Elastic Wrapping of Lower Extremity Free Flaps during Dangling Improves Microcirculation and Reduces Pain as well as Edema

2019 ◽  
Vol 35 (07) ◽  
pp. 522-528 ◽  
Author(s):  
Jonas Kolbenschlag ◽  
Alexandra Ruikis ◽  
Lisa Faulhaber ◽  
Adrien Daigeler ◽  
Manuel Held ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Oxygen Saturation ◽  
Microvascular Reconstruction ◽  
Reconstructive Procedure ◽  
Hemoglobin Content ◽  
Edema Formation ◽  
The Impact

Background Free tissue transfer has become a common and safe reconstructive procedure. However, total or partial flap losses remain a looming threat, especially for lower extremity free flaps due to the gravitational challenge associated with dependency. Thus, the majority of microsurgical centers apply some kind of structured flap training. However, due to the lack of evidence, these differ greatly, for example, in the application of an elastic wrapping during dangling. Therefore, the aim of this study was to assess the impact of an elastic wrapping on free flap microcirculation, edema, and pain during dangling. Methods Standardized dangling was performed from postoperative day (POD) 6 to 9 in 30 patients with microvascular reconstruction of the lower extremity. The first dangling per day was performed without elastic wrapping, followed by another session with 30 mm Hg of elastic wrapping. Tissue oxygen saturation (StO2), regional hemoglobin content (rHb), and blood flow (BF) were continuously measured in the free flap; the circumference of the flap as well as pain was assessed. Results During wrapped dangling, BF as well as StO2 was significantly increased, while rHb was significantly lower on all PODs. Wrapped dangling was rated significantly more comfortable and the girth of the free flaps was significantly less after wrapped dependency when compared with unwrapped dangling. Conclusion Dangling with an elastic wrapping with 30 mm Hg pressure improved flap microcirculation and reduced pain and edema formation.

Comparison of Outcomes of End-to-End versus End-to-Side Anastomoses in Lower Extremity Free Flap Reconstructions

2020 ◽  
Vol 36 (06) ◽  
pp. 432-437 ◽  
Author(s):  
Peter Niclas Broer ◽  
Nicholas Moellhoff ◽  
Julius M. Mayer ◽  
Paul I. Heidekrueger ◽  
Milomir Ninkovic ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Arterial Disease ◽  
Muscle Flaps ◽  
Anastomotic Technique ◽  
Arterial Anastomosis ◽  
End To End ◽  
Peripheral Arterial ◽  
The Impact

Abstract Background Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD). Methods Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites. Results We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome. Conclusion Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.

Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery

2018 ◽  
Vol 34 (04) ◽  
pp. 293-299 ◽  
Author(s):  
Qing Ruan ◽  
Shawn Diamond ◽  
Scott Zimmer ◽  
Matthew Iorio
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Microvascular Reconstruction ◽  
Safety And Efficacy ◽  
Flap Transfer ◽  
Pain Scores ◽  
Patient Morbidity ◽  
Free Flap Transfer ◽  
The Mean

Background Perioperative pain, increased sympathetic tone, and peripheral vasospasm may be safely managed with regional nerve blockade during microvascular reconstruction in the lower extremity. Limited reports exist in this setting; therefore, we evaluated our use of peripheral nerve catheters (PNCs) during microvascular limb salvage to determine safety and efficacy for both patient and flap. Methods A single-institution, retrospective review of a prospectively maintained database on all patients with lower extremity free tissue transfers between 2012 and 2017 was completed. Patients were matched into groups based on PNC utilization. The use of intravenous narcotics including patient-controlled analgesia (PCA), oral narcotics, antiemetics, length of stay (LOS), associated pain scores, flap-related performance, and patient morbidity was recorded. Results Of 48 patients who underwent lower extremity free tissue transfer, 35 satisfied criteria for comparison. Of these, PNC was utilized in 83%. The mean pain score in the immediate postoperative period was 3.84 ± 2.47 (10-point Likert scale). PCA and narcotic use were decreased in the PNC group, and no adverse effects of the catheter were identified. Microsurgical outcomes were not adversely affected in comparison. Conclusion PNC utilization for lower extremity free flap transfer significantly reduced concurrent narcotic use and attained a shorter LOS. The technique provided for safe analgesia during lower extremity free flap reconstructions satisfying the microsurgeon and the anesthesiologist.

scholarly journals Protocolo de avaliação clínica baseado em escore objetivo como preditor de sucesso de retalhos livres e reimplantes

