Microsurgical Free Tissue Transfer Research Articles

From Perforator Flaps to Free Style Free Flaps

Perforator-based surgery has added a new dimension to microsurgical free tissue transfers; the focus now extends beyond assuring flap survival and functional restoration of resected parts, but also places a large emphasis on preserving structures and minimizing morbidity at the donor site. The anterolateral thigh flap is an example and is becoming one of the most preferred options for soft-tissue reconstruction.

“Opened Book Technique for Accessing the Internal Mammary Vessels for Microanastomosis

The internal mammary (IM) vessels have been shown to be an excellent option for use as recipient vessels in microsurgical free tissue transfer. The authors preferentially use the IM vessels for all free flap breast reconstructions unless the IM perforators are suitable. Accessing the IM vessels in the past has involved the removal of an entire rib cartilage. Removal of an entire rib cartilage may be associated with increased postoperative pain, and a visible depression in the upper chest. In order to avoid these problems, they developed a method of accessing the IM vessels within the rib interspace, which does not require the removal of rib cartilage, is relatively bloodless, very reproducible, and can be performed under loupe magnification during the harvest of the free flap. The details of this procedure, which the authors call the “opened book” technique, were described in this report.

Outcome Comparison between Free Muscle and Free Fasciocutaneous Flaps for Reconstruction of Distal Third and Ankle Traumatic Open Tibial Fractures

The advantages of free muscle flaps for reconstruction of lower extremity defects have been largely reported to be superior to those of fasciocutaneous flaps. One hundred seventy-four patients received 177 microsurgical free tissue transfers for distal third and ankle open tibial fractures. Patients were divided into two groups. In group I, 96 patients received 98 free muscle flaps (55.4 percent). In group II, 78 patients were treated with 79 free fasciocutaneous flaps (44.6 percent). Complete flap survival was 92.9 percent and 91.1 percent in groups I and II, respectively. Postoperative infection was 11.2 percent in group I and 12.7 percent in group II. Chronic osteomyelitis developed in 9.3 percent and 12.7 percent in groups I and II, respectively. The rate of primary bone union was 84.5 percent in group I and 81 percent in group II and the rate of overall bone union was 96.9 percent in group I and 98.7 percent in group II. Finally, 92 patients in group I and 77 patients in group II could walk without crutches at 2-year follow-up. There were no statistically significant differences between the two flaps. The authors achieved equal functional outcomes in both soft-tissue transfers because of (1) preoperative adequate débridement of wounds and (2) selection of proper free flaps in appropriate defects. Defects with serious tridimensionality needed free muscle flaps because they conform better to such complex defects. However, free fasciocutaneous flaps are reliable and as effective for covering the less three-dimensional distal third and ankle traumatic open tibial fractures as free muscle flaps and can better tolerate the subsequent secondary surgical procedures.

Anterolateral Thigh Perforator Flaps in Head and Neck Reconstruction

Microsurgical free tissue transfer has revolutionized head and neck reconstruction. It allows functions and esthetics to be preserved without compromising the principles of oncologic surgery. To this end, the anterolateral thigh (ALT) flap has recently gained increasing popularity. This article reviews the advantages of the ALT flap, its anatomy, and various methods of its elevation. We have successfully utilized the ALT flap for reconstructing a wide range of complex head and neck defects; a selection of our methods are outlined herein. Additionally, various configurations of the ALT flap, including the elevation of two independent cutaneous flaps from the same pedical, chimeric, and flow-through flaps, are described. The unique anatomy of the thigh allows unparalleled flexibility in flap design, useful for reconstructing defects of the tongue, buccal region, mandible, midface, scalp, and through-and-through defects of the cheek. Resultant donor site morbidity is low in comparison to other flaps that are commonly utilized for head and neck reconstruction.

The Genioplasty and Beyond: An End-Game Strategy for the Multiply Operated Chin

Genioplasty has been a useful and frequently employed technique. In previous publications, the authors discussed the benefits and versatility of the genioplasty. Here, they briefly examine the entire experience of the senior author, from 1975 to the present. The authors examined a series of 580 genioplasties performed in 567 patients over a 28-year period by the senior author. This was done by chart review, which involved collection of demographic data and tabulation of the number of operations and type of genioplasty, as well as inspection of operative notes and clinical photographs. The focus was on the subgroup of patients who required multiple procedures to obtain a final satisfactory result. In one subgroup of patients, largely those with severe developmental or syndromic retrogenia, staged procedures were part of the original plan. A second subgroup included patients who had had problems with alloplastic chin implants; for these patients, further operations were not part of the original plan. RESULTSIn the first group of patients, with severe developmental or syndromic retrogenia, an osseous genioplasty was often associated with orthognathic surgery and could be repeated later as a staged procedure. In the second group of patients, who had multiple problems with alloplastic chin implants, an osseous genioplasty often provided the solution to difficult problems. In both groups of patients, an autogenous costal cartilage graft may be of great help after one has accomplished as much as one can with an osseous genioplasty. In rare cases, microsurgical free tissue transfer may be required.

Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases

We present a series of reconstruction of 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. All patients were reconstructed primarily by bipaddle pectoralis major myocutaneous (PMMC) flap. The age of patients ranged from 25 to 85 years (mean 49.5 years). All patients were male. The size of the paddle used for mucosal defect repair ranged from 5 x 3 to 9 x 7 cm and the size of the paddle used for skin cover ranged from 4 x 4 to 9 x 8 cm. The total flap size ranged from 10 x 5 to 17 x 7 cm. One patient had complete loss of flap (2.12%). Sixteen patients had minor complications all of which settled with conservative management. The follow up period varied from 1 month to 4 years. The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. We found the technique to be anatomically sound, technically easy and reliable. Precautions taken included proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising. We conclude that this technique is a useful alternative where microsurgical free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions. However, the disadvantages of this method include loss of nipple and areola and technical difficulty in obese patients and females.

Timing of the First Detection of Vascular Compromise Dictates the Salvage Outcome of Free Flap Transfers

Microsurgical free tissue transfer has become a reliable technique that can be applied to reconstruct a variety of composite tissue defects. Nevertheless, about 10 to 15% of all transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the relationship between the timing of ominous signs and the salvage outcome of free flaps with circulatory compromise.

Reliability of free-flap coverage in diabetic foot ulcers

As microsurgery advances, microsurgical free-tissue transfers have become the reconstructive method of choice over staged or primary amputation, and enabling independent ambulation in difficult lower-extremity wounds. In this report, we present our experiences with free-tissue transfer for the reconstruction of soft-tissue defects in 13 diabetic foot ulcers. Following radical debridement, soft-tissue reconstruction was achieved in the following ways: anterolateral thigh fasciocutaneous flap in 5 patients, radial forearm fasciocutaneous flap in 3 patients, lateral arm fasciocutaneous flap in 1 patient, gracilis musculocutaneous flap in 1 patient, tensor fascia latae flap in 1 patient, deep inferior epigastric perforator flap in 1 patient, and a parascapular flap in the remaining patient. In 8 cases, diabetic wounds were in the foot, while wounds were at the level of the lower leg in the remaining patients. In all patients, vascular patency was confirmed by the Doppler technique. In suspicious cases, arteriography was then performed. While all flaps survived well in the postoperative period, one patient died from cardiopulmonary problems on postoperative day 16 in an intensive care unit. Amputation was necessary in the early postoperative period because of healing problems. In the remaining 10 cases, all flaps survived intact. In one case, arterial revision was performed successfully. The ultimate limb salvage rate was 83% for the 12 patients. Independent ambulation was achieved in these cases. During the follow-up period of 8 months to 2 years, no ulcer recurrence was noted, and no revascularization or vascular bypass surgery was needed before or after the free-tissue transfers. The authors conclude that free-tissue transfer for diabetic foot ulcers is a reliable procedure, despite pessimistic opinions regarding the flap survival and low limb salvage rates. It should be considered a useful reconstructive option for serious defects in well-selected cases.

Managements of Sacral and Trochanteric Pressure Sores with Preoperative Topical Negative Pressure Therapy and Perforator-based Flap Surgery

The treatment of pressure sores remains a thorny problem for plastic surgeons. Perforator-flap surgery, one of the advancements in microsurgical free tissue transfers, has become popular in recent years. We have used 12 perforator-based island pedicled flaps, including the superior gluteal artery perforator-based of sacral and trochanteric pressure sores from September 2002 to December 2003. The topical negative pressure therapy has been applied to all these wounds before the reconstructive procedures were carried out. Unfortunately, one patient died of airway obstruction in prone position postoperatively. The other flaps survived with minor complications in two cases. These minor complications were wound dehiscence and infection. Both cases were managed by antibiotic administration, debridement surgery, negative pressure therapy, and secondary wound closure without the need of additional flap surgery. Based on our experience, we have come to favor pedicled perforator-based flaps as the method for the reconstruction of sacral and trochanteric pressure sores, and advocate preoperative topical negative pressure therapy for wound care in improving the wound condition. This combined therapy is one of the best options for pressure sore reconstruction.

Thumb reconstruction by pedicled transfer of the second toe

Microsurgery and free tissue transfer play a vital role in the modern practice of reconstructive surgery. Prior to the advent of microsurgical free tissue transfer pedicle flaps were the workhorse of a reconstructive surgeon. We report a case of thumb reconstruction by pedicled transfer of the second toe with functional and aesthetic outcome. This case was performed in Pakistan where microsurgical facilities were not available.

