Successful Flap Salvage Research Articles

Enhanced recovery for acute open lower limb fracture ‘fix and flap’

IntroductionEnhanced recovery (ER) aims to achieve earlier recovery, reduced hospital length of stay (LoS) whilst improving outcomes. Our ER protocol for acute lower-limb open fracture (ALLOFs) includes dangling at day 3 and mobilising fully weight-bearing from day 5. Our aims were to evaluate the outcomes of ALLOFs using our ER protocol for limb salvage, LoS following ‘fix & flap’, return to theatre, rate of successful flap salvage, flap failure and deep infection rates. MethodsAn observational study of a prospectively maintained lower limb flap database from September 2020 to January 2023 was undertaken. Search criteria encompassed patients with a Gustilo IIIB/C injury and a free flap reconstruction. Exclusions were for local/perforator flaps, soft tissue injury only, fracture related/prosthetic joint infections, or chronic osteomyelitis cases. Results161 patients were available for analysis, 126 male (78 %) and 35 female (22 %) with a median age of 40 years (12-79, interquartile range 30.0). 81 % of cases were high-energy injuries. For all patients, the median time to definitive fixation and soft tissue coverage from injury was 4 days (0-30, interquartile range 2). 18 cases (11.2 %) required return to theatre for flap exploration; 11 cases were successfully salvaged (61 %). Nine free flaps failed (5.4 %). The median total LoS from admission was 10 days (6 to 46, interquartile range 5), with a median LoS following definitive fixation and soft tissue coverage of 7 days (4 to 20, interquartile range 3). The median follow-up period was 18 months (12 to 38.2, interquartile range 9), with a deep infection rate of 6.5 %. ConclusionIn isolated ALLOFs, our ER protocol is safe and effective in shortening the LoS. Our outcomes sit comfortably within acceptable ranges of contemporary literature for return to theatre, flap salvage/failure and deep infection. Our ER protocol actively involves our allied health professional colleagues early to facilitate discharge.

Challenges in Complex Oncological Chest Wall Reconstruction with Free Anterolateral Thigh Flap and Titanium Rib Plate.

Extensive chest wall tumor resection and reconstruction possess a formidable challenge and require good collaboration between thoracic and reconstructive surgeons. In this article, we reviewed our experience in six consecutive cases requiring complex chest wall resection and reconstruction with titanium rib plates and free anterolateral thigh fasciocutaneous flap with fascia lata with a minimum 24 months follow-up postoperatively. Six patients with a mean age of 54 were diagnosed to have locally advanced malignant ( n = 5) and benign ( n = 1) tumors. They underwent wide local excision with a mean of six ribs resected, and the average size of the soft tissue defect was 389cm 2 . The integrity of the thoracic cage was restored by using titanium rib plates. Fascia lata was harvested along with free anterolateral thigh fasciocutaneous flap to achieve near airtight closure of pleural space for soft tissue coverage. Two patients required early flap exploration with successful flap salvage. One flap failure was reported on postoperative day 11 due to a mechanical cause and a redo surgery was required. With an average stay of 3 days in the intensive care unit, no perioperative pulmonary complications were recorded. Complex oncological chest wall resection and reconstruction with titanium rib plates and free anterolateral thigh fasciocutaneous flap with fascia lata yielded satisfactory aesthetic and physiological functional outcomes.

Comparing the Time-Dependent Evolution of Microcirculation in Gracilis vs. ALT Flaps Using Laser-Doppler Flowmetry and Tissue-Spectrometry.

Postoperative free flap monitoring is considered a key component of care after microsurgical reconstruction. To achieve successful flap salvage after surgical revision, early recognition of vascular compromise is required. The aim of this study was to assess and compare the time-dependent evolution of microcirculation in gracilis muscle (GM) and anterolateral thigh (ALT) flaps. This study included continuous measurements of blood flow (flow), hemoglobin oxygenation (SO2) and the relative amount of hemoglobin (rHb) using laser-doppler flowmetry and tissue-spectrometry (O2C, LEA Medizintechnik, Gießen, Germany) over a time-period of 72 h. Microcirculation was assessed in a total of 66 viable free flaps (GM n = 40; ALT n = 26). A statistically significant positive correlation between time post-anastomosis and microvascular flow was found for both GM and ALT flaps with rs = 0.384 (p < 0.001) and rs = 0.178 (p = 0.015), respectively. No significant positive or negative correlations between time post-anastomosis and SO2 were found for both GM and ALT flaps with rs = 0.052 (p = 0.387) and rs = −0.018 (p = 0.805), respectively. Overall, a significant negative correlation between time post-anastomosis and rHb was found for GM flaps with rs = −0.140 (p = 0.019). For ALT flaps, no significant positive or negative correlation was found with rs = −0.011 (p = 0.887). Microcirculation differs in different flap entities, and surgeons should be aware of these differences in order to correctly evaluate and classify the values of flow, SO2 and rHb obtained when using the O2C device for postoperative monitoring.

