Flow-through Free Flap Research Articles

319 A Case Series of Direct Multi-territory Cerebral Revascularizations Using a Three-Vessel Anastomosis

INTRODUCTION: The ability to perform simultaneous, multi-territory cerebral bypass using a single interposition graft has significant utility for the revascularization of multiple cerebral territories that would otherwise require multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. METHODS: Peri-operative data and outcomes were collected retrospectively for patients undergoing multi-territory cerebral revascularization using a three-vessel anastomosis over a 4-year period (2019-2023). RESULTS: Five patients underwent triple vessel bypass (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery (MCA) aneurysms (one ruptured) were treated multi-territory external carotid artery (ECA)-M2-M2 revascularization using a saphenous vein interposition graft, followed by either proximal ligation or partial/complete aneurysm clip trapping. Two patients with predominately bilateral anterior cerebral artery (ACA) territory moyamoya disease were treated with proximal superficial temporal artery (STA)-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap (RAFF) graft. Bypass patency was 100% and zero patients experienced surgery-related ischemia. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for a post-operative hematoma and RAFF debridement that did not affect bypass patency or neurologic outcome. Median Glasgow Outcome Scale (GOS) and modified Rankin Scale (mRS) scores on discharge were 4 (range 3-5) and 2 (range 0-5), respectively. GOS and mRS scores were stable or improved on follow up in 4/5 patients; one patient died from medical complications of their original stroke. CONCLUSIONS: In experienced hands, three-vessel anastomosis can be a viable option for the safe, simultaneous revascularization of multiple ACA and MCA territories.

Use of Flow-through Free Flaps in Head and Neck Reconstruction.

Reconstructive obstacles in composite head and neck defects are compounded in reoperated, traumatized, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel accessibility and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by supplying arterial inflow and venous outflow to a second flap in a contiguous fashion. This approach (1) permits the use of a singular native recipient vessel, (2) increases the reach of the vascular pedicle, avoiding the need for arteriovenous grafting, and (3) allows for a greater three-dimensional flexibility in configuring soft tissue and bony flap inset. To demonstrate this technique, we conducted a retrospective review of all head and neck reconstruction patients presenting to us from March 2019 to April 2021. We present seven oncological and two traumatic patients (N = 9) who received flow-through free flaps for head and neck reconstruction. The most common flap used as the flow-through flap was the anterolateral thigh flap (N = 7), followed by the fibula flap (N = 2). Mean follow-up time was 507 days. No flap failures occurred. In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single-stage reconstruction for patients with vessel-depleted, irradiated, and/or reoperated fields. We demonstrate that flow-through flaps in the head and neck may be used successfully for a variety of cases and flaps.

Three-Vessel Anastomosis for Direct Multiterritory Cerebral Revascularization: Case Series.

Cerebral revascularization of multiple territories traditionally requires multiple constructs, serial anastomoses, or a combination of direct and indirect approaches. A novel 3-vessel anastomosis technique allows for direct, simultaneous multiterritory cerebral revascularization using a single interposition graft. We herein present our experience with this approach. Retrospective review of perioperative data and outcomes for patients undergoing multiterritory cerebral revascularization using a 3-vessel anastomosis from 2019 to 2023. Five patients met inclusion criteria (median age 53 years [range 12-73]). Three patients with complex middle cerebral artery aneurysms (1 ruptured) were treated with proximal ligation or partial/complete clip trapping and multiterritory external carotid artery-M2-M2 revascularization using a saphenous vein interposition graft. Two patients with moyamoya disease, prior strokes, and predominately bilateral anterior cerebral artery hypoperfusion were treated with proximal superficial temporal artery-A3-A3 revascularization using a radial artery or radial artery fascial flow-through free flap graft. No patients experienced significant surgery-related ischemia. Bypass patency was 100%. One patient had new strokes from vasospasm after subarachnoid hemorrhage. One patient required a revision surgery for subdural hematoma evacuation and radial artery fascial flow-through free flap debridement, without affecting bypass patency or neurologic outcome. On hospital discharge, median Glasgow Outcome Scale and modified Rankin Scale scores were 4 (range 3-5) and 2 (range 0-5), respectively. On follow-up, 1 patient died from medical complications of their presenting stroke; Glasgow Outcome Scale and modified Rankin Scale scores were otherwise stable or improved. The 3-vessel anastomosis technique can be considered for simultaneous revascularization of multiple intracranial territories.

