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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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Chang CK, Wu CY, Lin YL, Lai CS, Lu CT, Yen JH, Chen IC, Tsai YC. Comparative study of arterial and venous grafting for pedicle lengthening in head and neck microvascular reconstruction. Microsurgery 2024; 44:e31133. [PMID: 37950581 DOI: 10.1002/micr.31133] [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: 08/14/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In the field of head and neck microvascular reconstruction, no previous study has compared arterial and venous grafting as methods of anterolateral thigh (ALT) pedicle lengthening. Therefore, we conducted this comparative study to compare the outcomes between the two pedicle lengthening techniques. METHODS We performed comparative effectiveness research by conducting a retrospective chart review from January 2012 to December 2021 to identify patients who underwent head and neck reconstruction with non-descending branch ALT perforator flaps using either the in situ pedicle lengthening (ISPL) technique or the vein graft (VG) technique. A total of 26 patients were analyzed, including 14 who underwent ISPL, and 12 who underwent VG. The collected data, including patient demographics, surgical indications, history of prior free flap, prior neck dissection, radiation therapy, chemotherapy, graft length, and flap outcomes, were analyzed. The flap outcomes were categorized as total flap loss, partial flap loss, flap compromise that required operating room visits, or minor issues, including infection or dehiscence. The flap characteristics and postoperative outcomes were compared between the two groups. RESULTS The VG group had two flap losses, whereas the ISPL group had none. Although the failure rate was higher in the VG group than that in the ISPL group, the difference was not statistically significant (0% vs. 16.7%, p = 0.203). Additionally, there were no significant differences in flap take-back (14.3% vs. 16.7%, p = 1) and minor complications between the two groups (35.7% vs. 33.3%, p = 1). CONCLUSIONS If pedicle lengthening with vessel graft is inevitable in head and neck reconstruction, arterial graft may provide a reliable outcome and may be considered an effective alternative when compared to vein grafts.
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Affiliation(s)
- Chieh-Kai Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Yi-Ling Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chih-Shen Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Jung-Hsing Yen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veteran General Hospital, Taichung, Taiwan
- Department of Nursing, Hungkuang University, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
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Abdelmegeed AG, Hifny MA, Abulezz TA, Saied S, Ellabban MA, Abo-Saeda MAA, Allam KA, Haredy MM, Mazeed AS. Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis. Arch Plast Surg 2023; 50:507-513. [PMID: 37808335 PMCID: PMC10556300 DOI: 10.1055/a-2126-7058] [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: 12/30/2022] [Accepted: 07/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.
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Affiliation(s)
| | - Mahmoud A. Hifny
- Department of Plastic Surgery, Faculty of Medicine, South Valley University, Qena, Egypt
| | - Tarek A. Abulezz
- Department of Plastic and Reconstructive Surgery, Sohag University Hospital, Sohag, Egypt
| | - Samia Saied
- Department of Plastic and Reconstructive Surgery, Sohag University Hospital, Sohag, Egypt
| | - Mohamed A. Ellabban
- Plastic and Reconstructive Surgery Unit, Suez Canal University Hospitals and Medical School, Ismailia, Egypt
| | | | - Karam A. Allam
- Department of Plastic and Reconstructive Surgery, Sohag University Hospital, Sohag, Egypt
| | - Mostafa Mamdoh Haredy
- Department of Plastic and Reconstructive Surgery, Sohag University Hospital, Sohag, Egypt
| | - Ahmed S. Mazeed
- Department of Plastic and Reconstructive Surgery, Sohag University Hospital, Sohag, Egypt
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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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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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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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Lai CS, Shen CH, Chang YT, Liu SA, Lu CT, Tsai YC, Chen IC, Feng CH, Wu CY. Recipient vessel selection for multiple free flap transfers in head and neck reconstruction at different periods. Microsurgery 2021; 41:438-447. [PMID: 33988860 DOI: 10.1002/micr.30752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Treatment decisions can be challenging in patients undergoing multiple oropharyngeal microsurgical reconstructions at different periods by various causes. We, retrospectively, reviewed patients with at least three consecutive free flap reconstructions to determine the optimal strategy for selecting recipient vessels. METHODS Then, 36 patients (33 men and 3 women) who underwent at least 3 microsurgical reconstructions with a total of 51 free flap transfers for head and neck defects were included in this report. The most common reason for multiple microsurgical reconstructions was recurrent disease. For reconstructions, recipient vessel candidates on the same side of the head and neck were prioritized; if ipsilateral vessels were unavailable, contralateral recipient vessels, which might necessitate vein grafts, were used. RESULTS The most common reconstructions were anterolateral thigh flaps (19 cases). The most commonly used contralateral recipient vessels were the superior thyroid artery, facial artery, and external jugular vein. All vessel anastomoses were performed using the end-to-end method. Postoperative complications occurred at the sites of 26 free flap reconstructions. The overall flap reconstruction success rate in patients with at least three surgeries was 90.2%. The median follow-up duration was 25.8 months. During follow-up, 26 patients survived until the end of follow-up. CONCLUSIONS In patients undergoing multiple free flap reconstructions, recipient vessels on the ipsilateral side that have not been subjected to radiation should be selected first. Recipient vessels contralateral to the reconstruction side can then be selected; however, they may require vein grafts. Finally, distant healthy recipient vessels can be selected through vein grafting.