A Simplified Cost-Utility Analysis of Inpatient Flap Monitoring after Microsurgical Breast Reconstruction and Implications for Hospital Length of Stay.

The number of free flap take-backs and successful salvages following microsurgical breast reconstruction decreases as time from surgery increases. As a result, the cost of extended inpatient monitoring to achieve a successful flap salvage rises rapidly with each postoperative day. This study introduces a simplified cost-utility model of inpatient flap monitoring and identifies when cost-utility exceeds the thresholds established for other medical treatments. A retrospective review of a prospectively maintained database was performed of patients who underwent microsurgical breast reconstruction to identify flap take-back and salvage rates by postoperative day. The number of patients and flaps that needed to be kept on an inpatient basis each day for monitoring to salvage a single failing flap was determined. Quality-of-life measures and incremental cost-effectiveness ratios for inpatient flap monitoring following microsurgical breast reconstruction were calculated and plotted against a $100,000/quality-adjusted life-year threshold. A total of 1813 patients (2847 flaps) were included. Overall flap take-back and salvage rates were 2.4 percent and 52.3 percent, respectively. Of the flaps taken back, the daily take-back and salvage rates were 56.8 and 60.0 percent (postoperative day 0 to 1), 13.6 and 83.3 percent (postoperative day 2), 11.4 and 40.0 percent (postoperative day 3), 9.1 and 25.0 percent (postoperative day 4), and 9.1 and 0.0 percent (>postoperative day 4), respectively. To salvage a single failing flap each day, the number of flaps that needed to be monitored were 121 (postoperative day 0 to 1), 363 (postoperative day 2), 907 (postoperative day 3), 1813 (postoperative day 4), and innumerable for days beyond postoperative day 4. The incremental cost-effectiveness ratio of inpatient flap monitoring begins to exceed a willingness-to-pay threshold of $100,000/quality-adjusted life-year by postoperative day 2. The health care cost associated with inpatient flap monitoring following microsurgical breast reconstruction begins to rise rapidly after postoperative day 2.

Skin Paddles Improve Muscle Flap Salvage Rates After Microvascular Compromise in Lower Extremity Reconstruction.

Free tissue transfer after lower extremity trauma is associated with notoriously high complication rates. Theoretically, the inclusion of a cutaneous paddle on muscle free flaps may improve clinical flap monitoring. The effect of skin paddle presence on muscle free flap salvage outcomes after take-back was examined. Retrospective query of our institutional free-flap registry (1979-2016) identified 362 muscle-based flaps performed for soft tissue coverage after below-knee trauma. Primary outcome measures were perioperative complications, specifically take-back indications, timing, and flap salvage rates. Univariate and multivariate regression analyses were performed where appropriate. The most common flaps were latissimus dorsi (166; 45.9%), rectus abdominis (123; 34%), and gracilis (42; 11.6%) with 90 flaps (24.9%) including skin paddles. Take-backs for vascular compromise occurred in 44 flaps (12.2%), of which 39% contained a skin paddle while 61% did not. Overall salvage rate was 20.5%, with 31.8% partial failures and 47.7% total flap losses. Muscle flaps with skin paddles were more likely to return to the operating room within 48 hours postoperatively than those without (57.1% vs 18.2%, P = 0.036). After take-back, significantly more muscle flaps with skin paddles were salvaged compared with muscle flaps without paddles (35.7% vs 4.5%, P = 0.024). Similarly, more muscle-only flaps after take-back failed compared with their counterparts with skin paddles (95.5% vs 65.3%, P = 0.024). Muscle flaps with a cutaneous paddle were associated with earlier return to the operating room and more successful flap salvage after take-back compared with muscle-only flaps. These findings suggest that skin paddle presence may improve clinical flap monitoring and promote recognition and treatment of microvascular compromise in lower extremity reconstruction.

