Flap Take-backs Research Articles

Microsurgical Preservation of Ambulation in Lower Extremity Sarcoma Treatment

INTRODUCTION: Lower extremity sarcoma treatment has evolved from primarily amputation procedures towards limb salvage.1 A survival advantage has not been shown for amputation compared to limb salvage, although amputation is associated with a significantly higher level of handicap. 2,3 Microsurgery has the potential to further expand the options in limb preservation by allowing coverage of massive soft tissue defects as well as by restoring function following the resection of critical nerves, muscles or tendons. These immediate reconstructive procedures are capable of preserving ambulation and therefore function. This study examines our institution’s experience with microsurgical techniques as they apply to lower extremity soft tissue sarcoma treatment. MATERIALS AND METHODS: A 5-year retrospective review of all microsurgical reconstructions for limb salvage in lower extremity sarcoma patients was completed at our institution. Limb salvage rates, oncological data, surgical techniques as well as complication rates were analyzed. Patients were additionally asked to complete the Toronto Extremity Salvage Score (TESS) quality of life survey. RESULTS: Over a five-year period, 22 patients (average age 52.2 years) underwent free flap reconstructions for 23 sarcomas (mean follow-up 14 months). 85% of patients underwent neoadjuvant radiation therapy. The thigh was the most common tumor site (56.5%) and 3 named muscles were resected on average. Perforator flaps were most frequently used (68.18%), and functional muscle transfers or immediate tendon transfers were used in three patients. There were no flap take-backs or failures, and 21 patients achieved independent ambulation. Two patients in the series died, each from metastatic disease and not local recurrence. A 77.3% response rate was achieved for the TESS survey, with a mean score of 83.1% as a representation of normal lower extremity function. The lowest average TESS scores were associated with kneeling, participating in sporting activities and getting up from kneeling. There was no relationship between TESS scores and tumor location, resection surface area, number of muscles resected, or days to ambulation. CONCLUSION: Microsurgical reconstruction of lower extremity sarcoma defects enables the preservation of ambulation. Restoration of function utilizing immediate functional microsurgical reconstructions should be considered safe and effective in lower extremity sarcoma limb salvage.

Challenging Traditional Thinking

PURPOSE: Parry Romberg’s Disease is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age of onset is associated with significant skeletal involvement and jaw abnormalities in 30-65% of patients, with up to 31% of patients requiring osseous reconstruction.1-4 Standard reconstructive treatment allows the disease to “burn out” with 2 years of no change prior to reconstructive intervention. We have found that early intervention in active disease is beneficial. METHODS: All pediatric free tissue transfer cases (1989-2013) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap was performed to treat deformities arising from Romberg’s hemifacial atrophy. RESULTS: In our series, 25 patients between the ages of 3-7 were operated on even in the presence of aggressive active disease. Follow up ranged from 1- 23 years. There were no flap takebacks or flap loss. There was one limited hematoma that was treated with bedside suction evacuation. There was one patient with preauricular incision dehiscence at the time of suture removal requiring resuturing. Flap revisions and secondary procedures were performed at 6 months following free tissue transfer including tissue rearrangement, debulking procedures, resuspensions, lip reconstructions, and minimal autologous fat transfers. In all patients the disease process seemingly halted and no disease process has recurred to date (Figures 1 and 2).Figure 1: Preoperative Photo.Figure 2: Postoperative Photo.CONCLUSION: Microsurgical correction of Parry Romberg’s Disease in young children is safe, reliable, and effective. It allows for correction of both severe and subtle deformities. Facial skeletal growth was markedly better than expected. These young children with severe disease would have classically gone on to have more severe skeletal deformities. Although one child had orbital repositioning, no other children who have undergone early free flap reconstruction have subsequently gone on to require any further osseous reconstruction. We theorize that the interposition of normal healthy tissue may halt or alter the disease process, preventing the skeletal hypoplasia that is classically seen. Biologic studies are currently underway to validate this surprising outcome. Ultimately, we feel strongly that young children with severe rapidly progressing disease should undergo early reconstruction with free tissue transfer to spare them the sequelae of a disease process that has been allowed to burn out, or the repetitive treatments required for fat grafting over a prolonged period of time.