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Affiliation(s)
- Chih-Sheng Lai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China.,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China
| | - Yi-Ting Chang
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Shih-An Liu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China.,Department of Otolaryngology, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chen-Te Lu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Yueh-Chi Tsai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - I-Chen Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Chin-Hsing Feng
- Division of Plastic and Reconstructive Surgery Laboratory, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - Cheng-Yeu Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
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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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Momeni A, Lanni MA, Levin LS, Kovach SJ. Does the use of arteriovenous loops increase complications rates in posttraumatic microsurgical lower extremity reconstruction?-A matched-pair analysis. Microsurgery 2017; 38:605-610. [DOI: 10.1002/micr.30197] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Revised: 04/22/2017] [Accepted: 06/09/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery; Stanford University Medical Center; Palo Alto California
| | - Michael A. Lanni
- Division of Plastic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
| | - Lawrence S. Levin
- Department of Orthopedic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
| | - Stephen J. Kovach
- Division of Plastic Surgery; University of Pennsylvania Health Systems; Philadelphia Pennsylvania
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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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Abstract
BACKGROUND Open wounds around the knee joint can often be managed with local flaps; however, free tissue transfer may be required when local tissue options are unavailable or inadequate. Free tissue transfer around the knee can be challenging due to unique anatomic features of the joint. The outcomes of such procedures remain largely unreported. METHODS We retrospectively analyzed 33 patients who underwent 34 free tissue transfer reconstructions to the knee from 1993 to 2010. Twenty-four flaps were composed of soft tissue only and 10 flaps included a bony component. Patient demographics, details of the defect, operative characteristics, and clinical outcomes were reviewed. Outcomes included rates of flap failure, flap reexploration, and limb salvage. RESULTS Thirty-three (97%) of 34 flaps survived. One flap failed secondary to arterial thrombosis. In total, 6/34 flaps (18%) required reexploration (2 arterial thromboses and 4 venous thromboses). A wide variety of donor and recipient vessels were used. Vessel selection did not affect vascular reexploration. Overall, 88% of lower extremities were salvaged. Four of 10 (40%) patients receiving bone free flap reconstruction experienced delayed union and 2 (20%) of these required amputation for eventual nonunion. CONCLUSIONS Free flap reconstruction of the knee has a high flap survival and limb preservation rate in threatened extremities. Flap survival rates in the knee are similar to reported rates elsewhere in the lower extremity. Despite flap survival, infected nonunions that occur after bone free flap reconstruction result in a high limb amputation rate.
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15
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Gupta A, Lakhiani C, Lim BH, Aho JM, Goodwin A, Tregaskiss A, Lee M, Scheker L, Saint-Cyr M. Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases. J Plast Reconstr Aesthet Surg 2015. [PMID: 26212638 DOI: 10.1016/j.bjps.2015.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction. METHODS Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests. RESULTS In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes. CONCLUSIONS This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure.
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Affiliation(s)
- Amit Gupta
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | | | - Beng Hai Lim
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | | | - Adam Goodwin
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Ashley Tregaskiss
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Michael Lee
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Luis Scheker
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
| | - Michel Saint-Cyr
- Plastic Surgery, Scott & White Memorial Hospital, Temple, TX, USA.
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16
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Abstract
Replantation and flap procedures employ microvascular techniques to salvage or reconstruct a severely damaged limb or digit. The most devastating complications include complete or partial flap loss, or replantation failure due to vascular complications. Often, these complications can be prevented by appropriate patient selection, careful surgical planning, meticulous technique, and proper postoperative management. This article discusses complications related to replantation and flap procedures in the upper limb, focusing on preventing and managing these complications.
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Affiliation(s)
- Douglas M Sammer
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390, USA.
