The Impact of Indocyanine-Green Fluorescence Angiography on Intraoperative Decision-Making and Postoperative Outcome in Free Flap Surgery

2020 ◽  
Vol 36 (08) ◽  
pp. 556-566 ◽  
Author(s):  
Amir Khosrow Bigdeli ◽  
Benjamin Thomas ◽  
Florian Falkner ◽  
Emre Gazyakan ◽  
Christoph Hirche ◽  
...  
Keyword(s):  
Decision Making ◽  
Free Flap ◽  
Postoperative Outcome ◽  
Free Flaps ◽  
Tissue Perfusion ◽  
Flap Necrosis ◽  
Tissue Necrosis ◽  
Flap Surgery ◽  
Free Flap Surgery ◽  
Flap Design

Abstract Background Reliable perfusion of the distal portions of free flaps is decisive for the reconstructive success. Indocyanine green near-infrared video angiography (ICG-NIR-VA) has been adopted for objective assessment of free flap tissue perfusion but is thus far not used on a routine basis. Therefore, we investigated its intraoperative impact on decision-making and postoperative outcome. Methods From January 2017 to June 2019, 88 consecutive adipo- or fasciocutaneus free flaps were performed in conjunction with intraoperative ICG-NIR-VA. Free flap tissue perfusion was first assessed clinically and then compared with ICG-NIR-VA findings. Based on the results, the decision for intraoperative trimming of critically perfused flap zones was made. The way of decision-making, flap success, and failure rates as well as intra- and postoperative complication rates were analyzed. Results The overall free flap success rate was 92.0%. Partial flap necrosis occurred in five cases (5.7%) and total flap necrosis in two cases (2.3%). ICG-NIR-VA aided decision-making and flap design in 34 cases (38.6%) and led to complication-free postoperative courses. When ICG-NIR-VA was relied on (82 out of 88 flaps; 93.2%), there was no unpredicted postoperative tissue necrosis (overestimation). When ICG-NIR-VA was not relied on (6 out of 88 flaps; 6.8%), there were five cases of postoperative partial flap necrosis and one case of uneventful healing (underestimation). The sensitivity of ICG-NIR-VA was 100% (95% confidence interval [CI]: 64.6–100) and the specificity was 98.8% (95% CI: 93.3–100) with a positive predictive value of 87.5% (95% CI: 52.9–99.4) and a negative predictive value of 100% (95% CI: 95.4–100). Conclusion Intraoperative ICG-NIR-VA objectified free flap perfusion and thus refined surgical decision-making on flap design in all cases. It could always predict tissue necrosis and subjectively improved outcomes in free flap surgery at our institution. Furthermore, it could be easily implemented in intraoperative routine, only adding minimal additional operative time.

scholarly journals Primary thrombolysis for free flap surgery in head and neck reconstruction: a case report and review

2021 ◽  
Vol 48 (5) ◽  
pp. 511-517
Author(s):  
Steven Liben Zhang ◽  
Hui Wen Ng
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Arterial Thrombosis ◽  
Free Flaps ◽  
Recombinant Tissue Plasminogen Activator ◽  
Head And Neck Reconstruction ◽  
Flap Surgery ◽  
Neck Reconstruction ◽  
Free Flap Surgery ◽  
Flap Perfusion

The use of free flaps is an essential and reliable method of reconstruction in complex head and neck defects. Flap failure remains the most feared complication, the most common cause being pedicle thrombosis. Among other measures, thrombolysis is useful when manual thrombectomy has failed to restore flap perfusion, in the setting of late or established thrombosis, or in arterial thrombosis with distal clot propagation. We report a case of pedicle arterial thrombosis with distal clot propagation which occurred during reconstruction of a maxillectomy defect, and was successfully treated with thrombolysis using recombinant tissue plasminogen activator. We also review the literature regarding the use of thrombolysis in free flap surgery, and propose an algorithm for the salvage of free flaps in head and neck reconstruction.

scholarly journals Current evidence for outcomes of free-flap reconstruction in factor V Leiden patients

2019 ◽  
Vol 2 (2) ◽  
pp. 58-66
Author(s):  
Isobel Yeap ◽  
Chris Ahn ◽  
Stuart Hoffman ◽  
Rowan Gillies ◽  
John Vandervord
Keyword(s):  
Free Flap ◽  
Factor V Leiden ◽  
Free Flaps ◽  
Current Evidence ◽  
Factor V ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Flap Surgery ◽  
Flap Failure ◽  
Free Flap Surgery

