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Periasamy M, Muthukumar V, Venkatramani H, Sabapathy SR. A Novel, Simple, and Reliable Technique to Monitor Free Gracilis Flap. Indian J Plast Surg 2024; 57:162-164. [PMID: 38774735 PMCID: PMC11105818 DOI: 10.1055/s-0044-1779659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024] Open
Affiliation(s)
- Madhu Periasamy
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Vamseedharan Muthukumar
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - S. Raja Sabapathy
- Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Thomas B, Falkner F, Gazyakan E, Harhaus L, Kneser U, Bigdeli AK. [The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023:10.1007/s00064-023-00806-w. [PMID: 37154965 DOI: 10.1007/s00064-023-00806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/14/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Durable and resilient soft tissue reconstruction of vast defects of the extremities or the torso. INDICATIONS Reconstruction of disproportionately large defects, particularly in cases of simultaneous bone and joint reconstruction. CONTRAINDICATIONS History of surgery or irradiation of upper back and axilla, impossibility of surgery under lateral positioning; relative contraindications in wheelchair users, hemiplegics, or amputees. SURGICAL TECHNIQUE General anesthesia and lateral positioning. First, the parascapular flap is harvested, with the initial skin incision made medially in order to identify the medial triangular space and the circumflex scapular artery. Flap raising then proceeds from caudal to cranial. Second, the latissimus dorsi is harvested, with the lateral border being dissected free first, before the thoracodorsal vessels are visualized on its undersurface. Flap raising then proceeds from caudal to cranial. Third, the parascapular flap is advanced through the medial triangular space. If the circumflex scapular and thoracodorsal vessels originate separately from the subscapular axis, an in-flap anastomosis is warranted. Subsequent microvascular anastomoses should be performed outside the zone of injury, typically in an end-to-end fashion of the vein and end-to-side fashion of the artery. POSTOPERATIVE MANAGEMENT Postoperative anticoagulation with low-molecular-weight heparin under anti-Xa monitoring (semitherapeutic in normal-risk and therapeutic in high-risk cases). Hourly clinical assessment of flap perfusion for 5 consecutive days, followed by stepwise relaxation of immobilization and commencement of dangling procedures in cases of lower extremity reconstruction. RESULTS Between 2013 and 2018, 74 conjoined latissimus dorsi and parascapular flaps were transplanted to cover vast defects of the lower (n = 66) and upper extremity (n = 8). The mean defect size was 723 ± 482 cm2 and the mean flap size was 635 ± 203 cm2. Eight flaps required in-flap anastomoses for separate vascular origins. There was no case of total flap loss.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Florian Falkner
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Emre Gazyakan
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Leila Harhaus
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland.
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Knoedler S, Hoch CC, Huelsboemer L, Knoedler L, Stögner VA, Pomahac B, Kauke-Navarro M, Colen D. Postoperative free flap monitoring in reconstructive surgery-man or machine? Front Surg 2023; 10:1130566. [PMID: 36911625 PMCID: PMC9992807 DOI: 10.3389/fsurg.2023.1130566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
Free tissue transfer is widely used for the reconstruction of complex tissue defects. The survival of free flaps depends on the patency and integrity of the microvascular anastomosis. Accordingly, the early detection of vascular comprise and prompt intervention are indispensable to increase flap survival rates. Such monitoring strategies are commonly integrated into the perioperative algorithm, with clinical examination still being considered the gold standard for routine free flap monitoring. Despite its widespread acceptance as state of the art, the clinical examination also has its pitfalls, such as the limited applicability in buried flaps and the risk of poor interrater agreement due to inconsistent flap (failure) appearances. To compensate for these shortcomings, a plethora of alternative monitoring tools have been proposed in recent years, each of them with inherent strengths and limitations. Given the ongoing demographic change, the number of older patients requiring free flap reconstruction, e.g., after cancer resection, is rising. Yet, age-related morphologic changes may complicate the free flap evaluation in elderly patients and delay the prompt detection of clinical signs of flap compromise. In this review, we provide an overview of currently available and employed methods for free flap monitoring, with a special focus on elderly patients and how senescence may impact standard free flap monitoring strategies.
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Affiliation(s)
- Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - Cosima C. Hoch
- Department of Otolaryngology, Head and Neck Surgery, Rechts der Isar Hospital, Technical University Munich, Munich, Germany
| | - Lioba Huelsboemer
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Viola A. Stögner
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
- Correspondence: Samuel Knoedler Martin Kauke-Navarro
| | - David Colen
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, Yale New Haven Hospital,New Haven, CT, United States
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Schiltz D, Lenhard J, Klein S, Anker A, Lonic D, Heidekrueger PI, Prantl L, Jung EM, Platz Batista Da Silva N, Kehrer A. Do-It-Yourself Preoperative High-Resolution Ultrasound-Guided Flap Design of the Superficial Circumflex Iliac Artery Perforator Flap (SCIP). J Clin Med 2021; 10:jcm10112427. [PMID: 34070779 PMCID: PMC8198546 DOI: 10.3390/jcm10112427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/18/2021] [Accepted: 05/26/2021] [Indexed: 11/21/2022] Open
Abstract
The superficial circumflex iliac artery perforator (SCIP) flap is a well-documented, thin, free tissue flap with a minimal donor site morbidity, and has the potential to become the new method for resurfacing moderate-size skin defects. The aim of this study is to describe an easy, reliable, systematic, and standardized approach for preoperative SCIP flap design and perforator characterization, using color-coded duplex sonography (CCDS). A list of customized settings and a straightforward algorithm are presented, which are easily applied by an operator with minimal experience. Specific settings for SCIP flap perforator evaluation were investigated and tested on 12 patients. Deep and superficial superficial circumflex iliac artery (SCIA) branches, along with their corresponding perforators and cutaneous veins, were marked individually with a permanent marker and the anatomy was verified intraoperatively. From this, a simplified procedure for preoperative flap design of the SCIP flap was developed. Branches could be localized and evaluated in all patients. A preoperative structured procedure for ultrasonically guided flap design of the SCIP flap is described. A 100% correlation between the number and emergence points of the branches detected by preoperative CCDS mapping and the intraoperative anatomy was found.