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17
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Clinical features of primary vein grafts in free tissue transfers. PLASTIC SURGERY INTERNATIONAL 2015; 2015:481402. [PMID: 25861471 PMCID: PMC4377485 DOI: 10.1155/2015/481402] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 02/18/2015] [Accepted: 03/02/2015] [Indexed: 11/23/2022]
Abstract
The outcomes of free tissue transfers combined with vein grafts have been inconsistent, and discussions continue regarding their appropriate use. Of the 142 free tissue transfers that we performed from January 2004 to December 2011, we retrospectively analyzed 15 consecutive patients who underwent free tissue transfers in combination with vein grafts. Etiologies included trauma (8 patients), infection (4), and tumor (3). Types of free tissue transfers were fibula (4), anterolateral thigh (3), groin (3), jejunum (3), latissimus dorsi (1), and dorsal pedis (1). Vein grafts were used for the artery (6), vein (2), or both (7). The donor veins were the saphenous vein (12) and the external jugular vein (3). The mean length of the grafted veins was 10.8 cm (range: 4–18 cm). Even though complications of congestion occurred in 2 patients, these flaps survived by reexploration. The flap success rate was 15 of 15 (100%) of vein grafted free flaps versus 124 of 127 (97.6%) of free flaps not requiring vein grafts. To improve the success rate of free tissue transfers combined with vein grafts, securing healthy recipient vessels, meticulous surgical handling, a reliable vascular anastomosis technique, and strict postoperative monitoring are crucial.
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18
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Nelson JA, Fischer JP, Grover R, Kovach SJ, Low DW, Kanchwala SK, Levin LS, Serletti JM, Wu LC. Vein grafting your way out of trouble: Examining the utility and efficacy of vein grafts in microsurgery. J Plast Reconstr Aesthet Surg 2015; 68:830-6. [PMID: 25812752 DOI: 10.1016/j.bjps.2015.02.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Accepted: 02/03/2015] [Indexed: 10/24/2022]
Abstract
INTRODUCTION There is limited data on the indications, outcomes, and associated complications with use of interpositional vein grafts (IVG) in microsurgery. This study sought to critically examine and update the utility of this microsurgical technique. METHODS All microsurgical cases at a single institution from 2005 to 2011 were examined for use of IVGs in the primary procedure or during take back or salvage attempts. We examined the cohort overall and performed a subgroup analysis by timing of initial IVG. RESULTS In the study period, 1718 patients underwent 2368 free flaps. 51 IVGs were utilized in 38 patients (2.2%) and 38 flaps (1.6%). Eight (42.1%) of the primary procedure IVGs (n = 19) were planned preoperatively. Nine total flap losses (24%) occurred when IVGs were utilized, 89% of which occurred in the take back cohort (p = 0.02). However, planned IVG had a 100% success rate, and IVG utilized in the primary procedure overall had a 95% success rate. Importantly, A significantly higher rate of thrombotic events was noted in all primary cases where IVGs were utilized (p = 0.005). CONCLUSIONS This study demonstrates that IVGs can be utilized in primary free flap reconstructions with success rates exceeding 95%. However, in salvage procedures, the use of vein grafts does not approach the same rate of success likely due to multiple factors. Yet when utilized appropriately with thrombectomy and resection of the thrombosed vessel to healthy intima, IVGs can provide an important tool for flap salvage. LEVEL OF EVIDENCE prognostic/risk category, level II.
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Affiliation(s)
- Jonas A Nelson
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ritwik Grover
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David W Low
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Suhail K Kanchwala
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph M Serletti
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Liza C Wu
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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19
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Shipkov H, Traikova N, Voinov P, Boucher F, Braye F, Mojallal A. Les boucles vasculaires en microchirurgie réparatrice : revue de la littérature. ANN CHIR PLAST ESTH 2014; 59:1-8. [DOI: 10.1016/j.anplas.2013.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 06/26/2013] [Indexed: 10/26/2022]
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20
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Classen DA. The indications and reliability of vein graft use in free flap transfer. THE CANADIAN JOURNAL OF PLASTIC SURGERY = JOURNAL CANADIEN DE CHIRURGIE PLASTIQUE 2013; 12:27-9. [PMID: 24115869 DOI: 10.1177/229255030401200105] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels. OBJECTIVES To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer. METHODS A retrospective review of 198 consecutive free flaps by a single surgeon. RESULTS Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts. CONCLUSION Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.
