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Continuous intraoperative perfusion monitoring of free microvascular anastomosed fasciocutaneous flaps using remote photoplethysmography. Sci Rep 2023; 13:1532. [PMID: 36707664 PMCID: PMC9883527 DOI: 10.1038/s41598-023-28277-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 01/16/2023] [Indexed: 01/29/2023] Open
Abstract
Flap loss through limited perfusion remains a major complication in reconstructive surgery. Continuous monitoring of perfusion will facilitate early detection of insufficient perfusion. Remote or imaging photoplethysmography (rPPG/iPPG) as a non-contact, non-ionizing, and non-invasive monitoring technique provides objective and reproducible information on physiological parameters. The aim of this study is to establish rPPG for intra- and postoperative monitoring of flap perfusion in patients undergoing reconstruction with free fasciocutaneous flaps (FFCF). We developed a monitoring algorithm for flap perfusion, which was evaluated in 15 patients. For 14 patients, ischemia of the FFCF in the forearm and successful reperfusion of the implanted FFCF was quantified based on the local signal. One FFCF showed no perfusion after reperfusion and devitalized in the course. Intraoperative monitoring of perfusion with rPPG provides objective and reproducible results. Therefore, rPPG is a promising technology for standard flap perfusion monitoring on low costs without the need for additional monitoring devices.
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Wearable, wireless, multi-sensor device for monitoring tissue circulation after free-tissue transplantation: a multicentre clinical trial. Sci Rep 2022; 12:16532. [PMID: 36192423 PMCID: PMC9529918 DOI: 10.1038/s41598-022-21007-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/21/2022] [Indexed: 12/05/2022] Open
Abstract
Wearable sensors have seen remarkable recent technological developments, and their role in healthcare is expected to expand. Specifically, monitoring tissue circulation in patients who have undergone reconstructive surgery is critical because blood flow deficiencies must be rescued within hours or the transplant will fail due to thrombosis/haematoma within the artery or vein. We design a wearable, wireless, continuous, multipoint sensor to monitor tissue circulation. The system measures pulse waves, skin colour, and tissue temperature to reproduce physician assessment. Data are analysed in real time for patient risk using an algorithm. This multicentre clinical trial involved 73 patients who underwent transplant surgery and had their tissue circulation monitored until postoperative day 7. Herein, we show that the overall agreement rate between physician and sensor findings is 99.2%. In addition, the patient questionnaire results indicate that the device is easy to wear. The sensor demonstrates non-invasive, real-time, continuous, multi-point, wireless, and reliable monitoring for postoperative care. This wearable system can improve the success rate of reconstructive surgeries.
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Real-Time Assessment of Free Flap Capillary Circulation Using Videocapillaroscopy. Plast Reconstr Surg 2022; 150:407-413. [PMID: 35674509 DOI: 10.1097/prs.0000000000009370] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free tissue transfer is a common method of reconstruction for various surgical defects. Many clinical assessment methods, including flap color monitoring and capillary refill time measurements, are commonly used to assess the microcirculation of the flap, yet there is no objective tool available that can clear real-time visualization of the flap microcirculation. The purpose of this study was to use a novel videocapillaroscope to evaluate the circulation changes on free flap skin surfaces while purposely clamping pedicle vessels. METHODS Ten patients who underwent free flap transfer for head and neck cancer from November of 2019 to June of 2020 were included in the study. Videocapillaroscopic observation was performed after flap elevation, and changes in the flap skin capillary circulation with artery-controlled and vein-controlled clamping were recorded. RESULTS Average total surgery time was 517.91 minutes (SD, 73.3 minutes), average flap elevation time was 102.9 minutes (SD, 18.3 minutes). When the pedicle artery or vein was purposely clamped, the movement of red blood cells in blood vessels stopped; when clamps were removed after 60 seconds, the restoration of red blood cell movements was rapidly observed. When the pedicle artery was clamped, the number of visualizable blood vessels decreased and flap color became relatively white. When the pedicle vein was clamped, the number of visualizable blood vessels increased, and flap color tone had a tendency toward red. CONCLUSION Novel videocapillaroscopy can be utilized for objective real-time flap monitoring by directly visualizing flap skin capillary microcirculation. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Denis B, Gourbeix C, Coninckx M, Foy JP, Bertolus C, Constantin JM, Degos V. Maxillofacial free flap surgery outcomes in critical care: a single-center investigation looking for clues to improvement. Perioper Med (Lond) 2022; 11:11. [PMID: 35264210 PMCID: PMC8908562 DOI: 10.1186/s13741-022-00244-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background Maxillofacial surgery for free flap reconstructions is associated with many complications due to technical complexity and comorbidity of patients. With a focus on critical care, the authors studied the impact of complications to highlight predictors of poor postoperative outcomes in order to implement optimization protocols. Methods This case-control study analyzed the relationship between perioperative variables and postoperative medical and surgical complications of patients who underwent head and neck surgery using fibular and forearm free flaps. The primary objective was the incidence of prolonged intensive care unit (ICU) length of stay (LOS). Secondary objectives were the incidence of ICU readmissions, postoperative infections, and 1-year mortality. A univariable logistic regression model was used. A study of mortality was performed with survival analysis. Regarding our primary objective, we performed a Benjamini-Hochberg procedure and a multivariable Poisson regression with defined variables of interest. Results The data of 118 hospital stays were included. Prolonged ICU LOS was observed in 47% of cases and was associated with chronic obstructive pulmonary disease, pneumopathies, intraoperative blood transfusion, and surgical duration. Medical and surgical complications were associated with prolonged ICU LOS. After the Benjamini-Hochberg procedure, infectious complications, complications, major complications, total number of pneumopathies, and operative time remained significant. At least one complication was experienced by 71% of patients during the hospitalization, and 33% of patients suffered from major complications. Infectious complications were the most common (40% of patients) and were mainly caused by pneumonia (25% of patients); these complications were associated with low preoperative hemoglobin level, intraoperative blood transfusion, accumulation of reversible cardiovascular risk factors, chronic alcohol consumption, and duration of surgery. Pneumonia was specifically associated with chronic obstructive pulmonary disease. The ICU readmission rate was 10% and was associated with lower preoperative hemoglobin level, pneumopathies, surgical duration, and use of a fibular flap. The 1-year mortality was 12%, and the survival analysis showed no association with prolonged ICU LOS. Poisson regression showed that ICU LOS was prolonged by smoking history, lower preoperative hemoglobin level, intraoperative blood transfusion, major complication, and pneumopathies. Conclusions Practices such as blood management and respiratory prehabilitation could be beneficial and should be evaluated as a part of global improvement strategies.
