Vascular complication in free tissue transfer to the leg.

The lower-extremity free flap has a high incidence of vascular complication. A retrospective study of 70 free flap transplants in 70 patients (1987-2000) was conducted to investigate factors leading to vascular complication and free flap failure. The overall success rate was 92% (64 of 70 flaps); the incidence of vascular complications was 22% (16 of 70 flaps). Among 16 complicated flaps, 7 were transferred in severely crushed legs, and 4 were in multioperated legs attributable to chronic osteomyelitis. Venous thrombosis occurred in 12 flaps (86%). The success rate of the patients operated on at Yamaguchi University Hospital was higher (96%) than at other hospitals tested. The key factors contributing to improved outcome in free tissue transplantation in the leg were careful preoperative planning for highly traumatized legs and proper selection of the recipient vein and of the hospital at which immediate reexploration can be performed for vascular complicated flaps.     

Both superficial and deep extremity veins can be used successfully as the recipient site for free flaps

Many controllable factors can influence free flap success rates, including the choice of recipient vessels, which can be as crucial as selecting the optimum donor site. The extremities are unique in that their dual venous systems offer an even greater diversity of options and perhaps risks. Whether the superficial as well as the more conventional deep veins can be used successfully as the recipient vein site is an important question analyzed in this retrospective, nonrandomized, yet inclusive review of 102 free flaps from the past decade used only for extremity defects. During this 10-year period, 144 venous microanastomoses, including 41 using superficial recipient veins, were utilized for these 102 flaps. There were 10 anastomotic catastrophes (9.8%): half were venous in origin and four fifths were salvaged by prompt reexploration. Only one venous thrombosis, and that in the deep system, resulted in flap failure. All arterial problems in every patient resulted in total flap loss, so that overall there was a 94.2% flap success rate. The overall incidence of complications and flap failure when the deep vein was the recipient site was 9.6% and 5.5% respectively. For superficial veins it was 15.4% and 7.7%, and, if used in a combination for dual venous outflow, the incidence was 6.3% for either category. There was no significant difference in these rates between groups, and in the vast majority of cases either the deep or superficial venous systems could indeed be used successfully as the recipient vein for microvascular tissue transfers.     

The importance of the pedicle for the survival of a vascularized free flap: An experimental study on rats

It has been assumed, but never shown experimentally, that the survival of a free vascularized full-thickness island flap is based on the vascular pedicle. A study using the rat was designed to assess the three parameters of flap survival: the vascular pedicle, the recipient bed, and the perimeter of the recipient area. Isolation of the pedicle by ligation caused flap necrosis in 18 out of the 20 groin flaps. An intact pedicle, with the other two parameters excluded, led to flap survival in 75% (9 of 12 flaps). Our results indicate that the critical factor to island flap survival in the immediate postoperative period is the vasculature supplying the pedicle. The two other factors are of limited importance.     

The role of meperidine in reduction of postanesthetic shivering and its possible impact on flap outcomes

Postoperative vascular compromise is a common but critical complication requiring emergent re‐exploration, and remains a chief cause of free flap failure. This study investigated the relationship between postanesthetic shivering (PAS) and the development of postoperative complications associated with free flap reconstruction. One hundred thirty‐six patients who underwent head and neck cancer resection and free flap reconstruction were retrospectively enrolled. Fifteen patients were assigned to the PAS group, while the others were assigned to the non‐PAS (NPAS) group. The odds ratios of acute re‐exploration or total failure of the free flap in the PAS group was 3.5 and 14.9, respectively. The dose of meperidine was positively correlated with PAS prevention in our statistical ROC curve analysis. The minimum effective dose of meperidine for PAS prevention was 0.35 mg/kg with 75% sensitivity and 60% specificity. These findings indicate that an optimal dose of meperidine could prevent PAS, which is shown to be associated with a decrease in the incidence of the early post‐surgical re‐exploration rate of these free flaps related to circulatory compromise. © 2013 Wiley Periodicals, Inc. Microsurgery 34:106–111, 2014.     

