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Major ablative surgery in the head and neck region may create large three dimensional defects requiring 2 skin flaps and a long bone flap. We present a reconstruction procedure with a single free flap from the sub scapular system.
From September 1998 to December 2008, 22 patients with through to through osteocutaneous defects of the mouth and face were reconstructed with a composite flap from the subscapular vascular system always harvested in dorsal position. The evaluated parameter included: site and dimension of tissue defect, Specific flap properties and composition, review of donor site and recipient morbidity.
18 latissimus dorsi double skin island musculocutaneous flap with one fragment of scapular bone from the angular branch, 2 combined flaps” latissimus dorsi musculocutaneous - parascapular” with one scapular bone fragment using the angular branch the scapular, and 2 latissimus dorsi double skin island musculocutaneous flap with two separate scapular bone fragments, one supplied by the angular branch and the other by the circumflex scapular system were used to reconstruct the composite facial defect. The defects mean dimensions were 56 cm2 for skin, 44cm2 for mucosa and 10,3 cm for bone. Anastomosis was all performed terminilateral on the external carotid artery and termino terminal on the thyrolingualfacial trunk. No flap failure but two failures of the smallest skin island during a hypovolemia accident. 2 extrinsic venous compressions caused by hematoma had to be treated by hematoma evacuation.
Composite flaps based on the subscapular artery system are versatile reconstructive modalities for large, through and through defects of the mouth and the face requiring a large surface of soft tissue to restore their defect.
The major importance of the sub scapular system in through to through oncologic head and neck reconstructions.
The partial superior latissimus muscle is a versatile flap that can be used for a variety of reconstructive defects with minimal compromise to donor site form and function. This paper illustrates the clinical utility and advantages of the partial superior latissimus flap.
Forty-four patients underwent microvascular transplantation of a partial superior latissimus flap by 2 surgeons over the past 4 years. Flap success rate, complications, and site of transplantation were analyzed.
Out of the 44 flaps, 20 were performed for lower extremity trauma, 9 for scalp reconstruction, 7 for hand coverage, 5 for glossectomy defects, 3 for facial paralysis, 2 for knee prosthesis salvage, and 1 for lip reconstruction. Eleven of the flaps were neurotized. Total flap failure occurred in 1 patient and partial flap loss in 5 patients. Donor site function was preserved in all cases.
The partial superior latissimus muscle is an ideal flap with minimal donor site morbidity that can be used to reconstruct a variety of microsurgical defects.
Transverse upper gracilis flap (TUG) is commonly considered an alternative choice for breast microvascular reconstruction. The literature describes its harvesting technique and its utility in breast reconstruction, however there is relatively little emphasis on the donor site complications and how to minimize them.
We report our TUG flaps donor site complications rate. Each particular donor site issue will be discussed in detail with its associated treatment.
A retrospective chart review of 60 TUG flaps in 37 consecutive patients for breast reconstruction was completed. Donor site complications were divided into minor and major. Minor complications included seromas, local wound infection unfavorable scars and minor dehiscence that did not need surgical intervention to close. Major complications included wound dehiscence that needed surgical intervention to close, DVT in the donor leg, lymphedema, chronic pain or numbness and infection needing debridement and IV antibiotics.
Data showed that 38% of patients developed some complication. Most of these complications were minor, including minor wound dehiscence (n= 11/60), minor seroma (n= 9/60), infection (n= 3/60), and leg numbness (3/60). Our major complications included 3 wound dehiscence, 3 cases of lymphedema, 2 major infections, and 1 DVT.
The upper inner thigh frequently provides enough tissue to reconstruct a mastectomy defect. Unfortunately the TUG donor site complication rate remains high. Awareness of these complications allows appropriate informed consent. Further modification of harvest and post-operative care techniques continues to decrease the donor site complications of this otherwise acceptable autologous tissue choice for breast reconstruction.
This study analyzes the surgical procedure 200 free abdominal flap reconstructions using the thoracodorsal vessels as the anastomotic recipient.
Compared to the internal mammary vessel (IMV) system, vessel conversion rate for the thoracodorsal system has been thought to be as high as 15% following radiation therapy and axillary lymph node dissection, and sentinel lymph node biopsy. Review of the senior author’s injury rate and complications indicates that the use of the thoracodorsal system as a recipient in microvascular anastomosis is a safe and reliable technique.
