Yu-Te Lin

Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers.

Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome. Methods: Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compromise was identified and correlated with salvage outcome. Results: Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed completely. Ninety-three flaps (82.3 percent) presented with circulatory compromise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the microsurgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p = 0.01). Conclusions: The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special microsurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes.

Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures.

Background: The advantages of free muscle flaps for reconstruction of lower extremity defects have been largely reported to be superior to those of fasciocutaneous flaps. Methods: One hundred seventy-four patients received 177 microsurgical free tissue transfers for distal third and ankle open tibial fractures. Patients were divided into two groups. In group I, 96 patients received 98 free muscle flaps (55.4 percent). In group II, 78 patients were treated with 79 free fasciocutaneous flaps (44.6 percent). Results: Complete flap survival was 92.9 percent and 91.1 percent in groups I and II, respectively. Postoperative infection was 11.2 percent in group I and 12.7 percent in group II. Chronic osteomyelitis developed in 9.3 percent and 12.7 percent in groups I and II, respectively. The rate of primary bone union was 84.5 percent in group I and 81 percent in group II and the rate of overall bone union was 96.9 percent in group I and 98.7 percent in group II. Finally, 92 patients in group I and 77 patients in group II could walk without crutches at 2-year follow-up. There were no statistically significant differences between the two flaps. Conclusions: The authors achieved equal functional outcomes in both soft-tissue transfers because of (1) preoperative adequate débridement of wounds and (2) selection of proper free flaps in appropriate defects. Defects with serious tridimensionality needed free muscle flaps because they conform better to such complex defects. However, free fasciocutaneous flaps are reliable and as effective for covering the less three-dimensional distal third and ankle traumatic open tibial fractures as free muscle flaps and can better tolerate the subsequent secondary surgical procedures.

Reconstruction of through-and-through cheek defects involving the oral commissure, using chimeric flaps from the thigh lateral femoral circumflex system.

&NA; Repairing full‐thickness cheek defects involving the oral commissure in the head and neck regions after tumor resection is a challenge for reconstructive surgeons. First, they are usually relatively large defects. Second, the axes of the cheek and intraoral lining are different from each other. Third, the shape and volume of the defect and the oral sphincter should be considered individually. Lateral femoral circumflex perforator flaps with at least two independent cutaneous perforators are suitable for reconstruction of such a defect in one stage. In this study, between January and December of 1999, a total of nine patients underwent reconstruction with chimeric lateral femoral circumflex perforator flaps immediately after resection of their oral cancers. The average age of the patients was 61 years (range, 42 to 74 years). The oral lining defects were between 5 × 5 cm and 6 × 12 cm in size, whereas the cheek defects were between 5×6 and 8 × 12 cm. Fifteen flaps were supplied by one perforator, and three flaps were supplied by two perforators. There were nine single arterial anastomoses, eight single venous anastomoses, and one double venous anastomosis. There were no total flap failures. One case of postoperative venous congestion was successfully treated by a second venous anastomosis. The average duration of hospitalization was 31.8 days (range, 18 to 49 days). The median follow‐up time was 8.6 months, and all patients were alive at the time of evaluation. Six of nine patients had satisfactory or good contours of the cheek. Five of nine patients had normal deglutition. Six of nine patients had adequate oral continence. Compared with other free flaps, use of the combined (chimeric) lateral femoral circumflex perforator flaps for the reconstruction of cheek through‐andthrough defects involving the oral commissure has several advantages: (1) easy three‐dimensional insetting, (2) a unique character suitable for the requirements of the oral lining and cheek skin to achieve good aesthetic appearance, (3) functional preservation of the oral sphincter and the resistance of gravity by use of the tensor fasciae latae, (4) minimal donor‐site morbidity, (5) economic design, and (6) no need for microsurgical fabrication, because major vascular branches such as the transverse branch, the ascending branch, and the feeding branch to the rectus femoris muscle are not sacrificed in the procedure. The disadvantages of these flaps include (1) the complicated anatomy of the perforators, (2) the learning‐curve requirement for their use, and (3) the occasional need for secondary venous drainage and shifts to double flaps. Although there are some difficulties, it was concluded that use of the chimeric lateral femoral circumflex perforator flaps in the selected cases is one of the good options available for the reconstruction of cheek through‐andthrough defects involving the oral commissure. (Plast. Reconstr. Surg. 109: 433, 2002.)

