Steffen Baumeister

A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group.

The popularity of the sural artery flap has increased markedly throughout the years, and favorable results are reported almost uniformly. Previous publications have mainly presented results of small groups and of predominantly younger patients with posttraumatic defects, or they have reported technical modifications of the sural artery flap. The authors have increasingly used the reversed sural artery flap in a high-risk, critically multimorbid, and older patient population, and in contrast to the results of other authors, a considerable necrosis rate of 36 percent was seen. For the first time, a detailed, critical, retrospective complication analysis of 70 sural artery flaps is presented. The results reveal the following risk factors, which can potentially impair successful defect coverage and thus contribute to flap complications: concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five-fold to six-fold; and patient age of over 40 years, because of an increased rate of comorbidity, underlying osteomyelitis, and the use of a tight subcutaneous tunnel. However, age alone did not seem to represent a risk factor by itself. Given the results of the analysis, the operative procedure was altered, as follows. In cases in which a lesser saphenous vein cannot be found, a delay procedure is recommended, or the flap is not utilized. In addition, an external fixation device seems to facilitate postoperative care markedly without adding specific complications; it is recommended in most patients. This analysis emphasizes specific risk factors that result in higher complication rates of the sural artery flap, and it leads to more realistic and appropriate expectations for this flap.

The distally based sural flap

Learning Objectives: After studying this article, the participant should be able to: (1) Describe the anatomy of the posterior lower leg as it is relevant to the distally based sural flap. (2) Describe the basic surgical technique of the distally based sural fasciocutaneous flap. (3) Understand the common complications associated with the sural flap and their approximate incidences in both a healthy and a multimorbid patient population. (4) Describe how skin, fascia, and muscle can be used to customize the sural flap for different purposes. (5) Understand the various modifications of the sural flap that have been described in the literature. Summary: Over the past decade, the distally based sural flap has become increasingly used in reconstruction of the foot and lower leg. The rise in popularity of this flap has been paralleled by an increase in the number of cases, innovations, and technical refinements reported in the medical literature. This review summarizes the 79 publications in the English language literature on the subject of the distally based sural flap. The anatomical studies are summarized in a unified description of the relevant flap anatomy. The flap’s indications and composition and a variety of modifications are described. Technical aspects are discussed and clinical insight to minimize complications is provided. In conclusion, the distally based sural flap offers an alternative to free tissue transfer for reconstruction of the lower extremity.

Management of Postneurosurgical Bone Flap Loss Caused by Infection

Learning Objectives: After studying this article, the participant should: 1. Be able to define indications and timing for secondary cranioplasty. 2. Understand the surgical options for reconstructing the cranium and overlying soft-tissue defect including their advantages and disadvantages. 3. Be able to apply this knowledge to the clinical setting of an infectious bone flap loss. Background: Infection after craniotomy occurs in approximately 1.1 to 8.1 percent of cases and often necessitates bone flap removal. For a secondary cranioplasty, there is an increased risk of recurrent infection, which influences the reconstructive plan. The soft tissue/scalp is frequently compromised by infection, sequelae of prior surgery, and/or adjuvant radiation therapy. Methods: A literature review was conducted to compile and summarize the indications for secondary cranioplasty after infectious bone flap loss, the timing of the procedure, and the surgical options for bone and soft-tissue reconstruction. In coordination with soft-tissue coverage, cranioplasty options include alloplastic reconstruction, allogeneic or autogenous bone grafts, and free tissue transfer. Results: The literature review identified the following factors that must be considered in the treatment plan for secondary cranioplasty after postneurosurgical bone flap loss: indications, timing of reconstruction, soft-tissue status and the need for soft-tissue reconstruction, and method of cranioplasty. Conclusions: Treatment recommendations for cranioplasty in the clinical setting of infectious postneurosurgical bone flap loss are presented. These guidelines consider the risk factors for a recurrent infection, the condition of the soft-tissue coverage, and the concavity of the preoperative cranial deformity.

Technical and anatomical considerations of face harvest in face transplantation.

Total face transplantation may become a reconstructive option in the treatment of patients with acquired facial deformity. Here, 2 face-harvesting techniques are presented in a fresh human cadaver model. In technique 1, the skin and soft tissue of the face is harvested by dissecting in a subgaleal, sub-SMAS, subplatysmal plane. In technique 2, the entire soft tissue and the bony structures of the midface are harvested by dissecting in a subperiosteal plane and performing a Le Fort III osteotomy. Each face was harvested successfully as a bipedicled flap based on the external carotid arteries, the external jugular veins, and the facial veins. Each of these 2 techniques is a theoretically viable approach to face harvest for composite allograft transplantation. These techniques represent the 2 extremes of which tissues can be harvested while maintaining vascular integrity. Each will address different reconstructive needs.

Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation.

Background: Traditionally, management of exposed hardware has included irrigation and débridement, intravenous antibiotics, and likely removal of the hardware. Increasingly, the goal of wound closure without hardware removal using plastic surgical techniques of soft-tissue reconstruction has been emphasized. Identification of parameters for retaining exposed hardware may assist surgeons with management decisions and outcomes. Methods: A current literature review was performed to identify parameters with prognostic relevance for management of exposed hardware before soft-tissue reconstruction. Results: The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: hardware location, infection, duration of exposure, and presence of hardware loosening. Conclusions: Management of exposed hardware has included the removal of the hardware. However, if certain criteria are met—specifically, stable hardware, time of exposure less than 2 weeks, lack of infection, and location of hardware—salvage of the hardware with plastic surgical soft-tissue coverage may be a therapeutic option.

The free gracilis perforator flap: anatomical study and clinical refinements of a new perforator flap.

Background: The free gracilis perforator flap is a fascioadipocutaneous flap on the medial thigh, based on perforators of the main pedicle of the gracilis myocutaneous flap. Methods: An anatomical study was performed using 43 cadaver dissections. The vascular anatomy of the gracilis perforator flap with regard to myocutaneous and septocutaneous perforators was assessed. Clinical application was demonstrated in 14 cases. Results: Musculocutaneous perforators of the gracilis muscle pedicle were present in all dissections and were 0.5 mm or more in 93 percent. Septocutaneous perforators were found in 84 percent of the dissections, and perforators of 0.5 mm or more were found in 63 percent. Most musculocutaneous perforators were found in the anterior quarter of the muscle where the pedicle enters the gracilis muscle. A constant intramuscular anastomosis between the main and second vascular pedicles of the gracilis was demonstrated that allowed design of an extended gracilis perforator flap. Conclusions: Successful clinical application in 14 cases confirmed vascular reliability. The gracilis perforator flap is a pliable, thin flap from the medial thigh that can be as large as 18 × 15 cm. The donor site is inconspicuous, and a functional gracilis muscle is preserved. By including a constant intramuscular anastomosis, it is possible to extend the territory of the free flap distally up to a length of 27 cm. Indications include reconstruction of cutaneous defects such as unstable scars or contractures. The medial thigh adipose tissue correlates well with the body mass index and thus can be used for breast reconstruction as a second choice if an abdominal perforator flap is not available.

Free Vascularized Tissue Transfer to Preserve Upper Extremity Amputation Levels

Background: Free vascularized tissue transfer to preserve upper extremity amputation level is an uncommon procedure. The authors investigate the role of free tissue transfer in preserving both morphology and function of the amputated upper extremity, with the goal of facilitating prosthetic rehabilitation. Methods: Thirteen patients who underwent microsurgical free tissue transfer to preserve upper extremity amputation level were reviewed retrospectively. These cases were selected from four centers: Duke University Medical Center (Durham, N.C.) University Hospital of Modena (Modena, Italy), Careggi University Hospital (Florence, Italy), and the University of Heidelberg (Heidelberg, Germany). Parameters that were evaluated included age, sex, cause of the defect, reconstructive procedure, structures to be salvaged, and functional outcome, among others. Results: The cause of amputation was trauma in 92 percent of patients. Mean age was 32 years. In 31 percent of the cases, an emergency free fillet flap was used, and in the remaining 69 percent, a traditional free flap was performed. Structures/function to be preserved included pinch function to the hand, function of the elbow and shoulder joints, and skeletal length greater than 7 cm. Complications occurred in 38 percent of the cases, but the final goal of the procedure was achieved in all cases. A treatment algorithm for the management of the amputated upper extremity is presented. Conclusion: Use of free vascularized tissue transfer for preservation of upper extremity amputation level in well-selected cases facilitates prosthetic rehabilitation and improves residual limb function.

Superior gluteal artery perforator flap in bilateral breast reconstruction.

