Laser-induced fluorescence of indocyanine green: plastic surgical applications

The objective assessment of tissue perfusion is of utmost importance to plastic surgeons. Nevertheless, clinical observation remains the accepted gold standard for assessment of microcirculation. Dynamic laser fluorescence videography is a new technique for objective assessment of blood flow. We describe our clinical experience using this technique in plastic surgical patients. Possible implementations include evaluation of pedicle (random and axial pattern) flaps, monitoring of free tissue transfer and replants, and the objective determination of burn depth. Compared with standard clinical assessment techniques indocyanine green imaging provides significant additional information which allows a rational and evidence-based planning of surgery.     

A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care

Due to the complex, and often tenuous nature of microsurgical tissue transfer, postoperative monitoring of free tissue flaps plays a vital role in the management of such patients. Some of the more challenging reconstructive problems occur in patients with lower extremity trauma, yet to date, no preferred protocol exists for the postoperative care of lower extremity free flaps. The present study sought to evaluate and assess current preferences in monitoring following lower extremity free tissue transfer. Members of the American Society of Plastic Surgeons (ASPS) were surveyed with regard to their choice for postoperative monitoring and return to dependent positioning ("dangling"). The results demonstrate that there is some agreement among surgeons regarding the optimal means for postoperative monitoring. Most rely on clinical observation in addition to conventional Doppler probe for an average of 4.8 days. Most surgeons follow their own flaps in addition to relying on the residents and nursing staff. The study also notes a wide variety in the times and frequencies at which dangling of the extremity was commenced. Most respondents initiate dangling within 2 weeks of surgery and begin with only 1 to 5 minutes per session.     

Postoperative monitoring of free vascularized bone grafts in reconstruction of bone defects

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing large bone defects. It is especially indicated in patients with challenging conditions, such as nonunions, postoncologic resections, severe trauma, and congenital defects. With increasing experience of reconstructive surgeons, improved microsurgical techniques, and more enhanced flaps, the failure rate of free flaps has been reduced in the last decades. Especially, the early‐postoperative period is decisive in the outcome of surgery. Several techniques have been described for monitoring the postoperative viability of microsurgical free vascularized graft, and their sensitivity and reliability continues to be the object of animal experiments and clinical trials. The qualities of an optimal monitoring device should be objective, continuous, noninvasive, safe, reproducible, easily managed, and interpretable for the nursing staff, inexpensive, and a clear indicator of changes in arterial and venous circulation. Presently, no one neither fulfills all of the criteria completely nor is uniformly accepted. In this article, relative advantages and disadvantages of these various postoperative monitoring techniques are discussed. © 2009 Wiley‐Liss, Inc. Microsurgery 2009.     

Use of suture anchors in the reconstruction of soft tissue defects with pedicled muscle flaps

Suture anchors have been commercially developed to facilitate stable attachment of soft tissues to bone. Although their use is well characterized in orthopedic literature, suture anchors may also be of benefit in the reconstruction of large soft tissue defects by plastic surgeons. Suture anchors (Mitek Surgical Products, Inc., Westwood, MA) were used to fasten pedicled muscle flaps to exposed bone in 7 patients at Duke University undergoing reconstruction of large soft tissue defects. The suture anchor appeared to provide stability for the advancement flap, and there were no suspected postoperative muscle dehiscences or suture breakages. The suture anchor provides an easy, secure method to attach soft tissue to exposed bone, and preliminary experience appears to support their use in certain soft tissue reconstruction procedures by plastic surgeons. Suture anchors should be reserved for cases in which a large muscle flap is needed to cover exposed bone and poses a risk of shearing away from the bone, or adequate periosteum and soft tissue is not available for standard suture techniques.     

Continuous postoperative monitoring of cutaneous free flaps using near infrared spectroscopy.

