Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels

[Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

[Acute and post-acute soft tissue reconstruction]

BACKGROUND

The precise analysis of the injured structures requiring reconstruction in complex wound defects is a prerequisite for successful restoration.

OBJECTIVE

The fundamental reconstructive strategies for soft tissue defects of the extremities including injuries to vessels, nerves and burn wounds in the context of the acute and post-acute trauma phases are presented.

MATERIAL AND METHODS

The different phases of soft tissue reconstruction are described. Recommendations for action with respect to the reconstruction of the functional structures are described. Two clinical case examples illustrate the approach.

RESULTS

The acute reconstruction phase is defined as the period 0-72 h after the traumatic event and includes surgical debridement, primary reconstruction of nerves and vessels using interpositional grafts if necessary and temporary soft tissue reconstruction. Combined thermomechanical trauma requires early debridement combined with internal fixation of open fractures. In the post-acute reconstruction phase, which is generally defined as a period of up to 6 weeks after the traumatic event, definitive soft tissue reconstruction is performed. In the case of long reinnervation distances, nerve transfer or motor replacement plastic surgery is performed in the post-acute phase.

CONCLUSION

The reconstruction of soft tissue after trauma necessitates a stage-dependent approach. In the acute phase procedures aim at the immediate preservation of the limb. In the post-acute phase, definitive soft tissue reconstruction is performed to enable maximum functional preservation. Combined thermomechanical injuries require early surgical treatment in order to prevent infections.

One vs. two-stage arteriovenous loops in lower extremity reconstruction with free flaps: Systematic review and metanalysis

BACKGROUND

Arteriovenous loops are one of the main therapeutic alternatives to address the absence of recipient vessels in lower extremity microsurgical reconstruction. However, there is no consensus on whether to perform them in one or two surgical stages. The objective of this work is to determine whether the outcome of lower limb free flaps anastomosed to vascular loops depends on the number of surgical stages.

MATERIALS AND METHODS

A literature review was conducted, following PRISMA guidelines, on vascular loops and free flaps in lower limb. Survival rate, as well as major and minor complications were studied. A forest plot and Pearson's chi-square were used for statistical analysis. Study quality was assessed in duplicate using Methodological Index for Non-Randomized Studies (MINORS) and Joanna Briggs Institute (JBI) tool. This study was registered on PROSPERO.

RESULTS

Thirty-two articles using free flaps anastomosed to vascular loops in lower limb, either one or two-stage, were selected. A total of 296 flaps were included, 52% (n = 154) in one and 48% (n = 142) in two surgical times. No statistically significant differences were found in the survival rate (OR = 1.85, 95% CI 0.62; 5.47, p = .09 and p = .344) or major complications (OR = 0.70, 95% CI 0.31; 1.57, p = .56 and p = .92) of flaps between both groups.

CONCLUSIONS

According to the available evidence, the outcome of free flaps anastomosed to vascular loops in the lower limb does not depend on the number of surgical stages they undergo. Although there is some heterogeneity in the groups studied, the decision on the number of procedures to be performed should be determined by the surgeon, concerning the clinical situation of the patient, as well as to the vascular, bone and soft tissue status of the extremity.

The use of a skin paddle-containing vein graft for arteriovenous looping in two-stage free flap reconstruction of lower extremities

BACKGROUND

Arteriovenous (AV) looping prior to the lower extremity free flap reconstruction enables better venous drainage in flap circulation, leading to less flap complications and better survival. A two-staged reconstruction including free tissue transfer after AV looping ensures a robust venous drainage of the flap. Arterialization of the AV loop results in less venous problems after the free flap reconstruction. However, major problems of this staged operation include AV loop kinking, heavy compression and loop exposure, leading to AV graft failure and interruption of surgical planning. The purpose of this article is to summarize probable flaws we noticed in conventional two-stage lower limb reconstruction and overcome those problems using the skin paddle-containing vein graft.

