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Cowan R, Mann G, Salibian AA. Ultrasound in Microsurgery: Current Applications and New Frontiers. J Clin Med 2024; 13:3412. [PMID: 38929941 PMCID: PMC11204189 DOI: 10.3390/jcm13123412] [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: 05/08/2024] [Revised: 06/01/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
Ultrasound has revolutionized reconstructive microsurgery, offering real-time imaging and enhanced precision allowing for preoperative flap planning, recipient vessel identification and selection, postoperative flap monitoring, and lymphatic surgery. This narrative review of the literature provides an updated evidence-based overlook on the current applications and emerging frontiers of ultrasound in microsurgery, focusing on free tissue transfer and lymphatic surgery. Color duplex ultrasound (CDU) plays a pivotal role in preoperative flap planning and design, providing real-time imaging that enables detailed perforator mapping, perforator suitability assessment, blood flow velocity measurement, and, ultimately, flap design optimization. Ultrasound also aids in recipient vessel selection by providing assessment of caliber, patency, location, and flow velocity of recipient vessels. Postoperatively, ultrasound enables real-time monitoring of flap perfusion, providing early detection of potential flap compromise and improved flap survival rates. In lymphatic surgery, ultra-high frequency ultrasound (UHFUS) offers precise mapping and evaluation of lymphatic vessels, improving efficacy and efficiency by targeting larger dilated vessels. Integrating ultrasound into reconstructive microsurgery represents a significant advancement in the utilization of imaging in the field. With growing accessibility of devices, improved training, and technological advancements, using ultrasound as a key imaging tool offers substantial potential for the evolution of reconstructive microsurgery.
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Affiliation(s)
| | | | - Ara A. Salibian
- Division of Plastic and Reconstructive Surgery, University of California, Davis School of Medicine, Sacramento, CA 95817, USA
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Borle F, Heymans S, Dhole S, Jaiswal D. Delayed Partial Venous Insufficiency of Free Flap: To Intervene or Not? Cureus 2023; 15:e51068. [PMID: 38269226 PMCID: PMC10807330 DOI: 10.7759/cureus.51068] [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: 10/30/2023] [Accepted: 12/25/2023] [Indexed: 01/26/2024] Open
Abstract
Delayed venous congestion of a free flap poses a dilemma for clinicians, as the optimal management strategy is often uncertain. This case report presents a successful outcome achieved through a strategy of watchful waiting for a delayed presentation of a partially congested free flap. This approach enabled the avoidance of unnecessary surgical interventions and minimized potential complications associated with flap exploration. By adopting a watchful waiting strategy, clinicians can navigate the challenging decision-making process in cases of partial venous congestion of free flaps, optimizing patient outcomes.
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Affiliation(s)
- Firoz Borle
- Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Sina Heymans
- Plastic and Reconstructive Surgery, Marienhospital Stuttgart, Stuttgart, DEU
| | - Simran Dhole
- General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Bishop JL, Vasudev M, Garcia N, Heslop G, Pham TT, Hicks MD, Chowdhury F, Grayson JW, Goddard JA, Tjoa T, Haidar Y, Thomas CM. Effect of Perioperative Antithrombotics on Head and Neck Microvascular Free Flap Survival After Anastomotic Revision. Otolaryngol Head Neck Surg 2023; 168:1353-1361. [PMID: 36939436 DOI: 10.1002/ohn.295] [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: 08/29/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine if antithrombotic therapy improves head and neck microvascular free flap survival following anastomotic revision. STUDY DESIGN A retrospective review of all patients with microvascular free tissue transfer to the head and neck between August 2013 and July 2021. SETTING Otolaryngology-Head and Neck Surgery Departments at University of Alabama at Birmingham, University of Colorado, and University of California Irvine. METHODS Perioperative use of anticoagulation, antiplatelets, intraoperative heparin bolus, tissue plasminogen activator (tPA) and vasopressor use, and leech therapy were collected plus microvascular free flap outcomes. The primary endpoint was free flap failure. Analyses of free flaps that underwent anastomotic revision with or without thrombectomy were performed. RESULTS A total of 843 microvascular free flaps were included. The overall rate of flap failure was 4.0% (n = 34). The overall rate of pedicle anastomosis revision (artery, vein, or both) was 5.0% (n = 42) with a failure rate of 47.6% (n = 20) after revision. Anastomotic revision significantly increased the risk of flap failure (odds ratio [OR] 52.68, 95% confidence interval [CI] [23.90, 121.1], p < .0001) especially when both the artery and vein were revised (OR 9.425, 95% CI [2.117, 52.33], p = .005). Free flap failure after the anastomotic revision was not affected by postoperative antiplatelet therapy, postoperative prophylactic anticoagulation, intraoperative heparin bolus, tPA, and therapeutic anticoagulation regardless of which vessels were revised and if a thrombus was identified. CONCLUSION In cases of microvascular free tissue transfer pedicle anastomotic revision, the use of antithrombotic therapy does not appear to significantly change free flap survival outcomes.