Retrospective study of 200 flaps used in 180 patients for breast reconstruction between 2000–2008. Reconstructions were identified as delayed, immediate, or salvage. Patients who had undergone preoperative radiation, sentinel node biopsy, or axillary lymph node dissection were identified (levels of dissection, number of nodes removed). Additional risk factors such as smoking, diabetes were identified along with demographic information. Data was collected on operative time, total or partial flap loss, and complications (infection, necrosis, hematoma, lymphedema).
The thoracodorsal artery and nerve were identified in 200 cases. 196 out of 200 (98.5%) were deemed suitable as a recipient. One case was converted to the IMV system, and three cases to pedicled procedures. Success rate for free abdominal flaps was 98%. No lymphedema was noted in any of the cases.
The thoracodorsal vessels are safe and effective as a recipient system. Rates of conversion and failure in this series are lower than previously described. For delayed reconstruction, no patient developed lymphedema due to the secondary axillary dissection. For immediate reconstructions, one must consider the morbidity of a level one axillary lymph node dissection versus the IMV exposure.
At the end of the lecture, the learner will be able to:
The internal mammary vessels have been increasingly adopted as recipients for free flap breast reconstruction. Access to the vessels traditionally entails the removal of a segment of the 3rd costal cartilage. Despite excellent exposure, some authors have reported that this technique may lead to pain and long-term tenderness at this site as well as a thoracic contour deformity.
We introduced this technique after specific request by a patient, and have used it for all subsequent reconstructions.
Patients who underwent free flap breast reconstruction using the total rib preservation method by a single surgeon at Addenbrooke’s Hospital were identified and assessed prospectively. Operative details and flap outcomes were noted. Measurements were taken intraoperatively to assess the available space for microvascular anastomosis. Operative details and flap outcomes were compared with a cohort of earlier patients.
A single surgeon performed 20 free flap breast reconstructions in 16 patients (18DIEPS, 2TRAM. In the first 4 patients the interspace between the 3rd and 4th ribs was used; subsequently that between the 2nd and 3rd ribs. There was no significant difference in mean warm ischaemia time or mean operative time between the two groups. The average distance between adjacent ribs was 21.2mm (13 to 25mm). All flaps were successful.
Total rib preservation is a viable and reliable option for micro-vascular breast reconstruction. It does not increase operative time and reduces recipient site morbidity. There is a learning curve and care has to be taken to avoid possible pitfalls.
Monopolar Cautery is not universally accepted as a safe method for direct dissection of perforators, pedicles and recipient vessels in microsurgery. Its main advantage is that it facilitates speed of dissection by providing a bloodless field and lessening the requirement for clip application in securing small branches. The potential disadvantage is for irreversible thermal damage leading to vessel thrombosis. The current literature suggests that cautery may lead to endothelial damage and thrombosis. At our institution monopolar cautery has been used exclusively by the 2 senior authors in over 800 DIEP/SIEA breast reconstructions with a failure rate of less 2%. Histological examination was performed on cautery dissected vessels.
Following ethics approval, recipient vessels samples were taken from patients undergoing DIEP breast reconstruction. These were sectioned and stained with H&E. A single pathologist reviewed them for features suggestive of thermal injury: nuclear streaming, coagulative necrosis and homogenization of parenchyma with hyper-eosinophillia. Cautery settings used for the procedure were recorded.
Nineteen arterial and 19 venous vessel segments were collected following cautery dissection. One arterial and one venous vessel segment was dissected without cautery and used as control. The control showed no arterial changes but segmental hyper-eosinophillia was noted in the vein. In cautery dissected vessels only 1/19 arteries showed mild histological features suggestive, but not conclusive of cautery effect. 1/15 veins showed segmental changes suggestive of cautery artifact. No failures or take-backs occurred in any of the cases.
Our study suggests that monopolar cautery microvascular dissection produces minimal thermal damage. Histologically, the arteries are generally well preserved while veins showed slightly more changes, but neither correlated with adverse clinical outcomes.
