In the angiosome concept advocated by Taylor et al. in 1987, the vasculature of the surgical flap is expressed by the number of anatomical territories (angiosomes) contained in the flap, such as ‘2-territory flap’ or ‘3-territory flap’. When the flap is raised, the choke vessels between the first and second vascular territories dilate and transform to the true anastomoses that can make a new larger territory by combination of the first and second territories. However, the third vascular territory is commonly not involved, because the choke vessels between the second and third territories will not fully dilate. “Opening of the first choke zone and capturing of the second vascular territory with safety” is supported by our series of experiments using flaps with various numbers and alignment of the vascular territories and vascular pedicles. Considering this law of flap survival, we can more safely design flaps with fairly accurate estimation of the expected survival area of the flap.
The purpose of this article is to report our technique and results of postoperative vascular monitoring after functioning free muscle transfer (FFMT) using compound muscle action potentials (CMAP) measurement. Thirty FFMTs were included in this study. Two epidural electrode catheters were inserted into the sub-fascial plane of the gracilis muscle. The proximal stimulating catheter was placed near to the motor point of the muscle and the distal recording one was placed at the distal muscle belly. Supramaximal stimulus was used to produce the potentials. The waveform of the potentials was monitored continuously. Amplitude and latency were calculated as a percentage of the baseline value. Twenty-nine FFMTs survived without any signs of vascular compromise. The amplitudes of the potentials gradually decreased with time due to Wallerian degeneration, 85 ± 20 % by 24 hours, 70 ± 22 % by 48 hours, and 35 ± 23 % by 72 hours. In 1 FFMT, the amplitude acutely decreased. Reexploration revealed a large hematoma. Removal of the hematoma and re-anastomosis of the vein resulted in recovery of the venous drainage. Measurement of CMAP has great potential as a sensitive and reliable method for monitoring muscle circulation after FFMT.
Purpose : Diabetic patients often present with both peripheral arterial occlusive disease (PAD) and soft tissue defects. We report our approach for limb salvage with diabetic and ischemic foot ulcers by free muscle flap transfer and microsurgical revascularization. Methods : In the past ten years, 72 patients (average 70 years; range 42 to 91) were treated for diabetic and ischemic foot ulcers. Among these patients, six selected patients underwent free LDmuscle flap transfer for soft tissue defects. Microsurgical revascularization was performed in 12 patients including distal bypass in 9, vein graft in 2, and venous arterialization in 1. Results : All flaps were initially viable; however, one was lost on day 3 because of venous hypertension of the recipient vein and was treated with below-the-knee amputation. All microsurgical revascularizations were successful; however, both of the patients with a successful vein graft and with successful venous arterialization died 1 month postoperatively due to cardiac failure. Five of 6 patients with free LD- muscle flap transfer showed complete wound healing and are currently ambulatory at an average follow up of 20.3 months. Ten of 12 patients with microsurgical revascularization are ambulatory at an average follow up of 30.5 months, and primary patency rate was 100%. Conclusions : Our microvascular approach was successful in preserving limb length and function in 83% of our patients. We believe that a microvascular surgical approach optimizes the treatment of diabetic and ischemic foot ulcers.
We have been promoting regional alliances to provide strategic remedies and treatment for the lower extremities of patients with diabetic foot lesion. We treated 221 patients with diabetic foot diseases during the 3-year period from January 2006 to December 2008 in Saga University Hospital and other related hospitals. The cure rate in all of the patients was 62%, and the rate of patients who received revascularization was 89%. It was confirmed that the use of common therapeutic algorithms would be effective for the treatment of diabetic foot lesions from the standpoint of therapeutic standardization. Microsurgical technique is essential for vascularization and limb salvage of the diabetic foot.
