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Free microvascular flaps for defects of limbs, head, and neck
Free Microvascular Flaps for Defects of Limbs, Head, and Neck
Arthur H. Salibian,
MD, Irvine, California
Bruce M. Achauer,
MD, Irvine, California
David W. Furnas, MD, Irvine, California
A microvascular free flap is a block of tissue transferred from one site to another by means of microvascular anastomosis. The single stage transplantation of composite tissue has opened new horizons in reconstructive surgery and has gained world-wide acceptance in a short period of time. The first successful microvascular skin flap transfer was performed in September 1972 by Harii et al [I], who used a free scalp flap based on the superficial temporal vessels to treat alopecia. The same year McLean and Buncke [Z] transferred the omentum with microvascular anastomoses to cover exposed skull after resection for a malignancy. Tamai [3], in May 1976, used a groin-osteocutaneous flap to resurface a traumatic soft tissue and calcaneal defect of the foot. Since these pioneering efforts, hundreds of free flaps have been used with a high rate of success. Harii et al [4], reporting on 184 free flap transfers, had only 12 failures (7 per cent), a failure rate comparable to that of any conventional flap procedure. A variety of flaps are available for different reconstructive procedures. The groin flap, which is the most commonly used flap, provides a large skin surface with good padding and is suitable for covering large traumatic defects. The donor site scar from a groin flap can be readily concealed. The main disadvantages of the groin flap are its short vascular pedicle and its bulkiness in obese patients. The dorsalis pedis flap, on the other hand, is a small (14 by 12 cm), thin flap with an easily accessible artery and nerve. When used as a neurovascular flap it is Framthe Division of Plastic Surgery, University of California at Irvine, Irvine, California. Reprint requests should be addressed to Arthur H. Salibian, MD, Division of Plastic Surgery, U.C.I. Medical Center, 101 City Drive South, Orange, California 92668. Presented at the 50th Annual Meeting of the Pacific Coast Surgical Association, Yosemite National Park, February 19-22, 1979.
Volume 136, July 1979
indispensable in hand reconstruction and intraoral resurfacing. The deltopectoral flap is better suited for facial coverage because of its color match. Osteocutaneous flaps have recently aroused tremendous interest because previously unrepairable major bony defects have become amenable to one-stage reconstruction. The osteocutaneous flap has its greatest use in irradiated areas such as the head and neck region. Finally, the omental flap differs from other skin flaps in that it can be folded on itself and subdivided into several pedicles. The gradations in thickness that can be achieved in an omental flap make it suitable for contouring facial irregularities. The technique of microvascular anastomosis is well established. Considerable experience in the lab is required before carrying out clinical microvascular operations. In planning a microvascular free flap transfer, the location of the defect, the structures to be covered, and the availability of arteries and veins must be taken into consideration. Doppler mapping and arteriograms are useful in choosing t,he appropriate vessels for anastomosis. In the extremities particular attention should be paid to the presence of collateral circulation if an end artery is to be sacrificed. The operation is done with two teams, one harvesting the flap and the other preparing the recipient site. Postoperatively, continuous Doppler monitoring of the donor vessels will aid in immediate detection of vascular thrombosis, making revision of the anastomosis a worthwhile effort. Anticoagulation is not advisable in free flap transfers. From September 1975 to December 1978, we transferred a total of 23 microvascular flaps, including 15 groin flaps, 1 dorsalis pedis neurovascular flap, 4 osteocutaneous groin flaps (with iliac crest), 1 osteocutaneous skin-rib flap, one omental flap, and
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one jejunal segment. The defects were caused by trauma in 15 cases (upper and lower limbs, head and neck) and by tumor ablation in 6 cases (head and neck only). Of the five osteocutaneous flaps, three were used to reconstruct bony defects in the limbs and two to reconstruct the mandible after tumor ablation. Six of the 23 flaps (26 per cent) were failures. Five of the 16 skin flaps (31 per cent) and 1 of the 5 osteocutaneous flaps (20 per cent) failed. All 6 failures were among the 11 flaps transferred to the
lower extremity, for a failure rate of 55 per cent in that group. All 12 flaps transferred to the head and neck and upper extremities were successful. Four cases had preoperative radiation to the recipient vessels but there were no problems with the flap circulation. The high loss rate in free flap transfers to the lower extremity, despite meticulous technique, suggests that many factors related to vessel spasm, arterial injury, and subsequent thrombosis are still not well understood.
