Microvascular Tissue Transfer Research Articles

Outcome of treatment and parameters influencing recurrence in patients with bisphosphonate-related osteonecrosis of the jaws

Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is now a well-recognised entity which is difficult to manage and often recurs. The aim of this study was to examine the success of resection of the necrotic bone and identify risk factors for recurrence in these patients. One hundred and eight patients were evaluated prospectively and investigated at least twice. Multiple logistic regression analysis was used to determine factors independently associated with the dependent variable of recurrence of BRONJ. Factors influencing the development of recurrence of BRONJ were the presence of bacterial bone infection of the necrotic area (P = 0.011), type of treatment (either conservative or surgical, P = 0.001) with a lower recurrence rate for surgically treated patients, extent of surgical treatment with better outcome in larger resections (P < 0.0001), number of debridements performed (P < 0.0001), and the extent of radiographic appearance of osteolysis assessed by dental panoramic tomogram (P = 0.028). An increased risk for recurrence can be found in cases with bacterial bone infection of the necrotic area, type of conservative or surgical treatment, extent of surgical treatment with better outcome in larger resections, and the number of debridements performed. Microvascular tissue transfer should be considered in selected cases if other options have been exhausted.

Mikrovaskulärer Gewebetransfer

Microvascular tissue transfer has rapidly developed to a routine method since is introduction approximately 30 years ago and is nowadays also the focal point of reconstructive procedures in oral and craniomaxillofacial surgery. Depending on the condition of the defect area, transplants with various tissue components can be acquired from many donor sites, which are distinguished by a constant anatomy and therefore allow standardized preparation techniques. Recently, the so-called perforator flaps have been discussed as an extension of this well-established technique and are characterized by minimal donor morbidity but often make an individual approach for flap raising necessary due to the wide variation in anatomy. Microvascular tissue transfer has become an indispensible component particularly in tumor surgery and success rates of 95% have been cited by large centers. It can therefore be considered an extremely safe reconstruction procedure in oral and craniomaxillofacial surgery.

Free microvascular tissue transfer for the reconstruction of midfacial defects in oncological patients

This study reviews our experience with free microvascular tissue transfer for the repair of midfacial defects in surgical oncology. From 2000 to 2008, eight patients with maxillectomy defects were immediately reconstructed using free flaps. Their clinical charts were retrospectively reviewed to record demographic data, ablative and reconstructive procedures, complications and outcome. Free tissue transfer was successful in all patients, giving an overall success rate of 100%. The mean follow-up time was 4 to 101 months (mr: 43.8). Three patients died from the disease giving a patient mortality of 30%, while five patients are alive, free of disease and back to their normal daily activities. The restoration of function and improvement of patients' quality of life was a common feature in all our reconstructions. The development of free tissue transfer has made surgical treatment of oncological patients with maxillectomy defects previously considered inoperable possible, improving at the same time their quality of life.

Prevention of thrombosis after microvascular tissue transfer in the head and neck. A review of the literature and the state of affairs in Dutch Head and Neck Cancer Centers

Free vascularized graft or free-flap reconstruction is frequently used in the reconstruction of defects in head and neck oncology patients. A common complication in free-flap surgery is thrombosis. Thrombosis occurs in 8-14% of cases and often leads to flap failure. A review of the literature on this subject was carried out and Dutch head and neck cancer centres were asked to share their guidelines concerning the prevention of thrombosis after free vascularized graft surgery. No consensus in the literature was found on how thrombosis could best be prevented. The Dutch Head and Neck Cancer Centers use routine deep venous thrombosis prophylaxis to prevent thrombosis in the anastomosis. It was also concluded that non-pharmacologic measures for preventing thrombosis, such as meticulous microvascular surgery and smoking cessation prior to the operation, are thought to play an important role in the prevention of thrombosis in microvascular free-flap reconstructions. It has not been determined which pre- and postoperative pharmacologic measure can prevent thrombosis most effectively. A pharmacologic regimen to prevent thrombosis that is customized to the patient is suggested. This should be based on an individual risk profile for the development of thrombosis.

Oronasal fistula in cleft palate surgery

ABSTRACTOronasal fistula (ONF) is the commonest complication associated with cleft palate surgery. The main symptoms associated with ONF are nasal regurgitation of food matter and hypernasality of voice. Repair of cleft palate under tension is considered to be the main reason of ONF though vascular accidents and infection can also be the cause. Most of the ONFs are situated in the hard palate or at the junction of hard and soft palate. Repair of ONF depends on its site, size and mode of presentation. A whole spectrum of surgical procedures starting from small local flaps to microvascular tissue transfers have been employed for closure of ONF. Recurrence rate of ONF is 25% on an average after the first attempt of repair.