METHOD

Eight patients with lower limb defects underwent lower limb reconstruction surgery using this technique at our institute. The mean age was 52 years old. Of the eight patients, three of them have the defect due to infection. Three of them was due to trauma and three of them was due to full-thickness burn. Five of the defects located at foot. The other three defects located at heel, knee, and pretibial region. All of them require AV looping because of unavailability of nearby recipient vessels. They all received a two-stage operation, including the first stage AV looping with a skin paddle-containing vein graft and the second stage definite free tissue transfer.

RESULTS

The mean defect size was 140 cm2 (72-225). The mean length of AV loops was 17.1 cm (8-25). The mean size of skin paddles for vein grafts was 19.4 cm2 (15-24). The mean size of free ALT flaps 154.4 cm2 (105-252). All eight patients experienced a smooth postoperative course with no major or minor complications. There were no graft thrombosis or graft rupture complications during the vascular maturation period. All eight AV loops survived during maturation. All eight patients progressed to the second stage surgery. Maturation time ranged from 5 to 7 days. Free ALT flap was employed during the second stage reconstruction. All flaps survived at the last follow-up visit. There was no partial flap loss and complications. The mean follow-up time was 12.25 months, ranging from 8 to 17 months.

CONCLUSION

The skin paddle-containing vein graft is an effective modification of the regular vein graft for AV looping procedure. The skin paddle prevents the underlying AV loop from compression, kinking and twisting during maturation. It also aids assessing patency of the AV loop and avoids the formation of adhesion between the AV loop and the surrounding tissue.

Analysis of intraoral microvascular anastomosis in maxillofacial defects reconstruction

This review summarizes the research progress in the field of intraoral microvascular anastomosis techniques (IAT) and attempts to investigate the indications for procedures in which IAT can be applied, the surgical procedure and the difficulties involved, technical assessments, result evaluation and the perspective. Currently, microvascular anastomosis technique is widely used in maxillofacial defects reconstruction from various causes including cutaneous injury or congenital deformity which usually required extensive flap reconstruction and therefore a vascular free flap is routinely used. Conventional microvascular anastomosis reconstruction techniques cannot avoid new incisions, which will affect the postoperative aesthetic situation. Surgeons have therefore attempted to improve this technique to effectively eliminate scars caused by surgery: some patients can be chosen to undergo microvascular anastomosis of the free flap intraorally, thus reducing the extraoral incision caused by the anastomosis located in neck or maxillofacial improving the postoperative appearance of the patients. In addition to preserving the external appearance, intraoral anastomosis technique (IAT) can also solve some other problems of maxillofacial vascular anastomosis, such as insufficient vessel pedicle length and high risk of facial nerve injury.

Vessel grafts for tissue engineering revisited-Vessel segments show location-specific vascularization patterns in ex vivo ring assay

OBJECTIVE

Transplantation of prefabricated tissue-engineered flaps can be a potential alternative for healing large tissue defects. Providing adequate vascular supply for an engineered tissue construct is one of the key points in establishing successful tissue engineering-based treatment approaches. In tissue engineering-based vascularization techniques like the arteriovenous loop, vascular grafts with high angiogenic potential can help to enhance neovascularization and tissue formation. Therefore, our study aimed to compare the angiogenic potential of vascular grafts from different locations in the rat.

METHODS

The angiogenic activity was investigated by an ex vivo vessel outgrowth ring assay using 1-mm height vascular segments embedded in fibrin for 2 weeks.

RESULTS

Maximum vessel outgrowth was observed on Days 10-12. Upper extremity vessels exhibited stronger outgrowth than lower extremity vessels. Moreover, arterial vessels demonstrated higher angiogenic potential compared with venous vessels.

CONCLUSION

Collectively, our ex vivo findings suggest that upper extremity arterial vessels have a higher angiogenic capacity, which could be used to improve neovascularization and tissue formation in tissue engineering.

