Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique

2017 ◽  
Vol 34 (04) ◽  
pp. 258-263 ◽  
Author(s):  
Adrian Ooi ◽  
Daniel Butz ◽  
Sean Fisher ◽  
Zachary Collier ◽  
Lawrence Gottlieb
Keyword(s):  
Three Dimensional ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Suture Line ◽  
Success Rates ◽  
Recipient Vessel ◽  
Wide Range ◽  
Extremity Reconstruction ◽  
Geometric Technique ◽  
The Ideal

Background End-to-side (ETS) anastomoses are useful when preservation of distal vascularity is critical. The ideal ETS microanastomosis should maintain a wide aperture and have a smooth take-off point to minimize turbulence, vessel spasm, and thrombogenicity of the suture line. We have developed a unique, dependable, and reproducible geometric technique for ETS anastomoses, and analyze its efficacy in our series of patients. Methods The geometric ETS technique involves creating a three-dimensional (3D) diamond-shaped defect on the recipient vessel wall, followed by a slit incision of the donor vessel to create a “spatula” fitting this defect. This technique removes sutures from the point of most turbulent blood flow while holding the recipient vessel open with a patch vesselplasty effect. We perform a retrospective review of a single surgeon's experience using this technique. Results The geometric 3D ETS technique was used in 87 free flaps with a total of 102 ETS anastomoses in a wide range of cases including head and neck, trunk and genitourinary, and extremity reconstruction. Overall, free flap success rates were 98%. Conclusions The geometric 3D ETS technique creates a wide anastomosis, minimizes turbulence-inducing thrombogenicity, and mechanically holds the recipient vessel open. It is reliable and reproducible, and when performed properly has been shown to have high rates of success in a large group of free tissue transfer patients.

scholarly journals Recipient Vessel Thrombectomy and Anastomosis within the Zone of Injury in Microvascular Extremity Reconstruction

2020 ◽  
Vol 05 (01) ◽  
pp. e15-e21
Author(s):  
Jeremy M. Powers ◽  
Jaime H. Choi ◽  
Santosh S. Kale
Keyword(s):  
Success Rate ◽  
Vein Graft ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Senior Author ◽  
Fogarty Catheter ◽  
Vein Grafts ◽  
Recipient Vessel ◽  
Flap Loss ◽  
Extremity Reconstruction

Abstract Background In traumatic extremity reconstruction, it is preferable to perform microvascular anastomoses outside the zone of injury. Alternatively, a recipient-vessel thrombectomy can be performed to improve the arterial inflow, potentially avoiding further proximal dissection and the use of a vein graft. The objective of this study was to evaluate the outcomes of microvascular anastomosis after thrombectomy in the zone of injury. Methods A retrospective review of patients who underwent free tissue transfer for traumatic extremity reconstruction by the senior author from 2013 to 2017 was conducted. Patient demographic and clinical data were gathered as well as use of vein grafts, recipient-vessel thrombectomy, postoperative anticoagulation, and flap outcomes. Results A total of 23 patients underwent 24 free flap procedures for traumatic extremity reconstruction. Ten patients underwent recipient-vessel thrombectomy with 2-Fr Fogarty catheter and were placed on postoperative anticoagulation. In this group overall, there was one case of flap loss due to late wound infection resulting in a 90% success rate. A total of 13 patients underwent 14 free flaps without the use of thrombectomy and vein grafts were performed for 3/14 (21%) patients. In this group, there were four cases of flap loss, resulting in a 71% overall success rate. Conclusion In traumatic extremity reconstruction, if the artery appears to be visibly appropriate with weak inflow, one may consider attempting thrombectomy to restore pulsatile flow prior to harvesting a vein graft. This study suggests this may be effective and safe with no anastomosis-related flap loss in the thrombectomy group. Further research is required to confirm our results.

The crystal structure of kalsilite, KAlSiO4

1965 ◽  
Vol 35 (272) ◽  
pp. 588-595 ◽  
Author(s):  
A. J. Perrotta ◽  
J. V. Smith
Keyword(s):  
Crystal Structure ◽  
Oxygen Atom ◽  
Crystal Structures ◽  
Bond Angle ◽  
Three Dimensional ◽  
Full Matrix ◽  
Ideal Position ◽  
Wide Range ◽  
The Ideal

SummaryA full-matrix, three-dimensional refinement of kalsilite, KAlSi04 (hexagonal, a 5·16, c 8.69 Å, P6a), shows that the silicon and aluminium atoms are ordered. The respective tetrahedral distances of 1·61 and 1·74 Å agree with values of 1·61 and 1·75 Å taken to be typical of framework structures. As in nepheline, an oxygen atom is statistically distributed over three sites displaced 0·25 Å from the ideal position on a triad axis. This decreases the bond angle from 180° to 163° in conformity with observations on some other crystal structures. The potassiumoxygen distances of 2·77, 2·93, and 2·99 Å are consistent with the wide range normally found for this weakly bonded atom.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review

