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Microsurgical composite tissue transplantation
MODERN OPERATIVE TECHNICS
Microsurgical Composite Tissue Transplantation A New Method of Immediate Reconstruction of Extensive Defects
Donald Serafin, MD, Durham, North Carolina Nicholas G. Georgiade, MD, Durham, North Carolina
Since the introduction of the tubed pedicle flap by Filatov [1,2] in 1917 (later popularized by Gillies [3-51 in 1920), plastic surgeons have diligently sought new and better technics to provide composite tissue coverage of extensive defects. Webster [6] in 1937 emphasized the importance of concealing the flap donor site in an unexposed area of the body. He introduced the thoracoepigastric flap based on the artery of the same name. A more predictable flap of greater length could now be transferred to a recipient site with a single delay. McGregor [ 71 in 1963 advocated the use of a forehead flap based on the superficial temporal artery. In this discussion, delay of the flap was suggested if the length of the flap extended beyond the midline of the forehead. Bakamjian [8] in 1973 described the deltopectoral flap. He emphasized its usefulness in the immediate reconstruction of extensive defects without delay. McGregor and Jackson [9] in 1970 postulated that the safety of this flap was related to a unique vascular characteristic of a distinct and predictable arterial and venous system within the flap. The anatomy and clinical implications of such an arterial flap were further expanded and popularized by McGregor and co-workers [IO--121. The distinctions between an arterial and random flap were also well defined and the relationship of one to another in a single flap discussed. The groin flap was most popular in their experience because of the consistency of its blood supply, its location, and th? donor site could be primarily closed without a significant secondary deformity. With the introduction of microsurgical technic by Jacobson and Suarez [13] in 1960 and with the ex-
From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, Duke University Medical Cehter, Durham, North Carolina. Reprint requests should be addressed to Donald Serafin, MD, Division of Plastic and Reconstructive Surgery, Duke UniversityMedical Center, Durham, North Carolina 27710.
752
perience gained from replantation [14-211 and in the laboratory [22-261, composite tissue transplantation became a clinical reality in 1973 [27]. Now, in one operative procedure, large segments of composite tissue, with a predictable vascular pattern, can be immediately transferred to a distant recipient site without creating a secondary deformity of the donor site. The ultimate goal in flap reconstruction is being realized. Experience is needed now to refine and adapt basic microsurgical procedures to ensure and enhance continued success and to minimize operative time. Results
Since 1974 thirty-five patients have undergone microsurgical composite tissue transplantation. (Table I.) In twelve cases involving the head and neck, eleven were successful and one was partially successful. (A flap is considered to be partially successful if it can still fulfill the function for which it was intended with only a minor secondary procedure, such as a skin graft). In the eighteen cases involving the lower extremity, ten were successful, three were partially successful, and five failed. Both flaps to the thorax were successful. Of the two flaps to the upper extremity, one was successful and one failed.
TABLE I
Location of Defect Head and neck Thorax Upper extremity Lower extremity
Summary of 35 Patients Undergoing Microsurgical Composite Tissue Transplantation Total No. of Cases
success
12 (34%) 2 (6%)
11 (91%) 2 (100%)
3 (8%)
2 (67%)
18 (51%)
10 (56%)
Partial Success
Failure
1 (8%) 0
0 0
0
1 (33%)
3 (17%)
5 (28%)
The American Journal of Surgery
Microsurgical
Technic
Valuable clinical experience in microsurgical composite tissue transplantation has been obtained during the past three years. Thirty-five patients with extensive soft tissue defects requiring full thickness coverage have undergone attempts at immediate reconstruction [Z&30]. In all patients the donor flap was the groin flap first described by Smith et al [IO] in 1972. This flap has several distinct advantages over all others. It consists largely of nonhair-bearing skin, making it desirable in reconstructive attempts, especially in the female. An extensive amount of tissue can be easily obtained (10 X 25 cm) and the donor site can be closed primarily without the need for a skin graft. The resulting incision is so favorably placed that it is concealed even by the most brief bikini. A disadvantage of the flap, however, is its poor color match in the region of the head and the neck. Hyperpigmentation may result and is especially troublesome in black patients. In all the cases under discussion the blood supply, especially the venous return, has been remarkably constant. The superficial circumflex iliac vein has always been present, not duplicated, with an average external diameter of 1.5 to 2.5 mm. It frequently enters the termination of the greater saphenous vein just prior to its junction with the deep femoral vein. (Figure 1.) The superficial circumflex iliac artery has
I
Composite Tissue Transplantation
,,
?hperficiol
Figure 1. A medial explorafory incision with pointer demonstrating superficial circumflex iliac vein and its junction with greater saphenous prior vein to joining femoral vein.
