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Ellen Garbuzov A, Katira K, Harvey D, Pourtaheri N, Soltanian H. Video Narrative of Upfront Above-knee Amputation for Fillet Flap Transfer in a Single Case of External Hemipelvectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4914. [PMID: 37020991 PMCID: PMC10069863 DOI: 10.1097/gox.0000000000004914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 02/14/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Anna Ellen Garbuzov
- From The University of Queensland – Ochsner Clinical School, New Orleans, La
| | - Kristopher Katira
- Intermountain Healthcare, Division of Plastic Surgery, Salt Lake City, Utah
| | - Donald Harvey
- Department of Plastic Surgery, University Hospitals of Cleveland; Cleveland, Ohio
| | | | - Hooman Soltanian
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, Md
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Chen JH, Vakharia KT. Fibula Free Flap Salvage From 10-hour Prolonged Arterial Insufficiency and Venous Thrombosis. J Craniofac Surg 2021; 32:e472-e473. [PMID: 33427786 DOI: 10.1097/scs.0000000000007417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Fibula free flaps are standard in facial reconstructions after head and neck cancer resection and typically have short flap ischemia times, often under 2 hours. Methods for short-term flap ischemia are characterized, but methods for extremely prolonged flap ischemia have not been well-described. We describe a 72-year-old patient who underwent composite floor of mouth and mandible resection with fibula free flap reconstruction. Patient intraoperative instability forced flap ischemia of over 10 hours with arterial insufficiency and venous thrombosis. Despite complicated and extremely prolonged ischemia, aggressive local and systemic anticoagulants with intraoperative leach therapy were still effective in flap salvage. The flap ultimately survived without necrosis. This case describes a method to guide surgeons faced with situations of forced, prolonged flap ischemia. Traditionally indicated in short-term ischemia, anticoagulation and leach methods can be effective for intraoperative treatment of extremely prolonged flap ischemia, arterial insufficiency, and venous thrombosis.
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Affiliation(s)
| | - Kalpesh T Vakharia
- University of Maryland School of Medicine.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Maryland Medical Center, Baltimore, MD
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Wolff KD, Ritschl LM, von Bomhard A, Braun C, Wolff C, Fichter AM. In vivo perfusion of free skin flaps using extracorporeal membrane oxygenation. J Craniomaxillofac Surg 2019; 48:90-97. [PMID: 31874806 DOI: 10.1016/j.jcms.2019.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 08/18/2019] [Accepted: 12/02/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The vessel-depleted, irradiated, and frozen neck, as well as severe atherosclerosis of recipient vessels represent challenging problems in free flap transfer. Extracorporeal free flap perfusion theoretically allows free flap reconstructions in the absence of local donor vessels, but is associated with a number of technical issues. In this study, a novel technique is presented using a commercially available system for extracorporeal membrane oxygenation (ECMO), modified for small blood volumes. METHODS After preclinical testing, an ECMO system certified for lung support was used to establish blood flow through the flap's artery with oxygenation, decarboxylation and warming of diluted packed blood cells. Venous blood was allowed to flow passively into a separate container. Perfusion was performed for 15 min at intervals of 4 h over 4-6 days. RESULTS Five patients with soft tissue defects requiring free flap reconstruction were included. Either primarily thinned anterolateral thigh (ALT) flaps (n = 3) or radial forearm flaps (n = 2) were used. We observed infection of the perfusate, with consequent subtotal flap loss, in one patient, complete epithelial loss in two patients, venous congestion in one case, and almost uneventful healing in the fifth patient. With conservative wound care and a split thickness skin graft in one case, stable wound coverage was achieved in all patients except one, who had secondary healing. None of the patients required a second flap for sufficient coverage. CONCLUSIONS The technique described is associated with the risks of infection, flap congestion, nutritive hypoperfusion, and consequent tissue loss. Nevertheless, stable defect closure seems to be achievable even in patients with depleted recipient vessels.
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Affiliation(s)
- Klaus-Dietrich Wolff
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany.
| | - Lucas M Ritschl
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Achim von Bomhard
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Christian Braun
- University of Munich, School of Medicine, Institute of Legal Medicine, Nußbaumstraße 26, Munich, 80336, Germany
| | - Constantin Wolff
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany
| | - Andreas M Fichter
- Technical University of Munich, School of Medicine, Department of Oral and Maxillofacial Surgery, Ismaninger Str. 22, Munich, 81675, Germany.
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Contact Cooling of Random-Pattern Cutaneous Flaps: Does it Increase Necrosis? Aesthetic Plast Surg 2017; 41:448-453. [PMID: 28144754 DOI: 10.1007/s00266-017-0787-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/10/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cooling after surgery reduces pain, swelling and ecchymosis. However, the fear of adverse effects of vasoconstriction caused by cooling may prevent its use when the skin is undermined extensively, for example, after rhytidectomy. The purpose of this study is to determine whether the contact cooling of random-pattern skin flaps increases the area of necrosis observed. METHODS Twenty-eight random-pattern skin flaps (4 × 10 cm) were raised on four pigs. Flaps were divided into three groups: control, intermittently cooled and continuously cooled. Pads connected to a ThermaZone cooling device delivered local hypothermia in the range of 4-6 °C for 24 h postoperatively. ImageJ software was used to calculate the area of necrosis on each flap on postoperative day 7, confirmed with histological analysis. RESULTS The average areas of necrosis observed were as follows: control (17.61 cm2; SD 5.23), intermittent cooling (15.65 cm2; SD 3.76) and continuous cooling (14.16 cm2; SD 3.91). An ANOVA revealed no statistically significant differences between the three interventions (p = 0.35). CONCLUSIONS Postoperative continuous or intermittent cooling does not increase the area of necrosis in random-pattern flaps. In fact, a trend was observed, demonstrating decreasing area of necrosis with increased periods of hypothermia. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .
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Kim JM, Ko JG, Oh DY. Deep Inferior Epigastric Perforator Flap Breast Reconstruction in a Patient with Huge Uterine Leiomyoma. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2017. [DOI: 10.14730/aaps.2017.23.2.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ji Min Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jun Gul Ko
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Pakyari M, Farokhi A, Khosravi-Maharlooei M, Kilani RT, Ghahary A, Brown E. A new method for skin grafting in murine model. Wound Repair Regen 2016; 24:695-704. [PMID: 27197606 DOI: 10.1111/wrr.12445] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 03/02/2016] [Accepted: 04/24/2016] [Indexed: 11/29/2022]
Abstract
Skin transplantation provides an excellent potential model to investigate the immunology of allograft rejection and tolerance induction. Despite the theoretical ease of performing skin transplantation, as well as the potential of directly observing the reaction to the transplanted tissue, the poor reliability of skin transplantation in the mouse has largely precluded the use of this model. Furthermore, there is controversy regarding the most appropriate skin graft donor site due to poor success of back skin transplantation, as compared with the thinner ear or tail skin. This study demonstrates a reliable method to successfully perform skin grafts in a mouse model, as well as the clinical and histologic outcome of syngeneic grafts. A total of 287 grafts were performed (in 126 mice) utilizing donor skin from the ear, tail or back. No graft failure or postoperative mortality was observed. Comparison of this technique with two previously established protocols of skin transplantation (5.0 absorbable Suture + tissue glue technique and no-suture technique) demonstrates the significant improvement in the engraftment success of the new technique. In summary, a new technique for murine skin grafting demonstrates improved reliability across donor site locations and strains, increasing the potential for investigating interventions to alter the rejection process.
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Affiliation(s)
- Mohammadreza Pakyari
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Ali Farokhi
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Khosravi-Maharlooei
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Ruhangiz T Kilani
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Aziz Ghahary
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Erin Brown
- Division of Plastic Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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Jonas R, Schaal T, Krimmel M, Gülicher D, Reinert S, Hoffmann J. Monitoring in microvascular tissue transfer by measurement of oxygen partial pressure: Four years experience with 125 microsurgical transplants. J Craniomaxillofac Surg 2013. [DOI: 10.1016/j.jcms.2012.10.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hölzle F, Rau A, Loeffelbein D, Mücke T, Kesting M, Wolff KD. Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. Int J Oral Maxillofac Surg 2010; 39:21-8. [DOI: 10.1016/j.ijom.2009.10.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Revised: 06/15/2009] [Accepted: 10/12/2009] [Indexed: 11/27/2022]
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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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An old dream revitalised: preconditioning strategies to protect surgical flaps from critical ischaemia and ischaemia-reperfusion injury. J Plast Reconstr Aesthet Surg 2008; 61:503-11. [DOI: 10.1016/j.bjps.2007.11.032] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2006] [Revised: 04/11/2007] [Accepted: 11/22/2007] [Indexed: 10/22/2022]
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Wolff KD, Hölzle F, Wysluch A, Mücke T, Kesting M. Incidence and time of intraoperative vascular complications in head and neck microsurgery. Microsurgery 2008; 28:143-6. [PMID: 18286659 DOI: 10.1002/micr.20468] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Klaus-Dietrich Wolff
- Klinik und Poliklinik für Mund-, Kiefer- und Gesichtschirurgie, Klinikum rechts der Isar, Technische Universität München, Germany.
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Guerra AB, Soueid N, Metzinger SE, Levine J, Bidros RS, Erhard H, Allen RJ. Simultaneous Bilateral Breast Reconstruction With Superior Gluteal Artery Perforator (SGAP) Flaps. Ann Plast Surg 2004; 53:305-10. [PMID: 15385761 DOI: 10.1097/01.sap.0000128619.83670.e1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The superior gluteal artery perforator (SGAP) flap is a useful technique for restoration of the breast after mastectomy. If appropriately planned, the soft-tissue envelope supplied by the superior gluteal artery perforator vessels can be harvested with minimal donor site morbidity and often results in a highly esthetic restoration of the breasts. Dissection of the flap is performed with complete preservation of gluteus maximus muscle function. The resulting vascular pedicle obtained via dissection through the muscle is longer than that of gluteal musculocutaneous flaps and affords the surgeon the luxury of avoiding vein grafts in the anastomotic phase of surgery. Despite these advantages, use of the SGAP flap is not popular among reconstructive surgeons. Many practitioners are not familiar with the vascular anatomy of the gluteal area and may not be comfortable with the dissection of the parent vessels or lack the desire to practice microsurgery. On the other hand, our group has reported the largest experience to date with this method of breast reconstruction and has found the SGAP flap to be a reliable and safe method of autologous breast restoration in unilateral absence of the breast. Although the indications to perform single-stage gluteal tissue transplantation for bilateral breast restoration are uncommon, they do occasionally arise in clinical practice. We have carried out concurrent bilateral breast reconstruction using SGAP flaps on 6 patients with acceptable overall morbidity. All flaps went on to survive and resulted in highly esthetic restorations of the breast. Though a challenging undertaking, in-unison transfer of bilateral SGAP flaps serves as a useful option for a subset of patients desiring 1-stage bilateral breast reconstruction.
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Affiliation(s)
- Aldo Benjamin Guerra
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
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