Free Flap Reconstruction of Posterior Trunk Soft-Tissue Defects: Single-Institution Experience and Systematic Literature Review

BACKGROUND

The posterior trunk is a technically demanding location for microvascular free tissue transfer. In this study, the authors report their own institutional experience with soft-tissue free flap reconstruction of the posterior trunk and provide a systematic review of the literature regarding this uncommon clinical scenario.

METHODS

A systematic review was performed using the PubMed database in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A single-institution retrospective review was also performed including all patients who received a soft-tissue free flap for a posterior trunk defect between 1990 and 2019.

RESULTS

The database search yielded 15 articles, representing 61 patients; the most commonly used flap was the latissimus dorsi (45.9 percent) and the most commonly reported defect location was the lumbosacrum (42.3 percent). Retrospective review of the authors' database identified 26 patients, with the latissimus dorsi being the most common flap and the sacrum the most common defect site. The authors' institutional case series showed a 30.7 percent major complication rate and 7.7 percent total flap loss rate; 38.4 percent of flaps required vein grafting.

CONCLUSIONS

In this study, the authors provided a systematic literature review and described their own long-term institutional experience with these rare and difficult reconstructions. Although the overall complication rate is high, these reconstructions are frequently necessary, and an algorithmic approach can improve outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Combined (endo-)vascular intervention and microsurgical lower extremity free flap reconstruction-A propensity score matching analysis in 5386 ACS-NSQIP patients

BACKGROUND

Compromised lower limb perfusion due to vascular changes such as peripheral artery disease impedes wound healing and may lead to large-scale tissue defects and lower limb amputation. In such patients with defects and compromised or lacking recipient vessels, combined vascular reconstruction with free flap transfer is an option for lower extremity salvage.

METHODS

By using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2018), we analyzed two patient cohorts undergoing (A) free flap lower limb reconstruction (LXTR) only and (B) combined (endo-)vascular reconstruction (vascLXTR). The preoperative variables assessed included demographic data and comorbidities, including smoking, diabetes mellitus, preoperative steroid use, and American Society of Anesthesiology (ASA) Physical Status Classification. Using a neighbor matching algorithm, we performed a 1:1 propensity score matching of 615 LXTR patients and 615 vascLXTR patients. Bivariate analysis for postoperative surgical and medical complications was performed for outcomes in the propensity-matched cohort.

RESULTS

We identified 5386 patients who underwent microsurgical free flap reconstruction of the lower extremity. A total of 632 patients underwent a combined (endo-)vascular intervention and lower extremity free flap reconstruction. Diabetes and smoking were more prevalent in this group, with 206 patients having diabetes (32.6%) and 311 being smokers (49.2%). More patients returned to the operating room in the cohort that underwent a combined vascular intervention (24.4% versus 9.9%; p<0.0001). The 30-day mortality for patients undergoing a combined vascular procedure was 3.5%, compared with 1.3% with free tissue transfer only (p<0.0001).

CONCLUSION

Despite the risks associated, the combined intervention decreases the very high mortality associated with limb amputation in severely sick patient populations. Careful preoperative assessment of modifiable risk factors may reduce complication rates while allowing limb salvage.

Arteriovenous Loops Enable Free Tissue Transfer With Otherwise Inadequate Local Donor and Recipient Vessels

BACKGROUND/AIM

Free flap reconstruction with damaged or diseased vessels is a challenging problem. We describe our case series using an arteriovenous loop or bypass surgery with free flaps for complex defect reconstructions at the lower extremity and the pelvic region.

PATIENTS AND METHODS

In this single-center retrospective cohort study 11 consecutive patients (mean age=73 years, range=53-88 years) were operated on, between June 2016 and August 2018. Patients were reconstructed with free gracilis flaps (n=8), free latissimus dorsi flap (n=1) and chimeric scapular flap (n=1), respectively.

RESULTS

The mean loop length was 30 cm (range=12-40 cm). The loop/bypass revision rate was 27% (3/11), and the overall flap loss rate was 20% (2/10). After a mean follow-up time of 17 months (range=12-24 months), the limb salvage rate was 75% (6/8).