Femwal a.
Figure ?. Medial expforatky incision with super&&l c&aiUbx Hi&cartery arising from femoral artery.
volume 193, June 1977
circumfle;
Serafin and Georgiade
varied in size,from 0.5 to 1.5 mm in external diameter, with an average size of 1.0 mm. It most frequently arises as a separate branch from the femoral artery (Figure 2) but is less constant in its origin, occasionally being duplicated or arising from the superficial inferior epigastric artery. The medial exploratory incision has become a valuable operative maneuver to assess the suitability of the vasculature and to save time during the dissection. (Figure 3.) Using this approach, one can afford protection against injury to the vasculature during the dissection. It has also provided the surgeon an option to use a flap based on the superficial inferior epigastric artery (the Shaw-Payne flap [31]). This may be especially important in the obese patient whose superficial inferior epigastric artery and vein are often larger in diameter, perhaps to supply a large panniculus. The, technical difficulties encountered in the groin flap because of a thickened medial portion of flap could be avoided. If the medial incision reveals a donor vasculature unsuitable for anastomosis, then the other groin could be explored and minimal time wasted. An arteriogram is obtained prior to composite tissue transplantation to assess the quality of the recipient vasculature. (Figure 4.) Previous attempts
evaluate donor vasculature were deemed too unreliable by experienced angiographers and have been abandoned. Since the arteriogram is always accomplished via a femoral artery catheterization approach, this should be obtained several weeks (if possible) prior to surgical consideration. If not, hematoma and swelling may negate exploration and use of a groin flap on that side. After the flap has been deemed suitable for transfer and the vasculature well dissected from the surrounding tissue through the medial incision, dissection is then begun laterally at the tip of the flap. This dissection is continued in the loose plane of areolar tissue just anterior to the fascia lata of the thigh and the inguinal ligament. (Figure 5A.) The superficial circumflex iliac artery, then, is more anterior to this plane of dissection. As the fascia overlying the sartorius is encountered, dissection is continued deep to this structure protecting the main trunk of the artery. The muscular branch to the sartorius, when present, can now be ligated, thus connecting the lateral dissection to the medial exploratory incision. (Figure 5B.) The operative procedure is carried out by two surgical teams, one to prepare the recipient bed and vasculature, the other to dissect out the groin flap. to
incision Figure 3. Left, medial exploratory incision groin with ftap @lined for if medial exploratory incision with most comkoti arterial blood supply.
754
vasculature &tab/e
for anastomosis. Right,
The American Journal of Surgery
Microsurgical
Initial dissection and identification is done with the aid of ocular loupes 4.5X. The anastomosis is carried out with 9 to 16X magnification utilizing the Week (Edward Week & Co, Inc, 49033 31st Place, Long Island City, NY 11101) operating diploscope. Microvascular instruments and atraumatic clamps are essential for success. Usually a single flap artery (superficial circumflex iliac) and as many veins as possible (average number, 2) are anastomosed to the recipient vasculature. A 10-O Ethicon (Ethicon, Inc, Sommerville, NJ 08876) on a BV-2 needle is employed in the arterial anastomosis and a 10-O on a BV-6 for the venous anastomosis. Approximately 4 to 5 interrupted sutures are placed in the artery and 5 to 8 in the vein, the open ends of the vessels being gently perfused with dilute heparin solution. If the extremity is the recipient site, a tourniquet is employed as well as atraumatic clamps on the flap vasculature to prevent blood accumulation at the anastomotic site until full flow is resumed. Either the artery or vein can be anastomosed first, the decision being determined solely by the position of the flap in the recipient bed. The atraumatic clamps are first removed and then the tourniquet let down when both anastomoses are complete. Every attempt is made to cover the anastomotic site as soon as possible with the flap to diminish vasoconstriction, Topical lidocaine 2 per cent (Xylocaine@) and magnesium sulfate 10 per cent are placed on the anastomotic site throughout surgery. If exposure is difficult or if the composite tissue is transplanted to the lower ex-
Figure 5A. Lateral approach utilized to dfssect majkfty of Hap a&r medial exploratory incision demonstrated vasculature satisfactory for anastomasts.
