Supercharging of delayed pedicled transverse rectus abdominis myocutaneous flaps, is it a viable option?

Which one is better for multi-territory perforator flap survival, central perforator artery or central perforator vein?

BACKGROUND

The survival of multi-territory perforator flap is associated with the position of the perforators. This study aimed to explore whether use of the central perforator artery or vein was better for flap survival.

METHODS

75 male Sprague-Dawley rats were randomly divided into three groups (n=25 per group). The flap contained the right and left iliolumbar, left posterior intercostal, and left thoracodorsal angiosomes, termed angiosomes Ⅰ to Ⅳ, respectively. The anastomosis between angiosomes Ⅱ and Ⅲ was termed choke 2. In experimental group 2, only the right iliolumbar vein and the left iliolumbar artery were preserved; in experimental group 1, only the right iliolumbar artery and the left iliolumbar vein were preserved; and in the control group, only the right iliolumbar artery and vein were preserved. On day-7 after the operation, the flap arteriography, intraluminal diameter, average microvascular density, vascular endothelial growth factor (VEGF) expression and flap survival were compared among groups. Moreover, the percentages of the angiosomes were measured.

RESULTS

The dilation of the choke 2 artery was most pronounced in experimental group 2, followed by experimental group 1, and, finally, the control group (p<0.05). Similar results regarding average microvascular density, VEGF expression, and survival rate were found among the three groups. The percentages of angiosomes Ⅰ to Ⅳ were 23.1%, 23.0±3.1%, 23.0±1.9%, and 31.0±3.1%, respectively.

CONCLUSIONS

Compared with the central perforator vein, the central perforator artery was more beneficial in enhancing flap survival. A multi-territory perforator flap with the central perforator artery could capture 3 angiosomes safely.

Breast reconstruction using delayed pedicled transverse rectus abdominis muscle flap with supercharging: reports of three cases

Breast reconstruction using a pedicled transverse rectus abdominis muscle (TRAM) flap is a well-established surgical procedure. Although studies suggest that transplanting this flap using a delayed method reduces the risk of partial flap necrosis, challenges persist. Hence, we present three cases of breast reconstruction using a pedicled TRAM flap with both delaying and supercharging. Patient age, excised tissue volume for mastectomy, and follow-up period were as follows: Case 1, 58 years, 429 cm³, 5 months; Case 2, 35 years, 910 cm³, 6 months; and Case 3, 56 years, 489 cm³, 4 months. One patient (Case 2) required a large flap tissue volume to achieve breast symmetry, whereas the other two (Cases 1 and 3) had long, longitudinal scars from previous cesareans sections. In a delayed surgery, the flap was partially elevated with partial dissection and no ligation of the deep inferior epigastric artery and vein (DIEAV). An artificial dermis with a silicone membrane (Teldermis^®) was used to prevent adhesion of the rectus abdominal muscles and DIEAV to the surrounding tissue. Supercharging was performed by anastomosis between the ipsilateral DIEAV and internal thoracic AV. Flaps in zones I-III and in half of zone IV for Case 2, and zones I-III for Cases 1 and 3, were transferred; all survived without infection. This method allowed the transferring of a larger tissue volume compared with the conventional pedicled TRAM flap-transfer method. Thus, it may be useful for patients who require larger tissue volume or high-risk patients.

Effects of arterial blood supply and venous return on multi-territory perforator flap survival

This study aimed to design arterial ischemic and venous congested areas on the same multi-territory perforator flap, assessing the effects of arterial blood supply and venous return on flap survival. Totally 68 rats were randomly divided into the experimental (Exp) and control (Con) groups. In the Exp group, flaps were based on left superficial epigastric artery and right superficial epigastric vein. In the Con group, flaps were based on the left superficial epigastric artery and vein. Immediate postoperative ink-gelatin angiography, epidermal metabolite levels detection, tissue edema measurement, survival rate evaluation in half of the flaps and average microvessel density assessment were performed. Blood in the Exp group flowed through most angiosomes, but only flowed around pedicled vessels in the Con group; metabolite levels of left halves in the Con and Exp groups were comparable with those of right halves. Angiosomes with high water contents occurred in the Exp group. Survival rates of left halves in the Con and Exp groups were higher than those of right halves, and more microvessels were found in the left ventral areas of both groups compared with the right ventral area in the Exp group. These findings revealed that on the same multi-territory perforator flap, arterial blood supply, affected by venous return, is a prerequisite for flap survival.