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Affiliation(s)
- Bruno Denis
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France. .,Intensive Care Unit, Saint-Luc Hospital, Université Catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Claire Gourbeix
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Marine Coninckx
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Philippe Foy
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Chloé Bertolus
- Maxillofacial Surgery Unit, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Jean-Michel Constantin
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
| | - Vincent Degos
- Department of Anesthesia and Intensive Care, Pitié-Salpêtrière Hospital, Boulevard de l'Hôpital 47-83, 75013, Paris, France
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Sayre KS, Kovatch KJ, Hanks JE, Stucken CL, Ward BB. Current Practices in Microvascular Reconstruction by Oral and Maxillofacial Surgeons. J Oral Maxillofac Surg 2021; 79:1963-1969. [PMID: 34022137 DOI: 10.1016/j.joms.2021.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/01/2021] [Accepted: 04/08/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE Microvascular free tissue transfer (MFTT) is a reliable reconstructive option with variation in perioperative care and a general lack of clinical practice guidelines. Oral and maxillofacial surgeons' (OMSs) current MFTT perioperative practices in the United States have not been described. This study describes these practices including surgeon practice environment, operative practices, perioperative management, and success. METHODS The study design is cross sectional. The sample is composed of OMSs who completed an Oral/Head and Neck Oncologic and Microvascular Surgery Fellowship prior to 2018 in the United States. Data were collected by means of a survey of the study sample. Descriptive statistics were reported. RESULTS Forty surgeons responded to the survey for a response rate of 33.9%. Respondents were 97.5% (n = 39) male and worked in private (n = 8), combination (n = 10), and academic practices (n = 23). Surgeons in private and academic practice performed an average of 23.3 (SD 13.9) and 48.6 (SD 28.6) flaps per year, respectively. The 2-team approach was used by 88.2% of surgeons. Immediate dental implants were placed in osteocutaneous free flaps by 28.6% (n = 2) of private practice surgeons and 70% (n = 14) of academic surgeons. Postoperatively, most patients went to an intensive care unit (ICU) (82.7%, average duration 2.6 days). Anticoagulation or antiplatelet medications were routinely used with the most common choice being aspirin (77.4%, n = 24). Antibiotics were universally administered, often for 3 days or longer (74.2%, n = 23). Self-reported success rates were 95.3% (SD 4.1) and 96.0% (SD 1.7) in private and academic settings, respectively. CONCLUSION This is the first report of practice trends by microvascular OMSs in the United States. The results of this study suggest that there is variation in MFTT operative and perioperative practices by individual surgeons and practice environment with minimal variation in self-reported success rates.
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Affiliation(s)
- Kelly S Sayre
- Former Resident, Section of Oral & Maxillofacial Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, MI; Current Fellow, Oral Oncologic and Microvascular Reconstructive Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kevin J Kovatch
- Former Resident, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI; Current Fellow, Head and Neck Oncologic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - John E Hanks
- Former Resident, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI; Current Assistant Professor, Otolaryngology, Veterans Administration Medical Center, Boston University, Boston, MA
| | - Chaz L Stucken
- Assistant Professor, Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine, Ann Arbor, MI
| | - Brent B Ward
- Chalmers J. Lyons Professor and Chair, School of Dentistry, Section Head, Department of Surgery, Michigan Medicine, Ann Arbor, MI.
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Molitor M, Mestak O, Pink R, Foltan R, Sukop A, Lucchina S. The use of sentinel skin islands for monitoring buried and semi-buried micro-vascular flaps. Part I: Summary and brief description of monitoring methods. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 165:113-130. [PMID: 33821844 DOI: 10.5507/bp.2021.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 02/26/2021] [Indexed: 11/23/2022] Open
Abstract
Micro-vascular flaps have been used for the repair of challenging defects for over 45 years. The risk of failure is reported to be around 5-10% which despite medical and technical advances in recent years remains essentially unchanged. Precise, continuous, sensitive and specific monitoring together with prompt notification of vascular compromise is crucial for the success of the procedure. In this review, we provide a classification and brief description of the reported methods for monitoring the micro-vascular flap and a summary of the benefits over direct visual monitoring. Over 40 different monitoring techniques have been reported but their comparative merits are not always obvious. One looks for early detection of a flap's compromise, improved flap salvage rate and a minimal false-positive or false-negative rate. The cost-effectiveness of any method should also be considered. Direct visualisation of the flap is the method most generally used and still seems to be the simplest, cheapest and most reliable method for flap monitoring. Considering the alternatives, only implantable Doppler ultrasound probes, near infrared spectroscopy and laser Doppler flowmetry have shown any evidence of improved flap salvage rates over direct visual monitoring.
