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Ghasroddashti A, Guyn C, Head L. Cost-benefit analysis of 3D-printed vascular models in abdominal free flap breast reconstruction. J Plast Reconstr Aesthet Surg 2024; 97:1-3. [PMID: 39121546 DOI: 10.1016/j.bjps.2024.07.068] [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: 07/27/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
3D-printed vascular models can enhance flap harvesting efficiency in abdominal free flap breast reconstruction, reducing the use of operating room time. However, no economic analyses with respect to model use in this context have been conducted to date. As such, this study examines model cost-benefit tradeoffs for use in abdominal free flap breast reconstruction.
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Affiliation(s)
| | - Colm Guyn
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Linden Head
- Division of Plastic Surgery, Department of Surgery, Queen's University, Kingston, ON, Canada
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Bhagat N, Berns J, Newsom K, Dawson S, Archual A, Christie BM, Weber EL, Hassanein AH. Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects. Ann Plast Surg 2023; 90:598-602. [PMID: 37311315 DOI: 10.1097/sap.0000000000003571] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. METHODS A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. RESULTS Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. CONCLUSIONS Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.
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Affiliation(s)
- Neel Bhagat
- From the Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis IN
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Cai L, Hong Z, Zhang Y, Xiang G, Luo P, Gao W, Li Z, Zhou F. Management of wounds with exposed bone structures using an induced-membrane followed by polymethyl methacrylate and second-stage skin grafting in the elderly with a 3-year follow-up. Int Wound J 2023; 20:1020-1032. [PMID: 36184261 PMCID: PMC10031252 DOI: 10.1111/iwj.13955] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 11/30/2022] Open
Abstract
The treatment of traumatic wounds with exposed bone or tendons is often challenging. An induced membrane (IM) is used to reconstruct bone defects, as it provides an effective and sufficient blood supply for bone and soft-tissue reconstruction. This study explored a novel two-stage strategy for wound management, consisting of initial wound coverage with polymethyl methacrylate (PMMA) and an autologous split-thickness skin graft under the IM. Fifty inpatients were enrolled from December 2016 to December 2019. Each patient underwent reconstruction according to a two-stage process. In the first stage, the defect area was thoroughly debrided, and the freshly treated wound was then covered using PMMA cement. After 4-6 weeks, during the second stage, the PMMA cement was removed to reveal an IM covering the exposed bone and tendon. An autologous split-thickness skin graft was then performed. Haematoxylin and eosin (H&E) staining and immunohistochemical analysis of vascular endothelial growth factor (VEGF), CD31 and CD34 were used to evaluate the IM and compare it with the normal periosteal membrane (PM). The psychological status and the Lower Extremity Function Scale (LEFS) as well as any complications were recorded at follow-up. We found that all skin grafts survived and evidenced no necrosis or infection. H&E staining revealed vascularised tissue in the IM, and immunohistochemistry showed a larger number of VEGF-, CD31- and CD34-positive cells in the IM than in the normal PM. The duration of healing in the group was 5.40 ± 1.32 months with a mean number of debridement procedures of 1.92 ± 0.60. There were two patients with reulceration in the group. The self-rating anxiety scale scores ranged from 35 to 60 (mean 48.02 ± 8.12). Postoperatively, the LEFS score was 50.10 ± 9.77. Finally, our strategy for the management of a non-healing wound in the lower extremities, consisting of an IM in combination with skin grafting, was effective, especially in cases in which bony structures were exposed in the elderly. The morbidity rate was low.
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Affiliation(s)
- Leyi Cai
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Zipu Hong
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Yingying Zhang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Guangheng Xiang
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Peng Luo
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Weiyang Gao
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Zhijie Li
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Feiya Zhou
- Department of Orthopaedics Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
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Levin LS. From replantation to transplantation: The evolution of orthoplastic extremity reconstruction. J Orthop Res 2022. [PMID: 36413095 DOI: 10.1002/jor.25488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022]
Abstract
For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.
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Affiliation(s)
- L Scott Levin
- Department of Orthopaedic Surgery, Department of Surgery, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Santanelli di Pompeo F, D'Orsi G, Firmani G, Paolini G, Renzi LF, Sorotos M. Total Breast Reconstruction with the Fat-Augmented Latissimus Dorsi (FALD) flap: high safety in a single-center uncontrolled case series. J Plast Reconstr Aesthet Surg 2022; 75:3004-3013. [DOI: 10.1016/j.bjps.2022.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/25/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
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Kohler LH, Köhler H, Kohler S, Langer S, Nuwayhid R, Gockel I, Spindler N, Osterhoff G. Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study. BMC Surg 2021; 21:222. [PMID: 33931056 PMCID: PMC8086299 DOI: 10.1186/s12893-021-01232-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/23/2021] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Free flap surgery is an essential procedure in soft tissue reconstruction. Complications due to vascular compromise often require revision surgery or flap removal. We present hyperspectral imaging (HSI) as a new tool in flap monitoring to improve sensitivity compared to established monitoring tools. METHODS We performed a prospective observational cohort study including 22 patients. Flap perfusion was assessed by standard clinical parameters, Doppler ultrasound, and HSI on t0 (0 h), t1 (16-28 h postoperatively), and t2 (39-77 h postoperatively). HSI records light spectra from 500 to 1000 nm and provides information on tissue morphology, composition, and physiology. These parameters contain tissue oxygenation (StO2), near-infrared perfusion- (NIR PI), tissue hemoglobin- (THI), and tissue water index (TWI). RESULTS Total flap loss was seen in n = 4 and partial loss in n = 2 cases. Every patient with StO2 or NIR PI below 40 at t1 had to be revised. No single patient with StO2 or NIR PI above 40 at t1 had to be revised. Significant differences between feasable (StO2 = 49; NIR PI = 45; THI = 16; TWI = 56) and flaps with revision surgery [StO2 = 28 (p < 0.001); NIR PI = 26 (p = 0.002); THI = 56 (p = 0.002); TWI = 47 (p = 0.045)] were present in all HSI parameters at t1 and even more significant at t2 (p < 0.0001). CONCLUSION HSI provides valuable data in free flap monitoring. The technique seems to be superior to the gold standard of flap monitoring. StO2 and NIR PI deliver the most valuable data and 40 could be used as a future threshold in surgical decision making. Clinical Trial Register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00020926.
