Reoperative Aesthetic & Reconstructive Plastic Surgery

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PATIENT EXAMPLE
A 4-year-old girl was brought to the emergency department after a massive scalp
avulsion that occurred when her hair was caught in the power-takeoff axle of a
tractor.The scalp had been brought with her and was judged suitable for replanta-
tion.
In the operating room, two arterial repairs were successfully completed. No veins
of suf cient caliber could be found to reestablish an adequate out ow despite ex-
tensive dissection and searching. The scalp was perfused and the edges were only
loosely approximated to allow bleeding. Unfortunately, venous congestion required
a return to the operating room the next day.The replanted scalp was removed and
used as a donor site for the harvest of split-thickness skin grafts. More than one
split-thickness graft was harvested from the avulsed scalp because of the thickness
of the skin.

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Two months later, the wounds were well healed and the patient and her family
asked for reconstruction.The defect was extensive:there was no hair-bearing scalp
on the top of the head. On the right side much of the temporal hairline and the
temporal and parietal scalp were absent. On the left side the remaining temporal
hairline was somewhat higher. A reconstruction program using soft tissue expansion
was planned.
Four months after the injury, three soft tissue expanders were placed under the re-
maining scalp. A 50 cc rectangular expander was placed under the right temporal
scalp,a 300 cc round backless expander was placed under the left side of the scalp,and
a 500 cc round backless expander was placed under the occipital scalp.The plan was
to surround the defect as much as possible and to expand all of the available scalp. Ex-
perience has taught that the expander should lie at when placed under tissues to be
expanded. Backless expanders were used because they can be folded when necessary
to best t the pockets dissected. Because the available scalp was limited, expanders
with back plates were avoided. Although folds in an envelope are usually trouble-
free, a folded stiff back might erode through the scalp, leading to exposure.

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Almost 3 months later, the rst scalp advancement was performed.The plan was to
advance the scalp and place larger expanders. Because the largest area of scalp lay
over the occiput, the plan was to preferentially expand the occipital scalp. Two
male-pattern baldness differential expanders were inserted under the advanced lat-
eral and posterior scalp.The differentially expanding ends, which would achieve the
greatest expansion, were positioned under the occipital scalp as can be seen in the
immediate postoperative view.
Three weeks later, on a return visit to the clinic, an exposure of the left expander
at the left temple suture line was observed. A small amount of drainage had been
noted at home. There was no purulence at the wound margin and she appeared
well. A smear of the wound surface was obtained, Gram stained, and examined im-
mediately by the surgeons.There were few polymorphonuclear leukocytes or bac-
teria seen.The exposure seemed to have occurred quite recently.

The patient was taken to the operating room for irrigation and debridement. A
closed suction drain was placed and the exposure site was closed. Postoperatively she
received parenteral and oral antibiotics. Cultures of the expander cavity obtained at
the time of the operation grew Streptococcus viridans.
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Six weeks later, after several injections had been performed in the clinic, the ex-
panders were expanding visibly. The treatment course to this point had been
smooth, but now the child seemed ill. Her mother reported increased irritability,
anorexia, and fever.The child appeared somewhat subdued in the clinic.The scalp
was slightly tender. Aspiration over the left injection port yielded a turbid uid that
contained abundant polymorphonuclear leukocytes and gram-positive cocci. She
was taken to the operating room where thorough irrigation and drainage were car-
ried out. A cephalosporin in saline solution was placed in the expander cavity af-
ter deflation of the expander devices. Closed suction drains were inserted and
placed to suction.The capsule surrounding the expanders appeared normal except
for some brin exudate in places. The scalp and adjacent soft tissues showed no
sign of cellulitis.To avoid extensive dissection and blood loss at a future date, the de-
cision was made to retain the expanders and simply drain the expander cavity.The
patient is shown after open irrigation and closed drainage for the periexpander in-
fection. Postoperatively, the patient received intravenous antibiotics for 4 days, and
then oral antibiotics for 10 days. Afterward, the expansion proceeded nicely.
Two and a half months later, the progress of expansion suddenly ceased and ex-
pander de ation was diagnosed. She was returned to the operating room for the
second scalp advancement to take advantage of the progress made and to replace the
expanders. A 300 cc backless expander was placed under the forehead skin and two
male-pattern baldness expanders were inserted as before, with the differentially ex-
panding ends located over the occiput. Her course was uncomplicated except for
some separation of the medial ends of the expanders.

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After 4 months of leisurely expansion during the summer after the injury, or
15 months after the initial injury, there was a noticeable gap between the ends of
the expanders in the midline under the occipital scalp. Because the unexpanded
area was xed to the occiput, she was brought to the operating room for a third
scalp advancement and placement of an occipital expander to ensure adequate ex-
pansion of the scalp.Without expansion of the scalp between the two expanders on
either side of the midline, the advancement of the occipital scalp would have been
severely limited.
Almost 3 months later, after satisfactory expansion of both the male-pattern bald-
ness expanders and the occipital expander, the patient was admitted for the fourth
scalp advancement procedure, this time of the scalp and forehead.

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Because of the large occipital expansion, the occipital scalp could be advanced far
forward.The temporal scalp also closed somewhat medially. It was possible to close
with almost total removal of the skin graft. Only a small area of skin graft remained
at the right anterior hairline. In the photo upper left, the scalp has been incised with
expanders in place. Upper right, the scalp and expander cavities are seen before ad-
vancement. Lower left, a trial advancement was done before excision of the skin
graft over the avulsion defect. The photo lower right shows nal advancement of
the expanded scalp and the expanded forehead.

The patient recovered without incident postoper-
atively. She could style her hair and was very
pleased with her appearance.
Two years after the injury, the patient had done
very well but the scalp had stretched back some-
what, widening the area of skin graft and moving
the anterior hairline somewhat more posterior
since the advancement 5 months earlier. There-
fore soft tissue expanders were placed under the
anterior scalp so that the scalp could be advanced
again with removal of all forehead skin graft. Be-
cause this young girl voiced a great fear of the
needles used for percutaneous injection of the ex-
pander ports, the expanders that were positioned on either side of the midline were
placed with the ports exiting through subcutaneous tunnels that opened behind
the ears, making the process of lling the expanders easier. Her early postoperative
course was fairly unremarkable. A small amount of drainage was noted from around
the tubing at the site where it entered the scalp.
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As the expansion proceeded,1 month later,the soft tissue expander appeared to move
somewhat downward under the scalp, and the ange that supported the tubing en-
try to the envelope actually protruded through the skin entry site, exposing the base
of the expander.Expansion was continued until measurements across the dome of the
expanders indicated that adequate expansion had been achieved to allow successful
advancement. An impetiginous crust developed over the right suture line, and was
treated with scrubbing and oral antibiotics.The problem resolved with treatment.

After another month, at advancement, the expanders were removed and the site of
the exposure was debrided. Granulation tissue was present, lining the capsule
around the tubing entry site on the right and around the exposure site on the left.
A routine culture of this tissue was carried out and organisms were recovered. De-
spite this infection, advancement of the scalp was possible, removing the widened
scar and skin graft and closing the tubing entry sites. Drains were left in place and
removed postoperatively. The patient tolerated the procedure well and obtained
additional improvement from this nal advancement. Her postoperative course was
uneventful. She is now able to style her hair almost any way she chooses.
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DISCUSSION
This case illustrates the full range of complications that can be encountered during
soft tissue expansion. Fortunately, as a surgeon’s expertise grows, dif culties pre-
sented here become rarer. However, certain patients, because of the size of the de-
fects, their inability to cooperate, or host factors that make the tissues less whole-
some, may experience dif culties.This patient suffered complications of exposure,
infection, de ation, and shifting of the expanders.Yet, despite these signi cant in-
terferences, a successful outcome was obtained.
Soft tissue expansion is particularly valuable because tissue viability is seldom threat-
ened by simple elevation. If proper care is taken during the expansion, it is unlikely
that tissue will be lost, even if other complications such as those experienced by this
patient, do occur.We wish to discuss elements of the management of this patient.
At the rst admission, this patient underwent surgery in an attempt to reattach the
scalp. If this reattachment had been successful, she would have been the youngest re-
ported patient to have successfully undergone scalp replantation in the literature at
that time. Unfortunately, we could not nd venous tributaries affording adequate
venous drainage, even after arterial anastomosis and reperfusion. A previous report
documenting the replacement of a portion of scalp and its ultimate survival, and our
knowledge of smaller composite replantations (for example, ngertip replantation)
prompted us to leave the perfused scalp in place with the hope that if adequate
drainage persisted until inosculation occurred, at least some scalp could be saved.
The following 12 hours showed that this strategy would not succeed, and the scalp
was promptly removed. Despite the failure of replantation, the avulsed scalp re-
mained important for wound closure. Because the scalp is thick, more than one
split-thickness skin graft may be obtained from its surface with subsequent satisfac-
tory take.
A segment of avulsed scalp may be harvested at least twice to obtain
skin to cover the defect.
Using this technique, we covered the avulsion defect completely with harvested
split-thickness skin grafts that closed the wound successfully.
At the second admission, 4 months later, three soft tissue expanders were placed
with the goal of expanding the occipital scalp and moving it up, over and across the
vertex like a visor advancement.The decision was made to use separate expanders
for reasons of convenience, and because we felt it would be dif cult to t one large
expander properly. There was also some concern that with the inflation of one
large expander, the corners might move forward, thinning the temporal scalp that

