Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery

Several methods can be used for identifying tissues for transfer in donor-site–depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Key points

  • Strategies for treating donor-site–depleted patients who require transfer of soft tissue or bone.

  • Fillet flaps from a severely traumatized lower extremity can be implanted to the forearm for temporary storage and transferred back to cover the amputated stump of the lower extremity.

  • Updates and summaries of arm transplant and postsurgical treatment.

  • The cosmetics of toe-to-hand transfer can be improved through insertion of free tissue transfers to the volar aspect of the transferred toe.

  • Diagnostic images and surgical treatment of breast lymphedema.

Video content accompanies this article at www.plasticsurgery.theclinics.com .

Introduction

Half a century after the advent of microsurgery, limited opportunities for straightforward innovations remain. However, many challenging clinical problems persist. Some of those difficult problems have been overcome with novel techniques and approaches. The lead editor (JBT) of this issue invited a panel of senior surgeons known for innovation to discuss their unique techniques and approaches to topics not covered by independent articles in this issue. The editor is pleased to present the wisdom, technique, and experience of these well-reputed surgeons.

Introduction

Half a century after the advent of microsurgery, limited opportunities for straightforward innovations remain. However, many challenging clinical problems persist. Some of those difficult problems have been overcome with novel techniques and approaches. The lead editor (JBT) of this issue invited a panel of senior surgeons known for innovation to discuss their unique techniques and approaches to topics not covered by independent articles in this issue. The editor is pleased to present the wisdom, technique, and experience of these well-reputed surgeons.

Flap prefabrication for donor-site–depleted patients

Jin Bo Tang: for years you and your colleagues have faced some of the most difficult situations in reconstructive microsurgery and treated those patients with innovative approaches. Can you summarize your current approaches for donor-site–depleted patients who have already undergone multiple microsurgical transfers, for whom lack of good donor tissues presents a problem?

Pedro Cavadas and Alessandro Thione

Complex reconstruction usually entails the use of specialized tissues. Such patients often have already been operated on, and optimal donor sites may be depleted. Flap prefabrication may allow the use of the required specialized tissues when the native donor areas are not available. Flap prefabrication comprises vascular induction with a vascular carrier, flap preassembly (mainly skeletal), and pregrafting (or prelamination). First described in the early 1990s, flap prefabrication has never become popular, in part because of its technical difficulty. Pregrafting has been well described and is not discussed here.

Vascular induction

Vascular induction is a modality of prefabrication that exploits natural wound healing and spontaneous vascular reconnection around vascularized tissue. The vascular carrier is usually thin microvascular subcutaneous tissue with a long pedicle, implanted under the surface to be transferred. Radial forearm or dorsalis pedis flaps are the most useful carriers; anterolateral thigh (ALT) flaps do not have a pedicle long enough for most indications. The pedicle should be planned to allow pedicled transfer of the prefabricated flap if possible. In facial reconstruction this is usually the case. The pink supraclavicular skin, the submental beard, or the hairy scalp can be transferred as a prefabricated flap for facial resurfacing in unfavorable cases. The external nose can be reconstructed with a prefabricated supraclavicular flap in the absence of frontal donor areas, using a radial forearm flap as a carrier ( Fig. 1 ). The entire nose can be prefabricated in the supraclavicular area using a dorsalis pedis flap for internal lining and vascular induction of the overlying pink skin, along with cartilage pregrafting in patients with multiple unsuccessful attempts with depletion of optimal donor areas ( Fig. 2 ).

Fig. 1
( A ) A patient with severe facial burn, after previous unsuccessful attempts at nasal reconstruction resulting in infected and exposed alloplastic material and depletion of both frontal forehead flaps. ( B ) The supraclavicular pink skin was used for flap prefabrication. A subcutaneous radial forearm flap was placed subdermally and anastomosed to the facial vessels. ( C ) Two months later the prefabricated flap was elevated and transferred as a pedicle flap for nasal external coverage. The remnants of the local flaps were recycled for internal lining. ( D ) End result after nasal reconstruction. The perioral area was reconstructed with submental flaps.

Fig. 2
( A ) Dorsalis pedis flap with long anterior tibial pedicle for complex nasal reconstruction in a patient with multiple previous attempts at reconstruction. Both frontal flaps had been used and lost because of recurrent infection. To minimize risk of infection, a remote complete prefabrication was performed. ( B ) The dorsalis pedis flap was used for internal lining and as a vascular carrier of the supraclavicular skin. Frugal skeletal construction was performed to maximize the contact surface between the vascular carrier and the overlying supraclavicular skin. ( C ) At 2 months the nose was ready for transfer. The skin was incised peripherally and sutured again to improve vascular supply from the underlying carrier. ( D ) The composite prefabricated flap, including the internal lining (dorsalis pedis), cartilage skeleton, and overlying supraclavicular skin, was transferred as a pedicle to the nasal defect. Because the skeleton was not manipulated at this stage, the risk of infection was minimal. ( E ) End result. There is a relative lack of fine details. The result is a compromise between enough skeletal support and unimpeded contact between the dorsalis pedis and the supraclavicular skin.