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Affiliation(s)
- Lukas H Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany.
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), University of Leipzig, Leipzig, Saxony, Germany
| | - Simon Kohler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Stefan Langer
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Rima Nuwayhid
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, Leipzig University Hospital, Leipzig, Saxony, Germany
| | - Nick Spindler
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
| | - Georg Osterhoff
- Department of Orthopedic, Trauma and Plastic Surgery, Leipzig University Hospital, Liebigstraße 20, 04103, Leipzig, Saxony, Germany
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Burkhard JP, Pfister J, Giger R, Huber M, Lädrach C, Waser M, Olariu R, Engel D, Löffel LM, Schaller B, Wuethrich PY. Perioperative predictors of early surgical revision and flap-related complications after microvascular free tissue transfer in head and neck reconstructions: a retrospective observational series. Clin Oral Investig 2021; 25:5541-5550. [PMID: 33686470 PMCID: PMC8370926 DOI: 10.1007/s00784-021-03864-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/25/2021] [Indexed: 11/15/2022]
Abstract
Objectives The aim of this study was to determine the influence of perioperative fluid management and administration of vasopressors on early surgical revision and flap-related complications in free tissue transfer. Materials and methods Intraoperative amount of fluid and of vasopressors, relevant perioperative parameters, and comorbidities were recorded in 131 patients undergoing head and neck microvascular reconstruction and compared with early surgical complications, defined as interventions requiring surgery after a flap-related complication, and/or other surgical problems in the operating room within 30 days after initial surgery. The relationship between perioperative variables for each revision category was determined using an optimized multiple logistic regression. Results The administration of diuretics (p=0.001) as a treatment for perioperative fluid overload and the type of flap (p=0.019) was associated with a higher risk of early surgical revisions. Perioperative fluid overload (p=0.039) is significantly related to flap-related complications. We found no effect of intraoperative administration of vasopressors on early surgical revisions (p=0.8) or on flap-related complications (norepinephrine p=0.6, dobutamine p=0.5). Conclusion Perioperative fluid overload is associated with higher risks of early surgical revision and flap-related complications. In contrast, the administration of vasopressors seemed to have no effect on either surgical revision rate or flap-related complications. Clinical relevance In patients receiving microvascular reconstructions, a balanced fluid administration perioperatively and a targeted use of vasopressors should be the necessary strategy to reduce the complication rates in head and neck surgery.
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Affiliation(s)
- John-Patrik Burkhard
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.
| | - Jelena Pfister
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Roland Giger
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Claudia Lädrach
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Manuel Waser
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Radu Olariu
- Department of Plastic, Reconstructive and Aesthetic Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Benoît Schaller
- Department of Cranio-Maxillofacial Surgery, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland
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8
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Han M, Ochoa E, Zhu B, Park AM, Heaton CM, Seth R, Knott PD. Risk Factors for and Cost Implications of Free Flap Take-backs: A Single Institution Review. Laryngoscope 2021; 131:E1821-E1829. [PMID: 33438765 DOI: 10.1002/lary.29382] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/06/2020] [Accepted: 01/03/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE/HYPOTHESIS For patients undergoing microvascular free tissue transfer (MFTT), we evaluated risk factors and financial implications of operating room (OR) take-back procedures. STUDY DESIGN Retrospective review at a tertiary care center. METHODS Patients who underwent MFTT for head and neck reconstruction from 2011 to 2018 were identified. We compared hospital length of stay and overall costs associated with OR take-back procedures. Multivariable regression analysis evaluated factors associated with OR take-backs during the same hospitalization. RESULTS A total of 727 free flaps were reviewed, and 70 OR take-backs (9.6%) were identified. Mean total length of stay (LOS) in the ICU was 3.4 days versus 6.7 days for non-take-back and take-back flaps, respectively (P < .001). Mean total LOS on the regular floor was 6.3 days versus 13.1 days, respectively (P < .001). This resulted in a cost differential of $33,507 (94.3% increase relative to non-take-back flaps). The total cost associated with an OR take-back was $39,786. Hematomas were the most common cause of take-backs and wound dehiscence was associated with the highest costs. On multivariable analysis, higher ASA class (OR, 2.06; 95% CI, 1.11-3.99; P = .026) and shorter ischemia times (OR, 0.52; 95% CI, 0.29-0.95; P = .030) were independently associated with increased risk of take-backs. CONCLUSIONS OR take-backs infrequently occur but are associated with a significant increase in financial burden when compared to free flap cases not requiring OR take-back. The large majority of the cost differential lies in a substantial increase of ICU and floor LOS for take-back flaps when compared to non-take-back flaps. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E1821-E1829, 2021.
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Affiliation(s)
- Mary Han
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Edgar Ochoa
- School of Medicine, University of California, San Francisco, California, U.S.A.,Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Bovey Zhu
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Andrea M Park
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Chase M Heaton
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - Rahul Seth
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
| | - P Daniel Knott
- Department of Otolaryngology Head and Neck Surgery, University of California, San Francisco, California, U.S.A
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Jones VM, Suarez-Martinez AD, Hodges NA, Murfee WL, Llull R, Katz AJ. A clinical perspective on adipose-derived cell therapy for enhancing microvascular health and function: Implications and applications for reconstructive surgery. Microcirculation 2020; 28:e12672. [PMID: 33174272 DOI: 10.1111/micc.12672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/18/2020] [Accepted: 11/04/2020] [Indexed: 12/21/2022]
Abstract
Restoration of form and function requires apposition of tissues in the form of flaps to reconstitute local perfusion. Successful reconstruction relies on flap survival and its integration with the recipient bed. The flap's precariously perfused hypoxic areas undergo adaptive microvascular changes both internally and in connection with the recipient bed. A cell-mediated, coordinated response to hypoxia drives these adaptive processes, restoring a tissue's normoxic homeostasis via de novo vasculogenesis, sprouting angiogenesis, and stabilizing arterialization. As cells exert prolonged and coordinated effects on site, their use as biological agents merit translational consideration of sourcing angio-competent cells and delivering them to territories enduring microcirculatory acclimatization. Angio-competent cells abound in adipose tissue: a reliable, accessible, and expendable source of adipose-derived cells (ADC). When subject to enzymatic digestion and centrifugation, adipose tissue separates its various ADC: A subset of buoyant oil-dense adipocytes (the tissue's parenchymal component) accumulates on a supra-natant layer, whereas the mesenchymal component remains in the infra-natant sediment, containing the tissue's stromal vascular fraction (SVF), where angio-component cells abound. The SVF can be further manipulated, selected, or culture expanded into more specific stromal subsets (herein defined as adipose stromal cells, ASC). While promising clinical applications for ADC await clinical proof and regulatory authorization, basic science investigation is needed to elucidate the specific ADC mechanisms that influence microvascular growth, remodeling, and function following flap surgery. The objective of this article is to share the clinical perspectives of reconstructive plastic surgeons regarding the use of ADC-based therapies to help with flap tissue integration, revascularization, and wound healing. Specifically, the focus will be on considering the potential for ADC as therapeutic agents and how their clinical application motivates basic science opportunities.
