Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Conclusion
Scar tissue is the end result of the normal healing process. Abnormal scarring is enhanced healing or
overhealing, usually with resulting aesthetic unacceptability and/or functional impairment. Exact
mechanisms of unfavorable scarring are not well elucidated, although excess TGF-beta receptor activity
appears to have a major molecular influence. Many treatment options are available either surgically or in
combination; however, problematic recurrence remains high. There is no single good therapeutic option
in all situations, and individual treatment is advised based on the clinical scenario, available modalities,
and patient preference.
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Questions
1. Radiation therapy is useful for treatment of keloids:
a. Preoperatively
b. Infrequently
c. As a sole modality
d. At high doses
e. In the immediate postoperative period
2. Common complications from corticosteroid injection for scar treatment include:
a. Skin atrophy
b. Cushing disease
c. Hypopigmentation
d. a, b, and c
e. a and c
3. Definitive scar improvement has been demonstrated with randomized controlled trials for which
of the following modalities?
a. Mechanomodulation
b. Laser therapy
c. Fat grafting
d. Pressure therapy
e. Excision and XRT
4. A 60-degree angle Z-plasty theoretically lengthens the central limb of the method by:
a. 50%
b. 60%
c. 75%
d. 100%
5. Concerning laser therapy for hypertrophic burn scars:
a. Pulsed dye laser is indicated for scar erythema.
b. CO2 laser is indicated for scar erythema.
c. CO2 laser is indicated for scar texture treatment.
d. Pulsed dye laser is indicated for scar texture treatment.
e. a and c
f. b and d
1. Answer: e. Radiation therapy is an effective, frequently used treatment as an adjunct to surgical
excision in a relatively low dose, usually in divided multiple sessions, immediately postoperatively.
Radiation therapy is not effective preoperatively, or as a solitary treatment, as recurrence rates of
keloids are high.
2. Answer: e. Corticosteroid injection for scar management is an effective management, usually
requiring multiple interval injections. Pain, skin atrophy, and hypopigmentation are common side
effects encountered. Cushing disease as a result of local corticosteroid injection would be very
unusual, because of the relative low doses and minimal systemic absorption of the drug.
3. Answer: a. Although evidence exists to consider laser therapy, fat grafting, pressure therapy, and
excision plus radiation therapy, the majority of reports utilizing these modalities are case series,
retrospective studies, and comparative studies. Only mechanomodulation with a device to alleviate
tension at the time of surgical incision has shown improvement in randomized controlled trials.
4. Answer: c. Theoretical geometric lengthening of the central limb of a Z-plasty with flaps incised at
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60 degrees is 75%.
5. Answer: e. Pulsed dye laser at 585/595-nm wavelength is used to treat scar erythema. CO2 laser
works by tissue ablation and water vapor absorption and is indicated for scar texture treatment.
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References
Walmsley, GG, Maan, ZN, Wong, VW, et al. Scarless wound healing: chasing the holy grail. Plast Reconstr Surg. 2015;135:907-917.
Ferguson, MWJ, O’Kane, S. Scar-free healing: from embryonic mechanisms to adult therapeutic intervention. Pil Trans R Soc Lond.
2004;359:839-850.
Robson, MC, Steed, DL, Franz, MG. Wound healing: features and approaches to maximize healing trajectories. Curr Prob Surg. 2001;38(2):61-
140.A comprehensive monograph on wound healing including abnormal wound healing and fibroproliferative/scarring entities. Discussion on the
molecular biology of scarring.
Robson, MC, Stenberg, BD, Heggers, JP. Wound healing alterations caused by infection. Clin Plast Surg. 1990;17(3):485-492.
Tredget, EE, Nedelec, B, Scott, PG, Ghahary, A. Hypertrophic scars, keloids and contractures. Surg Clin North Amer. 1977;77(3):701-730.
Dvorak, HF. Tumors that do not heal-similarities between tumor stroma generation and wound healing. N Engl J Med. 1986;315(26):1650-
1659.
Como, CB. Scars and keloids. In: Jurkiewicz, MJ , Krizek, TJ , Mathes, SJ , Ariyan, S , eds. Plastic Surgery: Principals and Practice. St Louis,
MO: CV Mosby; 1990:1411-1428.
Kisher, CW, Bunce, H, Shetlar, MR. Mast cell analysis in hyphic scars, hypertrophic scars treated with pressure, and mature scars. J Invest
Dermatol. 1978;70(6):355-357.
Ogawa, R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125:557-
568.Recent review of hypertrophic scar and keloid treatment by a long-time scar researcher.
Polo, M, Ko, F, Busillo, F, Cruse, CW, Krizek, TJ, Robson, MC. The 1997 Moyer Award. Cytokine production in patients with hypertrophic
burn scars. J Burn Care Rehibil. 1997;18:477-482.