Free Functioning Muscle Transfer for Lower Extremity Posttraumatic Composite Structure and Functional Defect

Background: Traumatized lower extremities may present not only composite soft-tissue defects but also flexor and/or extensor loss. Free functioning muscle transfer can provide composite structural and functional restoration. Methods: From 1996 to 2004, 19 patients with lower extremity injuries whose lesions exhibited composite soft-tissue damage, with or without bone defects, and certain accompanying functional disabilities were allocated to study groups on the basis of impression, as follows: group I, open fracture IIIB (n = 10); group II, neglected compartment syndromes [open IIIB (n = 4) and open IIIC (n = 1)]; and group III, crush injuries (n = 4). Free flap resurfacing was indicated for these lesions. Fifteen patients underwent free functioning muscle transfer; source muscles were the rectus femoris (n = 3), rectus femoris with anterolateral thigh flap (n = 5), and gracilis (for ankle dorsiflexion) (n = 7). Two patients underwent composite rectus femoris and vascular iliac crest for ankle dorsiflexion and segmental tibial defect reconstruction. Two received rectus femoris muscle and anterolateral thigh flaps for posterior compartment defect and quadriceps defect reconstruction, individually. Results: Two patients required reexploration; salvage was successful in only one, with below-knee amputation necessary in the other. Skin grafts were needed for partial skin paddle necrosis (n = 3) or remaining skin defect (n = 2). Functioning muscle reinnervation failed in four cases, with one individual undergoing ankle fusion, two people electing ambulation with stiff ankles, and one person using an orthosis. In the sample population, range of motion varied and was related to the severity of injury and the extent of skin grafting on the distal musculotendinous portion. Less function was exhibited in the compartment syndrome group (group II). Conclusion: Functioning muscle transfer can be performed posttraumatically in lower limbs with composite soft-tissue and motor-unit defects, resulting in acceptable functional results and reliable limb salvage.

Free flap reconstruction of foot and ankle defects in pediatric patients: long-term outcome in 91 cases.

Background: Free tissue transfer has not been fully adopted as the primary mode of treating foot and ankle defects in potentially indicated patients, partly because of the lack of sizable vessels and the potential in the long term of differential growth in the flap and the recipient site. Also lacking are long-term outcome studies in these growing patients. Methods: Between 1989 and 2002, 91 children with 93 foot and ankle defects underwent microsurgical reconstructions. The patients underwent reconstruction with flaps with a cutaneous component or with muscle flaps (skin-grafted). Results: Fifty-eight defects were reconstructed with cutaneous/musculocutaneous flaps (37 fasciocutaneous and 21 musculocutaneous flaps), and 35 were reconstructed with skin-grafted muscle flaps. Thirteen patients underwent secondary free flap surgery, for a total of 106 flaps used to complete the reconstructions. Twelve cases underwent reexploration, and overall survival was 95.3 percent (101 of 106). Secondary deformities were present in 37.9 percent of skin/musculocutaneous flaps and 58.9 percent of skin-grafted muscle flaps (p = 0.029). More resurfacing procedures were performed in skin-grafted muscle flaps than in skin/musculocutaneous flaps (32.4 percent versus 12.1 percent; p = 0.0386). Conclusions: Free tissue transfer in pediatric patients is a viable and reliable option. Skin/musculocutaneous flaps and skin-grafted muscle flaps both had equal survival rates; however, flaps with a skin component required fewer secondary procedures to correct deformities. Whenever a skin component was present, it provided useful tissue during the secondary procedure and minimized complications. For plantar foot reconstructions, skin-grafted muscle flaps demonstrated a higher incidence of trophic ulcers and a higher need for resurfacing procedures than flaps with a skin component. Reconstructions of tendons in the immediate setting led to fewer secondary operations than staged tendon reconstructions.

Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers.

Venous insufficiency is the most common cause of re-exploration in free-tissue transfers to the lower extremity. There is currently no consensus regarding the best approach to recipient vein selection. This study was designed to evaluate whether the type of venous system or the number of recipient veins would impact flap outcomes after microsurgical lower-extremity reconstruction. A retrospective study was conducted in 362 free-tissue transfers for lower-extremity reconstruction between 2003 and 2008. Flap outcomes were evaluated according to the selection of recipient vein system and number of veins. The deep venous system (80.4%) was more frequently selected than the superficial venous system (12.1%) or the combination of both systems (7.5%). In addition, one vein (65.5%) was more commonly used for anastomosis than two veins (34.5%). A total of 26 flaps (7.2%) presented with postoperative venous insufficiency. Male patients, composite defects including bones and the use of bone flaps presented higher rates of venous insufficiency with statistical significance. However, no significant differences were found among the different groups related to the age of patients, co-morbidities, aetiology, location of the defects or timing of reconstruction after trauma. The superficial venous system group was associated with a higher rate of venous insufficiency and partial flap loss compared with the deep venous system group (p = 0.036 and 0.018, respectively). One-vein-anastomosis flaps were associated with statistically significant fewer complete flap failure in comparison with two-vein-anastomosis flaps (p = 0.014). In conclusion, the assessment of recipient vein parameters by surgeons experience is the best predictor of flap outcome in lower-extremity reconstruction. In our cohort of patients, the deep venous system was more reliable than the superficial venous system, but the use of more than one vein for anastomosis did not correlate with better flap outcomes.

Free lateral arm flap for 1-stage reconstruction of soft tissue and composite defects of the hand: A retrospective analysis of 118 cases.