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had already been injured, especially on the right side where a large laceration had
been repaired at the initial surgery. To avoid local tissue problems, we believed it
would be advantageous to be able to control the rate of expansion in each major
area of the scalp. In retrospect, it may have been better for this particular patient to
carefully outline the remaining scalp and fashion a large single-lumen expander
that would have underlain the entire scalp and have expanded it all at the same
time. Such a tracing was made for this patient, but it was decided not to fashion an
individual expander in view of the above considerations. Using one expander does
offer signi cant advantages because webs of capsule at the site where adjacent ex-
panders touch do not develop;instead there is one smooth surface from one enve-
lope. In this patient such a web was a problem later in the treatment course.
At the third admission, 2 months and 1 week later, the rst scalp advancement was
carried out. She tolerated this surgery well, and the operation was successful. Our
goal was to expand the scalp and then advance it, followed by the immediate place-
ment of larger expanders underneath the scalp so that the process could be contin-
ued. It was desirable to change the expanders at this point because a more uniform
expansion could be obtained with larger expanders.The development of webs be-
tween adjacent expanders, which can limit advancement, would be eliminated by
the insertion of larger expanders that overlapped. An attempt was made to make the
pockets large enough so that the expander bases would not impinge on the suture
line. The pocket appeared adequate at the time of closure; however, at the fourth
admission 3 weeks later, it was clear that the pocket in the left temple area was
probably not wide enough. Although it is possible that this patient may have
scratched the area or picked it, it is more likely that the soft tissue expander en-
velopes pushed into the suture line, leading to exposure.
A great deal of thought went into the decision to simply drain the area without re-
moving the soft tissue expander. At this time the scalp was not under tension.The
patient was not ill, there were no signs of infection, and only scant evidence of col-
onization was found.To preserve the large pockets created and with the hopes that
reoperation and blood loss could be prevented, the decision was made to retain the
expanders after thorough irrigation and drainage of the cavities.
The patient was treated with antibiotics for several days in the hospital and then dis-
charged; an oral antibiotic regimen was prescribed. She did well and had begun
soft tissue expansion when she returned 6 weeks later not feeling well. Aspiration
over the injection port revealed a purulent uid.
The surgeon can obtain aspirate to determine whether infection is
present in the expander cavity by simply inserting the needle over the
injection port and aspirating some of the uid.

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This technique is successful even if a remote port is used. Purulent uid will track
along the tubing to the injection port, because the expander is in one cavity. Im-
mediate gram stains should be obtained to determine whether polymorphonuclear
leukocytes are present and whether bacteria can be identi ed. The material can
also be sent for culture and antibiotic sensitivity determinations for isolated organ-
isms. At this admission it was decided that an open operation would again be nec-
essary; the same concerns regarding the risk of leaving the expanders in place still
existed. Because of minimal tissue signs of in ammation, it was decided to proceed
with partial de ation of the expanders and insertion of drains after thorough irri-
gation. As before, the patient was treated with intravenous antibiotics for several
days and oral antibiotics on an outpatient basis. Soft tissue expansion was resumed
without dif culty after drain removal. She did very well until 10 weeks later, when
it became evident that the expansion, which had been proceeding nicely, was now
stalled by expander de ation.
At the time of exposure or overt infection of a soft tissue expander, the surgeon is
faced with a dif cult decision:to remove the expander or not. In most instances we
decide to remove the expander and carry out an advancement. At times it will be
impossible to effect an advancement.
In situations in which the patient appears ill and exhibits systemic
signs, or the survival of the tissue is threatened, it may be wiser to
simply remove the expanders, drain the cavity widely, and do nothing
more.
We have even gone so far as to leave the entire expander pocket open for the best
drainage possible; this maneuver, however, has never been necessary in the case of
a scalp expansion.
We recognize that the decision regarding drainage of an expander and continuation
of expansion without entire removal of the expanders is controversial. There are
precedents in cases of other prostheses, including heart pacemakers, vascular pros-
theses, metallic apparatus for orthopedic reconstructions, and implants such as Silas-
tic chin implants.
On the patient’s sixth admission, this time for replacement of leaking expanders, a
signi cant advancement was achieved despite the leaking that became evident af-
ter several weeks.We have removed soft tissue expanders from the scalp, breast, and
lower extremities only to discover there were multiple perforations in the en-
velopes. Obviously, satisfactory expansion can be achieved despite perforations and
a presumed slow leak.

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We have treated leaking expanders by aspirating the saline solution external to the
envelope and then rein ating the expander. After all available saline solution exter-
nal to the expander has been aspirated, a second needle is inserted while the rst
needle remains in place.The second needle enters the injection port and saline so-
lution is injected. As the envelope expands, this action will often force the saline so-
lution into the needle overlying the injection port with bevel down and further as-
piration can be carried out. Once the envelope is lled to the appropriate tenseness,
both needles are removed. At times when the silicone elastomer envelopes are ad-
jacent to the soft tissue capsule, the perforations are essentially closed and expansion
can proceed normally.
On the seventh admission, 4 months later, a third expander had to be inserted to el-
evate the occipital scalp. When soft tissue expanders are overlapped, one of three
things may happen. First, at sites where expanders signi cantly overlap, perhaps one
third to one half of their length, there is great impetus for continued overriding be-
cause the soft tissues will normally resist expansion. As in ation occurs, expansion
tends to become spherical, creating the smallest surface area for a given volume.
Therefore it is only natural that as one expander is lled, it slides over or under
the adjacent expander. Physics determines that this sequence will happen unless
the expander base plates are sewn down or the excursion of expanders is limited by
xation of their tubing or their shape.
Second, it is possible for two soft tissue expanders to stay exactly where positioned
next to each other, which has been the case in our practice on several occasions.
However, there is always a web of capsule that has a triangular cross-section that lls
the space between the two adjacent tissue expander domes.This web must be cut
transversely to allow the ap to advance, and sometimes it must be entirely excised
to allow shaping of a ap.This web is a bit of a nuisance, and when one expander
will do the job, that approach is preferred.
Third, the soft tissue expanders may drift apart.This scenario occurred in this case
and resulted in an unexpanded isthmus of scalp between the two differential scalp
expanders. This outcome meant a portion of the occipital scalp with the highest
density of hair was not expanded and could not be advanced.To obtain the proper
geometry to allow maximal advancement, an occipital expander was placed. Once
accomplished, soft tissue expansion proceeded smoothly.
After a full expansion of the occipital expander, and once measurements indicated
that satisfactory advancement would be possible, the patient was admitted for ad-
vancement three months after the third expander was placed. At this time it was
possible to advance the large visor of occipital scalp up across the top of the head
and forward.The anterior hairline was reconstructed.The advancement proceeded

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with some tension, however. As a result, there was significant stretch-back with
widening of the remaining skin graft scar to approximately three times its width
present at the conclusion of the advancement procedure 4 months earlier. Stretch-
back has been observed in a number of situations.The best defense is adequate soft
tissue expansion so that a tension-free closure can be accomplished.The degree of
widening of the postoperative scar seems to depend somewhat on the individual
and is site dependent; for example, sagittal scars always widen more than coronal
scars.
Because the patient desired elimination of much of the widened scar anteriorly,
another expansion was required. Five months later, this young girl was returned to
the operating room to insert the expanders. Expansion was performed during the
next 2 months.The vertex scalp was then advanced forward to allow successful re-
construction of the anterior hairline.
When planning the nal advancement procedure, because of the patient’s expressed
fear of needles, we elected to use exteriorized ports. It has been our experience
that such a fear is seldom a problem and can be usually overcome by simple con-
ditioning.We used to have patients rub the area of the injection port with a small
ice cube every day and in the clinic before injection. Now, topical local anesthetic
creams serve to anesthetize the area quite effectively and have supplanted the ice
cube method in our clinic. In the case of this particular patient, there was clearly an
element of secondary gain in her behavior.
Many surgeons have had great success using exteriorized ports. Our own experi-
ence has been mixed. In this patient the left expander migrated along the course of
the tubing and was eventually exposed.We still prefer buried ports when possible,
but we recognize the occasional utility of an exteriorized port.
This patient had a long and dif cult course.The end result is good. Subsequent to
the reconstruction reported here, she has grown into a young teenager who has
had one more scar revision on an outpatient basis. All has gone well for her, and she
and her family have recovered both physically and psychologically.
Although soft tissue expansion can be trying, with careful planning, meticulous ex-
ecution, good judgment, and persistence, remarkable results may be obtained.This
case catalogs the dif culties encountered in one patient. Taken singly, each of the
complications was by no means unusual. It should be stated, however, that we have
never had so many complications in one patient before or since.This patient, there-
fore, is all the more valuable for study, and we share the history of her treatment
course in the hope that the information presented will lead to safer and more suc-
cessful soft tissue expansion for future patients undergoing soft tissue expansion.