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Affiliation(s)
- Martin Molitor
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Ondrej Mestak
- Department of Plastic Surgery, First Faculty of Medicine Charles University and Na Bulovce Hospital, Prague, Czech Republic
| | - Richard Pink
- Department of Maxillofacial Surgery, University Hospital Olomouc and Faculty of Medicine and Dentistry, Palacky University Olomouc, Czech Republic
| | - Rene Foltan
- Department of Maxillofacial Surgery, General University Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Andrej Sukop
- Department of Plastic Surgery, University Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Stefano Lucchina
- Hand Unit, General Surgery Department, Locarno's Regional Hospital, Via Ospedale 1, 6600 Locarno, Switzerland
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Kamali A, Docherty Skogh AC, Edsander Nord Å, Lundgren K, Jergovic D, Hammarstedt Nordenvall L, Sommar P, Halle M. Increased salvage rates with early reexploration: A retrospective analysis of 547 free flap cases. J Plast Reconstr Aesthet Surg 2021; 74:2479-2485. [PMID: 33879412 DOI: 10.1016/j.bjps.2021.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/30/2020] [Accepted: 03/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Free flap complications are generally rare, but not negligible since they may exert paramount impact on both patients and care providers. The aim of the study was to identify risk factors for reexploration and assess predictors associated with increased salvage rates. METHODS A retrospective cohort study was conducted for free flaps performed between 2006 and 2015. Patient demographics, indications and flap types were analyzed together with complications and time to reexploration. RESULTS Among 547 consecutive free flaps, 11.5% required acute reexploration. Hematoma together with vascular compromise was the main cause (41.9%) for reexploration, followed by hematoma only (19.4%), venous (16.1%) and arterial (6.5%) thrombosis. Hematoma was associated with an increased risk for concomitant vascular complication (p < 0.02). The incidence of total and partial flap necrosis was 3.5% and 3.7% respectively. There was an overall 71.4% salvage rate. The median time from detection of a compromised flap to reexploration was 3.0 h. Significantly higher salvage rates were observed for cases reexplored within (82.4%) compared to after (57.1%) 3.0 h (OR 3.50 (95% CI 1.10 to 11.13, p = 0.034)). CONCLUSIONS The current study highlights the importance of early intervention, including evacuation of hematomas that may lead to vascular compromise. Adequate monitoring of venous outflow was found necessary to improve flap salvage rates, whereas arterial complications were mainly related to persistent arterial injury in traumatized extremities with reduced salvage rates. Free flap surgery requires trained staff and immediate access to operating facilities to ensure high flap survival rates.
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Affiliation(s)
- A Kamali
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - A-C Docherty Skogh
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Å Edsander Nord
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - K Lundgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden; Department of Craniofacial Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden
| | - D Jergovic
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - L Hammarstedt Nordenvall
- Department of Otorhinolaryngology, Head and Neck Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Clinical Science, Intervention and Technology, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - P Sommar
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - M Halle
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital, 171 76 Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden.
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Abstract
Advances in free flap reconstruction of complex head and neck defects have allowed for improved outcomes in the management of head and neck cancer. Technical refinements have decreased flap loss rate to less than 4%. However, the potential for flap failure exists at multiple levels, ranging from flap harvest and inset to pedicle lay and postoperative patient and positioning factors. While conventional methods of free flap monitoring (reliant on physical examination) remain the most frequently used, additional adjunctive methods have been developed. Herein we describe the various modalities of both invasive and noninvasive free flap monitoring available to date. Still, further prospective studies are needed to compare the various invasive and noninvasive technologies and to propel innovations to support the early recognition of vascular compromise with the goal of even greater rates of flap salvage.
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Affiliation(s)
- Adam Jacobson
- Department of Otolaryngology - Head and Neck Surgery, NYU Langone Health, New York, New York
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
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9
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Shinomiya R, Sunagawa T, Nakashima Y, Kodama A, Hayashi Y, Tokumoto M, Adachi N. Monitoring Vascular Compromise Using Ultrasound After Free Tissue Transfer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1213-1222. [PMID: 31880342 DOI: 10.1002/jum.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 12/08/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To report the clinical utility of high-resolution ultrasound (US) for monitoring vascular compromise after free tissue transfer. METHODS Fifty-two tissue transfers in the extremities were included in this study. Blood flow around the anastomotic pedicle and subcutaneous tissue of the grafted flap was monitored with pulsed color and power Doppler US whenever the conventional monitoring method, comprising the bedside assessment of the temperature, capillary refill, and flap color, showed abnormalities until 1 week after reconstruction. RESULTS All flaps were indicated for US monitoring, with 44 flaps showing Doppler signals in each position, even though conventional flap monitoring showed an abnormality. Forty of the 44 flaps showed no flap failure, whereas the remaining 4 flaps developed partial necrosis. Abnormal US findings were noted in 8 of the 52 flaps. Ultrasound revealed interruption of venous blood flow around the anastomotic pedicle in 6 of 8 flaps. Emergent exploration revealed venous occlusion at the anastomotic pedicle, similar to the US finding. In 2 of the 8 flaps, US showed no blood flow to either the anastomotic pedicle or subcutaneous tissue. Emergent exploration revealed arterial occlusion at the anastomotic pedicle. Seven of the 8 reexplored flaps were salvaged after revision surgery with complete flap survival. Partial flap survival was noted in 1 case, but complete flap failure was avoided. CONCLUSIONS Ultrasound is a useful adjunct that enables a direct assessment of perfusion in grafted tissues, which may reduce unnecessary exploration when conventional flap monitoring shows an abnormality.
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Affiliation(s)
- Rikuo Shinomiya
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Sunagawa
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nakashima
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akira Kodama
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuta Hayashi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Maya Tokumoto
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Retrospective evaluation of diagnostic accuracy of free flap monitoring with the Cook-Swartz-Doppler probe in head and neck reconstruction. J Craniomaxillofac Surg 2019; 47:1973-1979. [PMID: 31810844 DOI: 10.1016/j.jcms.2019.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/13/2019] [Accepted: 11/15/2019] [Indexed: 11/21/2022] Open
Abstract
The Cook-Swartz-Doppler probe is an easy to handle and reliable tool for free flap monitoring. In the head and neck region different confounders can affect the read out. We therefore analyzed the use of the Doppler probe regarding these potential difficulties and to compare the diagnostic accuracy in arterial or venous monitoring of free flaps in the head and neck region. A retrospective study was performed in which all patients were included who underwent free flap surgery in the head and neck region in the Department of Plastic Surgery and the Department of Maxillofacial Surgery of our institution between 2010 and 2018 and were monitored with an implanted Doppler probe. 147 free tissue transfers were included. No significance was found for arterial and venous placement of the Doppler probe for sensitivity (artery 83.3%; vein 84.6%; p = 0.87), specificity (artery 89.2%; vein 96.1%; p = 0.17) and negative predictive value (artery 96.7%; vein 94.2%; p = 0.55). A better positive predictive value for placing the Doppler probe around the artery (82.7%) than the vein (61.1%) was found in our study (p = 0.056). The better positive predictive value in arterial monitoring suggests that this is the more reliable measuring method to assess flap perfusion in the head and neck region.