Flow through fibula and fasciocutaneous free flaps in oromandibular reconstruction.

The osteocutaneous fibula is a workhorse flap for oromandibular reconstruction. Skin paddles not only perform soft tissue reconstruction but also serve as a monitor for the fibula. In cases where the skin paddle cannot be harvested as desired due to variations, two challenges arise, such as fibula follow-up and the need for a second free flap so recipient. Moreover, there may not be enough recipient vessels for the double flaps in the neck. This report aimed to address the difficulties mentioned above with the use of flow-through free flaps in composite oromandibular reconstructions. Between 2019 and 2021, five (three Female, two Male) patients underwent flow-through technique as free fibula and fasciocutaneous flaps due to variations in fibular skin paddle or insufficiency of recipient vessels in the neck. Ages of patients were between 45 and 75 years. Four patients underwent surgery for tumor and one patient for the result of radionecrosis. ALT, chimeric ALT, and RFFF were selected as second free flaps. The size of the fasciocutaneous flaps ranged from 6 × 4 cm to 14 × 11 cm. Mandibular defects ranged from 6 to 16 cm. 1 venous occlusion occurred post-op 1st day and was salvaged. One hematoma and one wound dehiscence occurred postoperatively and were salvaged successfully. One Partial tongue necrosis occurred due to previous radiotherapy and additional tumor surgery. No additional complication occurred. All flaps survived. Follow-up period was between 3 months and 2 years. Patient who had tongue necrosis experienced swallowing and speech difficulty and Percutaneous endoscopic gastrostomy tube was placed post-operative 2 months. Functional finale outcomes were successful for other patients. Flow-through technique provides fibula monitoring with avoiding to find second recipient. Customizing free flaps under more favorable conditions as on the operation table before fixation of the bone can be a useful approach.

P121. THE USE OF FLOW-THROUGH FREE FLAPS FOR HEAD AND NECK RECONSTRUCTION

PURPOSE: Reconstructive obstacles in composite head and neck defects are compounded in re-operated, irradiated, and vessel-depleted surgical fields. In cases that require multiple free flaps, recipient vessel availability and inset logistics become challenging. Strategic flow-through flap configurations mitigate these issues by providing a built-in option for inflow to a second flap. This approach permits use of one native recipient vessel, increased reach of the inflow vessels, and greater flexibility to configure soft tissue and bony flap inset. METHODS: 38 head and neck free flap cases were reviewed from an academic hospital in New Orleans, Louisiana, taking place between March 2019 - April 2021. Nine cases utilized flow-through free flaps for reconstruction. RESULTS: Seven oncologic and two traumatic patients (N=9) received multiple flaps arranged in flow-through configuration (ALT: 78%; Fibula: 78%; DCIA: 22%; Peroneal Artery Perforator: 11%; MSAP: 11%) for reconstruction. Configurations involved ALT -> Fibula (56%), ALT -> DCIA (22%), Fibula -> Peroneal artery perforator (11%), Fibula -> MSAP (11%). Recipient vessels included facial (78%), transverse cervical (11%), and occipital (11%) arteries. No flap failures occurred, though complications included infection (22%), dehiscence (44%), hematoma (22%), thrombosis (11%), and others (33%). CONCLUSIONS: In head and neck reconstruction, the use of the flow-through principle enables uninterrupted vascular flow for two distinct free flaps in single stage reconstruction for patients with vessel-depleted, irradiated, and re-operated fields.

Three-Vessel Anastomosis for Direct Bihemispheric Cerebral Revascularization.

In rare, complex cerebrovascular pathologies, patients may benefit from simultaneous revascularization of multiple arterial territories. Traditional strategies for these situations include the use of more than 1 interposition graft, multiple microvascular anastomoses, vessel reimplantations, and staged procedures. To improve upon traditional revascularization strategies by describing a novel 3-vessel microvascular anastomosis. This technique combines a side-to-side and an end-to-side anastomoses to facilitate simultaneous direct revascularization of 2 arterial territories in a single procedure, with a single donor vessel. We present an illustrative case of moyamoya angiopathy in which a 3-vessel anastomosis was performed in the interhemispheric fissure to simultaneously directly revascularize bilateral anterior cerebral artery (ACA) territories. A detailed step-by-step depiction of the anastomosis technique is provided. In the presented case, 3-vessel anastomosis was combined with a radial artery fascial flow-through free flap, allowing for an additional indirect revascularization. Technical execution of the 3-vessel anastomosis was uncomplicated. The patency of the anastomosis providing direct bilateral ACA territory revascularization was demonstrated intra- and postoperatively. With this report, we demonstrate technical feasibility of a novel 3-vessel anastomosis for direct 2 arterial territory revascularization This single-stage approach combines side-to-side and end-to-side techniques and has benefits over traditional revascularization techniques, as it is not deconstructive, requires only a single craniotomy and a single interposition graft, and does not require lengthy recipient artery dissection.