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GENERAL CONSIDERATIONS
Soft tissue expansion can be very effective in reconstructing major soft tissue de-
fects. Attention paid to several simple principles will aid the surgeon and the patient
in their quest for a successful reconstruction. Perhaps most important for success is
recognition of the link between surgeon and patient;the process of expansion will
bind them together on what may be a rather lengthy journey that cannot be
rushed.
The rst and foremost principle of tissue expansion is that the process
cannot be hurried.
The time course of expansion must be governed by the tolerance of the patient,
who should never sense pain, and by the appearance of the tissues being expanded.
Tissues should not become thinned by the process if enough time is allotted and in-
ation pressures are kept low. Adequate expansion time is important not only to
preserve the integrity and quality of the soft tissues being expanded, but also to
permit complete expansion. Expansion should proceed until it affords a ap of di-
mensions suf cient to allow reconstruction of the defect without tension. Perhaps
the most common error in soft tissue expansion is rushing the expansion. This
causes discomfort, expander exposure, and, even more common, an imperfect re-
construction resulting from the expanded ap being too small to do the job in-
tended.
Planning is crucial to success. The surgeon should begin by determining where
the final scars should lie, and then decide where to place the expander—under
what tissue and through which incision.
Ideally, the incision for expander placement is eliminated by the ad-
vancement.
The surgeon should attempt to minimize the scar burden for the patient. Often
this incision can be located at the edge of the defect.This site poses little risk if the
tissue is of good quality.
Usually the largest expander possible should be used. Expander size is, of course,
limited by the tissue available for expansion, and at times by the geometry of the
defect. In general, however, using the largest expander possible works best. Some-
times the patient is best served by the fabrication of a custom expander that can
serve in the place of two or more conventional off-the-shelf expanders.The use of
one large expander will for the most part eliminate the problems of webs of tissue
between adjacent expanders and inadequate expansion caused by the migration of
adjacent expanders.

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In addition, the larger the expander and the larger the dimensions of
the expanded ap, the greater the ap’s mobility at the time of inset.
A word should be added about making the decision to return to the operating
room for advancement of the expanded aps. When does the surgeon know that
the time is right? First, the base of the tissue expander is measured by sight, from
one edge where it rises above the plane of the unexpanded tissue to the other side.
Next, the arc of the expander is measured from side to side with a exible tape
measure. Subtracting the base width from the arc length provides an estimate of
the advancement that is possible. By following this measurement in the clinic, the
surgeon can know when enough tissue is available to allow a successful expansion.
The above measurements are not foolproof, however. Expanders that have a round
base or rectangular expanders that are nearly square produce hemispheric expan-
sions. Hemispheric aps do not advance well over at or cylindrical surfaces be-
cause the perimeter of the ap is not very elastic. This realization prompted the
design of the croissant expander, thus named because the crescent-shaped expander
enlarges to resemble the French pastry. Using the croissant expander to half sur-
round the defect provides a dimensionally matched advance with a minimum of
scar and no soft tissue redundancy. Now the conventional croissant design has been
advanced with the introduction of the adjustable-base expander shown above (Spe-
cialty Surgical Products, Hamilton, MT).This expander can be made long or short,
and the angle can be changed between the arms.This design allows each expander
to function as a custom expander for the defect to be treated. Four sizes can han-
dle any defect. The adjustable design is complemented by an integrated magnetic
port for easy detection and con dent lling, especially by people performing ex-
pansion at home or medical personnel with less experience.
Croissant expander

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De ation is seldom a problem. Leaks are sometimes discovered to the surgeon’s
surprise at the time of expander removal. Should a leak occur with concomitant
de ation and inability to continue expansion, the expander should simply be re-
placed, or its tube or remote port may be replaced, depending on the site of the
leak. The occurrence of a leak should not be regarded as a catastrophe. The ex-
pander can be replaced in a short outpatient procedure with the patient under lo-
cal anesthesia in all but pediatric patients and the most anxious adult patients.
Exposure is most often the consequence of infection. Despite skin preparation,
prophylactic antibiotic administration, drainage of the expander cavity, and care ap-
propriate to a given patient, infection is still an occasional problem. In most cases
the prudent decision is to remove the expander, allow a period of recovery, and
eventually replace the expander. The patient and surgeon should be encouraged
by the knowledge that no tissue will be lost and that a fully successful expansion is
probably possible after resolution of the infection.
Although some surgeons are reluctant to embrace the concept of expansion at
home performed by the patient and family members, patients themselves eagerly
pursue this option when it is offered. Home expansion saves money and time,
makes the patient an active partner in the process of reconstruction, and builds self-
esteem. For these reasons home expansion is a valuable part of the process of recon-
struction surgery. Patients are uniformly successful in this endeavor and generally
appreciative of the responsibility and con dence invested in them.
Tissue expansion has come of age. Its utility is widely recognized. With patience
and adherence to a few principles, both the patient and the surgeon are well served
by this technique.
References—With Key Annotated References
1. Manders EK, Schenden MJ, Hetzler PT, et al. Soft tissue expansion:Concepts and complications.
Plast Reconstr Surg 74:493-507, 1984.
An early paper in the history of soft tissue expansion describing the design strategies for using the tech-
nique and the complications that one sees.The unique advantages of tissue expansion are listed and
discussed. Major and minor complications are presented.
2. Antonyshyn O, Gross JS, Mackinnon SE, et al. Complications of soft tissue expansion. Br J Plast
Surg 41:239-250, 1988.
3. Neale HW, High RM, Billimire DA, et al. Complications of controlled tissue expansion in the
pediatric burn patient. Plast Reconstr Surg 82:840-845, 1988.
4. Elias DL, Baird WL, Zubowicz VN. Applications and complications of tissue expansion in pe-
diatric patients. J Pediatr Surg 26:15-21, 1991.
Another in a series of papers over the years documenting the seemingly greater challenge of tissue ex-
pansion in the pediatric age group.

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Suggested Readings
Manders EK, Au VK, Wong RKM. Scalp expansion for male pattern baldness. Clin Plast Surg
14:469-475, 1987.
Tissue expansion can be used for very impressive reconstructions of male-pattern baldness.The only
drawback is the temporary deformity, which can largely be disguised with appropriate hats.The ad-
vantage of rapid, complete reconstruction with uniform hair distribution in a natural pattern has much
to offer.
Manders EK, Graham WP III, Schenden MJ, et al. Scalp expansion to eliminate large scalp defects.
Ann Plast Surg 12:305-312, 1984.
The rst paper to describe scalp reconstruction using soft tissue expansion. Serial expansion is de-
scribed.The effectiveness of reconstructing hairless defects with scalp of uniform hair distribution is well
documented.
Manders EK, Oaks TE, Au VK, et al. Soft tissue expansion in the lower extremity. Plast Reconstr
Surg 81:208, 1987.
The experience of tissue expansion in the lower extremity is described.The chance of periexpander in-
fection is 80% if tissue expansion is used in patients with an open wound at or below the knee.
Manders EK, Saggers GC, Diaz-Alonzo P, et al. Elongation of peripheral nerve and viscera contain-
ing smooth muscle. Clin Plast Surg 14:551-562, 1987.
Tissue expansion can elongate tissues other than those of the integument. Peripheral nerve, ureter, and
even small bowel can be lengthened through tissue expansion. Intraluminal expansion of viscera con-
taining smooth muscle in their walls results in massive mural hypertrophy that negates any increase
in diameter.
McCarthy CM, Pusic AL, Disa JJ, et al. Unilateral postoperative chest wall radiotherapy in bilateral
tissue expander/implant reconstruction patients: A prospective outcomes analysis. Plast Re-
constr Surg 116:1642-1647, 2005.
A small prospective study of the natural history of irradiation of the breast reconstructed using tissue
expansion with the nonradiated side serving as control. Radiation did increase the incidence and
severity of capsular contracture, but the results overall were thought to be acceptable.

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1. Can an area of soft tissue be expanded more than once, and how soon can a re-
expansion, if possible, begin?
a. Never reexpand an expanded ap of soft tissue
b. You may reexpand beginning about a year after the last advancement sur-
gery
c. You may begin in about a month
d. You may begin in about a week after an advancement
e. You may begin immediately, stressing the line of closure with a tense ex-
pansion
2. How do you know when it is time to go to the operating room to perform an
advancement?
a. The patient tells you he and she is ready
b. The patient’s family tells you they are ready
c. The referring doctor tells you he/she is ready
d. You feel ready
e. Measurements reveal that you have the increase in tissue dimensions to al-
low the intended reconstruction
3. How do you know if there is an infection around an expander?
a. The patient feels like he/she “has the u”
b. The area of the expansion is red
c. The area of the expansion is tender
d. Aspiration over the port returns a turbid uid
e. All of the above
4. How is a periexpander infection treated?
a. Treat with expander removal, irrigation, and ap advancement
b. Remove the expander and pack open
c. Remove the expander, irrigate, and close over drains
d. Remove the expander, sterilize it in the autoclave or replace it, irrigate
and debride, replace the expander over a drain, and close
e. Potentially each of the above could be used depending on the circum-
stances of the case
5. Can expansion be conducted safely in the patient’s home?
a. Yes, with appropriate instruction given to the patient and family
b. No, it should be performed by a doctor on every occasion
c. No, it should be performed by a nurse in a medical of ce
d. No, it is against the law
e. Only if one uses osmotically driven expanders
R EVIEW QUESTIONS

(Trang không có chữ)

