A simple and effective method of monitoring free skin flaps

Summary A simple and effective method of monitoring a free skin flap transfer when the flap skin color is white in spite of having a good blood circulation is described. It is easy to confirm that the anastomosed vessels are patent or not by visualizing the flap skin color, because erythema will appear after topical application of dinitrochlorobenzene even if skin color is white.     

Infrared surface temperature monitoring in the postoperative management of free tissue transfers

BACKGROUND:

Early identification of failing free flaps may allow for potential intervention and flap salvage. The predictive ability of flap temperature monitoring has been previously questioned. The present study investigated the ability of an infrared surface temperature monitoring device to detect trends in flap temperature and correlation with anastomotic thrombosis and flap failure.

METHODS:

Postoperative measurement of surface temperature was obtained in 47 microvascular free flaps. Differences in temperature between survival and failure groups were evaluated for statistical significance using Student’s t test (P<0.05). In addition, a single variable analysis was performed on 30 different flap characteristics to evaluate their prediction of flap failure.

RESULTS:

In total, eight flaps failed. Five of these were re-explored, of which one was salvaged. The three other flaps died a progressive death secondary to presumed thrombosis of the microcirculation despite adequate Doppler signals. Temperatures of the flap failure group during the last 24 h yielded a mean difference of 2°C (3.56°F) compared with surviving flaps (P<0.05). The temperature of the failing flaps began to decline at the eighth postoperative hour. Single variable analysis identified prior radiation to be a predictor of flap failure.

CONCLUSIONS:

A surface temperature measurement device provides reproducible digital readings without physical contact with the flap. Technical difficulties encountered in previous research with implantable or surface contact temperature probes are obviated with this noncontact technique. Flap temperature monitoring revealed a trend in temperature that correlates with anastomotic thrombosis and eventual flap failure.     

Alternative techniques for pedicle transfer of an island flap and a free flap

Alternative techniques for pedicle transfer of a reverse radial forearm flap for hand coverage, and a latissimus dorsi myocutaneous free flap for pelvic wound coverage, are illustrated. Exteriorization of the vascular pedicle of a reverse radial forearm flap allows a greater arc of movement of the flap for more distal coverage, and avoids the potential vascular compromise of tunnelling under a tight skin bridge. Two-stage transfer of a latissimus dorsi myocutaneous free flap on a wrist carrier pedicle may be useful in circumstances when local recipient vessels are inadequate for free flap transfer. Although both of these vascular pedicle modifications have drawbacks, they may be of value in limited circumstances. Their advantages and limitations are discussed.     

Postoperative monitoring of free flap reconstruction: A comparison of external Doppler ultrasonography and the implantable Doppler probe

HYPOTHESIS:

The time to detection of vascular compromise and the postoperative time to re-exploration are shorter using the implantable Doppler (ID) probe, thereby resulting in earlier surgical re-exploration and a higher flap salvage rate.

METHODS:

A single-centre experience with 176 consecutive free flap reconstructions in 167 patients from 2000 to 2008 in a university-based teaching hospital by retrospective chart review is presented.

RESULTS:

There was a significant difference in overall flap survival (ID 98.0%, external Doppler [ED] 89.3%) and total flap loss (ID 2.0%, ED 10.7%) between the two groups (P=0.03). The difference in flap salvage rate was not significant (ID 90.9%, ED 63.6%; P=0.068). The false-positive (ID 0%, ED 3%; P=0.18) and false-negative rates (ID 0.0%, ED 4.5%; P=1.0) were not significantly different. There was also a lower median postoperative time to re-exploration for the ID group, from 48 h to one week after initial surgery (ID 74.5 h, ED 136.8 h; P=0.05).

CONCLUSION:

The present analysis revealed a potential benefit for the ID probe in the postoperative monitoring of free tissue transfers.     

Storage of a free groin flap

Summary The transplantation of a free skin flap with microvascular anastomoses after storing it for 30 h, at a temperature of 4°C is possible. This is demonstrated with a groin flap which healed without complications.     