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Affiliation(s)
- Daniel Schiltz
- Department of Plastic and Aesthetic Surgery, Hand Surgery, Helios Hospital Emil von Behring, 14165 Berlin, Germany;
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Jasmin Lenhard
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Silvan Klein
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Alexandra Anker
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Daniel Lonic
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Paul I. Heidekrueger
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
| | - Ernst-Michael Jung
- Department of Radiology, University Medical Center Regensburg, 93053 Regensburg, Germany; (E.-M.J.); (N.P.B.D.S.)
| | | | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; (J.L.); (S.K.); (A.A.); (D.L.); (P.I.H.); (L.P.)
- Correspondence: ; Tel.: +49-941-9446763
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Marks H, Bucknor A, Roussakis E, Nowell N, Kamali P, Cascales JP, Kazei D, Lin SJ, Evans CL. A paintable phosphorescent bandage for postoperative tissue oxygen assessment in DIEP flap reconstruction. SCIENCE ADVANCES 2020; 6:eabd1061. [PMID: 33355131 PMCID: PMC11206211 DOI: 10.1126/sciadv.abd1061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/17/2020] [Indexed: 06/12/2023]
Abstract
Flaps are common in plastic surgery to reconstruct large tissue defects in cases such as trauma or cancer. However, most tissue oximeters used for monitoring ischemia in postoperative flaps are bulky, wired devices, which hinder direct flap observation. Here, we present the results of a clinical trial using a previously untried paintable transparent phosphorescent bandage to assess the tissue's partial pressure of oxygen (pO2). Statistical analysis revealed a strong relationship (P < 0.0001) between the rates of change of tissue oxygenation measured by the bandage and blood oxygen saturation (%stO2) readings from a standard-of-care ViOptix near-infrared spectroscopy oximeter. In addition, the oxygen-sensing bandage showed no adverse effects, proved easy handling, and yielded bright images across all skin tones with a digital single-lens reflex (DSLR) camera. This demonstrates the feasibility of using phosphorescent materials to monitor flaps postoperatively and lays the groundwork for future exploration in other tissue oxygen sensing applications.
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Affiliation(s)
- Haley Marks
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Alexandra Bucknor
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Emmanuel Roussakis
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Nicholas Nowell
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Parisa Kamali
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Juan Pedro Cascales
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA
| | - Darya Kazei
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Samuel J Lin
- Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
| | - Conor L Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA.
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Schiltz D, Taeger CD, Biermann N, Ranieri M, Klein S, Prantl L, Geis S. Transcutaneous oxygen measurement using ratiometric fluorescence imaging as a valid method for monitoring free flap transplants. Clin Hemorheol Microcirc 2019; 73:113-123. [PMID: 31561353 DOI: 10.3233/ch-199225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reconstruction of soft tissue defects with free flaps is a common procedure in plastic and reconstructive surgery. Most postoperative complications occur within the first 48-72 hours after surgery. After postoperative complications, short perfusion restoration times may improve flap survival rates by up to 30-50%. Ratiometric fluorescence imaging is an additional or alternative method of postoperative flap monitoring. OBJECTIVE To test the efficacy and utility of transepidermal oxygen flux imaging to evaluate postoperative skin oxygenation of free and local flaps in the first 48 hours after surgery. METHODS The study included 32 patients (aged between 18 and 80 years; mean age 52.9) with a tissue defect covered with a free flap transplant at the Department of Plastic and Reconstructive Surgery of the University Medical Center Regensburg. Postoperative oxygen flux was measured with the 'VisiSens system' placed on the vascular pedicle as well as on the peripheral and central part of the flap. RESULTS Values of oxygen flux were higher in case of flap congestion (0.069±0.012) or flap necrosis (0.155±0.083) than in cases without any complications (0.061±0.006). Flux values of different areas of the same flap showed only minimal differences (central part: 0.065±0.008, peripheral part: 0.070±0.009, vascular pedicle: 0.056±0.004); the level of significance was p = 0.904. CONCLUSION Imaging transepidermal oxygen flux by ratiometric luminescence seems to be a reliable alternative, indirect method of postoperative flap monitoring with regard to microcirculatory function and flap viability.
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Affiliation(s)
- Daniel Schiltz
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Christian D Taeger
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Niklas Biermann
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Marco Ranieri
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Silvan Klein
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
| | - Sebastian Geis
- Department of Plastic, Reconstructive and Hand Surgery at the University Medical Center Regensburg, Germany
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Anker A, Prantl L, Strauss C, Brébant V, Heine N, Lamby P, Geis S, Schenkhoff F, Pawlik M, Klein S. Vasopressor support vs. liberal fluid administration in deep inferior epigastric perforator (DIEP) free flap breast reconstruction – a randomized controlled trial. Clin Hemorheol Microcirc 2018; 69:37-44. [DOI: 10.3233/ch-189129] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- A.M. Anker
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - L. Prantl
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C. Strauss
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - V. Brébant
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - N. Heine
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - P. Lamby
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - S. Geis
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - F. Schenkhoff
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - M. Pawlik
- Department of Anaesthesiology, Caritas Hospital St. Josef, Regensburg, Germany
| | - S.M. Klein
- Center for Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
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