Kuhn, A, Singh, S, Smith, PD, et al. Periprosthetic breast capsules contain the fibrogenic cytokines TGF-beta 1 and TGF-beta 2, suggesting
possible new treatment approaches. Ann Plast Surg. 2000;44:387-391.
Kuhn, MA, Payne, WG, Kierney, PC, et al. Cytokine manipulation of explanted Dupuytren’s affected human palmar fascia. J Surg Invest.
2001;2(6):443-456.
Pu, LL, Smith, PD, Payne, WG, et al. Overexpression of transforming growth factor beta-2 and its receptor in rhinophyma: an alternative
mechanism of pathobiology. Ann Plast Surg. 2000;45:515-519.
Brown, BC, McKenna, SP, Solomon, M, et al. The patient-reported impact of scars measure: development and validation. Plast Reconstr Surg.
2010;125:1439-1449.
Trong, PT, Lee, JC, Soer, B, et al. Reliability and validity testing of the patient and observer scar assessment scale in evaluating linear scars
after breast cancer surgery. Plast Reconstr Surg. 2007;119(2):487-494.
Kerrigan, CL, Homa, K. Visual assessment of linear scars: a new tool. Plast Reconstr Surg. 2009;124(5):1513-1519.
Thompson, CM, Sood, RF, Honari, S, Carrougher, GJ, Gibran, NS. What score on the Vancouver scar scale constitutes a hypertrophic scar?
Results from a survey of North American burn-care providers. Burns. 2015;41(7):1442-1448.
Bae, SH, Bae, YC. Analysis of frequency of use of different scar assessment scales based on the scar condition and treatment method. Arch
Plast Surg. 2014;41:111-115.
Fearmonti, R, Bond, J, Erdmann, D, Levinson, H. A review of scar scales and scar measuring devices. EPlasty. 2010;10:354-363.
Draaijers, LJ, Tempelman, FRH, Botman, YAM, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar
evaluation. Plast Reconstr Surg. 2004;113:1960-1965.
Khansa, I, Harrison, B, Janis, JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr
Surg. 2016;138;165S-178S. Recent comprehensive review of clinical scar therapies.
Wolfram, D, Tzankov, A, Pulzl, P, Piza-Katzer, H. Hypertrophic scars and keloids: a review of their pathophysiology, risk factors, and
therapeutic management. Dermatol Surg. 2009;35:171-181.
Perez, JL, Rohrich, RJ. Optimizing postsurgical scars: a systemic review on best practices in preventive scar management. Plast Reconstr Surg.
2017;140:782e-793e. Recent comprehensive, evidenced-based treatment review of scar prevention. Useful algorithms for treatment.
Wray, RC. Force required for wound closure and scar appearance. Plast Reconstr Surg. 1983;72(3):380-382.
Longacre, MT, Rohrich, RJ, Greenberg, L, et al. A randomized controlled rial of the embrace advanced scar therapy device to reduce
incisional scar formation. Plast Reconstr Surg. 2014;134(3):536-546.Excellent study design and execution showing benefits of tension reduction to
reduce scarring in high-tension abdominoplasty incisions.
Lim, AF, Weintraub, J, Kaplan, EN, et al. The embrace device significantly decreases scarring following scar revision surgery in a
randomized controlled trial. Plast Reconstr Surg. 2014;133(2):398-405.
Atiyeh, BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesth Plast
Surg. 2007;31:468-492.
Bloemen, MCT, van der Veer, WM, Ulrich, MMW, van Zuijlen, PPM, Niessen, FB, Middelkoop, E. Prevention and curative management of
hypertrophic scar formation. Burns. 2009;35:463-475.
Borges, AF. Elective Incisions and Scar Revision. Boston, MA: Little, Brown & Co; 1973.Classic textbook with definitive explanations of relaxed skin
tension lines, Z-plasty, and incision placement to reduce or minimize scarring.
Borges, AF. Relaxed skin tension lines (RTSL) versus other skin lines. Plast Reconstr Surg. 1984;73(1):144-150.
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Wilhelmi, BJ, Blackwell, SJ, Phillips, LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104:208-214.
Ault, P, Plaza, A, Paratz, J. Scar massage for hypertrophic burn scarring: a systematic review. Burns. 2018;44:24-38.
Mustoe, TA, Cooter, RD, Gold, MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560-
571.
Mustoe, TA. Evolution of silicone therapy and mechanism of action in scar management. Aesth Plast Surg. 2008;32:82-92.A comprehensive
review of silicone and its benefits and mechanism of action on scars.
Li-Tsang, CWP, Zheng, PY, Lau, JCM. A randomized clinical trial to study the effects of silicone gel dressing and pressure therapy on
posttraumatic hypertrophic scars. J Burn Care Res. 2010;31(3):448-457.
Tandara, AA, Mustoe, TA. The role of the epidermis in the control of scarring: evidence for the mechanism of action for silicone gel. J Plast
Reconstr Aesth Surg. 2008;61:1219-1225.