Volume 133, June 1977
Composite Tissue Transplantation
Figure 4. Preoperative arteriogram demonstrating patency of both the posterior and anterior tibia/ arteries.
Serafin and Georgiade
tremity, a reversed segment of vein graft is employed. Two anastomoses done with good exposure and visualization are far superior to a single one with difficulty. (Figures 6 A and B.) The flap is then sutured to the recipient bed with horizontal mattress sutures and a drain placed be-
A I’^‘\ ‘j’Jl\’ ’
Lateral cutaneous n.
! branch LA.
11;
i
I
Figure 5B. Lateral approach demonstrating muscular branch of superficial circumflex iliac artery to sartorius.
neath and not touching the anastomosis. The groin operative site is closed primarily and drained. Intraoperative low molecular weight Dextran 500 ml is given during and each day for three days following the procedure. Preoperative antibiotics are also given and continued into the postoperative period. The patient is placed on aspirin, 600 mg per OS twice a day, and dipyridamole (Persantinem), 25 mg per OSfour times a day, also postoperatively. No intravenous heparin is given. Excessive bleeding into the donor area resulted in one patient who mistakenly was given an excessive amount of heparin in an intraarterial line. The patient required reoperation and drainage after correction of the coagulopathy. Heparin is contraindicated because of the large area of soft tissue dissection both in the groin and recipient area. A hematoma under the free flap would be expected to diminish venous return. This is not necessarily true in digital replantation where only a small cross-sectional area is involved and heparin is frequently employed. The assessment of intra- and postoperative viability may be most difficult. Thermography may have a role but the Doppler has not been of value in our experience either intra- or postoperatively. It may offer some help in planning of the donor flap [32]. The two most reliable clinical signs of continued viability have been the presence of capillary filling (difficult to evaluate in black patients) and bleeding from the edge of the flap upon gentle manipulation. The flap may remain warm, but in the absence of capillary filling, arterial anastomotic thrombosis
Figure 6A. lntraoperative photograph demonstrating reversed segment of vein graft with end-fo-side anastomosis.
756
The American Journal of Surgery
Microsurgical
Composite
Tissue Transplantation
should be suspected. A cyanotic hue with brisk capillary filling and bleeding from beneath the flap should alert the surgeon to venous obstruction. The presence of blebs and bullae are ominous signs and portend flap failure. In those cases of complete anastomotic failure with definite clinical signs, a decision to reoperate must be made early in the postoperative course or else all will be lost. Summary
Of thirty-five cases of microsurgical composite tissue transplantation, twenty-five (71 per cent) were completely successful, four (11 per cent), were partially successful, and six (17 per cent) failed. If a microvascular flap should fail, older but more lengthy methods of reconstruction may be employed with a reasonable chance for success. The advantages of the donor groin flap are discussed. Operative technic and management are outlined. References 1. Filatov VP: Plastic procedure using a round pedicle (in Russian). Vestnik Oftatmologii 34 (45): 149, 159, 1917. (Translated by Lobunka M, Gnudi MT, Webster JP: Surg C/in North Am 39: 277, 1959.) 2. Webster JP: The early history of the tubed pedicle flap. Surg C/in North Am 39: 261, 1959. 3. Gillies HD: The tubed pedicle in plastic surgery. NY A&d J 111: 1, 1920. 