The main etiologies of diabetic foot ulcer are divided into three categories; neuropathic (45%), neuroischemic (24%), and ischemic ulcer (16%). After selection of neuropathic DM ulcers that did not show significant arterial disease, free flap transfer was performed using flow-through arterial anastomosis to avoid amputation of the limb. Free flaps based on the subscapular artery system and the lateral femoral circumflex artery system were transplanted in 7 patients. The transplanted flaps were latissimus dorsi muscle flap in 2 cases, thoracodorsal artery perforator flap in 1 case, combined flap of latissimus dorsi muscle and serratus anterior muscle in 1 case, scapular flap in 1 case, serratus anterior fascia flap in 1 case and the anterolateral thigh flap in 1 case. Flow-through anastomosis to dorsalis pedis artery using circumflex scapular artery or thoracodorsal artery was performed. All flaps survived. Arterial flow on the distal side of the anastomosis was confirmed by Doppler flowmeter or angiography. Microsurgical flap transplantation is useful for minimum amputation of diabetic foot. Postoperative care has to be paid to neuropathy in these patients because the causes of their foot ulcers include sensory and motor disturbance.
From 1996 to 2008, 161 patients (120 men and 41 women; 3 to 80 years old) with traumatic skin defect, nonunion, or osteomyelitis were treated with free vascularized composite tissue grafts. The lesions affected the upper limb in 100 out of the 161 patients and the lower limb in 61. Free grafts were raised from a variety of donor sites; the most common grafts were the peroneal flap or fibular graft (n=56), scapular flap or scapular graft (n=41), and lateral upper arm flap (n=11). Postoperative thrombosis of anastomotic vessel necessitated reexploration in 13 patients. In 4 of the 13 patients, the flaps could not be salvaged. The most common cause of the thrombosis was that the anastomotic vessel was compressed by a hematoma and / or hemorrhage. The incidence of this complication was significantly higher in the cases where the free vascularized composite graft was transferred to the lower limb.
Lower limb salvage has advanced since the introduction of the free flap. However, most series of lower extremity reconstructions report failure rates are still higher than for other sites, such as the head & neck and the breast. In order to achieve the higher flap success rate, we retrospectively investigated some controversial points including the timing of the operation, selection of the recipient vessels, and the style of the vascular anastomoses. Patients and Methods: Twenty-two patients underwent the lower leg reconstruction using 24 free flaps between 1995 and 2003 at the Univ. of Tokyo and Kyorin Univ. Hospitals. Results: As for the timing of the operation, patients were divided into three groups depending on the period from the trauma to the operation. All three patients who underwent the free flap reconstruction within three days after trauma achieved flap success. Three of nine patients who underwent the free flap after four days and within one month had arterial thrombosis and two of them were failed. Two and four of ten patients who underwent the free flap one month after the trauma had arterial and venous thrombosis respectively, resulting in all flap success except one patient who underwent the second flap transfer. Statistical difference was not seen among three groups. As for the selection of the recipient vessels, there was no significant difference between the anterior tibial and posterior tibial vessels. As for the type of the vascular anastomoses, there was no significant difference between the end-to-end and end-to-side anastomosis style. Discussion: Although statistical difference was not seen among the groups of the operation timing, the early phase reconstruction (within 3 days after trauma) is preferred because wound infection which may be a major risk of vascular thrombosis can be avoided. As for the selection of the recipient vessels, posterior tibial vessels should be first selected, because the damage to these vessels is less than that to the anterior tibial vessels in many cases. And end-to-side anastomosis should be first selected, because the distal blood flow is secured.
The management of a severe open fracture of an extremity requires early soft tissue coverage with a well-vascularized free flap after radical debridement and bone fixation. A total of 76 patients (57 male, 19 female) ranging from 10 to 81 years of age, underwent free flap transfer due to a traumatic injury to an extremity between January 1995 and June 2010. Seventy-one of the 76 flaps survived, one showed total necrosis and four showed tip necrosis. The rate of flap failure was 1.3%. The authors prefer to use an anterolateral thigh flap, which provides thin and pliable skin and long large-caliber pedicle. In delayed reconstruction, microvascular anastomoses should be performed apart from the defect, since fibrosis after edema and inflammation is present along the intermuscular space surrounding the recipient vessels and reaching an area far away from the defect. When little bleeding results from the recipient artery in the area where it is not contused, this is misjudged as a spasm; however it is improved or resolved after cutting perivascular sheath or periarterial fibrosis. The authors combined the triangular portion of the flap to avoid compression to the recipient vessels and to also allow for microvascular anastomoses proximal to the area of injury.
