小腿肿瘤保肢术皮肤缺损的修复

目的：比较游离皮瓣和局部皮瓣转移对于肢体肿瘤保肢术中皮缺损修复的安全性。方法：1995年9月-1999年10月，分别用游离皮瓣移植和局部皮瓣转移修复15例小腿恶性骨肿瘤和软组织肿瘤保肢术后形成的皮缺损，9例游离皮瓣移植，6例局部旋转皮瓣。结果：游离皮瓣移植切口均一期愈合，无感染，皮瓣坏死，化疗对游离皮瓣成活无影响。6例局部皮瓣3例在术后5d出现皮瓣循环障碍，皮瓣坏死，伤口开裂，灭活的肿瘤骨外露。结论：小腿肿瘤保肢治疗中，采用局部皮瓣安全性较差。带血管蒂皮瓣游离移植是小腿肿瘤保肢术修复皮肤缺损的理想方法。     

Sequential free tissue transfers for simultaneous upper and lower limb salvage

Background: The Iraq and Afghanistan Wars have presented military reconstructive surgeons with a high volume of challenging extremity injuries. In recent years, a number of upper and lower extremity injuries requiring multiple tissue transfers for multiple limb salvages in the same casualty have been encountered. Our group will discuss the microsurgical challenges, algorithms, and success and complication rates for this cohort of war injured patients. Methods: All consecutive limb salvage cases requiring free flaps from 2003 to 2012 were reviewed. Cases involving simultaneous free tissue transfers were identified. Data collected included success rates and complications with comparisons made between the single and multiple free‐flap limb salvage cohorts. Results: Seventy‐four free flap limb salvage cases were performed over the 10‐year period. Of these cases, four patients received two free flaps to separate upper and lower extremity injuries for limb salvage within a single operative setting. The complication rate was 63%, which was significantly higher than those cases in which a single microvascular anastomosis was performed (26%, p = 0.046). However, the higher complication rate did not increase the flap or limb salvage failure rates (p = 0.892 and 0.626). Conclusions: The last decade of war trauma has provided a high volume of extremity injuries requiring limb salvage procedures including casualties who underwent single and multiple free flap coverage procedures. Although multiple flap limb salvage procedures have a higher complication rate, they can be performed within the same patient without concern for increased failure rate in carefully selected and appropriately managed patients. © 2013 Wiley Periodicals, Inc. Microsurgery 33:447–453, 2013.     

Treatment of severe leg wounds with muscle and musculocutaneous flaps

The ten-year experience with difficult wounds of the lower extremity at the Atlanta Veterans Administration Medical Center is reviewed in order to evaluate the use of the muscle and musculocutaneous flap as regional and free-tissue transfers. Twenty-four patients had chronic wounds and five had acute bony and soft-tissue injury. A total of 34 procedures, including 18 regional flaps and 16 microvascular free-tissue transfers, were performed with an overall success rate of 74%. Regional transfer succeeded in 12 (67%) of 18 cases. Free-tissue transfer succeeded in 13 (81%) of 16 cases. Experience with regional muscle transfer has shown the gastrocnemius and soleus muscles to be excellent choices for reconstruction of the proximal and middle third of the lower leg. Free microvascular transfer of the latissimus dorsi, gracilis, and rectus muscles has provided reliable closure in wounds that are chronically infected with major bony and soft-tissue loss in the distal third of the lower extremity.     

Lower extremity salvage and reconstruction by free-tissue transfer. Analysis of results

The application of soft tissue or bone free-tissue transfers to lower extremity salvage or reconstruction was assessed in a review of 86 consecutive procedures done during a 36-month period. This group included 65 cases of free skin or muscle flap transfer and 21 cases of free vascularized bone transfer. In terms of tissue viability, the success rate was 80.2% (78.5% for the soft tissue group and 85.7% for the bone group). With due consideration of indications, the incidence of secondary sepsis in patients with chronic osteomyelitis, and other potential complications, free-tissue transfers are valuable for salvage and reconstructive surgery of the lower extremity.     

Anaesthesia for reconstructive surgery

Reconstructive surgery is aimed at the restoration of shape and function following tissue loss due to trauma, oncological surgery, burns and infection. Techniques range from simple primary wound closure at the bottom to complex microvascular free tissue transfer at the top rung of the reconstructive ladder.Free flap surgery involves separation of the flap from its original vascular supply and microvascular reanastomosis at a distant site and is associated with substantial transient ischaemia of the transferred tissue. Anaesthetic management plays an important role in successful free flap surgery.All factors promoting vasoconstriction need to be eliminated in order to facilitate blood flow through the transferred tissue.In this respect, maintenance of an adequate arterial blood pressure, normothermia and normocarbia, institution of moderate hypervolaemic haemodilution and effective pain management are the main principles.In spite of studies describing the effects of particular drugs on the microcirculation no single ideal anaesthetic agent has yet been identified for this type of surgery.Free flap failure occurs mainly during the first 48 hours postoperatively with venous thrombosis being more common than arterial occlusion. Prompt surgical revision is the mainstay of flap salvage. The overall success rate of microvascular free tissue transfer in high volume centres exceeds 90%.     