2018 ◽  
Vol 34 (05) ◽  
pp. 334-340 ◽  
Author(s):  
Zachary Borab ◽  
William Rifkin ◽  
Adam Jacoby ◽  
Z-Hye Lee ◽  
Lavinia Anzai ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Free Flaps ◽  
Pooled Analysis ◽  
Perioperative Outcomes ◽  
Complication Rates ◽  
Recipient Vessel ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
The Impact

Background Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Methods Retrospective review (1979–2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. Results More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Conclusion Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

scholarly journals Double free-flap for a bimalleolar defect of lower leg and ankle

2016 ◽  
Vol 49 (01) ◽  
pp. 95-98
Author(s):  
Naren Shetty ◽  
Narendra S. Mashalkar ◽  
Sunder Raj Ellur ◽  
Karishma Kagodu
Keyword(s):  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Lower Leg ◽  
Donor Site Morbidity ◽  
The Other ◽  
Limb Ischaemia ◽  
Distal Limb ◽  
Limb Defects ◽  
Recipient Vessel

ABSTRACTDouble free-flaps are necessary when tissue cover cannot be sufficed with a single flap. The other factors to be considered when using two free flaps for resurfacing of distal limb defects are the availability of more than one recipient vessel, the risk of distal limb ischaemia and the donor site morbidity of double flap harvest. If these factors are adequately addressed, double free-flaps can be safely executed for resurfacing distal limb defects with minimal morbidity. We report the simultaneous harvest and transfer of the anterolateral and anteromedial thigh flaps inset and vascularised as double free-flaps to resurface a large bimalleolar defect in a 14-year-old boy with no additional morbidity as compared to that of a single free tissue transfer.

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

2020 ◽  
Author(s):  
Joon Pio Hong ◽  
Changsik John Park ◽  
Hyunsuk Peter Suh
Keyword(s):  
Decision Making ◽  
Lower Extremity ◽  
Free Flaps ◽  
Recipient Vessel ◽  
Multiple Factors ◽  
Surrounding Environment ◽  
The Status ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Abstract Background Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect. Methods One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal. Results Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm. Conclusion In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.

‘Sit and tilt’ preparation for subscapular system free flaps

2018 ◽  
Vol 132 (2) ◽  
pp. 180-183 ◽  
Author(s):  
J Mark ◽  
H Patwa ◽  
M S Costello ◽  
Y Patil
Keyword(s):  
Head And Neck ◽  
Operative Time ◽  
Donor Site ◽  
Three Dimensional ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Head And Neck Reconstruction ◽  
Advanced Head ◽  
Neck Reconstruction ◽  
Harvesting Technique

AbstractBackground:The ablation of advanced head and neck cancer often results in large three-dimensional defects that require free tissue transfer to optimally address functional and cosmetic issues. The subscapular system is a highly versatile donor site for flaps used for head and neck reconstruction. Traditional methods of harvesting subscapular flaps require repositioning and re-preparing, which significantly increases the operative time and prevents simultaneous harvesting of the flap.Method:This paper presents our experience of a single-stage ‘sit and tilt’ technique, which provides a convenient method for harvesting subscapular system free flaps without significant repositioning.Results and conclusion:This technique was used for a variety of head and neck defects, and body habitus did not seem to affect free tissue harvesting. It is hoped that utilisation of this preparation and harvesting technique will make head and neck surgeons more willing to take advantage of the subscapular system.

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review

2021 ◽  
Author(s):  
Amanda Y. Shen ◽  
Sarah Lonie ◽  
Kaiyang Lim ◽  
Hannah Farthing ◽  
David J. Hunter-Smith ◽  
...  
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Cochrane Library ◽  
Success Rates ◽  
Reliable Technique ◽  
Free Flap Monitoring ◽  
Vascular Compromise ◽  
Flap Monitoring ◽  
Meta Analyses

Abstract Background Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. Methods A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. Results A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). Conclusion Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

scholarly journals Free tissue transfer for trophic ulcer complicating leprosy

2009 ◽  
Vol 42 (01) ◽  
pp. 115-117
Author(s):  
Yogesh C. Bhatt ◽  
Nikhil S. Panse ◽  
Kinnari A. Vyas ◽  
Gunjan A. Patel
Keyword(s):  
Treatment Options ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Local Flaps ◽  
Foot Care ◽  
Recipient Vessel ◽  
Bone Removal ◽  
Anterior Tibial ◽  
Leprosy Patients ◽  
Arterial Anastomosis

ABSTRACTPlantar ulceration is the commonest disability in leprosy and occurs in about 10 to 20% of leprosy patients. Various loco-regional flaps have been described for reconstruction of trophic ulcers; however, very large defects are not amenable to local flaps and free flaps form one of the important treatment options. We present a case of a post Hansen's trophic ulcer over the forefoot managed using a radial artery forearm free flap. Debridement of the osteomyelitic bone, removal of the bony prominences, coverage by a well-vascularised tissue, end-to-side arterial anastomosis, use of anterior tibial as the recipient vessel and good postoperative compliance in foot care on the part of the patient gave us good results.

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