Reliable detection of circulatory compromise threatening free-flap viability is essential for prompt surgical intervention and flap salvage. Numerous techniques have been developed to address the issue of postoperative flap monitoring but none have achieved universal acceptance. Near infrared spectroscopy (NIRS) is a noninvasive technique that allows continuous monitoring of tissue oxygenation and perfusion. It is increasingly recognised to be a reliable method for flap viability assessment. This study was designed to investigate the ability of NIRS to detect and identify microvascular thrombosis endangering flap survival. To our knowledge, this is the first clinical evaluation of NIRS used for continuous monitoring of free flaps. METHODS: Fifty flaps used for autologous breast reconstruction in 48 patients were included in this prospective clinical study. NIRS was employed for 72-h continuous postoperative monitoring. The data were compared to findings of clinical assessments. RESULTS: Ten flaps (20%) developed 13 anastomosis thromboses (two arterial and 11 venous). NIRS detected all cases of flow failure prior to clinical observation with no false positives or negatives. Based on consistent patterns of NIRS parameter changes, it was possible to differentiate between changes caused by arterial and venous thrombosis with accuracy before surgical re-exploration. The salvage rate was 70%. Overall flap viability was 94%. CONCLUSIONS: Continuous NIRS monitoring can reliably detect and identify early stages of arterial and venous thrombosis, and is a credible method for noninvasive postoperative flap surveillance. Based on these findings, we advocate its use for monitoring of flaps with a cutaneous component.     

Microdialysis detects postoperative perfusion failure in microvascular flaps

In microvascular tissue transfers, it is essential postoperatively to follow-up on the perfusion of the transferred flap because of the risk of anastomotic failure. The diagnosis of pedicle obstruction is usually made by clinical observation, but some techniques have been reported as more reliable than clinical observation in detecting perfusion failure. The authors used microdialysis (MD), a method developed to assess in situ tissue metabolism, in the follow-up of 80 consecutive microvascular flaps from October, 2001 to October, 2003. Of the 78 flaps with postoperative data, 58 flaps were uneventful clinically and using MD, and served as the reference material for normal postoperative metabolism. Twenty flaps showed some abnormality in the clinical course or with MD. Of these, 13 flaps were reoperated for anastomosis thrombosis (9 arterial, 4 venous). All thromboses were clearly recognized by MD via a decrease in the glucose concentration in the tissue (< 2.7 mmol/l) and an increase in the lactate concentrations (> 5.7 mmol/l). In some cases, MD indicated a pathological trend in glucose and lactate concentrations hours before there were any clinical signs. A system of alarm levels was developed for the staff: when the limits were reached, a critical evaluation of the situation was undertaken, and the need for reoperation was considered. In the series, the salvage rate of all thrombosed flaps was 77 percent, with a final success rate in microvascular reconstruction of 95 percent. No flap was lost due to a delay in the diagnosis of secondary ischemia, if on-line MD monitoring was available. Microdialysis is a clinically feasible and sensitive monitoring method for all kinds of microvascular flaps, especially for those in which clinical observation is difficult or impossible. The performance of the analysis is easy and can be done by even less experienced nursing staff working in institutes with a low frequency of microsurgery.     

Immediate breast reconstruction in the West Midlands: a survey of current practice.

Immediate reconstruction (IR) of the breast following mastectomy is not available to all appropriate patients. Previous studies have examined general surgeons attitudes toward reconstruction but have not assessed how these translate into surgical practice. We investigated the current rates of referral for, and availability of, IR across the West Midlands region.A postal questionnaire was sent to all breast surgery units in the region. Out of 20 units 19 responded. Units where IR was performed in-house were likely to have more breast surgeons (2.3 vs. 1.5, p=0.0106), and a higher annual workload (222 new cases vs. 174). Only two of 19 surgeons said they did not discuss IR with appropriate patients. Selection criteria in the other units included age, lack of co-morbidity, favourable pathology, smoking habit, and in one unit, only small-breasted women were offered IR. IR is performed in 13 of 19 units. Reconstructive procedures range from implants to deep inferior epigastric artery perforator (DIEP) flaps; the surgery is performed by breast and plastic surgeons together in seven units, breast surgeons alone in five and plastic surgeons alone in one. Six units do not carry out reconstruction. These units referred between two and 10 patients (average five) for IR in 2001. Units where some types of IR were available referred between three and 35 patients for surgery not performed in-house, and there was no relationship between complexity of surgery available in-house and referral rates. Reasons for low referral rates included: surgeons' attitudes; geographical isolation; long waiting times for plastic surgical opinion and for surgery; and loss of control of patients' management. Although surgeons' attitudes in the West Midlands are generally positive toward IR, availability and referral rates vary widely. Reconstructive surgeons should encourage referrals by increasing contact with general surgeons to overcome logistical problems and by ensuring appropriate systems for referral exist.     