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Affiliation(s)
- Dale A Classen
- Division of Plastic Surgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan
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21
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Abstract
The response of tissue to trauma is difficult to define. The zone of injury is an area surrounding a wound that, though traumatized, may not appear nonviable at initial debridement. Because of this, a policy of repeated debridements has been followed to monitor tissues for viability before final tissue coverage. Appreciation of the zone of injury has led to a controversy in the literature about how to define and approach the management of traumatic injuries requiring free-tissue coverage. This review examines the current literature with regard to the definition of the zone of injury, and seeks to establish a consensus statement about the application of free flaps to traumatized wounds. We have investigated the literature supporting the use of free flaps relying on proximally or distally based recipient vessels. Critical appraisal of this literature includes study design, determination of the power of the study, subject classification, inclusion and exclusion criteria, follow-up, and outcomes (free flap success). There has been little attempt in the literature to fully and objectively define the zone of injury. All studies to date have been observational alone. Although it would be impossible to rid a definition of the zone of injury of subjectivity entirely, a more objective, reproducible definition is vitally needed. Without a clear definition of what the zone of injury is, there can only be anecdotal, technique reports of the placement of free flap anastomoses. In this time of rising costs and lower reimbursements, this is one area that could provide vital information to improve care for patients, lessen costs, and further medical knowledge.
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22
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Dancey A, Blondeel PN. Technical tips for safe perforator vessel dissection applicable to all perforator flaps. Clin Plast Surg 2010; 37:593-606, xi-vi. [PMID: 20816515 DOI: 10.1016/j.cps.2010.06.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The introduction of perforator flaps by Koshima and Soeda in 1989 was met with much animosity in the surgical community. The flaps challenged conventional teaching and were often branded as being unsafe. Surgeries using perforator flaps are now routinely practiced all over the world, with increasing emphasis on minimizing donor site morbidity, and perforator flaps are becoming the current gold standard. The simple principles and techniques of perforator dissection can be applied to all perforator flaps, provided the surgeon has an intimate knowledge of the regional anatomy. Thus, virtually any piece of skin can be harvested as long as it incorporates a feeding vessel. This article highlights the essential techniques in planning and raising perforator flaps and the common pitfalls to be avoided.
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Affiliation(s)
- Anne Dancey
- Department of Plastic and Reconstructive Surgery, University Hospital Gent, De Pintelaan 185, Gent B-9000, Belgium
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23
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Abstract
Although many advances have been made in microsurgery, it is not without complications. As microsurgeons continue to make advances in technology, technique, and applications that expand the utility of this field to more and more patients, they must be prepared to deal with the complications related to donor and recipient sites and the medical comorbidity that accompanies these large endeavors in the pre-, post-, and intraoperative periods.
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Affiliation(s)
- Jaimie T Shores
- Division of Plastic and Reconstructive Surgery, University of Pittsburgh School of Medicine, Suite 667, Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA.
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24
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Yeo S, Perrot P, Duteille F. [Free tissue transfers with lengthening of vascular pedicle using interpositional vein grafts. About 10 cases]. ANN CHIR PLAST ESTH 2009; 55:143-6. [PMID: 19443094 DOI: 10.1016/j.anplas.2009.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Accepted: 03/03/2009] [Indexed: 11/20/2022]
Abstract
The realization of free flaps with lack of reliable vessels nearby the loss of substance is a difficult problem for plastic surgeons. We report 10 cases of free tissue transfers with a one-stage technique lengthening the vascular pedicle of the free flap with interpositional vein grafts. Taking into consideration the good results and the low rate of morbidity, the authors emphasize the use of this technique rather than a two-stage procedure.
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Affiliation(s)
- S Yeo
- Service de chirurgie plastique, reconstructrice et esthétique, centre des brûlés, CHU de Nantes, 30, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
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25
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Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2006; 59:737-42. [PMID: 16782570 DOI: 10.1016/j.bjps.2005.11.013] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2005] [Revised: 10/04/2005] [Accepted: 11/17/2005] [Indexed: 11/22/2022]
Abstract
In this retrospective study, all free flap transfers used for reconstruction following ablation of head and neck tumors in University Medical Centre Ljubljana between the years 1989 and 1999 were analysed. The data taken from the patients' charts covered the demographic profile, the tumor and free flap details (44 variables for each patient). Logistic regression model was used to identify factors associated with free flap failure and complications. One hundred and sixty-two patients with head and neck tumors underwent microsurgical reconstruction. One hundred and ninety-four free flaps were performed with an overall success rate of 85%. Two significant predictors of free flap complication were identified: diabetes and salvage free flap transfer. Patients with diabetes were five times more likely to develop complications associated with free flaps (p = 0.02). Free flap complications were four times more likely to develop after salvage free flap transfer (p = 0.04). In addition, two significant factors predicting free flap failure were identified: salvage free flap transfer (p = 0.019) and use of interposition vein grafts (p = 0.032). After this study we changed our strategy of free flap selection and preoperative evaluation of the patients with head and neck tumors requiring free tissue transfer. Between January 2000 and January 2005 we performed additional 105 free flaps for head and neck reconstruction after tumor resection in 101 patients and our success rate improved to 94.3%.