2020 ◽  
Vol 9 (2) ◽  
Author(s):  
Fernanda Ruiz de Andrade ◽  
Rafael Barra Caiado Fleury ◽  
Aleixo Abreu Tanure ◽  
Lauro Toffolo ◽  
Luis Guilherme Rosifini Alves Rezende ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Current Evidence ◽  
Statistical Computing ◽  
Long Term Outcome ◽  
Tissue Transfer ◽  
Free Flap Monitoring ◽  
Flap Monitoring

Os retalhos microcirúrgicos e reimplantes necessitam de cuidados específicos que devem ser realizados pelo cirurgião desde o momento da sua indicação, até os dias subsequentes à cirurgia. O trabalho em questão abordou à validação do protocolo utilizado pela equipe de um hospital terciário, desde o ano 2016. Os parâmetros clínicos (temperatura, cor, turgor, tempo de enchimento capilar e sangramento à perfuração) geraram um Escore que pode ser capaz de guiar a decisão do profissional, quanto à necessidade de uma reabordagem cirúrgica no período pós-operatório. Foram revisadas 55 tabelas de escores pós-cirúrgicos e correlacionados o escore obtido pelo paciente e o prognóstico da cirurgia, com o objetivo de definir valores de corte estatisticamente significativos para predição do sucesso da mesma, visando compreender à validade do protocolo em guiar a tomada de condutas. Foram determinados os valores de escores de 1 a 8 que definiram o grupo sem necessidade da intervenção cirúrgica; e aqueles superiores a 8 definiram o paciente com um risco de falha da cirurgia e necessidade da intervenção cirúrgica. Por não necessitar de procedimentos invasivos e exames de alta complexidade, o protocolo proposto torna-se uma eficiente ferramenta no diagnóstico precoce de um possível sofrimento vascular do procedimento microcirúrgico.Descritores: Retalhos Cirúrgicos; Reimplante; Microcirurgia; Protocolo Clínico; Cuidados Pós-Operatórios; Exames Médicos.ReferênciasRoehl KR, Mahabir RC. A practical guide to free tissue transfer. Plast Reconstr Surg. 2013;132(1):147-58.Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg. 2007;119(7):2092-100.Saint-Cyr M, Wong C, Buchel EW. Free tissue transfers and replantation. Plast Reconstr Surg. 2012;130(6):858-78.Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg. 2009;124(6 Suppl):295-302.Cervenka B, Bewley AF. Free flap monitoring: a review of the recent literature. Curr Opin Otolaryngol Head Neck Surg. 2015;23(5):393-98.Korompilias AV, Lykissas MG, Vekris MD, Beris AE, Soucacos PN. Microsurgery for lower extremity injuries. Injury. 2008;39(Suppl):S103-8.R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria, 2017. Disponível em: https://www.R-project.org/. Acesso em: 01 jan 2019.Bigdeli AK, Gazyakan E, Schmidt VJ. Long-term outcome after successful lower extremity free flap salvage. J Reconstr Microsurg. 2018;1:1-82.Chae MP, Rozen WM, Whitaker IS. Current evidence for postoperative monitoring of microvascular free flaps: a systematic review. Ann Plast Surg. 2015;74(5):621-32.Hidalgo DA, Jones CS. The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases. Plast Reconstr Surg. 1990;86(3):499-501.Giunta R, Geisweid A, Feller AM. Clinical classification of free-flap perfusion complications. J Reconstr Microsurg. 2001;17(5):341-45.

scholarly journals Long-Term Outcome after Successful Lower Extremity Free Flap Salvage

2018 ◽  
Vol 35 (04) ◽  
pp. 263-269 ◽  
Author(s):  
Amir Bigdeli ◽  
Emre Gazyakan ◽  
Volker Schmidt ◽  
Christoph Bauer ◽  
Günter Germann ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Component Score ◽  
Sf 36 ◽  
The Mean

Background Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage. Methods A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed. Results The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7. Conclusion Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

The Effect of Perforator Skeletonization on Pedicled Fasciocutaneous Flaps of the Lower Extremity: A Systematic Review

2020 ◽  
Vol 36 (09) ◽  
pp. 634-644
Author(s):  
Carol E. Soteropulos ◽  
Nikita O. Shulzhenko ◽  
Harry S. Nayar ◽  
Samuel O. Poore
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Complication Rate ◽  
Perforator Flap ◽  
Free Tissue Transfer ◽  
Cochrane Central Register ◽  
Fasciocutaneous Flaps ◽  
Tissue Transfer ◽  
Individual Participant ◽  
The Impact

Abstract Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity. Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used. Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01). Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

scholarly journals Use of the Anterolateral Thigh in Cranio-Orbitofacial Reconstruction