Abstract QS13: Bridging The Gap: Extending Free Flap Pedicle Length With Interposition Vein Grafts And Arteriovenous Loops

PURPOSE: The purpose of this study is to assess clinical outcomes for utilization of vein grafts and arteriovenous loops in the context of free flap reconstruction. Free tissue transfer in complex oncological and traumatic defects may require extension of the vascular pedicle to reach recipient vessels and complete microvascular anastomosis. This can be accomplished by using vein grafts as a bridging medium. When interposition vein grafts (IVG) are needed for extension of both the arterial and venous conduit, a temporary arteriovenous fistula (AV loop) can be constructed as an intermediary step. These techniques have traditionally been regarded with increased risk of thrombosis and flap failure, but the body of clinically relevant published data lags behind. METHODS: Following approval by our Institutional Review Board, we retrospectively analyzed patients requiring free flap reconstruction between March 2007 and June 2017. All patients utilizing any vein graft in this context were identified. Data collection included demographic, medical, surgical, and outcome variables. RESULTS: A total of 90 IVG were used in 56 patients, receiving a total of 54 free flaps. Reconstructive sites included: head/neck (29; 51.8%), breast (13; 23.2%), upper extremity/trunk (9; 16.1%), and lower extremity (5; 8.9%). Twenty out of 26 AV loops created received flaps (11 immediate; 9 staged). Five AV loops thrombosed in staging and were discarded; one patient died in staging due to medical comorbidity. The duration of staging ranged from 1 to 59 days (median=4). Forty-two procedures utilized IVG (n=22; 3 arterial conduit only, 13 venous conduit only and 6 both) or AV loops (n=19) in the index flap surgery, of which 10 (24.4%) were taken back for emergent flap salvage (2 AV loops, 8 IVG group). Seven of these cases (eight flaps) were successfully salvaged. In 13 cases (14 flaps) IVG was utilized for free flap salvage (3 arterial conduit IVG, 10 venous conduit IVG), with a 78.6% successful flap salvage rate (n=11). Out of 54 flaps overall, 11 flap failures occurred (20.4%; 95% CI 10.6–33.5%). All flap failures occurred in the patients that used any IVG (with or without AV loop) for immediate reconstruction (two in AV loop group, 1 in IVG for both conduits, 5 in IVG for single conduit) or failed salvage utilizing IVG (3 in IVG for single conduit). Of the nine staged AV loops that received flaps, flap survival was 100%. CONCLUSIONS: Interposition vein grafts and AV loops offer practical solutions for pedicle lengthening in order to successfully perform microvascular anastomosis, but increase risk of take-back and flap failure when utilized in the index flap surgery. Our data demonstrate that staged AV loops may be superior to immediate AV loops, owing to a de facto pre-identification of patients who may otherwise develop a flap complication after immediate reconstruction. Additionally, IVG appears to be an especially effective tool in cases of free flap salvage. T.J. Bos: None. N.A. Calotta: None. M.Y. Seu: None. B.H. Cho: None. A.H. Hassanein: None. G.D. Rosson: None. D.S. Cooney: None. J.M. Sacks: None.

A Retrospective Study: Maxillofacial Free Flap Take-Back Incidence and Preoperative Albumin Levels As A Predictor of Flap Take-Back and Successful Flap Salvage, 2009–2014

A Retrospective Study: Maxillofacial Free Flap Take-Back Incidence and Preoperative Albumin Levels As A Predictor of Flap Take-Back and Successful Flap Salvage, 2009–2014

Short-stay hospital admission after free tissue transfer for head and neck reconstruction.