Ahn, ST, Monafo, WW, Mustoe, TA. Topical silicone gel for the prevention and treatment of hypertrophic scar. Arch Surg. 1991;126:499-504.
Gold, MH, Foster, TD, Adair, MA, et al. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets
following a surgical procedure in an office setting. Dermatol Surg. 2001;27:641-644.
Quinn, KJ, Evans, JH, Courtney, JM, Gaylor, JD, Reid, WH. Non-pressure treatment of hypertrophic scars. Burns Incl Therm Inj.
1985;12(2):102-108.
Mustoe, TA, Gurjala, A. The role of the epidermis and the mechanism of action of occlusive dressings in scarring. Wound Rep Reg.
2011;19:S16-S21.
O’Brien, L, Pandit, A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2006;9:1-77.
Kisher, CW, Shetlar, MR, Shetlar, C. Alteration of hypertrophic scars induced by mechanical pressures. Arch Dermatol. 1975;111:60-64.
Macintyre, L, Baird, M. Pressure garments for use in the treatment of hypertrophic scars: a review of the problems associated with their use.
Burns. 2006;32:10-15.
Van den Kerckhove, E, Stappaerts, K, Fieuws, S, et al. The assessment of erythema and thickness on burn related scars during pressure
garment therapy as a preventive measure for hypertrophic scarring. Burns. 2005;31:696-702.
Al-Attar, A, Mess, S, Thomassen, JM, Kauffman, CL, Davison, SP. Keloid pathogenesis and treatment. Plast Reconstr Surg. 2006;117:286-300.
Agrawal, K, Panda, N, Arumugam, A. An inexpensive self-fabricated pressure clip for the ear lobe. Br J Plast Surg. 1998;51:122-123.
Brissett, AE, Sherris, DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. 2001;17(4):263-271.
Roques, C, Teot, L. The use of corticosteroids to treat keloids: a review. Int J Lower Ext Wounds. 2008;7(3):137-145.
Ketchum, LD, Robinson, DW, Masters, FW. Follow-up on treatment of hypertrophic scars and keloids with triamcinolone. Plast Reconstr
Surg. 1971;48(3):256-259.
Ketchum, LD, Smith, J, Robinson, DW, Masters, FW. The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone
acetonide. Plast Reconstr Surg. 1966;38(3):209-218.
Griffith, BH, Monroe, CW, McKinney, P. A follow-up study on the treatment of keloids with triamcinolone acetonide. Plast Reconstr Surg.
1970;46(2):145-150.
Ogawa, R, Mitsuhashi, K, Hyakusoku, H, Miyashita, T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars:
retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003;111:547-553.Extensive retrospective look at a
large series of patients treated by scar excision with postoperative radiation therapy, indicating benefit of the combined therapy.
Ogawa, R, Miyashita, T, Hyakusoku, H, et al. Postoperative radiation protocol for keloids and hypertrophic scars – statistical analysis of 370
sites followed for over 18 months. Ann Plast Surg. 2007;59(6):688-691.
Norris, JEC. Superficial x-ray therapy in keloid management: a retrospective study of 24 cases and literature review. Plast Reconstr Surg.
1995;95(6):1051-1055.
Kim, K, Son, D, Kim, J. Radiation therapy following total keloidectomy: a retrospective study over 11 years. Arch Plast Surg. 2015;42:588-595.
Sclafani, AP, Gordon, L, Chadha, M, Romo, T. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus
radiation therapy. Dermatol Surg. 1996;22:569-574.
Ogawa, R, Yoshitatsu, S, Yoshida, K, Miyashita, T. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis.
Plast Reconstr Surg. 2009;124(4):1196-1201.
Har-Shai, Y, Amar, M, Sabo, E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg.
2003;111(6):1841-1852.
Uberti, MG, Pierpont, YN, Bhalla, R, et al. Down regulation of scar fibroblasts by antineoplastic drugs: a potential treatment for
fibroproliferative disorders. Surg Sci. 2016;7:258-271.
Shridharani, SM, Magarakis, M, Manson, PN, et al. The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic
scars. Ann Plast Surg. 2010;64(3):355-361.
Gragnani, A, Warde, M, Furtado, F, Ferreira, LM. Topical tamoxifen therapy in hypertrophic scars or keloids in burns. Arch Dermatol Res.
2010;302:1-4.
Uppal, RS, Khan, U, Kakar, S, et al. The effects of a single dose of 5-flurouracil on keloid scars: a clinical trial of timed wound irrigation after
extralesional excision. Plast Reconstr Surg. 2001;108(5):1218-1224.
Haurani, M, Foreman, K, Yang, JJ, Siddiqui, A. 5-Flurouracil treatment of problematic scars. Plast Reconstr Surg. 2009;123(1):139-148.