Free flap transfer is a useful option for extensive tissue defects after resection of malignant bones and soft tissue tumors of the extremities. Limb salvage using reconstructive microsurgery is important to retain bone stability, joint mobility and coverage of skin. This paper describes a novel reconstruction strategy for such patients. From December 2002 to September 2009, we performed 25 limb salvage operations (upper arm 4 cases, forearm 5 cases, hand 1 case, thigh 6 cases, leg 4 cases, and foot 5 cases) using a novel free flap transfer strategy. When the forearm, hand or foot are affected, it is important to cover such defects with flexible and thin skin. We usually used free anterolateral thigh flaps to repair such defects following wide soft tissue resection. In the upper arm, a free vascularized fibula graft was transferred after resection of the humerus. Around the knee joint, it is advantageous to use a free latissimus dorsi musculocutaneous flap to salvage the knee joint for use with a prosthesis. In cases where the thigh and leg were affected, we used a combination method of heat-treated bone with a free vascularized fibula graft after resection of the femoral or tibial bone.
Between 1988 and 2007, eighteen cases were reconstructed by free vascularized fibula grafts after wide resection of sarcoma of the long bones. Cases consisted of eight males and ten females with an average age of 23 years (range, 7 to 65 years). The length of the fibula ranged from 15 to 26 cm (average: 20.9 cm). Follow-up periods ranged from 32 to 228 months (average: 137 months). In ten patients, free vascularized fibula was transferred to arthrodesis the knee or the ankle joints after tumor resection. The mean time for bone union was 5.4 months. Peroneal nerve palsy was observed in three patients and stress fracture in four of 10 patients. Four patients underwent reconstruction of a long bone intercalary defect with bilateral fibulas used for reconstruction of femoral defects in three of these patients. A sling procedure was performed for reconstruction after wide resection of the proximal humerus for malignant bone tumor in the remaining four patients. Three of four patients had absorption of the head of the fibula probably due to a deficient blood supply through the peroneal artery.
In surgical treatment of tumors, including facial nerve resection, it is necessary not only to reconstruct the facial nerve but to fill the complex defect. We report here a new surgical procedure using nerve grafts and free omental flap for facial nerve reconstruction. Between January 2004 and December 2008, we performed facial nerve reconstruction using nerve grafts and free flap transfer in 8 cases (3 were male and 5 were female, with an average age of 39.3years). We evaluated the results using Yanagihara's 40-point grading system. All free omental flaps were successfully transferred. Post operative facial nerves were 29.0. The omental flap has a long pedicle and flexibility. These properties of the omental flap make it useful for filling the complex defect and covering the reconstructed facial nerve. We consider that nerve grafts with a free omental flap transfer are useful for reconstruction of the facial nerves.
There are various postoperative complications of intracranial operation, such as defects of soft tissue and cranial bone, infection, abscesses, and deformity. We have performed 34 microsurgical free flap transfers to deal with such cases over the past 14 years. Thirty-four patients in those cases underwent neurosurgery as a result of cerebrovascular disease (20 patients), trauma (9), and brain tumors (5). Free flaps were used to repair the cranial defects. A rectus abdominis musculocutaneous (m-c) flap was used in 25 patients, an anterolateral thigh flap was used in 5, a latissimus dorsi m-c flap was used in 1, a tensor fascia lata m-c flap was used in 1, a deep inferior epigastric artery perforator flap was used in 1, and a radial forearm flap was used in 1. Free bone grafts were used to repair skull defects in 21 patients and the dura mater was reconstructed in 7. Problems encountered after reconstruction included local infection, recurrence of dead space, and delayed intracranial abscesses. In two cases, intracranial dead space had been recurrent after reconstruction because of incompetence of intracranial pressure, and was improved to a stable condition after adjusting V-P shunt pressure. The patients with complications after intracranial surgery had serious problems such as treatment of original cause, esthetic disorder, social difficulty and economical loss. Therefore, positive free flap transfer repairs were important.