CONCLUSION

We successfully reconstructed complex defects with poor recipient vessels using arteriovenous loops or bypass surgery and free flaps.

Early Results of Supporting Free Flap Coverage of Mangled Lower Extremities with Long Saphenous Arteriovenous Loop Grafts

BACKGROUND

The ability to salvage the mangled lower extremity is both technically challenging and time consuming. It requires the collaborative efforts among multiple surgical specialties in addition to comprehensive post-traumatic wound follow-up. Our institution has integrated a dynamic effort among these specialists in the planning and facilitating a successful limb salvage program with creation of a mangled extremity algorithm. An integral part in this process is the vascular inflow to prepare coverage for large tissue defects lacking adequate recipient targets. Utilization of long saphenous arteriovenous (AV) loop has been cited with minimal data available using larger inflow vessels in the acute trauma setting. We performed a retrospective review and describe our early experience using our protocol with AV loop creation with free flap reconstruction to salvage traumatic leg injuries. Using the data, we sought to develop a mangled extremity protocol for trauma centers to guide mangled limb salvage.

METHODS

Since June 2016, 398 patients were admitted to our level II trauma facility with isolated traumatic wounds to the lower extremities. Thirty-one limbs were deemed mangled in which 21 received primary amputations due to multiple factors. Ten patients admitted from the trauma service with isolated mangled lower extremities injuries were identified for review. All 10 patients sustained severe crush injuries with large soft tissue defects and decreased perfusion for healing but deemed salvageable by multispecialty assessment. Mangled extremity severity scores were tabulated. Patients age ranged from 21-44 years, with 8 men and 2 women. Repeated debridements until successful sterilization of the wounds were accomplished. Ten long saphenous vein AV loops were anastomosed to the at or above knee popliteal vessels for free flap reconstruction. All patients were followed post-AV loop creation for vascular complications and wound assessments.

RESULTS

All 10 patients had sterilization of the wounds with repair of the fracture site before vascular reconstruction. Mean debridement to surgical site sterilization was 4.3 washouts (range 2-7). Successful AV loop creation with long saphenous vein was completed in 100% of patients without vascular complications nor steal events. Free flap tissue transfers directly connected to the loop were completed using 6 rectus abdominis, 3 latissimus dorsi, and 1 anterior thigh graft within 10 days of its creation. Patency rates of the AV loop was 100% with 10 successful flap transfers and 90% amputation free survival. One flap did not survive due to recurrent bacterial infection of the hardware. The 9 patients with successful procedures reached preoperative ambulatory status within 3 months after their final surgery. At 24 months follow-up, 90% amputation free survival is still maintained.

CONCLUSIONS

Although a small patient cohort, utilization of long saphenous vein AV loop is successful as a bridge to free flap transfer for isolated mangled lower extremities. Development and incorporation of our mangled extremity protocol to guide limb salvage has proven successful in our early experience. Long-term data need to be complied to assess patency of the free flap transfer and quality of life outcomes.

Wound closure by means of free flap and arteriovenous loop: Development of flap autonomy in the long-term follow-up

Free flaps in combination with arterial reconstruction by means of arteriovenous loops or bypass have, meanwhile, been established as a therapeutic option in defect reconstruction for areas without recipient vessels. Our aim was to analyse the long‐term performance, flap autonomy, and the flap perfusion. Patients receiving this combined reconstruction at a single‐centre institution were included. During follow‐up examination, the patency of arterial reconstruction was investigated by duplex ultrasound. Flap micro‐circulation was assessed by laser Doppler flowmetry and white light tissue spectrometry (O2C) as well as by indocyanine green fluorescence angiography. Twenty‐three patients could be clinically followed up. Duplex ultrasound showed, in four cases, arterial pedicle occlusion in spite of vital flap. Comparison of the O2C perfusion parameters between flaps with occluded pedicles and those with intact inflow showed no significant difference (parameters sO2: P = .82; Flow: P = .31). Similar results were obtained by fluorescence angiography; no significant difference could be detected between both groups (parameters Ingress P = .13; Ingressrate P = .54). Combined vascular reconstruction with free tissue transfer is associated with a good long‐term outcome and wound closure. Even after flap transplantation to areas with critical tissue perfusion, the flap can develop autonomy and thus survive after pedicle occlusion.