Diabetic foot salvage with microsurgical free-tissue transfer.

The efficacy of microsurgical free-tissue transfer for the treatment of chronic nonhealing infected diabetic foot ulcers was evaluated in a retrospective study. Between January 1992-December 1997, 10 patients underwent surgery at the American University of Beirut. Muscular free flaps were used to salvage 8 feet, and fasciocutaneous free flaps were used in 2 feet. The flap survival rate was 90%, a result that is equivalent to other series of microvascular tissue transfer in nondiabetic patients; the postoperative morbidity rate was comparable to that of nondiabetic patients. Infection control was achieved in 87.5% of patients. Seven of the 9 surviving patients had bipedal gait and were ambulatory, with full weight-bearing on their flaps at the end of the 2-year follow-up period. Microvascular free-tissue transfer can be used successfully for the salvage of infected diabetic foot ulcers.

The use of fillet flaps in upper extremity reconstruction

In unusual cases, extensive soft-tissue defects of the upper extremity may be reconstructed with major fillet flaps. We discuss the use of these flaps as derived from the experience in using them on 8 selected patients during a 5-year period at 2 institutions. Etiology of injury for which these flaps are ideal include trauma and tumor resection or reconstruction. Defect locations included the shoulder, combined defects of the shoulder plus neck, arm or chest wall, upper arm, and forearm. The majority of flaps require microsurgical free-tissue transfer. Unlike the classic spare-part, fillet-flap concept, the partial or complete conversion of an anatomically intact arm can be performed, especially in tumor reconstruction. Major fillet flaps represent a valuable option in the armamentarium for reconstruction in the upper extremity with either pedicled or free-tissue transfers involving extensive tissue defects.

Temporary arteriovenous fistula and microsurgical free tissue transfer for reconstruction of complex defects.

Atiyeh, Bishara S. M.D.; Khalil, Ismail M. M.D.; Hussein, Maher K. M.D.; Amm, Christian A. Al M.D.; Musharafieh, Ramzi S. M.D. Author Information

Microsurgery in private practice: is it feasible economically?

Microsurgical free tissue transfer and replantations have long been the bailiwick of academic training centers and tertiary referral centers. However, the authors' experience with more than 350 consecutive free tissue transfers during a span of 15 years in a purely private setting illustrates the changing economics of the medical environment in that time frame. These data provide insight into the feasibility and practicality of maintaining a microsurgical practice outside an academic medical center.

Neophalloplasty in female-to-male transsexuals with the island tensor fasciae latae flap.

In the past 60 years, several different procedures have attempted to achieve a postoperative neophallus that is as aesthetic and as functional as possible after penile amputation or sex reassignment. Recently, with improvements in free tissue transfer and microvascular technique, many free flap procedures have been developed with the goal of an aesthetically acceptable neophallus of adequate bulk that enables urination in a standing position and sexual intercourse, with minimal functional and aesthetic donor-site defects. Most authors currently agree that the method of choice for penile reconstruction is microsurgical free tissue transfer, although it does not always fulfill all of the aforementioned goals in a predictable manner. In fact, complete urethroplasty, penile rigidity, and donor-site disfigurement remain challenges, thus making this operation one of the most difficult in plastic surgery. The vascular anatomy of the lateral circumflex femoral artery, which we studied in 1991 with the anatomic dissection of 27 cadavers, gave us the idea to use a long tensor fasciae latae neurovascular island flap as a donor source for neophalloplasty. Grounds for the procedure and its surgical planning have been carefully evaluated with 10 additional fresh cadaver dissections. Since 1991, we have performed five neophalloplasties using this procedure; all patients were female-to-male transsexuals. In four cases, the healing was uneventful; in one case, there was a marginal necrosis of the flap because of poor venous drainage, probably from a twisting of the pedicle. The island tensor fasciae latae provides a safe and sensate flap for phalloplastic procedure and leaves a less conspicuous donor scar.

Complex soft tissue reconstruction after facial trauma with microvascular free-tissue transfer

Complex soft-tissue reconstruction after facial trauma presents a difficult challenge. Microvascular free-tissue transfer with customized circumflex scapular fasciocutaneous flaps offers a reliable and stable long-term correction of facial contour asymmetry attributable to facial trauma. Principles of skeletal reconstruction preceding soft-tissue surgery should be adhered to. By using the approach outlined in this article, soft-tissue camouflage can maximize the aesthetic outocme of reconstruction with microsurgical free-tissue transfer.

New concepts and materials in microvascular grafting: prosthetic graft endothelial cell seeding and gene therapy.