195
Failed and Failing Free Flaps
William C. Lineaweaver, Stephanie A. Stover,
and Jacob Gerzenshtein
C ha pter 9
Reoperative Problems
Detection of ap circulation
Recognition and management of
impairment
ap failure
Nonoperative intervention
Reconstruction after ap failure
Operative reexploration
You do what you can as long as you can,
and when you nally can’t, you do the next best thing.
You back up, but you don’t give up.
Chuck Yeager
A surgeon’s approach to failing and failed aps consists of a complex of judg-
ments and actions. Recognition of ap circulation problems needs to come as close
as possible to the onset of the problem.Treatment should progress quickly through
nonoperative maneuvers to operative reexploration and anastomosis revision. A
failed ap requires thorough reassessment of reconstructive goals and options.
Microsurgical ap procedures are established reconstructive options for dif cult
and extensive defects of the head and neck, trunk, extremities, and genitalia.1-4 Mi-
crosurgical aps can be used for such diverse problems as total scalp loss, mastec-
tomy defects, and loss of a critical ngertip. In such areas as mandible reconstruc-

196
PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
tion and thumb reconstruction, microsurgical aps (for example, bula reconstruc-
tion of the jaw and toe reconstruction of the thumb) clearly show how micro-
surgery has revolutionized reconstructive strategies from prolonged series of staged
procedures to single-stage surgeries that can provide reconstructive units of vascu-
larized tissue with a variety of components.5
Since the 1980s, ap failure rates have been between 2% and 10% in large micro-
surgery series.6,7 Flap failures, although rare, are always a severe setback for the pa-
tient and surgeon and can be limb threatening, deforming, or fatal. Recognition of
ap complications preceding ap death can lead to interventions that can result in
ap rescue. Effective secondary strategies applied after a ap failure can lead ulti-
mately to satisfactory and functional outcomes for patients where initial microsur-
gical reconstruction failed.
DETECTION OF FLAP CIRCULATION
IMPAIRMENT
INTRAOPERATIVE INSPECTION
Clearly, the best time to detect and correct a circulatory complication in a micro-
surgical ap is at the time of the initial procedure. At the completion of the arte-
rial anastomosis, visible pulsations and lling of the pedicle artery, evidence of ap
perfusion (visible tissue perfusion, Doppler signals from the ap artery), and pedi-
cle venous return should be systematically con rmed by the surgeon. After com-
pletion of the venous anastomosis, the surgeon should con rm recipient vein ll-
ing. Sustained dilation of ap pedicle veins should be immediately evaluated for
possibilities of recipient vein obstruction.
After completion of the vascular anastomoses, ap procedures include ap inset,
donor site repair, and sometimes skin grafting. During these steps of the procedure,
the ap should be examined periodically for color changes or for loss of Doppler
signals.
Throughout the initial flap procedure, any evidence of perfusion compromise
should lead to careful inspection of the vascular anastomoses and implementation
of revision strategies such as the ones discussed later in this chapter.
POSTOPERATIVE MONITORING
Dressing, Splinting, and Positioning
The rst step toward effective postoperative examination is the application of dress-
ings and splints at the conclusion of the ap procedure. Dressings around and on a
ap should be minimal.

197
Chapter 9
Failed and Failing Free Flaps
In the lateral arm ap to a rst web space shown here, the dressing supplies a splint
to aid with stability and elevation, and a wide window for ap inspection. Dressings
should avoid any possibility of compressing the ap, and the ap should be par-
tially or totally visible for periodic examination. Splints should be applied as nec-
essary for skeletal stability and should be well padded and constructed to avoid ap
and pedicle compression. Splints can be effective stabilizers for postoperative ex-
tremity positioning. Speci c attention should be paid to patient positioning fol-
lowing microsurgical ap procedures.
Extremities should be comfortably but securely elevated to minimize swelling, but
potentially constricting slings or restraints should be avoided.
Flap at wrist
UPPER EXTREMITY FLAP

Head: Position of comfort
Hand/wrist: Above elbow
No circumferential suspension
or fixation
Flap
LOWER EXTREMITY FLAP

Head: Position of comfort
Upper extremities: Free
Lower extremity: Knee straight,
foot above knee

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SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
Patients with aps to the head and neck or breast can be effectively and comfort-
ably positioned with the head of the bed elevated to produce a reclined sitting
posture.
Clinical Examination
Some aps, such as those used for esophageal reconstruction or femoral head revas-
cularization, cannot be examined, but all aps with at least a partial component on
the surface of the body can be clinically evaluated. Even buried aps can be in-
spected if they are designed to have an externalized component (the so-called mon-
itoring ap).8,9 Generally, a knowledgeable observer who periodically inspects the
ap can reliably detect signs of arterial obstruction (pallor, loss of turgor) and venous
obstruction (increasingly brisk capillary return, cyanosis, distension).
Clinical detection of a vascular complication is necessarily dependent on
secondary changes; thus a vascular complication can be long-standing by
the time it is grossly indicated by visible changes in the ap.
Monitoring
Many devices have been applied to the task of monitoring ap circulation follow-
ing a microsurgical procedure. These instruments fall into two general categories:
(1) devices for detecting circulatory obstruction by measuring a physiologic pa-
rameter, such as temperature, tissue pH, or tissue electrical conductivity, and (2)
monitors that directly evaluate arterial circulation, venous circulation, or both.10
How effective are ap-monitoring devices? Despite an extensive literature on ap
monitoring published over several decades, useful data applicable to this question
are scarce.
Flap
HEAD AND NECK FLAP

Head: Elevated
No pressure on flap
Flap
BREAST FLAP

Head: Elevated; position of comfort
Arms: Free
Minimal dressings on flap margins
without circumferential wrapping

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Chapter 9
Failed and Failing Free Flaps
One basic error that limits the assessment of many monitoring systems is the appar-
ent detection of uncomplicated aps as a measure of monitoring success.11 For ex-
ample, if a ap monitor applied to a series of 100 aps gives a signal that all the aps
have uncomplicated circulation, and 95 of the aps survive, the ap monitor may
be reported as having a 95% success rate.The problem is that a monitor should not
be evaluated by its performance relative to uncomplicated aps. Meaningful out-
comes of ap monitoring should be based on detection of complicated aps and,
more precisely, the eventual survival of those complicated aps after operative res-
cue attempts.12
Complicated microsurgical flaps detected by clinical examination alone are re-
ported to have salvage rates of about 55%.8 Only four monitoring devices have
been reported to be associated with higher salvage rates than clinical monitoring:
the hand-held Doppler, quantitative uorimetry, laser Doppler owmetry, and im-
plantable Doppler probes.
Salvage Rates of Complicated Microsurgical Flaps
Salvage
Author
Monitoring Method
Rate (%)
Cho et al8 (2002)
Clinical examination
55
Disa et al13 (1998)
Surface Doppler
77
Whitney et al12 (1992)
Quantitative uorimetry
86
Goldberg et al14 (1990)
Laser Doppler
83
Kind et al15 (1998)
Implantable Doppler
100
Flap
The hand-held Doppler has been used as an easily applied adjunct to clinical ex-
amination. It is applied directly to the ap, and an audible signal is obtained. The
probe is best suited to monitoring arterial pulsations, but venous ow may also be
detectable. Salvage of complicated aps detected by this method has been reported
to be as high as 67% to 77%.13

200
PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
With quantitative uorimetry, a 2-hour injection cycle of uorescent dye is used to
monitor arterial in ow and out ow. A light source is connected to an otoscope-
shaped projector-reader, which ashes ultraviolet light onto the ap surface, and
then reads subsequent uorescence, which is related to the amount of uorescein
in tissue. The technique requires a skin component, and it does not work on pig-
mented skin, freshly applied skin grafts, or muscle. An 86% salvage rate of compli-
cated aps and toe transplants has been reported using this monitoring method.12
In laser Doppler owmetry, laser light is transmitted to a probe on the ap by a
beroptic cable.The probe detects capillary ow by scatter and wavelength change
in the re ected light.The source translates the probe data into an estimated ow ex-
pressed numerically.Thus laser Doppler provides a continuous monitor of capillary
ow, and signi cant decreases from baseline readings are associated with ap circu-
lation complications. Flap salvage rates using this monitoring method have ranged
from 69% to 83%.14
Flap
Flap
Functional arterial inflow
and venous outflow
Venous occlusion
Arterial occlusion
F
l
u
o
r
i
m
e
t
r
y

u
n
i
t
Time
Injection
0
10
20
30
40
50
60

201
Chapter 9
Failed and Failing Free Flaps
Implantable Doppler probes have been used to directly, audibly, and continuously
monitor ow distal to arterial and venous pedicle anastomoses. Monitoring the ve-
nous pedicle alone may be a very sensitive early detection strategy; one report de-
scribes 100% salvage of complicated aps using this method. Another advantage of
this monitor is that it can be applied to all tissue types as well as to buried aps.15
All monitoring systems must ultimately be judged by their ef cacy in in-
dividual practices and sites. Factors including false-positive alarms, cost,
and technical limitations of staff can set limitations of application of any
monitoring system, and each practicing microsurgeon must make deci-
sions about monitor utilization based on speci c needs and conditions.
Will there ever be an ideal clinical monitor for ap circulation? Power Doppler
imaging systems provide real-time dynamic images of arterial and venous circula-
tion, and the visualization of vessel ow is enhanced by audible signals and estimates
of blood flow. Continued refinements and affordability of this technology may
make it a real-time, noninvasive window on ap circulation.16
NONOPERATIVE INTERVENTIONS
When compromised ap circulation is suspected or identi ed postoperatively, some
speci c nonoperative interventions can be undertaken while a decision for opera-
tive exploration is nalized.
DRESSING R EMOVAL AND PATIENT POSITIONING
For a ap with questionable circulation, an initial intervention should be complete
removal of all dressings on or around the ap.This maneuver allows complete ex-
amination of the ap and removal of any constrictive or compressive dressing ele-
ments.
Artery
Vein
Flap