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Gu J, Tomioka Y, Kaneko A, Enomoto S, Saito I, Okazaki M, Someya T, Sekino M. Algorithm for evaluating tissue circulation based on spectral changes in wearable photoplethysmography device. SENSING AND BIO-SENSING RESEARCH 2019. [DOI: 10.1016/j.sbsr.2019.100257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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12
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Arnež ZM, Ramella V, Papa G, Novati FC, Manca E, Leuzzi S, Stocco C. Is the LICOX® PtO2system reliable for monitoring of free flaps? Comparison between two cohorts of patients. Microsurgery 2018; 39:423-427. [DOI: 10.1002/micr.30396] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/13/2018] [Accepted: 10/05/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Zoran Marij Arnež
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
- Plastic Surgery DepartmentOspedale di Cattinara, ASUITs Trieste Italy
| | - Vittorio Ramella
- Plastic Surgery DepartmentOspedale di Cattinara, ASUITs Trieste Italy
| | - Giovanni Papa
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
- Plastic Surgery DepartmentOspedale di Cattinara, ASUITs Trieste Italy
| | | | - Elisa Manca
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
| | - Sara Leuzzi
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
- Plastic Surgery DepartmentOspedale di Cattinara, ASUITs Trieste Italy
| | - Chiara Stocco
- Department of Medical, Surgical and Health Sciences, Plastic and Reconstructive Surgery UnitUniversity of Trieste Trieste Italy
- Plastic Surgery DepartmentOspedale di Cattinara, ASUITs Trieste Italy
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13
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Park SO, Son Y, Kim IK, Jin US, Chang H. Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction. Head Neck 2018; 40:2399-2408. [PMID: 30175898 DOI: 10.1002/hed.25347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/12/2018] [Accepted: 05/08/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Monitoring free muscle flaps with skin grafts is difficult. To intensify the monitoring process for this type of flap, a small skin paddle was included in the flap and analyzed its effects. METHODS A retrospective analysis of all patients who underwent scalp reconstruction with a free latissimus dorsi flap and skin graft between 1994 and 2016 was conducted. Flap monitoring was proceeded using a combination of clinical examination and handheld Doppler for both types of flaps. RESULTS A total of 71 patients were included in this study and were divided into a study group (skin paddle included; n = 30) and a control group (conventional method; n = 41). The time between initial surgery to pedicle exploration was significantly shorter in the study group (11.3 ± 2.5 vs 79.8 ± 42.6 hours; P = .024). The flap salvage rate was significantly higher in the study group (100% vs 16.7%; P = .048). CONCLUSION The efficacy of flap monitoring and flap salvage outcomes were improved by including a small monitoring skin flap.
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Affiliation(s)
- Seong Oh Park
- Department of Plastic and Reconstructive Surgery, Research Institute of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoosung Son
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Kug Kim
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ung Sik Jin
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hak Chang
- Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Korea
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14
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Is Postoperative Intensive Care Unit Care Necessary following Cranial Vault Remodeling for Sagittal Synostosis? Plast Reconstr Surg 2017; 140:1235-1239. [PMID: 29176416 DOI: 10.1097/prs.0000000000003848] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Of U.S. craniofacial and neurosurgeons, 94 percent routinely admit patients to the intensive care unit following cranial vault remodeling for correction of sagittal synostosis. This study aims to examine the outcomes and cost of direct ward admission following primary cranial vault remodeling for sagittal synostosis. METHODS An institutional review board-approved retrospective review was undertaken of the records of all patients who underwent primary cranial vault remodeling for isolated sagittal craniosynostosis from 2009 to 2015 at a single pediatric hospital. Patient demographics, perioperative course, and outcomes were recorded. RESULTS One hundred ten patients met inclusion criteria with absence of other major medical problems. Average age at operation was 6.7 months, with a mean follow-up of 19.8 months. Ninety-eight patients (89 percent) were admitted to a general ward for postoperative care, whereas the remaining 12 (11 percent) were admitted to the intensive care unit for preoperative or perioperative concerns. Among ward-admitted patients, there were four (3.6 percent) minor complications; however, there were no major adverse events, with none necessitating intensive care unit transfers from the ward and no mortalities. Average hospital stay was 3.7 days. The institution's financial difference in cost of intensive care unit stay versus ward bed was $5520 on average per bed per day. Omitting just one intensive care unit postoperative day stay for this patient cohort would reduce projected health care costs by a total of $540,960 for the study period. CONCLUSION Despite the common practice of postoperative admission to the intensive care unit following cranial vault remodeling for sagittal craniosynostosis, the authors suggest that postoperative care be considered on an individual basis, with only a small percentage requiring a higher level of care. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Nazir H, Lowe D, Rogers S. Patients’ experience of the monitoring of free flaps after reconstruction for oral cancer. Br J Oral Maxillofac Surg 2017; 55:1008-1012. [DOI: 10.1016/j.bjoms.2017.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/09/2017] [Indexed: 11/27/2022]
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Varadarajan VV, Arshad H, Dziegielewski PT. Head and neck free flap reconstruction: What is the appropriate post-operative level of care? Oral Oncol 2017; 75:61-66. [DOI: 10.1016/j.oraloncology.2017.10.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/22/2017] [Accepted: 10/23/2017] [Indexed: 11/25/2022]
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Multipoint Tissue Circulation Monitoring with a Flexible Optical Probe. Sci Rep 2017; 7:9643. [PMID: 28852022 PMCID: PMC5575279 DOI: 10.1038/s41598-017-10115-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/04/2017] [Indexed: 11/25/2022] Open
Abstract
Compromised circulation is a potential complication during the postoperative period following tissue transplantation. The use of a monitoring device allows physicians to detect compromised circulation immediately. Such monitoring devices need to be continuously usable, wearable, and area-detectable. However, existing devices fail to satisfy all of these requirements simultaneously. We developed a wearable, multipoint pulse wave-monitoring device. An array of reflective optical sensors implemented on a thin film substrate was used as a lightweight and flexible probe. As a model of tissue transplantation, an inguinal flap in a Wistar rat was dissected and freed from all subcutaneous tissue. By ligating the artery or vein, ischemia or congestion was induced in the tissue. In a human study, ischemia or congestion was induced in the palm by pressing the feeding artery or cutaneous vein, respectively. The amplitude of the pulse wave was evaluated using the power spectrum of Fourier transformed signals. Pulse wave amplitude significantly decreased under compromised circulation in both animal and human models. Moreover, we accomplished 1 week of continuous wireless monitoring in healthy subjects. These results demonstrated the potential utility of the developed device in postoperative blood-flow monitoring to improve the rescue rate of transplanted tissue.
