William C. Pederson

Microsurgical management of extremity wounds in diabetics with peripheral vascular disease

Plastic surgeons are frequently called upon to evaluate wounds in diabetic patients with compromised vascular inflow. Although a few authors have reported success in coverage of such wounds with microsurgical techniques, enthusiasm for this procedure has remained low due to concerns about flap viability, occlusion of flow to the distal limb, and the usually poor systemic status of such patients. We report here on our experience with 19 diabetic patients with peripheral vascular disease and a nonhealing wound of the lower extremity treated over the last 4 years with microvasccular tissue transfer. Two patients (10.5 percent) suffered anastomotic difficulties and there was one flap loss (5 percent). Major morbidity rates were acceptable, with only one perioperative death (5 percent) and three cases of nonfatal major systemic difficulties in the immediate postoperative period (16 percent). Despite the importation of well-vascularized tissue, local morbidity at the recipient site was seen in nine patients (47 percent). The overall limb salvage rate was 72 percent during the period of follow-up, which averaged 22 months. Despite this loss of five limbs, all but three of the patients eventually returned to ambulation. The overall death rate in our series was only 2/19 (10.5 percent) over the period of follow-up. Although further work needs to be done in this difficult group of patients to ascertain the long-term benefit (especially relative to the cost/benefit ratio), we feel that this series confirms the safety and short-term efficacy of microsurgical treatment of such individuals. (Plast. Reconstr. Surg. 92: 485, 1993.)

Establishment of normal ranges of laser Doppler blood flow in autologous tissue transplants.

Over a 3-year period, 136 patients were monitored following free autologous tissue transplantation using a laser Doppler flowmeter linked to a computerized data-acquisition system. This monitoring system has indicated perfusion compromise in free flaps more rapidly than clinical observation alone. Most important, this has resulted in an increase in salvage rate from 50.0 to 82.4 percent. In addition, our overall success rate has increased from 92.6 to 97.8 percent since introducing this monitor clinically. Computerization also has facilitated the collection of data, which has enabled us to establish expected values for postoperative blood flow in several types of donor tissues used for microvascular reconstruction. Finally, this computerized monitoring system has relieved personnel from basing decisions on subjective data.

Complications and vascular salvage of free-tissue transfers to the extremities.

Complications were examined in 122 free flaps to lower and upper extremities in 104 patients, and vascular salvage was examined in 182 free flaps to lower and upper extremities in 158 patients. All patients were treated by the same surgeon. The overall survival rate of flaps was 96 percent. Complications occurred in 22 percent of the flaps. Complication rates were lower in patients with one free flap than in patients with two. Flaps had more vascular complications than nonvascular. Accompanying skin islands were found to be necessary to monitor vascularized bone transfers in order to avoid flap failure. Flow in the pedicle was reestablished in all flaps, but a higher percentage of flaps with longer ischemic times were lost. Although vascular compromise occurred frequently (15 percent), prompt surgical exploration and reexploration were thought to have greatly increased free-flap survival.

Free tissue transfers and replantation.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the indications and contraindications for free flap reconstruction. 2. Describe the indications, anatomy, harvest technique, and advantages and disadvantages of the workhorse free flaps. 3. Describe the indications and contraindications for extremity replantation. 4. Describe the techniques and management for extremity replantation. Summary: Microsurgical free flap reconstruction uses a multitude of surgical flaps available to meet the needs of the recipient site. These include cutaneous, muscle, bone, fascia, or some combination of these as available options. Furthermore, sophisticated reconstruction has been enhanced by the development of perforator flaps, enabling multicomponent reconstruction to be performed with reduced donor-site morbidity. It is mandatory that proper débridement of the defect be performed before reconstruction, and that the anastomosis is performed without tension or twisting outside of the zone of injury. There are indications for both musculocutaneous and perforator flaps, and selection is dependent on recipient-site characteristics in addition to function and aesthetics of both the recipient and donor sites. Muscle flaps provide well-vascularized pliable tissue and are used for deep space obliteration, whereas fasciocutaneous flaps are used for flatter, more superficial wounds. Microsurgical replantation of an amputated extremity offers a result that is usually superior to any other type of reconstruction. However, replantation of extremities involves more than microsurgery, as repair of bony and tendon injury must be undertaken as well. This article focuses on the indications, technique, and results of free flap reconstruction and replantation.

Treatment of chronic nonunions of the humerus with free vascularized fibula transfer: a report of thirteen cases.

Chronic nonunions of the humerus remain a challenging problem. We reviewed 13 cases of chronic nonunion of the humerus resulting from trauma or osteomyelitis treated with vascularized fibula transfer after failure of conventional treatment. Patient averages were 35 years of age, follow-up of 19 months, and 4.2 prior operations. Healing was obtained in 12 of 13 (92%) patients with an average healing time of 18 weeks and graft length of 12.5 cm. In total, 11 of 12 (91%) patients who united had good to excellent range of motion of their shoulder and elbow. There were eight complications in 7 of 13 patients (54%). Two patients developed fractures of the graft, and three had superficial infections at the harvest site requiring operative debridement. Two patients had median neurapraxia that resolved by 4 months. Two patients complained of intermittent pain at the donor site. No significant correlations were found between time to heal and other covariates.