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Affiliation(s)
- V Morgan Jones
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Ariana D Suarez-Martinez
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Nicholas A Hodges
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Walter L Murfee
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Ramon Llull
- Department of Plastic Surgery, Hospital Quiron Salud PalmaPlanas, Palma, Spain
| | - Adam J Katz
- Department of Plastic and Reconstructive Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Impact of payer status and hospital volume on outcomes after head and neck oncologic reconstruction. Am J Surg 2020; 222:173-178. [PMID: 33223075 DOI: 10.1016/j.amjsurg.2020.11.026] [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: 07/05/2020] [Revised: 10/28/2020] [Accepted: 11/11/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND High-volume centers improve outcomes in head and neck cancer (HNCA) reconstruction, yet it is unknown whether patients of all payer status benefit equally. METHODS We identified patients undergoing HNCA surgery between 2002 and 2015 using the National Inpatient Sample. Outcomes included receipt of care at high-volume centers, receipt of reconstruction, and post-operative complications. Multivariate regression analysis was stratified by payer status. RESULTS 37,442 patients received reconstruction out of 101,204 patients who underwent HNCA surgery (37.0%). Privately-insured and Medicaid patients had similar odds of receiving high-volume care (OR = 0.99, 95% CI = 0.87-1.11) and undergoing reconstruction (OR = 0.96, 95% CI = 0.86-1.05). Medicaid beneficiaries had higher odds of complication (OR = 1.36, 95% CI = 1.22-1.51). The discrepancy in complication odds was significant at low-volume (OR = 1.44, 95% CI = 1.12-1.84) and high-volume centers (OR = 1.30, 95% CI = 1.15-1.47). CONCLUSIONS Medicaid beneficiaries are as likely to receive care at high-volume centers and undergo reconstruction as privately-insured individuals. However, they have poorer outcomes than privately-insured individuals at both low- and high-volume centers.
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Abstract
BACKGROUND The objective of this study was to compare the economic impact of complete decongestive therapy and lymphovenous bypass in the management of upper extremity lymphedema. METHODS Economics were modeled for a patient with breast cancer-related lymphedema undergoing three different clinical pathways: (1) complete decongestive therapy alone; (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy; or (3) lymphovenous bypass requiring ongoing complete decongestive therapy. Activity-based cost analysis identified costs incurred with complete decongestive therapy and lymphovenous bypass. Costs were retrieved from supplier price lists, physician fee schedules, lymphedema therapists, and literature reviews. The net present value of all costs incurred for each clinical pathway were calculated. RESULTS The estimated net present value of all costs for a patient with breast cancer-related lymphedema undergoing treatment were as follows: (1) complete decongestive therapy alone ($30,400); (2) lymphovenous bypass no longer requiring ongoing complete decongestive therapy ($15,000); or (3) lymphovenous bypass requiring ongoing complete decongestive therapy ($42,100). The expected net present value of all costs for lymphovenous bypass was $26,800, which was comparable to that of complete decongestive therapy alone. Sensitivity analysis demonstrated that the expected net present value of lymphovenous bypass was dependent on the patient's life expectancy, number of bypass anastomoses, and likelihood of discontinuing complete decongestive therapy. CONCLUSIONS Lymphedema has substantial ongoing costs irrespective of the treatment modality. The cost of lymphovenous bypass appears comparable to that of complete decongestive therapy alone-the surgical costs of lymphovenous bypass are offset by the savings from discontinued ongoing therapy. Despite its limitations as a theoretical economic model, this study provides insight into the potential economic impact of lymphovenous bypass.
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12
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Wan M, Zhang JX, Ding Y, Jin Y, Bedford J, Nagarajan M, Bucevska M, Courtemanche DJ, Arneja JS. High-Risk Plastic Surgery: An Analysis of 108,303 Cases From the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Plast Surg (Oakv) 2020; 28:57-66. [PMID: 32110646 PMCID: PMC7016398 DOI: 10.1177/2292550319880921] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is a lack of large-scale data that examine complications in plastic surgery. A description of baseline rates and patient outcomes allows better understanding of ways to improve patient care and cost-savings for health systems. Herein, we determine the most frequent complications in plastic surgery, identify procedures with high complication rates, and examine predictive risk factors. METHODS A retrospective analysis of the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program plastic surgery data set was conducted. Complication rates were calculated for the entire cohort and each procedure therein. Microsurgical procedures were analyzed as a subgroup, where multivariate logistic regression models determined the risk factors for surgical site infection (SSI) and related reoperation. RESULTS We identified 108 303 patients undergoing a plastic surgery procedure of which 6 264 (5.78%) experienced ≥1 complication. The outcome with the highest incidence was related reoperation (3.31%), followed by SSI (3.11%). Microsurgical cases comprised 6 148 (5.68%) of all cases, and 1211 (19.33%) experienced ≥1 complication. Similar to the entire cohort, the related reoperation (12.83%) and SSI (5.66%) were common complications. Increased operative time was a common independent risk factor predictive of a related reoperation or development of an SSI (P < 001). Of all microsurgeries, 23.3% had an operative time larger than 10 hours which lead to faster increase in reoperation likelihood. CONCLUSIONS The complication rate in plastic surgery remains relatively low but is significantly increased for microsurgery. Increased operative time is a common risk factor. Two-team approaches and staged operations could be explored, as a large portion of microsurgeries are vulnerable to increased complications.