A systematic approach to emergent breast free flap takeback: Clinical outcomes, algorithm, and review of the literature

Few evidence-based and detailed algorithms exist on the management of failing breast free flaps, including use of the numerous salvage tools that are available. The purpose of this study was to analyze our outcomes with an algorithmic approach to breast free flap salvage after vascular compromise. A review of the literature is also presented. A retrospective review of all breast free flaps performed at our institution between 2007 and 2012 was performed. Flaps with intraoperative and postoperative vascular complications were analyzed. A total of 612 microsurgical breast reconstructions in 442 patients were reviewed. Of these, 72 (11.8%) flaps had intraoperative vascular complications, and 36 (5.9%) had postoperative vascular complications. The total flap loss rate was 2.8%. The most commonly used salvage modalities were anastomotic revision (72%), heparin irrigation (72%), systemic heparin (37%), Fogarty catheter thrombectomy (17.6%), thrombolytics (13%), and indocyanine green angiography (10.2%). In 53 (49.1%) cases, flap salvage involved use of 1 modality, whereas in 55 (50.9%) cases multiple modalities were used. Factors associated with failure of these flap salvage tools included intraoperative arterial rather than postoperative arterial compromise (P = 0.01), and situations requiring use of a greater number of salvage modalities (P < 0.001). We found that intraoperative compromise had significantly better prognosis than postoperative compromise. By organizing the numerous salvage modalities available to microsurgeons into a well-defined algorithm that is supported by the literature, we have established a best practices protocol that has achieved flap salvage rates that compare favorably to the published literature.

Free Flap Take-Back following Postoperative Microvascular Compromise

The purpose of this study is twofold: (1) to stratify preoperative risk factors that predict successful free flap salvage and (2) to identify perioperative strategies that correlate with successful salvage. A retrospective chart review was performed on all free flaps performed from January of 2005 to April of 2011. The time until salvage was defined as the end of the initial procedure until the initiation of the salvage attempt. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss. A total of 2260 free flaps were reviewed, and 47 take-backs for delayed microvascular compromise were identified. Twenty-three of 47 flaps (49 percent) were salvaged. The mean time until take-back, presence of thrombophilia, and preoperative platelet counts were factors predictive of unsuccessful salvage. Preoperative platelet counts above 300 were associated with the lowest rates of salvage. Intraoperative maneuvers were examined, and surgeon experience (defined as >5 years in practice) was the only factor that was significant; however, intraoperative heparin anticoagulation and complete mechanical thrombectomy trended toward significance. The type of thrombolytic agent used was not found to result in a statistically significant difference. There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage, whereas intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies.

Perforator flap breast reconstruction in thin patients.

242 Background: Perforator flap breast reconstruction has strong appeal for many women seeking breast reconstruction, but the procedure requires adequate donor site tissue to produce realistic breasts. Thin women requesting perforator flaps are often advised that they lack sufficient donor site tissue for autologous tissue breast reconstruction, and that implants are their only option. We have expanded the reconstructive options for thin women who seek an alternative to implants with innovative new techniques. Methods: A retrospective review was done of 223 patients who underwent 293 consecutive perforator flap breast reconstructions from April 2007-May 2011. Preoperative imaging allowed visualization of the microvascular anatomy and subcutaneous tissue. Donor sites evaluated included the abdomen, medial thigh, buttocks, and back. Complications included flap loss, hematoma, seroma, takeback, and fat necrosis. No patients were turned away for perforator flap breast reconstruction due to insufficient donor site tissue. Results: Out of 293 perforator flap breast reconstructions, 45 perforator flap breast reconstructions (15.4%) were reported in 26 thin women with a BMI &lt; 23 (mean BMI 20.7, range BMI 18.2-22.7). Out of 45 perforator flap breast reconstructions in thin women, donor sites included 35 hemi-abdominal flaps (77.8%), 4 medial thigh flaps (8.9%), 7 buttock flaps (15.6%), and 2 back flaps (4.4%). Of the 35 hemi-abdominal flaps, 8 hemi-abdominal flaps were combined to create 4 stacked DIEP flaps (22.9%) while the remaining 27 hemi-abdominal flaps were regular DIEP flaps (77.1%). There was one seroma (2.2%) and one takeback for postoperative pain (2.2%); there were no flap losses. Conclusions: Even in thin women, perforator flap breast reconstruction is a safe, reliable, and consistent technique for recreating new breasts. While implant-based breast reconstruction may be acceptable to many women, there is a growing subgroup of patients who prefer autologous tissue breast reconstruction. By challenging common conceptions about the amount of donor site tissue required, we have been able to expand reconstructive options in thin women by using perforator flaps to construct natural, aesthetic breasts.