Clinical Use of Anticoagulants Following Free Tissue Transfer Surgery

ity, ing of m ity, roup arin sels ols its o e sta d of l the p cal r . In t tment f ous h 0.27 ( ot n d the r egat not f tion f flaps p nts, t bet days v lowm se d ial o ous t his g no e b red f that h able a r. rmac and A 001 r a l ult) of a day f ized s g an i sing t ing s is not a i In B ri ef HE INDICATIONS FOR pharmacologic anticoagulation in free tissue transfer remain unclear an a certain extent controversial. Based on ature of microvascular surgery and the need for onable studies of a large number of cases to enefit, the benefit of anticoagulation in these case till somewhat unclear. Past models of vascular thr osis in animals have shown benefit of heparin spirin, but it is not clear whether these models ex late to humans. Large multicenter surveys of clin enters have shown that the clinical application of icoagulation in microsurgery, and specifically repla ation, vary greatly. Major textbooks of hand surgery and review arti enerally advocate aspirin in the postoperative perio ll replantations, but beyond that, they differ so hat. Goldner and Urbaniak suggest aspirin with ddition of dipyridamole and intravenous dextran-40 he postoperative period. 1 Most would agree, howeve hat with a crush or avulsion injury, heparin shoul dded. A recent review of protocols for lower extrem ree tissue transfer found that surgeons perform hese procedures differ greatly in their application nticoagulants. These authors reviewed surveys fro 8 surgeons who regularly perform lower extrem ree flap reconstruction. It was noted that this g sed everything from aspirin to 10,000 units of hep iven intravenously during surgery when the ves ere transected. Likewise, the postoperative protoc aried widely from aspirin and dextran to 5000 un eparin twice a day for 7 days. These authors cam he conclusion that “it is very difficult to apply a

Median Nerve Injury and Repair

Median nerve injuries in the forearm are reasonably common and can lead to devastating functional sequelae for the hand if they are not managed in a timely and appropriate fashion. Most nerve lacerations should be repaired soon after injury, and current widespread application of microsurgical techniques should lead to reasonable results in most individuals. Despite these advances, many patients do not have ideal outcomes from injuries to the median nerve and are often left with permanent sequelae. This article will discuss current techniques in the management of median nerve injuries, with the goal of preventing or alleviating the potential negative sequelae of these injuries.

Medical and surgical considerations in patients with vasculitis and Raynaud's syndrome

Vascular problems in the foot are certainly common when one considers only arteriosclerosis on the macrovascular scale. The primary cause of ischemia of the foot undoubtedly is primary arteriosclerosis, whether related to smoking, diabetes, renal failure, or other causes. Vasculitis and vasospasm, in their many forms, are distinctly unusual as a cause of ischemia of the foot. These entities, nonetheless, can cause significant problems from the standpoint of symptoms and even ulceration or gangrene of the foot. This article addresses the pathophysiology of vasculitis and vasospastic problems in the foot and their management.

Prelamination of Radial Forearm Free Flap with Buccal Mucosa

Reconstruction of extripative defects in the head and neck with vascularized free tissue transfer has become the standard of care. In order to overcome disadvantages of the traditional radial forearm free flap (RFFF), e.g., color and texture difference, bulk, and donor site morbidity, the concept of prelamination of the RFFF with mucosa was developed. The term prelamination, introduced in 1994, is a process in which tissue is implanted into a vascular flap prior to transfer [1]. Prelamination with oral mucosa has been implemented in the reconstruction of a variety of intraoral and facial defects [2–4]. With their high cell renewal rate, morcelized buccal mucosal grafts can spread over a vascularized fascial bed and become functional in 3 weeks [2]. The resultant mucosa resembles the native oral mucosa both macroscopically and histologically [5], providing lubrication. Fasicomucosal flaps are thinner than fasciocutanous flaps since no subcutaneous tissue is included. This allows for better tongue mobility and rehabilitation [2]. We studied patients who underwent reconstruction with a prelaminated radial forearm fasciomucosal flap (RFFMF) to describe surgical technique and report multi-institutional outcomes.

Reoperative Indications in Vascular Disorders of the Hand

Fortunately in most cases of vascular or microvascular intervention, once the vessels have healed, the chances of needing repair are small. However, in some cases such as traumatic events, the vessels may thrombose or otherwise fail in the postoperative period. In these cases, reoperation is sometimes needed and is usually done in a very expeditious manner. Other cases relate to chronic vascular disease. In these cases, sympathetectomy sometimes may be of benefit. In other cases, a vascular access procedure may be stealing or shunting blood away from the hand resulting in ischemia. In these cases, revision options are sometimes needed in order to help the patient with their symptoms. Microvascular surgery requires not only a steady hand but also a steady mind, and these cases can be quite challenging.