Background: Factor V Leiden is the most common form of inherited thrombophilic syndrome, affecting five per cent of caucasians. While increased rates of venous thromboembolic complications have been regularly reported in factor V Leiden patients, little is known about their risk of microvascular complications or flap failure rates in free-flap surgery. The aim of this review is to qualitatively review the published literature on outcomes of free-flap surgery in patients with factor V Leiden. Methods: MEDLINE®, PubMed, EMBASE and Cochrane were searched from their dates of inception to March 2017. Nine studies of level IV evidence were included in this qualitative review. In total, these studies included 22 patients who underwent 24 free-flap operations. Results: Nine flap failures were reported due to thrombotic complications. Even heterozygous factor V Leiden patients had a relatively high risk of free-flap failure (3/15 free flaps), and patients who were heterozygous for factor V Leiden and had other coexistent thrombophilias had an even higher failure rate (5/6 free flaps). However, the small sample size across the nine studies, as well as the inevitable publication bias, means that definitive conclusions cannot be drawn. Conclusion: Despite factor V Leiden being a relatively common condition in Australia, current evidence for outcomes of free-flap reconstruction in this patient population is lacking.

Ischaemia-Reperfusion Injury

1998 ◽  
Vol 23 (5) ◽  
pp. 570-573 ◽  
Author(s):  
M. M. AL-QATTAN
Keyword(s):  
Reperfusion Injury ◽  
Free Flap ◽  
Tissue Necrosis ◽  
Flap Surgery ◽  
Ischaemia Reperfusion Injury ◽  
Ischaemia Reperfusion ◽  
Free Flap Surgery ◽  
Circulatory Flow

Prolonged ischaemia sometimes occurs in replantation and free flap surgery. The re-establishment of circulatory flow to the ischaemic tissue leads to a cascade of events which augments tissue necrosis. This paper reviews the pathophysiology of this ischaemia-reperfusion injury and discusses different methods to modulate this injury.

Considerations in Free Flap Reconstruction of the Midface

2021 ◽  
Author(s):  
Daniel Hammer ◽  
Aurora G. Vincent ◽  
Fayette Williams ◽  
Yadranko Ducic
Keyword(s):  
Free Flap ◽  
Preoperative Assessment ◽  
Free Flaps ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
Pedicle Flap ◽  
Free Flap Surgery ◽  
Management Of Complications ◽  
Flap Design ◽  
Midface Reconstruction

AbstractMidface reconstruction has been a consistent challenge for reconstructive surgeons even with the significant advances in technology and technique achieved over the recent years. A meticulous preoperative assessment of the patient is required to properly assess the defect or anticipated defect, determine proper reconstructive surgical plan, and discuss expected functional and aesthetic outcomes with the patient. For years we have employed local flaps, regional flaps, obturators, alloplastic implants, free flaps, or a combination of the previously mentioned techniques to address complex midface reconstruction. Free flap reconstruction in the midface requires special considerations for the pedicle, flap selection, and flap design to ensure an optimal outcome. The introduction of virtual surgical planning for reconstruction has enhanced patient outcomes to include advances in immediate dental rehabilitation at the time of free flap surgery. Postoperative considerations including quality of life, functional and aesthetic outcomes, and management of complications will also be discussed.

Free Flap Reconstruction of Extremity Defects in Pediatric Patients

2021 ◽  
Vol 53 (04) ◽  
pp. 349-355
Author(s):  
Jin Li ◽  
Hewei Xiong ◽  
Gongchi Li ◽  
Pan Zhou ◽  
Fangxin Ai ◽  
...  
Keyword(s):  
Success Rate ◽  
Free Flap ◽  
Pediatric Patients ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Functional Improvement ◽  
Flap Surgery ◽  
Global Functioning ◽  
Free Flap Surgery