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Subramaniam S, Sharp D, Jardim C, Batstone MD. Cost-effectiveness of monitoring free flaps. Br J Oral Maxillofac Surg 2016; 54:579-83. [DOI: 10.1016/j.bjoms.2016.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 03/04/2016] [Indexed: 11/28/2022]
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Experience of 592 free tissue transfers: the case for clinical assessment alone to monitor free flaps. EUROPEAN JOURNAL OF PLASTIC SURGERY 2015. [DOI: 10.1007/s00238-015-1064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kansy K, Mueller AA, Mücke T, Kopp JB, Koersgen F, Wolff KD, Zeilhofer HF, Hölzle F, Pradel W, Schneider M, Kolk A, Smeets R, Acero J, Hoffmann J. Microsurgical reconstruction of the head and neck--current concepts of maxillofacial surgery in Europe. J Craniomaxillofac Surg 2014; 42:1610-3. [PMID: 24954764 DOI: 10.1016/j.jcms.2014.04.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 04/23/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Microvascular surgery following tumour resection has become an important field of oral maxillofacial surgery (OMFS). This paper aims to evaluate current microsurgical practice in Europe. METHODS The questionnaire of the DOESAK collaborative group for Microsurgical Reconstruction was translated into English, transformed into an online based survey and distributed to 200 OMFS units with the aid of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS). RESULTS 65 complete and 72 incomplete questionnaires were returned. Hospitals from the United Kingdom, France, Italy, the Netherlands, Spain, Belgium, Greece, Slovenia and Lithuania participated. 71% of contributing centres were university hospitals, 87% out of these perform microvascular tumour surgery at least on a two-weekly base. Overall complication rate was at around five percent. Most frequently used transplants were the radial forearm flap and the fibular flap. The perioperative management varied widely. Success factors for flap survival, however, were uniformly rated, with the surgical skill being the most important factor, followed by the quality of postoperative management. Medication seems to play a less important role. CONCLUSION Within Europe microvascular surgery is a common and safe procedure for maxillofacial reconstructive surgery in the field of OMFS. While there is a major accordance for the surgical procedure itself and the most frequently used flaps, perioperative management shows a wide variety of protocols with low presumed impact on surgical outcome.
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Affiliation(s)
- Katinka Kansy
- Department of Oral and Maxillofacial Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany.
| | - Andreas Albert Mueller
- Department of Oral and Maxillofacial Surgery, Universitätsspital Basel, University of Basel, Basel, Switzerland
| | - Thomas Mücke
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich, Germany
| | - Jean-Baptiste Kopp
- Department of Oral and Maxillofacial Surgery, Universitätsspital Basel, University of Basel, Basel, Switzerland
| | - Friederike Koersgen
- Department of Oral and Maxillofacial Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Klaus Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich, Germany
| | - Hans-Florian Zeilhofer
- Department of Oral and Maxillofacial Surgery, Universitätsspital Basel, University of Basel, Basel, Switzerland
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, Aachen University Hospital, Aachen, Germany
| | - Winnie Pradel
- Department of Oral and Maxillofacial Surgery, Dresden University Hospital, Dresden, Germany
| | - Matthias Schneider
- Department of Oral and Maxillofacial Surgery, Dresden-Neustadt Hospital, Dresden, Germany
| | - Andreas Kolk
- Department of Oral and Maxillofacial Surgery, Technische Universität München, Klinikum Rechts der Isar, Munich, Germany
| | - Ralf Smeets
- Department of Oral and Maxillofacial Surgery, Hamburg University Hospital, Hamburg-Eppendorf, Germany
| | - Julio Acero
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
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Laporta R, Longo B, Sorotos M, Pagnoni M, Santanelli Di Pompeo F. DIEP flap sentinel skin paddle positioning algorithm. Microsurgery 2014; 35:91-100. [PMID: 24771292 DOI: 10.1002/micr.22269] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 03/17/2014] [Accepted: 04/11/2014] [Indexed: 11/11/2022]
Abstract
Although clinical examination alone or in combination with other techniques is the only ubiquitous method for flap monitoring, it becomes problematic with buried free-tissue transfer. We present a DIEP flap sentinel skin paddle (SSP) positioning algorithm and its reliability is also investigated using a standardized monitoring protocol. All DIEP flaps were monitored with hand-held Doppler examination and clinical observation beginning immediately after surgery in recovery room and continued postoperatively at the ward. Skin paddle (SP) position was preoperatively drawn following mastectomy type incisions; in skin-sparing mastectomies types I-III a small SP (sSP) replaces nipple-areola complex; in skin-sparing mastectomy type IV, SSP is positioned between wise-pattern branches while in type V between medial/lateral branches. In case of nipple-sparing mastectomy SSP is positioned at inframammary fold or in lateral/medial branches of omega/inverted omega incision if used. Three hundred forty-seven DIEP flap breast reconstructions were reviewed and stratified according to SP type into group A including 216 flaps with large SP and group B including 131 flaps with SSP and sSP. Sixteen flaps (4.6%) were taken back for pedicle compromise, 13 of which were salvaged (81.25%), 11 among 13 from group A and 2 among 3 from group B. There was no statistical difference between the groups concerning microvascular complication rate (P = 0.108), and time until take-back (P = 0.521) and flap salvage rate (P = 0.473) resulted independent of SP type. Our results suggest that early detection of perfusion impairment and successful flaps salvage could be achieved using SSP for buried DIEP flap monitoring, without adjunctive expensive monitoring tests.
