Microvascular Tissue Transplantation Research Articles

Oncological Skull Base Reconstruction with Microvascular Tissue Transplantation in Advanced Relapsed Cases

Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.

75 Years of Excellence: The Story of Reconstructive Surgery

75 Years of Excellence: The Story of Reconstructive Surgery

Management of open infected comminuted tibial fractures using Ilizarov concept

Bone loss is very common in high energy trauma. It could be treated either by amputation and prosthesis or by reconstruction of both bony and soft tissue structures. The choice of treatment in a given case must be based on the assessment of the local and general condition of the patient such as regional neurovascular supply, and the residual articular and muscular function. Reconstruction may require bone grafts, tibiofibular synostosis, free microvascular soft tissue or bone transplants. The use of Ilizarov concept gives another option for treatment of bone defects. In this study, infected tibial fractures were treated using Ilizarov concept. Twenty-eight patients (20 males and 8 females) with open comminuted infected fracture of the tibia were included. After debridement, all cases had variable amount of bone defects and were treated using Ilizarov technique. Follow-up was for at least 1year. Filling of the bone defect was achieved either by compression-distraction method in 13 cases (group I) or by means of bone transport in the other 15 cases (group II). The results were judged as excellent in 16 patients, good in 9 and fair in 2, while one patient was of poor result. Type of fracture, age of the patient and sex had no statistically significant relation with the final end results. Furthermore, there was no significant difference between the two groups. The average external fixator index was 45days/cm (range from 35 to 70days/cm). The mean external fixator index was less in group I. In the management of infected comminuted tibial shaft fractures, bone transport is indicated for the treatment of major bone loss, whereas compression-distraction is suitable only for treating less extensive bone gaps.

Evolution and Trends in Reconstructive Facial Surgery: An Update

Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.

Evaluation of dermal and subdermal microcirculation in free flaps with contrast harmonic ultrasound and indocyanine-green fluorescence video angiography

Purpose: Contrast harmonic ultrasound (CHI) with a linear transducer is a new diagnostic approach that allows dynamic and quantitative flow detection of tissue perfusion in microsurgery. The aim of the study was the evaluation of perfusion of the dermal and subdermal layers of microvascular tissue transplants with CHI in comparison to ICG-fluorescence angiography. Materials and methods: In a prospective clinical study Indocyanine-Green Fluorescence Video Angiography and Contrast Enhanced High Resolution Ultrasound (5–10MHz; linear transducer; Logiq 9; GE) were used for evaluation of the microcirculation in 10 transplanted free parascapular flaps. Two regions were analysed, the centre of the flap and the region of the anastomosis. The perfusion patterns of both methods were compared. Results: The perfusion indexes measured by ICG-fluorescence angiography correlated very precisely in all patients with the quantitative perfusion curves of contrast-enhanced US with CHI.Two flaps with slow filling and low dye intensity showed low contrast enhancement in CHI with modified perfusion curves with slow increase. In two cases a reduced perfusion and filling were found. There were no statistical differences between the two diagnostic methods (p>0.01). Conclusion: CHI improves US detections of dermal and subdermal microcirculation in comparison to ICG fluorescence angiography. CHI is a new diagnostic method for postoperative monitoring of free flaps.

Use of varioscope in free microvascular tissue transplants

Since July 2002, the author has performed 12 consecutive free flaps using a new device, the Varioscope AF3, in order to evaluate its efficacy. The Varioscope is a world-patent novelty by Life Optics (Vienna, Austria) that combines the philosophy of microscopes and loupes. Specific advantages such as reduced cost, freedom of movement, portability, and a magnification range between 3.6-7,2x are some of the reasons that convinced the author to use the Varioscope initially. The overall success rate is similar to that obtained with a microscope or high-power loupes. The results show that the Varioscope AF3 could be safely employed in the majority of free-tissue transfers as sole means of magnification. However, for digital replantations or vessels with a diameter of less than 1 mm, a microscope might be necessary.