External jugular vein (EJV) and internal jugular vein (IJV) are major options for recipient veins in microvascular free flap reconstruction of the head and neck. Recently, it has been reported that EJV has higher thrombosis rates and more flap complications than IJV. We recognized venous valve thrombosis of EJV in 3 cases, when we anastomosed EJV and donor vein at a distal part of the valve. To resolve the problem, we performed a segmental resection of EJV involving venous valves and also anastomosed end to end All anastomoses were successfully done and flaps were taken. There are several reports about venous valve thrombosis in EJV and the risk of thrombosis is higher due to neck dissection and other surgical interventions. To use EJV safely, we suggest careful observation of EJV and the valves that are mostly found at the lower neck. When venous valve thromboses are found, we recommend surgical procedures as a resolution of venous valve thromboses, as mentioned above.
Early reconstruction with emergency free flap for soft tissue loss due to upper extremity injury is important to prevent chronic infection and further tissue loss. Although we know the importance of applying an emergency free flap, delayed reconstruction may be performed because of lack of available staff, such as microsurgeons or nurses or anesthesiologists. We performed free flaps for 24 patients with severe upper extremity injury over the past ten years. We reviewed the severity of these injuries, the types of flaps and the interval from trauma to free flap reconstruction in order to clarify the indications for emergency free flap. We applied free flaps after intervals ranging from five days to five years. There was no flap loss in any case. Transient local infection occurred in one case, but there was no chronic infection such as osteomyelitis in any patient. Contrary to our expectations, only three of 24 cases showed deterioration because of delayed reconstruction. In conclusion, it is not necessary for patients with minimal eventual function to receive emergency free flap, even if important deep structures such as tendon, nerve, bone are exposed, although great care is needed to prevent infection by daily dressing change.
Wrap-around flap transfer provides good aesthetic results and sufficient functional recovery of an amputated thumb. However, this technique partially preserves the great toe and causes morbidities at the donor site, including skin erosion, pain, and poor aesthetic appearance. This study examined the incidence of donor-site complications after wrap-around flap transfer. We reviewed 28 patients (18 men and 10 women) who underwent wrap-around flap transfer between 1982 and 2008. The average age was 24.9 years. The mean duration of follow-up was 52.0 months. The donor defect was reconstructed using a cross-toe flap in 14 cases, reverse metatarsal artery flap in 2, peroneal flap in 3, skin graft in 4, and artificial skin graft in 3. In 2 patients, the donor defect could be closed without any grafts. Donor-site complaints and satisfaction were assessed by a questionnaire in 16 cases. All of them could walk more than 2 km without stopping. Seven of them could not wear thongs. Three had pain; 4, numbness; and 9, cold intolerance. Most patients were satisfied with the outcome, and some of them were not satisfied with the donor-site recovery because of skin erosion, cold intolerance, and poor aesthetic appearance.
Hand transplantations have revolutionized the reconstruction field for patients with hand defects. However, immunosuppressants are essential for maintaining human hand transplant survival despite lethal side effects. Recent studies indicate that Mesenchymal stem cells (MSCs) have some immunomodulatory properties to suppress T cell mediate responses that cause tissue rejection. The purpose of this study is to evaluate the effect of intravenous donor MSC infusion for immunomodulation in the rat composite tissue allotransplantation model. Orthotopic rat hind limb transplantation was performed using donor Wister rats and recipient Lewis rats. The recipient rats were injected intravenously with 2 × 106 donor MSCs on day 6 with 0.2 mg/kg/day tacrolimus administered over 7 days. Graft survival was assessed by daily inspection and histology. Recipients' immunological reactions were also evaluated. The graft survival was significantly prolonged in comparison with those of control groups. Recipient rats significantly reduced serum pro-inflammatory cytokine. Cytokine expression analysis of the skin of grafted limbs showed that MSC treatment significantly decreased pro-inflammatory cytokine expression. MSCs induce T cell hyporesponsiveness and prolong graft survival in the rat composite allotransplantation model. MSCs demonstrate some immuno-modulatory properties for transplant rejection that can be accomplished without the need for significant recipient immunosuppression.