The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap

Sir: We read with great interest the recent publication by Kim et al. entitled “The Efficacy of Prophylactic Low-Molecular-Weight Heparin to Prevent Pulmonary Thromboembolism in Immediate Breast Reconstruction Using the TRAM Flap” (Plast Reconstr Surg. 2009;123:9–12). The authors compared a group of 450 patients receiving a free microvascular transverse rectus abdominis musculocutaneous (TRAM) flap without medical prophylaxis with 200 patients receiving low-molecular-weight heparin for prophylaxis of deep vein thrombosis, and found a significant decrease in asymptomatic pulmonary thromboembolism in the latter group. Because antithrombotic therapy may influence not only deep vein thrombosis but also anastomotic patency and the incidence of microvascular anastomosis thrombosis, we would like to ask the authors about the incidence of anastomotic failure, requiring surgical revision, in their series. Did the authors observe a reduction of either venous or arterial anastomotic thrombosis in the heparin group? Finally, did the authors observe a difference in flap survival between the two groups? In large studies of microvascular breast reconstruction, the incidence of anastomotic venous and arterial thrombosis is reported to be 1.5 and 0.6 percent, respectively.1 Arterial anastomotic thrombosis is associated with flap loss in 11.1 percent of the cases, whereas venous anastomotic thrombosis may lead to flap loss in 26.7 percent of these cases.1 In concordance with the results from Kim et al., these data suggest a need for medical prophylaxis of vascular thrombosis following microvascular free tissue transfer. However, postoperative anticoagulation and antiaggregation regimens are not standardized, and it is unclear which thromboembolic risk factors may contribute to anastomotic thrombosis. In this context, we would like to point out the possible role of hereditary thrombophilia in postoperative thrombosis of both deep leg veins and microvascular anastomosis. Factor V Leiden mutation was first described in 1994 and has since been identified as a major risk factor for thromboembolic complications.2 Heterozygous carriers of the gene mutation carry a 5- to 10-fold higher risk for deep vein thrombosis, and the risk is 80-fold higher in homozygous carriers. In the white population, the prevalence of the factor V Leiden mutation is between 2 and 10 percent, thus resembling the most common type of hereditary thrombophilia in the Western world.2 We have recently published a case in which a patient with factor V Leiden mutation suffered from recurrent venous and arterial thrombosis at the microvascular anastomosis following breast reconstruction with a TRAM flap.3 Other authors also suggest a possible impact of factor V Leiden mutation on thrombotic occlusion of microvascular anastomosis.4,5 Because of the relatively high prevalence of factor V Leiden mutation in whites, further research on the impact of this thrombophilic disorder in patients undergoing free microvascular tissue transfer is warranted. Alexander E. Handschin, M.D. Kay Busch, M.D. Peter M. Vogt, M.D., Ph.D. Plastic, Hand, and Reconstructive Surgery Medical School Hannover Hannover, Germany

Nonvascularized Bone Grafts for Segmental Reconstruction of the Mandible—A Reappraisal

To evaluate the success rate and complications of segmental mandibular reconstructions with autogenous nonvascularized iliac crest bone grafts, and to refine treatment strategies. Seventy-four patients with segmental mandibular defects were included. Malignant lesion, immediate reconstruction, smoking habit, radiotherapy, site of the defect, surgical approach, and method of graft fixation were analyzed as factors of influence on success. Success was defined as maintenance of bone continuity and stability, and absence of infection 1 year after reconstruction upon clinical and radiographic examination. Complications were divided into recipient and donor-site complications and classified as minor or major. The reconstruction was considered functionally complete if prosthetic rehabilitation was accomplished or if there was a sufficient remaining dentition for mastication. In 56 (76%) patients, the initial reconstruction was successful. Multivariate analyses showed that symphyseal involvement (SI) and intraoral approach (IA) were significantly associated with failure (P(SI) = .022, P(IA) = .038) and major recipient-site complications (P(SI) = .022, P(IA) = .038). Thirty-two (43%) patients showed complications in the first postoperative year: 27 recipient-site complications and 6 donor-site complications. Nineteen (70%) recipient-site complications were classified as major. The reconstruction was functionally complete in 48 (86%) of the 56 patients with a successful initial reconstruction. Nonvascularized iliac crest bone grafts for segmental reconstruction of the mandible is the method of choice on the condition that the defect is truly lateral and only an extraoral approach is used. In these cases, microvascular tissue transfer is not necessary.