Hu, L, Zou, Y, Chang, S, et al. Effects of botulinum toxin on improving facial surgical scars: a prospective, split-scar double-blind,
randomized controlled trial. Plast Reconstr Surg. 2018;141(3):646-650.Recent study describing improvement of scars treated intraoperatively with
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botulinum toxin. A split-scar study demonstrating efficacy.
Curran, JN, Crealey, M, Sadadcharam, G, et al. Vitamin E: patterns of understanding, use, and prescription by health professionals and
students at a university teaching hospital. Plast Reconstr Surg. 2006;118(1):248-252.
Shih, R, Walzman, J, Evans, GRD. Review of over-the-counter topical scar treatment products. Plast Reconstr Surg. 2007;119(3):1091-1095.
Morganroth, P, Wilmot, AC, Miller, C. Over-the-counter scar products for postsurgical patients: disparities between online advertised
benefits and evidence regarding efficacy. J Am Acad Dermatol. 2009;61:e31-47.
Moiemen, NS, Staiano, JJ, Ojeh, NO, et al. Reconstructive surgery with a dermal regeneration template: clinical and histologic study. Plast
Reconstr Surg. 2001;108(1):93-103.
Frame, JD, Still, J, Lakhel-LeCoadou, A, et al. Use of dermal regeneration template in contracture release procedures: a multicenter
evaluation. Plast Reconstr Surg. 2004;113(5):1330-1338.
Bloemen, MCT, van Leeuwen, MCE, van Vucht, NE, et al. Dermal substitution in acute burns and reconstructive surgery: a 12-year follow
up. Plast Reconstr Surg. 2010;125(5):1450-1459.
Clayman, MA, Clayman, SM, Mozingo, DW. The use of collagen-glycosaminoglycan copolymer (Integra) for the repair of hypertrophic scars
and keloids. J Burn Care Res. 2006;27:404-409.Comprehensive review describing current evidence for the use of laser therapy for hypertrophic burn
scars.
Hultman, CS, Fredstat, JS, Edkins, RE, et al. Laser resurfacing and remodeling of hypertrophic burn scars. Ann Plast Surg. 2014;260(3):519-
532.
Friedstat, JS, Hultman, CS. Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized
controlled trials. Ann Plast Surg. 2014;72:S198-S201.
Jin, R, Huang, X, Li, H, et al. Laser therapy for prevention and treatment of pathologic excessive scars. Plast Reconstr Surg. 2013;132(6):1747-
1758.
Brewin, MP, Lister, TS. Prevention or treatment of hypertrophic burn scarring: a review of when and how to treat with the pulsed dye laser.
Burns. 2014;40:797-804.
Al Harithy, R, Pon, K. Scar treatment with lasers: a review and update. Curr Derm Rep. 2012;1:69-75.
Kim, DH, Ryu, HJ, Choi, JE, et al. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in
surgical scars. Dermatol Surg. 2014;40:973-978.
Alster, TS, Williams, CM. Treatment of keloid sternotomy scars with 585-nm flashlamp-pumped pulsed dye laser. Lancet. 1995;345:1198-1200.
Alster, T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg.
2003;29(1):25-29
Goldman, MP, Fitzpatrick, RE. Laser treatment of scars. Dermatol Surg. 1995;21:685-687.
Negenborn, VL, Groen, J, Smit, JM, et al. The use of autologous fat grafting for treatment of scar tissue and scar-related conditions: a
systematic review. Plast Reconstr Surg. 2016;137(1):31e-43e.
Conde-Green, A, Marano, AA, Lee, ES, et al. Fat grafting and adipose-derived regenerative cells in burn and wound healing and scarring: a
systematic review of the literature. Plast Reconstr Surg. 2016;137(1):302-312.
Klinger, M, Caviggioli, F, Klinger, FM, et al. Autologous fat in scar treatment. J Craniofac Surg. 2013;24:1610-1615.
Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108S-120S.
Kan, HJ, Selles, RW, van Nieuwenhoven, CA, et al. Percutaneous aponeurotomy and lipofilling (PALF) versus limited fasciectomy in
patients with primary Dupuytren’s contracture: a prospective, randomized, controlled trial. Plast Reconstr Surg. 2016;137(6):1800-1812.
Khouri, RK, Khouri, RK. Current clinical applications of fat grafting. Plast Reconstr Surg. 2017;140(3):466e-486e.Review of a broad spectrum of
fat-grafting indications including the utility in scar and fibroproliferative disease treatment.
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C H A P T E R 4
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Principles of Flap Design and Application
Julian J. Pribaz and Katherine M. Huber
Key Points
A flap is a body of tissue with its own inherent blood supply that can be elevated and moved to
reconstruct defects.
Thorough knowledge of blood supply to tissue is critical for safe and reliable flap elevation and
transfer.
Use of two- and three-dimensional templates will assist with proper flap design.
Attempt to minimize residual donor site deformity. Consider the consequences of scar contracture,
contour deformity, and functional loss.