Double Antero-lateral Thigh Flow-Through Free Flaps in Series Connection to Reconstruct a Huge Defect in Back

Soft tissue sarcomas can occur anywhere in the body. In the back, they pose a significant problem due to their large size. Surgery is the main stay of treatment for soft tissue sarcoma management. However, removal of such tumors results in large soft tissue defects. Skin grafts can resurface large defects, but skin grafts have their own limitations and can delay initiation of radiotherapy. Providing a stable soft tissue cover which can withstand post-op radiotherapy is desirable. Single flap cannot cover large defects. We report one such technique where two antero-lateral thigh free flaps were connected in series for the first time as “chain flaps” for large defect coverage. Six months follow-up showed no complications following radiotherapy. We recommend this technique to cover large size defects which are not amenable to cover via single flap, for optimal outcome.

Radial Artery Fascial Flow-Through Free Flap for Complex Cerebral Revascularization: Technical Notes and Long-Term Neurologic and Radiographic Outcomes.

Surgical innovation is critical for the management of challenging cerebrovascular pathology. Flow-through free flaps are versatile composite grafts that combine viable tissue with a revascularization source. Neurosurgical experience with these flaps is limited. To provide an in-depth technical description of the radial artery fascial (and fasciocutaneous) flow-through free flap (RAFF and RAFCF, respectively) for complex cerebral revascularizations. An Institutional Review Board-approved, prospective database was retrospectively reviewed to identify patients that underwent extracranial-to-intracranial cerebral bypass with a RAFF or RAFCF. Patient demographics, underlying pathology, surgical treatment, complications, and outcomes were recorded. A total of 4 patients were treated with RAFFs or RAFCFs (average age 40 ± 8.8 yr). Two patients with progressive moyamoya disease involving multiple vascular territories with predominantly anterior cerebral artery (ACA) symptoms and flow alterations underwent combined direct ACA and indirect middle cerebral artery (MCA) bypass with a RAFF. The third patient with moyamoya disease and concomitant proximal fusiform aneurysms requiring internal carotid artery sacrifice underwent dual direct ACA and MCA bypass and indirect MCA revascularization with posterior tibial artery and RAFF grafts. The fourth patient with a large MCA bifurcation aneurysm and recurrent wound complications underwent a direct MCA bypass and complex wound reconstruction using a RAFCF. Good neurologic outcomes (Glasgow Outcomes Scale score ≥4 at discharge) were achieved in all patients. There were no perioperative surgical complications, and graft patency was confirmed on long-term follow-up. The RAFF and RAFCF are versatile grafts for complex cerebral revascularizations.

Application of MDCTA in free Flow-through anterolateral thigh flap for reconstructing the combined limb soft tissue with main vascular defect

Objective To evaluate the clinical value of MDCTA (Multi-detector computed tomographic angiography) in reconstruction of the soft tissue defect of the limbs combined with the main vascular defects by using Flow-through anterolateral thigh flap. Methods From September, 2013 to May, 2016, 12 cases of limb soft tissue with main vascular defects were examined by MDCTA. The length of vascular defect was measured. The length of bridging vessel needed to design a Flow-through anterolateral thigh flap was measured. The points of anterolateral thigh flap perforator were positioned. The relationship between the perforation and the trunk vascular pedicle was defined. The outcomes were evaluated based on Berton scores for upper extremities and John-Wruh scores for lower extremities. Results The length of the main vascular defects, the positions of flap perforators and the configuration of vascular pedicles were successfully imaged through MDCTA. The length of the main vascular defects were 5-12 cm, which was consistent with the intraoperative findings. The length of bridging vessel for the defects were 7-14 cm, which was enough for the vascular defects. There were not vessel grafts. Twenty perforators were imaged by MDCTA preoperatively, and 22 perforators were found during the operations, which means 2 perforators were not imaged. All flaps survived completely. All patients were followed-up from 6 to 21 months (average, 11 months) . According to the Berton scores for upper extremities and John-Wruh scores for lower extremities, the excellent/good were 6 in 8 cases and 4 in 4 cases, respectively. Conclusion MDCTA can be used to evaluate the pedicle conditions of the free Flow-through anterolateral thigh flap for the reconstructions. It is worthy to be popularized in clinical application. Key words: Anterolateral thigh flap, Flow-through flap; Extremities; Vascular defect; MDCT angiography; Repair