Head and neck oncology: the UK experience. Who is publishing what?

Using the MEDLINE database (OVID), a retrospective review of the UK literature on head and neck oncology was performed for the period 1994-2000, each publication being categorised by department and first author. Tumours almost exclusively managed by general surgeons, cardiothoracic surgeons and neurosurgeons were excluded. In the years 1994 to 2000, there were a total of 120 UK publications, 72% of which came from non-academic NHS units; 23% of the publications were from ENT units, 23% from oral and maxillofacial (OMF) surgery units and 18% from plastic surgery units. The majority of plastic surgery publications described reconstructive techniques, whereas a wider range of topics was observed in the publications by ENT and OMP surgeons. Several irregularities in the MEDLINE database were discovered and are discussed. The findings of this study may be relevant to the future planning of head and neck oncology services.     

Flap monitoring after head and neck reconstruction: evaluating an observation protocol

This study evaluated the postoperative free-flap monitoring frequency protocol used in a maxillofacial unit for patients receiving free-tissue transfer for reconstruction following orofacial cancer. All free-tissue transfers undertaken in the unit between January 1992 and October 1998 were reviewed retrospectively. Of the 370 patients evaluated, 46 returned to theatre with compromised free flaps. The compromise was purely venous in origin in 37 of these cases, arterial in three and due to a combination of arterial and venous problems in six. Thirty-five of the flaps were successfully salvaged. On average, the clinical manifestation of the problem occurred 25.5 hours postoperatively. However, there was a significant time difference between flaps that were salvaged successfully and those that were not: in the salvaged group the compromise was identified 17.5 hours postsurgery compared with 51 hours for the unsuccessful group. The timing of the return to theatre following the identification of the compromise was a significant factor in the success rate: 71 minutes for those salvaged and 103 minutes for those not salvaged. It is recommended that flaps are monitored hourly for the first 72 postoperative hours and observations recorded on a chart.     

Hirudo Medicinalis and the plastic surgeon.

Medicinal leech therapy is an ancient craft that dates back to ancient Egypt and the beginnings of civilisation. The popularity of Hirudo Medicinalis has varied throughout history, reaching such a peak in Europe in the early 19th century that supplies were exhausted. During the latter half of the 19th century, their use fell out of favour, as they did not fit in with the emerging concepts of modern medicine. Leeches have enjoyed a renaissance in the world of reconstructive microsurgery during recent years, and their first reported use in alleviating venous engorgement following flap surgery was reported in this journal [M Derganc, F Zdravic, Venous congestion of flaps treated by application of leeches, Br J Plast Surg 13 (1960) 187]. Contemporary plastic and reconstructive surgeons in units throughout the United Kingdom and Ireland continue to use leeches to aid salvage of failing flaps. We carried out a survey of all 62 plastic surgery units in the United Kingdom and the Republic of Ireland to assess the current extent of use, and to investigate current practice. We have shown that the majority of plastic surgery units in the UK and Ireland use leeches post-operatively and that the average number of patients requiring leech therapy was 10 cases per unit per year. Almost all units use antibiotic prophylaxis, but the type of antibiotic and combination used is variable. We outline current practice and suggest a protocol for the use of leeches. Whilst the use of leeches is widespread, the plastic surgery community has progressed little in defining indications for their use or in achieving an accepted protocol for their application in units throughout the UK and Ireland.     

Little flaps in hand surgery

Cutaneous flaps, with spontaneous healing and skin grafts, are parts of the armaentarium of plastic surgeons. Many publications have emphasized the use of island flaps or distant flaps for soft tissue reconstruction of the hand. We will only focus on random flaps in this work. We will describe the different techniques and indications.     