2011 ◽  
Vol 2011 ◽  
pp. 1-6 ◽  
Author(s):  
William J. Parkes ◽  
Howard Krein ◽  
Ryan Heffelfinger ◽  
Joseph Curry
Keyword(s):  
Free Flap ◽  
Case Series ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Loss ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Anterolateral Thigh ◽  
The Many ◽  
Soft Tissue Loss

Objective. To detail the clinical outcomes of a series of patients having undergone free flap reconstruction of the orbit and periorbita and highlight the anterolateral thigh (ALT) as a workhorse for addressing defects in this region. Methods. A review of 47 patients who underwent free flap reconstruction for orbital or periorbital defects between September 2006 and May 2011 was performed. Data reviewed included demographics, defect characteristics, free flap used, additional reconstructive techniques employed, length of stay, complications, and follow-up. The ALT subset of the case series was the focus of the data reviewed for this paper. Selected cases were described to highlight some of the advantages of employing the ALT for cranio-orbitofacial reconstruction. Results. 51 free flaps in 47 patients were reviewed. 38 cases required orbital exenteration. The ALT was used in 33 patients. Complications included 1 hematoma, 2 wound infections, 3 CSF leaks, and 3 flap failures. Conclusions. Free tissue transfer allows for the safe and effective reconstruction of complex defects of the orbit and periorbital structures. Reconstructive choice is dependent upon the extent of soft tissue loss, midfacial bone loss, and skullbase involvement. The ALT provides a versatile option to reconstruct the many cranio-orbitofacial defects encountered.

scholarly journals Cross-Leg as Salvage Procedure after Free Flaps Transfer Failure: A Case Report

2012 ◽  
Vol 2012 ◽  
pp. 1-3
Author(s):  
F. Contedini ◽  
L. Negosanti ◽  
E. Fabbri ◽  
V. Pinto ◽  
B. Tavaniello ◽  
...  
Keyword(s):  
Free Flap ◽  
Latissimus Dorsi ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Lower Leg ◽  
Salvage Procedure ◽  
Soft Tissue Defects ◽  
Vascular Thrombosis ◽  
Flap Failure ◽  
Tissue Defects

Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.

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.

Compromised microvascular free flaps; salvage using Fogarty vascular catheter thrombectomy

2020 ◽  
Vol 13 (12) ◽  
pp. e239251
Author(s):  
Santhosh Rao ◽  
Nitin Kumar Kashyap ◽  
Chinmaya Panda ◽  
Naveen Kumar
Keyword(s):  
Free Flap ◽  
Thrombus Formation ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Transfer ◽  
Microvascular Free Flaps ◽  
Flap Perfusion

Compromised free flap perfusion secondary to thrombus formation is a routinely encountered complication in microvascular free tissue transfer. Various modalities were tried out prophylactically to prevent thrombus formation, and likewise, various methods are tried for salvaging the flap with effective thrombectomy. We present the use of Fogarty vascular catheter for thrombectomy and effective salvage of the flap.

scholarly journals Microsurgical free tissue transfer as avaluable reconstructive procedure in foot reconstruction

2007 ◽  
Vol 40 (02) ◽  
pp. 141-146
Author(s):  
mohamed el-shazly ◽  
mohamed makboul
Keyword(s):  
Free Flap ◽  
Motor Vehicle ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Vehicle Accidents ◽  
Tissue Transfer ◽  
Scapular Flap ◽  
Radial Forearm ◽  
Foot Reconstruction

ABSTRACT Background: owing to the limited soft tissue donor sites in the foot area, the use of microsurgical tissue transfer is frequently becoming mandatory in this area, especially in cases of massive defects due to the common motor vehicle accidents in the territory of upper egypt. free flaps offer a great variety of available tissues to cover larger, multifocal or multistructural defects. they also improve the perfusion of the infected poorly perfused areas.Objectives: in this study, we tried to evaluate foot defects according to their size, shape and site and to determine the general and specific parameters of free tissue transfer to the foot area in concomitance with the patients needs.Materials and methods: eleven patients were included in this study. for each patient, complete history was taken, general and local examination, photographic documentation, laboratory investigations, imaging and other investigations were performed. free flap transfers were applied in all cases as follows: latissimus dorsi flap in five cases, rectus abdominis flap in three cases, scapular flap in one case, gracilis flap in one case and radial forearm flap in one case.Results: nine flaps survived. no infection or donor site complications were recorded. every patient had the optimum free flap as regards the defect size, site, depth, condition, shape, donor site availability and the recipient vessels′ condition.Conclusion: the study of the optimum free flap for foot reconstruction in relation to the defect present and patient conditions is crucial to have significant results.

Sign in / Sign up

Export Citation Format

Share Document