Brachytherapy tubes and free tissue transfer after soft tissue sarcoma resection

Irradiation commonly is used after resection of soft tissue sarcomas to decrease the local recurrence rate. Brachytherapy spares more normal tissue than external beam irradiation and permits irradiation to the tumor bed in the immediate postoperative period. After vascular anastomosis and irradiation, flap survival can be affected by vascular coagulation in the immediate postoperative period and later by vascular fibrosis secondary to irradiation effects. The purpose of the current retrospective study was to evaluate the survival of free tissue transfer when combined with brachytherapy after resection of soft tissue sarcomas. Thirty-six patients had wide resection of extremity tumors, free flap coverage, and brachytherapy 5 days after surgery. Followup averaged 54 months. There were three major and four minor complications. The major complications included two patients with free flaps who required revision of anastomosis before radiation therapy (they had brachytherapy 5 days after the second surgery without additional complications) and one patient who had a deep wound infection develop 2 months after the index procedure and required a second flap. Minor complications included one hematoma, one partial skin graft loss, and two superficial infections. Brachytherapy can be done safely at the site of microvascular anastomosis in the immediate postoperative period.     

Predictive risk factors of free flap thrombosis in breast reconstruction surgery

Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage. © 2014 Wiley Periodicals, Inc. Microsurgery 34:589–594, 2014.     

Principles of microvascular reconstruction in burn and electrical burn injuries

Free tissue transplantation is a rarely indicated procedure in burn reconstruction. As the versatility and variability of free flaps have significantly developed during recent years, so have the indications for this procedure expanded. This study reports retrospectively the results of 75 free flaps in 60 severely burned patients using 20 different free flaps. This experience enabled us to establish reconstructive principles pertinent to the type of injury (burn versus high voltage injuries) and the timing of reconstruction procedures. In high voltage injuries (n = 26) early free flap coverage (<21 days after trauma) with muscular flaps was the most frequently used type of reconstruction. Reconstruction site was predominantly the upper extremity and forearm. In burn injuries (flame, contact, fluid), free flap coverage was performed during a later stage of the treatment course (3-6 weeks after trauma), or as a secondary procedure. Reconstruction with cutaneous flaps was the preferred method. In contrast to high voltage injuries, the trunk and the face were also recipient sites. In the upper extremity, the elbow and dorsum of the hand were the most frequent sites of reconstruction. Overall, the flap failure rate was 13% (n = 10). We were able to show a relationship between flap failure rate and timing of the procedure. Eight out of 10 flap failures occurred within 5-21 days after trauma, all 10-flap failures occurred between 5 days and 6 weeks. No flap failure occurred during secondary reconstruction. For the reconstruction of complex or large defects (n = 14), we recommended combined 'chimeric' flaps, pre-expansion of free flaps, or the combination of a free and local flap. Our data demonstrate that burn and high voltage injuries are distinct entities, each requiring custom tailored reconstructive solution.     

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.     

Free microvascular TRAM flaps for breast reconstruction: the first 50 patients

Skin blood flow in the free TRAM flap has been shown to be superior to that in the pedicled TRAM flap, and in 1990 the free TRAM flap was adopted as the procedure of choice for breast reconstructions. The findings in the first 50 patients whose breasts were reconstructed with free microvascular TRAM flaps are reported. Although 92% of the patients had undergone previous axillary operation and 78% had received radiotherapy, recipient vessels could be found in all axillae. Fortyeight patients had unilateral and two bilateral reconstructions. Reduction or mastopexy was performed on the opposite breast in 50% of the patients. One flap was lost. Skin edge necrosis was found in two patients. Acceptable results with good symmetry or slight asymmetry were achieved in 96%. Seven patients had abdominal laxity due to use of Gore-Tex sutures for closure. Abdominal wall complications ceased once the suture material was changed. The complication rate decreases quickly, as experience increases. Nineteen immediate postoperative or later complications occurred in the first 25 free TRAM flap patients but only 5 in the second 25 patients. The free TRAM flap results in fewer skin problems and is an easier operation for the patient than a pedicled TRAM.     

Scapula osteocutaneous free flap reconstruction of the head and neck: impact of flap choice on surgical and medical complications

BACKGROUND: The scapula osteocutaneous free flap is frequently used to reconstruct complex head and neck defects given its tissue versatility. Because of minimal atherosclerotic changes in its vascular pedicle, this flap also may be used as a second choice when other osseous flaps are not available because of vascular disease at a preferred donor site. METHODS: We performed a retrospective chart review evaluating flap outcome as well as surgical and medical complications based upon the flap choice. RESULTS: The flap survival rate was 97%. The surgical complication rate was similar for the 21 first-choice flaps (57.1%) and the 12 second-choice flaps (41.7%; p = .481). However, patients having second-choice flaps had a higher rate of medical complications (66.7%) than those with first-choice flaps (28.6%; p = .066). Age and the presence of comorbidities were associated with increased medical complications. All patients with comorbidities that had a second-choice flap experienced medical complications, with most being severe. CONCLUSIONS: The scapula osteocutaneous free flap has a high success rate in head and neck reconstruction. Surgical complications occur frequently regardless of whether the flap is used as a first or second choice. However, medical complications are more frequent and severe in patients undergoing second-choice flaps.     