A Preliminary Study of the Effects of Venous Drainage Position on Arterial Blood Supply and Venous Return within the Conjoined Flap

Background:

Conjoined flap viability is associated with arterial blood supply and venous return. This study aimed to assess the effects of venous drainage position on arterial blood supply and venous return within the conjoined flap.

Methods:

Fifty-four rats were divided randomly into three groups (n = 18 per group). In experimental group 2, only the right intercostal posterior artery and the left iliolumbar vein were maintained; meanwhile, only the right intercostal posterior artery and the left intercostal posterior vein were preserved in experimental group 1. The control group had only the right intercostal posterior artery and vein preserved. The distances between angiosomes were measured. At 7 days after surgery, flap survival was evaluated, lead oxide–gelatin flap angiography was performed, and average microvessel density was assessed by hematoxylin and eosin staining, and lactate levels were assessed.

Results:

The distance between angiosomes I and II was the shortest, whereas angiosomes I and III were most distant (p < 0.05). At 7 days after surgery, survival rates in experimental group 2 and experimental group 1 were both 100 percent, whereas 86.5 ± 1.6 percent of controls survived. Furthermore, angiogenesis was more obvious in experimental group 2 than in experimental group 1 and controls. Moreover, lactate levels were lower in experimental group 2 (7.47 ± 0.17 mM) and experimental group 1 (8.03 ± 0.31 mM) compared with control values (9.98 ± 0.37 mM; p < 0.05).

Conclusion:

Changes in position of venous drainage might cause continuous arterial high-pressure perfusion and venous superdrainage, which improves flap survival.

Vascularised and modified lower-leg rotationplasty for the treatment of severe infection and bone loss of the proximal femur: a case report

CASE DESCRIPTION

We report a reconstructive case in a paraplegic patient, who suffers from a severe proximal femur infection. Aiming at the preservation of the capacity to remain in a seated position to operate a wheelchair, lower leg rotationplasty was considered suitable for reconstruction. Due to severe infection and subclinical femoral artery stenosis, rotationplasty was supercharged by the inferior epigastric artery. Furthermore, extensor tendons of the foot were attached to the acetabulum to facilitate stability of the neo-hip joint.

RESULTS

Follow-up examination 1 year after surgery revealed no complications and a satisfied patient.

CONCLUSIONS

Especially in paraplegic patients, lower leg rotationplasty is a possible treatment option for severe femoral infection. Supercharging provides well-vascularised tissue to the former infection site and improves wound healing.

Multi-staged flap reconstruction for complex radiation thoracic ulcer

INTRODUCTION

Chest wall reconstruction due to previous radiation therapy can be challenging and complex, requiring a multidisciplinary approach.

PRESENTATION OF CASE

The authors present the case of a 84-year-old woman with a right chest wall radionecrosis ulcer, that was submitted to an ablative surgery resulting in a full-thickness defect of 224 cm², firstly reconstructed with a pedicled omental flap. Due to partial flap necrosis, other debridements and chest wall multi-staged flap reconstruction were performed.

DISCUSSION

This case highlights that the reconstructive choice should be individualized and dependent on patient and local factors. The authors advise that surgical team should work closely and be well versed in chest wall reconstruction with a variety of pedicled flaps, when a complication occurs.

CONCLUSION

A multi-staged flap reconstruction could be a salvage procedure for the coverage of complex, great and complicated chest wall defects due to previous radiation therapy.