Risk factors and therapeutic strategy after failure of free flap coverage for lower-limb defects

From 2004 to 2007, 148 limb free flaps were performed in a series of 138 patients at the University Hospital in Nantes, France. Flaps were successful in 127 instances (rate: 86%; group A) and failed in 21 (group B). An analysis of the various factors (pre-, intra-, and postoperative) in both groups that may have influenced the outcome of surgery identified the following: operating time, cold ischemia time, and the interval before reoperation. This report is based on our experience in managing 21 free flap failures during reconstructive surgery of the limbs. The causes of failure were analyzed, and possible therapeutic strategies defined (i.e., a second free flap procedure, a pedicle flap, coverage with artificial dermis, or amputation). In our opinion, careful analysis of the causes of flap failure is essential to an appropriate choice of subsequent therapeutic strategy.     

Reconstruction of Lateral Skull Base Defects with Radial Forearm Free Flaps: The Double-Layer Technique

Introduction The radial forearm flap has fallen out of favor in lateral skull base reconstruction in recent literature. However, especially when used in a double layer, a radial forearm may be able to provide the thickness of a large flap while taking advantage of the pliability for which the flap is renowned. Objective To report the results of the double-layer technique of radial forearm free flap reconstruction of lateral temporal bone defects. Design A retrospective chart review. Setting A tertiary care institution. Participants All consecutive patients who underwent lateral temporal bone resections and were reconstructed with free flaps from 2006 to 2012. Major Outcome Measures Flap success rate, complications, and rate of revision surgery. Results A total of 17 patients were identified with free flap reconstruction of the lateral skull base. Seven received reconstruction with a double-layer radial forearm flap. Reconstruction-related complications in this group included one case of facial cellulitis. The flap success rate was 100%. These results were comparable with patients who had other flaps. Conclusions The radial forearm free flap may be an effective reconstruction option for lateral temporal bone defects especially when used in the double-layer technique.     

Free flap failures

A retrospective analysis of 75 consecutive free flap patients, operated on during 1989–1990, was performed to find out more about factors associated with free flap failure or immediate vascular complications. The overall failure rate was 9.3% (7/75) and the immediate vascular complication rate 22.7% (17/75). Sixteen patients required explorative surgery during the first postoperative day. The results were statistically analysed to find factors promoting either failure or vascular complications. Pre-operative infection of the recipient site or prolonged operation time correlated with flap failure. The use of a vein graft or long per-operative ischaemia correlated with immediate vascular complications. It is interesting that many factors often blamed for failure (age, body mass, history of cardiovascular disease, smoking, or previous irradiation of the recipient site) were not significant in this study. © 1995 Wiley-Liss, Inc.     

About cover of ballistic wounds of distal third of leg in civilian ways

Major causes of ballistic wounds are shooting accidents. Goals of this work are to suggest a position about ballistic wounds of leg's distal third. Reconstruction of ballistic wounds of leg's distal third is difficult, because of lack of laxity and veinous drainage in distal third; and characteristics of ballistic wounds. Ballistic traumas give a temporary cavity, which induce levelled wounds of neurovascular pedicules. We present three cases. One patient benefits from a sural flap, whereas the two others benefit respectively from a free parascapular flap and a free latissimus dorsi flap with free osseous graft. Functional results were considered as good. Treatment of ballistic wounds ask for certain specificities: 1) meticulous evaluation of wounds; 2) evaluation of vascular axis of leg. Debridments are numerous under general anaesthesia before a reconstruction with axial regional flap or free flap, which vessels are anastomosed distant. Reconstruction must be done before the tenth day.     

Foot reconstruction using a serratus anterior muscle flap from the same donor site after failure of a thoracodorsal artery perforator flap

The free flap failure rate for the lower extremities is high, which adversely affects limb salvage efforts. In this article, we report a case of failure of a thoracodorsal artery perforator flap, which was simultaneously reconstructed with a serratus anterior muscle flap from the same donor site. A 56‐year‐old male patient had infected wound for 3 months due to Achilles tendon rupture. We reconstructed the defect using a thoracodorsal artery perforator flap. However, 2 days after the operation, we found the congested flap. We were obliged to discard the whole flap and harvested a serratus anterior muscle flap from the same donor site. The patient's foot healed uneventfully. After flap failure, the use of a second free flap from the same donor site may be an effective and safe procedure in specific cases. © 2013 Wiley Periodicals, Inc. Microsurgery 34:153–156, 2014.     

Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction

Background.

The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction.

Methods.

We retrospectively reviewed 1310 free flap reconstructions for head and neck defects performed between July 1995 and June 2006.

Results.

Forty‐nine cases of flap compromise due to vascular obstruction (3.7%) were identified, and 27 flaps were lost (2%). Arterial occlusions occurred in 12 flaps, with a salvage rate of 33%. Eight flaps failed within the first 24 hours, and only 1 of these was salvageable. Five of the 8 flaps had intraoperative thrombosis due to technical difficulties. Venous occlusions occurred in 31 flaps, with a salvage rate of 58%. Twenty‐two venous occlusions occurred within the first 72 hours. The main reason for venous failure was mechanical obstruction due to compression, twisting, kinking, or stretching of the vein. The most common cause of late failures (after 7 days) was unrecognized failure of a buried flap owing to the lack of reliable monitoring. Overall, there was no correlation between surgeon experience and flap failure, but the flap failure rate was lower in surgeons who had performed more than 70 free flap procedures.

Conclusion.

Precise surgical techniques, avoidance of mechanical obstruction, and better monitoring of buried flaps may further improve the success rate of free tissue transfer in complex head and neck reconstruction. © 2008 Wiley Periodicals, Inc. Head Neck, 2009     

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps

Reconstruction of the cervical esophagus using cutaneous or musculocutaneous flaps is described. The delto-pectoral cutaneous flap, latissimus dorsi or pectoris major musculocutaneous flap, free forearm cutaneous flap, and free rectus abdominis musculocutaneous flap are generally used for reconstruction of the cervical esophagus. Although free jejunal transfer with microsurgery is now common for reconstruction of the cervical esophagus, cutaneous or musculocutaneous flaps remain useful in high-risk patients or patients in whom free jejunal transfer or gastrointestinal reconstruction would prove incompetency due to a history of abdominal surgery or other reasons. Cutaneous or musculocutaneous flaps are also used in patients with failure of free jejunal transfer or incurable fistula after reconstruction using the stomach or colon for thoracic esophageal cancer.     

Pharmacological thrombolysis: the last choice for salvaging free flaps

Abstract

Microvascular free flap transfer has become a prevailing surgery with a failure rate of <5%. However, pedicle thrombosis occurs more frequently than indicated by the failure rate. This difference is due to the successful salvage of failing flaps. During exploration, thrombi are often encountered at anastomotic sites, whereas these causes could not explain vascular compromise in other patients. Thus, we hypothesized that thrombogenic processes might occur at remote sites, specifically within microvessels of the transferred flap. This study retrospectively evaluated 323 patients who underwent microvascular free flap transfer between March 2012 and October 2016 at Korea University Guro Hospital. All patients requiring emergency exploration within 7?days after surgery were retrospectively reviewed. Of patients, 15 required explorative surgery for suspected circulatory compromise. Eight were diagnosed with thrombosis at the perianastomotic site and salvaged in accordance with our protocol. There was no detectable thrombosis at the anastomotic site in seven patients, including one patient in whom thrombosis resolved with topical papaverine application and heparinization. The remaining six patients were diagnosed with intra-flap microthrombosis without discernable thrombosis at the anastomotic site. All patients were treated following our urokinase administration protocol and salvaged without complications. Possible external causes should first be evaluated when salvaging free flaps; in the absence of such evidence, urokinase administration may be utilized as a last resort. This study is the first report describing the effectiveness of pharmacological thrombolysis in resolving intra-flap microthrombosis. Furthermore, a safe and efficient urokinase administration protocol is suggested for perianastomotic thrombosis and intra-flap microthrombosis.     