耳后游离皮瓣移植修复鼻部分缺损

目的 应用能携带耳廓软骨，色泽与鼻部相近的小型游离皮瓣修复鼻部分缺损。方法 采用以耳后动、静脉为血管蒂的耳后游离皮瓣行吻合血管的移植，对5例鼻部缺损进行了修复。结果 3例术后皮瓣血运完全正常，2例术后1－4d内有不同程度的静脉回流障碍。5例皮瓣最终全部成活，术后效果较为满意。结论 本手术供区隐藏，皮瓣不臃肿，色泽与鼻部相近，1次手术即可达到较满意的修复效果，是修复鼻尖、鼻翼大部缺损可供选择的一种方法。     

游离皮瓣眶窝充填再造眼窝手术方法探讨

目的 探讨游离皮瓣修复眶窝空旷及眼窝闭锁畸形的效果。方法 2001年10月至2005年1月，我们为21例眶窝空旷及眼窝闭锁患者采用游离皮瓣移植，其中19例采用前臂游离皮瓣，2例采用肩胛游离皮瓣。利用显微外科血管吻合技术将游离皮瓣移植于眶窝内，以填充空旷和再造眼窝，同时根据移植后眶窝空旷程度选择性同期眶内充填羟基磷灰石材料，一期重建眼窝。结果 所有眶窝内移植的皮瓣均成活良好，术后随访4～42个月，外观佳，义眼配戴满意。结论 游离皮瓣移植修复重度的眶窝空旷畸形和再造眼窝是一种可取的方法。     

小腿内侧(胫骨滋养血管皮支)游离皮瓣

通过对10具新鲜成年尸体(20侧)的下肢解剖观察及5具(10侧)小腿内侧皮瓣透明标本观测,见胫骨滋养动脉本干起自胫后动脉后壁,沿腘肌下缘或深面紧贴胫骨斜向下行,在胫骨粗隆平面下61.62±15(42～98)mm处分出筋膜皮支,其外径为2.04±0.6(1.3～3.5)mm,于胫骨与比目鱼肌间隙内下行至胫骨粗隆平面以下96.47±28(67～190)mm,穿出深筋膜、浅筋膜达真皮下血管丛,是小腿内侧皮瓣的主要血供来源之一。我们以胫骨滋养动脉筋膜皮支为血管蒂,进行了小腿内侧游离皮瓣吻合血管的移植并获得成功。此皮瓣具有薄,质佳,面积中等,切取方便,不牺牲小腿主要动脉等优点。     

The free lateral thigh flap

Experience with 13 free lateral thigh flaps is presented. In only one case was there necrosis and this was partial. The method of raising the flap is describe in detail and the advantages and disadvantages are described. This flap is more difficult to raise than the medial thigh flap and care must be taken in searching for its supplying vascular pepdicle.     

The free lateral thigh flap

Summary Experience with 13 free lateral thigh flaps is presented. In only one case was there necrosis and this was partial. The method of raising the flap is described in detail and the advantages and disadvantages are described. This flap is more difficult to raise than the medial thigh flap and care must be taken in searching for its supplying vascular pedicle.     

小腿内侧（胫骨滋养血管皮支）游离皮瓣

通过对１０具新鲜成年尸体（２０侧）的下肢解剖观察及５具（１０侧）小腿内侧皮瓣透明标本观测，见胫骨滋养动脉本于起自胫后动脉后壁，沿肌下缘或深面紧贴胫骨斜向下行，在胫骨粗隆平面下６１．６２±１５（４２～９８）ｍｍ处分出筋膜皮支，其外径为２．０４±０．６（１．３～３．５）ｍｍ，于胫骨与比目鱼肌间隙内下行至胫骨粗隆平面以下９６．４７±２８（６７～１９０）ｍｍ，穿出深筋膜、浅筋膜达真皮下血管丛，是小腿内侧皮瓣的主要血供来源之一。我们以胫骨滋养动脉筋膜皮支为血管蒂，进行了小腿内侧游离皮瓣吻合血管的移植并获得成功。此皮瓣具有薄，质佳，面积中等，切取方便，不牺牲小腿主要动脉等优点。     

The versatility of a glycerol-preserved skin allograft as an adjunctive treatment to free flap reconstruction

Skin allografts have been used in medical practice for over a century owing to their unique composition as a biological dressing. Skin allografts can be obtained in several preparations such as cryopreserved, glycerol-preserved, and fresh allograft. A glycerol-preserved allograft (GPA) was introduced in the early 1980s. It has several advantages compared with other dressings such as ease of processing, storage and transport, lower cost, less antigenicity, antimicrobial properties, and neo-vascularisation promoting properties. Skin allografts are mainly used in the management of severe burn injuries, chronic ulcers, and complex, traumatic wounds. Published reports of the use of skin allografts in association with free flap surgery are few or non existent. We would like to share our experience of several cases of free tissue transfer that utilised GPA as a temporary wound dressing in multiple scenarios. On the basis of this case series, we would like to recommend that a GPA be used as a temporary dressing in conjunction with free flap surgery when required to protect the flap pedicle, allowing time for the edema to subside and the wound can then be closed for a better aesthetic outcome.     