The incidence of bilateral breast reconstruction is increasing particularly due to genetic counseling and the option for bilateral prophylactic mastectomies. The decision to undergo a prophylactic mastectomy depends on the achievable outcomes of breast reconstruction. The free superior gluteal artery perforator flap (sGAP) flap is one option for autologous bilateral reconstruction which has rarely been reported.All bilateral sGAP flaps performed in the department of plastic surgery at the Behandlungszentrum Vogtareuth over a period of 4.5 years were retrospectively analyzed for indication, success rate, and complications.Thirty sGAP flaps were performed for bilateral breast reconstruction. The average age of the 15 women was 42 years and the average body mass index was 20.8. Indications for breast reconstruction were predominantly prophylactic mastectomies (60%). Indication for a sGAP flap was either a thin patient with insufficient abdominal tissue or a 2-staged bilateral reconstruction. 83% of the breast reconstructions were performed secondarily and 93% in 2 stages. The average operating time was 7 hours 12 minutes. Twenty-nine flaps (97%) were successful. Complications were fat necrosis (n = 3), hematoma (n = 3), and breast seroma (n = 1). Donor site complications were seroma (n = 8), infection (n = 1), and wound dehiscence (n = 1).Our results with bilateral breast reconstruction with the sGAP flap show cosmetically appealing results with high success and low complication rates on the breast. However, seromas on the donor site occurred in 27%. In addition, the sGAP flap is a technically demanding and time consuming operation. We recommend the sGAP flap when the abdomen has not enough tissue bulk to perform a deep inferior epigastric perforator flap or for a 2-staged bilateral reconstruction. This is often the case in women with a hereditary high risk of breast cancer who often present as young and slim patients.

Strategy for reoperative free flaps after failure of a first flap.

Background: Free vascularized tissue transfer is generally associated with high success rates, but failures do occur. After a flap failure, the decision is often made to perform a second, reoperative free flap. Methods: A retrospective review of all microsurgical free tissue transfers performed at the authors’ institution identified 13 patients who underwent a second, reoperative free flap after a failed primary flap. The records of these patients were reviewed, with particular emphasis on identifying changes in treatment strategy between the initially failed and the reoperative free flap. Results: Thirteen patients were identified as having undergone a reoperative free flap. In nine of 13 primary free flaps, at least one likely cause for the failure was identified (69 percent). In the approach to the second free flap, strategy changes were performed in 10 of 13 cases (77 percent); 11 were successful (85 percent). One of the two patients with a failed reoperative free flap underwent a third attempt at free tissue transfer, which also failed. Conclusions: The authors’ overall approach to the failed free flap includes the following four steps: (1) reconsideration of the need for vascularized free tissue transfer, (2) a sensitive psychosocial approach to the patient and family, (3) analysis of the cause of the first flap failure, and (4) change in microsurgical strategy. Based on the authors’ experience, they consider two previously failed free flaps without an obvious cause to be a contraindication to a third attempt.

Reduction of Skeletal Muscle Injury in Composite Tissue Allotransplantation by Heat Stress Preconditioning

Ischemia-reperfusion injury is a dominant factor limiting tissue survival in any microsurgical tissue transplantation, a fact that also applies to allogeneic hand transplantation. The clinical experience of the 12 human hand transplantations indicates that shorter ischemia times result in reduced tissue damage and, ultimately, in better hand function. Heat stress preconditioning and the accompanying up-regulation of the heat shock protein 72 have been shown to reduce the ischemia-reperfusion injury following ischemia of various organs, including organ transplantation. The aim of this study was to reduce the ischemia-reperfusion injury in a model of composite tissue allotransplantation. Allogeneic hind limb transplantations were performed from Lewis (donor) to Brown-Norway rats. Donor rats in group A (n = 10) received a prior heat shock whereas rats in group B (n = 10) did not receive any prior heat shock. Group C served as a control group without transplantation. The transplantations were performed 24 hours after the heat shock, at which time the heat shock protein 72 was shown to be up-regulated. The outcome was evaluated 24 hours after transplantation by nitroblue tetrazolium staining and wet-to-dry weight ratio of muscle slices (anterior tibial muscle). The nitroblue tetrazolium staining showed a significant reduction of necrotic muscle in group A (prior heat shock) (p = 0.005). The wet-to-dry ratio was significantly reduced in group A (prior heat shock), indicating less muscle edema and less tissue damage (p = 0.05). Heat shock preconditioning 24 hours before an ischemic event leads to an up-regulation of heat shock protein 72 in muscle and to a tissue protection reducing ischemia-reperfusion injury in composite tissue transplantation.