Jeroen M. Smit

Advancements in Free Flap Monitoring in the Last Decade : A Critical Review

Background: The authors conducted a review of the recent literature on the monitoring of free flaps to create an overview of the current monitoring devices and their potential as an ideal monitoring method. Methods: A literature-based study was conducted using the PubMed and Cochrane databases. The following search terms were used: “flap” and “monitoring.” All monitoring methods found between January of 1999 and January of 2009 were evaluated. Monitoring methods that were described in five or more clinical reports were further investigated. Results: The advantages and disadvantages of conventional monitoring methods, the implantable Doppler system, color duplex sonography, near-infrared spectroscopy, microdialysis, and laser Doppler flowmetry are presented. Furthermore, an overview is given of their potential as ideal monitoring method. Conclusions: The implantable Doppler system, near-infrared spectroscopy, and laser Doppler flowmetry appear to be the best monitoring devices currently available. As most of the publications on monitoring have focused on the reliability of the systems, future research should also address their cost efficiency.

Preoperative CT angiography reduces surgery time in perforator flap reconstruction

UNLABELLED The use of perforator flaps in breast reconstructions has increased considerably in the past decade. A disadvantage of the perforator flap is difficult dissection, which results in a longer procedure. During spring 2006, we introduced CT angiography (CTA) as part of the diagnostic work-up in perforator flap reconstructions to visualise each perforator more accurately. The main objectives were to reduce surgery time and the number of complications. A chart review was conducted 1 year after CTA introduction to investigate if these objectives were met. MATERIALS AND METHODS Patients with a deep inferior epigastric perforator (DIEP) flap who underwent preoperative analysis through CTA were retrospectively evaluated. The population <or=1 year before CTA introduction were the control group. The two groups were compared with respect to surgery time and complications (including flap failure). RESULTS One hundred and thirty-eight DIEP breast reconstructions were done; 70 underwent preoperative CTA analysis, and 68 had preoperative Doppler investigation. Surgery time in the CTA group was significantly lower (P<0.001) than in the control group, 264 min (SD+/-62) versus 354 min (SD+/-83), respectively. There was a tendency for fewer complications in the CTA group compared with the control group. All flaps were successful in the CTA group. In the control group, one flap failed and partial necrosis occurred in three flaps. The differences were not statistically significant. CONCLUSIONS Preoperative CTA in the assessment of vascular anatomy during perforator flap reconstruction was safe and reliable. It helped reduce surgery time, and may prevent the number of postoperative complications.

Untreated Hemangiomas : Growth Pattern and Residual Lesions

Background: Hemangiomas of infancy can give rise to alarm because of their rapid growth and occasional dramatic appearance. The objective of this study was to investigate the growth pattern of hemangiomas and risk factors for residual lesions. Methods: A follow-up study was performed of patients with hemangiomas that were clinically monitored between 1985 and 2000 and who did not receive any treatment. The data were retrieved from medical files. Patients (parents) were asked to complete a questionnaire and invited to our outpatient clinic where the questionnaire was discussed and physical examination was performed. The growth phases of the hemangioma were documented, the timeline of these phases was constructed, and an assessment was made of the residual lesion if present. Results: In 97 patients, 137 hemangiomas were evaluated. A precursor lesion was present in 48 percent of children. Maximum size was reached in 8 months. Involution started at a median age of 2 years and was completed at a median age of 4 years. Residual lesions were present in 69 percent of cases. Superficial nodular hemangiomas showed significantly more residual lesions (74 percent) than the deep hemangiomas (25 percent) (p < 0.001; odds ratio, 8.4; 95 percent confidence interval, 2.4 to 29.1). Untreated infection, ulceration, or bleeding produced a scar in 97 percent of the cases. Conclusions: Epidermal invasion of the hemangioma is of predictive value for residual lesions. There is no correlation between the growth pattern of a hemangioma and the risk for a residual lesion. This may add to a more detailed prediction of outcome and may help to decide which patient should be treated or not.

