Early use of microvascular free tissue transfer in the management of electrical injuries

High-tension electricity can cause devastating injuries which may result in major soft-tissue loss, limb loss and sometimes major threat to life. Deep structures may be exposed and require flap cover, but microvascular flap transfer in electrical burn has a comparatively high-failure rate. This article aims to evaluate the outcome of early reconstruction of such injuries using free tissue transfer. In the course of 3 years (2004-2006), 16 free tissue transfers were performed in 13 cases of electrical injury from 24h to 3 weeks after trauma. All flaps survived except one. The failure was due to vascular erosion and secondary haemorrhage. There was no incident of vascular occlusion. Thus, if wound debridement is meticulous and microvascular anastomosis is performed well away from the trauma site, free flaps should survive as well in electrical burn cases as in any other.     

吻合血管组织移植在创伤与修复外科的临床应用

目的：探讨吻合血管组织移植在创伤与修复外科临床应用经验。方法：1986年以来行吻合血管组织移植127例，其中各种皮瓣或肌皮瓣60例，骨皮瓣移植6例，骨或半关节移植15例，足趾移植拇手指再造35例41指，趾甲皮瓣修复拇，指末节6例，趾关节移植修复指间关节2例，空肠或结肠移植重建咽食道3例。结果：2例皮瓣坏死，余均成活，效果良好。结论：以皮支血管为蒂的皮瓣移植、肌腱穿皮瓣组合移植，血管的端－侧或端－残支吻合、指－趾或跖血管吻合的应用使组织移植更为精确。     

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目的探讨腹部闭合性损伤延迟性肠坏死的诊断与治疗。方法回顾性分析2000年1月至2008年1月第二军医大学附属长海医院普外科治疗415例腹部闭合性损伤的临床资料,其中11例(2.65%)发生延迟性肠坏死,均于明确诊断后行手术治疗。结果 8例行一期肠段切除吻合术,3例因腹腔污染严重无法行一期确定性手术,先施行肠造口术,6个月后再行二期肠吻合术。11例全部治愈,其中2例发生肠瘘,经积极治疗后痊愈。结论腹部闭合性损伤致延迟性肠坏死临床症状不典型,易导致漏诊或延迟处理,病死率高,临床医生应严密动态观察,CT的正确诊断率较高,早期剖腹探查有利于提高治疗效果。     

膝部超时限腘动脉损伤的治疗

目的 总结超时限胭动脉损伤的诊治经验和教训。方法 1995年2月～2006年1月，收治28例胭动脉损伤时间超过8h的患者。其中男25例，女3例；年龄3～53岁。车祸伤12例，高处坠落伤3例，火器伤2例，锐器伤3例，绞扎伤2例，其他6例。20例未扪及动脉搏动，8例动脉搏动减弱。2例见裸露胭动脉和／或活动性喷血，8例直接手术探查，18例彩色多普勒检查示胭动脉及分支有彩色血流信号通过。7例胭动脉缺损〈5cm，9例缺损〉5cm。损伤至血管再通时间8～150h，平均31．8h。采用端端吻合、大隐静脉移植修复16例，截肢12例。结果 行动-静脉吻合或桥接术的16例患者，15例血管再通，肢体存活，其中12例1年内下肢功能基本恢复，3例遗留不同程度足下垂和踝关节挛缩，另1例枪伤患者因吻合血管术后1d再次栓塞，行二期截肢；血管吻合术后肢体存活率94％（15／16）。28例患者均获随访6个月～11年，平均4．2年。无死亡患者，截肢率43％，病残率54％。结论 胭动脉损伤的预后主要取决于血管再通时间和侧支循环的血氧代偿能力；延误诊断和治疗是严重胭动脉损伤截肢率居高不下的主要原因。     

Clinical experience with the nasolabial fold as receptor site in microvascular reconstruction

We report our experience using the vessels at the nasolabial fold as receptor site in free tissue transfer in head and neck reconstructions; a site that proved more convenient than the submandibulary site in selected cases. Six cases as well as the dissection technique of the nasolabial fold are reported. No complications occurred during or post surgery and in all cases the vessels were of adequate diameter for an end to end anastomosis. The advantages this site offers are discussed.     