In this article, the long-term outcomes of hand defects after 1-stage reconstruction with lateral arm flap were retrospectively analyzed in a large series. Between the years 1990 and 2004, 118 traumatic hand defects were reconstructed using lateral arm fasciocutaneous flap (n = 104), lateral arm fascial flap (n = 6), and composite lateral arm flap (n = 8) in Chang Gung Memorial Hospital. There were 22 females and 96 males with an average age of 32.5 ± 13.3 years. The mean follow-up period was 17 ± 6.2 months. The overall success rate was 97.5%. The cosmetic outcomes were satisfactory and only 16.1% of the patients required debulking. The functional recovery of the hand contractures secondary to crush injury were generally associated with poor results. In the composite flap group, reconstruction of the extensor tendons with triceps tendon yielded limitation in tendon excursion and poor functional results. However, complete bone healing without complication was uniformly detected in all cases. Lateral arm fasciocutaneous flap endured secondary interventions well and no complications regarding wound healing was encountered.

Functional assessment of the reconstructed fingertips after free toe pulp transfer.

Background: Posttraumatic fingertip reconstruction with free toe pulp transfer was first described in 1979. Several studies have tested the sensibility of the reconstructed digits using the two-point discrimination test. The goal of this study was to comprehensively assess the functional outcome of the reconstructed fingertips after free toe pulp transfer. Methods: There were 15 flaps in 14 male patients in this retrospective study. Objective sensory recovery was assessed with two-point discrimination and Semmes-Weinstein monofilament tests. Pinch power of the reconstructed digits and subjective pain and discomfort were also evaluated. Results: Six flaps had good results, six had fair results, and three could perceive only one point. The Semmes-Weinstein monofilament test revealed diminished light touch in six flaps, diminished protective sensation in eight flaps, and loss of protective sensation in one flap. There was strong correlation between static and moving two-point discrimination (&ggr; = 0.78747, p = 0.0005) but weak correlation between static two-point discrimination and the Semmes-Weinstein monofilament test (&ggr; = 0.34240, p = 0.2116). There was a significant difference in static two-point discrimination (p < 0.01) but no significant difference in Semmes-Weinstein results between the contralateral toes and flaps. The mean difference in pinch power between the dominant and nondominant hands was 6.72 percent with involvement of the dominant hand and 34.16 percent with involvement of the nondominant hand. There was no significant difference between the pinch power of the reconstructed digits and adjusted values. Conclusions: After free toe pulp transfer, the reconstructed digits had equal sensory threshold as the donor toes, but functional sensibility varied. Pinch power was restored. Free toe pulp transfer restored the sensibility, stability, and durability of the finger pulp and achieved functional recovery of the traumatized digits.

The medial sural artery perforator flap: a versatile donor site for hand reconstruction.

BACKGROUND The challenge of modern hand reconstruction goes beyond simple coverage. Thanks to the advances of microsurgery, there are ever-improving standards of functional and esthetic outcomes in hand reconstruction. The versatile donor site of the medial sural artery perforator flap can fulfill this purpose. MATERIALS Between June 2006 and October 2008, we used free medial sural artery perforator flaps for hand reconstruction in 14 cases. The sites of reconstruction included digits (n=7), dorsal hand (n=3), palmar hand (n=2), and wrist (n=2). Associated tendon and nerve defects were found in five patients. The plantaris tendon (n=4), split Achilles tendon (n=1), saphenous nerve (n=1), and sural nerve (n=1) were harvested for reconstructive purpose from the same donor site in this series. RESULTS The proximal perforator of the medial sural artery emerged 8 cm to 13 cm from the midpoint of the popliteal crease, correlating with the axis of the medial sural artery. Twelve flaps were raised with a single perforator. One flap failed because of perioperative vasospasm. The donor defect could be closed without skin grafts when the flap width was <6 cm. CONCLUSION The free medial sural artery perforator flap transfer is appropriate for small- to medium-sized hand defect reconstruction. The donor site not only supplies a thin fasciocutaneous flap but also provides the option to harvest a segment of tendon or nerve graft through the same incision for composite tissue reconstruction in a single stage.

Hand and finger replantation after protracted ischemia (more than 24 hours).

Ischemia tolerance has been a major concern during hand and finger replantation. Because of multiple referrals and damage control resuscitation, ischemia is occasionally prolonged for more than 24 hours. Amputation impairs functional efficiency in amputees; therefore, if there is a favorable indication for replantation, microsurgical replantation can be performed to salvage the function of the affected part to an acceptable extent. Between 1998 and 2006, 14 patients underwent 25 replantations after prolonged ischemia of more than 24 hours. Of the 14 patients, 12 were referred to our hospital after unsuccessful replantations and admitted to the emergency room. Two of these patients underwent thumb amputations, and 10 patients underwent multiple digit amputations. Two patients underwent wrist amputation with associated polytrauma and profound shock, both hand replantations were performed on the following day after ICU management with damage control resuscitation was performed to control excessive bleeding and stabilize vital signs. In this study, 16 replantations were successful and 9 failed; thus, the success rate was 64.0%. Several secondary procedures were required for restoring the functional ability of the reconstructed parts. Ischemia time is critical for limb salvage. Hands and fingers have very little muscle tissue. Hence, replantation of these parts can be performed even in the case of prolonged ischemia to restore the hand function.