Figure 1. Case I. A, advanced squamous carcinoma eroding the skull and brain. B, extent oi resection. Dural repair with a fascia lafa graft. C, split rib craniop/asfy carried out 3 months later. D, postoperative result. 112
The American Journal of Surgery
Free Microvascular
Case Reports Case I (Figure 1). A 58 year old man had a large (12 by 12 cm) fungating squamous cell carcinoma of the mid forehead. The tumor had been irradiated only to necrose and bleed repeatedly. He had received multiple transfusions but, because of threatening hemorrhage, an urgent operation was performed. With the help of the neurosurgical staff, the tumor was excised with the underlying bone and part of the radionecrotic frontal lobe. An 18 by 18 cm groin flap was transferred to the defect and revascularized
Flaps
by suturing the superficial circumflex iliac vessels to the superficial temporal vessels. In spite of its being a grossly contaminated wound, primary healing occurred without infection. Several months later a split rib cranioplasty was done. At 2 years there has been no recurrence. Case II (Figure 2). A 32 year old woman had left hemifacial atrophy. Preoperative facial moulages were done to map out the depressed areas. An omental flap was transferred using the right gastroepiploic vessels, which were joined to the anterior facial vessels. A depression of the left
Figure 2. Case II. A, preoperative hemffactal atrophy. 6, isolation of the omentum on tfte feft gastmepiploic vessels. C, elevation of facial skin to accommodate the omental flap. D, resuft at 2 months. Volume 138,July 1979
Salibian et al
lower eyelid was corrected with a separate vascularized island of omental fat. The facial incision was left open to avoid tension, and the exposed omentum was simply covered with a skin graft. Postoperatively an acrylic splint was used to support the omentum during the initial healing process. The patient’s appearance was greatly improved.
was excised and an 8 cm jejunal segment was interposed. It was vascularized by joining a segmental branch of the superior mesenteric vessels to the transverse cervical artery and vein. The patient drank fluids on the 10th postoperative day and ate a regular diet by the 3rd postoperative week.
Case III (Figure 3). A 35 year old man had a stricture of the cervical esophagus and difficulty in eating solid food. An esophogram showed a stricture at the seventh cervical vertebra with marked proximal dilatation of the esophagus. At surgery a 6 cm scarred segment of the cervical esophagus
Case IV (Figure 4). A 24 year old man lost the entire soft tissue over the heel in a motorcycle accident. The wounds were initially skin grafted. After 18 months a left groin flap was used to resurface the entire heel. The superficial circumflex iliac artery and the superficial circumflex iliac vein
Figure 3. Case Ill. A, preoperative esophogram showing steno& and prestenotic dilatation. B, 8 cm jejunal segment being isolated on a single vascular pedicle. C, jejunum being sutured in place just before to completion of microvascular anastomosis. D, patient drinks fluids with ease 2 weeks postoperatively.
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The American Journal of Surgery
Free Microvascular Flaps
were anastomosed to the dorsalis pedis artery and long saphenous vein, respectively. After several trimming procedures the patient was able to wear shoes and return to work. Case V (Figure 5). A 50 year old man with a gunshot wound to the distal forearm had extensive loss of soft tissue, extensor tendons, and a segment of the distal radius and ulna. The wound was initially debrided and split skin grafts applied over the exposed muscle. An osteocutaneous free groin flap was transferred on the 7th day after injury, which included a 6 by 3 cm piece of the iliac crest. This was used to bridge the defect in the radius; the exposed tendons were covered with the groin flap. The superficial circumflex iliac artery was sutured end-to-side to the radial artery and the superficial circumflex iliac vein to the cephalic vein. Bone scans at 8 weeks showed good pick-up by the transplanted bone. The patient subsequently underwent tendon grafting to repair the extensor tendons.