Lower extremity free flap reconstruction outcomes using venous coupler

Background: Microvascular anastomotic coupling devices have been available to microsurgeons for over 20 years. Many studies have validated the efficacy of these devices for venous anastomosis. To date, there have been no large reports of their success in the anatomical region with the highest free flap failure rate, the lower extremity. Methods: A retrospective review of 67 consecutive patients who underwent lower extremity microvascular reconstruction performed from August 2003 to September 2010 was performed. Patient charts were reviewed for age, sex, medical comorbidities, etiology of defect, location of defect, flap type, anastomotic technique, complications, flap survival, and limb salvage outcome. Results: No patients returned to the operating room to have an arterial or venous anastomosis revised. Despite 100% vascular anastomosis patency rates in 67 consecutive lower extremity free flaps, flap survival rate was 95.5%. Total complication rate (13.4%) was due to two partial and one complete flap loss, three infections, two skin graft loses, and one hematoma. There were no intraoperative or perioperative complications involving the use of a microvascular anastomotic coupling device itself. Thirty‐day and long term limb salvage rate was 97% and 92.5%, respectively. Conclusion: Microvascular anastomotic coupling devices create effective venous anastomoses in lower extremity microvascular reconstruction. Thus, it presents an important tool in the armamentarium for lower extremity microsurgical reconstruction. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Free tissue transfers at Hutt Hospital

Background: The Wellington Regional Plastic, Maxillofacial & Burns Unit based at Hutt Hospital provides comprehensive reconstructive services to central New Zealand with a population of 1.1 million. Free tissue transfer procedures in the Unit were audited to determine the indications and rate of usage in our population, our success and complication rates, and how these compare with published series. Methods: Prospectively collected data on all free tissue transfer procedures between January 2006 and September 2010 were analysed. Results: Two hundred and seven free flaps including 17 flap types being performed on 186 consecutive patients including 199 primary and 8 salvage flaps. Eighty‐three percent were elective and 17% were acute cases. The majority of the flaps were used for head and neck (48%) and breast (31.5%) reconstruction. Ulnar forearm flap was the most commonly used fasciocutaneous flap. 18.8% of patients had major complications requiring return to theatre. Microsurgical revision was performed in nine (4.3%) flaps of which six were successfully salvaged. Overall, 13 flaps (6.3%) failed completely, giving an overall success rate of 93.7%. Haematoma requiring formal drainage occurred in 12 (5.8%) cases. Discussion: The wide variety of flaps used reflects the very broad range of defects requiring free flap reconstruction. We show a free flap success rate of 93.7% in our medium‐sized regional unit. Our microsurgical revision rate of 4.3% is lower than the revision rate of 10% in reported series with high overall success rates. More consistent early detection of failing flaps is likely to further improve our overall success rate.     

Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity

Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm-Shoulder-Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors' unit of 89 days. The average defect size after debridement was 10.0 x 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm-Shoulder-Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1-10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.     

Long-term evaluation of patients with free tissue transfer to the lower leg in terms of functional,socioeconomic, and esthetic aspects

A retrospective, quantitative, long-term evaluation of patients with a free flap transfer to the lower extremity was carried out with respect to functional, socioeconomic, and esthetic outcome. The study included 57 patients who were examined by questionnaire filled out by both an examiner and the patients themselves. Indications for the free flaps were acute trauma or osteomyelitis and unstable scars arising from a previous trauma to the lower leg. The flap success rate was 94.7%. The period between the operation and evaluation was at least 3 years. A local, flap-specific functional impairment was found in 17 patients (30%) and a general impairment of the lower extremity in 56% of the subjects. With respect to the socioeconomic outcome more than two-thirds of the patients returned to their previous occupation with no restrictions; approximately 20% of subjects had to switch to a less strenuous job. Although from the viewpoint of the examiner the esthetic appearance was satisfactory in 44 free flaps (77%), the majority of the patients were conscious of pigmental, textural, or contour changes which produced a subjective esthetic compromise in 56% of cases. In conclusion, despite a considerably high rate of local functional impairment the majority of patients (89%) were satisfied and judged the application of a free flap as having been beneficial in preventing a loss in socioeconomic status. The high rate of esthetic problems demonstrates the importance of including esthetic considerations in designing the free flap, in particular with regard to (a) meticulously tailoring the flap, (b) aiming at a homogeneous skin surface, and (c) thoroughly shaping the affected lower extremity.     