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Affiliation(s)
- Melissa Wan
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacques X. Zhang
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yichuan Ding
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Yiwen Jin
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Bedford
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Mahesh Nagarajan
- Sauder School of Business, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marija Bucevska
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Douglas J. Courtemanche
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
| | - Jugpal S. Arneja
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Plastic Surgery, Department of Surgery, BC Children’s Hospital, Vancouver, British Columbia, Canada
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13
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A comparative analysis using flowmeter, laser-Doppler |spectrophotometry, and indocyanine green-videoangiography for detection of vascular stenosis in free flaps. Sci Rep 2020; 10:939. [PMID: 31969630 PMCID: PMC6976589 DOI: 10.1038/s41598-020-57777-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/03/2020] [Indexed: 01/31/2023] Open
Abstract
The effects of gradual vascular occlusion on the blood supply of perfused areas are poorly described. Information relating to the comparison of flap monitoring techniques is lacking. Varying stenotic conditions (0%, 25%, 50%, 75% and 100%) were generated on purpose at the A. and V. femoralis in the rat model. Analyses included flowmeter, simultaneous laser-Doppler flowmetry and tissue spectrophotometry (O2C) and indocyanine green- (ICG-) videoangiography with integrated FLOW 800 tool. A Random Forests prediction model was used to analyse the importance of each method to diagnose the stenotic conditions. The ability to discriminate and to accurately estimate the probability of stenosis was assessed by Receiver Operating Characteristic (ROC) curves and calibration plots. Blood flow changes for all modalities were described in detail. Flowmeter displayed earliest a linear decrease as a result of increasing stenosis. A stenosis of 50% degrees was most difficult to detect correctly. The combination of flowmeter and ICG-videoangiography showed high diagnostic power for each stenotic situation (area under the ROC > 0.79). Flowmeter and ICG-videoangiography showed to be most relevant in detection of varying stenotic conditions and may change the clinical outcome. The O2C showed less effect on varying stenotic situations as the only surface monitoring device.
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McMillan LJ, Parikh HR, Cunningham BP. Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases. JBJS Case Connect 2019; 9:e0148. [PMID: 31140985 DOI: 10.2106/jbjs.cc.18.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication. CONCLUSIONS Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.
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Affiliation(s)
- Logan J McMillan
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
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15
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Taufique ZM, Daar DA, Cohen LE, Thanik VD, Levine JP, Jacobson AS. The medial sural artery perforator flap: A better option in complex head and neck reconstruction? Laryngoscope 2018; 129:1330-1336. [DOI: 10.1002/lary.27652] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Zahrah M. Taufique
- Department of Otolaryngology–Head and Neck Surgery New York New York U.S.A
| | - David A. Daar
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Leslie E. Cohen
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Vishal D. Thanik
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Jamie P. Levine
- Hansjorg Wyss Department of Plastic SurgeryNew York University Langone Health New York New York U.S.A
| | - Adam S. Jacobson
- Department of Otolaryngology–Head and Neck Surgery New York New York U.S.A
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16
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Multicenter prospective micro-costing study evaluating mandibular free-flap reconstruction. Eur Arch Otorhinolaryngol 2016; 274:1103-1111. [DOI: 10.1007/s00405-016-4360-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/25/2016] [Indexed: 01/07/2023]
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17
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Abstract
BACKGROUND Optimizing functional and aesthetic outcomes in postburn head and neck reconstruction remains a surgical challenge. Recurrent contractures, impaired range of motion, and disfigurement because of disruption of the aesthetic subunits of the face, can result in poor patient satisfaction and ultimately, contribute to social isolation of the patient. In an effort to improve the quality of life of these patients, this study evaluates different surgical approaches with an emphasis on tissue expansion of free and regional flaps. METHODS Regional and free-flap reconstruction was performed in 20 patients (26 flaps) with severe postburn head and neck contractures. To minimize donor site morbidity and obtain large amounts of thin and pliable tissue, pre-expansion was performed in all patients treated with locoregional flap reconstructions (12/12), and 62% (8/14) of patients with free-flap reconstructions. Algorithms regarding pre- and intraoperative decision-making are discussed, and complications between the techniques as well as long-term (mean follow-up 3 years) results are analyzed. RESULTS Complications, including tissue expander infection with need for removal or exchange, partial or full flap loss, were evaluated and occurred in 25% (3/12) of patients with locoregional and 36% (5/14) of patients receiving free-flap reconstructions. Secondary revision surgery was performed in 33% (4/12) of locoregional flaps and 93% (13/14) of free flaps. CONCLUSIONS Both locoregional as well as distant tissue transfers have their role in postburn head and neck reconstruction, whereas pre-expansion remains an invaluable tool. Paying attention to the presented principles and keeping the importance of aesthetic facial subunits in mind, range of motion, aesthetics, and patient satisfaction were improved long term in all our patients, while minimizing donor site morbidity.
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18
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Beard reconstruction: A surgical algorithm. J Plast Reconstr Aesthet Surg 2016; 69:e111-e118. [DOI: 10.1016/j.bjps.2016.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 02/03/2016] [Accepted: 03/18/2016] [Indexed: 11/18/2022]
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Noninvasive Free Flap Monitoring Using Eulerian Video Magnification. Case Rep Otolaryngol 2016; 2016:9471696. [PMID: 27092284 PMCID: PMC4820586 DOI: 10.1155/2016/9471696] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/10/2016] [Indexed: 11/18/2022] Open
Abstract
Eulerian Video Magnification (EVM) can enhance subtle changes in videos to reveal what was once invisible to the naked eye. In this proof of concept study, we investigated using EVM as a novel form of free flap monitoring. Free flaps with skin paddles were filmed in the operating room with manipulation of their pedicles. In a representative 77-year-old female who received a latissimus dorsi-serratus-rib composite free flap, EVM was able to detect blockage of arterial or venous supply instantaneously, providing a visible representation through degree of color change in videos. EVM has the potential to serve as a powerful free flap monitoring tool with the benefit of being noninvasive, sensitive, easy-to-use, and nearly cost-free.