Complications associated with breast reconstruction using a perforator flap compared with a free TRAM flap

This study evaluated the recipient and donor site complications associated with breast reconstruction using a deep inferior epigastric artery perforator flap (DIEAP) flap compared with a free TRAM flap. The charts of 108 patients who underwent breast reconstruction using these techniques were reviewed. There were 130 flaps. Patients with free TRAM flaps had a significantly longer hospital stay (P=0.003). There were significantly more cases of fat necrosis in the unilateral DIEAP flaps (P=0.001). In patients who were overweight or obese (body mass index >25 kg/m), there were significantly more breast complications (P=0.006). There were more cases of abdominal flap necrosis at the donor site in smokers (P = 0.018) and the diabetic patients (P=0.013). This study suggests that postoperative complications are related to patient comorbidities, and personal factors and should be considered when selecting the most appropriate reconstructive option.     

Superficial inferior epigastric artery (SIEA) free flap using perforator vessels as a recipient site: clinical implications in autologous breast reconstruction

BackgroundBreast reconstruction with autogenous tissue is a well-established technique, but there are some limitations related to donor-site morbidity. Among available techniques, the superficial inferior epigastric artery (SIEA) flap is the least invasive procedure because it does not require harvesting or incision of the rectus muscle or the abdominal fascia. Besides adequate flap choice, the proper selection of the recipient vessels is an important factor. Thus, the internal mammary perforator branches (IMPBs) have been an attractive option regarding recipient pedicle morbidity.MethodsThe investigators reported the use of the free SIEA flap with the IMPBs as a recipient site to reconstruct radical mastectomy.ResultsFive patients with invasive ductal carcinoma underwent modified radical mastectomy and reconstruction. The IMPBs were selected as the recipient site and a free SIEA flap was used. The donor defect was closed directly without synthetic mesh. Satisfactory breast shape was achieved, and no complications were observed.ConclusionsFor selected patients, the SIEA flap and IMPBs may constitute a new alternative for immediate breast reconstruction, because of the possibility of large tissue transfer with minimal donor and recipient area morbidity. The SIEA pedicle size and the quality of IMPB vessels should be carefully evaluated.     

Lower extremity reconstruction with the anterolateral thigh flap

The versatility and location of the anterolateral thigh (ALT) flap make it well suited for lower extremity reconstruction. The purpose of this study was to evaluate surgical and functional outcomes by specific anatomic regions in the lower extremity to better define the role of the ALT flap in lower extremity reconstruction. A retrospective review of patients undergoing lower extremity reconstruction with an ALT flap between July 2002 and December 2010 was performed. Total 46 patients underwent lower extremity reconstruction with an ALT flap, of whom 29 (63%) had a pedicled flap and 17 (37%) a microvascular free flap. Defects were located in the hip/buttocks (n = 8), groin (n = 13), thigh (n = 8), knee (n = 5), leg (n = 6), and foot/ankle (n = 6). The mean postoperative follow-up was 4 months. Total flap loss occurred in two patients (4%). There were 11 recipient site complications (24%). The most common complication was recipient site seroma, which occurred in five patients (11%), all of whom had hip/buttock or groin defects. Overall, 38 patients (83%) returned to their preoperative functional status. The ALT flap is an effective method of lower extremity reconstruction. It can be performed as a pedicled or free flap, with good surgical and functional outcomes.     

Comparison of reconstruction plate and double flap for reconstruction of an extensive mandibular defect

Functional reconstruction of the anterior mandibular defect in combination with a significant glossectomy is a challenging problem for reconstructive micro‐surgeons. In this retrospective study, clinical results were compared between mandibular reconstruction plate (MRP) procedures and double flap transfers. The subjects were 23 patients who underwent immediate reconstruction, after an anterior segmental mandibulectomy in combination with a significant glossectomy, from 1993 to 2009. The patients were divided into two groups based on the reconstructive methods used: MRP and soft tissue free flap transfer (MRP group: 12 patients) or double free flap transfer (double flap group: 11 patients). Operative stress, postoperative complications and oral intake ability were compared between the groups. The rate of recipient‐site complication in the double flap group tended to be lower than that in the MRP group. The most frequent complications in the MRP group included infection and orocutaneous fistula. Operative stresses (operation time and blood loss) were significantly less in the MRP group than in the double flap group. Overall, 19 patients (82.6%) were able to tolerate an oral diet without the need for tube feeding. This study demonstrates that laryngeal preservation is possible in more than 80% of patients even after such an extensive ablation. Double flap transfer provides a more stable wound closure than MRP and should be the preferred reconstructive procedure if the patients can tolerate the associated operative stresses. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts

Traumatic limb injuries requiring free tissue transfer for coverage, often lack healthy recipient vessels adjacent to the defect. In these patients, vein grafts are required to bridge the gap of either the artery, vein or both. For the latter situation, a temporary arteriovenous fistula (AVF) can be created and allowed to mature and then divided and used as recipient artery and veins for the free flap. These cases are challenging and several variables including vein graft length, vein graft diameter, and arterial inflow affect the patency of the vessels and the final outcome of the reconstruction. Sixty-five defects were reconstructed with free tissue transfers using vein grafts of significant length (>20 cm for the arterial gap). The ipsilateral or contralateral great saphenous veins were used for vessel lengthening in all cases. Inflow arteries were either major arteries (superficial femoral, popliteal or brachial), or lesser arteries (sural, anterior or posterior tibial, thoracodorsal, or superior gluteal). The patients were divided into those that underwent AVF followed by free tissue transfer in two stages (n = 6), AVF followed by free tissue transfer in one stage (n = 28) and patients that underwent vein grafting for the arterial defect only with (n = 6) or without (n = 25) a simultaneous bypass graft for lower limb revascularization. In the two-stage AVF group, the rate of occlusion of the graft after AVF creation was 50% (3/6); re-exploration rate was 33.3% (2/6); free flap failure rate was 33.3% (2/6); and limb salvage rate was 83.3% (5/6). In the one-stage AVF group: re-exploration rate was 28.6% (8/28); free flap success rate was 89.3% (25/28); and limb salvage rate was 92.9% (26/28). In the long vein graft group for arterial defects only: re-exploration rate was 25.8% (8/31); free flap success rate was 96.8% (30/31); and limb salvage rate was 87.1% (27/31). In patients where the graft was anastomosed to a major artery the re-exploration rate and free flap failure rate were 22.4% (11/49) and 8.2% (4/49). In patients where the graft was anastomosed to a lesser artery, the re-exploration rate and free flap failure rate were 43.4% (7/16) and 12.5% (2/16). The limb salvage rate was comparable in both groups (89.8%, 44/49, versus 87.5%, 14/16). In all groups, patients undergoing re-exploration were noted to have a an arterial gap of 31.78 cm as compared with the patients that did not require re-exploration which had an arterial gap of 26.26 cm. Vein grafting for bridging vascular defects is a safe procedure when proper indications and techniques are followed. Although a longer graft length seemed to be associated with a higher re-exploration rate, there was no statistical significance. One-stage AVFs can be used with good results, however, two-stage AVFs are associated with a high graft occlusion rate, wound failure rate and limb amputation rate. In all cases, a large caliber graft such as the great saphenous vein provided a large (relatively low resistance) conduit for bridging the defect.     

Pharyngoesophageal reconstruction with lateral thigh free flap

BACKGROUND: We evaluated the use of a lateral thigh free flap in pharyngoesophageal reconstruction, which is often overlooked and less widely used despite its distinct advantages. METHODS: This study reviewed the patient's medical records, including the patient's age, gender, histopathologic diagnosis, surgical defects, flap size, flap survival, donor and recipient site complications, and swallowing function and voice rehabilitation. RESULTS: Twelve lateral thigh free flaps were used to primarily reconstruct the pharyngoesophagus in 11 patients after tumor resection from July 1997 to May 1999. Eleven of the 12 flaps (91.7%) were transferred successfully. In one patient, the flap failure occurred as a result of venous thrombosis, and therefore another lateral thigh free flap from the opposite thigh was used 3 days later. The swallowing function was restored in all patients. Prosthetic voice rehabilitation was successfully achieved in all five patients, who primarily underwent tracheoesophageal punctures. No frank fistula or stricture developed. Significant donor site morbidity was not noted. CONCLUSIONS: The lateral thigh free flap is useful and reliable in selected cases of pharyngoesophageal reconstruction and versatile in flap design with favorable functional outcomes of swallowing and voice rehabilitation with minimal donor site morbidity.     