4. Gillies HD: Plastic surgery of facial burns. Surg Gynecol Obstet 30: 121, 1920. 5. Gillies HD: Plastic Surgery of the Face. London, Fronde, 1920. 6. Webster JP: Thoraco-epigastric tubed pedicles. Surg C/in North Am 17: 145, 1937. 7. McGregor IA: The temporal flap in intra-oral cancer: Its use in replacing the post excisional defect. Br J P/as/ Surg 16: 316, 1963. a. Bakamjian VY, Long M, Rigg B: Experience with the medically based deltopectoml flap in reconstructive surgery of the head and neck. Br J Plast Surg 24: 174, 1971. 9. McGregor IA, Jackson IT: The extended role of the delto-pectoral flap. Br J Plast Surg 23: 173, 1970. 10. Smith PJ, Foley B, McGregor IA, Jackson IT: The anatomical basis of the groin flap. Plast Reconstr Surg 49: 41, 1972. 11. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25: 3, 1972. 12. Lister GD, McGregor, IA, Jackson IT: The groin flap in hand injuries. Br JAccident Surg 4: 229, 1973. 13. Jacobson JH, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 11: 243, 1960. 14. Kleinert HE, Kasdan ML: Anastomosis of digital vessels. J Ky Med Assn 63: 106, 1965. 15. Kleinert HD, Kutz JE, et al: Replantation of nonviable digits: 10 years experience. J Bone Joint Surg (In press.) 16. Lendvay PG: Anastomosis of digital vessels. Med J Aust 2: 773, 1968. 17. Lendvay PG. Owen ER: Microvascular repair of a completely severed digit. Fate of digital vessels after six months. A&d JAust 2: ala, 1970. 16. Malt RA, McKhann CF: Replantation of severed arms. JAMA 169: 716, 1964. 19. O’Brien EM, MacLeod AM, Miller GDH: Clinical replantation of
Volume 133, June 1977
Figure 66. lntraoperative photograph demonstrating patency of graft vein used to obviate tension and insure adequate flap perfusion (arrow on vein graft).
digits. Plast Reconsfr Surg 52: 490, 1973. 20. Horn JS: Reattachment of severed forearm. Lancet 1: 1152. 1964. 21. Chen CW: Sixth Peoples Hospital Shanghai: Replantation of severed fingers. Clinical experiences on 162 cases involving 270 severed fingers. (To be published.) 22. Daniel RK, Williams HB: The free transfer of skin flaps by microvascular anastomosis: an experimental study and a reappraisal. Plast Reconsfr Surg 52: 16, 1973. Krizek TJ, Tani T, DesPrez JD, Kiehn CL: Experimental transplantation of cbmposite grafts by microsurgical vascular anastomosis. Plast Reconstr Surg 36: 536, 1965. Strauch B, Murray DE: Transfer of composite graft with immediate suture anastomosis of its vascular pedicle measuring less than 1 mm in external diameter using microsurgical technique. Plast Reconstr Surg 50: 325, 1967. Dstrup LT, Fredrickson JM: Distant transfer of a free, living bone graft by microvascular anastomoses: an experimental study. Plast Reconstr Surg 54: 274, 1974. 26. Ostrup LT. Fredrickson JM: Reconstruction of mandibular defects after radiation using a free, living bone graft transferred by microvascular anastomosis: an experimental study. Plast Reconstr Surg 55: 563, 1975. 27. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg 52: 111, 1973. 26. Serafin D, Georgiade NG: Microsurgical composite tissue transplantation: a new horizon in plastic and reconstructive surgery. North Carolina Med J 37: 246, 1976. 29. Serafin D, Georgiade NG, Peters CR: Microsurgical composite tissue transplantation: a method of immediate reconstruction of the head and neck. C/in Plast Surg 3: 447, 1976. 30. Serafin D, Villarreal Rios A, Georgiade NG: Fourteen free groin flap transfers. Plast Reconstr Surg 57: 707, 1976. 31. Shaw DT, Payne RL: One staged abdominal flap. Surg Gynecol Obstet 63: 205, 1946. 32. Karkowski J, Buncke HJ: A simplified technique for free transfer of groin flaps by use of a Doppler probe. P/as/ Reconstr Surg 55: 682, 1975.