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20
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Hand WR, Stoll WD, McEvoy MD, McSwain JR, Sealy CD, Skoner JM, Hornig JD, Tennant PA, Wolf B, Day TA. Intraoperative goal-directed hemodynamic management in free tissue transfer for head and neck cancer. Head Neck 2016; 38 Suppl 1:E1974-80. [PMID: 26829494 DOI: 10.1002/hed.24362] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine the effect of algorithmic physiologic management on patients undergoing head and neck free tissue transfer and reconstruction. METHODS Ninety-four adult patients were randomized to treatment and control groups. The blood pressure of the control group was managed consistent with contemporary standards. The treatment group was managed using an algorithm based on blood pressure and calculated physiologic values derived from arterial waveform analysis. Primary outcome was intensive care unit (ICU) length of stay. RESULTS ICU length of stay was decreased in the treatment group (33.7 vs 58.3 hours; p = .026). The complication rate was not increased in the treatment group. CONCLUSION The goal-directed hemodynamic management algorithm decreased the ICU length of stay. Judicious use of vasoactive drugs and goal-directed fluid administration has a role in improving perioperative outcomes for patients undergoing head and neck free tissue transfer. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1974-E1980, 2016.
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Affiliation(s)
- William R Hand
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - William D Stoll
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Julie R McSwain
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Clark D Sealy
- Medical University of South Carolina, Charleston, South Carolina
| | - Judith M Skoner
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Joshua D Hornig
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Paul A Tennant
- Department of Otolaryngology-Head and Neck Surgery, University of Louisville, Louisville, Kentucky
| | - Bethany Wolf
- Department of Biostatistics, Medical University of South Carolina, Charleston, South Carolina
| | - Terry A Day
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg 2015; 72:S135-8. [PMID: 24691344 DOI: 10.1097/sap.0000000000000076] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
General anesthesia induces hypotension and this is commonly treated intraoperatively with administering vasopressors. Microsurgeons are hesitant to use vasopressors due to the potential risk of inducing vasoconstriction and flap necrosis. The aim of this study was to determine the frequency of intraoperative vasopressor utilization in patients undergoing free tissue transfer reconstruction and to determine its impact on patient outcomes. An IRB-approved retrospective review was performed for 47 consecutive patients undergoing free tissue transfer for head, neck, and extremity reconstruction at Wake Forest Baptist Health over a 3-year period. Free flap survival was 97%, with 3% of patients having total flap necrosis and 17% with partial flap necrosis. The frequency of intraoperative vasopressor use was 53.2%. There was no significant difference in the frequency of total or partial flap necrosis between patients who received intraoperative vasopressors and those who did not. Similarly, there was no statistical significance in the rate of arterial or venous thrombosis between the 2 groups (P = 0.095 and P = 0.095, respectively). The use of vasopressors did not significantly increase postoperative complications. The timing of vasopressor administration did not affect outcomes. Intraoperative vasopressors are used more frequently than previously realized during free tissue transfer for reconstructive surgery. The use of intraoperative vasopressors does not appear to adversely affect outcomes of free tissue transfer. Further investigation and larger study size are needed to analyze the timing of drug administration, dose, and type of vasopressor to better understand the impact of intraoperative vasopressor use in free tissue transfer outcomes.
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22
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Externalized monitoring of totally buried free flap in hypopharyngeal reconstruction. J Craniofac Surg 2014; 24:575-8. [PMID: 23524745 DOI: 10.1097/scs.0b013e31827c8077] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Defects after ablation for the treatment of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Because the neohypopharynx is totally buried, various methods have been suggested for monitoring. Here, we propose techniques that can be used to monitor the buried fasciocutaneous free flap for reconstruction after pharyngolaryngectomy, which has an exteriorized part that can be used for clinical monitoring. MATERIALS AND METHODS Between January 2011 and May 2012, 6 consecutive patients with advanced hypopharyngeal cancer underwent reconstructive surgery of the fasciocutaneous free flap after pharyngolaryngectomy. The anterolateral thigh free flap was used in 4 patients, and the radial forearm free flap was used in the other 2 patients. All flap designs were elongated into a fusiform shape because a part of the flap was used for exteriorized monitoring using deepithelialized bridge. RESULTS Patients 1 and 2 demonstrated uneventful postoperative courses, including healthy skin color and fresh pin-prick bleeding. Patient 3 also demonstrated a healthy monitoring flap, but distal leakage was noted on the computed tomographic scan, and Fistula repair with monitoring flap excision was performed on postoperative day 16. In patient 4, defects that manifested after cancer ablation were shorter than usual, and deepithelialized bridge was longer. When the general hemodynamic status of the patient was aggravated during the postoperative course, the color of the monitored skin did change. The viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks, and repair was necessary. Patients 5 and 6 demonstrated healthy monitoring flap and no postoperative complications. The monitoring flap was excised after 2 weeks under local anesthesia. CONCLUSIONS Using our techniques, clinical monitoring by examining the exteriorized monitoring flap is possible. However, the possibility of false positives exists, and physicians must be cautious when performing these techniques, and patients must be carefully selected because of the danger of leakage.
