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

doi:10.1016/j.bjps.2010.07.028

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 64, Issue 5, May 2011, Pages 649-655

https://doi.org/10.1016/j.bjps.2010.07.028 Get rights and content

Summary

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 surgeon’s 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.

Section snippets

Patients and methods

A retrospective study was performed of all free-tissue transfers for lower-extremity reconstruction during a 6-year period (2003–2008) at Chang Gung Memorial Hospital. Demographic data and medical history were obtained by retrospective chart review from our computerised database program. Data collection included patient demographics, defect features, flap type used for reconstruction, recipient vein and flap outcomes. Exclusion criteria included insufficient medical records, the use of vein

Results

A total of 404 free-tissue transfers were performed for reconstruction of lower-extremity defects in 379 patients during the study period. After excluding 42 flaps (the use of vein grafts for the vein in 22 flaps and incomplete charts in 20 flaps), 362 free flaps in 342 patients were evaluated in the current study. The mean age was 38.6 years (range, 2–84 years). The demographics, co-morbidities, defect features and type of reconstruction are summarised in Table 1. The most common soft-tissue

Discussion

In the majority of the cases with venous insufficiency in our study (15/26, 57.7%), the most common causes of flap congestion (haematoma compression, pedicle kinking and tight closure) are not related to intrinsic vessel quality. This finding is compatible with a multicentre study of failures in free-tissue transfers reported more than one decade ago, where it was noted that even in the hand of expert microsurgeons, the majority of thromboses were probably related to identifiable technical

Acknowledgements

The authors would like to thank Miss Nian-Yi Hsu for her assistance with the preparation of this article.

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Cited by (72)

