattern flaps and pedicled flaps are frequently utilized to cover soft tissue defects of the outer auricle. Because of the difficulty and unpredictable nature of outer ear reconstruction after burn injury, a case-control study was conducted to determine the best reconstructive approach. The microcirculatory properties of different types of soft tissue reconstruction of the outer ear with burns in six severely burned Caucasian patients (three men and three women; mean age, 46 years (range, 22-70)) were compared to those in the healthy tissue of the outer ear using the O2C device (Oxygen to See; LEA Medizintechnik, Gießen, Germany). The results of this study revealed that the investigated microcirculation parameters such as the median values of blood flow (control group: 126 AU), relative amount of hemoglobin (control group: 59.5 AU), and tissue oxygen saturation (control group: 73%) are most similar to those of normal ear tissue when pedicled flaps based on the superficial temporal artery were used. These findings suggest that this type of reconstruction is superior for soft tissue reconstruction of the outer ear with burns in contrast to random pattern flaps and full skin grafts regarding the microcirculatory aspects. These findings may improve the knowledge on soft tissue viability and facilitate the exceptional and delicate process of planning the reconstruction of the auricle with burns.
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Affiliation(s)
- Fabian Medved
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany.
| | - Raluca Medesan
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Jens Martin Rothenberger
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Hans-Eberhard Schaller
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Thomas Schoeller
- Department of Plastic Surgery, Microsurgery and Reconstructive Surgery, Marien Hospital Stuttgart, Böheimstraße 37, 70199, Stuttgart, Germany
| | - Theodora Manoli
- Department of Plastic, Reconstructive, Hand and Burn Surgery, BG Trauma Center, Eberhard Karls University Tuebingen, Schnarrenbergstr. 95, 72076, Tuebingen, Germany
| | - Lennart Weitgasser
- Department of Plastic Surgery, Microsurgery and Reconstructive Surgery, Marien Hospital Stuttgart, Böheimstraße 37, 70199, Stuttgart, Germany
| | - Aline Naumann
- Institute for Clinical Epidemiology and Applied Biometry, Eberhard Karls University Tuebingen, Silcherstraße 5, 72076, Tübingen, Germany
| | - Laurenz Weitgasser
- Department of Plastic Surgery, Microsurgery and Reconstructive Surgery, Marien Hospital Stuttgart, Böheimstraße 37, 70199, Stuttgart, Germany
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Palanca AA, Yang A, Bishop JA. The Effects of Limb Elevation on Muscle Oxygen Saturation: A Near-Infrared Spectroscopy Study in Humans. PM R 2016; 8:221-4. [DOI: 10.1016/j.pmrj.2015.07.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Revised: 07/09/2015] [Accepted: 07/13/2015] [Indexed: 11/30/2022]
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Assessment of sural flap microcirculation: Which position maintains the optimal perfusion? J Plast Reconstr Aesthet Surg 2016; 69:538-44. [PMID: 26785706 DOI: 10.1016/j.bjps.2015.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 11/19/2015] [Accepted: 11/23/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Limb elevation is a commonly used approach for reducing edema and increasing venous drainage. Considering the anatomy of the sural flap with retrograde perfusion and hence potentially difficult blood outflow, the best angle for positioning the leg following operation is not yet known. METHODS A total of 14 patients undergoing sural flap lower limb reconstruction were enrolled in the study. We assessed the perfusion dynamics of the flaps using the oxygen-to-see (O2C) device that combines laser light, to determine blood flow, and white light to determine the relative amount of hemoglobin and oxygen saturation. Three different positions were evaluated: 45° angle downward, the horizontal position, and 45° angle upward. RESULTS The blood flow was significantly higher in the 45° upward position compared to the 45° downward position. The relative amount of hemoglobin was significantly lower in the 45° upward position compared to the 45° downward position. No significant differences with regard to oxygen saturation were observed. CONCLUSION The results of this study show a more precise pattern of perfusion due to different positioning. The 45° upward position of the leg generally maintains the best blood flow and venous drainage. However, compared to horizontal positioning, these differences were not statistically significant. As an elevation of 45° can be uncomfortable for patients, we recommend an elevation of the leg which approximates the 45° upward position but is still comfortable.
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