吻闭合器在结直肠癌手术中的应用

为探讨吻闭合器在结直肠癌手术中的应用价值,自2003年6月至2007年3月,应用吻闭合器行回结肠端侧、直结肠端端、端侧及结肠端端、端侧吻合治疗94例结直肠癌患者,对治疗结果进行总结。结果显示,94例患者中,根治性切除81例,姑息性切除13例。术后随访,1年生存率93．6％（88／94）,2年生存率8d．0％（79／94）。行根治性切除的81例患者中,盆腔复发4例,吻合口狭窄2例,吻合口漏1例。结果表明,采用吻闭合器行回结肠端侧、直结肠端端、端侧技结肠端端、端侧吻合治疗结直肠癌,具有创伤小、操作简单、吻合成功率高、并发症少等优点,值得临床推广。     

儿童皮瓣移植手术75例分析

目的　回顾分析儿童皮瓣移植修复四肢软组织缺损的治疗效果。　方法　 1997年 1月～ 2 0 0 2年 5月实施了 75例儿童皮瓣移植手术。男 5 2例 ,女 2 3例 ,年龄 3～ 14岁。选择轴力或非轴形皮瓣移位、吻合血管的皮瓣移植 ,皮瓣范围 3cm× 5 cm～ 15 cm× 4 2 cm。其中急诊一期手术修复 2 6例 ,二期手术修复 4 9例 (感染性创面如骨髓炎、骨折术后钢板外露 )。手术修复部位 :前臂、手背、拇食指、小腿及足部等。皮瓣移植类型及应用范围 :轴形皮瓣移位或移植 39例(顺、逆行移位 2 7例 ,吻合血管的皮瓣移植 12例 )。非轴形皮瓣移位 36例 ,均是在伤口临近处设计的顺行或逆行皮瓣 ,其中 2 7例皮瓣长宽比例为 2 .5～ 3.5∶ 1,9例皮瓣长宽比例大于 3.5∶ 1。术前应注意麻醉的选择、术中无创操作及术后皮瓣的观察和护理。　结果　术后轴形皮瓣发生血液循环危象 2例 ,其中动、静脉危象各 1例 ,经积极处理后皮瓣成活 37例 ,失败 1例 ,部分失败 1例 ,手术成功率为 96 .2 % ;非轴形皮瓣成活 34例 ,部分失败 2例。手术成功率为 97.3%。术后随访 3个月～ 5年 ,皮瓣血运、弹性、质地均良好 ,功能满意。　结论　轴形或非轴形皮瓣移植 ,对一期修复患儿皮肤缺损或二期修复骨关节感染性创面有较高的成功率 ,要尽量选用非轴形皮     

Free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmann's contracture of the forearm.

Some articles have reported the use of medial gastrocnemius transfer to repair soft-tissue defects caused by trauma and inflammation (Morris, 1978; Feldman et al., 1978; Arnold and Mixter, 1983). However, we have not found any report describing the use of free medial gastrocnemius myocutaneous flap transfer with neurovascular anastomosis to treat Volkmann's contracture of the forearm. Since 1982, 20 cases of Volkmann's contracture of the forearm have been treated by transfer of medial gastrocnemius flap with neurovascular anastomosis. These 20 patients ranged in age from 6-18 years, with a mean of 10 years. There were 18 males and 2 females. All cases resulted from ischaemia of the extrinsic and intrinsic muscles of the forearm and hand. The most common causes were severe supracondylar fractures or, less frequently, fracture-dislocations of the elbow. Six to twenty months after operation, the transplanted muscles exhibited normal electromyographic potentials, good volume and contractile power with satisfactory functional recovery of the forearms. The deformities of the hand and wrist were also corrected. In this paper we describe the anatomy of the donor site and the operative procedure.     