Nakiyama paced back and forth with his knife in hand, saying, “Ready, ready?“, and the response was “No, no.” This went on for 5 minutes. Finally the television camera people waved that they were ready and zoop! the professor was in the abdomen. Within an incredibly brief time the stomach was out. An impressive presentation! However, after the cameras and lights were off and the patient was back on the ward, it took us 3 months to clear up subphrenic abscesses and other complications from the surgery. Circumspection must be practiced in applying new procedures.
Summary Twenty-three free microvascular flaps were transferred during the period September 1975 to December 1978. These included skin flaps, osteocutaneous flaps, and flaps of omentum and jejunum. These flaps were used for a variety of conditions ranging from life-threatening bleeding from a tumor to facial contouring in congenital deformities. In selected patients a microvascular free flap has significant advantages over multi-staged conventional flaps.
References 1. Harii K, Ohmori K, Ohmori S: Hair transplantation with free scalp flap. Plast Reconstr Surg 53: 410, 1974. 2. McLean BH, Buncke l-R Jr: Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 49: 266, 1972. 3. Tamai S: Microsurgical Composite Tissue Transplantation (Serafin D, Buncke HJ, ed), chap 27, pp 391-397. St. Louis, CV Mosby, 1979. 4. Harii K, Ohmori K, Torii S, Sekiguchi J: Microvascular free skin flap transfer. C/in Plast Surg 5: 239, 1978.
Discussion Irving Rappaport (Santa Ana, CA): As we move into the area of microvascular anastomosis and microneuroanastomosis, we must not forget what has been done before because the failure of a free flap in the head and neck area can sometimes mean death to the patient. Cases have to be chosen carefully. A few years ago I had the pleasure of working with Professor Nakiyama on a television presentation of a total gastrectomy. I prepared a patient with a gastric ulcer for Dr. Nakiyama’s surgery. Waiting for the red light, Dr.
Volume 139,July 1979
Figure 4. Case IV. A, sofl &sue defect of the heel and ankle with a recurrenl pressure sore over the plantar surface. 6, 18 by 72 cm groin Nap ready for fransfer (after preliminary delay procedures). C, result after several trimming procedures.
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Figure 5. Case I/. A, preoperative X-rays of segmenfal loss of the ulna and the radius. B, soft tissue defect (partial/y skin grafted) with exposed exfensor tendons. C, osteocutaneous groin flap including a 6 by 3 cm piece of the iliac cresi ( forceps pointing fo bone and vascular pedicfe) . 0, postoperative X-ray showing the iliac bone positioned in the radial defecf. E, forearm defect corrected with the osfeocutaneous groin flap. I would like to emphasize that in reconstructive surgery for malignancies of the head and neck, the so-called radical neck dissection does not exist, Most of us are doing modifications. If we expect to do a free flap, it is wise if we can save the jugular vein. That’s contrary to what we’ve been brought up with, but unless there is tumor invasion of the jugular vein or the carotid sheath, it is not necessary to sacrifice the jugular vein. Furthermore, the transverse cervical artery can be preserved for anastomosis as well as the superior thyroid artery, the anterior facial artery, and the anterior facial vein; and last but not least, we should preserve, if we can, the 11th nerve because if a free flap fails, it’s nice to have a trapezius musculocutaneous flap available.
116
David W. Furnas (closing): I want to thank Dr. Rappaport for his comments; it is his innovative modifications of the radical neck procedure that made it possible to combine these free flaps with lymphadenectomy. As you can see, the possibilities are limit-less. Each week we must dash to the anatomy lab to see if this week’s inspiration is valid. Since reconstructive microsurgery is the very essence of teamwork, and we usually have two teams going, it is a great opportunity to work shoulder to shoulder with surgeons from other specialties. I want to express my appreciation to the many colleagues that have referred these challenging cases to us. We are also indebted to Dr. John Connolly for his great encouragement in this work.