Towards performance measurement in reconstructive surgery: a multicentre pilot study of free and pedicled flap procedures.

OBJECTIVES: To pilot the acceptability and feasibility of clinical audit in free and pedicled flap reconstruction. To establish a baseline flap failure rate in participating units, so that a sample size calculation could be performed for future national audit. METHODS: A proforma was piloted over a 3-month period in four participating units, during which time data on 93 reconstructive procedures involving free and pedicled flaps was collected. The patients included those where large transfers of tissue were required such as for coverage of grade IIIb compound tibial fractures and breast reconstruction after mastectomy, and also smaller flap transfers such as after skin cancer excision. RESULTS: The proforma was found to be acceptable to clinicians and the feasibility of the data collection process was established. Overall there was a total flap survival of 89% and secondary operations to the donor or recipient sites were required in 11% of patients. CONCLUSIONS: This study demonstrates the feasibility of comparative audit for free and pedicled flap procedures using the methods proposed. Based on the incidence of flap failure observed in this pilot study, at least 18 months of prospective data collection on consecutive patients is required to fulfil the statistical requirements of comparative audit. The establishment of a routinely collected minimum dataset is proposed as one means of meeting these requirements.     

Upper extremity reconstruction using free SCIA/SIEA flap

The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft‐tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft‐tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Experimental cutaneous free flap transfers in the horse

Equine limb wounds often heal slowly by epithelialization, and large scars are a frequent end result. In some ways, they resemble the wound associated with human tibial injuries. The literature indicates that previous investigators have failed to transfer free skin flaps successfully in the horse. In this paper, we review our experimental work with the deep circumflex iliac flap in the horse. Dissections of 20 cadavers confirmed the anatomical consistency of the flap. Four flaps survived well when elevated as island flaps, but five orthotopic and nine heterotopic free flap transfers all failed. The cause of failure is still unknown, but our experiments suggested that the horse must be highly susceptible to ischemic reperfusion injury.     

A comparison between fibula and iliac crest in mandibular reconstruction

Nowadays the vascularized free fibula flap and the free iliac crest flap are the methods most frequently used to reconstruct the mandible. This is also the case in our clinic. A retrospective nonrandomized study was performed to compare both flaps. The vascularized fibula free flap and the iliac crest free flap were compared in terms of logistics, flap failure, revisionary surgery, donor site morbidity, and recipient site morbidity. No significant differences in flap failure and revision surgery were found between the fibula group and the iliac crest group. Recipient site and donor site complications (major and minor) were significantly less in the fibula group compared to the iliac crest group. In mandibular reconstruction, the free vascularized fibula flap appears to be superior to the free vascularized iliac crest flap in terms of both recipient site and donor site morbidity.     

口腔口咽肿瘤切除术后较大缺损修复的研究

目的总结口腔口咽肿瘤切除后较大缺损的修复方法，讨论影响组织瓣相关并发症的因素。方法回顾性分析2004年12月～2006年4月我院头颈外科收治的部分口腔口咽肿瘤患者64例，肿瘤切除后出现较大缺损，使用组织瓣66块进行修复，其中带蒂组织瓣39块，游离组织瓣27块。结果27例游离组织瓣中，2例前臂皮瓣坏死，成功率92．6％；39例带蒂组织瓣中，4例胸大肌肌皮瓣出现部分坏死。成功率90％。64例患者中，除1例死亡外，全部恢复经口进食。带蒂或游离组织瓣的选择及术前放疗与否不影响组织瓣相关并发症的发生。结论对口腔口咽部肿瘤切除后的较大缺损，应视缺损的范围、大小及患者的一般情况、术前放疗、颈部手术史等综合考虑，选择最合适的组织瓣进行修复。如果出现皮瓣相关井发症，尤其对术前放疗者应积极处理。     

Heparin-induced thrombocytopenia syndrome as a cause of flap failure: a report of two cases.