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Affiliation(s)
- Rosaria Laporta
- Plastic Surgery Department, Sant'Andrea Hospital, School of Medicine and Psychology, "Sapienza" University of Rome, Italy
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Goodson AMC, Payne KFB, Simmons J, Jain A. Free-flap telemonitoring to the surgeon's handheld device: proof of concept. Microsurgery 2014; 34:413-4. [PMID: 24664985 DOI: 10.1002/micr.22241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 02/14/2014] [Accepted: 02/28/2014] [Indexed: 11/09/2022]
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Kalra GDS, Gupta RK. Facial contouring with parascapular free flap: A case series of 22 cases. Indian J Plast Surg 2014; 46:561-7. [PMID: 24459350 PMCID: PMC3897105 DOI: 10.4103/0970-0358.122020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The facial asymmetry correction in complex craniofacial malformations presents a challenging problem for reconstructive surgeons. Progressive hemifacial atrophy (HFA) and hemifacial microsomia (HFM) can manifest in different grades of severity. Most patients require only soft-tissue augmentation. Free flaps are the best option for correction of severe facial soft-tissue deficiency. Materials and Methods: Twenty-two patients of HFM and HFA were included in this study from January 2006 to March 2009 in the Department of Plastic and Reconstructive Surgery, SMS Medical College and Hospital. In all cases, atrophy correction was done using de-epithelialised parascapular free flap with the de-epithelialised surface was placed under the skin. A small skin paddle was taken for monitoring. Results: All cases were reconstructed with de-epithelialised parascapular free flap. There was no flap loss in this series. Hematoma was noted in five cases. Debulking and removal of skin paddle were done in all cases after 6 months. Atrophy recurrence was not observed in any of the cases on follow-up. Conclusion: Contouring of face in cases of HMF and HFA is satisfactorily done with the parascapular free flap. It gives better cosmetic results with minimal donor site morbidity. Facial vessels are better recipient vessels for anastomosis. Keeping de-epithelialised surface of flap under the skin helped in preventing sagging.
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Affiliation(s)
- Guru Dayal Singh Kalra
- Department of Plastic and Reconstructive Surgery, SMS Hospital and Medical College, Jaipur, Rajasthan, India
| | - Ram Krishna Gupta
- Department of Plastic and Reconstructive Surgery, SMS Hospital and Medical College, Jaipur, Rajasthan, India
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GOONERATNE H, LALABEKYAN B, CLARKE S, BURDETT E. Perioperative anaesthetic practice for head and neck free tissue transfer -- a UK national survey. Acta Anaesthesiol Scand 2013; 57:1293-300. [PMID: 24028305 DOI: 10.1111/aas.12180] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anaesthetic management of microvascular head and neck free flap surgery is based on physiological principles, but data on how these affect clinical outcomes in this challenging group are limited. There are no evidence-based guidelines available in this area. METHODS To establish current perioperative anaesthetic practice by surveying all UK centres performing head and neck free flap surgery. Anaesthetists from 73 centres performing head and neck microvascular reconstructive surgery in the UK were asked to complete a structured online survey. The survey included general questions, a hypothetical clinical scenario with multiple choice questions and questions about perioperative management. The main outcomes measured were protocols of pre-operative assessment, perioperative fluid and blood pressure strategies, monitoring and post-operative management. RESULTS Seventy-three units were contacted, and fifty-five responded (75%). Most respondents performed up to two cases per month. Opinion was divided as to how best to manage intra-operative blood pressure, fluid balance, pre-operative assessment and monitoring. Notably 52% preferred crystalloid infusion to increase blood pressure, while 35% stated crystalloids were contraindicated. CONCLUSIONS Currently in the UK, anaesthetic perioperative management for head and neck free flap transfer is varied, reflecting the paucity of high-quality data in this area; but some techniques, in particular avoidance of excessive crystalloid use, is associated with improved flap outcome.
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Affiliation(s)
- H. GOONERATNE
- Department of Anaesthesia; Broomfield Hospital Mid Essex NHS Trust; Broomfield Chelmsford Essex UK
| | - B. LALABEKYAN
- Head and Neck Centre; University College London Hospitals NHS Foundation Trust; London UK
| | - S. CLARKE
- Department of Anaesthesia; University College London Hospitals NHS Foundation Trust; London UK
| | - E. BURDETT
- Department of Anaesthesia; University College London Hospitals NHS Foundation Trust; London UK
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Clert V, Guédon C, Cristofari JP, Halimi C, Barry B, Albert S. Le micro-doppler implantable dans la surveillance des lambeaux microanastomosés en chirurgie reconstructrice cervico-faciale. ANN CHIR PLAST ESTH 2013; 58:82-8. [DOI: 10.1016/j.anplas.2013.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/09/2013] [Indexed: 11/25/2022]
Affiliation(s)
- V Clert
- Service de chirurgie ORL et cervico-faciale, hôpital Bichat, GHU Paris Nord - Val de Seine, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France
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Analysis of Routine Intensive Care Unit Admission following Fronto-Orbital Advancement for Craniosynostosis. Plast Reconstr Surg 2013; 131:582e-588e. [DOI: 10.1097/prs.0b013e3182818e94] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Benign paediatric mandibular tumours: Experience in reconstruction using vascularised fibula. J Plast Reconstr Aesthet Surg 2012; 65:e325-31. [DOI: 10.1016/j.bjps.2012.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 04/10/2012] [Accepted: 07/09/2012] [Indexed: 11/18/2022]