Although anticoagulation therapy has been part of replantation therapy for 45-years, no consensus exists on the use of antithrombotic agents. Our replantation patients have been routinely treated with a combination of 240,000 IU/d of urokinase and 80 μg/d of prostaglandin E1 for 7 days, which is added to an intravenous drip infusion of 2,000 ml/d of hydroxyethylated starch. If the crushing of the replanted digits distal to the metacarpophalangeal joints is severe, heparin is added and administered continuously for 1 week. This report discusses the use of postoperative antithrombotic agents based on our experience with 29-patients. The amputation levels included six digits in zone I, 13 digits in zone II, 10 digits in zone III, eight digits in zone IV, and two digits in zone V. The injury types included clean-cut and crush (7 cases), and compression and avulsed (22 cases). Unlike our anticoagulation protocol, heparin was used in 28 patients, independently of amputated parts and types of injury. Additionally, patients aged 50 years and older were administered significantly less total heparin than patients aged 50 years and younger. Our findings suggest that heparin is the most beneficial agent for antithrombotic therapy in patients with replanted digits.
Recently, several perforator flaps have been described in the literature. Covering a tissue defect in a limb generally requires a thin flap to provide the reconstructive site with aesthetic and functional refinement in a single stage. The medial sural artery perforator flap presents a new concept that involves a single musculocutaneous perforator to supply a whole skin flap. We used the pedicled medial sural artery perforator flap for coverage of the skin defect around the knee. The patients were 2 men and 3 women who were 36-72 years old. The causes of the skin defect were one by osteomyelitis of the tibia and 4 by infection after total knee arthroplasty. The flaps were 4 × 2 cm - 23 × 5 cm. All flaps survived and infections healed. The donor site was closed in a single stage of no more than 5 cm width. Results show that the pedicled medial sural artery perforator flap is useful for the coverage of skin defects around the knee.
The distally based sural flap (DBSF) has become increasingly used in reconstruction of the foot and the lower leg. In DBSF, however, flap failure rates may be increased especially when applied to high-risk patients with vascular disturbance such as diabetes mellitus or peripheral arterial disease. Delay procedure has been used to prevent flap necrosis and other complications. We report our modifications of delayed DBSF. We created five delayed DBSFs in five patients. Our standard delay procedure has two stages. In the first stage, the flap is raised except for the pedicle. In the second stage, the entire flap including the pedicle is raised after 7-12 days. In 2 patients, DBSFs were raised by another method, involving re-anastomosis of the short saphenous vein (SSV) to relieve critical flap congestion combined with our standard delay procedure. Flap elevation with re-anastomosis of the SSV was followed by ligation of the SSV after 6-10 days and then by raising of the entire flap at 13-14 days after the initial procedure. All of the flaps took completely. Our modifications of delayed DBSF were useful for high-risk patients with vascular disturbance such as diabetes mellitus or peripheral arterial disease.
Total carotid occlusion may involve chronic occlusion as a result of chronic arterial disease caused by arteriosclerosis or acute occlusion caused by artificially induced permanent closure of the carotid artery. We report our experience of reconstruction of the head and neck region in four patients with carotid occlusion. Two cases involved secondary reconstruction for esophageal deficit following rupture of the carotid artery after surgery for esophageal cancer. Two cases involved primary reconstruction for palate cancer in one case of chronic carotid occlusion and for cervicothoracic esophageal carcinoma in a case of subclavian artery occlusion. In the case of acute occlusion, there was rich blood flow in the carotid artery branches due to the collateral circulation via the circle of Willis; therefore the graft bed blood vessels were fully utilized. In the case of chronic occlusion, the collateral flow is complex and diverse, and almost impossible to identify. Since the collateral pathway may be the main artery for important organs, caution has to be exercised. In the case of chronic occlusion, use of the graft bed vessels on the side of occlusion should be avoided as far as possible.
Major craniofacial defects of the calvaria including the scalp, cranial bone, and sometimes dura mater, are often refractory to treatment and produce a difficult therapeutic problem for reconstructive surgeons. Free flap transfer has revolutionized craniofacial surgery by improving the quality of reconstruction. This study involved a total of 4 patients whose craniofacial defects were reconstructed with free anterolateral thigh flap transfer over a 4-year period from 2006 to 2009. All cases showed advanced cranial defect including dura mater. In all cases that needed dural reconstruction, fascial component was used for dural reconstruction. In 1 case, a fascial component was used as a vascularized component with anterolateral thigh flap. The most commonly used recipient vessels were the superficial temporal artery and vein. An average 11.3 cm length of flap pedicle was necessary to reach the recipient vessels. In all cases, successful reconstruction was achieved by using free anterolateral thigh flap. Major complications including CSF leakage or flap loss were not observed. The anterolateral thigh flap seemed to be one of the most available flaps for reconstruction of major craniofacial defect, because it has a long pedicle and can be elevated with fascia, which can be used for dural reconstruction. Furthermore, the anterolateral thigh flap with well vascularized fascia components is available for reconstruction of the infected dural defects.