The American Journal of Surgery
Arthur H. Salibian,
MD, Irvine, California
Bruce M. Achauer,
MD, Irvine, California
David W. Furnas, MD, Irvine, California
A microvascular free flap is a block of tissue transferred from one site to another by means of microvascular anastomosis. The single stage transplantation of composite tissue has opened new horizons in reconstructive surgery and has gained world-wide acceptance in a short period of time. The first successful microvascular skin flap transfer was performed in September 1972 by Harii et al [I], who used a free scalp flap based on the superficial temporal vessels to treat alopecia. The same year McLean and Buncke [Z] transferred the omentum with microvascular anastomoses to cover exposed skull after resection for a malignancy. Tamai [3], in May 1976, used a groin-osteocutaneous flap to resurface a traumatic soft tissue and calcaneal defect of the foot. Since these pioneering efforts, hundreds of free flaps have been used with a high rate of success. Harii et al [4], reporting on 184 free flap transfers, had only 12 failures (7 per cent), a failure rate comparable to that of any conventional flap procedure. A variety of flaps are available for different reconstructive procedures. The groin flap, which is the most commonly used flap, provides a large skin surface with good padding and is suitable for covering large traumatic defects. The donor site scar from a groin flap can be readily concealed. The main disadvantages of the groin flap are its short vascular pedicle and its bulkiness in obese patients. The dorsalis pedis flap, on the other hand, is a small (14 by 12 cm), thin flap with an easily accessible artery and nerve. When used as a neurovascular flap it is Framthe Division of Plastic Surgery, University of California at Irvine, Irvine, California. Reprint requests should be addressed to Arthur H. Salibian, MD, Division of Plastic Surgery, U.C.I. Medical Center, 101 City Drive South, Orange, California 92668. Presented at the 50th Annual Meeting of the Pacific Coast Surgical Association, Yosemite National Park, February 19-22, 1979.
Volume 136, July 1979
indispensable in hand reconstruction and intraoral resurfacing. The deltopectoral flap is better suited for facial coverage because of its color match. Osteocutaneous flaps have recently aroused tremendous interest because previously unrepairable major bony defects have become amenable to one-stage reconstruction. The osteocutaneous flap has its greatest use in irradiated areas such as the head and neck region. Finally, the omental flap differs from other skin flaps in that it can be folded on itself and subdivided into several pedicles. The gradations in thickness that can be achieved in an omental flap make it suitable for contouring facial irregularities. The technique of microvascular anastomosis is well established. Considerable experience in the lab is required before carrying out clinical microvascular operations. In planning a microvascular free flap transfer, the location of the defect, the structures to be covered, and the availability of arteries and veins must be taken into consideration. Doppler mapping and arteriograms are useful in choosing t,he appropriate vessels for anastomosis. In the extremities particular attention should be paid to the presence of collateral circulation if an end artery is to be sacrificed. The operation is done with two teams, one harvesting the flap and the other preparing the recipient site. Postoperatively, continuous Doppler monitoring of the donor vessels will aid in immediate detection of vascular thrombosis, making revision of the anastomosis a worthwhile effort. Anticoagulation is not advisable in free flap transfers. From September 1975 to December 1978, we transferred a total of 23 microvascular flaps, including 15 groin flaps, 1 dorsalis pedis neurovascular flap, 4 osteocutaneous groin flaps (with iliac crest), 1 osteocutaneous skin-rib flap, one omental flap, and
111
Salibian et al
one jejunal segment. The defects were caused by trauma in 15 cases (upper and lower limbs, head and neck) and by tumor ablation in 6 cases (head and neck only). Of the five osteocutaneous flaps, three were used to reconstruct bony defects in the limbs and two to reconstruct the mandible after tumor ablation. Six of the 23 flaps (26 per cent) were failures. Five of the 16 skin flaps (31 per cent) and 1 of the 5 osteocutaneous flaps (20 per cent) failed. All 6 failures were among the 11 flaps transferred to the
lower extremity, for a failure rate of 55 per cent in that group. All 12 flaps transferred to the head and neck and upper extremities were successful. Four cases had preoperative radiation to the recipient vessels but there were no problems with the flap circulation. The high loss rate in free flap transfers to the lower extremity, despite meticulous technique, suggests that many factors related to vessel spasm, arterial injury, and subsequent thrombosis are still not well understood.