To show that, for patients with few medical comorbidities and at low risk for airway compromise or fistula formation, early discharge after free tissue transfer for head and neck reconstruction is a safe and viable option. Retrospective chart review. A cohort of patients who underwent free tissue transfer for head and neck reconstruction between February 2010 and December 2014 and who were discharged from the hospital by postoperative day 3 were reviewed. Fifty patients undergoing 51 free-tissue transfer surgeries were discharged by postoperative day 3. The surgeries performed included anterolateral thigh free flaps (ALT) (n = 46), radial forearm free flaps (n = 2), latissimus myogenous and myocutaneous free flaps (n = 1), supraclavicular free flap (n = 1), and serratus free flap (n = 1). All ALT flaps were harvested exclusively as perforator free flaps; and the vast majority used superficial temporal, angular, or facial vessels. All free flaps were viable without evidence of vascular compromise at discharge and the initial follow-up appointment. One patient required take-back for successful flap salvage. One patient experienced late flap failure (between 2-3 weeks postoperatively), requiring another surgery. This resulted in an overall success rate of 98% in this cohort. No other postoperative complications related to early discharge were identified. In a carefully selected subset of patients undergoing free tissue transfer, early discharge has been shown to be possible without compromising patient safety or surgery success rates. 4. Laryngoscope, 126:2679-2683, 2016.

A 10-year retrospective study of free anterolateral thigh flap application in 872 head and neck tumour cases

The aim of this study was to report the clinical features, reliability, and various applications of free anterolateral thigh (ALT) flaps and to provide a 10-year retrospective review of the application of this flap in head and neck tumour patients. A retrospective study was performed of 872 patients who underwent immediate reconstruction of head and neck tumour-induced defects with ALT flaps between April 2005 and April 2014. The study sample consisted of 609 males and 263 females aged 18–79 years. The shapes and sizes of the flaps were designed individually to meet various demands of reconstruction in the head and neck region. The overall rate of successful reconstruction was 97.4%. The reasons for 57 cases of flap compromise were analyzed. The time to detection of flap crisis was often within the first 8h after surgery (64.9%). One- and two-vein anastomosis strategies in microsurgery were compared, and significant differences were observed in terms of the time to detection of flap compromise and the rate of successful flap salvage. In conclusion, the free ALT flap provides unique features for the reconstruction of oral and facial defects in a reliable and versatile approach. The ALT flap is a favourable and versatile ‘workhorse’ flap for head and neck reconstruction.

Der temporoparietale Faszienlappen zur Rekonstruktion von Weichteildefekten

Soft tissue reconstruction with a temporoparietal fascial flap (TPFF). Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 17 × 14cm. Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision. Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C. Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day5. Dangling protocol instituted on postoperative day7. Removal of sutures/staples at the donor site on postoperative day5-7 and at the recipient site on postoperative day12-14. The TPFF was utilized for soft tissue reconstruction in 8patients. A pedicled TPFF was used in 2patients. Mean time to healing was 16.3days. Mean follow-up was 13.4months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.

Vascular complications and microvascular free flap salvage: The role of thrombolytic agents

Vascular thrombosis with flap loss is the most dreaded complication of microvascular free tissue transfer. Thrombolytic agents such as tissue plasminogen activator have been used clinically for free flap salvage in cases of pedicle thrombosis. Yet, there is a paucity of data in the literature validating the benefit of their use. A retrospective review of the breast reconstruction free flap database was performed at a single institution between the years of 1991-2010. The incidence of vascular complications (arterial and/or venous thrombosis) was examined to determine the role of adjuvant thrombolytic therapy in flap salvage. Pathologic examination was used to determine the incidence of fat necrosis after secondary revision procedures. Seventy-four cases were identified during the study period. In 41 cases, revision of the anastamoses was performed alone without thrombolytics with 38 cases of successful flap salvage (92.7%). In 33 cases, anastamotic revision was performed with adjuvant thrombolytic therapy, and successful flap salvage occurred in 28 of these cases (84.8%). Thrombolysis did not appear to significantly affect flap salvage. Interestingly, only two of the salvaged flaps that had received thrombolysis developed fat necrosis, whereas 11 of the nonthrombolysed flaps developed some amount fat necrosis (7.1% vs. 28.9%, P < 0.05). The decreased incidence of fat necrosis may be attributable to dissolution of thrombi in the microvasculature with the administration of thrombolytics. Although the use of adjuvant thrombolytic therapy does not appear to impact the rate of flap salvage, their use may have secondary benefits on overall flap outcomes.