757
Microsurgical Composite Tissue Transplantation A New Method of Immediate Reconstruction of Extensive Defects
Donald Serafin, MD, Durham, North Carolina Nicholas G. Georgiade, MD, Durham, North Carolina
Since the introduction of the tubed pedicle flap by Filatov [1,2] in 1917 (later popularized by Gillies [3-51 in 1920), plastic surgeons have diligently sought new and better technics to provide composite tissue coverage of extensive defects. Webster [6] in 1937 emphasized the importance of concealing the flap donor site in an unexposed area of the body. He introduced the thoracoepigastric flap based on the artery of the same name. A more predictable flap of greater length could now be transferred to a recipient site with a single delay. McGregor [ 71 in 1963 advocated the use of a forehead flap based on the superficial temporal artery. In this discussion, delay of the flap was suggested if the length of the flap extended beyond the midline of the forehead. Bakamjian [8] in 1973 described the deltopectoral flap. He emphasized its usefulness in the immediate reconstruction of extensive defects without delay. McGregor and Jackson [9] in 1970 postulated that the safety of this flap was related to a unique vascular characteristic of a distinct and predictable arterial and venous system within the flap. The anatomy and clinical implications of such an arterial flap were further expanded and popularized by McGregor and co-workers [IO--121. The distinctions between an arterial and random flap were also well defined and the relationship of one to another in a single flap discussed. The groin flap was most popular in their experience because of the consistency of its blood supply, its location, and th? donor site could be primarily closed without a significant secondary deformity. With the introduction of microsurgical technic by Jacobson and Suarez [13] in 1960 and with the ex-
From the Division of Plastic, Reconstructive, and Maxillofacial Surgery, Duke University Medical Cehter, Durham, North Carolina. Reprint requests should be addressed to Donald Serafin, MD, Division of Plastic and Reconstructive Surgery, Duke UniversityMedical Center, Durham, North Carolina 27710.
752
perience gained from replantation [14-211 and in the laboratory [22-261, composite tissue transplantation became a clinical reality in 1973 [27]. Now, in one operative procedure, large segments of composite tissue, with a predictable vascular pattern, can be immediately transferred to a distant recipient site without creating a secondary deformity of the donor site. The ultimate goal in flap reconstruction is being realized. Experience is needed now to refine and adapt basic microsurgical procedures to ensure and enhance continued success and to minimize operative time. Results
Since 1974 thirty-five patients have undergone microsurgical composite tissue transplantation. (Table I.) In twelve cases involving the head and neck, eleven were successful and one was partially successful. (A flap is considered to be partially successful if it can still fulfill the function for which it was intended with only a minor secondary procedure, such as a skin graft). In the eighteen cases involving the lower extremity, ten were successful, three were partially successful, and five failed. Both flaps to the thorax were successful. Of the two flaps to the upper extremity, one was successful and one failed.
TABLE I
Location of Defect Head and neck Thorax Upper extremity Lower extremity
Summary of 35 Patients Undergoing Microsurgical Composite Tissue Transplantation Total No. of Cases
success
12 (34%) 2 (6%)
11 (91%) 2 (100%)
3 (8%)
2 (67%)
18 (51%)
10 (56%)
Partial Success
Failure
1 (8%) 0
0 0
0
1 (33%)
3 (17%)
5 (28%)
The American Journal of Surgery
Microsurgical
Technic
Valuable clinical experience in microsurgical composite tissue transplantation has been obtained during the past three years. Thirty-five patients with extensive soft tissue defects requiring full thickness coverage have undergone attempts at immediate reconstruction [Z&30]. In all patients the donor flap was the groin flap first described by Smith et al [IO] in 1972. This flap has several distinct advantages over all others. It consists largely of nonhair-bearing skin, making it desirable in reconstructive attempts, especially in the female. An extensive amount of tissue can be easily obtained (10 X 25 cm) and the donor site can be closed primarily without the need for a skin graft. The resulting incision is so favorably placed that it is concealed even by the most brief bikini. A disadvantage of the flap, however, is its poor color match in the region of the head and the neck. Hyperpigmentation may result and is especially troublesome in black patients. In all the cases under discussion the blood supply, especially the venous return, has been remarkably constant. The superficial circumflex iliac vein has always been present, not duplicated, with an average external diameter of 1.5 to 2.5 mm. It frequently enters the termination of the greater saphenous vein just prior to its junction with the deep femoral vein. (Figure 1.) The superficial circumflex iliac artery has
I
Composite Tissue Transplantation
,,
?hperficiol
Figure 1. A medial explorafory incision with pointer demonstrating superficial circumflex iliac vein and its junction with greater saphenous prior vein to joining femoral vein.
