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 Postoperative Free-Flap Monitoring Techniques

2019 ◽  
Vol 33 (01) ◽  
pp. 013-016 ◽  
Author(s):  
Scott Kohlert ◽  
Alexandra Quimby ◽  
Masoud Saman ◽  
Yadranko Ducic
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Potential Complication ◽  
Postoperative Monitoring ◽  
Monitoring Techniques ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring ◽  
Flap Monitoring

AbstractFree tissue transfer is commonly employed in the reconstruction of large or complicated defects. Postoperative flap failure from microvascular compromise is an uncommon but major potential complication of this procedure. As such, many postoperative monitoring techniques devices have been developed. This paper provides an overview of the wide variety of options available for surgeons today.

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 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.

Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care

2018 ◽  
Vol 34 (06) ◽  
pp. 597-604 ◽  
Author(s):  
Jacob D'Souza ◽  
Wendy King ◽  
Michael Bater ◽  
Daniel van Gijn
Keyword(s):  
Free Flap ◽  
Microvascular Complications ◽  
Free Tissue Transfer ◽  
Congenital Defects ◽  
Head And Neck Reconstruction ◽  
Functional Rehabilitation ◽  
Immediate Reconstruction ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring

AbstractMicrosurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances in microsurgical techniques have helped balance the restoration of both form and function—decreasing the significant morbidity once associated with large ablative, traumatic, or congenital defects—while providing immediate reconstruction enabling early aesthetic and functional rehabilitation. There are a multitude of perioperative measures and considerations that aim to maximize the success of free tissue transfer. These include nutritional support, tight glycemic control, acknowledgment of psychological and psychiatric factors, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology. While the success rates of free tissue transfer in experienced hands are comparable to alternative options, the consequences of flap failure are catastrophic—with the potential for significant patient morbidity, prolonged hospital stay (and associated increased financial implications), and increasingly limited options for further reconstruction. Success is entirely dependent on a continuous arterial inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial and represents a dynamic process from the potentially reversible failing flap to the necrotic irreversibly failed flap—necessitating debridement, prolonged wound care, and ultimately decisions concerned with future reconstruction. The overriding goal of free flap monitoring is therefore the detection of microvascular complications prior to permanent injury occurring—identifying and intervening within that critical period between the failing flap and the failed flap—maximizing the potential for salvage. With continued technique refinement, microvascular free flap reconstruction offers patients the chance for both reliable functional and aesthetic restoration in the face of significant ablative defects. The caveat to this optimism is the requirement for considered perioperative care and the optimization of those factors that may offer the difference between success and failure.

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.

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.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

2019 ◽  
Vol 36 (01) ◽  
pp. 032-040 ◽  
Author(s):  
Jacob R. Rinkinen ◽  
Shawn Diamond ◽  
Jonathan Lans ◽  
Curtis L. Cetrulo ◽  
Kyle R. Eberlin
Keyword(s):  
Systematic Review ◽  
Soft Tissue ◽  
Activities Of Daily Living ◽  
Free Flap ◽  
Daily Living ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Ulcer Formation ◽  
Soft Tissue Reconstruction ◽  
Tissue Transfer

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

scholarly journals Free Tissue Transfer Optimizes Stump Length and Functionality Following High-Energy Trauma

2019 ◽  
Vol 04 (02) ◽  
pp. e96-e101
Author(s):  
Merisa L. Piper ◽  
Dominic Amara ◽  
Sarosh N. Zafar ◽  
Charles Lee ◽  
Hani Sbitany ◽  
...  
Keyword(s):  
Lower Extremity ◽  
San Francisco ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
High Energy ◽  
Limb Length ◽  
Flap Reconstruction ◽  
Free Flap Reconstruction ◽  
High Energy Trauma ◽  
Tissue Transfer

Abstract Background Advances in medicine and surgery have allowed patients, who in the past would have required more aggressive amputations, to maintain longer stump lengths. Microvascular free tissue transfer has become increasingly popular to preserve limb length and optimize functionality. We present our experience using microvascular free flap reconstruction to preserve lower extremity limb length in the setting of high-energy trauma. Methods We conducted an Institutional Review Board-approved retrospective review of patients at three San Francisco hospitals who underwent free flap reconstruction after high-energy trauma between 2003 and 2015. We included all patients who underwent free flap reconstruction for lower extremity limb length preservation. We reviewed patient demographics, preoperative variables, intraoperative details, and postoperative outcomes, including complications, functional status, reoperation rates, and need for revision amputation. Results Twelve patients underwent microvascular free tissue transfer for limb length preservation. Overall, the patients had similar preoperative comorbidities and a mean age of 44. Six patients had postoperative complications: three minor complications and three major complications. Seven patients had additional surgeries to improve the contour of the flap. One patient required revision amputation, while the remaining 11 patients preserved their original limb length. The majority of patients were fully ambulatory, and four used a prosthesis. Conclusion Microvascular free tissue transfer can be used to effectively maintain lower extremity stump length following trauma. Although these patients often require multiple surgeries and face lengthy hospital courses, this technique enables preservation of a functional extremity that would otherwise require a more proximal amputation.

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