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For extremity aps, positioning of the ap and extremity should be evaluated at this
time. Extremity positioning should follow the rules of “foot above knee” and “hand
above elbow” to avoid dependent hands and feet with proximal extremity elevation.
Slings and positioning pillows, if used, should be adjusted to avoid extremity or
ap compression.
INSET R ELEASE
Inspection of the ap may reveal tension of the ap inset over the pedicle or a tight
skin closure over the pedicle. In some cases, inset suture or skin closure sutures can
be released at the bedside and the effect on ap circulation assessed. If no vessels or
signi cant underlying structures are exposed, these areas may often be allowed to
heal with dressings.
In some cases, an underlying hematoma may also be relieved by partial inset release,
and this drainage may restore the ap circulation by relieving compression.
ANTICOAGULATION
Anticoagulation medication as an adjunct to microsurgical ap procedures has a
long and inconclusive history. Such agents are often used in complicated circum-
stances, and their actual effects are dif cult to determine.17
For a ap with questionable or failing circulation, systemic heparin may be admin-
istered in the hope of averting clot development and propagation. Heparin admin-
istration is variably used by microsurgeons, with doses ranging from full therapeu-
tic anticoagulation (with frequent bleeding at donor and recipient sites) to fractional
doses that may not change the results of clotting studies. When it is used, heparin
administration generally continues for 5 to 7 days after initiation. Low-molecular-
weight dextran may be administered as a volume expander, and there is some
evidence that it may function as a fibrinolytic in capillary beds. In adults, low-
molecular-weight dextran is commonly given as an infusion of 25 ml/ hr for 3 to
5 days after the ap procedure.
LEECHES
Leeches function as a route for evacuation of venous blood in tissue that has arte-
rial in ow but inadequate venous out ow. These creatures have a recognized and
ef cacious role in complicated replantation cases, but their utility in aps is very
limited.

203
Chapter 9
Failed and Failing Free Flaps
Leeches remove blood until venous out ow is established between compromised
tissue and its bed. In replanted ngers, this venous revascularization can occur as
quickly as 3 days, and leeches can be used for this period, as long as the tissue arte-
rial circulation is intact. Leeches drain off suf cient amounts of blood to require
transfusion in some cases.18,19
Leech use in large aps is a questionable undertaking. It is not clear that leeches ad-
equately drain large tissue units, and blood loss could be prohibitive. Leeches only
attach to skin, so they are not effective on tissue surfaces with muscle or fresh skin
grafts.18
Leeches may be considered in complicated small cutaneous aps when reopera-
tion seems unfeasible.20 Arterial ow to the tissue must be intact for any hope of
success, and the patients should be given systemic antibiotics effective against
Aeromonas hydrophila to prevent infection by this leech-borne bacterium.21
OPERATIVE REEXPLORATION
TIMING
Generally, operative reexploration of a compromised microsurgical ap should be
considered as soon as the complication is recognized or strongly suspected.
During the initial operation, the pedicle vessels should be reinspected at any time
during the procedure if circulation appears unsatisfactory.22
Postoperatively, surgical reevaluation should be prompt.Warm ischemia times of 4
hours for muscle aps and 6 to 10 hours for skin aps and toes are generally asso-
ciated with irreversible tissue damage.23

204
PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
EXPOSURE
In surgery, the rst maneuver in exploring a complicated ap should be recreating
the exposure used for the initial vessel anastomoses.This exposure may require par-
tial release of the ap inset, complete reelevation of the ap, or extended incisions.
This 31-year-old man lost his thumb, index, and middle nger in a crush injury. Re-
construction consisted of a great toe transplant to the thumb position.The dorsalis
pedis artery to the toe was connected end-to-side to the dorsal radial artery. In the
recovery room, arterial occlusion was diagnosed clinically. Reexploration consisted
of exposure and inspection of the vascular anastomoses, followed by revision of the
end-to-side anastomosis to an end-to-end anastomosis. Healing of the toe trans-
plant was uncomplicated thereafter, and the patient went on to have a functional
result.
If the complication consists of vessel kinking or compression from a hematoma,
pedicle exposure alone may correct the problem.The reinset must be designed to
prevent recurrence of the complication. The ap inset can be revised to change
the course of the pedicle or eliminate angulation. Local aps from the margin of the
recipient site can be considered, and split-thickness skin grafts can be directly ap-
plied to areas of pedicle vessel exposure with satisfactory healing, especially in small
areas.24

After evacuation of a hematoma, any obvious bleeding points should be controlled,
either in the ap or in the bed. The recipient and pedicle vessels should be evalu-
ated microscopically to detect unsecured branches or other sources of bleeding in
these critical structures, and microscopic techniques of either suturing or clip ap-
plication should be used to control bleeding points.
Drains may be carefully placed beneath the ap. If suction drains are used, they
should be positioned so that they are reliably isolated from the area of the vascular
pedicle.
R EVISION OF ANASTOMOSES
Exposure of the pedicle and recipient vessels allows microscopic evaluation of the
anastomoses. Thrombosis is usually visibly obvious, but partial anastomotic take-
down can be done initially if circumstances are not clear.
Once thrombosis is identi ed, the affected vessel is controlled with microvascular
clamps, and the immediate area of the anastomosis is resected. Attempting subtotal
revision of an anastomosis after clot removal using the frayed margin of the origi-
nal vessel repair is often unsatisfactory.
Inspection of the resected anastomosis can be useful. Detection of a technical prob-
lem (such as a back-wall stitch) can be transiently mortifying for the surgeon but ul-
timately reassuring since a competent second anastomosis may be the key to rescue.
In revising the arterial anastomosis, the surgeon must be certain that the recipient
vessel still has satisfactory ow. If ow is poor or absent, a more proximal site on the
artery must be explored, or another recipient artery selected. Either of these cir-
cumstances may require a vein graft;thus a suitable vein graft donor site should be
included in the patient positioning and preparation for surgery.The pedicle artery
should be carefully cleaned of all clots by extraction and irrigation. If the recipient
and pedicle arteries are satisfactorily dissected and declotted, a second arterial anas-
tomosis is then performed. After its completion, the surgeon should be satis ed
with its ow and should con rm venous return.
Venous anastomotic thrombosis should also be approached by vessel control and re-
section of the anastomosis. All clot should be carefully removed and ow from the
pedicle vein con rmed. If there is no ow from the pedicle vein, the artery should
be reinspected and revised as necessary. If the artery is patent, absence of venous
ow may indicate infarction of the ap with a no-re ow phenomenon.
The recipient vein is then con rmed to be patent by irrigation. If the vein does not
irrigate easily, then another vein may need to be used.These eventualities may re-
quire vein grafting. When both the recipient and pedicle veins are found to be
functional, a second venous anastomosis is performed.
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Chapter 9
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PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
After revision anastomoses, the surgeon should inspect the ap for satisfactory per-
fusion and then reinspect the anastomoses for evidence of uncomplicated ow.The
inset placement should take into account any swelling of the ap and recipient site
tissues, and consider local aps and skin grafts as necessary. Administration of sys-
temic heparin and dextran, as well as local irrigation with heparin, brinolytics,
and vasodilators can be considered at any time.
ALTERNATIVE R ECIPIENT VESSELS
At reexploration, the surgeon may nd that the original recipient vessels are unsuit-
able for another attempt, either because of extensive clotting or progression of some
initial damage. Alternative recipient vessels should be promptly considered.
In the head and neck, super cial temporal vessels can be replaced by facial vessels,
usually requiring vein grafts if the ap is in the midface or higher. Nonfunctional
facial vessels can be replaced by going directly to the external carotid artery and
jugular veins.25 If one side of the neck is extensively damaged by scar and radiation,
making the major vessel mobilization dif cult, recipient vessels from the other side
of the neck can be used with submental vein grafts.26 The cephalic vein can also be
brought up to the neck as a recipient vessel.27
External jugular vein
Facial artery
Superficial temporal artery
External carotid artery
Cephalic vein
Lingual artery
Hypoglossal nerve

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Chapter 9
Failed and Failing Free Flaps
The recipient vessels for the upper chest are used most often for breast reconstruc-
tion.The surgeon should be able to utilize thoracodorsal vessels, including serratus
branches, internal mammary vessels, and thoracoacromial vessels.22,28 The external
jugular vein and the cephalic vein can also be brought to this region.29
External jugular vein
Thoracoacromial artery
Thoracodorsal artery
Cephalic vein
Internal mammary artery
Ulnar artery
Radial artery
Dorsal radial artery
In the upper extremity, the surgeon should be able to use digital vessels, deep and
super cial arches, and dorsal vessels as necessary for toe transplants and other aps
to the hand. In the forearm, end-to-side anastomoses may be necessary if an initial
unsatisfactory recipient site requires use of a single remaining vessel in the arm.

