Early Mobilization after Free-flap Transfer to the Lower Extremities: Preferential Use of Flow-through Anastomosis

Impact Assessment of Pituitary Adenylate Cyclase Activating Polypeptide (PACAP) and Hemostatic Sponge on Vascular Anastomosis Regeneration in Rats

The proper regeneration of vessel anastomoses in microvascular surgery is crucial for surgical safety. Pituitary adenylate cyclase-activating polypeptide (PACAP) can aid healing by decreasing inflammation, apoptosis and oxidative stress. In addition to hematological and hemorheological tests, we examined the biomechanical and histological features of vascular anastomoses with or without PACAP addition and/or using a hemostatic sponge (HS). End-to-end anastomoses were established on the right femoral arteries of rats. On the 21st postoperative day, femoral arteries were surgically removed for evaluation of tensile strength and for histological and molecular biological examination. Effects of PACAP were also investigated in tissue culture in vitro to avoid the effects of PACAP degrading enzymes. Surgical trauma and PACAP absorption altered laboratory parameters; most notably, the erythrocyte deformability decreased. Arterial wall thickness showed a reduction in the presence of HS, which was compensated by PACAP in both the tunica media and adventitia in vivo. The administration of PACAP elevated these parameters in vitro. In conclusion, the application of the neuropeptide augmented elastin expression while HS reduced it, but no significant alterations were detected in collagen type I expression. Elasticity and tensile strength increased in the PACAP group, while it decreased in the HS decreased. Their combined use was beneficial for vascular regeneration.

Parallelogram Excision: An Algorithmic Approach for Excision Designs in High-Tension Skin Areas

INTRODUCTION

The excision of lesions that are not oriented along the skin tension lines may cause the surgeon to design extremely broad elliptical preoperative markings, with the intent to follow the tension lines as recommended for the best postoperative course and the best quality scars. The aim of this study is to describe and clinically apply a new surgical technique called the parallelogram excision technique, in which the traditional ellipse with a major axis parallel to the tension lines is converted into a parallelogram whose lesser sides are coincident with the local skin tension lines. This technique was specifically conceived for lesions whose major axis is non-coincident with skin tension lines, and the primary advantage is that it reduces the amount of healthy tissue excised.

METHODS

Preliminarily to this clinical study, a comparative geometrical analysis was conducted between various excision shapes and angles using Geometry Pad version 2.7.10 (Bytes Arithmetic LLC) and verifying the data obtained through AutoCAD 2D 2016 (Autodesk, San Rafael, CA, USA), with the purpose of optimizing the technique from a geometrical point of view. A comparison was performed between the theoretical traditional elliptical excision and the hypothetical parallelogram excision. A pilot proof of concept clinical study was performed to verify the validity of the excisional design proposed. The patients considered for parallelogram excision suffered from skin lesions with a diameter no greater than 4 cm and oriented 45° to 60° with respect to tension lines. In order to limit variability, patients' ages were between 40 and 80, and the selected areas were limbs, sternum and dorsum. Scar quality was assessed with the validated POSAS method at 6 months post-operation.

RESULTS

The geometrical analysis of the parallelogram's design showed that it allows a diminution of the excised healthy skin compared to the traditional ellipse. The clinical series included 16 patients, with a mean age of 63.5. Of these, nine patients were men and seven were women. Diagnoses included basal cell carcinoma in seven cases, dysplastic naevus in five patients, Bowen's disease in three individuals, and one case where a wider excision of a malignant melanoma was performed. Six-month follow up results showed: (1) an uneventful postoperative course; (2) good scar healing with an observer's POSAS median score of 16 and a patient's POSAS median score of 19; and (3) complete excision of lesions.

CONCLUSIONS

When indicated, the parallelogram excision technique appears to be a good option for the excision and primary closure of skin lesions that are not parallel to skin tension lines, since it allows a reproducible and surgeon-friendly method of preoperative marking and implies a favorable use of the local tension, which determines good quality scars. The amount of healthy tissue removed is smaller compared to traditional elliptic excisions.