Tissue Engineering of the Microvasculature

The ability to generate new microvessels in desired numbers and at desired locations has been a long-sought goal in vascular medicine, engineering, and biology. Historically, the need to revascularize ischemic tissues nonsurgically (so-called therapeutic vascularization) served as the main driving force for the development of new methods of vascular growth. More recently, vascularization of engineered tissues and the generation of vascularized microphysiological systems have provided additional targets for these methods, and have required adaptation of therapeutic vascularization to biomaterial scaffolds and to microscale devices. Three complementary strategies have been investigated to engineer microvasculature: angiogenesis (the sprouting of existing vessels), vasculogenesis (the coalescence of adult or progenitor cells into vessels), and microfluidics (the vascularization of scaffolds that possess the open geometry of microvascular networks). Over the past several decades, vascularization techniques have grown tremendously in sophistication, from the crude implantation of arteries into myocardial tunnels by Vineberg in the 1940s, to the current use of micropatterning techniques to control the exact shape and placement of vessels within a scaffold. This review provides a broad historical view of methods to engineer the microvasculature, and offers a common framework for organizing and analyzing the numerous studies in this area of tissue engineering and regenerative medicine. © 2019 American Physiological Society. Compr Physiol 9:1155-1212, 2019.

Ipsilateral Arteriovenous Loop and Latissimus Dorsi Free Flap for Knee Reconstruction in an Elderly Patient: A Case Report

Herein, we report an unusual indication of an arteriovenous (AV) loop with a latissimus dorsi free flap after wound-edge necrosis in an 81 year old patient. The patient underwent multiple revision procedures after total knee arthroplasty and total hip arthroplasty. After a dramatic reduction of femoral bone, a total femoral replacement was performed. The lateral knee incision wound was broke down and the hardware became exposed. Local flaps were not available and a free flap with an ipsilateral AV loop from the great saphenous vein was used to cover the large defect. The functional status of the hip and knee joints was good after 6 months, and enough the patient was able to ambulate without any assistance. The patient did not show any signs of infection.

ROLE OF ARTERIOVENOUS VASCULAR LOOPS IN MICROSURGICAL RECONSTRUCTION OF THE EXTREMITIES

Objective:

To analyze 10 consecutive cases of microsurgical arteriovenous loops created to reconstruct complex injuries from March 2011 to May 2012.

Methods:

This observational cohort-type study conducted by the Hand and Microsurgery Group at the HC-FMUSP included patients who were candidates for microsurgical reconstruction as a last alternative to amputation of the limb with proven absence of adequate recipient vessels for primary microsurgical anastomosis, in a prospective and consecutive manner. We analyzed 14 variables (epidemiological, clinical, procedure-related, and outcome) in patients who underwent reconstruction using an arteriovenous loop utilizing a single-stage or two-stage procedure.

Results:

The injuries were mostly traumatic (80%). The success rate of the single-stage procedure was 75%, and 17% for the two-stage procedure. The rate of preservation for the injured limb was 44%.

Conclusion:

This study reinforces the more recent understanding that the indication for single-stage or two-stage reconstruction should be individualized; our findings favor the single-stage reconstruction. This technique should be used in selected cases, as a last reconstructive alternative before amputation, and further studies are necessary to confirm its safety and efficacy in our practice. Level of Evidence IV; Case series.