208
PART II
SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
Peroneal artery
Anterior tibial artery
Posterior tibial artery
Dorsalis pedis artery
Deep inferior
epigastric
artery and vein
Superficial
circumflex iliac
artery and vein
Femoral
artery and vein
Saphenous vein
Similarly, in the lower extremity, an initial vessel
choice may fail, requiring careful end-to-side
anastomosis to a single functioning artery in the
leg or to the popliteal artery proximally.30
Flaps to the groin and pelvis are rare but critical
procedures when undertaken for such problems
as extensive defects or penile reconstruction. Re-
cipient sites in this region include the femoral
vessels, the deep inferior epigastric vessels, and,
with less consistency, the super cial circum ex il-
iac vessels.The saphenous vein can be turned up
to this region, and remote pedicles, such as the
thoracodorsal vessels, can be considered with long
vein grafts.31

ALTERNATIVE FLAP VESSELS
Some aps have alternative vessels that can be considered for salvage if the initial
pedicle vessels cannot be reused. The radial forearm ap can be drained either by
veins accompanying the radial artery or by subcutaneous veins. If either system
fails, the other system can be explored.32 The rectus muscle ap can be sustained by
the superior epigastric vessels if the deep inferior epigastric pedicle cannot be
used.33 The super cial inferior epigastric vessels can be used as alternatives if the
original pedicle of the deep inferior epigastric perforator ap is compromised.34
The skin paddle of the deep circum ex iliac crest ap can be independently vascu-
larized through the super cial circum ex iliac vessels.35
RECOGNITION AND MANAGEMENT
OF FLAP FAILURE
NO R EFLOW
Recognition of a failed ap is an important clinical decision. At reexploration, a
ap that has obvious tissue changes and no venous out ow should be declared dead
and removed despite patent arterial ow.36 Delays at this point only prolong subse-
quent complications of infection or fruitless systemic anticoagulation.
DEBRIDEMENT
Operative debridement after a failed ap can be an important and sometimes mul-
tistaged part of management after ap failure. Most aps die completely when they
fail, but the recipient beds can very rapidly develop signi cant granulation tissue.
The goal of debridement should be careful removal of dead tissue with sparing of
any viable tissue. Cultures can be obtained, especially if infection is present in the
original lesion or complication.
INTERVAL DRESSINGS AND COVERAGE
The defect can initially be managed by debriding dressings, such as saline solution
on gauze wet-to-dry dressings. A clean, stable wound can be treated with a vacuum
dressing device to minimize dressing changes during any prolonged interval be-
tween ap failure and subsequent procedures. Speci c wounds may be managed
comfortably with allografts for extended periods of time.37
209
Chapter 9
Failed and Failing Free Flaps

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SALVAGE AFTER A FLAP FAILURE
EVALUATION AND R ECONSTRUCTIVE GOALS
Failure of a microsurgical ap procedure forces the patient and surgeon to reassess
the original reconstructive goal and factor in the elements of patient motivation and
surgeon con dence. Some reconstructive problems leave little choice but to con-
sider another microsurgical procedure. Large areas of scalp loss, skull-base defects,
and defects of the mandible and oropharynx condemn patients to extraordinary
morbidity if not satisfactorily reconstructed, and frequently another microsurgical
ap is the only alternative.
This 40-year-old patient developed chronic osteomyelitis following an open distal
tibia fracture. An initial reconstructive attempt consisted of sequestrectomy, excision
of his chronic soft tissue wound, and a rectus microsurgical ap based on an end-
to-side anastomosis to the posterior tibial artery, the patient’s only remaining arte-
rial supply to the foot. On day 5, the ap failed because of venous thrombosis.The
ap was debrided with preservation of the posterior tibial artery. The wound was
treated with dressings.The patient remained committed to limb salvage. After sta-
bilization of the wound, the patient underwent rotation of his long medial gastroc-
nemius muscle belly to the fracture site. A skin graft was applied after muscle via-
bility was clear in 3 days. A residual distal wound was covered with a delayed distally
based fasciocutaneous rotation ap. The patient had stable coverage and no evi-
dence of infection 2 years after this nal reconstructive procedure.

This 28-year-old man suffered a crush injury to his hand with loss of his thumb,
three nger metacarpals, exterior tendons, and dorsal skin. Initial reconstruction
was attempted using an iliac crest osteocutaneous ap based on the dorsal radial
vessels as recipients.This ap failed.The wound was thoroughly debrided and the
hand skeleton was stabilized with an external xator. A latissimus dorsi ap was
then successfully transplanted to the radial vessels and covered with a skin graft.
Subsequent procedures, including index pollicization, rib grafts to the metacarpals,
and two-stage exterior tendon grafting, have resulted in a functional hand.
A patient with a failed second toe to ngertip transplantation, however, may choose
to live with the original amputation. A patient with a failed microsurgical breast re-
construction may choose an expander/implant reconstruction as an alternative. A
patient with a failed muscle ap over a long-standing lower extremity osteomyelitis
may wish to consider a below-the-knee amputation and a prosthesis. Consensus
between the patient and surgeon is critical at this point, and if a second microsur-
gical procedure is elected, it should be undertaken with thorough planning.38
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Chapter 9
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ASSESSMENT OF R ECIPIENT VESSELS
In head and neck cases, as well as in breast reconstruction, second ap procedures
should be planned to use recipient vessels that were not involved in the original
procedure. In head and neck cases, this principle suggests using another zone of
vessels, such as moving from facial vessels to the external carotid artery and jugu-
lar vein; or moving to the other side of the neck entirely and using vein grafts.25,26
In breast reconstruction, entirely new recipient vessels should be chosen.22
In extremities, arteriography should be given very serious consideration for the
delineation of any arterial changes subsequent to the failed ap procedure. Recip-
ient site options and vein graft possibilities should then be an explicit part of the
operative plan.38
FLAP SELECTION O PTIONS
Most aps exist in pairs, and a second latissimus can be considered for a scalp recon-
struction, while a second bula can be used to rebuild a mandible (when the ini-
tial donor site was uncomplicated).
Perforator aps have added several choices for second attempts at breast reconstruc-
tion. An initial failure that used the deep inferior epigastric system can be suc-
ceeded by a gluteal perforator ap procedure.34 However, a second rectus ap may
be a poor choice for a salvage procedure because of the extensive consequent ab-
dominal wall defect.
Generally, the ap type should be selected within the limits of acceptable donor site
morbidity.
OUTCOMES
Several groups have described in detail their management of failures following ini-
tial microsurgical ap procedures.
Outcomes After Failed First Flaps
Nonmicrosurgical
Second
Success
Author
Failed Flaps
Treatment
Flap
Rate (%)
Oliva et al39 (1993)
54
36
18
89
Beahm and Walton40 (2005)
28 (breast)
27
1
0
12 (head and neck)
70
44
92
7 (lower extremity)
3
4
75
Wei et al41 (2001)
42 (head and neck)
25
17
94
59 (extremity)
42
17
88