Reconstruction of hypopharynx after pharyngolaryngectomy with U-shaped radial forearm flap

After pharyngolaryngectomy reconstructive procedures of the upper digestive tract are necessary. Since the introduction of microvascular tissue transplantation jejunal loops proved to be a versatile transplant. Nevertheless it has some disadvantages as i. e. the increased donor morbidity, a rather high sensitivity to hypoxia and the tendency of shrinkage and formation of stenosis. We perform the reconstruction of the hypopharynx with the radial forearm flap. The fasciocutaneous flap is harvested on the radial artery in a size of 12 x 6 cm in average and is sutured U-shaped paramedian to the prevertebral fascia. In addition the posterior wall of the oesophagus and the oropharynx have to be adapted to the prevertebral fascia. Between 1997 and 2001 we performed these reconstructions in 20 patients. In one case we found a complete flap necrosis, which required secondary reconstruction with a pectoralis major flap. In 2 patients we saw a stenosis at the junction to the oesophagus, which was treated by revision surgery and bougienage. In 18 patients swallowing was regular. 6 patients were able to learn oesophageal speech. The radial forearm flap in its U-shaped transposition to the prevertebral fascia represents a functionally good reconstructive procedure for the hypopharynx.

Lower extremity microsurgical reconstruction.

After studying this article, the participant should be able to: 1. Understand the indications for the use of free-tissue transfer in lower extremity reconstruction. 2. Understand modalities to enhance the healing and care of soft tissue and bone before free-tissue transfer. 3. Understand the lower extremity reconstructive ladder and the place of free-tissue transfer on the ladder. 4. Understand the specific principles of leg, foot, and ankle reconstruction. 5. Understand the factors that influence the decision to perform an immediate versus a delayed reconstruction. Free-tissue transfer using microsurgical techniques is now routine for the salvage of traumatized lower extremities. Indications for microvascular tissue transplantation for lower extremity reconstruction include high-energy injuries, most middle and distal-third tibial wounds, radiation wounds, osteomyelitis, nonunions, and tumor reconstruction. The authors discuss the techniques and indications for lower extremity reconstruction.

The effect of an implantable doppler probe on salvage of microvascular tissue transplants: Kind G, Butnic R, Buncke G, et al. Plast Reconstr Surg 101:1268, 1998

The effect of an implantable doppler probe on salvage of microvascular tissue transplants: Kind G, Butnic R, Buncke G, et al. Plast Reconstr Surg 101:1268, 1998

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

One hundred forty-seven flaps in 135 consecutive patients undergoing microvascular transplantation were monitored using a miniature Doppler ultrasonic probe. Using a modification of a technique described previously by Swartz, the probes were secured to the outflow vein of the flap with Vicryl mesh. Twenty instances of thrombosis or spasm were detected in 16 patients, and all flaps were salvaged (100 percent). There were four false positive and no false negative results. This probe allows for safe, continuous monitoring of flap blood flow, which permits the rapid detection and hence rapid treatment of postoperative complications. Our experience suggests that a significant improvement in the salvage rate of microvascular transplants may be attainable with the use of this device.

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

The Effect of an Implantable Doppler Probe on the Salvage of Microvascular Tissue Transplants

A clinical study of microvascular tissue transplantation in our department

A clinical study of microvascular tissue transplantation in our department

The limited value of preoperative angiography in microsurgical reconstruction of the lower limb.

Biplanar angiography has been a prerequisite in microvascular reconstruction of the lower extremity. While defining arterial anatomy, the procedure is not without morbidity. More important, angiography does not determine the acceptability of arterial blood flow through a particular recipient vessel. The purpose of this study was to evaluate the safety of microvascular tissue transplantation for reconstruction of complex lower-limb wounds, without preoperative angiography. A consecutive series of 48 patients undergoing tissue transplantation for complex wound reconstruction during a recent 8-month period is presented. Sixty percent of patients had soft-tissue wounds classified as Gustilo IIIB preoperatively, although 89 percent of wounds ultimately arose from trauma. Preoperative and intraoperative clinical assessment of recipient vessels allowed successful reconstruction in all but one case. The only loss of a transplant arose as a result of venous outflow obstruction, a situation not to be improved by preoperative angiography. In no instance was a patient explored and reconstruction deferred due to inadequate recipient vasculature. The results of this study support microvascular tissue transplantation to lower-limb wounds without preparatory angiography in almost all circumstances. Adequate clinical parameters are presented for determining recipient pedicle status, both preoperatively and intraoperatively.