Figure 1. Case I. A, advanced squamous carcinoma eroding the skull and brain. B, extent oi resection. Dural repair with a fascia lafa graft. C, split rib craniop/asfy carried out 3 months later. D, postoperative result. 112
The American Journal of Surgery
Free Microvascular
Case Reports Case I (Figure 1). A 58 year old man had a large (12 by 12 cm) fungating squamous cell carcinoma of the mid forehead. The tumor had been irradiated only to necrose and bleed repeatedly. He had received multiple transfusions but, because of threatening hemorrhage, an urgent operation was performed. With the help of the neurosurgical staff, the tumor was excised with the underlying bone and part of the radionecrotic frontal lobe. An 18 by 18 cm groin flap was transferred to the defect and revascularized
Flaps
by suturing the superficial circumflex iliac vessels to the superficial temporal vessels. In spite of its being a grossly contaminated wound, primary healing occurred without infection. Several months later a split rib cranioplasty was done. At 2 years there has been no recurrence. Case II (Figure 2). A 32 year old woman had left hemifacial atrophy. Preoperative facial moulages were done to map out the depressed areas. An omental flap was transferred using the right gastroepiploic vessels, which were joined to the anterior facial vessels. A depression of the left
Figure 2. Case II. A, preoperative hemffactal atrophy. 6, isolation of the omentum on tfte feft gastmepiploic vessels. C, elevation of facial skin to accommodate the omental flap. D, resuft at 2 months. Volume 138,July 1979
Salibian et al
lower eyelid was corrected with a separate vascularized island of omental fat. The facial incision was left open to avoid tension, and the exposed omentum was simply covered with a skin graft. Postoperatively an acrylic splint was used to support the omentum during the initial healing process. The patient’s appearance was greatly improved.
was excised and an 8 cm jejunal segment was interposed. It was vascularized by joining a segmental branch of the superior mesenteric vessels to the transverse cervical artery and vein. The patient drank fluids on the 10th postoperative day and ate a regular diet by the 3rd postoperative week.
Case III (Figure 3). A 35 year old man had a stricture of the cervical esophagus and difficulty in eating solid food. An esophogram showed a stricture at the seventh cervical vertebra with marked proximal dilatation of the esophagus. At surgery a 6 cm scarred segment of the cervical esophagus
Case IV (Figure 4). A 24 year old man lost the entire soft tissue over the heel in a motorcycle accident. The wounds were initially skin grafted. After 18 months a left groin flap was used to resurface the entire heel. The superficial circumflex iliac artery and the superficial circumflex iliac vein
Figure 3. Case Ill. A, preoperative esophogram showing steno& and prestenotic dilatation. B, 8 cm jejunal segment being isolated on a single vascular pedicle. C, jejunum being sutured in place just before to completion of microvascular anastomosis. D, patient drinks fluids with ease 2 weeks postoperatively.
114
The American Journal of Surgery
Free Microvascular Flaps
were anastomosed to the dorsalis pedis artery and long saphenous vein, respectively. After several trimming procedures the patient was able to wear shoes and return to work. Case V (Figure 5). A 50 year old man with a gunshot wound to the distal forearm had extensive loss of soft tissue, extensor tendons, and a segment of the distal radius and ulna. The wound was initially debrided and split skin grafts applied over the exposed muscle. An osteocutaneous free groin flap was transferred on the 7th day after injury, which included a 6 by 3 cm piece of the iliac crest. This was used to bridge the defect in the radius; the exposed tendons were covered with the groin flap. The superficial circumflex iliac artery was sutured end-to-side to the radial artery and the superficial circumflex iliac vein to the cephalic vein. Bone scans at 8 weeks showed good pick-up by the transplanted bone. The patient subsequently underwent tendon grafting to repair the extensor tendons.