Is the ratio of functional fibrinogen to platelets as measured by thromboelastography a predictive parameter for thrombotic complications in free tissue transfer surgery?

The risk of total flap loss after free microvascular tissue transfer is estimated to be between 2 and 6%. Flap failure is most frequently due to anastomotic thrombosis, occurring in the early postoperative period. The exact causes of events leading to thrombotic occlusion still are not clearly elucidated, although authors have observed detrimental effects of increased platelet counts, platelets aggregation, and elevation of fibrinogen levels on flap survival. In patients with hyperfibinogenemia related to oral cancer, the safety of performing a successful microsurgical procedure for complex tissue defects has been debated, and the correlation between hyperfibrinogenemia and vascular thrombosis in microsurgery remains unclear.

Oronasal fistula in cleft palate surgery

Oronasal fistula (ONF) is the commonest complication associated with cleft palate surgery. The main symptoms associated with ONF are nasal regurgitation of food matter and hypernasality of voice. Repair of cleft palate under tension is considered to be the main reason of ONF though vascular accidents and infection can also be the cause. Most of the ONFs are situated in the hard palate or at the junction of hard and soft palate. Repair of ONF depends on its site, size and mode of presentation. A whole spectrum of surgical procedures starting from small local flaps to microvascular tissue transfers have been employed for closure of ONF. Recurrence rate of ONF is 25% on an average after the first attempt of repair.

The distal superficial femoral arterial branch to the sartorius muscle as a recipient vessel for soft tissue defects around the knee: Anatomic study and clinical applications

Complex wounds surrounding the knee and proximal tibia pose a significant challenge for the reconstructive surgeon. Most of these defects can be managed using local or regional flaps alone. However, large defects with a wide zone of injury frequently require microvascular tissue transfers to aid in soft tissue coverage and closure of large cavities. We describe a unique recipient vessel for microvascular anastomosis for free flap reconstruction involving the knee and proximal tibia through anatomic and clinical studies.

Multiple bilateral asymmetrical deficiency of trunk muscles

Trunk muscles are an important source for pedicled and free flaps in reconstructive surgery. Unilateral deficiencies of trunk muscles are well known, either isolated or as part of Poland’s syndrome. Bilateral muscular deficiencies and a “bilateral Poland anomaly” have also been sporadically reported, but this is rare. We report on an 82-year-old male cadaver with clinically obscure, asymmetric bilateral deficiencies of the majority of trunk muscles. There was a history of acute poliomyelitis in childhood. Histological examination of representative muscle samples of the trunk showed extensive muscle atrophy with fat and connective tissue replacement. This was compatible with the prior diagnosis of poliomyelitis. However, representative sections of the spinal cord failed to reveal the antecedent poliomyelitis. The possibility of subclinical bilateral deficiencies of trunk muscles has to be taken into account in patients with a history of poliomyelitis when planning reconstructions in cases of regional pedicled muscle transfers or free microvascular tissue transfers in reconstructive surgery.

Varioscope M5: A New Type of Magnification System in Anterolateral Thigh Perforator Free-Flap Surgery

Free microvascular tissue transfer has become a key procedure for the surgical treatment of large tissue defects that requires specialized practitioners and magnification instruments. The operating microscope traditionally has filled this requirement. A study was performed focusing on the evaluation of a new magnification system, the Varioscope M5 (Life Optics, Vienna, Austria), in reconstructive procedures with a perforator free flap. The device was employed by the same operator during dissection and microvascular anastomosis of 12 anterolateral thigh perforator flaps in head and neck reconstruction. The need to operate in a different way, not provided by an operating microscope, gave us the idea of exploring an alternative to the classical visualization systems. Specific advantages such as reduced cost, freedom of movement, auto focus, minimal upkeep, and a variable range of magnification are some of the reasons that convinced us to try this new type of magnification system. Increasing interest in microsurgery magnification highlights the need for further technical developments in this field. We consider the Varioscope M5 an alternative option for surgical magnification in most free tissue transfers, especially when an operating microscope is not supplied.