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Lu L, Liu A, Zhu L, Zhang J, Zhu X, Jiang H. Cross-Leg Flaps: Our Preferred Alternative to Free Flaps in the Treatment of Complex Traumatic Lower Extremity Wounds. J Am Coll Surg 2013; 217:461-71. [DOI: 10.1016/j.jamcollsurg.2013.03.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 03/12/2013] [Accepted: 03/13/2013] [Indexed: 11/25/2022]
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Kessler P, Poort L, Böckmann R, Lethaus B. Definition of quality indicators in microsurgery in head and neck reconstruction based on a 5-year follow-up without a loss. J Craniomaxillofac Surg 2013; 41:2-6. [DOI: 10.1016/j.jcms.2012.05.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 05/11/2012] [Accepted: 05/14/2012] [Indexed: 10/28/2022] Open
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Lindau RH, Detwiller K, Wax MK. Buried free flaps in head and neck surgery: Outcome analysis. Head Neck 2012; 35:1468-70. [DOI: 10.1002/hed.23171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Nguyen JT, Ashitate Y, Buchanan IA, Ibrahim AMS, Gioux S, Patel PP, Frangioni JV, Lee BT. Face transplant perfusion assessment using near-infrared fluorescence imaging. J Surg Res 2012; 177:e83-8. [PMID: 22572616 DOI: 10.1016/j.jss.2012.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 04/02/2012] [Accepted: 04/10/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Composite tissue allografts (CTAs) including partial face transplantation have been achieved clinically. However, risks of complications including tissue ischemia, rejection, and transplant failure are significant. Safe and effective techniques to assess perfusion are needed to decrease complications in composite tissue flaps. Near-infrared (NIR) fluorescence imaging has been previously shown to provide a real-time, intraoperative evaluation of perfusion. This study investigates the use of NIR imaging in partial face CTA harvest. METHODS We created hemifacial CTAs (n = 8) using an established porcine model. This included ear cartilage, nerve, lymphoid tissue, muscle, and skin with perfusion by the carotid artery and external jugular vein. We injected animals systemically with indocyanine green and obtained NIR fluorescence images simultaneously with color video. In addition, we assessed the elevated hemifacial flaps using standard of care (i.e., clinical examination and Doppler). RESULTS Flap design was facilitated by NIR imaging with localization of perforators to the hemifacial CTA flap. In particular, an arterial and venous phase could be clearly identified. We assessed perfusion of the flap by NIR fluorescence intensity after injection of indocyanine green. Sequential clamping of the artery and vein confirmed correlation of perfusion deficits with NIR imaging as well as with clinical examination and Doppler. CONCLUSIONS Evaluation and assessment of perfusion are important in facial transplantation. The results from our pilot study indicate that NIR imaging has the capability to assess perfusion of partial facial CTAs. This emergent technology shows promise in assessing tissue perfusion in a composite flap.
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Affiliation(s)
- John T Nguyen
- Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Liu Y, Zhao YF, Huang JT, Wu Y, Jiang L, Wang GD, Li W, Chen XQ, Shi RH. Analysis of 13 cases of venous compromise in 178 radial forearm free flaps for intraoral reconstruction. Int J Oral Maxillofac Surg 2012; 41:448-52. [PMID: 22361300 DOI: 10.1016/j.ijom.2012.01.016] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 01/20/2012] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to analyse the causes of venous compromise and flap failure in radial forearm free flap (RFFF) surgery for intraoral reconstruction. One hundred seventy-eight RFFF reconstructions were reviewed retrospectively for intraoral defects. Of the 13 flaps with venous obstruction, 9 flaps were salvaged, and 4 were lost, with a salvage rate of 69.2%. Eleven venous occlusions occurred within the first 72h. The main reasons for venous failure were mechanical obstruction or technical errors due to inadequate pedicle length and geometry, inadequate venous drainage, compression and kinking of the vein. The main cause of failure for oropharynx reconstruction was unrecognized vascular events due to the lack of reliable monitoring for buried flap. Oozing of dusky blood from the flap margin may be directly related to venous congestion in the early postoperative period and a late indication of a change in skin colour. In conclusion, a thorough operative plan, including carefully selected drainage vein for the flap and recipient vessels, adequate pedicle length and geometry, precise surgical technique, avoidance of haematoma, and expert monitoring of buried flaps may improve the success rate of RFFF transfer in intraoral reconstruction.
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Affiliation(s)
- Y Liu
- Department of Stomatology, Changzheng Hospital, Second Military Medical University, Shanghai, PR China
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29
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Raittinen L, Pukander J, Laranne J. Early recognition of ischaemia with continuous real-time tissue oxygen monitoring in head and neck microvascular flaps. EUROPEAN JOURNAL OF PLASTIC SURGERY 2012. [DOI: 10.1007/s00238-011-0688-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pratt GF, Rozen WM, Westwood A, Hancock A, Chubb D, Ashton MW, Whitaker IS. Technology-assisted and sutureless microvascular anastomoses: evidence for current techniques. Microsurgery 2011; 32:68-76. [PMID: 22121054 DOI: 10.1002/micr.20930] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 05/12/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Since the birth of reconstructive microvascular surgery, attempts have been made to shorten the operative time while maintaining patency and efficacy. Several devices have been developed to aid microsurgical anastomoses. This article investigates each of the currently available technologies and attempts to provide objective evidence supporting their use. METHODS Techniques of microvascular anastomosis were investigated by performing searches of the online databases Medline and Pubmed. Returned results were assessed according to the criteria for ranking medical evidence advocated by the Oxford Centre for Evidence Based Medicine. Emphasis was placed on publications with quantifiable endpoints such as unplanned return to theatre, flap salvage, and complication rates. RESULTS There is a relative paucity of high-level evidence supporting any form of assisted microvascular anastomosis. Specifically, there are no randomized prospective trials comparing outcomes using one method versus any other. However, comparative retrospective cohort studies do exist and have demonstrated convincing advantages of certain techniques. In particular, the Unilink™/3M™ coupler and the Autosuture™ Vessel Closure System® (VCS®) clip applicator have been shown to have level 2b evidence supporting their use, meaning that the body of evidence achieves a level of comparative cohort studies. CONCLUSION Of the available forms of assisted microvascular anastomoses, there is level 2b evidence suggesting a positive outcome with the use of the Unilink™/3M™ coupler and the Autosuture™ VCS® clip applicator. Other techniques such as cyanoacrylates, fibrin glues, the Medtronic™ U-Clip®, and laser bonding have low levels of evidence supporting their use. Further research is required to establish any role for these techniques.
