Transcutaneous carbon dioxide pressure ( TcPCO2 ) was originally used for noninvasive measurement of the partial pressure of carbon dioxide ( PaCO2 ) during arterial blood monitoring, and in various conditions, TcPCO2 values were found to be more stable than transcutaneous oxygen pressure ( TcPO2 ) values. In experiments involving animals, TcPCO2 values were found to increase rapidly with each arterial and venous occlusion for abdominal pedicle flaps. In addition, at 37℃, TcPO2 and TcPCO2 were measured in healthy men. In these men, these variables were measurable at all skin surface sites ; moreover, the median values of TcPCO2 ranged from 40 to 70mmHg. This study included the last 49 patients who underwent free flap surgery between January 2002 and June 2011. Of these patients, 2 had venous thrombosis. For those with compromised flaps, reanastomosis was immediately performed after identifying a TcPCO2 value of >90mmHg. Our experimental and clinical results indicat that, at 37℃, TcPCO2 values are more stable than TcPO2 values ; moreover, TcPCO2 can be used as a predictable method for monitoring vascular skin complications. Continuous monitoring of TcPCO2 at 37℃ can provide objective information and alert doctors and nurses to the need for checking the free flaps.
The Tissue Oximeter OXY-2 is a device to measure local tissue oxygen saturation ( StO2 ) noninvasively using near-infrared light. In the present study, we report our experience of this device in postoperative continuous flap monitoring. Seven free flaps ( gracilis flap : 2, anterolateral thigh ( ALT ) flap : 1, latissimus dorsi ( LD ) flap : 1, fibula graft : 1, toe transfer : 1, toe joint transfer : 1 ) and two pedicle flaps ( reverse posterior interosseous artery flap ( PIA ) : 1, LD island flap: 1 ) were monitored until the third postoperative morning. Eight of nine flaps survived without complications. The StO2 values of gracilis, ALT, fibula, toe and toe joint flaps fluctuated somewhat during the first 40 hours and then subsequently stayed between 70 and 82%. Generally, the StO2 values of the LD flaps were lower than those of the other flaps ( 50 ∼ 60% ). The PIA flap used for a child with radial ray deficiency, who had demonstrated an StO2 value lower than 30% just after surgery, developed necrosis within 24 hours after the operation. The OXY-2 has the potential to become a useful device in flap monitoring during the postoperative period. However, special attention should be paid in mounting the oximeter probe and the cord on non-flat surfaces of the extremities.
Although mandibular reconstruction plates ( MRP ) are often used for mandibular reconstruction, plate-related surgical complications such as plate infection or exposure have been reported. We developed a new technique named “no touch technique” to prevent postoperative MRP infection, and our experience of this new procedure was reported. Between 2010 and 2012, the new operative procedure was applied for mandibular reconstruction using MRP in 9 patients ( 4 men and 5 women ; mean age, 75.0 years ). A rectus abdominis musculocutaneous flap was used for soft tissue coverage in most cases. Mandible bridging with MRP was reestablished after completion of free flap transplantation and vascular anastomosis. In this way, MRP could be kept out of contact with the oral mucosa and saliva due to complete separation of the neck area from the oral cavity. Finally, dead spaces around the MRP were meticulously filled with soft tissue flap. All free flaps survived successfully and no local complications related to MRP were observed. The no touch technique during plate fixation and sufficient soft tissue coverage to fill the dead space might reduce postoperative complications in cases after MRP reconstruction. More clinical experience and long-term follow-up are necessary to establish this procedure.
An implant that becomes infected or exposed after internal fixation must usually be removed. In some cases, a muscle flap can be used to salvage an implant, because of its soft tissue coverage and fresh vascularity. However, there are no reports of implant salvage using an anterior tibial artery perforator flap. Here we describe a case of an amateur runner who suffered a tibial comminuted fracture in a traffic accident. Four weeks after undergoing internal fixation in a private hospital, the patient developed an infection around a locking plate. At the orthopedic surgeon's request, and after discussing the situation with the patient, we transferred a pedicled fasciocutaneous flap nourished by the anterior tibial artery onto the infected implant, after debridement and washing. This procedure successfully salvaged the implant. There are only a few reports on factors that influence the successful salvage of an implant using muscle flaps, and no reports on those influencing salvage by a fasciocutaneous flap. Here we showed that an anterior tibial artery perforator flap is useful in some cases of lower leg reconstruction.
The treatment of fistulas communicating with a joint is a challenging issue. We report the case of a fistula communicating with the knee joint that formed after surgery for a traumatic injury. The fistula could not be closed with a pedicled perforator flap ; however, it was successfully closed by using a turbocharged chimeric anterolateral thigh flap and vastus lateralis double mini-flaps. The diameter of the perforator derived from the distal portion of the descending branch of the lateral circumflex femoral artery ( LCFA ) was very small, and the dominant perforator was derived from the transverse branch ; therefore, to ensure vascular augmentation, the transverse branch was anastomosed with a muscle branch for the rectus femoris diverging from the proximal side of the LCFA. In addition, a chimeric flap was constructed by using double muscle branches given off from the distal portion of the descending branch of the LCFA, and double fistulas were closed with vascularized double muscle flaps.