The Histamine Reaction: A Useful Adjunct for Monitoring Free Flaps

Sir: Regular observation in the immediate postoperative period following free tissue transfer is imperative to flap survival.1–4 Free flaps are most vulnerable until the reepithelialization of the anastomosis.2,3 Clinical vigilance and careful monitoring are essential during this period to ensure successful outcomes. Survival rates of greater than 50 percent can be expected in salvaged flaps, with survival being inversely proportional to both the delay in detecting compromised perfusion and the subsequent delay in surgical exploration.1–5 Flap monitoring is therefore a crucial prerequisite to successful flap salvage. A commonly used method of monitoring is capillary refill measurement, which involves digital pressure on the skin for 3 seconds and then release. The skin blanches temporarily but returns to normal skin color within 2 seconds. A prolonged capillary refill time indicates inadequate flap perfusion, whereas a brisk return may represent compromised venous drainage of the flap.2,3,5 However, assessment of capillary return in, for example, perforator flaps can be challenging on account of the difficulty of eliciting a blanching response on application of digital pressure because of paleness of flaps. Histamine and serotonin are the primary mediators released in inflammatory reactions. These preformed mediators are found in mast cells, basophils, and platelets, and their release leads to an increase in vascular permeability, resulting in local tissue edema. The senior author (M.S.K.) often induces a histamine flare onto the cutaneous surface of pale free flaps postoperatively (Fig. 1). Typically, this is achieved by gently scratching the surface of the flap with a handle of a pair of Adson's forceps. This mechanical irritation of the epidermis results in histaminergic activation with local angioedema characterized by a wheal and flare.4 This flare can be used as a landmark to subsequently assess capillary refill. Histamine is directly released from cutaneous mast cells in response to mechanical stimuli, although eicosanoids, in addition to other cytokines, may also have a role to play in this immunoglobulin E–mediated process.Fig. 1.: (Above, left) Free flap before scratch test. The flap perfusion status is difficult to determine accurately, as the flap is pale. (Above, right) Primed flap following scratch. A transverse strip of hyperemic skin is visible along the flap. (Below, left) Assessment of capillary refill of primed free flap by gentle compression with the handle of a pair of tenotomy scissors. (Below, right) A blanched area corresponding to the scissors handle is readily visible, thus allowing an accurate assessment of the capillary refill time.The authors propose the histamine reaction scratch test to surmount the assessment difficulties of pale flaps. This method of augmenting the innate capillary return greatly improves the ability to undertake accurate flap observations in pale free flaps. The limitation to the histamine scratch test is its duration of action, which we estimate to be on the order of 2 to 6 hours. The test can be readily repeated at the bedside until the flap observation period has ceased. It is common practice to assess flap perfusion by using a hypodermic needle to scratch or prick the cutaneous portion of the flap to induce capillary bleeding; indeed, in certain situations, such as head and neck reconstruction, a small portion of the flap may be deepithelialized to facilitate direct observation of capillary bleeding on repeated occasions. We have used these techniques in our unit; however, we are cognizant of the attendant risks of infection, hematoma formation, and potential iatrogenic injury to the pedicle itself. The histamine scratch test all but obviates these risks, as the epidermis is not breached. This response occurs independently of the sympathetic and parasympathetic nervous systems. We have shown that scratching a pale flap is a good, reliable, and safe way of monitoring a free flap. Although physiologically this assessment works in clinical practice, the response does not last long enough for the flap to be monitored for sustained periods of time. Assessment of capillary return in pale flaps (such as the deep inferior epigastric perforator and anterolateral thigh flaps) can be problematic on account of the difficulty of eliciting a blanching response on application of digital pressure. The authors feel that this test is a technically straightforward, noninvasive, bedside test that aids in informing the clinician of the underlying flap perfusion status. The test is therefore an invaluable adjunct in the monitoring of pale free flaps. Zeeshan Ahmad, M.R.C.S. Marc C. Swan, D.Phil. Department of Plastic and Reconstructive Surgery and Burns Matthew Flynn, F.R.C.Path. Department of Histopathology Mansoor S. Khan, F.R.C.S.(Plast.) Department of Plastic and Reconstructive Surgery and Burns Salisbury District Hospital Salisbury, Wiltshire, United Kingdom DISCLOSURE No funding was received in the production of this article. There is no conflict of interest.