Skeletal preassembly

The number of possible donor areas for long cortical bone flaps is limited. In cases requiring reconstruction of long segments of bone, without available fibular donor areas and with poor indication of bone transport techniques, preassembly of smaller segments of bone to form a longer segment is an option. The construction is completed remotely, piggy-backing the vascular pedicles and with simplified plate-and-screw fixation. Once healed, the whole block can be free-transferred to the bone defect, allowing more formal internal fixation. The iliac crest free flap and the scapular angular bone flap can be piggy-backed and connected to the descending branch of the lateral circumflex femoral vessels distal to the cutaneous perforator. Minimal plate fixation reduces interference with blood flow. For example, a 20-cm long construct can be used for reconstruction of a massive femoral defect in an irradiated limb, combined with trifocal lengthening of the tibia ( Fig. 3 ).

Fig. 3
( A , B ) Massive defect of the left femur after radionecrosis and sepsis. The ipsilateral fibula was not usable and the contralateral one had been previously used. Bone transport was not feasible in irradiated fields. ( C ) The remaining iliac crest was elevated as a 10-cm vascularized bone. The only remaining thoracodorsal artery was used to elevate a 10-cm scapular angular bone. This flap was connected to the descending branch of the right circumflex femoral vessels, after the take-off of the cutaneous ALT perforator. ( D ) The iliac crest was anastomosed to the thoracodorsal vessels of the previous flap and it was plated to the scapula with a locking 3.5-mm reconstruction plate, creating a 20-cm bone flap. ( E ) Two months later, the preassembled flap was elevated including the ALT skin paddle on the circumflex femoral vessels and transferred to the left side. The pedicle was anastomosed to the pedicle of a previous latissimus dorsi flap end to side. Bone was fixed with a long locking compression plate. Because of hardware infection, the plate was removed at 1 month and replaced by an Ilizarov construct. The tibia was lengthened by bifocal callotaxis to compensate the short femur. ( F ) Final result with stable skeletal healing.

Prefabrication is a staged procedure that requires dissection and transfer of scarred tissues and vessels. It is complex, difficult to plan, and usually of long duration, calling for significant patient compliance. In return, it allows the transfer of nonanatomic tissue combinations or, in complex cases, may bypass the depletion of optimal native donor areas of specialized tissue.

Ectopic storage of fillet flaps from the lower extremity

Jin Bo Tang: ectopic implantation of an amputated hand for temporary storage at other anatomical sites has been reported over several decades and is currently used by some surgeons. Although ectopic implantation of a flap is uncommon, I know you have unique experience with this procedure. Our readers would appreciate hearing your thoughts and experience. To me, a better term is ectopic storage of a fillet flap, and this is neither implantation nor replantation; it is a temporary storage of a fillet flap. Please comment on a possible better terminology for this unique method.

Luis Landín

Reconstruction of the mangled leg typically results in 2-year outcomes equivalent to those of amputation. The energy expenditure of walking is exponentially related to the length of the lower extremity. Therefore, we perform revascularization or replantation of the lower extremity in patients with trauma less than the age of 60 years and retain almost the full length of the lower extremity ( [CR] ).

Crush injury associated with traumatic amputation of the lower limb is usually extensive and does not permit replantation. However, from the amputated part, fillet flaps can be harvested for coverage of the amputated stump or other tissue defects ( Fig. 4 ). Ectopic implantation of the fillet flaps allows for serial surgical debridement and adjuvant surgical procedures on the remaining stump and permits a period of several days to determine delimitation and necrosis of borderline tissues ( Fig. 5 ).

Fig. 4
Crushed stump at the level of middle third of the tibia. The distal third of the tibia was lost. The foot was deemed to be not replantable. However, the sole of the foot was uninjured.

Fig. 5
The stump was clean after being debrided twice and underwent an Ertl procedure.

Ectopic implantation requires radical debridement of the fillet flap. In the heavily crushed foot when the sole remains uninjured, we favor filleting a sole flap ( Fig. 6 ). Our favorite recipient vessels for ectopic implantation of a sole flap are the radial artery and its accompanying veins ( Fig. 7 ), because they provide a long pedicle when the ectopically implanted sole flap is transferred back to the lower extremity. However, occupational therapy is demanding, because a few days after ectopic implantation both the fillet part and the stump become edematous and the vessels and nerves granulate, hampering vascular anastomoses. If the ectopically implanted part is elevated based on a long pedicle, the clinicians can search for recipient vessels proximal to the injury zone at the stump, maximizing the chances for success. When the implanted flap is transferred back to the lower extremity, the flap remains edematous for long periods. Although it may take months for the sole of the foot to adapt to the curvature of the leg stump, coverage is excellent and permits prosthesis adaptation with few aesthetic sequelae in the forearm ( Fig. 8 , [CR] ).

Fig. 6
Sole fillet flap from the amputated foot. The posterior ( 1 triangle ) and anterior ( 2 triangles ) tibial vessels and the plantar nerves were preserved, in continuity with the plantar fat pad.

Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery
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