BACKGROUND: Flap failure is a major complication in reconstructive plastic surgery. One of the most frequent etiologies of flap failure is venous thrombosis. However, infrequent causes also need to be explored, especially when faced with recurrent thrombosis. Heparin is frequently used in the prevention of venous thrombosis; however, the use of the medication itself may cause a serious thromboembolic state via an immune-related pathophysiological process. This adverse reaction to heparin may be life threatening. CASE PRESENTATION: We present two cases, one pedicled and one free flap, with venous congestion concomitant to heparin-induced thrombocytopenia syndrome, in conjunction with severe life-threatening sequelae. CONCLUSIONS: Heparin-induced thrombocytopenia syndrome can be the cause of postoperative venous congestion. It is necessary to be alert for this syndrome in the presence of recurrent unexplained venous thrombosis or thrombocytopenia in patients receiving anticoagulation therapy.     

The super thin external pudendal artery (STEPA) free flap for oropharyngeal reconstruction – A case report

The radial forearm flap is one of the most used micro‐anastomotic flaps in cervicofacial reconstruction in a carcinological context. This flap is an ideal in terms of reliability and fineness; it has, however, some disadvantages in terms of the functional and aesthetic complications of its donor site. In alternative to a radial forearm free flap, we report the use of the free super thin external pudendal artery flap (STEPA flap) for an oropharyngeal reconstruction. The aim was to decrease the donor site morbidity. A 71‐years‐old man with a T2N0M0 oropharyngeal squamous cell carcinoma has undergone surgical treatment. A left STEPA free flap was performed to reconstruct a defect about 8 × 6 cm². This flap was designed as a half‐scrotal free flap sized 9 × 7 cm² and was inset after tunneling of the pedicle at the floor of the mouth. A surgical revision was needed on the 15th day postoperative for disunion. There was no skin flap failure. After 12 month of follow‐up, no complication was observed at the donor site and no erectile dysfunction was recorded. Its characteristics in terms of fineness, flexibility, ease of conformation, and pedicle length are similar to those of the radial forearm flap with less aesthetic and functional sequelae of the donor site. The STEPA flap may be a promising free flap in oropharyngeal or oral cavity reconstruction.     

Analysis of the Risk Factors for Free Flap Necrosis in Soft Tissue Reconstruction of the Lower Limbs

Objective

Free flaps are widely used for the repair of soft tissue defects in the lower limbs, but there is still a specific rate of necrosis. Few clinical retrospective studies have analyzed the nontechnical risk factors for lower limb free flap necrosis. This study aimed to analyze the nontechnical causes of flap necrosis in lower limb soft tissue reconstruction in order to identify risk factors and improve the survival rate of free flaps.

Methods

Clinical data from 244 cases of soft tissue defects of the leg or foot that were repaired with a free flap from January 2011 to June 2020 were retrospectively analyzed. The flap results were divided into complete survival and necrosis groups. The patients' general information, smoking history, soft tissue defect site, Gustilo-Anderson classification, shock after injury, type and size of the flap, and time from injury to flap coverage were recorded. A logistic regression model was used to analyze the correlations between flap necrosis and possible risk factors.

Results

Of the 244 flaps, 32 suffered from partial or total necrosis, and 212 completely survived. Univariate analysis showed that age, smoking history, soft tissue defect site, and time from injury to flap coverage were significantly correlated with flap necrosis (p ≤ 0.2). Multivariate logistic regression analysis showed that moderate-to-severe smoking history (p < 0.001, odds ratio [OR] = 10.259, 95% confidence interval [CI] = 2.886–36.468), proximal leg defect (p = 0.006, OR = 7.095, 95% CI = 1.731–29.089), and time from injury to flap coverage >7 days (p = 0.003, OR = 12.351, 95% CI = 2.343–65.099) were statistically significant risk factors for flap necrosis (p < 0.05), and age was excluded (p = 0.666; p = 0.924).

Conclusion

The risk of flap necrosis was significantly increased when the soft tissue defect was located in the proximal leg, the time from injury to flap coverage was >7 days, and the patient had a moderate-to-severe smoking history. These three risk factors have an increased influence on flap necrosis and have guiding significance in predicting flap prognosis.     