A New Pedicled Internal Mammary Osteomyocutaneous Chimeric Flap (PIMOC) for Salvage Head and Neck Reconstruction: Anatomic Study and Clinical Application

Well-vascularized composite tissue offers improved outcomes for complex head and neck reconstruction. Patients with vessel-depleted necks and failed reconstructions require alternative reconstructive options. We describe a pedicled internal mammary artery osteomyocutaneous chimeric flap (PIMOC) for salvage head and neck reconstruction. Bilateral dissections of 35 fresh cadavers were performed to study individual tissue components and vascular pedicles to develop the PIMOC technique. The flap was then utilized in a series of patients with vessel-depleted neck anatomy. The PIMOC was dissected bilaterally in all cadavers and there were no statistical differences in vascular pedicle caliber or length with regards to laterality or gender. Five patients subsequently underwent this procedure. The flaps included a vertical rectus abdominis myocutaneous component and a 6^th or 7^th rib with adjacent muscle and skin to restore bone defects, internal lining, and external coverage. All donor sites were closed primarily. There were no flap losses and all patients gained improvements in facial contour, speech and swallow. Although technically complex, the PIMOC is reproducible and provides a safe and reliable option for salvage head and neck reconstruction. The harvest of the 6^th or 7^th rib and rectus abdominis muscle renders an acceptable donor site.

Free flaps in scar treatment

Introduction:

Scar management needs defined concepts and an algorithm to restore functional and aesthetic units. After an unsuccessful conservative treatment, surgical measures provide a vast spectrum of possibilities for remediation. The spectrum of possibilities consists of excision and Z-plasty, regional flaps, vascularized pedicled flaps, tissue expansion, and finally free tissue transfer. Severe scarring and highly destructed tissues with inferior functional and aesthetic units can be effectively treated with radical excision and free flap reconstruction. The complexity of flap architecture and tissue qualities allows for an individualized approach. Specific attention should be paid to the long-term consequences of severe scarring with progressive loss of functionality.

Materials and methods:

We worked out the most common surgical approaches and treatment algorithm for a stepwise and effective approach. Part of this algorithm is a seven-step surgical approach.

Results:

This article provides modern plastic and reconstructive surgery concepts with an algorithm for scar management.

Discussion:

The treatment of scars follows an algorithm with the level of complexity of techniques adjusted to the individual case and the conditions. Disabilities induced by scarring can lead to further functional loss. In these cases, surgical strategies have to be considered.

Extending the limits of the anterior tibial artery as the recipient vessel for around the knee and proximal lower extremity defect reconstruction using the free anterolateral thigh and gracilis flap

PURPOSE

The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end-to-end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps.

PATIENTS AND METHODS

Between March 2009 and May 2014, 22 patients undergoing lower extremity reconstruction were evaluated. Of those, 4 patients were included. The locations of injury were 3 defects around the knee and 1 defect at the proximal and middle third of the lower leg (mean defect size 18 x 8.5 cm and a range of 17-20 x 5-10 cm). There were 2 cases after trauma and 2 cases with infection. Two free gracilis and 2 free ALT flaps were performed of equal size to the defects. The mean flap pedicle length was 11 cm (range of 7-16 cm) and the mean length of the mobilized recipient vessels was 10.5 cm (range of 6-14 cm).

RESULTS

One flap loss (ALT) occurred, requiring a salvage procedure with a latissimus dorsi flap, whereas wound dehiscence at the donor site and a hematoma below the ALT flap was observed in 2 cases, requiring small revision. After a mean follow-up of 52 months (range of 38-87 months), there was stable soft tissue coverage in all patients.

CONCLUSION

By orthograde dissection of the ATA, an adequate vessel length and size may be achieved, improving arc of rotation to successfully cover more distant defects.

Plastic reconstructive surgery techniques for defect coverage of extended skull base defects

BACKGROUND AND AIM

Large skull base defects are extremely difficult to treat and have a severe impact on patients' physical appearance and functional aspects. These extensive defect zones are mainly caused by trauma, surgical interventions, or wide tumor excision. High-level microsurgical techniques are necessary to provide sufficient treatment. The aim of this study is to describe successful reconstructive strategies for surgical treatment.