Oliva et al39 analyzed 54 patients who suffered ap failure. Of these, 36 patients re-
treated from the original reconstruction goal and either accepted the original de-
fect, underwent alternative reconstruction, or proceeded to amputation. Eighteen
patients chose to try a second microsurgical ap, and 16 (89%) of these operations
succeeded.
Beahm and Walton40 found that breast reconstruction patients rarely chose a second
microsurgical procedure after the failure of a rst one. Patients with head and neck
lesions and patients with extremity lesions underwent secondary microsurgical pro-
cedures in 44% and 57% of cases, respectively, following initial microsurgical fail-
ures. Success rates for the second aps were 92% in the head and neck and 75% in
the extremities.
Wei et al41 also reported that the majority of their patients with failed aps do no
go on to a second attempt. For those who do, however, second ap success rates
were 94% in the head and neck and 88% in the extremities.
In general, most patients with failed microsurgical aps do not proceed to second
microsurgical aps.Those patients who do, however, have success rates comparable
to initial microsurgical procedures.
References—With Key Annotated References
1. Swartz W, Banis J. Head and Neck Microsurgery. Baltimore:Williams & Wilkins, 1992.
An excellent textbook of microsurgical aps and reconstructive options for the head and neck.
2. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction with the free TRAM or
DIEP ap:Patient selection, choice of ap, and outcome. Plast Reconstr Surg 110:466-475;dis-
cussion 476-477, 2002.
3. Saint-Cyr M, Goodwin A, Tregaskiss A, et al. Free tissue transfer for reconstruction of the
traumatized extremities: Predictors of outcome in 347 cases. Plast Reconstr Surg 116(3
Suppl):107-109, 2005.
4. Mutaf M. A new surgical procedure for phallic reconstruction. Plast Reconstr Surg 105:1361-
1370, 2000.
5. Lineaweaver W. New microsurgical applications. Clin Plast Surg 29:81-102, 2002.
6. Lineaweaver W, Buncke HJ,Whitney TM, et al. Factors associated with microvascular ap fail-
ure. Plast Surg Forum 12:252, 1989.
7. Hidalgo D, Disa JJ, Cordeiro P, et al. A review of 716 consecutive free aps for oncologic sur-
gical defects. Plast Reconstr Surg 102:722-732, 1998.
8. Cho BC, Shin DP, Byun JS, et al. Monitoring ap for buried free tissue transfer:Its importance
and reliability. Plast Reconstr Surg 110:1249-1258, 2002.
9. Hallock GG. Free ap monitoring using a chimeric sentinel muscle perforator ap. J Recon-
str Microsurg 21:351-354, 2005.
10. Buncke HJ, Lineaweaver W, Valauri F, et al. Monitoring. In Buncke HJ, ed. Microsurgery.
Philadelphia: Lea & Febiger, 1991, pp 715-721.
A detailed atlas of microsurgical aps and related anatomy.
11. Lineaweaver W.The implantable Doppler probe [letter]. Plast Reconstr Surg 82:1009, 1988.
213
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SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
12. Whitney T, Lineaweaver W, Billys J, et al. Improved salvage of complicated microvascular trans-
plants monitored with quantitative uorometry. Plast Reconstr Surg 90:105-112, 1992.
This article contains a detailed discussion of the analysis of monitor ef cacy.
13. Disa J, Cordeiro P, Hidalgo DA. Ef cacy of conventional monitoring techniques in free tissue
transfer: An 11-year experience in 750 cases. Plast Surg Forum 21:254-255, 1998.
14. Goldberg J, Sepka RS, Perona BP,et al. Laser Doppler blood ow measurement of common cu-
taneous donor sites for reconstructive surgery. Plast Reconstr Surg 85:581-586, 1990.
15. Kind G, Buntic RF, Buncke G, et al. The effect of an implantable Doppler probe on the sal-
vage of microvascular tissue transplants. Plast Reconstr Surg 101:1268-1273, 1998.
16. Loh N, Ch’en I, Olcott E, et al. Power Doppler imaging in preoperative planning and postop-
erative monitoring of muscle aps. J Clin Ultrasound 25:456-472, 1997.
17. Lineaweaver W,Valauri F. Pharmacology. In Buncke HJ, ed. Microsurgery. Philadelphia: Lea &
Febiger, 1991, pp 696-714.
18. Lineaweaver W, O’Hara M, Stridde B, et al. Clinical leech use in a microsurgery unit. Blood
Coag Fibrinolysis 2:201-209, 1991.
19. Furnas HJ, Lineaweaver W, Buncke HJ. Blood loss associated with anticoagulation of patients
with replanted digits. J Hand Surg 174:226-230, 1992.
20. Amato M, Rodriguez L, Lineaweaver W. Survival of free tissue transfer following internal jugu-
lar venous thrombosis. Plast Reconstr Surg 104:1406-1407, 1999.
21. Lineaweaver W, Hill M, Buncke GM, et al. Aeromonas hydrophilas infections following use of
medicinal leeches in replantation and ap surgery. Ann Plast Surg 29:238-244, 1992.
22. Temple C, Strom E,Youssef A, et al. Choice of recipient vessels in delayed TRAM reconstruc-
tion. Plast Reconstr Surg 115:105-113, 2005.
This article is a thorough review of regional vascular anatomy.
23. Picard-Ami L Jr,Thompson JG, Kerrigan CL. Critical ischemia times and survival patterns of
experimental pig aps. Plast Reconstr Surg 86:739-743, 1990.
24. McDonald H, Buncke HJ, Goodstein WA. Split-thickness skin grafts in microvascular surgery.
Plast Reconstr Surg 68:731-736, 1981.
25. Takamatsu A, Harashima T, Inoue T. Selection of appropriate recipient vessels in dif cult mi-
crosurgical head and neck reconstruction. J Reconstr Microsurg 12:499-507, 1996.
This article helps the reader distinguish among various recipient vessel systems in free ap transfer to
the head and neck. It is critical to make these decisions ahead of time to maximize success in dif -
cult head and neck reconstructions.
26. Lineaweaver W, Hui KC, Kauffman D. Cross-facial vein grafting in complicated ap recon-
struction of the head and neck. J Reconstr Microsurg 13:545-549, 1997.
27. Kim KA, Chandrasekhar BS. Cephalic vein in salvage microsurgical reconstruction in the head
and neck. Br J Plast Surg 51:2-7, 1998.
28. Beer GM. The thoracoacromial vessels as recipient vessels in microsurgery and supermicro-
surgery. Plast Reconstr Surg 115:77-83, 2005.
The thoracoacromial vessels are uncommonly used as recipient vessels in free ap transfer.This paper
outlines an excellent technique to access these vessels which can be a ap saver when primary recipi-
ent vessels are inadequate.
29. Mehrara B, Santoro T, Smith A, et al. Alternative venous out ow vessels in microvascular breast
reconstruction. Plast Reconstr Surg 112:448-455, 2003.
This well-written article outlines a variety of secondary venous out ow sources which can be used dur-
ing critical intraoperative problems with reestablishing free ap circulation.
30. Chaivanichsiri P. In uence of recipient vessels on free tissue transplantation of the extremities.
Plast Reconstr Surg 104: 970-975, 1999.
31. Oswald TM, Lineaweaver WC, Hui K. Recipient vessels for microsurgical aps to the groin and
pelvis: A review. J Reconstr Microsurg 22:5-14, 2006.
32. Soutar DS, Scheker LR,Tanner NSB, et al.The radial forearm ap:A versatile method for in-
tra-oral reconstruction. Br J Plast Surg 36:1-8, 1983.
33. Canales FL, Furnas H, Glafkides M, et al. Microsurgical transfer of the rectus abdominis mus-
cle using the superior epigastric vessels. Ann Plast Surg 24:534-537, 1990.

34. Gill P, Hunt JP, Guerra A, et al. A 10-year retrospective review of 758 DIEP aps for breast re-
construction. Plast Reconstr Surg 113:1153-1160, 2004.
35. Koshima J, Nanba Y, Tsutsui T, et al. Sequential vascularized iliac bone graft and a super cial
circum ex iliac artery perforator ap with a single source vessel. Plast Reconstr Surg 113:101-
106, 2004.
36. May J, Chait L, O’Brien B, et al.The no-re ow phenomenon in experimental free aps. Plast
Reconstr Surg 61:256-267, 1974.
37. Riccio M, Pangrazi P, Campodonico A, et al. Delayed microsurgical reconstruction of the ex-
tremities for complex soft tissue injuries. Microsurgery 25:272-283, 2005.
38. Smith AA, Duncan SFM. Preoperative planning for free tissue transfer. Microsurgery 25:365-
372, 2005.
39. Oliva A, Lineaweaver W, Buncke HJ, et al. Salvage of wounds following failed tissue transplan-
tation. J Reconstr Microsurg 9:257-263, 1993.
This article comprises a detailed analysis of treatment after ap failure.
40. Beahm EK, Walton R L. What is done when free flaps fail? Plast Reconstr Surg 116(3
Suppl):116-118, 2005.
The authors review their experience with secondary reconstruction following failed free aps and pres-
ent an algorithm for decision-making.
41. Wei F, Demirkin F, Chen H, et al.The outcome of failed aps in head and neck and extrem-
ity reconstruction. Plast Reconstr Surg 108:1154-1160, 2001.
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SCARS,TISSUE MOVEMENT, AND TRANSPLANTATION
1. Which monitoring technique theoretically provides continuous monitoring of
ap circulation?
a. Clinical examination
b. Examination with a hand-held Doppler probe
c. Quantitative uorometry
d. Implantable Doppler probes
e. None of the above
2. Which bacterium is speci cally associated with infection following clinical use
of leeches?
a. Serratia marcesans
b. Haemophilus spp.
c. Aeromonas hydrophila
d. Vibrio spp.
e. Enterococcus spp.
3. Which ap tissue has the lowest tolerance for primary ischemia?
a. Skin
b. Muscle
c. Bone
d. Small intestine
e. Fascia
4. The super cial inferior epigastric vein may be an alternative venous pedicle for
which ap?
a. Radial forearm ap
b. Latissimus dorsi myocutaneous ap
c. Deep circum ex iliac artery bone ap
d. Deep inferior epigastric perforator ap
e. Gracilis myocutaneous ap
5. Patients with which defects most frequently go on to second microsurgical aps
after failure of a rst ap?
a. Head and neck
b. Upper extremity
c. Breast
d. Pelvis
e. Lower extremity
R EVIEW QUESTIONS

P a r t III
REOPERATIVE SURGERY
OF THE HEAD AND NECK

(Trang không có chữ)

219
Will and Ariel Durant, authors of the monumental 10-volume The Story of Civ-
ilization,1 also later published a complementary book entitled The Lessons of History.2
In the last chapter, provocatively titled “Is Progress Real?” these brilliant authors
make a compelling case that progress cannot be measured by, for instance,“happi-
ness.” Our ancestors, they point out, who led simpler lives than ours, were un-
doubtedly happier.
Milestones in the Evolution
of Face-Lift Techniques
Brunno Ristow
C ha pter 10
Breakthroughs in Face-Lift Procedures
Excision of the submental fat pad
Division of the platysma to sculpt the jaw and neck
Progression into the deep facial layers
Discovery of the SMAS: Advent of full-thickness facial aps
Suspension of the anterior SMAS to the zygomatic fascia
Full-sized SMAS aps and the reimplementation of thin skin aps
Multidirectional redraping of the SMAS
Abandonment of platysmal midline plication
We are what we practice.
Therefore, excellence is not an act but a habit.
Aristotle
Facial Rejuvenation