For a complex defect, consider staged reconstruction with methodical planning of each stage. Always
have a backup plan.
The primary goal of flap reconstruction is to maintain adequate flap vascularity. Plan for secondary
revisions to improve contour and appearance.
The word principle stems from the Latin princeps meaning a beginning. Tenets of practice should begin
with the principles, yet these should be subject to change as knowledge of the subject increases. 1 There
has been significant evolution of our knowledge of flaps in recent years, primarily due to improvements
in the understanding of vascular anatomy. This has led to noteworthy advances in the reconstructive
options available.
The simplest definition of a flap is a body of tissue with its own original inherent blood supply that can
be elevated and moved to repair and reconstruct defects. In this way, a flap differs from a graft, which
does not carry its own blood supply. Flaps, in one form or another, serve as the basis of reconstructive
surgery.
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Flap Blood Supply and Physiology
A thorough knowledge of blood supply to the skin and accompanying tissue is critical in safe and reliable
flap elevation and transfer of flaps. The skin, because of its role in thermoregulation to maintain
homeostasis and its immunological function, has a rich blood supply, far greater than what is needed for
its own inherent metabolic demand. This is an important fact in facilitating skin flap survival. The blood
reaches the skin from deeper named vessels, via multiple perforating arteries and their accompanying
veins that course through overlying muscles, septa, and fascia to supply the more superficial vascular
plexuses, creating a continuous three-dimensional (3D) network of vessels supplying all layers of tissues.
For the skin, the blood supply is concentrated at the suprafascial and subdermal levels, from which
smaller vessels branch to supply the intervening tissues 2 (Figure 4.1).
FIGURE 4.1 Vascular plexuses of the skin and subcutaneous tissue.
In 1987, Taylor and Palmer rediscovered and further elaborated on the work of Manchot and Salmon on
the blood supply of the skin and underlying tissue, and proposed the concept of the angiosome, which
they defined as a 3D body of tissue supplied by a source (segmental or distributing) artery and its
accompanying vein(s) that span between the skin and bone. 3 Each angiosome could be subdivided into a
matching arteriosome (arterial territory) and venosome (venous territory). Angiosomes can vary in size
and interdigitate with adjoining angiosomes via true small anastomotic bidirectional arterioles and
venules by reduced-caliber choke (retiform) anastomotic vessels. 4
More recent work by Saint-Cyr et al. 5 advanced the angiosome concept to provide additional and more
practical insight into vascular territory and flow characteristics that are important in flap design. They
studied both 3D (static) and 4D (dynamic) blood flow through multiple single perforators and mapped
out the territory supplied, calling this a perforasome (Figure 4.2). They found greater complexity and
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variability than was initially anticipated, and they confirmed that each perforasome is connected to an
adjacent perforasome by both direct (fascial) and indirect (subdermal) linking vessels (Figure 4.3).
FIGURE 4.2 Perforators have a distinct arterial and venous vascular territory. This image depicts the vascular arterial anatomy
of a perforasome. Note the dense vascular network centered around the perforator that decreases progressively toward the
periphery. Large linking vessels branch peripherally in multiple directions away from the perforator origin.
From Saint-Cyr, M, Wong, C, Schaverien, M, Mojallal, A, Rohrich, RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr
Surg. 2009;124(5):1529-1544; with permission.
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FIGURE 4.3 Interperforator flow occurs by means of direct and indirect linking vessels. Direct linking vessels communicate
directly with an adjacent perforator to maintain perfusion, and travel within the suprafascial and adipose tissue layers. Indirect
linking vessels communicate with adjacent perforators by means of recurrent flow through the subdermal plexus.
Communicating branches between direct and indirect linking vessels are also seen and help maintain vascular perfusion in
case of injury.
From Sur, YJ, Morsy, M, Michel Saint-Cyr, M. The pedicled perforator (propeller) flap in lower extremity defects. In: Strauch, B , Vasconez, LO , Herman, CK ,
Lee, BT , eds. Grabb’s Encyclopedia of Flaps: Upper Extremities, Torso, Pelvis, and Lower Extremities. 4th ed, vol. 2. Philadelphia, PA: Wolters Kluwer;
2016:1420-1425.
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Nomenclature and Classification
The nomenclature of flap classification is somewhat imperfect and fluid. As Converse stated, “There is no
simple and all-encompassing system which is suitable for classifying skin flaps.” 6 This is true for skin
flaps as well as flaps of other tissue types. Although the nomenclature is imperfect and overlapping, it is
important to develop a vocabulary of terms to describe flaps for improved understanding and
communication with other medical professionals.
Flaps can be classified in multiple ways. Classification occurs according to flap content and tissue type,
mechanics of movement or transfer, blood supply, and manipulation prior to harvest.