Tissue Oximetry Changes during Postoperative Dangling in Lower Extremity Free Flap Reconstruction: A Pilot Study

Background: Lower extremity free flap dangling protocols are still widely practiced, despite a paucity of evidence for their use. This pilot study investigates the use of tissue oximetry to provide further insight into the physiological effect of postoperative dangling in lower limb free flap transfer. Methods: Ten patients undergoing lower extremity free flap reconstruction were included in this study. Free flap tissue oxygen saturation (StO₂) was continuously measured using non-invasive near-infrared spectroscopy. Measurements were performed on the free flap and contralateral limb during dangling from postoperative day (POD) 7 until 11, according to the local dangling protocol. Results: StO₂ values measured in the free flap diminished to 70 ± 13.7% during dangling. This minimum StO₂ was reached significantly later, and correspondingly the area under the curve (AUC) was significantly larger on POD 11 compared to the start of the dangling protocol on POD 7, reflecting an improving free flap microvascular reactivity. The dangling slope was equal between the free flap and contralateral leg. The reperfusion slope was significantly flatter on POD 7 compared to the other PODs (p < 0.001). Thereafter, no significant differences between PODs were observed. Patients with a history of smoking had significantly lower tissue oximetry values compared to non-smokers. Conclusions: The application of tissue oximetry during dangling provides further insight into the physiological effect (i.e., changes in microcirculatory function) of the free flap of the reconstructed lower extremity. This information could potentially be useful to either revise or disrupt the use of such dangling protocols.

Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction

Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.

Nasal alar reconstruction using the free auricular helix flap based on the flow-through concept: Report of two cases

Nasal alar reconstruction with the free auricular helix flap is challenging because the flap is prone to congestion. We report two cases of successful nasal alar reconstruction using free auricular helix flaps utilizing the flow-through concept. Case 1 was a 37-year-old man presented with a basal cell carcinoma in the nasal cavity. After radical excision, we transferred a 20 × 20 mm² free flow-through auricular helix flap by interposing the T-portion of the superficial temporal artery of the flap to the transected facial artery. Case 2 was a 39-year-old man presented with neurofibromatosis type I and a nasal alar deformity after multiple excision of the neurofibroma. We corrected the deformity with a 26 × 22 mm² free auricular helix flap. We used a flow-through arterial graft of the descending branch of the lateral circumflex femoral artery to bridge the gap between the flap artery and the recipient facial artery of the submandibular region because an appropriate recipient artery was not available around the defect. Both of the flaps survived without vascular compromise and no donor-site complication occurred. The esthetic results of the nasal ala were satisfactory. The flow-through arterial anastomosis diverted the arterial flow to the peripheral side of the recipient artery and relieved flap congestion. These physiological properties of flow-through anastomosis may stabilize the flap circulation and improve the success rate of free auricular helix flap transfer.

Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

BACKGROUND

Complex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy.

METHODS

Between January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up.

RESULTS

All 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm². The flap sizes ranged from 14 × 7.5 to 24 × 21 cm². The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed.

CONCLUSIONS

The modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.

Repair of Compound Dorsal Defects of the Digits Using a Free Antegrade Palmaris Longus Tendocutaneous Venous Flap

PURPOSE

To investigate the clinical effect of repairing small dorsal digit compound tissue defects using a free palmaris longus tendocutaneous flap nourished by venous blood.

METHODS

In a retrospective analysis of patients treated between March 2010 and October 2017, 18 patients were identified as having small compound tissue defects, which were repaired using a free palmaris longus tendocutaneous flap nourished by venous blood. The average age of the patients, including 15 male and 3 female patients, was 34 years (range, 22-55 years). The mean wound size was 6 cm² (range, 2.0 × 1.5 to 3.5 × 2.0 cm²). All the patients had dorsal defects. The average length of extensor tendon defect was 2.0 cm (range, 1.0-3.0 cm). The mean area of the flap was 7 cm² (range, 2.5 × 2.0 to 4.0 × 3.5 cm²). The donor sites were primarily closed.

