Immediate skin grafting on microvascular free tissue transfers

Clinical reports of pedicled muscle flaps and microvascular tissue transfers include two distinctly different strategies for skin grafting. Some authors describe immediate grafting, whereas others recommend a three- to 5-day interval between flap transfer and grafting. No systematic analysis of either strategy has been reported. We reviewed 51 consecutive successful free tissue transfers that involved immediate skin grafting. Ninety-six percent of the grafts survived without complication. Bot muscle and fascial flaps supported skin grafts. Skin grafts survived infected recipient sites, pedicle revisions, partial flap necrosis, and secondary operation. We conclude that immediate skin grafting on free tissue transfers is reliable.     

Influence of vein-patch angioplasty on carotid endarterectomy healing

We studied the influence of venous patching on the patency, endothelial regeneration, and wall healing of endarterectomized carotid arteries in a canine model. Thirteen dogs underwent bilateral common carotid endarterectomies (intimectomy and partial media excision). In each dog, one artery was closed by continuous suture and the contralateral artery was closed by external jugular vein-patch angioplasty; arteries were excised at two postoperative intervals (two to three and four to five weeks) for light, scanning, and transmission electron microscopy. The patency of arteries closed primarily (9/13 [69%]) was not significantly different compared with arteries closed with venous patches (12/13 [92%]). By scanning electron microscopy, regeneration of the endothelial monolayer occurred by migration from the endarterectomy end points and suture lines. Despite survival of the vein-patch endothelium, the rate and pattern of reendothelialization was not altered by venous patching. In both patched and unpatched vessels, endothelial regeneration was incomplete at two to three weeks and completed by four to five weeks. The histologic characteristics of the endarterectomized arterial wall after operation were also not influenced by the closure technique. In contrast with the healing artery wall, vein-patch walls did not develop a thickened intima. Although venous patching does not influence early patency, endothelial regeneration, or wall healing after endarterectomy, vein-patch angioplasty does increase vessel diameter and prevents the development of circumferential intimal thickening, attributes that are beneficial in minimizing restenosis.     

Liposuction-assisted revision and recontouring of free microvascular tissue transfers

Liposuction has become a widely accepted and utilized technique that allows the aesthetic surgeon to improve regional definition and contour. Although the techniques of liposuction have now been extended to a variety of noncosmetic procedures as well, the application of this technique in the area of reconstructive surgery has lagged. To ascertain the applicability and effectiveness of liposuction for the revision of free microvascular tissue transfers we undertook a retrospective analysis of our free flap reconstruction cases that were revised and recontoured using liposuction. From this review of 12 cases we found liposuction to be a safe and effective technique for the delayed revision of free flap reconstructions of the head and neck region and lower extremity.Presented at the Annual Meeting of the Lipoplasty Society of North America, Seattle, Washington, September 1991; and the Robert H. Ivy Society Meeting, Pittsburgh, Pennsylvania, April 1992     

Clinical and experimental studies of cigarette smoking in microvascular tissue transfers

Circulatory crisis, attributed to cigarette smoking, in three microvascular cases (two toe transfers, one musculocutaneous flap) is reported. After anticoagulation and antispasm treatment only one transfer survived. Coordinated experimental studies in the rat demonstrated that cigarette smoking delayed anastomotic healing. Five days after anastomoses were performed, endothelial cells completely covered the sutures in the experimental smoking group in only 16–19% of sutures, while the control group had a 75% coverage rate. Mechanisms and characteristics of circulatory crisis caused by cigarette smoking are discussed. © 1993 Wiley-Liss Inc.     

Use of varioscope in free microvascular tissue transplants

Since July 2002, the author has performed 12 consecutive free flaps using a new device, the Varioscope AF3, in order to evaluate its efficacy. The Varioscope is a world-patent novelty by Life Optics (Vienna, Austria) that combines the philosophy of microscopes and loupes. Specific advantages such as reduced cost, freedom of movement, portability, and a magnification range between 3.6-7,2x are some of the reasons that convinced the author to use the Varioscope initially. The overall success rate is similar to that obtained with a microscope or high-power loupes. The results show that the Varioscope AF3 could be safely employed in the majority of free-tissue transfers as sole means of magnification. However, for digital replantations or vessels with a diameter of less than 1 mm, a microscope might be necessary.     

Use of microvascular island pedicle flaps for facial tissue defects

Microsurgical dissection was used with satisfactory results to construct a microvascular island pedicle flap for the coverage of small facial tissue defects in 3 patients. The advantages of this flap include improved survival, excellent mobility, and elimination of cosmetic problems usually encountered with rotation or distant flaps.     

Microvascular free tissue transfers

Recent advances in microvascular surgery enable direct transfers of various types of large composite tissues by means of anastomoses of their small nutrient vessels. Such transferable tissues now include the free skin flap, muscle, bone, omentum, jejunum, and toes, sometimes in combination. The practical technique of microvascular free tissue transfer is described in this paper, and representative clinical cases are presented. A total of 256 microvascular transfers have been performed. These include 222 free skin flaps, some of which were combined with muscle, bone, and nerve. Necrosis (total, partial, and superficial) occurred in 33 free skin flaps with a satisfactory result in 189 (85%).

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Résumé Grâce aux progrès récents de la microchirurgie vasculaire, il est possible de transplanter, par anastomose de leur pédicule vasculaire, des lambeaux composés de tissus différents. Peau, muscle, os, épiploon, jéjunum, orteils peuvent être transplantés isolément ou en combinaison. Les modalités techniques de ces transplantations tissulaires sont décrites dans l'article et illustrées par des exemples. Nous avons réalisé 256 transplantations de ce type, dont 220 transferts de peau, associés dans certains cas à des transferts de muscle, d'os et de nerf. Les transplantations cutanées se sont compliquées dans 33 cas de nécrose totale, partielle ou superficielle; le résultat a été satisfaisant dans 189 cas (85%).