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Flap Content
Flap classification begins with the content of the planned flap. The simplest flap contains skin and
subcutaneous tissue. These are referred to as cutaneous flaps. Cutaneous flaps can be harvested relatively
thinly to fit a similar defect. Generally, the blood supply in a cutaneous flap is random in nature and
located within the subdermal plexus.
As defects become more complex, so can the harvested flap. Flaps containing skin, subcutaneous tissue,
and fascia are referred to as fasciocutaneous flaps. 7 Fascial flaps devoid of the overlying skin can also be
harvested if a very thin flap that is easily contoured is desired. These are known as fascial and adipofascial
flaps and are usually accompanied by an overlying skin graft to maintain a thin contour. Fasciocutaneous
flaps were described and further classified by their pattern of blood supply by Cormack and Lamberty in
1984 8 (Table 4.1). The temporoparietal and anterolateral thigh fasciocutaneous flaps are excellent
examples.
TABLE 4.1
Cormack and Lamberty Classification of Fasciocutaneous Flaps
Type
Description
Example
A
A pedicled fasciocutaneous flap dependent on multiple fasciocutaneous perforators at the base and orientated with
the long axis of the flap
Lateral arm
flap
B
A pedicled or a free flap depending on a single sizeable and consistent fasciocutaneous perforator feeding a plexus
at the level of the deep fascia
Parascapular
fap
C
The blood supply of the skin is dependent upon the fascial plexus that is supplied by multiple small perforators
along its length, which reach it from a deep artery by passing along the fascial septum between muscles.
Radial
forearm flap
D
The fascial septum is taken in continuity with adjacent muscle and bone which derive their blood supply from the
same artery
Free fibula
flap
Muscle flaps are a staple of reconstructive surgery. They may be used in stand-alone fashion, or with an
overlying skin graft. These flaps can be harvested with overlying skin and soft tissue for added bulk and
are called myocutaneous flaps. Muscle and myocutaneous flaps were classified by Mathes and Nahai in
1981 based on their inherent blood supply 9 (Figure 4.4). Often in cases of lower extremity trauma with
exposed bone or hardware, well-vascularized muscle tissue is desired for coverage and has the advantage
of conforming to an irregular wound bed to minimize dead space. However, recent literature shows that
muscle and fasciocutaneous flaps achieve comparable rates of limb salvage and functional recovery. 10
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FIGURE 4.4 Mathes and Nahai classification. Patterns of vascular anatomy: type I, one vascular pedicle; type II, dominant
pedicle(s) and minor pedicles; type III, two dominant pedicles; type IV, segmental vascular pedicles; type V, one dominant
pedicle and a secondary segmental pedicle.
Reproduced with permission from Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast
Reconstr Surg. 1981;67(2):177-187.
When structural support at the defect is required, flaps containing bone can be used. Vascularized bone
flaps, or osseous flaps, can be harvested free from surrounding tissue. For example, a bone-only free fibula
can be harvested on the peroneal artery and is a workhorse of head and neck bony reconstruction.
Conversely, overlying soft tissue and skin can be included. In this case, the flap is categorized as
osteomyocutaneous and osteocutaneous.
In a separate category are omental and intestinal flaps. The omental flap can be raised on the
gastroepiploic vessels and utilized in pedicled fashion to fill sternal or other chest wall defects. The
omentum has angiogenic and immunogenic properties that make it ideal for reconstruction of sternal
wound infections. As a free flap, it is extremely useful as thin vascularized tissue that can be covered with
skin grafts for defects in the head and neck or lower extremity. 11 Various intestinal flaps can be harvested
to reconstruct laryngopharyngeal and esophageal defects. 12
Composites of any of the above categories are used frequently and can include other local tissue such as
cartilage, tendon, or mucosa.
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Movement and Proximity to Defect
The type of movement or transfer required to inset a flap provides an additional system of classification.
Based on proximity to the defect to be reconstructed, flaps are described as local, regional, or distant. Local
flaps are moved into an adjacent defect by a process of advancement, transposition, rotation, and
interpolation, or combinations of these basic movements (Table 4.2).
TABLE 4.2
Classification of Flaps by Movement Type
Flap
Movement
Subtypes
Illustration
Rotation
Rotation
Advancement
V-Y
Bipedicled
Keystone
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Transposition
Z-plasty
Rhomboid
Bilobed
Islandization
Propeller
Pedicled
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Regional flaps such as pedicled muscle flaps require larger movements than those seen in local flaps.
These often still include rotations (Figure 4.5), advancements (Figure 4.6), and transpositions (Figure 4.7).
Distant flaps include tubed flaps and free flaps. Tubed flaps are the oldest known type of flaps, first
described in the literature in 1917 by Filatov. 13,14 These involve harvest of a pedicled flap followed by a
series of transpositions known as walking. After inset of each transposition, the flap obtains new blood
supply from the surrounding tissue by neovascularization and vessel ingrowth. At the subsequent stage,
the opposite end is transposed, allowing for movement of the flap and maintenance of blood supply. In
this way, the flap is walked or waltzed to its final destination for inset, often necessitating several stages.