RESULTS

All 18 flaps survived. A vascular crisis due to a venospasm occurred within 48 hours in 3 flaps, but ultimately, all the flaps survived. The patients were followed-up for a mean period of 10 months (range, 3-15 months). All the patients returned to their previous work after 10-12 weeks. No pain or scar contracture was reported in either the recipient or donor site.

CONCLUSIONS

The free antegrade palmaris longus tendocutaneous venous flap enabled the repair of compound tissue defects of the dorsal digit, resulting in acceptable aesthetics, repaired tendon defects, and wound coverage. This surgical method is an option for the reconstruction of small compound defects of digits with extensor defects.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A Quantitative Evaluation of the Flow-Increasing Effect of Flow-Through Arterial Anastomosis in the Vascular Pedicle of Free Flaps: A Prospective Clinical Before-and-After Study

BACKGROUND

The clinical application of flow-through anastomosis has been reported in various studies; however, no studies have quantitatively evaluated and compared the actual hemodynamics in flow-through anastomosis and end-to-end anastomosis. This study quantitatively evaluated the blood inflow (volumetric flow rate) and vascular resistance (pulsatility index) of flow-through arterial anastomosis using an ultrasonic flowmeter, and compared these values with those of end-to-end anastomosis in actual clinical settings. In addition, factors affecting the outcomes have also been examined.

METHODS

Twenty-eight patients who underwent free flap reconstruction after tumor resection were subjected to flow-through arterial anastomosis and flow examination. First, in the end-to-end state, the proximal anastomotic site was measured. This was followed by the opening of the distal arterial clamp, and measurement was then continued (in the flow-through state).

RESULTS

In flow-through arterial anastomosis compared with end-to-end anastomosis, the volumetric flow rate was significantly increased (18.9 ± 14.1 ml/minute versus 6.0 ± 6.3 ml/minute) and the pulsatility index was significantly decreased (5.2 ± 3.7 versus 13.6 ± 10.2), when comparing paired data. Multiple regression analyses revealed that a perforator flap (versus a musculocutaneous flap) was independently associated with both reduced volumetric flow rate and increased pulsatility index in end-to-end anastomosis, and that hypertension was independently associated with an increased pulsatility index in end-to-end anastomosis. However, no factors in flow-through anastomosis were significantly associated with those values.

CONCLUSION

In terms of blood flow and vascular resistance, flow-through arterial anastomosis was considered to have promising quantitative effects and should be performed when the conditions of both the donor and recipient vessels meet the requirements.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Qualitative and Quantitative Analyses of Donor Site Morbidity Following a Graft of the Acellular Dermal Matrix Versus Primary Fascial Repair After ALT Flap Harvesting

Background

The anterolateral thigh (ALT) flap is one of the most useful flaps in reconstruction because of its reliability, large skin flap territory, and versatility. The relatively small number of side effects is a common reason for preferring this flap. Primary repair is usually performed at the donor site closure; however, this requires substantial tension and causes many donor site morbidities, including pain. We attempted to use acellular dermal matrix graft to overcome these problems.

Methods

We analyzed a total of 41 cases (41 flaps) in this study. Among these flaps, we conducted donor fascia suture with artificial dermis in 20 cases (study group) and primary fascial suture in 21cases (control group). Post-operative ambulation recovery times, pain scores, drainage removals, and wound problems of the donor site were recorded.

Results

There were no serious complications, including infection, at the donor sites of all 41 cases. Of 20 cases using the acellular dermal matrix, seroma occurred in 2 cases and partial skin necrosis occurred in 2 cases. In 1 case of skin necrosis, the acellular dermal matrix was removed. However, in comparison to the control group, the group using the artificial dermis recovered ambulatory ability 3.9 days earlier and had a 1.8-point lower visual analogue scale score 5 days post-operatively.

Conclusions

Our study suggested that, if used selectively, the acellular dermal matrix may play an effective role in donor site closure in cases with procedures involving the ALT flap.