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Affiliation(s)
- K Bozikov
- Department of Plastic Surgery and Burns, University Medical Centre, Zaloska 7, 1000 Ljubljana, Slovenia.
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26
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Abstract
The purpose of this study was to determine the rate of major and minor flap, donor site, and systemic complications in a consecutive series of 250 free flap operations. The following factors were analyzed to determine their significance on complication rates: age of patient, gender, wound etiology, smoking history, type of flap, operative time, vein graft use, surgeon experience, and the presence of comorbid disease. The major flap, donor-site, and systemic complication rates were 17.2%, 2%, and 6.4%, respectively. The minor flap, donor-site, and systemic complication rates were 7.2%, 12.8%, and 7.2%, respectively. The presence of comorbid medical condition was the only factor which had a statistically significant impact on the rate of major flap complications (P = 0.02). Age and comorbid disease impacted on major systemic complications (P = 0.04).
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Affiliation(s)
- Dale A Classen
- Division of Plastic Surgery, Department of Surgery, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
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27
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Abstract
Although unexplained thrombotic failures still exist, the majority of free-flap failures are due to identifiable technical failures, indicating that an excellent operative technique remains the key point. However, some clinical circumstances, such as damaged or deeply located vessels, are related to a higher thrombotic risks, demanding refinements of the microsurgical procedure to avoid higher failure rates. We reviewed 195 free flaps in the lower leg in order to quantify these situations and how we dealt with them. In total, six flaps were performed with a T-interposition to cope with difficult end-to-side anastomoses on damaged vessels. In two cases, the use of a funnel-shaped vein graft facilitated difficult end-to-side anastomoses in the popliteal area. The authors believe that these refinements of microsurgery should not be first-choice procedures, but they have proven to be a useful tool for certain microsurgical reconstructions.
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28
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Tham C, Tan BK, Hong SW, Chew WYC, Low CK, Tan KC. Salvage of the Massively Traumatized Lower Extremity with Sequential Free Flaps. Plast Reconstr Surg 2004; 113:1746-50. [PMID: 15114139 DOI: 10.1097/01.prs.0000117373.67460.2a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Colin Tham
- Department of Plastic Surgery, Singapore General Hospital, Outram Road, Singapore 169608.
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29
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Abstract
Microsurgical reconstructions are considered an integral art of modern reconstructive concepts, especially in the fields of trauma, tumor reconstruction, and correction of congenital deformities. Patient expectations regarding function and aesthetics of plastic surgical reconstructions are satisfied with permanently improved flap designs that also lead to a significant reduction in donor site morbidity. Together with steadily decreasing complication rates, these options have made microsurgical reconstructions a prime choice in plastic surgery, in contrast to the past, where they were considered the "last line of defense."
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Affiliation(s)
- G Germann
- Klinik für Hand, Plastische und Rekonstruktive Chirurgie, - Schwerbrandverletztenzentrum -, Plastische und Handchirurgie-Universität Heidelberg, BG-Unfallklinik, Ludwigshafen.
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30
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Sönmez A, Bayramiçli M, Sönmez B, Numanoğlu A. Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps. Plast Reconstr Surg 2003; 111:2230-6. [PMID: 12794464 DOI: 10.1097/01.prs.0000062564.35426.07] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.
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Affiliation(s)
- Ahmet Sönmez
- Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey
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31
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Kubo T, Yano K, Hosokawa K. Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction. Microsurgery 2003; 22:391-5. [PMID: 12497578 DOI: 10.1002/micr.10059] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Microvascular tissue transfer has become an indispensable procedure for head and neck reconstruction. Although remarkable progress has been made technically, anastomosed vessel occlusion is still a serious complication. Even with technically skilled microsurgeons, anastomosed vessel occlusion occurs because the technique is not the sole prophylaxis against thrombosis in microsurgery. Therefore, to minimize the possibility of an unfavorable result in microsurgery, microsurgeons must be familiar with management options for a vascular compromised flap. Most investigators have agreed that venous obstruction occurs more often than arterial obstruction. Here, we reviewed the published literature on the salvage of venous compromised flaps from the viewpoints of surgical correction, including reanastomosis and catheter thrombectomy, and nonsurgical procedures, such as a medicinal leech, hyperbaric oxygen, and thrombolytic therapy.
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Affiliation(s)
- Tateki Kubo
- Department of Plastic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
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