The advent of free tissue transfer has reduced the use of tubed flaps; however, a distant tubed flap may
still play a role in patients who are poor candidates for free tissue transfer.
FIGURE 4.5 Rotation flap. A. Cheek defect after excision of a basal cell cancer with plans for a cheek rotation flap and
excision of dog-ear. B. Scars are placed along natural crease lines to maximize cosmesis.
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FIGURE 4.6 V-Y advancement flap. A. Left temple basal cell carcinoma showing planned excision and design of V-Y flap. This
type of advancement flap causes minimal distortion to surrounding tissues and replaces like with like. B. Final result includes a
well-vascularized flap without alteration of brow position.
FIGURE 4.7 Transposition flap. A. Ulcerated lesion with planed excision and rhomboid flap. B. Transposed flap closes defect
while distributing tension along the planes of the donor site.
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Blood Supply
A flap can be further classified by the orientation of its blood supply. The pattern of blood supply to
cutaneous flaps is generally described as either axial or random. An axial pattern flap has a known or
named artery coursing along its longitudinal axis. A random-pattern flap is designed without a known
vessel at its core and relies on the random subdermal plexus for perfusion. 15 Random-pattern flaps must
generally be limited to a 3:1 length to width ratio to remain viable at the tip. 16,17 Axial pattern flaps can be
designed with a longer length to width ratio and may carry a random extension with the same limitations
described earlier.
Flaps containing muscle or fascia can also be classified further by the type of blood flow that supplies
them. The Mathes and Nahai classification of muscle flaps and the Cormack and Lamberty classification
of fascial flaps are mentioned above (see Figure 4.4 and Table 4.1).
The blood supply of a flap can additionally be classified as either pedicled or free. Pedicled flaps remain
attached to a known native vascular pedicle and are limited to the arc of rotation or advancement that
these vessels afford. The pedicle can be dissected free from surrounding tissues and the flap islandized for
maximizing transfer distance. Conversely, a free flap is one that is raised on a known vascular pedicle
that is transected and anastomosed to a new blood supply at the recipient site, largely requiring
microsurgical techniques. 18 Free flaps allow for true freedom of tissue transfer. A flap harvested in one
location can reconstruct a defect that is distant from it, assuming adequate blood flow exists at the
recipient site.
Perforator flaps are those based on a perforating artery from a named vessel and include the surrounding
3D area of tissue perfused by that perforator, also known as the perforasome 5,19 (see earlier). Perforating
vessels can be thought to travel in a plane perpendicular to that of the skin surface and the axial vessels
beneath. Perforators are frequently identified by use of a handheld Doppler on the skin, and one or more
perforators can be included in any given flap. Blood flow then arborizes and fills vessels linking one
perforasome to the next (see Figure 4.2). Flaps designed around a perforator often also include proximal
dissection of the named vessel from which the blood flow originates, and this allows for longer pedicle
length or larger caliber of vessels for free tissue transfer. Perforator flaps have become increasingly
popular as local flaps for reconstructing both difficult small and larger defects that previously had
required a free tissue transfer.
The keystone perforator island flap was described by Behan and has been used throughout the body as
an island flap designed adjacent to a defect, and typically based on one or more smaller perforators. The
flap has the shape of a keystone-like arch that is designed parallel to the defect and is at least as wide as
the defect. It extends beyond each end of the defect, completing the archlike design (Figure 4.8). The
dissection extends through the skin, subcutaneous tissue, and fascia, thus mobilizing the flap to advance
into the defect. The closure borrows tissue from all directions, as each end is repaired as a V-Y
advancement. 20
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FIGURE 4.8 Keystone flap. A. Lower extremity lesion with planned excision and keystone flap design. B. Resulting flap
redistributes tension as each end is closed in V-Y fashion.
Another local use of a perforator flap is as a propeller flap. This was first described by Hyakusoku et al. in
1991 21 and is based on a single large perforating vascular pedicle close to the defect that is rotated up to
180°. The main perforator is identified with a handheld Doppler and will be the pivot point for flap
rotation. Careful measurement and precise flap design to reach the distal end of the defect is mandatory.
The perforator can be visualized early in the dissection and the flap design confirmed prior to
circumscribing the island flap. It is important to dissect the perforator through the fascia and free up the
adventitia so that there is no venous kinking 21,22 (Figure 4.9).
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FIGURE 4.9 Propeller flap. A. Unstable scar in patient undergoing total knee replacement. Perforator marked with red dot is
used as center of rotation. B. Flap elevation includes dissection of perforator. C. Rotation and final inset offers excellent
coverage of hardware and primary closure of donor site.