Assessment of donor site morbidity for free radial forearm osteocutaneous flaps

Purpose: Assessment of donor site morbidity and recipient site complications following free radial forearm osteocutaneous flap (FRFOCF) harvest and evaluation of patient perceived upper limb disability for free radial forearm osteocutaneous versus fasciocutaneous flaps (FRFF). Methods: First a case series was undertaken of 218 patients who underwent an FRFOCF at two tertiary referral centers between February 1998 and November 2010. Outcomes included forearm donor site morbidity and recipient site complications. Second, the disability of the arm, shoulder, and hand (DASH) questionnaire assessing patient perceived arm disability was administered by phone to 60 consecutive patients who underwent an FRFOCF or FRFF. Results: Mean patient age was 63 years with male predominance (62.8%). Median bone length harvested was 8 cm (range, 3–12 cm) with prophylactic plating of the radius following harvest. Donor site morbidity included fracture (1 patient, 0.5%) and sensory neuropathy (5 patients, 2.3%). Mean DASH scores were comparative between groups and to established normative values. Mandibular malunion rate was 3.2% and hardware extrusion at the recipient site occurred in 15.6%. Conclusion: Reluctance to perform FRFOCF by surgeons usually centers on concerns regarding potential donor site morbidity and adequacy of available bone stock; however, we identified minimal objective or patient perceived donor site morbidity or recipient site complications following harvest of FRFOCFs. Mild wrist weakness and stiffness are common but do not impede ability to perform activities of daily living. Data from this and other reports suggest this flap is particularly useful for midfacial and short segment mandibular reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Morphostructural changes in transferred fasciocutaneous free flaps: a preliminary clinical and immunohistochemical report.

Many local factors, yet to be investigated, can promote changes in tissue transferred by microsurgical technique into the recipient site. Several studies have attempted to assess the nature of modifications that occur in the vascular network of such a flap after transfer. Although these investigations have interesting conclusions, the majority of them were based only on indirect evaluations. The aim of this study was to detect, by histological and statistical analysis, the morphostructural changes that occurred in fasciocutaneous free flaps transferred to the cephalic region or to the lower limb. Patients were enrolled in this study only when neither local inflammatory reactions nor systemic diseases were observed at the time of biopsy. Six patients consented to undergo biopsy at both the donor and the recipient area of a previously transferred fasciocutaneous free flap. Three flaps were used for facial reconstruction, and three others for lower limb reconstruction. Standard staining and immunohistochemical investigations were performed. The sections were also analysed by specific software. Statistical analysis of the data was performed using the student's t-test and Fisher's test. In five out of six transferred flaps (83%), there was increased microvascularity compared to the donor area. It was correlated to the neoangiogenesis in the dermal layer of the flaps. In five recipient sites there were more new vessels. In particular, a higher score of angiogenesis was observed both in the cheek (one flap) and in the non weight-bearing area of the foot (two flaps) (P<0.001). Some differences in microvascularity between the donor and the recipient site in the same flap were related to the specific recipient site. This represents the first demonstration of adaptation of fasciocutaneous free flaps to the recipient area, as well as to their new function, at both the macroscopic and microscopic level.     

足跟部软组织缺损的显微外科修复

目的：应用显微外科技术修复足跟部软组织缺损。方法：应用带血管蒂皮瓣转移、吻合血管皮瓣或肌皮瓣移植修复３３例足跟部软组织缺损。结果：３１例获得成功并恢复足功能与外形，２例失败。结论：足跟部软组织缺损应及时修复；皮瓣供区选择应就近避远，修复方法应就简避繁；正确处理创面、合理设计皮瓣、加强术中监护有助于修复成功。     

Incidence and significance of microscopic pathological lesions found in pedicle and recipient vessels used in microsurgical breast reconstruction

The purpose of this study was to assess the incidence of abnormal vascular histology and to determine whether or not this was correlated with the incidence of postoperative microvascular problems. The microvascular histology of both donor and recipient vessels was studied in 38 patients (40 flaps) undergoing breast reconstruction with free TRAM flaps. Preoperative risk factors were assessed and correlated with histological changes in vessels, and both were tested against anastomotic complications. Thrombosis of either the artery or the vein of the flap was seen in 6 cases (15%), and of these, two flaps failed completely and one suffered partial necrosis. The occlusion affected the arterial anastomosis in 3 patients, and the venous anastomosis in 2 patients, while both the artery and the vein were thrombosed in one case. Preoperative risk factors such as smoking, obesity, radiotherapy, and chemotherapy were not associated with a significantly higher incidence of thrombosis or with significant histological abnormalities in vessels (P value varied between 0.3-0.06). Microvascular histology showed variable degrees of pathological changes in six flaps (15%); nevertheless, in this group, only one flap suffered a venous thrombosis, which ended in total flap loss. Among those with one or more risk factors (24 patients), only 2 had some evidence of histological abnormality of the blood vessels used for the microvascular anastomosis (P = 0.2).