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Affiliation(s)
- George F Pratt
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy and Cell Biology, University of Melbourne, Melbourne, Vic., Australia
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31
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Monitoring of intraoral free flaps with microdialysis. Br J Oral Maxillofac Surg 2011; 49:521-6. [DOI: 10.1016/j.bjoms.2010.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 09/29/2010] [Indexed: 11/20/2022]
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Engel H, Huang JJ, Tsao CK, Lin CY, Chou PY, Brey EM, Henry SL, Cheng MH. Remote real-time monitoring of free flaps via smartphone photography and 3G wireless internet: A prospective study evidencing diagnostic accuracy. Microsurgery 2011; 31:589-95. [DOI: 10.1002/micr.20921] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 04/25/2011] [Indexed: 11/07/2022]
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The best salvage operation method after total necrosis of a free jejunal graft? Transfer of a second free jejunal graft. J Plast Reconstr Aesthet Surg 2011; 64:1030-4. [DOI: 10.1016/j.bjps.2011.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Revised: 01/29/2011] [Accepted: 02/04/2011] [Indexed: 11/20/2022]
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Nahabedian MY, Patel KM. Maximizing the use of the handheld Doppler in autologous breast reconstruction. Clin Plast Surg 2011; 38:213-8. [PMID: 21620146 DOI: 10.1016/j.cps.2011.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The handheld acoustic Doppler is commonly used in the setting of autologous reconstruction. Like the color duplex Doppler, it can be used preoperatively but has the advantage of being used intraoperatively and postoperatively. It can be used as a sole modality or it can be used in conjunction with or to confirm the findings of CTA or MRA. This article focuses on the preoperative, intraoperative, and postoperative use of the handheld Doppler for free tissue transfer with an emphasis on perforator flap breast reconstruction.
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Affiliation(s)
- Maurice Y Nahabedian
- Department of Plastic Surgery, Johns Hopkins University, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA.
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Abstract
The evolution of techniques in plastic surgery and orthopedic surgery over the past few decades has enabled a great level of success in limb salvage. Limb salvage can now be achieved when faced with trauma, tumor, sepsis, or vascular disease. In fact, "What can be salvaged?" is now a less common debate among clinicians than "What should be salvaged?" Often discussions among surgeons from various subspecialties, including orthopedics, plastics, trauma, and vascular surgery, are characterized by how each of them can perform their respective part of the salvage operation, be it bony fixation, revascularization, or soft-tissue coverage, but none of them is certain whether it should be attempted. What is needed in these clinical situations is an interdisciplinary team approach led by individual or groups of clinicians who are familiar not only with their own subspecialized skills but also with those of their colleagues and the outcomes associated with integrated efforts at limb salvage. The concept of orthoplastic surgery is based on such an idea, where the combined skills and techniques of the orthopedic surgeon and reconstructive microsurgeon are used in concert to direct efforts toward limb salvage or decide against it when it is not indicated. This article presents a review of the roles of the two subspecialties and how an orthoplastic team can function with the current techniques to improve outcomes in limb salvage surgery.
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Power modulation contrast enhanced ultrasound for postoperative perfusion monitoring following free tissue transfer in head and neck surgery. Int J Oral Maxillofac Surg 2010; 39:1211-7. [DOI: 10.1016/j.ijom.2010.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 04/21/2010] [Accepted: 07/19/2010] [Indexed: 11/20/2022]
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Gardiner M, Nanchahal J. Strategies to ensure success of microvascular free tissue transfer. J Plast Reconstr Aesthet Surg 2010; 63:e665-73. [DOI: 10.1016/j.bjps.2010.06.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 05/30/2010] [Accepted: 06/09/2010] [Indexed: 11/26/2022]
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Keereweer S, Sewnaik A, Kerrebijn J, Meeuwis C, Tilanus H, de Wilt J. Salvage or what follows the failure of a free jejunum transfer for reconstruction of the hypopharynx? J Plast Reconstr Aesthet Surg 2010; 63:976-80. [DOI: 10.1016/j.bjps.2009.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 02/10/2009] [Accepted: 03/15/2009] [Indexed: 10/20/2022]
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Chubb D, Rozen WM, Ashton MW. Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. Int J Oral Maxillofac Surg 2010; 39:742-3; author reply 743. [PMID: 20335006 DOI: 10.1016/j.ijom.2010.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 02/19/2010] [Indexed: 10/19/2022]
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Franken JM, Hupkens P, Spauwen PHM. The treatment of soft-tissue defects of the lower leg after a traumatic open tibial fracture. EUROPEAN JOURNAL OF PLASTIC SURGERY 2010; 33:129-133. [PMID: 20502513 PMCID: PMC2869440 DOI: 10.1007/s00238-010-0405-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2009] [Accepted: 12/11/2009] [Indexed: 12/03/2022]
Abstract
The treatment of large soft-tissue defects of the lower leg remains a challenge. The timing of the operation, the most suitable type of tissue, and the decision between local or free flap coverage still remains under discussion. Fifty-two patients were treated with local or free flap coverage after a traumatic soft-tissue defect of the lower leg. We compared the results after treatment with local versus free flaps and fasciocutaneous flaps versus musculocutaneous flaps. In the case of primary reconstruction, we also compared the results regarding the timing of the operation: patients treated within 72 h after the trauma versus patients treated after 72 h. Thirty-five patients (67%) have been treated because of posttraumatic soft-tissue defects and, therefore, insufficient fracture coverage. Seventeen patients (33%) were treated because of a chronic osteomyelitis that arose after the trauma. In our study, we did not find a statistically significant difference between the postoperative complications of local and free flaps. A significant increase could be demonstrated in the number of revisions after treatment with a free flap. Treatment with a fasciocutaneous flap in the entire study group was associated with significantly more postoperative complications than treatment with a musculocutaneous flap. There was no significant difference in results after early or late flap coverage. Patients treated with local or free flaps achieved equal outcomes, except for the number of postoperative revisions in which local flaps required lesser revisions. Treatment with a musculocutaneous flap is preferable to treatment with a fasciocutaneous flap regarding postoperative complications. The timing of operation proved not to be a discriminating factor.
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Vasopressor use in free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142:169-73. [PMID: 20115969 DOI: 10.1016/j.otohns.2009.11.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Revised: 10/14/2009] [Accepted: 11/02/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To document the frequency of vasopressor use in free tissue transfer surgery and to compare the incidence of flap complications and flap survival in patients receiving or not receiving intraoperative vasopressors. STUDY DESIGN AND SETTING Case series with chart review of free tissue transfers performed between 2004 and 2006 at a large-volume tertiary academic hospital. RESULTS Of 241 free flaps, 169 had data available for analysis. Flap survival was 96.5 percent. The rate of other flap complications was 29 percent. A total of 139 (82%) patients received vasopressors intraoperatively. Of these, four (2.9%) flap failures and 40 (29%) complications occurred. In the 30 (18%) patients who did not receive vasopressors, two (6.7%) flap failures and nine (30%) complications occurred. The most common reasons for flap failure were arterial thrombus (n = 3) and thrombosis of the venous pedicle (n = 3). CONCLUSION Intraoperative vasopressors are used more frequently than previously realized but do not appear to increase overall flap failure and the incidence of complications. Intraoperative vasopressor use in free flap surgery may not be as harmful as previously feared.