Understand the safety profile of monopolar cautery microvascular vessel dissection.
Microsurgical breast reconstruction has rapidly advanced in popularity over the past few decades, broadening the options for breast reconstruction. The selection of recipient vessels for these autologous tissue reconstructions has shifted from the thoracodorsal to the internal mammary (IMA) vessels.
The increasing use of percutaneous coronary intervention has resulted in decreased numbers of traditional coronary artery bypass graft (CABG) surgery; however, bypass is still the optimal choice for patients with triple vessel disease. In cardiac surgery, the conduit of choice for revascularization is the left internal mammary artery because it has a significantly higher long term graft patency rates and improved patient survival.
The purpose of this study was to review the cardiac risk factors in this breast reconstruction population and to report the incidence of post-operative cardiac events.
A retrospective, cumulative audit of one institutions’ breast reconstruction practice from 2005 to 2009 was conducted. Patient demographics, cardiac risk factors (smoking, obesity, diabetes, hypertension, previous cardiac events, and family history), the incidence of cardiac events post-reconstruction, and other postop complications were reviewed.
Over one hundred autologous reconstructions were reviewed. Two women were noted to have experienced post-operative myocardial infarction requiring intervention. Both were noted to have triple vessel disease, an indication for CABG, however, with the recent reconstruction their IMA had been utilized. Both women subsequently underwent percutaneous intervention with good outcomes.
In conclusion, while there is limited overlap of the breast reconstruction and cardiac disease populations, there can be significant cardiac health implications in the post-operative status of women undergoing autologous breast reconstruction using the IMA as recipient vessels.
At the end of this presentation, the learner will be able to describe the pros and cons of using the internal mammary vessels in breast reconstruction.
Immediate breast reconstruction has both aesthetic and psychological advantages over delayed reconstruction. However, previous reports on irradiated autologous tissue reconstruction suggested a significant increase in fat necrosis, fibrosis and flap contracture. Up to 24% of cases required a secondary flap to complete the reconstruction leading to the recommendation that all reconstruction should occur post radiation. We reviewed our series of 80 immediate DIEP/SIEA breast reconstructions that were subsequently radiated.
A four year retrospective review was performed using the University of Manitoba’s Database, patient charts and follow-up examination.
Over 800 perforator flap breast reconstructions were performed by the two senior authors. 80 patients received postoperative radiation. 69 had adequate follow up (6 to 42 months, mean 16) post radiation to be included in this study. There were 57 DIEP and 12 SIEA flaps with an average age of 48 years (29–67) and BMI of 26.7 (18.3–49.1). 13 patients had bilateral reconstruction with unilateral radiation. Two flaps (3 %) developed post radiation fat necrosis and 7 flaps (10 %) showed fat necrosis prior to radiation. One reconstruction required a secondary flap to correct a contour deformity. No total flap loss occurred.
Immediate breast reconstruction with free DIEP/SIEA flaps showed minimal radiation induced fat necrosis. While native mastectomy skin tightening post radiation does occur, symmetry is still obtained with a contralateral balancing procedure. In our opinion this is still aesthetically superior to a delayed reconstruction. In only one case was a secondary flap needed to achieve the desired result. Fat necrosis appears to be determined primarily by the initial surgical technique and we suggest that postoperative RT should not relegate patients to a delayed reconstruction.
Demonstrate the effect of radiation on DIEP/SIEA breast reconstruction.
To evaluate the correlation between CT angiography (CTA) perforator identification and intra-operative transit time flow measurements (TTFM) in DIEP flaps.
Preoperative CTA and intra-operative transit flow measurements were performed in consecutive DIEP flaps. Intra-operatively, all perforating vessels >1mm with pulsatile hand-held Doppler signals (8 Hz) were preserved. Vessel location was mapped and correlated with preoperative CTA. Waveform patterns and TTFM using the MediStim VeriQTM System were recorded for each vessel.
In 10 consecutive DIEP flaps, 54 eligible vessels with a diameter of >1mm and a pulsatile Doppler signal were isolated. Pre-operative CTA had identified only 16 of these as arterial. Arterial flow waveforms were present in 15 of these 16 perforators. Of the 38, non-CTA identified vessels, only 2 had arterial waveforms. (p<0.0001); the remaining 36 waveforms were venous. Arterial vessels visualized on CTA had a transit time flow volume of 5.3 ml/min, while the vessels not seen on CTA had slower flow (2.1 ml/min, p<0.0001).