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Affiliation(s)
- Jessica L Bishop
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Milind Vasudev
- University of California Irvine School of Medicine, University of California Irvine, Irvine, California, USA
| | - Natalie Garcia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gabriela Heslop
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tiffany T Pham
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Melanie D Hicks
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Farshad Chowdhury
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jessica W Grayson
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Julie A Goddard
- Department of Otolaryngology-Head & Neck Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Tjoson Tjoa
- Department of Otolaryngology-Head & Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Yarah Haidar
- Department of Otolaryngology-Head & Neck Surgery, University of California Irvine, Irvine, California, USA
| | - Carissa M Thomas
- Department of Otolaryngology-Head & Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Rapoport NA, Lee DS, Lee JJ, Puram SV, Jackson RS, Pipkorn P. Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer. Ann Otol Rhinol Laryngol 2023; 132:226-232. [PMID: 35373592 PMCID: PMC9526756 DOI: 10.1177/00034894221088179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients. METHODS A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients. RESULTS All flaps had full survival at follow up (median follow up 3 months, range 1-39 months) without concerns for vascular compromise. CONCLUSION These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.
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Affiliation(s)
- Nicholas A. Rapoport
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
| | - David S. Lee
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
| | - Jake J. Lee
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
| | - Sidharth V. Puram
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
| | - Ryan S. Jackson
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
| | - Patrik Pipkorn
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine in St. Louis, 660 S. Euclid Ave. Campus Box 8115, St. Louis, MO 63110
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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: 7] [Impact Index Per Article: 3.5] [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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Should Antiplatelet Therapy Be Withheld Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population. Plast Reconstr Surg 2022; 149:95e-103e. [PMID: 34936629 DOI: 10.1097/prs.0000000000008666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antiplatelet agents are typically withheld perioperatively because of bleeding concerns. Dual antiplatelet therapy, such as aspirin and clopidogrel, has significant morbidity and mortality benefits in patients with ischemic heart disease or peripheral vascular disease. This study aims to evaluate the impact of perioperative dual antiplatelet therapy in the lower extremity free tissue transfer population. METHODS Lower extremity free tissue transfers performed by the senior author (K.K.E.) from 2011 to 2019 were retrospectively reviewed. Demographics, comorbidities, perioperative dual antiplatelet therapy, and free tissue transfer characteristics were recorded. Outcomes of interest included flap success, hematoma formation, blood transfusion requirements, and cardiac event occurrence. RESULTS One hundred ninety-five free tissue transfers were included. Median age at the time of free tissue transfer was 56.5 years. Median Charlson Comorbidity Index was 3. Thirty-four patients were on clopidogrel, which was either withheld (n = 20) or continued (n = 14) on the day of free tissue transfer. Incidence of blood transfusion was significantly higher in both the withheld and continued versus nonclopidogrel groups. Flap success was statistically equivalent between groups (withheld, 90.0 percent; continued, 92.9 percent; nonclopidogrel, 95.0 percent; p = 0.346). Cardiac events occurred most often in the continued group (21.4 percent) compared to the withheld (5.0 percent) and nonclopidogrel (0.6 percent) groups. On multivariate analysis, holding clopidogrel remained significant for increased odds of postoperative transfusion. The clopidogrel group was no longer significant for intraoperative transfusion. CONCLUSIONS Despite increases in volume of blood products transfused, free tissue transfer can be performed safely with perioperative dual antiplatelet therapy. Withholding dual antiplatelet therapy on the day of free tissue transfer was not associated with decreased intraoperative transfusion; thus, dual antiplatelet therapy can safely be continued throughout the operative course to minimize cardiovascular risk. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Moellhoff N, Broer PN, Heidekrueger PI, Ninkovic M, Ehrl D. Impact of patients' gender on microvascular lower extremity reconstruction. J Plast Surg Hand Surg 2021; 56:47-52. [PMID: 34292803 DOI: 10.1080/2000656x.2021.1914638] [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] [Indexed: 10/20/2022]
Abstract
The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.