Femwal a.
Figure ?. Medial expforatky incision with super&&l c&aiUbx Hi&cartery arising from femoral artery.
volume 193, June 1977
circumfle;
Serafin and Georgiade
varied in size,from 0.5 to 1.5 mm in external diameter, with an average size of 1.0 mm. It most frequently arises as a separate branch from the femoral artery (Figure 2) but is less constant in its origin, occasionally being duplicated or arising from the superficial inferior epigastric artery. The medial exploratory incision has become a valuable operative maneuver to assess the suitability of the vasculature and to save time during the dissection. (Figure 3.) Using this approach, one can afford protection against injury to the vasculature during the dissection. It has also provided the surgeon an option to use a flap based on the superficial inferior epigastric artery (the Shaw-Payne flap [31]). This may be especially important in the obese patient whose superficial inferior epigastric artery and vein are often larger in diameter, perhaps to supply a large panniculus. The, technical difficulties encountered in the groin flap because of a thickened medial portion of flap could be avoided. If the medial incision reveals a donor vasculature unsuitable for anastomosis, then the other groin could be explored and minimal time wasted. An arteriogram is obtained prior to composite tissue transplantation to assess the quality of the recipient vasculature. (Figure 4.) Previous attempts
evaluate donor vasculature were deemed too unreliable by experienced angiographers and have been abandoned. Since the arteriogram is always accomplished via a femoral artery catheterization approach, this should be obtained several weeks (if possible) prior to surgical consideration. If not, hematoma and swelling may negate exploration and use of a groin flap on that side. After the flap has been deemed suitable for transfer and the vasculature well dissected from the surrounding tissue through the medial incision, dissection is then begun laterally at the tip of the flap. This dissection is continued in the loose plane of areolar tissue just anterior to the fascia lata of the thigh and the inguinal ligament. (Figure 5A.) The superficial circumflex iliac artery, then, is more anterior to this plane of dissection. As the fascia overlying the sartorius is encountered, dissection is continued deep to this structure protecting the main trunk of the artery. The muscular branch to the sartorius, when present, can now be ligated, thus connecting the lateral dissection to the medial exploratory incision. (Figure 5B.) The operative procedure is carried out by two surgical teams, one to prepare the recipient bed and vasculature, the other to dissect out the groin flap. to
incision Figure 3. Left, medial exploratory incision groin with ftap @lined for if medial exploratory incision with most comkoti arterial blood supply.
754
vasculature &tab/e
for anastomosis. Right,
The American Journal of Surgery
Microsurgical
Initial dissection and identification is done with the aid of ocular loupes 4.5X. The anastomosis is carried out with 9 to 16X magnification utilizing the Week (Edward Week & Co, Inc, 49033 31st Place, Long Island City, NY 11101) operating diploscope. Microvascular instruments and atraumatic clamps are essential for success. Usually a single flap artery (superficial circumflex iliac) and as many veins as possible (average number, 2) are anastomosed to the recipient vasculature. A 10-O Ethicon (Ethicon, Inc, Sommerville, NJ 08876) on a BV-2 needle is employed in the arterial anastomosis and a 10-O on a BV-6 for the venous anastomosis. Approximately 4 to 5 interrupted sutures are placed in the artery and 5 to 8 in the vein, the open ends of the vessels being gently perfused with dilute heparin solution. If the extremity is the recipient site, a tourniquet is employed as well as atraumatic clamps on the flap vasculature to prevent blood accumulation at the anastomotic site until full flow is resumed. Either the artery or vein can be anastomosed first, the decision being determined solely by the position of the flap in the recipient bed. The atraumatic clamps are first removed and then the tourniquet let down when both anastomoses are complete. Every attempt is made to cover the anastomotic site as soon as possible with the flap to diminish vasoconstriction, Topical lidocaine 2 per cent (Xylocaine@) and magnesium sulfate 10 per cent are placed on the anastomotic site throughout surgery. If exposure is difficult or if the composite tissue is transplanted to the lower ex-
Figure 5A. Lateral approach utilized to dfssect majkfty of Hap a&r medial exploratory incision demonstrated vasculature satisfactory for anastomasts.