Assuming CTA is accurate in identifying arterial perforators, the sensitivity of TTFM to identify arterial perforators was 94%, and the specificity was 95%. Given that the underlying incidence of arterial perforators in this series was 30% (16/54), the positive predictive value was 88% and the negative predictive value was 97%. In contradistinction, hand held Doppler assessment of perforators was misleading in 70.4% of vessels.
TTFM distinguishes between arterial and venous waveforms in vessels which “appear” arterial by traditional criteria. CTA and TTFM are highly correlated. Use of CTA and TTFM may prevent the unexpectedly poor perfusion seen in some DIEP flaps.
To understand the potential role for transit time flow measurements as an adjunct to traditional perforator selection.
Clinical and injection studies have demonstrated that Zone IV is not reliably perfused in free DIEP / TRAM flap transfers. Contralateral balancing reduction mammaplasty in most cases will allow mastectomy reconstruction with a DIEP hemi-abdomen eliminating the need for Zone IV. However, in some cases the entire abdomen will be needed to create an aesthetic outcome acceptable to the patient. Often these patients are younger and receive post-operative radiation rendering implant reconstruction less desirable.
From 2004 to 2009, 17 cases utilizing the entire abdomen (all 4 zones) for both immediate and delayed unilateral breast reconstruction were reviewed. Minimum follow up was 6 months. The different techniques utilized included 1) DIEP’s connected in series (11): DIEP pedicles are harvested on both sides and anastomosed in series. 2) Standard DIEP (2): a single pedicle used to supply all zones. 3) DIEP with SIEV augmentation (4): A DIEP with the contralateral SIEV to improve venous drainage to Zone IV.
The best aesthetic outcomes appear to be in patients who had DIEP’s connected in series where the flaps were coned in a U-shape (4 patients). When flaps in series were stacked obliquely one on top of another (7 patients) all had a step deformity that required secondary correction. 2 flap losses occurred in this group likely due to the difficulty of pedicle orientation. All flaps based on only a single DIEP pedicle had some component of fat necrosis.
When the all 4 zones are required for a unilateral breast reconstruction it should be done by harvesting a DIEP pedicle on each side of the abdomen, connecting them in series, and coning the flap in a U-shape.
Understand the best technique to utilize all 4 Zones for a unilateral breast reconstruction.
The incidence of late microvascular complications in free flaps has been reported in up to 5%. Most microvascular complications occur within the first 24 hours; however late failures occasionally occur. We reviewed our experience of late microvascular complications in order to better understand this disconcerting event.
The University of Manitoba microsurgical database and hospital charts were retrospectively reviewed for breast free flap reconstructions from 2004–2009. Microvascular complications occurring on the fifth post-operative day or later were analyzed.
Seven late microvascular complications were identified in 800 free breast reconstructions (1%). There were 3 Superficial Inferior Epigastric Artery flaps, 2 Deep Inferior Epigastric Perforator flaps, 2 Superior Gluteal Artery Perforator flaps, and 1 Transverse Upper Gracilis flap. The mean day of post-operative failure was 14 (range 6 – 33). Two patients had prior radiation treatment. One patient was taking an aromatase inhibitor. Another patient was diabetic and a smoker. The mean Body Mass Index (BMI) was 36. Isolated arterial failure occurred in one case, isolated vein failure occurred in one case, and in five cases both artery and vein were thrombosed or avulsed at the time of exploration. The causes of flap failure varied: two were avulsed at the anastomosis, one failed due to problems with radiation changes in the vessels, one failed due to a hematoma, one due to a deep abscess, and two failed from indeterminate causes. One flap was partially salvaged but ultimately needed further surgery to complete the reconstruction.
Late microvascular complications of free flaps have multiple potential etiologies and appear to be more common in patients with a high BMI. Causes can include pedicle avulsion, hematoma, infection, and pre-existing radiation changes.
Understand factors affecting late microvascular failure.