Dangle Protocols in Lower Extremity Reconstruction

INTRODUCTION

Dangling protocols are known to vary by surgeon and center, and their specific regimen is often largely based on single surgeon or institutional experience. A systematic review was conducted to derive evidence-based recommendations for dangling protocols according to patient-specific and flap-specific considerations.

METHODS

A systematic review was performed using PubMed, Embase-OVID and Cochrane-CENTRAL. Study design, patient and flap characteristics, protocol details, dangling-related complications, and flap success rate were recorded. Studies were graded using the Oxford Center for Evidence-Based Medicine Levels of Evidence Scale. Data heterogeneity precluded quantitative analysis.

RESULTS

Eleven articles were included (level of evidence (range):IIb-IV; N (range):8-150; age (range):6-89). Dangling initiation, time, and frequency varied considerably. Flap success rate ranged from 94 to 100%. Active smoking, diabetes, and hypertension are associated with characteristic physiologic changes that require vigilance and potential protocol modification. Early dangling appears to be safe across a variety of free flap locations, sizes, and indications. Axial fasciocutaneous flaps may tolerate more aggressive protocols than muscular flaps. While flaps with single venous anastomosis tolerate dangling, double venous or flow-through anastomoses may provide additional benefit. Major limitations included small sample sizes, uncontrolled study designs, and heterogeneous patient selection, dangling practices, monitoring methods, and outcome measures.

CONCLUSIONS

Significant heterogeneity persists in postoperative dangling protocols after lower extremity microvascular reconstruction. Patient comorbidities and flap characteristics appear to affect tolerance to dangling. We propose two different standardized pathways based on risk factors. Clinical vigilance should be exercised in tailoring lower extremity protocols to patients' individual characteristics and postoperative course.

Importance of Postoperative Use of External Warming Devices in Flap Reconstructive Surgery

Flap failure, partial or complete, can have great negative impact on the patient and the reconstructive outcome. The effect of thermal regulation on flap survival is well recognized. This article focuses on the importance of external warming devices as a standard on postoperative flap care to avoid any temperature-related vascular compromise. PubMed, Medline, and EMBASE search had been performed. More than 60 papers have been reviewed. Out of them, that 29 references have been included in this review. The authors emphasize on the importance of strict postoperative flap temperature control with active warming devices as a standard of practice to minimize any related microcirculatory changes.

Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity

Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.

Canadian Postoperative Dependency Protocols Following Lower Limb Microvascular Reconstruction: A National Survey and Literature Review

Introduction

Microsurgical free tissue transfer for lower limb reconstruction presents unique challenges in the postoperative period where dependency promotes interstitial fluid diffusion and reduced tissue perfusion. Management of flap edema, venous congestion, and ischaemic conditioning is critical for flap survival. Little evidence exists to guide postoperative protocols in the initiation and progression of lower extremity dangle, monitoring, and anticoagulation. We aim to describe current trends for postoperative dependency protocols by surveying Canadian microsurgeons.

Methods

Plastic surgeons performing lower limb microvascular reconstruction at Fellow of The Royal College of Surgeons of Canada approved teaching institutions were administered a 17-question anonymous electronic survey. A literature review was conducted to identify protocols and consensus opinions in other jurisdictions.

Results

All respondents (n = 16) monitored flaps clinically, with conventional Doppler used by 13 respondents. Anticoagulation was employed by 15 of 16 respondents, and 9 of 16 used 2 or more agents. The most common agents were aspirin, followed by low-molecular-weight heparin. Significant variability existed in dangling protocols. Dependency was initiated at postoperative day (POD) 3 to 10 (mean POD: 6 ± 1.64 standard deviation), with intervals ranging from 5 to 20 minutes and frequencies ranging from 1 to 6 times per day. Nearly half allowed both increasing duration and frequency of dependency. Flap success rates were above 90%, and the median length of stay was 10 to 12 days.

Conclusion

While flap success rates across the country are similar, no consensus exists for postoperative dependency protocols amongst Canadian microsurgeons. Prospective randomised controlled trials are warranted to evaluate early aggressive dependency protocols to reduce length of stay and cost.