Monitoring bei freien Lappenplastiken und Replantationen. Eine Bestandsaufnahme im deutschsprachigen Raum

The risk of total flap loss after free microvascular tissue transfer is estimated to be between 2 and 6 %. According to the literature the main reason for flap loss is thrombosis of the anastomosis. The percentage of successful revision is decreasing depending on the time period between circulatory failure and its detection. For this reason postoperative monitoring has been developed. The focus of interest was the question if there are generally accepted principles for postoperative flap monitoring. This research focused on finding standards for postoperative monitoring methods. Further topics of interest were surgical technique, anticoagulation, decision criteria for revision, the use of technical support and monitoring plans. Therefore all 150 members of the Society for Microsurgery in the German-speaking countries Austria, Germany and Switzerland received a questionnaire. 74 out of 150 surgeons answered and returned the questionnaire (49.3 %). Only a minority of responders use couplers routinely for anastomosis with only 10.3 %, whilst 89.7 % use conventional anastomosis. 65.6 % of the surgeons use heparin for the anastomosis, 45.6 % of them systemically. 44.1 % continue a systemic use of heparin postoperatively. We could show that monitoring and decision for revision is done for clinical reasons. Altogether only 29.4 % use technical support for monitoring. The Doppler US is used most often by 16.2 % for routine use, followed by licox pO (2) sensor by 5.9 % and the thermo-sensor by 4.4 %. Most common postoperative interval for monitoring is (43.1 %): every hour until day 3, every second hour until day 5 and decreasing intervals until discharge from the hospital. A well-working anastomosis is obligatory for successful free microvascular tissue transfer. Most of the surgeons perform hand-made anastomosis. We could show that monitoring and decision for revision is mainly for clinical reasons. Most commonly in use for technical support was the Doppler US method for accessing flap viability.

Monitoring of microcirculation in free transferred musculocutaneous latissimus dorsi flaps by confocal laser scanning microscopy – a promising non-invasive methodical approach

For the survival of a microvascular tissue transfer, early detection of vascular complications is crucial. In vivo confocal laser scanning microscopy allows real-time, non-invasive evaluation of tissue microcirculation with a high cellular resolution. The aim of this study was to evaluate confocal laser scanning microscopy for early recognition of flap failure. Fourteen patients (ages: 40.2+/-12.4 years) were monitored postoperatively for a period of 24h following free microvascular M. latissimus dorsi transfer to the lower extremity using confocal laser scanning microscopy (Vivascope1500; Rochester; New York; USA). The following parameters were evaluated: quantitative blood-cell flow, diameter of capillary loops and minimal thickness of the epidermis. Venous congestion was characterised by a decrease in blood-cell flow of up to 41%, accompanied by an increase of the diameter of capillary loops of up to 22% and the minimal thickness of the epidermis up to 32%. By contrast, arterial occlusion was clearly verified by a decrease in blood flow of up to 90%, accompanied by an insignificant change of both capillary loop size and epidermal thickness. Confocal laser scanning microscopy appears to be a useful non-invasive tool for early recognition of flap failure during the monitoring of microsurgical tissue transfer prior to its clinical manifestation.

Factor V Leiden Mutation and Thrombotic Occlusion of Microsurgical Anastomosis After Free TRAM Flap

The transverse rectus abdominis muscle flap is widely used in free microvascular tissue transfer for breast reconstruction following mastectomy. Flap survival may be compromised by failure at the microsurgical anastomosis due to both venous and arterial thrombosis. It is unclear, whether hereditary thrombophilia represents a risk factor for early thrombotic occlusion following free flap procedures. We present a case of a patient with previously diagnosed activated protein C resistance caused by heterozygous factor V (position 1691 G-->A) Leiden mutation in whom a free transverse rectus abdominis muscle flap was performed. The postoperative course was complicated by repeated thrombosis of both the venous and arterial part of the anastomosis. Immediate thrombectomy and repeated arteriography allowed for partial flap salvage. More data are needed to analyze the impact of hereditary thrombophilia on microvascular anastomosis failure.

Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer

The human midface is a complex anatomic region. The maxilla is the structural support between the skull base and the occlusal plane, resisting the forces of mastication, anchoring the dentition, separating the oral and nasal cavities, supporting the globe, and supporting the face and its mimetic musculature. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar The midface region dominates our outward appearance, which is unique to each individual, and its esthetic restoration after loss of the maxilla is of major importance for quality of life. Destruction of the midface may result from trauma, infectious or malignant disease, as well as from rare disorders of the immune system. The morbidity associated with total maxillectomy potentially includes impairment of deglutition and nutrition, orbital function and vision, speech and communication, self-image and mental health, and maintenance of hygiene and social acceptability. 1 Futran N.D. Mendez E. Developments in reconstruction of midface and maxilla. Lancet Oncol. 2006; 7: 249 Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar Reconstruction of midfacial defects still remains a surgical challenge, especially in cases with total loss of the maxilla including the orbital floor and preservation of orbital contents. 2 Cordeiro P.G. Santamaria E. Kraus D.H. et al. Reconstruction of total maxillectomy defects with preservation of the orbital contents. Plast Reconstr Surg. 1998; 102: 1874 Crossref PubMed Scopus (128) Google Scholar The overall goal is to replace the form and function of native tissue. In addition to separation of oral and nasal cavities, the contours of the bony orbit and the zygomatic prominence should be exactly restored, preserving optical function and facial symmetry. The prevention of diplopia as a result of postoperative enophthalmos should be of major importance, especially when orbital contents are not affected. ErratumJournal of Oral and Maxillofacial SurgeryVol. 72Issue 4PreviewIn “Complex Midfacial Reconstruction: A Combined Technique of Computer-Assisted Surgery and Microvascular Tissue Transfer” (Kokemueller et al., J Oral Maxillofac Surg 66:2398-2406) the author Martin Rücker MD, DMD, PhD should be listed as “Martin Rücker, MD, DMD”. Full-Text PDF