Bilateral Simultaneous Laterally Placed Superior Gluteal Artery Flap for Unilateral Breast Reconstruction

Sir: The superior gluteal artery perforator (SGAP) flap has become an important alternative donor site for breast reconstruction, especially if abdominal tissue is inadequate or unavailable.1 Although a few centers have reported the performance of bilateral simultaneous SGAP flaps for bilateral breast reconstruction,2,3 and bilateral simultaneous deep inferior epigastric artery perforator flaps have been used for unilateral breast reconstruction,4 to our knowledge, the use of bilateral simultaneous SGAP flaps has not been reported for reconstruction of a single breast. The patient (body mass index, 18.6 kg m2) was first diagnosed with left-sided breast cancer in 2004. She underwent bilateral mastectomies with immediate implant reconstruction (the right mastectomy was prophylactic because of a strong family history of breast cancer). She then developed two local recurrences (in 2005 and 2007) and underwent left axillary lymph node dissection, and irradiation and further chemotherapy of the left side of the chest wall. Given her history of chest irradiation and obvious abdominal tissue inadequacy, we felt that the best option for her left breast reconstruction was bilateral simultaneous SGAP flaps. To ensure blood flow and adequate length to the recipient vessels (internal mammary), we created an arteriovenous fistula to the internal mammary artery and internal mammary vein using a saphenous vein (arteriovenous) graft (Fig. 1, above). In the second stage, the bilateral lateral SGAP flaps were transferred for single-breast reconstruction 4 days after the creation of the arteriovenous fistula.Fig. 1.: (Above) Saphenous vein graft anastomosed to the ipsilateral internal mammary vessels to create a temporary arteriovenous fistula. (Center) The “superior” SGAP flap pedicle is anastomosed to a side branch off the main pedicle of the “inferior” SGAP flap. In turn, the main pedicle of the “inferior” SGAP flap is then anastomosed to the two ends of the divided saphenous vein graft. (Below) Two new saphenous vein grafts are then anastomosed to the contralateral internal mammary vein and one of its intercostal perforators during the emergent flap take-back on postoperative day 1. The arterial anastomosis to the ipsilateral internal mammary artery is not shown because it remained patent and was not revised.The procedure began in the supine position by first ensuring patency of the arteriovenous fistula. The lateral septal SGAP dissection was performed in the septum between the gluteus maximus and medius toward the medusa head, as described previously.5 On the back table, the pedicle of one flap was sutured to large side branches of the other flap, leaving only one superior gluteal artery and vein pedicle for the internal mammary artery and internal mammary vein anastomoses (by means of the saphenous vein graft arteriovenous fistula). The flaps were then transferred to the chest and their pedicles were anastomosed to the existing saphenous vein graft loop (Fig. 1, center). Because of signs of venous congestion, the patient returned to the operating room on postoperative day 1. The initial vein graft appeared thrombosed and thus new vein grafts were used to the contralateral internal mammary vein and a contralateral, medial, intercostal perforator vein branch (Fig. 1, below). The patient was discharged on postoperative day 5 and had a nice result at 6-month follow-up (Fig. 2).Fig. 2.: The patient at 6-month postoperative follow-up after bilateral SGAP flap surgery for unilateral breast reconstruction. Note the incision on the medial aspect of the right breast that was used to access the contralateral internal mammary vein during the take-back.Given this patient's abdominal tissue inadequacy and her irradiated chest wall, the best potential donor site was her lateral gluteal tissue from both sides to accomplish projection and adequate skin coverage over her irradiated skin. To further support this approach, one must also consider that using bilateral SGAP flaps, as opposed to unilateral flaps, in a low-weight patient provides better donor-site symmetry. This case report exemplifies a safe, viable expansion of the previously reported surgical technique using the SGAP flap for breast reconstruction. With the successful use of bilateral simultaneous SGAP flaps for the reconstruction of a single breast, the authors of this article report an approach that proved to be a useful alternative for breast reconstruction in this patient with insufficient abdominal, back, inner thigh, and gluteal tissue. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Michael Magarakis, M.D. Jaime I. Flores, M.D. Sachin M. Shridharani, M.D. Philip S. Brazio, M.D. Raghunandan Venkat, M.D. Gedge D. Rosson, M.D. Division of Plastic, Reconstructive, and Maxillofacial Surgery Department of Surgery The Johns Hopkins University Baltimore, Md.