Phalloplasty: The dream and the reality

Phalloplasty has come a long way as Plastic Surgery has evolved over the years. The complication ridden multistage tube pedicles popularized by Gillis were, with the advent of microsurgery, replaced by radial forearm flaps. The composite osteo-cutaneous version of this flap promised ‘All for one and one for all’ assuring both a reliable urinary conduit and a phallus stiffener. Prelamination and prefabrication to make the neo-urethra came with the promise of reducing both fistula and strictures but that did not happen and flap failure rates increased. Penile stiffeners of various types have been introduced; the artificial ones were associated with high infection and failure rates and are best inserted after the neo-penis regains some sensitivity. With the introduction of perforator flaps the Anterolateral thigh flap in its sensate pedicled form has started replacing the Radial forearm free flap as the first choice flap because of a hidden donor area and lack of microsurgical expertise requirement. Being sensate it tolerates a stiffener better. It is now possible to reconstruct an aesthetically pleasing glans as well, thus meeting both the aesthetic and functional desires of the patient. Complications encountered in this reconstructive effort include flap failure, urethral fistula, urethral stricture and stiffener related problems.KEY WORDS: Gender reassignment, penile reconstruction, phalloplasty     

Considerations on 100 cases of free microsurgical flaps in the reconstruction of the soft tissues of the lower limb

The authors evaluate the results for 100 cases of severe loss of substance of the lower limb treated by microvascular free flaps at the Division of Plastic Surgery, Bellaria Hospital in Bologna, between 1994 and 2001. The cases involved recent traumatic loss of substance in 48 cases, post-traumatic defects such as osteomyelitis, ulcers, unstable scarring, sequelae of burns in 40, and neoplasms in 12. Muscular flaps were used in 89 cases, skin flaps in 9, a flap of the omentum in 1; the latissumus dorsi flap was that most frequently used (50 cases). A total of 87 cases had favorable results, while in 13 cases there was failure of the flap. Based on the results obtained, and experience, current indications and causes of failure are discussed.     

The use of a free and pedicled lateral arm flap for coverage of an extensive degloving injury of the upper extremity

Classical skin free flaps are rarely used to cover large skin defects of the upper extremity because of the limited donor size. Muscle flaps with a skin graft are preferred because they provide a large amount of cover and a good blood supply. A case report is presented in which a double skin flap was used to cover a large defect (40×8 cm) extending from the lateral humeral condyle to the dorsal aspect of the hand. A free lateral arm flap from the contra–lateral arm was successfully used in conjunction with a pedicled reversed lateral arm flap from the injured limb. We suggest that skin flaps should be considered for cover of skin defects. The lateral arm flap, which is a versatile flap, offers thin, pliable and sensate skin with minimal donor site morbidity.     

The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath.

Harvesting the rectus abdominis myocutaneous flap results in defects in both the rectus abdominis muscle and the anterior rectus sheath, which may be circumvented by dissecting a perforator flap (DIEP flap) instead. However, the latter is associated with a reduction in the number of myocutaneous perforators nourishing the flap, which has been hypothesised to lead to an increased risk of partial flap failure. We present a technical modification that maintains all the feeding perforators within the flap while fully preserving the anterior rectus sheath. The anterior rectus sheath is incised along a line connecting the perforators. A muscle cuff including all the feeding perforators was raised with the flap. This technique was used in 20 consecutive patients. Nine patients underwent free TRAM flap transfers for breast reconstruction (10 flaps), and 11 patients underwent thoracic-wall reconstruction with a superiorly based pedicled flap. The median follow-up was 11 months. One patient with a pedicled flap developed a partial failure that required surgical revision; all other flaps healed spontaneously. One patient in each subset had preoperative abdominal-wall laxity that was partly corrected after surgery; no abdominal bulging or hernia occurred in the other patients. Our results suggest that the technical modification presented here may enable the surgeon to dissect a rectus abdominis myocutaneous flap with maximal perforator-related flap perfusion and minimal donor-site morbidity. An advantage over the DIEP flap is that this technique is applicable to both free and pedicled flaps.