A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: Investigating the effect on venous congestion and flap survival

Background: Venous complications have been reported as the more frequently encountered vascular complications seen in the transfer of deep inferior epigastric artery (DIEA) perforator (DIEP) flaps, with a variety of techniques described for augmenting the venous drainage of these flaps to minimize venous congestion. The benefits of such techniques have not been shown to be of clinical benefit on a large scale due to the small number of cases in published series. Methods: A retrospective study of 564 consecutive DIEP flaps at a single institution was undertaken, comparing the prospective use of one venous anastomosis (273 cases) to two anastomoses (291 cases). The secondary donor vein comprised a second DIEA venae commitante in 7.9% of cases and a superficial inferior epigastric vein (SIEV) in 92.1%. Clinical outcomes were assessed, in particular rates of venous congestion. Results: The use of two venous anastomoses resulted in a significant reduction in the number of cases of venous congestion to zero (0 vs. 7, P = 0.006). All other outcomes were similar between groups. Notably, the use of a secondary vein did not result in any significant increase in operative time (385 minutes vs. 383 minutes, P = 0.57). Conclusions: The use of a secondary vein in the drainage of a DIEP flap can significantly reduce the incidence of venous congestion, with no detriment to complication rates. Consideration of incorporating both the superficial and deep venous systems is an approach that may further improve the venous drainage of the flap.

Treatment options for mallet finger: a review.

Background: Mallet finger is a common injury. The aim of this review is to give an overview of the different treatment options of mallet injuries and their indications, outcomes, and potential complications. Methods: A literature-based study was conducted using the PubMed database comprising world literature from January of 1980 until January of 2010. The following search terms were used: “mallet” and “finger.” Results: There are many variations in the design of splints; there are, however, only a few studies that compare the type of splints with one another. Splinting appears to be effective in uncomplicated and complicated cases. Equal results have been reported for early and delayed splinting therapy. To internally fixate a mallet finger, many different techniques have been reported; however, none of these studies examined their comparisons in a controlled setting. In chronic mallet injuries, a tenodermodesis followed by splinting or a tenotomy of the central slip is usually performed. If pain and impairment persist despite previous surgical corrective attempts, an arthrodesis of the distal interphalangeal joint should be performed. Conclusions: Uncomplicated cases of mallet injuries are best treated by splinting therapy; cases that do not react to splinting therapy are best treated by surgical interventions. Controversy remains about whether mallet injuries with a larger dislocated bone fragment are best treated by surgery or by external splinting.

Post operative monitoring of microvascular breast reconstructions using the implantable Cook-Swartz doppler system: a study of 145 probes & technical discussion.

INTRODUCTION Accurate post operative assessment of free tissue transfers is challenging despite all the subjective and objective techniques available today. In our continual search to optimise patient outcomes, we introduced the Cook-Swartz probe into our clinical practice in May 2006. METHODS We present our single centre experience in 103 patients undergoing 121 microvascular breast reconstructions and monitored using implantable Cook-Swartz venous dopplers between May 2006 and January 2008. RESULTS In total, we used 145 probes on 121 microvascular breast reconstructions (DIEP=102, SIEP=15, SGAP=4) in 103 female patients. The mean operative time was 4h and 55 min (mu=295; range 117-630; ó+/-101 min) and we suffered 2 complete flap losses. A problem with the audible signal was noted in 15 patients (4 intra-operatively). We revised 14 of the 15. All fourteen had compromised anastomoses. In the remaining case, the patient was not returned to theatre as the primary surgeon was confident there were no other signs of vascular compromise. Overall, when using the venous doppler probe we found a false positive rate of 6.7% and 0% false negatives. DISCUSSION We advocate the use of a Cook-Swartz probe which has been well received by both surgeons, nursing staff and patients, as an adjunct to traditional clinical monitoring techniques. We also include a comprehensive experience based technical discussion concerning its application, attachment, use and post-operative removal.