Nakiyama paced back and forth with his knife in hand, saying, “Ready, ready?“, and the response was “No, no.” This went on for 5 minutes. Finally the television camera people waved that they were ready and zoop! the professor was in the abdomen. Within an incredibly brief time the stomach was out. An impressive presentation! However, after the cameras and lights were off and the patient was back on the ward, it took us 3 months to clear up subphrenic abscesses and other complications from the surgery. Circumspection must be practiced in applying new procedures.
Summary Twenty-three free microvascular flaps were transferred during the period September 1975 to December 1978. These included skin flaps, osteocutaneous flaps, and flaps of omentum and jejunum. These flaps were used for a variety of conditions ranging from life-threatening bleeding from a tumor to facial contouring in congenital deformities. In selected patients a microvascular free flap has significant advantages over multi-staged conventional flaps.
References 1. Harii K, Ohmori K, Ohmori S: Hair transplantation with free scalp flap. Plast Reconstr Surg 53: 410, 1974. 2. McLean BH, Buncke l-R Jr: Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg 49: 266, 1972. 3. Tamai S: Microsurgical Composite Tissue Transplantation (Serafin D, Buncke HJ, ed), chap 27, pp 391-397. St. Louis, CV Mosby, 1979. 4. Harii K, Ohmori K, Torii S, Sekiguchi J: Microvascular free skin flap transfer. C/in Plast Surg 5: 239, 1978.
Discussion Irving Rappaport (Santa Ana, CA): As we move into the area of microvascular anastomosis and microneuroanastomosis, we must not forget what has been done before because the failure of a free flap in the head and neck area can sometimes mean death to the patient. Cases have to be chosen carefully. A few years ago I had the pleasure of working with Professor Nakiyama on a television presentation of a total gastrectomy. I prepared a patient with a gastric ulcer for Dr. Nakiyama’s surgery. Waiting for the red light, Dr.
Volume 139,July 1979
Figure 4. Case IV. A, sofl &sue defect of the heel and ankle with a recurrenl pressure sore over the plantar surface. 6, 18 by 72 cm groin Nap ready for fransfer (after preliminary delay procedures). C, result after several trimming procedures.
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Figure 5. Case I/. A, preoperative X-rays of segmenfal loss of the ulna and the radius. B, soft tissue defect (partial/y skin grafted) with exposed exfensor tendons. C, osteocutaneous groin flap including a 6 by 3 cm piece of the iliac cresi ( forceps pointing fo bone and vascular pedicfe) . 0, postoperative X-ray showing the iliac bone positioned in the radial defecf. E, forearm defect corrected with the osfeocutaneous groin flap. I would like to emphasize that in reconstructive surgery for malignancies of the head and neck, the so-called radical neck dissection does not exist, Most of us are doing modifications. If we expect to do a free flap, it is wise if we can save the jugular vein. That’s contrary to what we’ve been brought up with, but unless there is tumor invasion of the jugular vein or the carotid sheath, it is not necessary to sacrifice the jugular vein. Furthermore, the transverse cervical artery can be preserved for anastomosis as well as the superior thyroid artery, the anterior facial artery, and the anterior facial vein; and last but not least, we should preserve, if we can, the 11th nerve because if a free flap fails, it’s nice to have a trapezius musculocutaneous flap available.
116
David W. Furnas (closing): I want to thank Dr. Rappaport for his comments; it is his innovative modifications of the radical neck procedure that made it possible to combine these free flaps with lymphadenectomy. As you can see, the possibilities are limit-less. Each week we must dash to the anatomy lab to see if this week’s inspiration is valid. Since reconstructive microsurgery is the very essence of teamwork, and we usually have two teams going, it is a great opportunity to work shoulder to shoulder with surgeons from other specialties. I want to express my appreciation to the many colleagues that have referred these challenging cases to us. We are also indebted to Dr. John Connolly for his great encouragement in this work.
The American Journal of Surgery