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity
2023, JPRAS Open
During free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery.
We retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases.
The conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery.
The AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.
Bone-based versus soft-tissue free flaps in lower extremity reconstruction
2023, Journal of Orthopaedic Science
Most lower extremity defects and minor bone defect wounds requiring a free flap are treatable with soft-tissue flaps, whereas large bone defect wounds are treated with bone-based flaps. This study aimed to compare bone-based and soft-tissue-free flaps in terms of operative procedures and postoperative complications, including long-term outcomes of lower extremity reconstruction.
This two-center retrospective cohort study collected data from all lower-extremity reconstructions with free flaps performed between March 2014 and February 2022; the level of evidence is considered to be therapeutic level III. We investigated the operative procedure and postoperative complications classified as being related to either bone-based or soft-tissue flaps. The data were further classified into the trauma and non-trauma groups and the long-term postoperative outcomes of patients who were followed up for ≥12 months were analyzed.
A total of 122 free flaps were included: 29 bone-based flaps (1 scapular and 28 fibular flaps) and 93 soft-tissue flaps (22 muscle-based and 71 fasciocutaneous flaps). There was no significant difference in postoperative complications, including long-term outcomes, between the free flap types, regardless of etiology. Vein grafts were used more often for bone-based flaps than for soft-tissue flaps (20.7% vs. 7.5%; p = 0.045). The donor veins of bone-based flaps were more often anastomosed to superficial veins than were those of soft-tissue flaps (37.9% vs. 10.8%; p < 0.001).
Using bone-based free flaps resulted in no significant differences in postoperative complications, including long-term outcomes, despite involving more complicated operative procedures than soft-tissue flaps. Thus, the use of vein grafts and anastomosis to the superficial venous system of the vascularized fibula graft may help avoid flap-related complications in bone-based free flaps.
Efficacy of the microscopic parachute end-to-side technique for creating large-to-small venous anastomoses in free flaps in the extremities
2022, JPRAS Open
The availability of reliable and suitably sized veins is limited for creating free flaps to treat severe trauma and infection, and it is important to manage vessel size discrepancy between the recipient and flap veins. We evaluated the clinical outcomes of free flaps with large-to-small venous end-to-side (ETS) anastomoses using the microscopic parachute end-to-side (MPETS) anastomosis in soft tissue defects in the extremities. This procedure comprises mainly a wide-slit venotomy and parachute procedure at the heel.
We examined 24 free flaps in 23 patients given a large-to-small venous anastomosis using the MPETS technique. Patient demographics, details of vessel anastomoses, and flap outcomes and complications were obtained from medical records.
Two veins were anastomosed in six flaps. Thirty anastomosed veins were assessed, and 24 deep veins, all of which accompanied main arteries, were chosen as recipient veins. The mean diameters were 1.5 mm in the recipient veins and 2.7 mm in the flap veins, and the mean vessel size discrepancy was 1.8-fold (range 1.3–3.3 fold). Because of the presence of venous valves at the anastomotic site, trimming of venous cusps was performed in six veins. All flaps survived, though one venous thrombosis occurred because of pedicle kinking in a case with a short pedicle.
The MPETS technique is simple, reliable, and useful for performing various types of venous anastomoses regardless of a vessel size discrepancy and the presence of a venous valve. This may be a good option for large-to-small venous anastomosis in free flaps.
The Medial Sural Artery Perforator Flap in Lower Extremity Reconstruction
2021, Clinics in Plastic Surgery
Postoperative care in microvascular free flap reconstruction of the lower extremity: A systematic review
2020, Orthoplastic Surgery
Free tissue transfer is a commonly used procedure to reconstruct defects of the lower extremity. However, measures of postoperative care to promote flap maturity vary greatly. Dangling protocols tend to be highly divergent regarding the start, duration, schedules and monitoring of dangling, as well as the additional use of compression stockings or bandaging. The aim of this systematic review to review and evaluate current literature and to provide recommendations.
A systematic literature review was performed in accordance with PRISMA guidelines. Literature databases were searched for relevant articles about early ambulation following lower leg reconstruction.
A total of 10 articles met the inclusion criteria: 2 randomized controlled trials and 7 case-series and one cohort study. The optimal start, duration and frequency of the dangling and compression procedures remain unclear, and so does the necessity of dangling and compression in general. An early and aggressive dangling procedure can be safely introduced on postoperative day (POD) 3, taking possible comorbidities into consideration. Early initiation might help shorten hospital stay, thereby reducing associated medical costs. Furthermore, compressive wrapping applied to the dangled leg seems to have a positive effect on flap perfusion and patient comfort.
Based on the current literature, it is suggested that an early and aggressive dangling procedure can safely be started on POD 3. Compression therapy during dangling increases perfusion and venous return of the free flap and increases the comfort of the patient.
Treatment of traumatic losses of substance in the foot
2020, Annales de Chirurgie Plastique Esthetique
Citation Excerpt :
Une précaution particulière devra être portée sur les traumatismes par écrasement, pouvant générer des micro-lésions de la paroi interne vasculaire rendant le vaisseau inexploitable pour accueillir des anastomoses de lambeaux libres. Dans ces cas, il est préférable de remonter la dissection du vaisseau dans une zone moins contuse et moins inflammatoire afin d’accéder à un vaisseau nourricier en meilleur état [28]. Ce cas de figure nécessitera alors un lambeau avec un pédicule suffisamment long ou une allonge du pédicule par une greffe veineuse [29].
Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.
La prise en charge des pertes de substances traumatiques osseuses et des parties molles du pied nécessite une considération particulière de l’anatomie et de la physiologie de ce segment. Les causes des traumatismes du pied sont multiples et souvent violentes induisant une souffrance tissulaire évolutive ce qui requière parfois un parage en plusieurs étapes. L’objectif thérapeutique est de reconstruire un pied fonctionnel permettant l’appui, une marche et un chaussage indolores en restituant un cadre osseux stable, une couverture résistante et adaptée aux différentes zones du pied. La couverture doit être fine pour le dos du pied et matelassée pour les zones plantaires. La sensibilité plantaire doit également être une préoccupation du chirurgien reconstructeur. Pour relever ce défi chirurgical il est important de maîtriser un vaste arsenal thérapeutique allant des greffes conventionnelles aux lambeaux libres composites, afin de proposer la solution la plus adaptée au type, à la taille et à la localisation de la perte de substance tout en générant le moins de séquelles du site donneur. La collaboration pluridisciplinaire entre chirurgiens plasticiens, orthopédistes et médecin est préconisée pour mener à bien cette reconstruction.

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^☆: Part of this work was presented in Annual Scientific Meeting of American Society of Reconstructive Microsurgery, Boca Raton, Florida, on 11 January 2010.

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

Summary

Section snippets

Patients and methods

Results

Discussion

Acknowledgements

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

Clin Plast Surg

J Plast Reconstr Aesth Surg

One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities

Plast Reconstr Surg

Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect

Plast Reconstr Surg

Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases

J Trauma

Algorithm for recipient vessel selection in free tissue transfer to the lower extremity

Plast Reconstr Surg

Selection of recipient vessels for free flaps to the distal leg and foot following trauma

Microsurgery

Influence of recipient vessels on free tissue transplantation of the extremities

Plast Reconstr Surg