Abstract Background Microsurgical reconstruction of extremity defects with free flaps has been carried out for many years. The aim of this retrospective study is to characterize free flap surgery on children of 1 to 7 years old by evaluating a series of 20 cases of free flap surgeries that have been performed in pediatric patients. Methods From February 2014 to January 2018, 20 patients, 10 boys and 10 girls aged from 1 to 7 years (average, 4.6 years), were engaged in this study. Several types of free flaps were used, including anterolateral thigh flaps (ALT), inferior ulnar collateral artery flap, latissimus dorsi flap, medial plantar flap, fibular osteocutaneous flap and hallux toenail flap. After operations, follow-up period was at least for 2 years and the average follow-up period was 48.5 months. The long-term outcomes were estimated by questionnaires derived from the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collection Instrument (PODCI). Results A total of 21free-flap reconstructions were performed on 20patients, including 15 ALT, 3 composite flaps, and 3 other cutaneous flaps. The size of the tissue flap ranged from 1.5 to 280 cm2 (average, 74.1cm2). The diameter of the anastomosed artery of the flap ranged from 0.7 to 1.2 mm. Among the 21 flaps, 20 survived and the success rate was about 95 %. Contour adaption was achieved in all flaps. Fifteen children received a secondary operation for debulking or functional improvement. Secondary deformity was present in 3 children, among which ankle joint valgus was seen in two children and a flexion deformity of injured toe occurred in one child. The mean global functioning score of PODCI was 94 (ranging from 81 to 98, maximum 100). Conclusion The success rate of free-flap surgery in pediatric patients was comparable to that achieved in adults. Post-operative caring for pediatric patients was easier than expected. For pediatric patients, the final outcomes were not varied remarkably from different types of free tissue transfer.

scholarly journals 240 Aetiology and Outcomes of Head and Neck Free Flaps in Patients Aged ≥ 65 Years: The Cambridge Experience

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
C Hjalmarsson ◽  
T Chan ◽  
R Chawla ◽  
A Patel
Keyword(s):  
Free Flap ◽  
Free Flaps ◽  
Flap Surgery ◽  
Related Factors ◽  
Flap Failure ◽  
Standard Management ◽  
Free Flap Surgery ◽  
Radial Forearm ◽  
Surgery Department

Abstract Introduction Elderly patients often present to the Head & Neck Plastic Surgery department with complex reconstructive needs, for which free flaps are the gold-standard management. In order to provide appropriate, patient-centred care, it is imperative to understand how increasing age and related factors affect long-term free flap outcomes. Method The authors carried out a retrospective review of all patients 65+ years who underwent free flap surgery at Addenbrooke’s Hospital from 2008-2019. Patient, operative, and flap characteristics, and outcomes, were analysed using Excel and RStudio. Results 163 patients were identified (54F, 109M). The majority were ALT (n = 74), radial forearm (n = 35), and fibula flaps (n = 23). Of pre-operative comorbidities, only neurological comorbidities (n = 16), were significantly associated with long-term flap failure (p = 0.016). There was no significant association between number of comorbidities and flap outcome. There was no association between age group and length of stay. Flap site complications, and particularly venous complications, were significantly associated with later failure (p = 0.001). No other complications were statistically associated with flap failure. Conclusions The high success rate supports the use of free flaps in the 65+ population. This data supports a case-by-case approach to assessing fitness for free flap surgery rather than excluding patients on the basis of age or specific comorbidities.

Reversed Arterial and Venous Flow in Free-Flap Surgery for Leg Reconstruction

2006 ◽  
Vol 22 (04) ◽  
Author(s):  
Soo Hahn ◽  
Sung Kim ◽  
Ho Kang ◽  
Sun Joo
Keyword(s):  
Free Flap ◽  
Flap Surgery ◽  
Venous Flow ◽  
Free Flap Surgery

scholarly journals Improvised perioperative techniques to meet the challenges of microvascular free flap surgery

2016 ◽  
Vol 3 (2) ◽  
pp. 99-100
Author(s):  
Soumi Pathak ◽  
Itee Chowdhury ◽  
Ajay Kumar Bhargava
Keyword(s):  
Free Flap ◽  
Neck Region ◽  
Flap Surgery ◽  
Surgical Morbidity ◽  
Head And Neck Region ◽  
Form And Function ◽  
Free Flap Surgery ◽  
And Function ◽  
Microvascular Free Flap

Deformities of the head and neck region after radical oncosurgery can have devastating effects on the appearance of the patient with significant impact on patients quality of life. Reconstruction of such defects continues to be an extremely demanding challenge for plastic surgeons who aim to restore form and function with minimal surgical morbidity. The purpose of this communications is to highlight the various interventions and the protocols that are adopted to decrease the free flap failure rate.  

scholarly journals Does Low-Dose Heparin Have a Significant Role in Free Flap Surgery?

2017 ◽  
Vol 18 (3) ◽  
pp. 162-165 ◽  
Author(s):  
Mun-Young An ◽  
Jin Yong Shin ◽  
Young-Keun Lee ◽  
M. Diya Sabbagh ◽  
Si-Gyun Roh ◽  
...  
Keyword(s):  
Significant Role ◽  
Free Flap ◽  
Low Dose ◽  
Flap Surgery ◽  
Dose Heparin ◽  
Free Flap Surgery ◽  
Low Dose Heparin
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