Delay in unipedicled TRAM flap reconstruction of the breast: a review of 76 consecutive cases.

Since its introduction in 1982, the transverse rectus abdominis musculocutaneous (TRAM) flap has become the standard therapy in autogenous breast reconstruction. A lower rate of partial flap (fat) necrosis is associated with microvascular free-flap transfer compared with the conventional (unipedicled) TRAM flap because of its potentially improved blood supply. A TRAM flap delay before flap transfer has been advocated, especially in a high-risk patient population (obesity, history of cigarette smoking, radiation therapy, or abdominal scar). The authors reviewed a series of 76 consecutive delayed unipedicled TRAM flap breast reconstructions during a 5-year period. Data were analyzed with respect to type of procedure and time of delay, overall outcome, general surgical complications, flap-related (specific) complications (partial or complete flap loss), and patient satisfaction. Seventy-six unilateral breast reconstructions using the unipedicled TRAM flap were performed between 1995 and 2000 in 76 patients (mean age, 47.4 years). Fifty-four flaps were performed as immediate reconstructions, and 22 as secondary procedures. Seventy-two flaps were based on the contralateral pedicle, and four flaps were based on an ipsilateral pedicle. In all cases, a flap delay consisted of ligature of both deep inferior epigastric arteries and veins, accessed from an inferior flap incision down to the fascia, with a mean of 13.9 days before the flap transfer. No acute flap take-back procedure had to be performed. There was no complete flap loss, and breast reconstruction was achieved in all cases. In five cases (6.6 percent), a partial (fat) flap necrosis occurred. Interestingly, the majority of these cases (four of five) were secondary breast reconstructions. In addition, of the five patients who had partial flap necrosis, four had a history of smoking, two received radiation therapy, three received chemotherapy, and three patients were obese (body mass index greater than or equal to 30) or overweight (body mass index greater than or equal to 25). In three cases, an early surgical complication (two wound infections at the flap interface and one at the donor site) occurred. One patient developed a deep vein thrombosis. Five patients developed secondary ventral hernias necessitating repair (6.6 percent). Forty-one patients underwent secondary nipple-areola reconstruction. In 19 patients of this group, a secondary procedure (e.g., scar revision, limited liposuction, and/or excision of contour deformities) was simultaneously performed. A survey of patient satisfaction was performed using a modified SF-36 questionnaire. Fifty-one patients participated (67 percent). The overall satisfaction was very high and 51 patients reported that they would recommend the procedure to others (100 percent). Multiple factors such as patient selection, surgical expertise, and preoperative and postoperative management contribute to the success of any type of autogenous breast reconstruction. However, rare partial and absent complete flap necrosis in the authors' series may be attributable to the flap delay. A low morbidity rate and short hospital stay may become increasingly relevant, with limited structural and financial resources in the future. Therefore, the delayed unipedicled TRAM flap should be regarded as a valuable option in attempted breast reconstruction using autogenous tissue in both a high-risk and the general patient population.