Reliability of primary vein grafts in lower extremity free tissue transfers.

Free flaps transferred to the lower extremity have a higher risk of failure, which may be expected to increase further with the use of vein grafts. The results of 103 consecutive free flaps to the lower extremities of 98 patients who were operated from March 1994 to December 1999 were evaluated to assess the reliability of vein grafts in lower extremity reconstruction. Five flaps were lost and the overall success rate was 95.1%. Eighty-four free tissue transfers in 79 patients were performed for the reconstruction of traumatic cases, and 81 of these flaps were performed in a delayed manner, between 1 week and 4 months after the injury. Interpositional vein grafts were used primarily in 22 flaps--all in traumatic cases--and 21 of them survived completely (95.4%). Primary vein grafts were used both for arteries and veins in 15 flaps and for arteries only in 7 flaps. The most common cause of tissue loss in these patients was a crush injury in earthquake survivors, followed by electrical injuries, gunshot injuries, motor vehicle accidents, and chronic infections. Free muscle flaps in 13 patients, skin flaps in 4 patients, osseous flaps in 2 patients, and temporal fascial flaps in 2 patients were the flaps of choice in vein graft reconstructions. Although a higher incidence of flap loss has been reported with the use of interpositional vein grafts than with regular transfers, and the technical and pathophysiological problems in flap transfers are also high in the lower extremity, the success rate in vein-grafted free flaps did not differ from that of the simple free flap transfers in the current series. This appears to be the result of meticulous preoperative planning and proper selection of recipient vessels during optimal operative conditions.     

Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.     

Preventing postoperative haematomas in microvascular reconstruction of the head and neck: lessons learnt from 126 consecutive cases

Background: Free tissue transfer has become a safe and reliable means for repairing soft tissue and bony defects of the head and neck. Although operative success has reached 98%, the incidence of significant postoperative complications is also relatively high (32%). One common and significant complication is haematoma formation, occurring at both donor and recipient sites, and yet there are minimal published studies on its incidence, aetiology or outcome. A retrospective analysis of both donor‐ and recipient‐site wound haematoma was carried out to identify causative factors and the effect on patient outcome. Methods: A 5‐year review of 132 consecutive microvascular free tissue transfers to head and neck defects at The Royal Melbourne Hospital, for the period February 2001 to February 2006, was conducted. Results: Of 126 included cases, 27 postoperative haematomas resulted. Statistically significant associations were found for each of smoking, non‐steroidal anti‐inflammatory drug use and the use of corticosteroids preoperatively with the incidence of postoperative haematoma formation. Postoperative blood pressure control and the adequacy of primary tumour excision at the flap recipient site were also found to have significant associations with haematoma formation. Drain tube outputs served as accurate indicators for haematoma. Conclusion: There are significant reversible factors that contribute to the development of postoperative haematomas in head and neck reconstructive surgery. Preoperative modifications should, therefore, be sought. Similarly, close monitoring of patient blood pressure during the initial 24 h postoperative period by theatre and recovery staff is important, as is the adequacy of postoperative analgesia.     

Microsurgery in the hypercoagulable patient: review of the literature

Improved techniques in microvascular surgery over the last several decades have led to the increased use of free tissue transfers as a mode of reconstructing difficult problems with a high success rate. However, undiagnosed thrombophilias have been associated with microsurgery free flap failures. We present a case of successful free tissue transfer in a patient with lupus anticoagulant and review the literature.     

双侧上颌骨缺损的显微外科修复

目的 探讨应用游离组织瓣移植行双侧上颌骨缺损修复的可行性和应用价值。方法 对1999年7月～2003年8月期间完成的16例应用游离组织瓣行双侧上颌骨缺损修复的病例作回顾性研究，分析上颌骨缺损的原因、缺损的分类、所采用组织瓣的类型、受区血管、游离瓣成活情况及术后并发症的发生情况，并分析应用游离组织瓣行双侧上颌骨缺损修复的适应证和可行性。结果 所采用的游离瓣包括腓骨瓣(9块)、腹直肌皮瓣(6块)、前臂皮瓣(3块)。术后1例腓骨瓣出现血管危象，经抢救成活，其余的游离瓣术后均未出现血管危象，并全部获得成活。受区和供区总的并发症发生率为31．3％，除了早期的2例供区并发症外，其余的并发症均不严重，没有造成严重后果。结论 应用游离组织瓣行双侧上颌骨缺损修复安全可靠，成功率高，且有利于改善患者术后的功能和外形，值得进一步研究和应用。应根据不同缺损的具体特点选择合适的游离组织瓣移植。     

Lower Limb Revascularization and Free Flap Transfer for Major Ischemic Tissue Loss