A six-year-old boy who had bilateral radial deficiency (type 4 in the right and type 2 in the left according to the modified Bayne classification including bilateral thumb deficiency) demonstrated 110° in supination and 0°in pronation in his left forearm. He was subjected to osteotomy of the left radius and ulna to improve the forearm rotation. While the ulna united within two months after surgery, the union of the radius was delayed and fixation using a long arm-cast and orthosis was needed for six months after surgery. After removal of the orthosis, a fracture occurred at the osteotomy site of the radius by a low-energy trauma. Despite the fixation with the long arm orthosis for additional nine months, bone union was not obtained. Fixation of the fracture using a plate combined with a vascularized bone graft (VBG) taken from the medial femoral condyle resulted in successful bone union of the radius in two months. His postoperative supination and pronation arcs were 30°and 65°, respectively. This case gave us an alarm for osteotomy of the radius of patients with the radial ray deficiency. Vascularized bone graft is a powerful tool to obtain bone union in such patients.
A 62-year-old man was admitted to this hospital with a complaint of frostbite in multiple fingers. Twenty-four days after the injury, the fingertips of seven fingers were reconstructed using a free anterolateral thigh flap harvested from one thigh, dissected into two parts. Consequent surgery involving the separation of the fingers was performed two times, 22 and 35 days after the first surgery. The patient experienced symptoms of intolerance to cold and was prescribed beraprost sodium orally, resulting in a gradual alleviation of his symptoms. The exact point to which necrosis permeates frostbite-affected fingers is a difficult judgment in the early stages. However, debriding earlier and covering the tips with a well vascularized flap can succeed in reserving the length and function of the fingers. From this perspective, a free anterolateral thigh flap dissected into two parts is effective.
Recurrence of pressure sores remains a major challenge in surgical treatment. Recently the perforator flap has proven to be effective in the reconstruction of pressure sores in a variety of regions. We describe our experience using the proximal pedicled anterolateral thigh (ALT) flap in the treatment of trochanteric pressure sores. In this study, five ALT flap procedures were performed in 4 patients who had trochanteric pressure sores (NPUAP classification grade IV). They were 2 females and 2 males, and averaged 74.3 years old. In these patients, after the sores were debrided, pedicled ALT flaps were transferred to defects in trochanteric regions. After the operations, all of the flaps survived, with primary closure of the donor site. One flap had a superficial peripheral erosion that was treated conservatively. At the final follow up, there was no recurrence of pressure ulcers. Trochanteric coverage with the proximal pedicled ALT flap gave excellent results. The ALT flap has the following advantages: 1) reliability because of the pedicled flap, 2) good matching of thickness and skin texture, 3) less damage comparative to muscle flap, 4) primary closure of the donor site, and 5) simultaneous operations of debridement and flap elevation. We conclude that the ALT flap is a reliable alternative flap for trochanteric coverage.
We have treated a 61-year-old man with isolated abdominal wall metastasis of gastric cancer. The abdominal wall defect after tumor and colon resection was reconstructed using a free anterolateral thigh flap. As recipient vessels, we chose intraperitoneal vessels for convenience. Postoperative course was uneventful, and color Doppler sonography was used to postoperatively monitor blood flow in the flap. As a result, the patient could assume a sitting position by 4 days postoperatively. Other reports have described ambulation times of 1 or 2 weeks, due to anxiety about the risk of kinking or elongation of anastomosed vessels with body movement. Using frequent checks with color Doppler sonography, the patient achieved early ambulation after 30 days with no trouble. This method of monitoring shows numerous advantages for abdominal wall reconstruction using intraperitoneal vessels.