S.P.J. Kay

Long term study into surgical re-exploration of the ‘free flap in difficulty’

BACKGROUNDnFree tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the failing free flap, and practice is often guided by anecdote.nnnMATERIAL AND METHODSnWe have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times. We analysed these flaps with regard to indication for re-exploration, operative findings and outcome.nnnRESULTSnThirteen percent (327) of free flaps were re-explored. Of these, 291 (83%) had a successful outcome. Successful re-explorations took place at a mean 19h post-op and unsuccessful re-explorations at a mean 56h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases.nnnCONCLUSIONnWe have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at its core. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates.

Toe to hand transfer in children: Ten year follow up of psychological aspects

Our previous study found positive psychosocial effects from hand reconstruction in children, by microsurgical toe transfer. The aim of the current study was to determine whether these are enduring at ten years or more postoperatively. Twenty-five patients with congenital (n=21) or post-traumatic (n=4) hand anomalies underwent transfer of either one or two toes. (Nineteen of the patients had taken part in the previous study while six had not.) All families had undergone preoperative counselling. Ten years or more after surgery, the patients and their parents underwent review to assess the long-term psychosocial outcome of the surgery. As in the previous study, a high level of satisfaction was reported, in terms of function, appearance, donor site, psychosocial well-being and the reactions of others. This was true regardless of the gender of the child. Patient and parent responses were more similar to each other than they had been in the earlier study. It was concluded that the positive effects of toe transfer surgery are enduring at long-term follow-up.

Free tissue transfers in the first 2 years of life – A successful cost effective and humane option

Experience shows that young children are favourable candidates for microsurgical reconstruction, having few of the established risk factors for flap failure. In childrens reconstructive surgery free tissue transfer (FTT) permits reconstruction whilst retaining growth potential, and reduces the overall number and duration of care episodes, and their related distress to the child and family. We present one centres experience of free tissue transfer in children less than 2 years of age, over a 15-year period, demonstrating that free tissue transfer can be successfully employed in children under 2 years old. Salient aspects of patient selection, pre-operative counselling, and per-operative management are presented. Data from all free flaps in children under 2 years of age at the time of surgery were collected prospectively. Forty-seven flaps were performed as 37 separate procedures, in 32 children under 2 years of age. In ten patients, double transfers were performed in single procedures. Free tissue transfers were performed for reconstruction of congenital defects, following trauma and meningococcal septicaemia. All but one flap survived. In our series operative and ischaemia times, re-exploration, complication and flap failure rates were not higher than in comparable adult or older paediatric series from this unit, suggesting that there is no microvascular, or other, factor inherent to the infant that should preclude the use of free tissue transfer. Individual microsurgeons with appropriate facilities should not be inhibited from performing free tissue transfers which are humane and cost effective when compared with alternatives for very young children.

The anatomy of the subscapular nerves: A new nomenclature

We propose a new nomenclature for the consistent, additional nerves that branch from the posterior cord of the brachial plexus. We hope this will aid the plexus surgeon and the evolution of plexus reconstruction for both obstetric and adult cases of injury.

Two for the price of one: Recycling a free flap *

Free flaps are now an established, successful, method of reconstruction for complex soft tissue defects. Improvements in microsurgical techniques, anatomical understanding and instruments have resulted in the evolution of free flap surgery to now encompass synchronous double free flap surgery and free style type flaps based on perforators. Although there have been reports of a single free flap split in two to reconstruct a defect at a single site, we report what we believe to be the first case of a single free groin flap used to reconstruct two distant and separate defects sequentially.

Fanconi’s anaemia and unilateral thumb polydactyly – Don’t miss it

Fanconis anaemia (FA) is a rare, life threatening inherited syndrome. Patients usually present late in the first decade of life with aplastic anaemia or acute myeloid leukaemia. FA children are also at high risk of solid organ tumours, anogenital squamous cancers, and endocrinopathies. These patients can present with unilateral radial abnormalities including thumb duplication. Hand surgeons can help achieve early diagnosis and improved survival in this group by early referral for screening. In a retrospective study of 202 children with radial ray anomalies seen over a 20 year period seven children had FA. Of these seven with FA, four had bilateral thumb hypoplasia and three had unilateral thumb anomalies--two unilateral thumb hypoplasias and one thumb duplication. The three children with unilateral anomalies were diagnosed late, presenting with bone marrow failure. All three have subsequently died following late bone marrow transplants. This study highlights the link between unilateral radial anomalies, including thumb duplication and FA and the importance of early genetic referral for diagnosis and surveillance.

Cross-over limb replantation: A case report

Following traumatic bilateral arm amputation in a 46-year-old woman, orthotopic replantation was not possible. The patient underwent replantation of the left forearm to the right proximal forearm. At two years she has a sensate hand, with good recovery of her long flexors of the hand and wrist extensors. DASH score is 93.9 and Chens score is III (medium). We demonstrate a high level of function compared to the contralateral prosthetic limb. There have only been four similar cases described. Although a rare circumstance, a cross-limb replant can provide a level of function and independence superior to a simple prosthesis. Cross-limb transfer should be considered in situations where bilateral arm amputation is present and neither can be orthotopically replanted.