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Smit J, Klein S, de Jong E, Zeebregts C, de Bock G, Werker P. Value of the implantable doppler system in free flap monitoring. J Plast Reconstr Aesthet Surg 2012; 65:1276-7. [DOI: 10.1016/j.bjps.2012.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 03/08/2012] [Indexed: 10/28/2022]
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Monitoring of intraoral free flaps with microdialysis. Br J Oral Maxillofac Surg 2011; 49:521-6. [DOI: 10.1016/j.bjoms.2010.09.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 09/29/2010] [Indexed: 11/20/2022]
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Mücke T, Müller AA, Kansy K, Hallermann W, Kerkmann H, Schuck N, Zeilhofer HF, Hoffmann J, Hölzle F. Microsurgical reconstruction of the head and neck – Current practice of maxillofacial units in Germany, Austria, and Switzerland. J Craniomaxillofac Surg 2011; 39:449-52. [DOI: 10.1016/j.jcms.2010.10.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Revised: 10/13/2010] [Accepted: 10/21/2010] [Indexed: 10/18/2022] Open
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Management of post-operative maxillofacial oncology patients without the routine use of an intensive care unit. J Maxillofac Oral Surg 2011; 9:329-33. [PMID: 22190819 DOI: 10.1007/s12663-010-0147-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 12/02/2010] [Indexed: 10/18/2022] Open
Abstract
AIM To assess the safety and efficacy of immediate postoperative management of major maxillofacial oncology patients in a High Dependency Unit (HDU). PATIENTS AND METHODS All operated maxillofacial oncology patients were included. Detailed records and clinical parameters were assessed for diagnosis, procedure, diagnosis, American Society of Anaesthiologists (ASA) grade, procedure, type of reconstruction, duration of surgery, post operative location, days of hospitalization risk factors and complications if any. RESULTS All the patients were placed in a HDU care for 48 h for closed monitoring and thereafter were shifted to the head and neck general ward. Only 7/117 (6%) patients required ICU admission because of development of systemic complications. Of our cases, 108/117 made an uneventful recovery (92.3%) with no serious complications. We noted a correlation between the incidence of perioperative complications and risk factors of ASA status (χ(2) = 7.81, P = 0.005). Majority of the patients (94%) were managed successfully in the HDU care in the post operative period. Survival of free flaps proved to be extremely reliable with a survival rate of 99.1% (1/15 failed). CONCLUSIONS The routine use of a HDU care for 48 hours followed by shifting the patient to a maxillofacial head and neck general ward is more appropriate for management of post-operative maxillofacial oncology patients. This practice has helped in offering high quality, cost effective and efficient services without having any adverse effect on the quality of care.
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Power modulation contrast enhanced ultrasound for postoperative perfusion monitoring following free tissue transfer in head and neck surgery. Int J Oral Maxillofac Surg 2010; 39:1211-7. [DOI: 10.1016/j.ijom.2010.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 04/21/2010] [Accepted: 07/19/2010] [Indexed: 11/20/2022]
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Gardiner M, Nanchahal J. Strategies to ensure success of microvascular free tissue transfer. J Plast Reconstr Aesthet Surg 2010; 63:e665-73. [DOI: 10.1016/j.bjps.2010.06.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2010] [Revised: 05/30/2010] [Accepted: 06/09/2010] [Indexed: 11/26/2022]
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Pratt GF, Rozen WM, Chubb D, Whitaker IS, Grinsell D, Ashton MW, Acosta R. Modern adjuncts and technologies in microsurgery: An historical and evidence-based review. Microsurgery 2010; 30:657-66. [DOI: 10.1002/micr.20809] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 05/13/2010] [Indexed: 11/11/2022]
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Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010; 30:105-10. [PMID: 19790183 DOI: 10.1002/micr.20706] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND An important element in achieving high success rates with free flap surgery has been the use of different techniques for monitoring flaps postoperatively as a means to detecting vascular compromise. Successful monitoring of the vascular pedicle to a flap can potentiate rapid return to theater in the setting of compromise, with the potential to salvage the flap. There is little evidence that any technique offers any advantage over clinical monitoring alone. METHODS A consecutive series of 547 patients from a single plastic surgical unit who underwent a fasciocutaneous free flap operation for breast reconstruction [deep inferior epigastric artery perforator (DIEP) flap, superficial inferior epigastric artery (SIEA) flap, or superior gluteal artery perforator (SGAP) flap] were included. A comparison was made between the first 426 consecutive patients in whom flap monitoring was performed using clinical monitoring alone and the subsequent 121 patients in whom monitoring was achieved with the Cook-Swartz implantable Doppler probe. Outcome measures included flap salvage rate and false-positive rate. RESULTS There was a strong trend toward improved salvage rates with the implantable Doppler probe compared with clinical monitoring (80% vs. 66%, P = 0.48). When combined with the literature (meta-analysis), the data prove statistically significant (P < 0.01). There was no statistical difference between the groups for false-positive rates. CONCLUSION Flap monitoring with the implantable Doppler probe can improve flap salvage rates without increasing the rate of false-positive takebacks.
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Affiliation(s)
- Warren M Rozen
- Jack Brockhoff Reconstructive Plastic Surgery Research Unit, Department of Anatomy, University of Melbourne, Parkville 3050, Victoria, Australia.
