Meta-analysis of venous anastomosis techniques in free flap reconstruction

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

Background

Propeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction.

Methods

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected.

Results

Out of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%.

Conclusion

PPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

A Survey of Microvascular Technique Preferences Among American Head Neck Society Members

OBJECTIVE

To identify practices in microvascular techniques in routine and challenging scenarios.

STUDY DESIGN

Cross-sectional study.

METHODS

A national survey addressing practices related to microvascular free flap reconstruction was distributed to AHNS members between October and November 2021.

RESULTS

The respondents encompassed 95 microvascular surgeons. Median years of practice was 6 (interquartile range, 2-13) and median flaps per year was 35 (22-50). Common practices in arterial anastomosis included limited cleaning of artery (84.2%), use of a double approximating clamp (64.2%), and use of interrupted suture (88.4%). Common practices in venous anastomosis included limited cleaning (89.5%), downsizing the coupler (53.7%), and coupling to two independent venous systems (47.4%). In arterial anastomosis, respondents felt that kinking (50.5%) and tension (24.2%) were the riskiest challenges. Kinking was handled by loose sutures or native tissue/dissolvable biomaterial to orient pedicle. Excess tension was handled by additional dissection. With regards to associated practices, most surgeons perform anastomosis after partial inset (52.6%), give aspirin immediately postoperatively (66.3%), reserve transfusion for hemodynamic instability (69.5%), and utilize intraoperative pressors when needed (72.6%). More senior surgeons reported placing more suture to address leaks (p = 0.004) and perform end to side anastomosis on larger vein in case of venous mismatch (p = 0.012). In cases of tension, higher volume surgeons perform more extensive dissection (p = 0.035) and end to side coupling (p = 0.029).

CONCLUSIONS

This survey of AHNS members indicates patterns of microvascular techniques in routine and challenging scenarios. There exists a variation in approaches amongst surgeons based on volume and practice length.

LEVEL OF EVIDENCE

5 Laryngoscope, 134:1265-1277, 2024.

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

Background

During free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery.

Materials and methods

We retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases.

Results

The conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery.

Conclusions

The AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.

Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis

BACKGROUND

Various techniques have been described for performing microsurgical anastomosis with providing high patency rates. Although the total anastomotic time may not be an issue when dealing with a single set of anastomoses, using a faster technique may save significant amount of time in cases of transferring flaps with shorter critical ischemia time or where multiple anastomoses are required. This study compares the total anastomosis time between four different combinations of commonly used suturing and knot tying techniques.

METHODS

Twenty-four rats were divided into 4 groups. Simple interrupted suture with conventional knot tying technique (SIS-CT) was used in group I, continuous suture technique with conventional knot tying (CST) was used in group II, simple interrupted suture with airborne knot tying technique(SIS-AT) was used in group III, and continuous-interrupted suture with airborne knot tying technique(CIS-AT) was used in group IV for microsurgical anastomosis. Total anastomosis time and patency rates with each technique and samples from anastomotic sites were analyzed.

RESULTS

The mean time required for microvascular anastomosis of the femoral artery was 1075 s in group I, 799 s in group II, 844 s in group III, and 973 s in group IV. The difference between four groups was statistically significant. The anastomoses in group II and group III were completed in the shortest period of time. Intergroup comparison revealed that the difference between group II and group III was not statistically significant, however, total anastomosis time for completion of the anastomosis was significantly longer for group I, followed by group IV. Thrombosis rates and histological analysis revealed no significant differences among four groups.

CONCLUSION

CST and SIS-AT techniques can significantly reduce microsurgical anastomosis time and provide high patency rates. Also, the time needed to complete an anastomosis was significantly shorter for CIS-AT when compared to SIS-CT.

Risk Factors for Free Flap Outcomes: A Retrospective Study of 318 Free Flaps for Head and Neck Defect Reconstruction

OBJECTIVES

This study was conducted to identify the risk factors for free flap outcomes in head and neck reconstruction.

METHODS

A retrospective review of 318 free flaps were used for head and neck reconstructions in 317 patients over seven years. The patient characteristics, surgical data, and flap outcomes were recorded. The impact of risk factors related on the outcomes of free flaps were analyzed using single and multivariate analysis.