Recipient vessel analysis for microvascular reconstruction of the head and neck

The selection of recipient vessels that are suitable for microvascular anastomosis in the head and neck region is one of many components that is essential for successful free tissue transfer. The purpose of this study was to evaluate a set of factors that are related to the recipient artery and vein and to determine how these factors influence flap survival. A retrospective review of 102 patients over a 5-year consecutive period was completed. Indications for microvascular reconstruction included tumor ablation (n = 76), trauma (n = 13), and chronic wounds or facial paralysis (n = 13). The most frequently used recipient artery and vein included the facial, superficial temporal, superior thyroid, carotid, and jugular. Various factors that were related to the recipient vessels were analyzed and included patient age, recipient artery and vein, diabetes mellitus, tobacco use, the timing of reconstruction, the method of anastomosis, previous radiation therapy, creation of an arteriovenous loop, and use of an interposition vein graft. Successful free tissue transfer was obtained in 97 of 102 flaps (95%). Flap failure was the result of venous thrombosis in 4 and arterial thrombosis in 1. Statistical analysis demonstrated that anastomotic failure was associated with an arteriovenous loop (2 of 5, P = 0.03) and tobacco use (3 of 5, P = 0.03). Flap failure was not related to patient age, choice of recipient vessel, diabetes mellitus, previous irradiation, the method of arterial or venous anastomosis, use of an interposition vein graft, or the timing of reconstruction.     

The operative trauma workload in a plastic surgery tertiary referral centre in Scotland

The trauma workload in plastic surgery is not well documented in the literature. The authors wished to investigate the operative trauma caseload in a tertiary referral plastic surgery centre to determine the demographics, mechanisms of injury, sites of injury and procedures performed. This study was conducted using a prospectively tabulated comprehensive database in which details of every trauma operation performed at the Canniesburn Plastic Surgery Unit (Glasgow, Scotland) are logged. The data from an 8-year study period (2003–2010) were collected for patient demographics, site of injury and operative procedures performed. The data from a shorter study period (April 2006–December 2010) were collected separately to investigate the mechanisms of injury. Data analysis was undertaken using Mintab 15 Statistical Software English. Analysis of 21,929 operative procedures on 8,880 patients was undertaken. There was a predominance of young male patients. More than 75% of trauma affected the limbs. The mechanism of injury was predominantly accidents (31%) including RTAs. The second most common mechanism was violent crime (17%), of which more than a quarter involved a knife. Notably, alcohol was a contributing factor in 3.4% of all trauma cases. Plastic surgery trauma involves injury to all sites of the body and the mechanisms are variable. However, certain mechanisms are arguably preventable through public health initiatives and legislative change in order to reduce the unnecessary economic burden on the health service. There is a significant operative caseload with a requirement for a varying complexity of reconstruction, ranging from debridements to microvascular free tissue transfer. Arguably, the plastic surgeon must be an integral part of any trauma centre.     

Review of microsurgical posterior urethral reconstruction

Posterior urethra reconstruction can be a challenging proposition for both patient and surgeon. The vast majority of urethras can be successfully reconstructed with either anastomosis or grafting. However, there are some patients who have recurrent urethral strictures that require more complex reconstruction. There is some speculation that microsurgical penile revascularization may allow subsequent graft reconstruction with lower stricture rates, but this is not yet proven. For the most tenacious urethral strictures, free tissue transfer may be required. The free radial forearm flap is well suited for urethral reconstruction, and the free anterolateral thigh flap may also have a role for these patients. This article will review urethral trauma and strictures and microsurgery's role in reconstruction of the posterior urethra.     

The utility of the microvascular anastomotic coupler in free tissue transfer

BACKGROUND:

The microvascular anastomosis remains a technically sensitive and critical determinant of success in free tissue transfer. The microvascular anastomotic coupling device is an elegant, friction-fit ring pin device that is becoming more widely used.

OBJECTIVE:

To systematically review the literature to examine the utility of the microvascular coupler in free tissue transfer.

METHODS:

A comprehensive database search was performed to identify eligible publications. Inclusion criteria were anastomotic coupler utilization and free-tissue transfer. Recorded information from eligible studies included patient age, follow-up, radiation history, number of free-flaps and failure rates, reconstruction subsites, number of coupled venous and arterial anastomoses, coupling time, conversion to sutured anastomosis, coupler size and thrombosis rates.