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Introduction of the Implantable Doppler System Did Not Lead to an Increased Salvage Rate of Compromised Flaps: A Multivariate Analysis. Plast Reconstr Surg 2010; 125:1710-1717. [DOI: 10.1097/prs.0b013e3181d0ace8] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Efficacy of Clinical Assessment in the Postoperative Monitoring of Free Flaps: A Review of 1140 Consecutive Cases. Plast Reconstr Surg 2010; 125:1157-1166. [DOI: 10.1097/prs.0b013e3181d0ac95] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Smit J, Whitaker I, Liss A, Audolfsson T, Kildal M, Acosta R. Post operative monitoring of microvascular breast reconstructions using the implantable Cook–Swartz doppler system: A study of 145 probes & technical discussion. J Plast Reconstr Aesthet Surg 2009; 62:1286-92. [DOI: 10.1016/j.bjps.2008.06.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Revised: 06/09/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
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Brennan P, Shekar K, McLeod N, Puxeddu R, Cascarini L. A synopsis of oncology and oncology-related papers published in the British Journal of Oral and Maxillofacial Surgery 2007–2008. Br J Oral Maxillofac Surg 2009; 47:515-20. [DOI: 10.1016/j.bjoms.2009.06.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2009] [Indexed: 11/28/2022]
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Chubb DP, Rozen WM, Whitaker IS, Ashton MW. Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: A systematic review of current techniques. Br J Oral Maxillofac Surg 2009; 47:574-5. [DOI: 10.1016/j.bjoms.2009.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2009] [Indexed: 11/24/2022]
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Yoshimoto S, Kawabata K, Mitani H. Analysis of 59 cases with free flap thrombosis after reconstructive surgery for head and neck cancer. Auris Nasus Larynx 2009; 37:205-11. [PMID: 19700252 DOI: 10.1016/j.anl.2009.06.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 05/18/2009] [Accepted: 06/25/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There have been few reports addressing methods of dealing with free flap thrombosis after reconstructive surgery for head and neck cancer. The present study, through a detailed analysis of the subsequent course of patients who developed postoperative flap thrombosis, aims to clarify possible methods of salvage surgery in the event of vascular occlusion despite rigorous postoperative follow-up. METHODS We analyzed 59 cases of postoperative thrombosis in 1031 patients who underwent free flap transfer and considered the most appropriate salvage surgery in the event of total flap necrosis. RESULTS The flap salvage rate through vascular reanastomosis was highest for radial forearm flaps, with salvage of jejunal flaps being problematic if postoperative thrombosis occurred. For cases of postoperative thrombosis among patients who underwent reconstruction using a jejunal flap, the period of hospitalization was significantly extended for those patients in whom a second jejunal flap grafting was impossible. For cases of postoperative thrombosis among patients who underwent reconstruction using a radial forearm flap (FA), rectus abdominis flap (RA), or anterior lateral thigh flap (ALT), no significant difference was observed between those undergoing re-grafting with a free flap and those with a pedicled flap. CONCLUSION We concluded that, among patients who undergo reconstruction using a jejunal flap, thrombosis should be discovered at an early stage to enable another jejunal flap re-grafting. For patients who undergo reconstruction using a FA, RA, or ALT, if thrombosis can be discovered at an early stage, there is a possibility of salvaging the flap by means of vascular reanastomosis. If it should prove impossible to salvage the flap, however, primary suture of the defect or reconstruction with a pedicled flap may also be considered.
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Affiliation(s)
- Seiichi Yoshimoto
- Department of Head and Neck, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-10-6 Ariake, Koto-ku, Tokyo, Japan.
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Winterton RIS, Pinder RM, Morritt AN, Knight SL, Batchelor AG, Liddington MI, Kay SP. Long term study into surgical re-exploration of the 'free flap in difficulty'. J Plast Reconstr Aesthet Surg 2009; 63:1080-6. [PMID: 19527943 DOI: 10.1016/j.bjps.2009.05.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 05/12/2009] [Accepted: 05/20/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. MATERIAL AND METHODS We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome. RESULTS Thirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. CONCLUSION We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.
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Affiliation(s)
- R I S Winterton
- Leeds General Infirmary, Leeds Teaching Hospital NHS Trust, Great George Street, Leeds LS1 3EX, UK.
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Marsh M, Elliott S, Anand R, Brennan P. Early postoperative care for free flap head & neck reconstructive surgery - a national survey of practice. Br J Oral Maxillofac Surg 2009; 47:182-5. [DOI: 10.1016/j.bjoms.2008.06.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2008] [Indexed: 11/28/2022]
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Dassonville O, Poissonnet G, Santini J, Bozec A. Réparation par lambeaux libres en cancérologie des voies aérodigestives supérieures. ONCOLOGIE 2009. [DOI: 10.1007/s10269-008-1030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Betz CS, Zhorzel S, Schachenmayr H, Stepp H, Havel M, Siedek V, Leunig A, Matthias C, Hopper C, Harreus U. Endoscopic measurements of free-flap perfusion in the head and neck region using red-excited Indocyanine Green: preliminary results. J Plast Reconstr Aesthet Surg 2008; 62:1602-8. [PMID: 19036663 DOI: 10.1016/j.bjps.2008.07.042] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 06/28/2008] [Accepted: 07/24/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND Free-tissue transfer has become a standard procedure for reconstructive surgery in the head and neck area. Flap failures are relatively rare (<or=5%), and a high percentage can be salvaged if detected early. Indocyanine Green (ICG) angiography might be able to improve the detection of flap malperfusion at an early stage. METHODS So far, 11 patients with free-flap reconstructions of the upper aerodigestive tract (UADT) have participated in this study. Each participant underwent three endoscopic ICG angiographies (24h intra-operatively and 72h postoperatively). The data obtained were evaluated online as well as offline on a personal computer (PC), and the results compared to the clinical outcome. RESULTS There were no partial or complete flap losses. One flap was successfully salvaged following initial arterial kinking with impeded perfusion. The ICG fluorescence angiography was tolerated well in all patients. The free flaps showed a delayed yet equal ICG fluorescence as compared to the surrounding tissue. The timing and slope of fluorescence build-up were dependent on circulatory factors. The relative fluorescence maxima of flap versus surrounding were 33% in the initially failing flap and >or=64% for all other examinations. CONCLUSIONS It was possible to prove the feasibility of endoscopic ICG fluorescence angiography in patients undergoing free-flap transfer to the UADT. The method provides instant information about the perfusion state of the tissue and is easily performed without greater patient discomfort or risk of side effects. Due to the endoscopic approach, the method seems highly promising for this indication and merits further evaluation.
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Affiliation(s)
- C S Betz
- Department of Otorhinolaryngology, Head & Neck Surgery, Ludwig Maximilian University, Grosshadern Medical Campus, Marchioninistr 15, D-81377 Munich, Germany.
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Timing of Presentation of the First Signs of Vascular Compromise Dictates the Salvage Outcome of Free Flap Transfers. Plast Reconstr Surg 2008; 122:991-992. [DOI: 10.1097/prs.0b013e3181811fd8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Anand R, Geyer M, Ethunandan M, Ilankovan V. Nasopharyngeal tube facilitates endoscopic monitoring of pharyngeal flaps. Clin Otolaryngol 2008; 33:171-3. [PMID: 18429898 DOI: 10.1111/j.1749-4486.2008.01621.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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