Reconstruction for Severe Extracorporeal Membrane Oxygenation-induced Ischemic Lower Limb Injury Complicated by Osteomyelitis

Summary: Extracorporeal membrane oxygenation (ECMO) is a well-established mechanical circulatory support system used in patients with life-threatening cardiopulmonary conditions. However, severe complications associated with vascular access require consideration. We report a patient with fatal ventricular arrhythmia who was successfully resuscitated with ECMO but who developed severe lower limb ischemia, which resulted in compartment syndrome. Even with emergent fasciotomy, tissue necrosis developed in wide areas of the limb, with subsequent tibial osteomyelitis. After extensive debridement and tibial sequestrectomy, the soft tissue and bone defect were simultaneously reconstructed with free tissue transfer of the latissimus dorsi muscle and scapular tip composite flap. The limb was successfully salvaged with satisfactory functional outcomes without major complications. This report discusses limb reconstruction for ECMO-induced compartment syndrome and illustrates the importance of appropriate selection of reconstruction methods among various composite flaps.

Investigating Lower Limb Hemodynamics during Flap Training Regimens and Patient-led Isometric Contraction Protocols

Supplemental Digital Content is available in the text.

The evidence for lower limb flap (LLF) training regimens is equivocal. The commonest cause of LLF failure is venous congestion. The aim of this study was to investigate whether venous congestion could be reduced by patient-led isometric calf contractions during flap training. A prospective clinical study was conducted using photospectroscopy and laser Doppler (Oxygen to See) to assess healthy limbs and LLF characteristics during flap training and isometric calf contractions. Tissue oxygen saturation, venous congestion, and blood flow were measured at rest, as well as during and after limb dangling and calf contraction exercises. In the acute postoperative period following LLF surgery, dependency markedly reduced superficial flow (−55.20% ± 19.17%), with a concurrent increase in venous congestion (33.80% ± 28.80%); supine isometric contractions improved superficial flow and reduced venous congestion from postoperative day 5. Contractions cause a significant increase in blood flow in the outpatient cohort (+84.40% ± 7.86%, P = 0.009), with a mean time since discharge of 14 weeks. Our data suggest patient-led isometric calf exercises are well tolerated and may reduce venous congestion in the acute phase. Progressive changes toward normal physiological function were demonstrated in the outpatient rehabilitation period. Incorporating calf exercises into LLF rehabilitation may allow longer periods of leg dependency, quicker recovery from surgery, and ultimately improve outcomes.

The experience of the free superficial palmar branch of the radial artery perforator flap application

PURPOSE

The purpose of this study is to retrospect and summarize clinical efficacy and experience of the free perforator flap base on the superficial palmar branch of the radial artery for tissue defect reconstruction in hand.

METHOD

17 patients who underwent tissue defect in hands reconstruction by the free superficial palmar branch of the radial artery (SPBRA) perforator flaps in our department from July 2014 to October 2018 were reviewed.

RESULTS

All the flaps in our series application were survival uneventful except one, which was necrosis because of venous thrombosis postoperative 5 days, and then the abdominal pedicle flap was executed to recover the defect in second stage. The first dorsal metacarpal artery flap and the arterial venous flap were utilized to cover the defect in one right index finger and one right ring finger due to the absence variation of the SPBRA. 2 cases presented tension vesicle of superficial skin and 1 case occurred venous congestion. All donor sites were closed primarily. The follow-up period means 13.5 months (range, 4-50 months). The static 2 point discrimination test mean 7.53 mm (range, 4-11 mm). All flaps acquire protective feeling at the latest follow-up. The self-assessment of patients: 13 cases in good, 4 cases in fair.

CONCLUSION

The goal of physiological reconstruction and esthetic effect can be achieved for hand tissue defect by the free SPBRA perforator flap, multiple tissues of the flap can be contained according to the defect. Even though the SPBRA is variation, arterial venous flap could be applied thanks to abundant superficial cutaneous veins.