RESULTS:

Twenty-five studies reporting on 3207 patients were included in the analysis. A total of 3576 free-flaps were performed within the following subsites: 1103 head and neck, 2094 breast, 300 limb or body, and 79 nonspecified. There were only 26 reported flap failures (0.7%). A total of 3497 venous and 342 arterial coupled anastomoses were performed. The primary outcome measure was thrombosis rates, and there were 61 venous (1.7%) and 12 arterial (3.6%) thromboses reported. Mean coupling time was 5 min, and 30 anastomoses (0.8%) were converted to suture.

CONCLUSION:

Flap survival and revision-free application of the microvascular coupler occurred in more than 99% of cases. There is a substantial time savings with coupler use. Venous and arterial thrombosis rates are comparable with the best results achieved by sutured anastomosis and, when used by experienced surgeons, the coupler achieves superior results.     

小腿外侧腓动脉皮支皮瓣的解剖与临床应用

目的研究以腓动脉皮支血管为蒂的小腿外侧皮瓣吻合血管游离移植的解剖学与临床应用。方法解剖20具40侧成人尸体小腿,测量小腿外侧腓动脉皮支的有关数据。多普勒血管仪测定30侧成人活体小腿外侧腓动脉皮支血管穿出点。临床行21例小腿外侧腓动脉皮支皮瓣吻合血管的游离移植手术。结果40侧小腿共观察到皮支140支,每侧1~7支不等,平均3.5支,其中一侧只有1支高位皮支。皮支的穿出点大多(76%)在腓骨头最凸点下方7~21 cm范围。每侧最粗的皮支动脉外径平均为(1.8±0.4)mm(1.4~2.9 mm),两条伴行静脉外径平均(3.0±0.5)mm和(2.4±0.4)mm。30侧活体小腿共测到小腿外侧皮支血管穿出点145个,平均每侧4.8个。临床切取皮瓣大小5.0 cm×3.5 cm~28 cm×11 cm,21块皮瓣均成活。结论小腿外侧皮瓣由不同数目的腓动脉皮支供养,其主皮支能满足显微外科吻合血管的要求。以皮支血管为蒂的小腿外侧游离皮瓣移植,比以腓血管为蒂创伤小、操作简单、血运重建符合生理。     

Free flaps in reconstructive surgery.

Advances in technique, training and instrumentation have improved the patency rates for small vessel anastomosis. This, together with the introduction of more reliable donor sites for free tissue transfer, have resulted in success rates in excess of 90%. The technique is not associated with an increase in mortality or morbidity; on the contrary there is the advantage of primary reconstruction with a wide choice of donor sites offering the correct amount and type of tissue required. Single-stage, effective reconstruction, aimed at primary wound healing remains the aim of the reconstructive surgeon and free tissue transfer offers the most versatile and reliable method currently available.     

Open guide suture technique for safe microvascular anastomosis

Despite the evident advances in microsurgery, anastomosis of small vessels or anastomosis of vessels having size discrepancy, remains one of the most precise and technically demanding issues in replantation surgery and free tissue transfer procedure. The patency of the vascular anastomosis is critical and essential for a successful outcome. In this study, a microvascular anastomosing technique called open guide suture technique is introduced. The technique starts with a conventional whole-layer stitch and continues under the control of a guided suture that is inserted but not completed to a knot 180 degrees distant from the initial suture. Recently, we used this technique in 30 free flap transfers and 4 replantation procedures. A total of 103 anastomoses were performed. Only 1 flap, which had both arterial and venous problems, and 1 finger replantation case that had arterial problems required revision. Both the revised cases were salvaged, giving a revision rate of 2.91% for the total number of anastomoses (3 of 103), and a 100% success rate for final flap and replanted part survival. In conclusion, this technique provides a safe anastomosis performed under completely clear visualization at each step with well-arranged knot intervals.     

闭合性腘动脉损伤11例

目的总结闭合性动脉损伤的诊治经验.方法1983～2000年共11例闭合性动脉损伤患者.肢体血循环重建时间最短3.5h,最长27h,平均9h.结果8h以内重建血循环5例肢体循环功能恢复功能,8～10h2例遗有小腿缺血性挛缩,超过10h 4例中有1例小腿肌肉坏死,3例截肢.截肢率为27%,总病残率达55%.结论 动脉损伤应在6～8h内进行修复,超过这一时限病残率及截肢率均明显上升.延误诊断是导致闭合性动脉损伤后截肢率居高不下的主要因素.     