Introduction of the Implantable Doppler System Did Not Lead to an Increased Salvage Rate of Compromised Flaps: A Multivariate Analysis

Background: The Cook-Swartz implantable Doppler system was introduced at the Uppsala University Hospital to ease free flap monitoring and improve salvage rates by an earlier detection of vascular compromise. The aim of the current analysis was to investigate whether the system indeed improved the salvage rate of revisions. Methods: All cases that needed revision among a consecutive series of patients being monitored with the implantable Doppler system between June of 2006 and January of 2009 were compared with a similar set of patients operated on before the introduction of the implantable Doppler system over an equal time span monitored with conventional methods. Data were extracted from the medical files of the patients. Logistic regression was used to identify factors associated with the outcome of the revision. Values of p < 0.05 were considered statistically significant. Results: A total of 327 flaps were monitored with the implantable Doppler system, of which 35 needed revision. In the control group, 303 flaps were included, of which 40 needed revision. The revision was successful in 69 percent of the cases in the implantable Doppler system group; in the group monitored by only conventional methods, this rate was 60 percent. Univariate analysis showed no statistical difference between these success rates (p = 0.441; odds ratio, 1.455; 95 percent confidence interval, 0.560 to 3.775). Multivariate analysis did not show a statistical difference either (p = 0.799; odds ratio, 1.143; 95 percent confidence interval, 0.410 to 3.182). Conclusion: The introduction of the implantable Doppler system did not lead to a significant increase in the salvage rate of revised flaps.

Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent.

BackgroundBreast reconstruction often requires multiple operations. In addition to potential complications requiring reoperation, additional procedures are frequently essential in order to complete the reconstructive process, with aesthetic outcome and breast symmetry shown to be the most important factors in patient satisfaction. Despite the importance of these reoperations in decision-making and the consent process, a thorough review of the need for such operations has not been definitively explored.MethodsA review of 370 consecutive autologous breast reconstructions (326 patients) was undertaken, comprising 365 deep inferior epigastric artery perforator (DIEP) flaps and 5 superficial inferior epigastric artery (SIEA) flaps. The need for additional procedures for either complications or aesthetic refinement following initial breast reconstruction was assessed.ResultsOverall, there was an average of 1.06 additional interventions for every patient carried out after primary reconstructive surgery. Of 326 patients, 46 underwent early postoperative operations for surgical complications (0.17 additional operations per patient as a consequence of complications). Procedures for aesthetic refinement included those performed on the reconstructed breast, contralateral breast, or abdominal donor site. Procedures for aesthetic refinement included nipple reconstruction, nipple–areola complex tattooing, dog-ear correction, liposuction, lipofilling, scar revision, mastopexy, and reduction mammaplasty.ConclusionWhile DIEP flap surgery for breast reconstruction provides favorable results, patients frequently require additional procedures to improve aesthetic outcomes. The need for reoperation is an important part of the consent process prior to reconstructive surgery, and patients should recognize the likelihood of at least one additional procedure following initial reconstruction.

Performing two DIEP flaps in a working day: an achievable and reproducible practice

BACKGROUND While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day. METHODS A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14). RESULTS Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004). CONCLUSION Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.

A Clinical Review of 9 Years of Free Perforator Flap Breast Reconstructions: An Analysis of 675 Flaps and the Influence of New Techniques on Clinical Practice

The aim of this study is to review our 9-year experience with deep inferior epigastric perforator (DIEP) breast reconstructions to help others more easily overcome the pitfalls we experienced. A chart review was conducted for all 543 patients who had 622 DIEP breast reconstructions in our clinic between January 2000 and January 2009. In this time, there were an additional 28 superior gluteal artery perforator and 25 superficial inferior epigastric artery reconstructions, bringing the total free flap reconstructions to 675. In the early years, the success rate was 90.7%, the average operative time was 7 hours and 18 minutes, and the complication rate was 33.3%; these have improved to 98.2%, 4 hours and 8 minutes, and 19.3%, respectively. We describe our selection criteria, preoperative vascular mapping, surgical techniques, and postoperative monitoring as they relate to these improvements in outcome, operative time, and complications. The DIEP flap is a safe and reliable option in breast reconstructions. By acquiring experience with the flap and introducing new and improving existing techniques we have improved the ease of the procedure and the success rate and have shortened the operative time.