METHODS

Nine patients with skull base defects were treated in our department from 2008 to 2014 (n = 9). Plastic surgical reconstruction was performed with latissimus dorsi (LD;) (n = 4), LD-scapula flaps (n = 2), vertical rectus abdominis myocutaneous (VRAM) flaps (n = 2), and a greater omentum flap (n = 1). The mean follow-up period was 2.3 ± 2.2 years (0.5-4.5 years). Oncologic diseases (8 patients) and iatrogenic damage (1 patient) caused the massive skull base defects.

RESULTS

In all cases, we achieved the final surgical treatment of large skull base defects by free flaps with permanent wound closure. The mean operating time was 5:53 h (range 4:45-7:52 h). The primary outcome measures were survival and sufficient defect coverage. Flap survival rate was 100%, and none of the patients deceased during the follow-up period. Furthermore, we demonstrated the surgical key points of LD-scapula flap closure in detail.

CONCLUSION

Plastic surgical defect coverage by well-perfused tissue flaps of large skull base defects provides an efficient and effective treatment option. Complex skin, soft tissue, and dural defects can be successfully covered with these preformed free flaps. The choice of flap is based on the individual case.

[Free latissimus dorsi flap transfer for reconstruction of soft tissue defects of the lower extremity]

OBJECTIVE

Sustainable and durable soft tissue coverage at the lower extremity following trauma, tumor resections, sequelae of radiation therapy or osteomyelitis using free latissimus dorsi muscle transfer is provided by a free latissimus dorsi muscle flap.

INDICATIONS

Soft tissue defects at the lower extremity following trauma, tumor resections, and sequelae of radiation therapy or osteomyelitis.

CONTRAINDICATIONS

Thoracotomy with incision of the latissimus dorsi muscle; a relative contraindication in wheelchair drivers as well as in overhead athletes due to potential diminished strength and shoulder proprioception following latissimus dorsi muscle transplantation.

SURGICAL TECHNIQUE

Under general anesthesia the patient is positioned laterally, and a substantial and meticulous debridement of the defect is performed, as is the identification and preparation of the target vessel, which is preferentially the posterior tibial artery at the calf, or more proximally the popliteal or femoral artery from the medial side as well as concomitant veins/the great saphenous vein. A tailored latissimus dorsi musculocutaneous flap is harvested with subsequent microsurgical anastomosis to the target vessel with preferential end-to-side anastomosis of the artery and end-to-end anastomosis of one or two veins.

POSTOPERATIVE MANAGEMENT

A 24-h intermediate care unit, clinical flap monitoring for at least 5-7 days, dangling of the flap using an elastic bandage for an initial 3  times  5 min starting on POD 7, compression stockings for at least 6 months subsequently.

RESULTS

From 2001-2007 75 free latissimus dorsi flaps were performed (53 ± 17 years) for soft tissue coverage at the lower extremity. In 58% the target vessel was the posterior tibial artery, in 11% the femoral artery, in 8% the anterior tibial artery and in 8% the popliteal artery. In 15% an arteriovenous (AV) loop was applied. Overall free flap survival was 95%. We encountered four total flap losses, exclusively in complex reconstructions with AV-loop situations.

Anticoagulative strategies in reconstructive surgery--clinical significance and applicability

Advanced strategies in reconstructive microsurgery and especially free tissue transfer with advanced microvascular techniques have been routinely applied and continously refined for more than three decades in day-to-day clinical work. Bearing in mind the success rates of more than 95%, the value of these techniques in patient care and comfort (one-step reconstruction of even the most complex tissue defects) cannot be underestimated.

However, anticoagulative protocols and practices are far from general acceptance and – most importantly – lack the benchmark of evidence basis while the reconstructive and microsurgical methods are mostly standardized.

Therefore, the aim of our work was to review the actual literature and synoptically lay out the mechanisms of action of the plethora of anticoagulative substances.