游离皮瓣移植在整形外科的临床应用

目的 回顾总结游离皮瓣在整形外科应用的范围与经验,方法 收集近８年来临床应用游离皮瓣的病例５０例进行统计分析。结果 ５０例中有４７例用于早晚期严重创伤伴有深部组织缺损与外露者,另３例为肿瘤切除后的创面覆盖,成功且效果良好者４８例（９６％）有２例由于血清栓塞而失败,结论 游离皮瓣的应用提高了整形外科的救治水平,对某些疑难病例的治疗是其它方法不可替代的。     

Free radial forearm adiposo-fascial flap for inferior maxillectomy defect reconstruction

A free radial forearm fascial flap has been described for intraoral reconstruction. Adiposo-fascial flap harvesting involves few technical modifications from the conventional radial forearm fascio-cutaneous free flap harvesting. We report a case of inferior maxillectomy defect reconstruction in a 42-year-old male with a free radial forearm adiposo-fascial flap with good aesthetic and functional outcome with minimal primary and donor site morbidity. The technique of raising the flap and closing the donor site needs to be meticulous in order to achieve good cosmetic and functional outcome.     

小儿游离肩胛皮瓣移植

目的儿童创伤愈合后的瘢痕组织挛缩影响外形、功能及局部生长发育,应用带血运的游离皮瓣移植效果良好。方法近年,对旋肩胛动脉皮支供血的肩胛皮瓣解剖上有了更进一步的认识:血管出三边孔后分为向上行的升支;平行于肩胛冈向内行的水平支;平行于肩胛骨腋缘向下行的降支。形成了上可超过肩胛冈5cm,下达两侧髂嵴平面的长肩胛游离皮瓣,利用吻合微血管技术,治疗5～9岁患儿面颈部损伤8例,获得良好效果。结果游离肩胛皮瓣最大面积为22.0cm×6.5cm,无一例出现血管危象,平均历时5小时,术中出血量平均约100ml。结论我们认为尽可能缩短手术时间,控制出血量在儿童体重的1％以内,掌握熟练的显微整形外科技术和解剖学基础是小儿游离皮瓣移植成功的关健。在4～10岁儿童应用游离皮瓣移植治疗面颈部损伤,具有手术成功率高,血管不易栓塞,术后恢复快,切口愈合良好,效果可靠等优点。     

The free lateral arm flap in reconstructive hand surgery

Microsurgical tissue transplantation has provided a great advance in reconstructive surgery, especially regarding upper limb defects. Compared to conventional pedicled flaps, mobilisation can occur earlier, hospital stay is shorter and no additional interventions for pedicle detachment and flap inset are needed. The lateral arm flap is an exceptionally versatile free flap with straightforward dissection and low donor site morbidity. End-to-side anastomosis preserves blood flow through the main arteries to the hand and reduces the risk of vascular compromise of the hand, which is especially important in case of severe hand injuries. Sixteen patients who underwent hand reconstruction using the lateral arm free flap are reviewed. All arterial anastomoses were conducted in end-to-side-technique either to the radial or the ulnar artery. There was no total- or partial-flap failure and only one revisional procedure due to a haematoma under the anastomosis. Eight flaps required secondary defatting, combined with removal of osteosynthesis material or tenolysis. From our point of view the free lateral arm flap is a very reliable and versatile method to resurface small and medium sized hand defects.     

The indications and reliability of vein graft use in free flap transfer

BACKGROUND:

Adequate recipient vessels are critical for free flap success. There are, however, situations in which the local recipient vessels are inadequate. In these situations, vein grafts are required to allow pedicle extension to recipient vessels.

OBJECTIVES:

To determine the indications, technique, reliability and outcome of vein graft use in free flap transfer.

METHODS:

A retrospective review of 198 consecutive free flaps by a single surgeon.

RESULTS:

Vein grafts were required in 9.6% of free flaps. The most common indication was vein graft use in a planned preoperative fashion. The vein graft was most commony placed as an arteriovenous fistula loop. There was no statistically significant difference in survival between flaps with or without vein grafts.

CONCLUSION:

Vein graft use in free flap transfer is reliable, effective and often necessary for free flap survival.