The objective of this study was to assess the value of lower limb revascularization and free flap transfer (LLR-FFT) in the management of critical leg ischemia and major tissue loss. A total of 29 consecutive patients with critically ischemic leg and major tissue loss underwent 24 simultaneous and 6 staged LLR-FFT procedures. The main outcome measures were bypass graft patency, free flap viability, leg salvage, patients alive with salvaged leg, and survival. At the 2-year follow-up, the bypass graft patency rate was 85%, secondary free flap viability rate was 82%, and 82% of patients achieved leg salvage and were ambulant. If the success was defined as patients being alive with a salvaged leg, the corresponding rate was 80%. Three patients achieved long-term primary patency and leg salvage despite free flap failure, which occurred during the 30-day postoperative period. Lower extremity revascularization plus free flap coverage of large ischemic lesions is valuable in achieving long-term leg salvage. Because revascularization and conventional management of major tissue loss alone can be effective in the management of a small number of cases, staged LLR-FFT is indicated, when appropriate, for better selection of patients undergoing such an aggressive and demanding treatment.     

Free tissue transfer and deep vein thrombosis

Reconstruction of the post-oncologic defect of the lower limb frequently requires free tissue transfer and these often extensive bone and soft tissue resections can occasionally be compounded by the presence of a deep venous thrombosis (DVT). We describe two patients in whom free tissue transfer was attempted, following extensive resection of a sarcoma in the thigh. Both patients had been diagnosed with DVT prior to surgery and received therapeutic low molecular weight heparin preoperatively. In the first patient, flap failure occurred due to venous congestion initially resulting from poor flow in the reconstructed femoral vein and then thrombosis and failure of the vascular reconstruction. In the second patient the superficial venous system was used for successful microvascular anastomosis leading to survival of the flap. Therefore, patients undergoing lower extremity free tissue transfer who are at high risk of DVT, or when there is a clinical suspicion of DVT, thorough preoperative assessment of the deep and superficial venous system is warranted for reconstruction planning.     

The use of microvascular free groin flaps for the closure of difficult lower extremity wounds.

Proficiency with techniques of microvascular anastamoses allows the successful transfer of free composite grafts from distant sources. We have used the free groin flap in the reconstruction of defects of the lower extremity not amenable to standard methods of closure. A series of representative cases has been presented in this article to illustrate our approach and technique.     

Microvascular free-tissue transfer for traumatic defects of the upper extremity: a 25-year experience

Microvascular free-tissue transfer has been a major advance in the treatment of complex traumatic defects of the upper extremity. One hundred and fifty microvascular free-tissue transfers were performed in 133 patients with complex traumatic upper extremity defects at Bellevue Hospital Center from 1976 to 2000. The indication for microvascular free tissue transfers was exposure of vital structure (81 percent), bone defect (11 percent), and functional deficit (8 percent). The parascapular region was the most common donor site used (26 percent). Microvascular free-tissue transfer was performed either emergently at the time of injury (9.3 percent), during days 1 to 5 post injury (19.3 percent), during days 6 to 21 (19.3 percent), or after day 21 (52 percent). The overall flap failure rate was 9 percent. A decreased incidence of flap failure was observed in patients treated from 6 to 21 days post injury (3 percent p<0.05). The most common acute complication was infection at the recipient site, observed in 14 percent of patients overall. A decreased incidence of recipient-site infection was seen in patients who received free flaps at days 6 to 21 (3 percent; p<0.05). In long-term follow-up, the incidences of osteomyelitis and nonunion were lowest in patients treated from 6 to 21 days post injury (0.0 percent and 11 percent, respectively; p<0.05). During the last 10 years, the timing of reconstruction has been altered, and now preferentially microvascular free flaps are performed 6 to 21 days post injury. The treatment algorithm has been simplified and now only four different flaps are used in the majority of patients (70 percent). With this, the authors have witnessed a decrease in failure rates from 11 percent to 4 percent, a decrease in recipient-site infections from 16 percent to 10 percent and a decrease in osteomyelitis from 12 percent to 4 percent. The preferred timing for microvascular free-tissue transfers to the upper extremity is concluded to be 6 to 21 days post injury.     

Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.     

Reconstruction of lower extremity complex wounds with combined free tissue transfer using the anterolateral thigh flap as a link

In this report, the authors present the experience on the reconstruction of the totally degloved foot and extremely long soft tissue defect of a lower limb with the combined free tissue transfer using the anterolateral thigh flap as a link in two male patients between October 2009 and December 2010. The anterolateral thigh flap has been commonly used as a link between the recipient site and the distal flap. The anterolateral thigh flap and latissimus dorsi muscle flap were selected for the distal flap, according to their reconstructive needs. Two combined free flaps survived without major complication. The authors could salvage of the lower extremity through the reconstruction of complex wound with the combined free tissue transfer using the anterolateral thigh flap as a link. This combined flap may be an alternative for reconstruction of complex soft tissue defect in the lower extremity. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.