皮肤软组织创伤的早期整形外科处理

目的 探索应用整形外科原则和技术，处理急性皮肤软组织创伤的方法和经验。方法对体表皮肤软组织急性创伤进行严格清创，根据创面情况选择适当的整形外科原则和技术进行处理。不伴组织缺损的普通裂伤应用整形外科精细缝合法关闭伤口，伴有组织器官缺损的创面应用组织移植方法进行修复，包括皮片、皮瓣移植等常用的整形外科技术。结果本组共治疗2000例患者，1988例伤口Ⅰ期愈合，随访6个月至1年，无明显瘢痕增生，无功能障碍，不需要Ⅱ期修复，美容效果良好。结论应用整形外科基本原则和技术处理各种急性皮肤软组织创伤。可获得满意的效果，值得临床推广应用。     

Wiederherstellung der verbrannten Extremität durch Transplantation freier Lappenplastiken

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.     

Sequential microsurgical flap reconstruction following purpura fulminans during infancy and childhood

Purpura fulminans is a potentially lethal complication of meningococcal septicemia, characterized by progressive hemorrhagic skin lesions, which can result in extensive necrosis and mummification of all the extremities. With improving survival rates in infancy and childhood, plastic surgeons are challenged more often to provide sufficient and stable soft-tissue coverage. Usually, conservative methods, such as skin grafting or amputation, are favored by many pediatric surgeons, since further specialized departments and training are not required. Often secondary reconstructive procedures to improve soft-tissue coverage have to be performed to achieve proper prosthetic fitting. Microsurgical techniques are used only in selected cases, after failure of other procedures for defect coverage. In two cases of post-acute purpura fulminans, two free flaps and three microsurgically dissected flaps were used as primary measures for defect coverage and preservation of stump length. Despite the presence of vasculitis, all flaps survived. In a third case, secondary reconstructive measures had to be performed 1 year after purpura fulminans due to insufficient soft-tissue coverage after lower leg amputation. This patient also had contractures on both hands and no grip function after complete finger loss. Several microsurgical procedures were performed to improve grip function and soft-tissue coverage. The primary use of microsurgical techniques prevents lengthy secondary reconstructive measures.     

The use of dextran post free tissue transfer.

Dextran has been used in microsurgery to reduce the risk of free tissue transfer loss. A number of regimens which vary considerably in dosage and timing have been published in the literature. Using a postal questionnaire, a survey was conducted to delineate the current practise of UK plastic surgeons. Data were received from 161 plastic surgeons in 51 units (response rate of 61%). Forty-five percent of microsurgeons routinely use dextran post-operatively whilst 29% use alternative thromboprophylaxis. The indications, post-operative regimes and duration of administration of dextran vary significantly amongst surgeons and units. The reported success rates of free tissue transfer and digital replants were 97 and 85.1%, respectively, and was not significantly affected by the use of dextran. We conclude that there is considerable variation amongst UK plastic surgeons regarding thromboprophylaxis post microsurgery. Our data suggest that the use of dextrans does not affect free tissue transfer success rates.     

The effect of postoperative anticoagulation on microvascular thrombosis

BACKGROUND: Numerous protocols exist to prevent thrombosis after free-tissue transfer. Many surgeons advocate using aspirin or other antiplatelet agents, but little objective evidence supports this practice. This study evaluates the rate of microvascular thrombosis in patients undergoing free-tissue transfer treated with or without antiplatelet agents. METHODS: All consecutive free flaps from 2002-2005 at a single center were reviewed using a prospectively maintained database. Patients were in 2 groups based on postoperative anticoagulation administration. In group 1, 325 mg of aspirin was administered daily for 5 days postoperatively. In group 2, patients were treated with 5000 units of low-molecular-weight heparin (LMWH) per day until ambulating. Patient demographics, procedure type, diagnosis, adjuvant treatment, and procedure type were recorded. Outcome variables included microvascular thrombosis, partial or total flap loss, hematoma, bleeding, deep venous thrombosis (DVT), pulmonary embolism, and death. RESULTS: Four hundred seventy patients underwent 505 microvascular free flaps to reconstruct oncologic defects. Two hundred sixty flaps (group A) received postoperative aspirin therapy; 245 flaps (group B) received LMWH therapy. Both groups were statistically similar in their composition. No statistically significant difference was noted between the 2 groups when comparing outcome variables including microvascular thrombosis, partial or total flap loss, hematoma, bleeding, DVT, pulmonary embolism, and death. CONCLUSIONS: Postoperative anticoagulation choice has no statistically significant effect on the incidence of free flap complications, including bleeding, thromboembolism, and flap loss. We conclude that aspirin or LMWH therapy demonstrates equivalent outcomes when used as single-agent postoperative anticoagulation in oncologic free flap reconstruction.     