Microvascular anastomoses in reconstructive head and neck surgery

At the ENT Department of the University of Lübeck, 57 microvascular tissue transplants with 129 anastomoses (61 arterial and 68 venous) have been performed in the last three years. Arteries have always been anastomosed end to end. The venous anastomoses have primarily been performed as end-to-side unions with the jugular vein. In nine patients, great distances between the donor and recipient vessel had to be connected with venous interponates. In two cases in which veins were lacking in the neck after radical neck dissection or radiation fibrosis, we used the cephalic vein or veins of the capsule of the thyroid gland as recipient vessels. The jejunal or osteomyocutaneous transplants were first fitted into the defect before performing the anastomosis. The jejunal peristalsis and the required freedom of movement in shaping the bone necessitated this technique. Microvascular anastomosis was first performed on the transplant of the radialis flap and the neurovascular infrahyoid muscular flap, and then they were integrated into the defect. We lost two transplants postoperatively because of venous thrombosis. In this article wie describe our anastomosis technique, the frequency distribution of recipient vessels, and the rules and characteristics of microvascular anastomosis after radiation and neck dissection.

口腔外科領域における遊離組織移植術後の口腔機能 アンケートによる調査

The oral function after maxillofacial reconstruction using microvascular tissue transplantation was investigated by a questionnaire survey of 335 oral and maxillofacial surgery centers in Japan. The patient's speech. mastication and deglutition were evaluated and classified as good. almost good, and poor. The number of reported cases was 220. Among these. The rates of good and almost good were 98.2% for speech. 89.1% for mastication, and 95.4% for deglutition. These results were considered to indicate satisfactory oral functions after surgery.

Microvascular tissue transplantation in plastic reconstruction of the external head-neck area

Free tissue transfer is under certain circumstances an ideal reconstructive method for skin and soft tissue defects of the head and neck region. These are multilayer, large defects, recurrences after previous reconstructive methods, in cases of aesthetic disturbances due to local flaps, in difficult reconstructive areas due to chronic infection and radiotherapy and if local tissue is not available. From 1987 to 1993 we performed 30 reconstructions of the surface of the head and neck region with free flaps, mainly the forearm flap and the scapular flap. But also the latissimus dorsi flap and in one case the rectus abdominis flap were used. There was no flap failure. In only one case of a forearm flap we saw a delayed healing of the donor defect. There was no functional impairment of the donor defect. All cosmetical results were acceptable. Flaps from the trunk mainly showed considerable differences in colour and texture to the surrounding skin.

SIMULTANEOUS FREE-TISSUE TRANSFER AND ILIZAROV DISTRACTION OSTEOSYNTHESIS IN LOWER EXTREMITY SLAVAGE

The last decade has witnessed the refinement of microvascular tissue transplantation and its application in treating difficult open wounds. Nonetheless, severe type III tibial injuries continue to challenge reconstructive surgeons. The clinical presentation and surgical treatment of a type IIIB tibial fracture, complicated by long-standing chronic osteomyelitis, angulation deformity, and bone shortening, is presented. This case illustrates the benefit of combining microvascular transplantation of distant tissues with the Ilizarov technique of distraction osteosynthesis in the treatment of complicated lower extremity injuries.

Use of intercostal nerves as nerve grafts in hand reconstruction with rectus abdominis flaps

Following complex crush and avulsion hand injuries with significant tissue loss and exposed vital structures, microvascular tissue transplantation can reliably provide soft tissue coverage in one setting. Rectus abdominis muscle free flaps are frequently used in hand reconstruction because of the ease of dissection, low donor site morbidity, reliable, large diameter vessels for anastomosis, and supine positioning of the patient, allowing two teams of surgeons to work simultaneously reducing the operative time.’ Because of the segmental innervation of the rectus muscle, it is not used for functional transplantation, and the innervating intercostal nerves are routinely sacrificed during harvesting of muscle. We propose that the intercostal nerves within the rectus sheath can be used for primary nerve grafting in complicated hand injuries when soft tissue loss requires rectus muscle free flaps for coverage and nerve grafting is attempted within the injury.