Volume 133, June 1977
Composite Tissue Transplantation
Figure 4. Preoperative arteriogram demonstrating patency of both the posterior and anterior tibia/ arteries.
Serafin and Georgiade
tremity, a reversed segment of vein graft is employed. Two anastomoses done with good exposure and visualization are far superior to a single one with difficulty. (Figures 6 A and B.) The flap is then sutured to the recipient bed with horizontal mattress sutures and a drain placed be-
A I’^‘\ ‘j’Jl\’ ’
Lateral cutaneous n.
! branch LA.
11;
i
I
Figure 5B. Lateral approach demonstrating muscular branch of superficial circumflex iliac artery to sartorius.
neath and not touching the anastomosis. The groin operative site is closed primarily and drained. Intraoperative low molecular weight Dextran 500 ml is given during and each day for three days following the procedure. Preoperative antibiotics are also given and continued into the postoperative period. The patient is placed on aspirin, 600 mg per OS twice a day, and dipyridamole (Persantinem), 25 mg per OSfour times a day, also postoperatively. No intravenous heparin is given. Excessive bleeding into the donor area resulted in one patient who mistakenly was given an excessive amount of heparin in an intraarterial line. The patient required reoperation and drainage after correction of the coagulopathy. Heparin is contraindicated because of the large area of soft tissue dissection both in the groin and recipient area. A hematoma under the free flap would be expected to diminish venous return. This is not necessarily true in digital replantation where only a small cross-sectional area is involved and heparin is frequently employed. The assessment of intra- and postoperative viability may be most difficult. Thermography may have a role but the Doppler has not been of value in our experience either intra- or postoperatively. It may offer some help in planning of the donor flap [32]. The two most reliable clinical signs of continued viability have been the presence of capillary filling (difficult to evaluate in black patients) and bleeding from the edge of the flap upon gentle manipulation. The flap may remain warm, but in the absence of capillary filling, arterial anastomotic thrombosis
Figure 6A. lntraoperative photograph demonstrating reversed segment of vein graft with end-fo-side anastomosis.
756
The American Journal of Surgery
Microsurgical
Composite
Tissue Transplantation
should be suspected. A cyanotic hue with brisk capillary filling and bleeding from beneath the flap should alert the surgeon to venous obstruction. The presence of blebs and bullae are ominous signs and portend flap failure. In those cases of complete anastomotic failure with definite clinical signs, a decision to reoperate must be made early in the postoperative course or else all will be lost. Summary
Of thirty-five cases of microsurgical composite tissue transplantation, twenty-five (71 per cent) were completely successful, four (11 per cent), were partially successful, and six (17 per cent) failed. If a microvascular flap should fail, older but more lengthy methods of reconstruction may be employed with a reasonable chance for success. The advantages of the donor groin flap are discussed. Operative technic and management are outlined. References 1. Filatov VP: Plastic procedure using a round pedicle (in Russian). Vestnik Oftatmologii 34 (45): 149, 159, 1917. (Translated by Lobunka M, Gnudi MT, Webster JP: Surg C/in North Am 39: 277, 1959.) 2. Webster JP: The early history of the tubed pedicle flap. Surg C/in North Am 39: 261, 1959. 3. Gillies HD: The tubed pedicle in plastic surgery. NY A&d J 111: 1, 1920. 4. Gillies HD: Plastic surgery of facial burns. Surg Gynecol Obstet 30: 121, 1920. 