TTP (time to PEAK) and RBV (regional blood volume) as valuable parameters to detect early flap failure

Free flap transplantation is used more and more frequently in order to cover extensive wound defects. The basic prerequisite for successful flap salvage after flap failure is a short time interval from failure until revision. For this reason many different flap monitoring systems have been tested over the last years. The aim of the experiment was to detect critical capillary perfusion using contrast enhanced ultrasound. Quantitative analysis should be performed by a special perfusion software (QONTRAST; Bracco, Italy) appraising digital raw data of contrast enhanced ultrasound (CEUS). Additionally diverse risk factors for free flap transplantation were determined. Thirty-one patients were examined after free flap transplantation during the first 72 hours after operation. CEUS was performed with a linear transducer (6-9 MHz, LOGIQ E9/GE) and a bolus injection of 2.4 ml of contrast agent (SonoVue, Bracco, Italy). Operation and examination were performed by either an experienced plastic surgeon or an experienced ultrasound examiner. Depth dependent capillary perfusion was analysed and quantitative perfusions analysis was performed using the perfusions software QONTRAST (Bracco, Italy). Eleven revisions had to be performed: 7 due to haematoma and 4 due to superficial necrosis. Reduced capillary perfusion was seen in all 11 complications using CEUS. Significant difference comparing the no complication and the complication group was observed using TTP (time to PEAK) and RBV (regional blood volume) quantitative analysis. Mean RBV was 922.1 ± 150.9 in the no complication and 303.0 ± 53.9 in the complication group (p = 0.001). Mean TTP was 37.6 ± 3.8 in the no complication and 21.3 ± 3.4 in the complication group (p = 0.006). Tendency to higher complication rate was seen in older male patients with vascular or malignant primary disease. In this clinical trial, capillary perfusion after free flap transplantation as well as detection of vascular complications was demonstrated using CEUS. Quantitative perfusions analysis could be performed and flap viability could be assessed easily.

Postoperative assessment of free skin flap viability by transcutaneous pO2 measurement using dynamic phosphorescence imaging

Free flap transplantation is used more and more frequently in order to cover extensive wound defects. The basic prerequisite for successful flap salvage after flap failure is a short time interval from failure until revision. For this reason many different flap monitoring systems have been tested over the last years. But none of them has made the way into clinical routine. The aim of this clinical study was to study whether luminescence lifetime imaging (LLI) is an adequate method to assess flap viability during the postoperative period. In previous experiments LLI was proven to be a precise and non-invasive monitoring system for transcutaneous oxygen measurement. ptcO2 of 9 patients was detected during a postoperative period of 72 hours. In all cases the transplantation was performed by the same experienced surgeon. During the first 4 hours almost constant ptcO2 values were detected (53±0.7 mmHg). During the following time intervals ptcO2 values decreased and reached a more or less constant level after approximately 12 hours. The mean ptcO2 decreased from 53±0.7 mmHg to 39±1.0 mmHg. In one case an immediate decrease of ptcO2 below 10 mmHg was observed and a subsequently intervention was necessary to improve flap perfusion. In this clinical trial, perfusion dynamics after free flap transplantation as well as the detection of vascular complications were demonstrated using LLI. Based on these data, LLI seems to be a sensitive and adequate monitoring system for the evaluation of free flap viability.

Additional Benefit of Heparin in the Thrombolytic Salvage of Ischemic Skin Flaps

Microvascular thrombosis is known to play an important part in the cessation of flow seen in a flap following ischemia and revascularization. Its reversal, using thrombolytic therapy, is associated with higher rates of successful flap salvage. Although this procedure restores patency to the microcirculation, the damaged endothelial cell layer remains highly thrombogenic and a definite risk of rethrombosis exists in the early period of reperfusion. In an inferior epigastric flap model in a rat, we investigated the effect of additional heparin (subcutaneous and intravenous administration) following a standardized urokinase washout (100,000 iu) of the ischemic flaps. Flap survival was assessed at 1 week and morphological changes in the microcirculation were observed using electron microscopy. Results showed a significant increase in flap survival in the group receiving intravenous heparin following urokinase washout and suggest that systemic heparin may play a beneficial role in the early reperfusion period following thrombolytic flap salvage.