Emergency repair of upper extremity large soft tissue and vascular injuries with flow-through anterolateral thigh free flaps

Background/ObjectivesComplex extremity trauma commonly involves both soft tissue and vascular injuries. Traditional two-stage surgical repair may delay rehabilitation and functional recovery, as well as increase the risk of infections. We report a single-stage reconstructive surgical method that repairs soft tissue defects and vascular injuries with flow-through free flaps to improve functional outcomes. MethodsBetween March 2010 and December 2016 in our hospital, 5 patients with severe upper extremity trauma received single-stage reconstructive surgery, in which a flow-through anterolateral thigh free flap was applied to repair soft tissue defects and vascular injuries simultaneously. Cases of injured artery were reconstructed with the distal trunk of the descending branch of the lateral circumflex femoral artery. A segment of adjacent vein was used if there was a second artery injury. Patients were followed to evaluate their functional recoveries, and received computed tomography angiography examinations to assess peripheral circulation. ResultsTwo patients had post-operative thumb necrosis; one required amputation, and the other was healed after debridement and abdominal pedicle flap repair. The other 3 patients had no major complications (infection, necrosis) to the recipient or donor sites after surgery. All the patients had achieved satisfactory functional recovery by the end of the follow-up period. Computed tomography angiography showed adequate circulation in the peripheral vessels. ConclusionsThe success of these cases shows that one-step reconstructive surgery with flow-through anterolateral thigh free flaps can be a safe and effective treatment option for patients with complex upper extremity trauma with soft tissue defects and vascular injuries.

The use of innervated radial artery superficial palmar branch perforator free flap for complex digital injuries reconstruction

Loco-regional flaps have been widely used for the reconstruction of digital injuries without requiring microvascular anastomosis, however, they result in scarring and compromised functional outcomes. This study demonstrates our experience utilizing the innervated radial artery superficial palmar branch (RASPB) perforator free flap for complex digital injury reconstruction. From May 2007 to March 2014, the innervated RASPB perforator free flap was used to reconstruct 79 distal complex hand and digital soft tissue defects of which 14 were used to re-vascularise the distal digit in a flow-through fashion. All free flaps were innervated by the palmar cutaneous branch of the median nerve. All 79 free flaps survived and all 14 digits re-vascularized successfully. One flow-through free flap developed distal skin necrosis which healed uneventfully without further procedure. The average follow-up was 21.5 months. Measurement of two-point discrimination ranged from 7 to 13 mm. All patients were satisfied with the aesthetic results. The innervated RASPB perforator free flap is a feasible and effective option for the reconstruction of complex digital defects and the flow-through concept, when utilized in cases with compromised vascularity, provides reliable re-vascularization. Level III, therapeutic study.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases. Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap. All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications. The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Flow-through forearm flaps in palmar finger reconstruction

Objective To report the treatment and outcome of two kinds of flow-through forearm flaps in repairing palmar digital skin and artery defects. Methods The study included 15 patients (15 fingers) with palmar digtial skin combined with digital artery defects hospitalized from September 2011 through February 2014. Cut injuries were noted in 6 patients, crush injuries in 5 patients, and chain saw in 4 patients. There were 11 fingers with poor blood supply to the distal area and 4 no blood supply. One-stage reconstruction of the finger composite tissue defects was performed with flow-through free flaps including arterialised venous flaps (AVF) in 9 patients and superficial palmar branch of the radial artery (SPBRA) flaps in 6 patients. Discriminative sensation on the flap and active range of motion of the injured finger were analyzed and compared between the two groups. Results All the flaps survived and blood circulation in the finger restored. In AVF group, blister developed in 4 patients but healed within 5-10 days with no special care. Other than this the wound healed by the first intention. At a follow-up of 8-12 months, all the flaps that survived exhibited good restoration of the appearance, texture, thickness and protective sensation and the finger function was restored. According to the replanted finger function scoring system of Society of Hand Surgery of Chinese Medical Association, there were 6 excellent, 2 good, and 1 poor results in AVF group, with the excellent-good rate of 89%; there were 4 excellent, 1 good, and 1 poor results in SPBRA group, with the excellent-good rate of 83%. At postoperative 12 months, the two-point discrimination of the flaps was 6-9 mm[(7.6±1.3)mm] in AVF group versus 7-11 mm [(8.5±3.1)mm] in SPBRA group (P>0.05). Total active motion (TAM) of the injured fingers was (196.9±0.6)° in AVF group and was (196.2±0.5)° in SPBRA group (P> 0.05). Conclusion SPBRA flaps and AVF are both effective to cover digital wounds and restore blood circulation by flow-through technique. Key words: Surgical flaps; Soft tissue injuries; Fingers; Flow-through technique