Necrotizing fasciitis is a rapidly progressive and often life-threatening infection of the soft tissues. Early aggressive debridement and broad spectrum antibiotics are the main components of treatment. The purpose of this study was to evaluate the largest series of acute free tissue transfer reconstruction following necrotizing fasciitis.
From 2004 to 2008, eleven consecutive cases of necrotizing fasciitis requiring free tissue tissue transfer were reviewed. Average follow up was 14 months (range 1 month to 4 years).
A total of 11 patients required free tissue transfer for reconstruction. There were 6 males and 5 females; the mean age was 38.6 years (range of 23 to 69 years). The most common site for reconstruction was the lower legs (3), followed by the digits (2), thumb (2), hand and forearm (2), and perineum (1). Co morbidities were present in 5 of the 11 patients and included diabetes, hypertension, and drug abuse. All patients were treated surgically, with the majority requiring two debridements prior to reconstruction. Defect dimensions ranged from 6×8 cm to 40×15 cm. The most frequently utilized flap was the ALT (9), followed by DIEP (1), Radial forearm (1), Gracilis (1), and TAP flap (1). All flaps survived. Infections at the site of reconstruction occurred in 2 patients. There was 1 donor site infections. Non flap related complications occurred in 4 patients. Average length of hospital stay was 35 days.
Immediate free flap reconstruction following necrotizing soft tissue infection appears to be a safe and viable alternative. Early reconstruction can potentially decrease the overall functional and aesthetic morbidity associated with this disease.
Participants will be able to identify risks, benefits, and complications of early free tissue transfer following acute necrotizing fasciitis.
The Programme Universitaire de Réimplantation Provincial du Quebec (PURP), a centralized replantation program for the province of Quebec, was established in an effort to offer optimal care to patients considered candidates for upper extremity replantation or revascularization. The purpose of this study was to describe our experience with upper extremity replantation/revascularization in the largest published North American patient cohort.
Prospective data collection included demographic information, injury and operative details, as well as post-operative course (including in-hospital stay and out-patient follow-up). In addition, functional, subjective and occupational outcomes were obtained throughout the short- and long-term follow-up period.
Four hundred and forty six revascularizations (212) and replantations (234) were performed in 264 patients (mean age, 44). The majority of patients (74.1%) presented with guillotine-type injuries, which involved a single digit (28.9%) at the level of the proximal phalanx (28.5%). Primary survival of the replanted or revascularized appendage was 92.7% (291/314). Approximately thirteen percent of patients required more than one operative intervention during their initial hospital stay. Anti-coagulation therapy and leech therapy was required in 30.9% and 10.8% of patients, respectively. Post-operative complications, including secondary revision amputation due to circulatory embarrassment, occurred in 23.1% of patients. Mean hospital stay was 5.8 days and post-operative occupational therapy averaged 5.6 months. Long-term subjective and functional data are currently being obtained from these patients.
While replantation is a considerable endeavor from an economic standpoint when compared with primary revision amputation, anatomic integrity can be re-established in the majority of injuries referred to a specialized center and, based on preliminary data, with satisfactory subjective and functional long-term results.
This analysis should provide the audience with information on outcomes following replantation/revascularization in a large population base.
Replantation of ring avulsion injuries is a challenge because of the long segment damage to the vessels and intrinsic damage caused to soft tissues at the proximal edge of the amputation. Arterial repair can be done by direct vessel suture, vein graft or cross anatomosis of digital artery. Venous problems are corrected by direct repair or by vein grafting. When inadequate circulation and soft tissue system is involved, venous flow through flap can be used. Revascularistion/Replantation of avulsion ring injury is the standard of care at majority of institution for Urbaniak grade 2-2A. In selected cases, the soft tissue and criculation is inadequate and venous flow through flap was performed in treatment of avulsion ring injury. At a minimum follow-up of one year, these patients showed good functional and cosmetic recovery. We present our indications, technique, timing and outcomes of venous flow through flap in treatment of avulsion injury.
This is a retrospective chart review of our Microsurgery Database.
9 free venous flow through flap tissue transfers were reviewed in the database between July 2006 and December 2008. Of these 5 patients underwent free venous flow through flap in treatment of avulsion ring injury. No free flaps were compromised. 1 finger amputation was requested by patient secondary ankylosis at PIP.