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Temporary implantation of vacuum-assisted closure dressing beneath flaps: a novel adjunctive technique for staged lower extremity wound closure in chronic wounds. CURRENT ORTHOPAEDIC PRACTICE 2010. [DOI: 10.1097/bco.0b013e3181b67500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bianchi B, Copelli C, Ferrari S, Ferri A, Sesenna E. Free flaps: Outcomes and complications in head and neck reconstructions. J Craniomaxillofac Surg 2009; 37:438-42. [DOI: 10.1016/j.jcms.2009.05.003] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 05/19/2009] [Accepted: 05/26/2009] [Indexed: 10/20/2022] Open
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Winterton RIS, Pinder RM, Morritt AN, Knight SL, Batchelor AG, Liddington MI, Kay SP. Long term study into surgical re-exploration of the 'free flap in difficulty'. J Plast Reconstr Aesthet Surg 2009; 63:1080-6. [PMID: 19527943 DOI: 10.1016/j.bjps.2009.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 05/12/2009] [Accepted: 05/20/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.
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Affiliation(s)
- R I S Winterton
- Leeds General Infirmary, Leeds Teaching Hospital NHS Trust, Great George Street, Leeds LS1 3EX, UK.
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Extensor Digitorum Brevis Muscle Flap: Modified Approach Preserving Extensor Retinaculum. ACTA ACUST UNITED AC 2009; 66:835-9. [DOI: 10.1097/ta.0b013e318165c835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tenorio X, Mahajan AL, Wettstein R, Harder Y, Pawlovski M, Pittet B. Early Detection of Flap Failure Using a New Thermographic Device. J Surg Res 2009; 151:15-21. [DOI: 10.1016/j.jss.2008.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 02/28/2008] [Accepted: 03/07/2008] [Indexed: 10/22/2022]
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Bakri K, Moran SL. Monitoring for upper-extremity free flaps and replantations. J Hand Surg Am 2008; 33:1905-8. [PMID: 19084200 DOI: 10.1016/j.jhsa.2008.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 09/09/2008] [Indexed: 02/02/2023]
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Betz CS, Zhorzel S, Schachenmayr H, Stepp H, Havel M, Siedek V, Leunig A, Matthias C, Hopper C, Harreus U. Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: preliminary results. J Plast Reconstr Aesthet Surg 2008; 62:1602-8. [PMID: 19036663 DOI: 10.1016/j.bjps.2008.07.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 06/28/2008] [Accepted: 07/24/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Free-tissue transfer has become a standard procedure for reconstructive surgery in the head and neck area. Flap failures are relatively rare (<or=5%), and a high percentage can be salvaged if detected early. Indocyanine Green (ICG) angiography might be able to improve the detection of flap malperfusion at an early stage. METHODS So far, 11 patients with free-flap reconstructions of the upper aerodigestive tract (UADT) have participated in this study. Each participant underwent three endoscopic ICG angiographies (24h intra-operatively and 72h postoperatively). The data obtained were evaluated online as well as offline on a personal computer (PC), and the results compared to the clinical outcome. RESULTS There were no partial or complete flap losses. One flap was successfully salvaged following initial arterial kinking with impeded perfusion. The ICG fluorescence angiography was tolerated well in all patients. The free flaps showed a delayed yet equal ICG fluorescence as compared to the surrounding tissue. The timing and slope of fluorescence build-up were dependent on circulatory factors. The relative fluorescence maxima of flap versus surrounding were 33% in the initially failing flap and >or=64% for all other examinations. CONCLUSIONS It was possible to prove the feasibility of endoscopic ICG fluorescence angiography in patients undergoing free-flap transfer to the UADT. The method provides instant information about the perfusion state of the tissue and is easily performed without greater patient discomfort or risk of side effects. Due to the endoscopic approach, the method seems highly promising for this indication and merits further evaluation.
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Affiliation(s)
- C S Betz
- Department of Otorhinolaryngology, Head & Neck Surgery, Ludwig Maximilian University, Grosshadern Medical Campus, Marchioninistr 15, D-81377 Munich, Germany.
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Altintas MA, Altintas AA, Guggenheim M, Knobloch K, Niederbichler AD, Vogt PM. Monitoring of microcirculation in free transferred musculocutaneous latissimus dorsi flaps by confocal laser scanning microscopy--a promising non-invasive methodical approach. J Plast Reconstr Aesthet Surg 2008; 63:111-7. [PMID: 19027386 DOI: 10.1016/j.bjps.2008.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2008] [Revised: 07/26/2008] [Accepted: 08/08/2008] [Indexed: 11/30/2022]
Abstract
INTRODUCTION For the survival of a microvascular tissue transfer, early detection of vascular complications is crucial. In vivo confocal laser scanning microscopy allows real-time, non-invasive evaluation of tissue microcirculation with a high cellular resolution. The aim of this study was to evaluate confocal laser scanning microscopy for early recognition of flap failure. METHODS Fourteen patients (ages: 40.2+/-12.4 years) were monitored postoperatively for a period of 24h following free microvascular M. latissimus dorsi transfer to the lower extremity using confocal laser scanning microscopy (Vivascope1500; Rochester; New York; USA). The following parameters were evaluated: quantitative blood-cell flow, diameter of capillary loops and minimal thickness of the epidermis. RESULTS Venous congestion was characterised by a decrease in blood-cell flow of up to 41%, accompanied by an increase of the diameter of capillary loops of up to 22% and the minimal thickness of the epidermis up to 32%. By contrast, arterial occlusion was clearly verified by a decrease in blood flow of up to 90%, accompanied by an insignificant change of both capillary loop size and epidermal thickness. CONCLUSION Confocal laser scanning microscopy appears to be a useful non-invasive tool for early recognition of flap failure during the monitoring of microsurgical tissue transfer prior to its clinical manifestation.
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Affiliation(s)
- M A Altintas
- Department of Plastic, Hand and Reconstructive Surgery, Medical School Hannover, 30625 Hannover, Germany.
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