Ureteral injury due to external violence: 49 cases over 5 years

Summary A total of 49 cases of ureteral trauma secondary to external violence occurring over 5 years were reviewed with regard to etiology, diagnosis, associated injury, management, and follow-up. In all, 47 cases (95.9%) of penetrating and 2 (4.1%) of blunt trauma occurred; 45 cases (91.8%) occurred in men and 4 (8.2%), in women. Both blunt ureteral injuries were secondary to auto/pedestrian accidents. Overall, 92% of ureteral injuries were associated with injury to other organ systems. Our management principles for ureteral injuries have previously been reported [2, 3]. These include debridement, a watertight, tension-free anastomosis, isolation of the anastomosis, and Penrose drainage of the area proximal to the anastomosis. Postoperative complications occurred in eight patients; these consisted of three strictures, two urinomas, two cutaneous fistulas, and one perinephric abscess. There were six perioperative deaths, all unrelated to the genitourinary injuries.     

结肠损伤临床特点和手术疗效分析

目的:总结结肠损伤的临床特点和预后因素,探讨提高结肠损伤手术疗效的措施。方法:回顾性总结58例结肠损伤的住院资料、剖腹探查结果、手术类型和术后恢复情况,分析临床上采纳I期或Ⅱ期手术的标准和影响手术效果的关键步骤。结果:右半结肠损伤35例,左半结肠损伤17例,左右结肠均损伤6例,54例合并有腹腔多脏器或腹部以外的损伤。27例在8h内手术治疗,20例术前术中出现低血压超过1h。56例术前术中确诊,2例剖腹探查术后漏诊。总体手术治愈率87.9%(51/58),死亡率12.1%(7/58),合并症发生率25.5%(13/51)。I期结肠修补或吻合术治愈率90.6%(29/32),死亡率8.4%(3/32),合并症发生率20.7%(6/29);Ⅱ期吻合术治愈率84.6%(22/26),死亡率15.4%(4/26),合并症发生率31.8%(7/22)。结论:准确判断结肠损伤程度、全面了解合并损伤脏器、术中仔细探查、彻底的肠道和腹腔冲洗以及损伤部位严格的清创消毒,是I期手术也是Ⅱ期手术成功的关键。     

Lawn mower injuries in children

Lawn mowers cause severe injuries, particularly to the lower limbs in children. The study of 52 inpatient cases treated over 12 years shows that ride-on lawn mowers cause the most severe trauma, resulting in longer hospitalization. These children more often require further admissions for reconstructive surgery including free tissue transfer. These accidents can be avoided if young children are prevented from playing near or using power lawn mowers.     

Major trauma transfer in Western Australia

Background: The transfer of critically injured patients in a rural Australian setting presents a unique challenge to medical services due to the constraints of distance and time. The purpose of this study is to analyse which injuries are being transferred, how they occur, pretransfer intervention, transfer methods and transfer times. Methods: The Trauma Registry Database collected data prospectively on all major rural trauma cases attending the Royal Perth Hospital between August 1994 and January 2000. Patients were divided into rural and metropolitan groups on the basis of trauma location, and the latter group used as a control. Results: A total of 1275 major trauma patients were treated of which 566 (44%) were from rural areas. Driver road traffic trauma was the most common cause of injury throughout, although most prominent in rural areas (30%vs 18%). For rural patients, the Royal Flying Doctor Service was responsible for 440 (79%) of transfers of which 83% had a doctor and a nurse escort. The most commonly transferred injuries from rural areas were head injury (63%) and thoracic injury (55%). A total of 450 (93%) rural patients were transferred to Royal Perth Hospital within 24 h of trauma although the mean transfer time was over 9 h. Conclusions: This data produces a realistic framework of how major trauma in rural areas is treated in Western Australia. It highlights some areas of good practice, such as transfer methods and escorts, but also highlights problem areas such as transfer times and pretransfer intervention.