Intraoperative and postoperative monitoring of microsurgical free tissue transfers.

Numerous techniques have been described for monitoring the postoperative viability of microsurgical free tissue transfers, and their sensitivity and reliability continue to be evaluated in animal experiments and clinical trials. Relative advantages and disadvantages of these various postoperative monitoring techniques are discussed. The concept of intraoperative monitoring of the microsurgical anastomoses during closure and inset of a free flap is introduced because many free flaps may fail on the operating table, but this only becomes clinically apparent several hours later in the early postoperative period.     

Transcutaneous Po2 monitoring for assessing viability and predicting survival of skin flaps: Experimental and clinical correlations

Rectangular skin flaps based on the right superficial epigastric vessels were designed on the groins of 36 rats. Preoperative control, intraoperative, and postoperative readings of oxygen tension (Po₂) were made atproximal, central, and distal sites on the flaps with a transcutaneous Po₂ (tcPo₂) monitor under various conditions of oxygen inspiration. The results of this experimental work indicated that the tcPo₂ monitor was useful in continuously and rapidly measuring changes in oxygen concentration in skin flaps in a noninvasive fashion. The monitoring demonstrated that the response time of the flaps to changes in the concentration of inspired oxygen was rapid (less than 15 seconds). The monitoring also was valuable in assessing viability of the flaps, in predicting flap survival, and in detecting any systemic factors influencing oxygen transport, such as pneumonia. As a result of the experimental series, tcPo₂ monitoring was used clinically to evaluate 18 flaps in 16 patients. As in the experimental series, the clinical measurements were significant and reproducible. They demonstrated that the tcPo₂ monitor provides safe, reliable monitoring of peripheral oxygenation in the microcirculation that is rapid, continuous, and totally noninvasive. It is concluded that simultaneous tcPo₂ measurements at control and flap sites provides a continuous record of the status of a flap that can improve the postoperative management of the surgical patient.     

Plastic surgery repair of abdominal wall and pelvic floor defects

Urologists often encounter large perineal and abdominal wall defects, the treatment of which may require close collaboration with the plastic surgeon. These complex defects can be successfully treated using a variety of techniques. Ventral hernias or freshly created abdominal wall defects can be treated with the basic principles of tension-free closure using abdominal wall components separation, synthetic mesh reconstruction, and, more recently, biosynthetic acellular dermis reconstruction. Pelvic floor defects often require flap reconstruction using gracilis flaps, vertical rectus abdominis myocutaneous flaps, or local fasciocutaneous flap. In this article, we seek to familiarize the urologists with the most common techniques used by plastic and reconstructive surgeons in the treatment of these complicated pelvic floor and abdominal wall defects.     

The Cook-Swartz venous Doppler probe for the post-operative monitoring of free tissue transfers in the United Kingdom: a preliminary report.

Accurate assessment of the perfusion of free tissue transfers has always been a challenge for surgeons undertaking microvascular reconstructive procedures. The complexities of flap microcirculation are often difficult to assess despite all the subjective and objective examination techniques available today, particularly when the free tissue transfer is buried, and not visible for monitoring. The Cook-Swartz venous Doppler system is a technique for monitoring venous flow in free tissue transfer consisting of an implantable, removable, 20 MHz ultrasonic probe around the venous pedicle and a battery operated portable monitor. We perceive it as a quick and easy to use system, which in our study was well received by both medical and nursing staff. It can be used in conjunction with other monitoring techniques and we found it of value following revascularisation, during inset and in post-operative monitoring of free flaps particularly when operating outside our base hospital. We believe our initial experiences, on 24 patients, with the device, supports the use of a Cook-Swartz probe as an adjunct to traditional clinical monitoring techniques. We have had no technical difficulties with its application, use and removal, so far and we plan to continue with its use when it becomes available outside of a clinical trial.