The pharmacologic prevention and the surgical intervention of thrombembolic events represent an established and essential part of microsurgery. The high success rates of microvascular free tissue transfer as of today are due to treatment of patients in reconstructive centers where proper patient selection, excellent microsurgical technique, tissue transfer to adequate recipient vessels, and early anastomotic revision in case of thrombosis is provided. Whether the choice of antithrombotic agents is a factor of success remains still unclear. Undoubtedly however the lack of microsurgical experience and bad technique can never be compensated by any regimen of antithrombotic therapy. All the more, the development of consistent standards and algorithms in reconstructive microsurgery is absolutely essential to optimize clinical outcomes and increase multicentric and international comparability of postoperative results and complications.

[The carotid artery as recipient vessel: troubleshooting for free jejunal transfer after esophagectomy in preradiated patients]

BACKGROUND

In the treatment of esophageal cancer neoadjuvant radiotherapy often leads to vascular damage of the usual recipient arteries for free jejunal transfer. End-to-side anastomosis to the carotid artery could be a potential alternative.

PATIENTS AND METHODS

A total of 70 patients with locally advanced carcinoma of the esophagus underwent esophagectomy after neoadjuvant radiochemotherapy. In all patients reconstruction was carried out with a free jejunal transfer. Smaller vessels could be used for anastomoses in 54 of these patients and in 16 cases the jejunal flap artery was attached to the carotid artery.

RESULTS

Out of 54 patients 9 (17%) with microvascular anastomoses to the smaller vessels needed surgical intervention for ischemia. In 16 patients with anastomosis to the carotid artery no significant failure of perfusion occurred.

CONCLUSION

The carotid artery as recipient vessel in free jejunal transfer seems to be a safe therapeutic option for intestinal reconstruction of preradiated esophageal cancer with good functional results.

Limb salvage in malignant tumors

Limb-sparing resection and reconstruction has become the treatment of choice in extremity malignancies, as amputation does not provide better long-term survival rates or functional advantages. R0 resection, the removal of the tumor in sano, remains the prerequisite and most important oncologic parameter to avoid local recurrence. Successful treatment requires the combination of surgical eradication and the patient's specific functional and aesthetic rehabilitation. Our clinical rationale resulting from more than 2000 cases will be demonstrated. The problematic aspects of different tumor entities and the locoregional clearance of lymphatic pathways will be discussed. Differential diagnosis and multimodality treatment in high-volume tumor centers is likely to achieve superior oncologic statistics. Long-term survivors after microsurgical reconstructions and possible secondary malignancies will be addressed.

[Postoperative complications in plastic surgery]

Plastic surgery covers a broad spectrum of diseases and conditions in the areas of reconstructive surgery, hand, burn and aesthetic surgery. Besides acquired defects or malformations an increasing number of patients are being treated for surgical or multimodal complications. In a considerable number of patients plastic and reconstructive surgery remains the only therapeutic alternative after other therapy has failed. Therefore complication management in plastic surgery is of utmost importance for a successful outcome. In addition patient expectations in the results of plastic surgery as a discipline of invention and problem solving are steadily increasing. This challenge is reflected in clinical patient management by intensive research in tissue engineering and regenerative medicine. Patients in plastic surgery are recruited from all age groups of either gender, involving traumatic and oncologic as well as congenital and aesthetic disorders. The demographics of aging, multimorbidity and obesity pose new challenges to plastic surgery. Although age over 70 years is not an independent risk factor per se for complications in plastic surgery, e.g. for complex free flap transfer, medical problems are present at a higher rate, which is to be expected in this age group. Risk factors such as alcoholism and coronary heart diseases seem to be independent predictors of perioperative complications. Therefore older patients can also benefit from plastic surgery and recurrent operations by the corresponding risk and complication management. Complication management necessitates careful patient selection, estimation of operative risks and patient-adapted selection of procedures. In addition to expertise in plastic surgery a thorough knowledge of non-surgical and surgical back-up procedures for technical incidents as well as vascular circulatory and wound healing disorders is required to deal successfully with complications in plastic surgery. This article presents these specific aspects of postoperative complication management in plastic surgery.