Treatment of avulsion ring injury by revascularisation-replantation is standard care but if soft tissue is inadequate and expectations are not met, venous flow through flap is adequate treatment and can result in the desired outcome.
The brachial nerve injuries are cause major functional deficiency. Avulsion injuries leave no surgically reparable stumps. A variety of nerve transfers allow to restore neuromuscular function in the affected upper limb. The phrenic nerve is frequently transferred to various recipient nerves.
From 1999 to 2007, a total 46 patients (15 adults, 32 children) with brachial plexus injury underwent modified end-to-side neurorrhaphy in which the phrenic side was widely opened, one or two nerve grafts were interpositioned and sutured between the phrenic nerve side and the recipient nerve end, which included various recipient ends on different nerve injuries (musculocutaneous nerve, anterior or posterior division of the upper trunk, axillary nerve, suprascapular nerve).
34 patients have been followed postoperatively from a mean of 25.5 months, with the following RESULTS: 17/34 (50%) patients had muscle grade 4; 10/34 (30%) patients had muscle grade 3; 4/34 (11%) patients had muscle grade 2; 3/34 (9%) patients had muscle grade 1. Also, the patients that underwent modified end-to-side neurorrhaphy in which the phrenic side did not show impair of the diaphragm function as evaluated by chest x-ray.
Clinical surgical outcomes showed excellent results obtained with phrenic nerve transfer end-to-side technique. The modified widely opened end-to-side technique allows one or more nerve grafts by oblique repair methods. The suitability of the phrenic nerve as a donor nerve for this type of repair is allowed by the fast and intense side sprouting of the axons. This advantage is probably due to its dense and strong spontaneous electrical discharge.
Participants will be able to identify the modified phrenic nerve transfer as a suitable technique with excellent outcomes and low morbidity.
Microsurgery has been traditionally taught using a self-directed study technique. Residents are usually handed a set of instructional learning videos, followed by a period of self-directed technical training which is usually preformed on rats. The objectives of this study are to compare the current self-directed teaching protocol to a structured hands-on teaching program utilizing a tissue model (turkey legs).
In order to evaluate the efficacy of microsurgery training programs, a microsurgical objective structured assessment of technical skill (MOSATS) evaluation was created. A total of 20 microsurgery trainees (residents and medical students) were assigned to 2 groups. Each candidate completed 2 weeks of either self-directed or hands-on training. The MOSATS evaluation has 2 parts, a global rating and a checklist. The time spent performing a single vessel anastomosis, and the MOSAT scores were compared between groups. Statistical analysis included a paired t-test to analyze the data the Mann Whitney U test to assess inter-rater variability. The level of significance was set at p<0.05.
The preliminary data describes the overall performance of 5 candidates in each group. The data includes the mean scores from the checklist, global rating and duration spent to perform a single vessel anastomosis. The hands-on group had a statistically significantly faster vessel anastomosis time compared to the self-directed group (P=.007).
We report an accurate and objective way of assessing microsurgery skills (MOSATS). The tissue model utilized in this study is cost-effective and easier to attain, and allows for extensive practicing. It appears that the hands-on teaching approach may yield significantly improved microsurgical laboratory training.
To develop an instrument to evaluate competency in microsurgery.
A bench-training model for the acquisition of microsurgical skills was developed. Students participated in three, three-hour sessions during which they completed a number of increasingly complex, standardized microsurgical tasks. Performance was recorded and graded using a newly developed University of Western Ontario Microsurgery Skills Acquisition (UWOMSA) instrument, with knot-tying and anastomosis modules.
Each module contained 3 categories with 5 point-Likert scales. Each learner was assessed at two time-points (for intra-rater reliability) and by two surgeons (for inter-rater reliability) blinded to the identity and training level of the novice. Additionally, Reznick’s validated global rating scale (GRS) for operative performance was utilized to establish criterion validity. Within-scale scores were compared via intra-class correlation (ICC), and between-scale scores with Pearson correlation coefficient. Linear regression was used to evaluate the effect of various predictors on UWOMSA score.