     

Current techniques in the post-operative monitoring of microvascular free-tissue transfers

Accurate assessment of the perfusion of free-tissue transfers has always been a challenge for surgeons undertaking microvascular reconstructive procedures. Microvascular free-tissue transfer today has a high success rate, which is partly due to the monitoring of flap circulation post-operatively. Recent advances in technology and improvements in surgical technique have led to reported success rates of between 95% and 98%. The aim of post-operative surveillance is the early recognition of flap compromise to improve chances of flap salvage and lower morbidity and mortality rates. There is extensive literature available on post-operative monitoring, and, although many techniques to assess flap perfusion have been described, a standard, reliable, universally accepted method, other than bedside clinical observation by the medical and nursing staff, remains elusive. This review outlines the current clinical and experimental flap monitoring methods available.     

Reconstruction of congenital hand defects with microvascular toe transfers

From 1977 through 1984, the author transferred 49 toes in 38 patients to treat congenital defects of the hand. Eleven patients had successful transfer of two toes from different feet, with a six-month interval between operations. There was one failure in a 16-month-old infant with finger aplasia. On the basis of this experience, the author has refined his indications and timing, which are as precise and well defined as the technique.     

Locally applied hypothermia and microvascular muscle flap transfers.

The success rate for wound closure of grade III open tibia-fibula fractures with free muscle flaps is approximately 90%. Complications and loss of free flaps are due mainly to anastomotic problems, local anatomical considerations, or recipient vessel injuries, which prolong the ischemic time of the transferred free muscle tissue. We present the techniques used at the Shock Trauma Center of The Maryland Institute for Emergency Medical Services Systems (MIEMSS), which has allowed us a 100% success rate for the last 80 free muscle transfers performed. This surgical technique involves the use of locally applied hypothermia to decrease muscle metabolism and no-reflow phenomena. Representative cases are illustrated, which could have been failures because of increased ischemic time.     

Naked eye free tissue transfers

Over the past ten years, neither the operating microscope nor magnifying glasses have been used routinely for elective microsurgery. The whole operation is performed with the naked eye, vascular anastomoses included. From January of 1992 to December of 1993, 37 free tissue transfers have been performed on 36 patients. An operating microscope was used in only 6 cases (5 free flaps, and 1 emergency exploration for thrombosis). In the other 37 cases (33 free flaps, and 5 emergency explorations for thrombosis), the anastomoses were performed with the naked eye. In a total number of 103 vascular anastomoses, the microscope was used in 14 cases, and the naked eye in 89 cases. The only failure of our series was performed in the classical way, in addition to the emergency exploration and its salvage by a second free flap. There were no failures in the naked eye cases. In the 5 other cases, emergency exploration allowed salvage of the flap. No technical error in the vascular anastomoses occurred in any of those cases.The authors conclude that elective free-tissue transfer in plastic surgery is routinely possible, safe and reliable, without the microscope or magnifying glasses, provided that vessels of the flap and recipient vessels be chosen with sufficient diameter. In practice, this situation was encountered in more than 85 percent of the cases.     

Experimental microvascular growth plate transfers. Part I--Investigation of vascularity

A model was developed in the dog to allow both the metaphysis and epiphysis of the distal ulnar growth plate to be microsurgically revascularised from the pedicle of the anterior interosseous vessels. With both circulations revascularised, grafts retained their structural integrity and growth continued at rates only slightly less than normal (mean 85%). If either or both circulations were not revascularised, growth rates were lower and were associated with skeletal collapse in the ischaemic bone segment.     

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.     

Experimental microvascular growth plate transfers. Part 2--Investigation of feasibility

We investigated the feasibility in the dog of using transfers of the distal ulna into the radius either as growth plate replacements or as accessory growth plates in the diaphysis. Preliminary work determined the most satisfactory method of skeletal fixation. The experimental study showed that transfers used as growth plate replacements grew at almost normal rates, uniting with the recipient bone in a mean of 7.1 weeks. Transfers into the diaphysis initially nearly doubled the growth rate of the radius, although in the long-term results were unsatisfactory, because of fracture of the graft after a mean period of 8.2 weeks.     

Long-term results of finger reconstruction with microvascular toe transfers after trauma

Amputation of all or most of the fingers severely disturbs the gripping function of the hand. The purpose of this study was to evaluate the long-term functional results of finger-amputation patients rehabilitated with microvascular toe transfers.Fifteen such patients (10 males, median age at injury 26 years (range 5–49 years)) were examined after a median follow-up of 18 years. Eight patients had no fingers spared by the initial trauma and the rest had at least two fingers amputated. The function of the hand was accessed subjectively (questionnaires) and objectively (tests). Further, physical parameters were measured and compared to the other healthy hand.Patients scored consistently well in the test measuring function (the Sollerman hand function test and the modified Tamai score). Activities of daily living presented on average minor difficulties. Patients regained on average 42% of grip and 84% of key pinch strength compared to the other hand. The average movement of the transfer was 28°. One transfer was lost due to inability to restore permanent circulation. In addition, there were one donor and one recipient site superficial infections.We conclude that microvascular toe transfer is a reliable way to improve gripping function after amputation of fingers. Patient approval is generally good and the achieved function satisfactory. Two toe transfers should be considered for patients with no fingers left. Work-related injury may be related to decreased occupational capability.