Microsurgical free tissue transfer is currently associated with very high success rates and few complications. While interposition vein grafting is clearly an important adjunct to the microsurgeon's armamentarium, it has been associated with higher free flap/replantation failures and complication rates. With appropriate flap planning and surgical techniques, the need for interposition vein grafting should be quite infrequent and hopefully avoided if at all possible. Nevertheless, when necessary, the vein graft remains the gold standard, with virtually all alternative interposition grafts demonstrating lower patency rates. One of the more promising areas of research is the concept of genetic manipulation of the endothelial cell via molecular biological techniques. It is likely that in the near future this may become a clinical reality, not only improving the patency of microsurgical anastomoses and interposition vein grafts, but quite possibly altering the target organ functionally as well.

Three-dimensional reconstruction of types IV and V midfacial defects by free rectus abdominis myocutaneous (RAM) flap.

Extensive midfacial defects after ablative surgery constitutes a challenging problem for reconstructive surgeons. Particularly for types IV and V midfacial defects, provision of missing bony support and obliteration of the maxillary cavity defects require microsurgical free tissue transfers. In the last three years, four patients have undergone total maxillectomy for midfacial tumours and the postmaxillectomy defects were three-dimensionally repaired with free rectus abdominis muscle flap and skin graft or myocutaneous flaps. Obliteration of maxillary cavity defects and orbital support were achieved with this type of free flap. The least follow-up period of the patients is one year and slight ectropion, later corrected, was seen in two patients. In this study, the free rectus abdominis myocutaneous (RAM) flap, with its long vascular pedicle and availability of various skin paddle designs and muscle bulk, is presented in treatment of extensive midfacial defects. In spite of initial overcorrection of contour, the denervated rectus abdominis muscle gradually atrophies, resulting in loss of contour. The muscle bulk fills the cavity defect, but, in order to achieve good facial contour, it is necessary to support the bony skeleton with some material.

Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine.

Pedicled flaps and microsurgical free tissue transfers are increasingly being used for reconstruction in the elderly and poorer risk patient. The use of systemically administered vasoactive agents to date has been avoided because of the fear that systemic levels of these agents perioperatively (particularly the vasopressors) might decrease blood flow and compromise the viability of the flap. There are no large-animal, real-time hemodynamic studies that support or disprove this belief. The objectives of this study were to (1) develop a musculocutaneous flap model in the pig that allows accurate, simultaneous monitoring of systemic and flap hemodynamic parameters such as flow and resistance and (2) identify the effects of commonly used vasoactive substances (dopamine, dobutamine, and phenylephrine) at clinically used levels on systemic and flap pressure/flow relationships. Vertically based rectus abdominis musculocutaneous flaps were raised in 8 anesthetized, 50- to 55-kg pigs, and a flow probe was placed around the artery. Catheters within the pulmonary artery and aorta were used to measure cardiac output and aortic root pressures. Measures of arterial blood pressure, cardiac output, and musculocutaneous flap flow were obtained at baseline and during the administration of varying doses of dopamine dobutamine and phenylephrine. Cardiac output increased significantly with low and high doses of dopamine and dobutamine, but decreased with increasing doses of phenylephrine. Flap flow, on the other hand, is increased only with dobutamine but remains unchanged with dopamine despite increased cardiac output. Flap flow decreases with high doses of phenylephrine. Flap flow also decreases relative to cardiac output with both dopamine and dobutamine. We conclude that (1) phenylephrine clearly affects flap flow adversely in a large-animal musculocutaneous model and therefore should be avoided, (2) dopamine does not affect total flap flow at either low or high doses despite increasing cardiac output, (3) dobutamine increases both flap flow and cardiac output, and (4) both dopamine and dobutamine should still be used with caution because the flap flow is not equally increased relative to total cardiac output. Possible changes in systemic and flap metabolic demand induced by these vasopressor drugs may therefore still be injurious to the flaps.

A rational approach to ischemic and ischemic-diabetic foot reconstruction

Microsurgical techniques have been well documented to be of great use in reconstruction of post-traumatic defects of the lower extremity. The same techniques are also increasingly useful in reconstruction for chronic atherosclerotic disease of the lower extremities. Extremely small, heavily calcified vessels can be reliably reconstructed using delicate microsurgical techniques and high magnification. Additionally, revascularization followed by microsurgical free tissue transfer has proven to be a valuable alternative to amputation in patients with major soft tissue loss, or bony or tendon lesions requiring soft tissue reconstruction. Although this is an elderly population with a high number of comorbid risk factors, limb salvage can be obtained with a very low morbidity and mortality when carried out in a closely coordinated approach with the appropriate medical and surgical specialists. Microsurgical techniques have greatly expanded the number of patients that can be offered vascular reconstruction, including patients with severely calcified and tiny vessels (1 mm outflow vessels being routinely successful). Minor modifications in microsurgical technique (working with heavy calcification, presence of atherosclerotic plaques) allow these techniques to be applied to the chronic atherosclerotic and diabetic patient population, thus affording broadened horizons of reconstructive possibilities to these patients.