Biodynamic Excisional Skin Tension Lines for Excisional Surgery of the Lower Limb and the Technique of Using Parallel Relaxing Incisions to Further Reduce Wound Tension

Background:

Closing of defects of the lower limb after skin cancer excision poses a challenge in lower limb skin. Although the concept of relaxed skin tension lines has been established as ideal on the face, on the lower limb there remains confusion between Langer’s lines and wrinkle lines, and this study was done with the task of identifying and mapping biodynamic excisional skin tension (BEST) lines on the lower limb.

Methods:

Following studies on BEST lines elsewhere on the body, the author investigated BEST lines on the lower limb. Using a specially designed tensiometer, inherent skin tension (pretension) and wound-closing tension were studied along with the force needed to bring the wound edges together after excision of a lesion in 23 cases with defects ranging from 1.5 to 4.5 cm in diameter. Skin tension measurements of skin lines (relaxed skin tension lines (RSTL) versus BEST) and vertical closure (BEST) versus vertical closure with a parallel relaxing incision were undertaken and followed by statistical analyses utilizing the paired t test and the unpaired Student’s t tests.

Results:

BEST lines run in the vertical direction on the lower limb, that is, closure in a vertical direction resulted in a statistically significant reduction in closing tension when compared with other directions. Using a parallel relaxing incision can offer further reduction in tension, if needed.

Conclusion:

BEST lines of the lower limb are discussed, and a new technique of using parallel relaxing incisions to achieve closure of larger defects is also presented as an alternative to cutaneous flaps or grafts in the lower limb.

Early mobilizing and dangling of the lower leg after one-stage reconstruction of Achilles tendon and overlying tissue defect using an anterolateral thigh flap with vascularized fascia lata

We have treated two patients who had an Achilles tendon and overlying tissue defect using an anterolateral thigh flap with fascia lata. Postoperatively, skeletal suspension of the affected leg and intra-arterial heparin infusion were performed for seven days. Six weeks postoperatively, the patients could walk again.

Efficacy of the postoperative management after microsurgical free tissue transfer

INTRODUCTION

The physical and medical postoperative measures after free flap reconstruction vary substantially between surgical units. The objective of this review was to identify the postoperative measures which proved a significant positive effect on free flap survival.

METHOD

A review was conducted in the MEDLINE database on the English and French literature.

RESULTS AND DISCUSSION

Twenty-eight articles were retained. A meta-analysis of 4984 patients who were given antithrombotics (viz. antiplatelets and anticoagulants) postoperatively found that these treatments were of no significant benefit to free flap survival and increased the risk of postoperative hematoma. Postoperative transfusions did not favor free flap survival and were associated with a higher incidence of medical complications. Preoperative anemia was a risk factor for free flap failure. Blood pressure control, vasodilators, antioxidants, corticotherapy, oxygen therapy, and prolonged immobilization were of no proven benefit.

CONCLUSION

No postoperative therapy, whether drug-based or not, has been shown to have a significant positive effect on free flap survival.

Effects of preserving different veins on flow-through flap survival: An experimental study