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Affiliation(s)
- Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Paul I Heidekrueger
- Department of Plastic, Hand, and Reconstructive Surgery, University Medical Center, Regensburg, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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Salvage of late flap compromise in deep inferior epigastric perforator flaps: To revise or not to revise. Arch Plast Surg 2020; 47:97-101. [PMID: 31964131 PMCID: PMC6976755 DOI: 10.5999/aps.2019.01578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/14/2019] [Indexed: 11/08/2022] Open
Abstract
Although the success rate of deep inferior epigastric perforator (DIEP) flaps has increased, late flap failures still occur and have a low salvage rate. The present article describes a case of salvage of a case of late flap failure using the pedicle vein as a vein graft source. A 50-year-old woman underwent a bilateral DIEP free flap procedure. On postoperative day 6, she experienced flap compromise and underwent emergency flap revision. In the flap revision, flap venous drainage and the superficial inferior epigastric vein were completely obstructed. A Fogarty catheter was used to remove a thrombus from the completely obstructed pedicle vein, and this pedicle vein was used as a graft source and was ligated in retrograde fashion to the flap vein stump. After injection of urokinase into the arterial branch, venous flow to the flap was restored. At a 6-month follow-up visit in the outpatient clinic, only partial fat necrosis at the flap was noted. By dissecting various perforators in the initial operation, decisions regarding immediate revision can be made with more confidence. Additionally, the combined procedures performed in this case may be helpful even for practitioners treating cases of late flap compromise.
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Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis. Plast Reconstr Surg 2018; 143:361-370. [PMID: 30489498 DOI: 10.1097/prs.0000000000005191] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors' aim was to assess the quality of care associated with safety-net hospital setting. METHODS The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes. RESULTS A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay. CONCLUSIONS Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non-safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Late Arterial Thrombosis after Microvascular Head and Neck Reconstruction due to Combined Factors of Pedicle Artery Loop and Submandibular Gland Swelling. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2017; 5:e1446. [PMID: 28894665 PMCID: PMC5585438 DOI: 10.1097/gox.0000000000001446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 06/20/2017] [Indexed: 12/03/2022]
Abstract
Late arterial thrombosis of a free flap is rare and usually unsalvageable because it is hard to detect. We herein report 2 cases of arterial thrombosis of a free flap after microvascular head and neck reconstruction due to the combined factors of pedicle artery loop and compression by a swollen submandibular gland, the occurrence of thrombosis in both of which was > 72 hours after the operation. In case 1, the arterial thrombosis was undetectable, and it was too late for a successful take-back operation, so the flap was lost. However, we applied the lessons learned from case 1 and were able to detect the late arterial thrombosis of case 2 at an early stage; we subsequently salvaged the flap successfully. During the take-back operation in both cases, it was found that the submandibular gland became swollen and compressed the pedicle artery, which then became occluded due to a steep loop formation. Postoperative swelling of the submandibular gland can sometimes compress the vascular pedicle, and complete occlusion of the pedicle artery may occur when it is looped. Meticulous care concerning the geometry of the vascular pedicle is required to avoid such complications.
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Transversus Abdominis Plane Blocks with Single-Dose Liposomal Bupivacaine in Conjunction with a Nonnarcotic Pain Regimen Help Reduce Length of Stay following Abdominally Based Microsurgical Breast Reconstruction. Plast Reconstr Surg 2017; 140:240-251. [DOI: 10.1097/prs.0000000000003508] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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