5. Gillies HD: Plastic Surgery of the Face. London, Fronde, 1920. 6. Webster JP: Thoraco-epigastric tubed pedicles. Surg C/in North Am 17: 145, 1937. 7. McGregor IA: The temporal flap in intra-oral cancer: Its use in replacing the post excisional defect. Br J P/as/ Surg 16: 316, 1963. a. Bakamjian VY, Long M, Rigg B: Experience with the medically based deltopectoml flap in reconstructive surgery of the head and neck. Br J Plast Surg 24: 174, 1971. 9. McGregor IA, Jackson IT: The extended role of the delto-pectoral flap. Br J Plast Surg 23: 173, 1970. 10. Smith PJ, Foley B, McGregor IA, Jackson IT: The anatomical basis of the groin flap. Plast Reconstr Surg 49: 41, 1972. 11. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25: 3, 1972. 12. Lister GD, McGregor, IA, Jackson IT: The groin flap in hand injuries. Br JAccident Surg 4: 229, 1973. 13. Jacobson JH, Suarez EL: Microsurgery in anastomosis of small vessels. Surg Forum 11: 243, 1960. 14. Kleinert HE, Kasdan ML: Anastomosis of digital vessels. J Ky Med Assn 63: 106, 1965. 15. Kleinert HD, Kutz JE, et al: Replantation of nonviable digits: 10 years experience. J Bone Joint Surg (In press.) 16. Lendvay PG: Anastomosis of digital vessels. Med J Aust 2: 773, 1968. 17. Lendvay PG. Owen ER: Microvascular repair of a completely severed digit. Fate of digital vessels after six months. A&d JAust 2: ala, 1970. 16. Malt RA, McKhann CF: Replantation of severed arms. JAMA 169: 716, 1964. 19. O’Brien EM, MacLeod AM, Miller GDH: Clinical replantation of
Volume 133, June 1977
Figure 66. lntraoperative photograph demonstrating patency of graft vein used to obviate tension and insure adequate flap perfusion (arrow on vein graft).
digits. Plast Reconsfr Surg 52: 490, 1973. 20. Horn JS: Reattachment of severed forearm. Lancet 1: 1152. 1964. 21. Chen CW: Sixth Peoples Hospital Shanghai: Replantation of severed fingers. Clinical experiences on 162 cases involving 270 severed fingers. (To be published.) 22. Daniel RK, Williams HB: The free transfer of skin flaps by microvascular anastomosis: an experimental study and a reappraisal. Plast Reconsfr Surg 52: 16, 1973. Krizek TJ, Tani T, DesPrez JD, Kiehn CL: Experimental transplantation of cbmposite grafts by microsurgical vascular anastomosis. Plast Reconstr Surg 36: 536, 1965. Strauch B, Murray DE: Transfer of composite graft with immediate suture anastomosis of its vascular pedicle measuring less than 1 mm in external diameter using microsurgical technique. Plast Reconstr Surg 50: 325, 1967. Dstrup LT, Fredrickson JM: Distant transfer of a free, living bone graft by microvascular anastomoses: an experimental study. Plast Reconstr Surg 54: 274, 1974. 26. Ostrup LT. Fredrickson JM: Reconstruction of mandibular defects after radiation using a free, living bone graft transferred by microvascular anastomosis: an experimental study. Plast Reconstr Surg 55: 563, 1975. 27. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomosis. Plast Reconstr Surg 52: 111, 1973. 26. Serafin D, Georgiade NG: Microsurgical composite tissue transplantation: a new horizon in plastic and reconstructive surgery. North Carolina Med J 37: 246, 1976. 29. Serafin D, Georgiade NG, Peters CR: Microsurgical composite tissue transplantation: a method of immediate reconstruction of the head and neck. C/in Plast Surg 3: 447, 1976. 30. Serafin D, Villarreal Rios A, Georgiade NG: Fourteen free groin flap transfers. Plast Reconstr Surg 57: 707, 1976. 31. Shaw DT, Payne RL: One staged abdominal flap. Surg Gynecol Obstet 63: 205, 1946. 32. Karkowski J, Buncke HJ: A simplified technique for free transfer of groin flaps by use of a Doppler probe. P/as/ Reconstr Surg 55: 682, 1975.
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