37 videos (9.6 hours) were reviewed, including 20 knot-tying sessions and 17 anastomoses. Inter-rater reliability of UWOMSA was high, with an ICC coefficient of 0.755 [0.573,0.866]. ICC of the GRS was 0.793 [0.621,0.892]. Intra-rater reliability of the UWOMSA was also high, with an ICC of 0.692 [0.480, 0.829]. ICC of the GRS was 0.695 [0.466,0.837].
Measures of criterion validity demonstrated strong agreement between UWOMSA and GRS (Pearson 0.964, p<0.001). Measures of construct validity demonstrated that higher scores on the UWOMSA were associated with faster knot tying (p<0.0001), increased PGY level (p=0.05), and previous microsurgical experience (p=0.09).
The UWOMSA instrument performed well in terms of reliability and validity. Further study is planned to assess the instrument’s ability to predict microsurgical skills translation to the clinical setting.
To understand a new model for microsurgical training and the validation of an instrument for assessing microsurgical skills.
The purpose of this report was to highlight the particular physiologic behavior of complex multi-unit microvascular free tissue transfers.
From our series of 89 composite free flaps based on the sub-scapular system that were comprised of at least two units, we extracted all cases that resulted in complete necrosis of one or more units. We found two cases in which vascular embarrassment and consequent necrosis occurred after the first 24 hours.
Case 1: A two paddle free flap based on the sub-scapular system was used for lower extremity reconstruction. Hemorrhagic shock in the immediate postoperative period resulted in loss of the proximal cutaneous portion based on the circumflex scapular artery at the expense of the distal muscular segment (complete latissimus dorsi flap) based on the thoracodorsal artery.
A three-component flap based on the thoracodorsal artery was designed for reconstruction of a multifaceted oro-pharyngeal defect following tumor extirpation. The arterial tree consisted of two muscular branches and the angular branch for inclusion of a scapular bone segment. Post-operative hypovolemia manifested as ischemia and subsequent necrosis of the most distal portion of the flap.
Where flap design includes an arterial circuit, in which a differential in resistance to flow exists, vascular compromise may result in a steal phenomenon within the flap. This is in contrast to a pattern of end-vessel arborization, where ischemia favors distal tissue. Based on the latter findings, one may argue that patients’ post-operative hemodynamic profile should be adapted in consequence of the physiology of the transferred tissue.
This report should provide the audience with information regarding the behavior of complex multi-unit microvascular free flaps in the face of critical hypovolemia.
In June of 2008 we reported a 2.5% incidence of pulmonary embolism (PE) and a 0.2% incidence of fatal PE in 484 microvascular breast reconstruction patients. There had been no standard application of venous thromboprophylaxis. By definition, this group falls under the high risk category according to the American College of Chest Medicine. Thus the recommended protocol should include administration of both pre-operative and postoperative heparin thromboprophylaxis. A major concern in perforator flap surgery is intraoperative bleeding making perforator dissection more difficult, as well as post operative bleeding from the mastectomy site(s), de-epithelialized flap surface(s), and abdominal donor. Since June 2008, all patients have received one of two standardized venous thromboprophylaxis regimens. We prospectively compare these 2 regimens.
80 consecutive patients were prospectively evaluated from June 2008 to January 2009. All free flap breast reconstruction patients received a standardized post-operative subcutaneous (SC) heparin thromboprophylaxis regimen as well as TED stockings and SCD’s. Group A (40 patients) received only post-operative subcutaneous heparin, while Group B (40 patients) received the same post-operative subcutaneous heparin regimen as Group A, but also received a single pre-operative dose.
The incidence of PE, DVT, surgical and bleeding complications in microvascular breast reconstruction patients comparing 2 different heparin thromboprophylaxis regimens will be outlined in detail.
Our results suggest an overall decreased incidence of PE following breast reconstruction with free flaps when using a standardized peri-operative venous thromboprophylaxis protocol. Further evaluation suggests that post-operative heparin alone appears adequate in preventing PE while the addition of pre-operative heparin may increase the risk of a post-operative bleeding complication.
The participant will be able to identify the risks and effectiveness of two different venous thromboprophylaxis regimens in microvascular breast reconstruction.