Late Salvage of the Ischemic Finger After Crush Injury Using Flow-Through Flaps: Case Report

The progressive evolution and late salvage of a posttraumatic digit with poor vascularization has not been discussed in the literature. We report the cases of 3 patients whose fingers were rescued at referral 5 to 16 days after the traumatic event by restoring the arterial inflow by means of flow-through free flaps. All 3 fingers were compromised vascularly with patchy necrosis and absence of Doppler signal distal to the injury. All were salvaged. In our experience, in the setting of a posttraumatic digit with poor vascularization, it is possible to reverse impending necrosis by late revascularization. Frank infection or mummification is considered an irreversible state and a contraindication to salvage.

Upper Extremity Salvage With a Flow-Through Free Flap

In complex extremity injuries, which include composite tissue lost with devascularization caused by segmental vascular damage, simultaneous coverage of the defects with revascularizations should be required. One-stage reconstruction of both soft tissue coverage and vascular damage can be performed by a flow-through-type free flap. In this series, 5 patients between 13 and 36 years of age with wide composite tissue defects in the cubital region and segmental defects in brachial arteries were operated at our clinic between 1996 and 2003. With the aim of reconstructing the wide tissue defects in the cubital region as well as that of the brachial artery, a radial arterial flow-through flap was applied. The radial artery of the flow-through flap was anastomosed to the proximal ends of the brachial and ulnar arteries in an end-to-end fashion. In 4 of the patients, the radial arterial flow-through flap was prepared from the distal aspect of the wounded forearm and in 1 patient from the contralateral forearm. In the postoperative period, no complications related to the anastomosis were encountered in the flap with all anastomoses found to be patent, and distal circulation was restored. The radial arterial flow-through flap is very useful in the clinical field of major trauma of the cubital region with brachial artery damage with numerous advantages that include the opportunity to work in one single surgical area, shorter dissection times resulting from simple and fixed anatomy, perfect color and tissue adaptation, and the suitability of the vessel caliber and length.

Salvage of femoropedal bypass graft complicated by interval gangrene and vein graft blowout using a flow-through radial forearm fasciocutaneous free flap

We report the case of a 71-year-old man who had interval gangrene of his calf with subsequent vein graft blowout 3 months after undergoing a femoral–to–dorsalis pedis saphenous vein bypass grafting procedure. To provide wound coverage, restore vascular continuity, and preserve functional ambulation, a flow-through radial forearm fasciocutaneous free flap was interposed between cut ends of the bypass graft. Venous drainage of the flap was from the cephalic vein to the popliteal vein. At 1 month after the operation, the patient had complete wound healing and began to ambulate. At 11 months an asymptomatic high-grade stenosis in the distal radial artery segment of the reconstruction was successfully treated with percutaneous angioplasty. After 22 months of follow-up there have been no further complications, and the patient continues to have full, functional ambulation. The radial forearm flow-through free flap allows single-stage restoration of bypass graft continuity and coverage of extensive, complex tissue defects. This technique represents a novel approach to this difficult problem and provides a viable alternative to major limb amputation. (J Vasc Surg 1997;26:711-4.)

The flow-through free flap in replantation surgery: a new concept

The concept of flow-through circulation in free flaps was previously described as a one-staged technique for cover and revascularisation of ischaemic traumatized extremities. This paper describes the practical use of the concept in replantation surgery. Two clinical cases of hand replants are presented in which an uninterrupted flow was established through the selected free flap.