Free flap transfer in cranio-maxillofacial surgery: a review of the current data

The advances of cranio-maxillofacilal surgery are considerably driven by the evolution of microsurgical techniques. At present, these methods continue to provide new therapeutic options to the field. Especially, free flap transfer has evolved to become an integral part of current treatment protocols for head and neck malignancies. It ensures uneventful wound healing even after previous radiotherapy and can often preserve form and function. For many patients, this may lead to a significant improvement in their quality of life. This review summarizes aspects of tumor therapy, the impact of radiation, and discusses different techniques of microvascular tissue transfer. Specific advantages in different anatomical sites of the head and neck region are highlighted in contrast to existing alternatives. Selected cases exemplify the use of popular transplants. While planning reconstructions, it is important to consider both the functional and aesthetic aspects. The best individual outcome is based on a thoughtful match of available methods to a given defect and the patient's condition.

Free and locoregional flap associations in the reconstruction of extensive head and neck defects

Head and neck surgical defects after oncological resection of advanced carcinoma involving the oral cavity are often composite and involve bone, mucosa, soft tissues and skin. For the most extensive defects, the simultaneous association of two free flaps is the best choice to improve the function of the preserved structures. This procedure is difficult and involves prolonged surgery, therefore it is only possible in selected patients. In some composite head and neck defects the association of free and locoregional flaps seems to be indicated. This study, discusses the use of free and locoregional flap association, focusing on its aesthetic advantages and functional results. From January 1995 to December 2006, 30 patients received simultaneous locoregional and free flap transfer for closure of post-ablative oral cavity defects. Microvascular tissue transfer included the radial forearm, anterolateral thigh, rectus abdominis, and fibula and iliac crest free flaps. Locoregional flaps included the cervicofacial, cervicopectoral, deltopectoral, pectoralis major, latissimus dorsi and posterior scalp flaps. Based on the good functional and aesthetic outcome and low rate of complications, the association of free and locoregional flaps represents a good reconstructive option for patients with extensive post-oncological composite head and neck defects.

Use of Flap Based on Anterior Tibial Artery for Free Transfer

Free flap transfer can be a challenge because of the risk of anastomotic failure, especially in microvascular tissue transfers. Free lateral crural flap based on the anterior tibial artery has good vascular condition that results in a low rate of failure. To avoid loss of the anterior tibial artery of the donor, we reconstructed the anterior tibial artery after the flap was harvested with a "half-half" technique in a simple way. Ten patients underwent this type of flap transfer and succedent artery reconstruction. All flaps survived. In no case was a subsequent anastomosis thrombosis operation required. Donor site morbidities were negligible. By contrast, the vessels of the free lateral crural flap were in better condition than that of other flaps. The flap can be used reliably and successfully without loss of the major artery trunk. We believe that the flap has special characteristics that may be useful in selected instances.

Management of exposed total knee prostheses with microvascular tissue transfer

Exposure of a knee endoprosthesis represents a limb-threatening condition, requiring long-term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three-dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re-sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. We treated 11 complex wounds with exposed total knee arthroplasty prostheses with free tissue transfer. Three of 11 patients had failed previous local muscular rotation flap coverage. Five latissimus dorsi muscle flaps and 6 rectus abdominis muscle flaps were used in our series. Wounds were closed after aggressive surgical debridement, antibiotic irrigation, and intravenous antibiosis. Eleven of 11 free flaps were successful (100%), and we achieved limb salvage in 11/11 limbs (100%) and prosthesis salvage in 10/11 knees (91%), with one prosthesis removed at an outside facility followed by knee arthrodesis. The advantages of microvascular tissue transfer are well suited to the treatment of exposed knee endoprostheses. The reliable rectus and latissimus flaps provide robust local perfusion to the wound, fill complex three-dimensional contour defects around knee implants, and lead to a high rate of salvage of both limbs and prostheses.