RESULTS

For single factor analysis, 295 free flaps for the first reconstruction were included. Hypertension and the type of recipient vein are associated with venous thrombosis (P = .018, P = .047). Hypertension, type of free flap, recipient artery, and recipient vein were associated with the incidence of re-exploration (P = .009, P = .011, P = .017, P = .021). Hypertension had an obvious effect on the flap survival (P = .005). For multivariate analysis, hypertension (odds ratio = .166, 95% confidence interval: .043 - .636; P = .009) was a statistically significant risk factor for flap survival. For types of recipient artery and vein, selecting two venous anastomosis (one of IJVS and one of EJVS) had the minimum incidence of venous thrombosis (2.2%), and selecting facial artery, single vein (one of IJVS), and two veins (one of IJVS and one of EJVS) for anastomosis had lower incidence of re-exploration, which were 4.4%, 2.9%, and 6.0%, respectively (P < .05).

CONCLUSIONS

Risk factors as hypertension, type of free flap, recipient artery and vein should be paid more attention in the free flaps for head and neck reconstructions. We believe proper measures will lead to better results in head and neck reconstruction.

Revision Rates of Left and Right Breast Reconstruction Differ With DIEP Flaps: Implications for Inexperienced Surgeons

BACKGROUND

The internal mammary system provides the recipient vessel of choice in free autologous tissue breast reconstruction. However, left internal mammary veins (IMVs) are smaller than right IMVs, thus raising questions about their reliability. Here we analyzed right and left breast deep inferior epigastric perforator (DIEP) flap reconstruction performed by an experienced versus less experienced surgeon and hypothesized that less experienced surgeons might encounter difficulty in cases of smaller left IMVs.

METHODS

We respectively reviewed the charts of 714 DIEP flap breast reconstructions performed by an experienced surgeon (>15 years' DIEP flap experience) and 231 performed by a relatively inexperienced surgeon (<4 years' DIEP flap experience). Reconstructions requiring microvascular revisions were compared with nonrevision controls, and left-side reconstructions were compared with right-side controls.

RESULTS

Preoperative risk factors were not significantly different between the left and right cohorts for either surgeon. The experienced surgeon performed 17 microvascular revisions (2.4%), including 9 left (52.9%) and 8 right (47.1%). The less experienced surgeon performed 7 microvascular revisions (3.0%), all left. The left- and right-side revision rates were 2.4% and 2.3% for the experienced surgeon versus 6.1% and 0% for the less experienced surgeon, respectively, with a higher rate for the left side (P = 0.0299).

CONCLUSIONS

The left-side microvascular revision rate was higher for the less experienced surgeon. Considering that left IMVs are smaller, less experienced surgeons should carefully perform left-side free flap breast reconstructions and be prepared to convert to thoracodorsal recipient vessel use.

A retrospective evaluation of 182 free flaps in extremity reconstruction and review of the literature

Introduction: During the past decades, free flaps have been given a central role in the reconstructive surgery. Especially in the extremities, where there is a scarcity of available tissues for local flaps, free flaps play a central part. The aim of this study was to evaluate the risk factors contributing to partial and total flap failure. Patients and methods: In a retrospective cohort study, all data concerning patients who underwent free flap reconstruction of the extremities during the first five years since the founding of the department of plastic surgery were gathered. Patient- and surgery-related risk factors were analyzed in correlation to the postoperative complications. Results: In total, 182 free flaps were included in this study. Partial and total flap failure were noted in 21.42% and 17.03%, respectively. A correlation was seen between the time lapsed from debridement until flap coverage, with flaps performed between day 4 and 14 having the least quote of flap failure (p=0.022). Gender, age, arterial hypertension, nicotine abuse, diabetes mellitus, peripheral arterial disease and the number of anastomosed veins were not significantly associated with free flap failure. Conclusion: Our study showed that free flaps can be safely performed in healthy patients as well as in patients with risk factors, with an acceptable flap loss rate. Randomized controlled studies are needed to clarify the exact role of each risk factor in free flap surgery.

Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity

INTRODUCTION

Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity.

METHODS

We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest.

RESULTS

14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient.

CONCLUSION

The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.