Flow-through skin flap grafting is becoming widely used for the reconstruction of skin and soft tissue defects, particularly for patients with poor blood supply around the defect. However, the treatment of the veins remains controversial. In the present study, 5×2-cm skin flaps were created on the left inner thighs of rabbits in order to investigate the effects of various treatments of the veins on the survival of a flow-through skin flap. A femoral artery perforator running through the flap was preserved. Five groups were established in which no veins, one superficial vein (SV), one accompanying vein (AV), one SV plus one AV, or all trunk veins (control) were retained. The percentage of flap area survival was determined on day 10. On days 3, 5, 7 and 9, tissues were harvested from the skin flaps and immunohistochemical analysis was performed in order to count the number of microvessels. Western blot analysis was subsequently completed in order to determine the expression levels of vascular endothelial growth factor (VEGF). The flap areas in which no veins were retained demonstrated significantly reduced survival rates on day 10, as compared with those in the other four groups (P<0.01). Furthermore, flaps with the retention of a SV also demonstrated reduced survival rates, as compared with the AV, AV plus SV and all veins groups (P<0.01); however, there no significant differences were detected between the latter three groups (P>0.05). Immunohistochemical analysis on day 3 detected a greater number of microvessels in the flaps of the control group, as compared with the flaps of the other groups. Furthermore, the AV and AV plus SV groups demonstrated a greater number of microvessels, as compared with the SV and no vein groups, and he no vein group demonstrated the fewest microvessels. No significant differences were found between the AV, AV plus SV and control groups on day 5, 7 and 9. Western blot analysis on day 5 demonstrated that the expression levles of VEGF were significantly increased in the flaps of the AV, AV plus SV and control groups, as compared with those in the SV and no vein groups. No significant differences were detected between the former three groups, and increased VEGF expression levels were detected in the flaps of the SV group, as compared with the no vein group. The flow-through flap grafts with no retained veins barely survived. Anastomosing one AV was adequate for flap survival; however, further studies are required in order to investigate the survival of flow-through flaps in more detail.

A cross flow-through pedicle free latissimus dorsi flap for high voltage electrical burns

BACKGROUND

The management of a high voltage electrical injury and lower limb salvage remains a challenging task for plastic surgeons. Reconstruction with flaps is often the only alternative to limb amputation. The purpose of this study was to present a cross flow-through pedicle free latissimus dorsi muscle flap for the salvage of severely traumatized lower limbs perfused by one remaining vessel (a single vessel lower limb) in high voltage electrical injuries.

METHODS

In this retrospective study, between 2000 and 2014, six men underwent cross-leg free Latissimus dorsi muscle flap operations for limb salvage. They had soft tissue lower leg defects due to high voltage electrical injuries. Their medical records were retrospectively reviewed. All had only one artery that perfused the leg. Free pedicled thoracodorsal artery latissimus dorsi flaps were harvested and connected to the contralateral posterior tibial artery.

RESULTS

All defects were successfully covered. No flap loss or major amputation occurred during follow-up (mean; 5.9 years). A computerized tomography angiogram showed intact vessel continuity in the recipient vascular system. The patients were able to walk without any apparatus or assistance after long term follow-up.

CONCLUSION

We recommend that the cross flow-through pedicle free muscle flap should be considered as a salvage procedure for single vessel lower extremities resulting from high voltage electrical burns. Extremity perfusion was not compromised by this procedure.

Impact of active thermoregulation on the microcirculation of free flaps

BACKGROUND

While it is a known fact that warming increases blood flow in healthy tissue, little is known about the impact of active thermoregulation on the altered microcirculation of free flaps. The objective of the study was to identify the impact of postoperative active thermoregulation on free flap microcirculation.

METHODS

Tissue temperature was assessed in 25 free perforator flaps using an implanted probe. Active thermoregulation was achieved using a water circulation based system. Changes in microcirculation were evaluated at the day of surgery and throughout the first three postoperative days after passive cooling (room temperature), passive warming (wound dressing), active warming (38 °C) and active cooling (15 °C) using laser Doppler flowmetry and remission spectroscopy.

RESULTS

Active warming increased flap temperature by 7.7% to 36.4 °C ± 0.5 °C in comparison to the initial values of flaps without dressing (P < 0.001). As a result, the blood flow increased by 77.7% of the base value (P < 0.001). A significant correlation between all microcirculation parameters and tissue temperature was observed with a 5.52 AU blood flow increase per degree temperature increase (r = 0.7; P < 0.001). All microcirculation parameters showed a statistically significant increase after both passive and active warming, whereby active warming showed significantly higher values than passive warming.

CONCLUSIONS

Active thermoregulation using water-based circulation is an effective and safe procedure to improve microcirculation in free flaps and is superior to conventional passive warming strategies.

Accompanying artery of sciatic nerve as recipient vessel for free-flap transfer: a computed tomographic angiography study and case reports

Suitable recipient vessels for free-flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid-thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free-flap transfer in selected patients.