220
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
Examining the excellent results of face lifts obtained nearly half a century ago by
Sir Harold Gillies, and considering that there have been too many less-favorable
results since then, I decided to examine the progress in face-lift surgery in an inci-
sive manner: Has the progress been real, or has it always depended on the particu-
lar artistry of a surgeon? Gillies’s results are still quite signi cant by today’s standards,
as demonstrated by the preoperative view and postoperative result above.
Myriad new incisions and techniques have been proposed since that time, yet if
we study the most effective vectors of traction in regard to the best obtainable re-
sults, aren’t Sir Harold’s proposed lines of face-lift incisions almost as modern today
as they were in his day? In the twenty- rst century, this statement by Gillies and
Millard is still true:“Certainly a beautiful woman is worth preserving and should be
kept youthful while she is still young enough to enjoy it.The desire to look young
is not the prerogative of any one class, and it is not the good fortune of everyone
to grow old gracefully.The removal of wrinkles, folds, and fat is justi able if the pa-
tients are chosen with due discrimination.”3

Any attempt to evaluate the progress in the development of face lifts will necessar-
ily be colored by my own prismatic experience and view of the events. I want to
examine the breaks with established paradigms that redirected our thoughts and
techniques to achieve ever more re ned aesthetic results. My aim is to highlight
cardinal ideas that have been expressed before, as well as new concepts that I believe
modify the surgical pathway of facial rejuvenation.
My personal involvement with face-lift surgery spans more than 37 years. My ear-
liest instructor in this art was Ivo Pitanguy and, after my arrival in the United States
in 1967, I was privileged to study with gifted surgeons such as John Marquis Con-
verse,Thomas D. Rees, Cary Guy, and Blair O. Rogers. I also had the good fortune
to have a short but interesting contact with Tord Skoog.With the possible excep-
tion of Skoog’s approach in the 1960s, the universally practiced face lift was the
“skin face lift.” This particular technique proposed that “the skin ap [be] raised
with a very thin layer of fat, almost as in a full-thickness graft.When such a ap is
retracted and seen from underneath, it is almost transparent.”4
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Chapter 10
Milestones in the Evolution of Face-Lift Techniques
Although this standard technique of the time delivered a significant number of
good results, as shown above, the outcome depended exclusively on a predeter-
mined type of facial structure. It was preferable that the patient seeking a face lift
in those days be an old beautiful person, so that she could appear again as a young
beautiful person. An unattractive old person would be the recipient of a result that
at best quali ed as an unattractive young person. How well I remember those days!
Submental fat, preparotid fat, and simple excess facial fat were strict contraindica-
tions. A warm but evasive “It is best for you to get to your ideal weight before we
do your surgery” was a guarantee that the patient would never return. The now
well-known and scientifically proven effective treatments for chronic obesity
through behavior modi cation were still a decade away.5

222
PART III
R EOPERATIVE SURGERY OF THE HEAD AND NECK
The fact that the skin lift would make a naturally slim-faced person look more
youthful was understandable;the technique ts the available facial fat into a tighter
skin envelope. Sadly, however, it is also true that in a patient with excessive facial fat,
the skin lift causes the fat to be compacted into a smaller envelope. The result, of
course, is an even rounder face. I recall a patient in my rst months of practice in
San Francisco. She had traveled from the East, where a notable surgeon had oper-
ated on her with little improvement. With the overcon dence typical of a new
practitioner, I operated on her.When the dressings came off, she looked at her face
and said,“I don’t like it.”Worst of all, I had to agree;with the swelling and the still-
present fat, the improvement appeared to be nil. Gillies and Millard made a point
of removing fat:“As the facial and neck skin is stretched back, it will be noted that
the fat piles up in front and below the ear, fat that has, in fact, been squeezed up
from the neck. This must be excised but do not take parotid with it.”3 This step,
however, was only a rudimentary beginning to the precise scissors sculpting of fa-
cial and neck fat that is performed routinely today.
The skin ap face lift leads to another technical sin. Fear of injury to the branches
of the facial nerve led to a most unfortunate technique. I refer to the use of the scis-
sors, with tips up, being pushed under the skin to elevate the ap.This approach has
much potential to damage the subdermal plexus of the vessels and to cause “embar-
rassment of circulation, thrombosis, and sloughing of the skin.”4 I have therefore
condemned it for the past three decades. There is simply no place for this techni-
cal assault in the modern face lift.
I believe that gentle dissection under direct vision is the preferred technique that
can achieve signi cant improvement and avoid potential disasters. The “pushing
scissors” technique is the very same one that for so long precluded access to crows’-
feet, contributed to hair loss, and resulted in contour deformities by causing the
death of skin and fat necrosis.
Therefore the days of the skin face lift appeared to be numbered. (Curiously, the
ability to develop thin aps later became an important skill that allowed substan-
tial SMAS aps to be raised.) According to George Leonard’s “mastery curve,”6 the
first significant elevation in the plateau of knowledge that I experienced at the
time occurred with the publication of Millard’s results with the removal of sub-
mental fat.
FIRST BREAKTHROUGH:
SUBMENTAL FAT PAD OF THE NECK
The direct surgical access and removal of the submental fat pad was the major
breakthrough offering hope to all patients who have a heavy neck. An early men-
tion of this maneuver was found again in Gillies and Millard:“The patient must
give permission for a short, transverse neck incision along the natural crease for
the safe and complete removal of the central fat pad.”3 However, it was with the

publication of the classic report by Millard et al7 that I realized what was now pos-
sible. Examination of the results convinced me that Millard had shared with plastic
surgeons a novel approach that has not been surpassed to this day. A submental in-
cision that affords direct vision and thus direct gentle dissection of the submental fat
pad is paramount to an excellent postoperative neck appearance. Later,“closed” li-
posuction of the submental fat pad gained favor. Except in young patients, the re-
sults have been mixed.The proper amount of subcutaneous fat to be left under the
ap in older patients is dif cult to preserve. Also, no treatment of platysmal bands
or subplatysmal fat is possible.Thus, with the exception of correction of lesser de-
formities in young patients, a direct open approach to the neck remains the opti-
mal means for producing superior results.
SECOND BREAKTHROUGH:
LATERAL EDGES OF THE PLATYSMA
The method of elevating the platysma on its lateral border from the deep structures,
low cutting of these muscles from lateral to medial, and subsequent lateral superior
displacement of this muscle ap over the sternocleidomastoid muscle was rst re-
lated to me by Friedland,8 who had observed Peterson’s successful manipulations of
this muscle.This area has to be approached with reverence and caution, because the
0.7 mm diameter marginal mandibular nerve lies here under tenuous cover. The
scissors must be advanced very gently here (especially in secondary face lifts), always
by spreading, never by a cutting action.
When signi cant platysmal bands are present, transection of this muscle at the level
of the cricoid cartilage remains the preferred technique. Whenever possible—and
in most instances it is—I develop a SMAS/platysma sling9 just below the angle of
the mandible and attach it to the occipital region with appropriate tension. This
further enhances the jaw-neck contour and adds signi cant support to the sub-
mandibular gland region.
THIRD BREAKTHROUGH:
THE SKOOG TECHNIQUE—ADVANCEMENT
INTO THE DEEP LAYERS OF THE FACE
In October 1975, at the annual meeting of the American Society of Plastic and
Reconstructive Surgeons (ASPRS) in Toronto, I encountered a publication that
would cause me to again reexamine face-lift techniques. Fascinated, I looked at the
royal blue book that I had just purchased at the exhibits—Tord Skoog’s book.10 I
knew then that I had never seen better results or a more novel approach. I studied
this book intensely, word by word (Skoog wrote succinctly).This remarkable text-
book did not go on a shelf in my library—it went into the operating room. Many
times in the following months, in a quest for better and higher quality results, I
had a nurse hold Skoog’s book open for me for reference so I could make doubly
certain that I was operating precisely where he instructed.
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R EOPERATIVE SURGERY OF THE HEAD AND NECK
I used the markings for Skoog’s technique illustrated in his book and transferred
them to a patient who was about to undergo surgery. The results achieved a new
dimension. Inroads into the deep face and below the platysma became the rule.
Skoog’s deep thrusts into the face, combined with Millard’s technique of defatting
the neck and the advancement of the platysma aps as advocated by Peterson, gave
truly excellent results.
FOURTH BREAKTHROUGH:
THICKNESS OF THE FLAPS
As recalled earlier, it was the accepted standard to have thin aps, whether at the
neck or face. In 1976 Mitz and Peyronie11 described the nature of the super cial
musculoaponeurotic system (SMAS) of the face and correctly predicted its impor-
tance in face lifts. In November of the same year, Millard had just presented some
excellent postoperative results as a panel member at the Denver ASPRS Sympo-
sium. The question period had opened when someone asked the innovative sur-
geon, “Why do you place so much tension on such a thin flap, so far from the
blood supply [supraauricular and retroauricular key sutures]?” In response, Millard
stated emphatically that “the aps should never be thin!” Connell, in the spring of
1977, explained his technique as follows:“I dissect in front of the tragus until the
level of the preparotid fascia and then proceed forward at this level below the super-
cial investing fascia.”12 Thus both Millard and Connell were active early on in im-
plementing the concept of full-thickness aps.
Louis Pasteur stated,“Chance favors the prepared mind.” I feared the thin aps, and
the thought-provoking statements of Millard and Connell made an immediate im-
pression on me.The retroauricular aps were never to be thin again, and the preau-
ricular aps remained thick until the advent of the separate SMAS aps years later.