Modifications to flap blood flow have resulted in added classifications such as the reverse-flow flap, the
venous flap, and the supercharged flap. A reverse-flow flap is one in which the native direction of flow
through the main pedicle is reversed at inset. An example is the reverse radial forearm flap, in which the
radial artery is transected proximally, and the flap must rely on reverse blood flow in the radial artery
across the palmar arch 23 (Figure 4.10). A venous flow-through flap is composed of skin, subcutaneous
tissue, and a plexus of veins. It is devoid of arterial tissue within the flap. A linear vein is anastomosed to
an artery proximally and a vein distally, allowing for both inflow and outflow. These are generally small
flaps and can be prone to congestion and partial necrosis. 24 A supercharged flap is one in which the
arterial inflow or venous outflow is augmented by using microsurgical techniques to perform a second
anastomosis, bringing in an additional inflow or outflow capabilities. 25
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FIGURE 4.10 Reverse radial forearm flap. A. 70-year-old woman with a left dorsal hand wound after intravenous extravasation
injury. B. Reverse radial forearm flap is designed based on retrograde flow across the palmar arch. Note the inclusion of
palmaris longus tendon for extensor tendon reconstruction. C. An added layer of antebrachial fascia is utilized to wrap the
tendon reconstruction for improved glide. D. Routine inset and healing with primary closure of the donor site.
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Manipulation
A discussion of classification of flaps would be incomplete without mention of the different types of flap
manipulation that can occur prior to harvest. First, tissue that is desired for a planned flap can undergo
tissue expansion. An expanded flap allows for greater reach and coverage and can minimize the donor site
defect. 26 Furthermore, the mechanical force of stretching tissues has also been shown to enhance tissue
neovascularity, 27 and the accompanying thinning of the flap can be an additional bonus in
reconstruction.
In situations where there is concern for the ultimate perfusion of the flap, flap delay can be employed. A
delayed flap is one in which a preliminary surgical stage is planned to partially raise the flap and divide a
portion of the blood supply, delivering a sublethal ischemic insult that stimulates vessel dilation,
ischemic preconditioning, and neovascularization. This allows for axialization of blood flow and
conditioning of the flap tissues to lower oxygen levels in anticipation of flap transfer at a second stage 28
(Figure 4.11).
FIGURE 4.11 Diagrammatic representation of the same flap raised with and without a surgical delay to illustrate the necrosis
line and the changes in the choke vessels between a and b. In B, vessel a has been delayed by a previous operation before
raising the flap. Note the dilation of choke vessels and the more distal site of the necrosis line.
The techniques of flap prefabrication and prelamination are other more recent additions to our
armamentarium and can greatly expand the functional capacity of the flap. These will be discussed in
more detail later in this chapter.
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Flap Design and Application
The reconstructive surgeon must be familiar with the full spectrum of reconstructive options and select
the flap or method of repair that will give the best outcome. The optimal reconstructive strategy may
involve multiple modalities of treatment and/or multiple staged procedures. One must take care not to
burn bridges and compromise the final result.
The flap options available have increased greatly in recent years, and the focus has shifted from ensuring
flap survival to limiting the number of flaps required to close a defect and ultimately to enhanced flap
selection and refinements. Refinements are achieved by careful preoperative and intraoperative
assessment of the defect, determining the reconstructive requirements, and then selecting the donor
tissue that gives the best functional and aesthetic result.
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Assessing the Defect
For successful flap reconstruction, an accurate diagnosis of the defect, its underlying causes, and
reconstructive requirements is needed. The surgeon should consider what tissues are missing (e.g., skin,
functional muscle, bone). Precise measurements of shape and size should be taken, including
consideration of the 3D depth of the defect for appropriate contour restoration. Photos, templates, and 3D
moulages are of great assistance in defect assessment and should be used liberally 29 (Figure 4.12).
Modern image-guided planning, especially in planning bony flaps, is also advantageous and can reduce
operative time. 30
FIGURE 4.12 A. A 67-year-old woman had a complex defect of the left orbit with palatal and nasal defect after cancer
resection. B. Three-dimensional alginate moulage is used for on-table flap planning. C. Moulage is wrapped with a template to
represent flap folding. D. Template is used to create flap outline overlying the deep inferior epigastric vessels on the abdomen.
E. Flap elevation including a portion of rectus abdominis for filling of dead space. F. Final inset with complete reconstruction of
internal lining and excellent external contour.
One of the most important steps in reconstruction is satisfactory preparation of the defect. The wound
bed should be debrided of necrotic material, granulation tissue, and attenuated or scarred tissue. In some
cases, quantitative cultures are beneficial to verify the wound is free from infection and bacterial balance
has been achieved. 31 In oncologic defects, pathology should ensure clear margins prior to reconstruction.
Despite excellent flap selection and harvest technique, inadequate preparation of the wound can lead to
flap compromise and reconstructive failure.
Patient selection is also a consideration when planning reconstruction. Inherent patient factors such as
diabetes, clotting disorders, and poor compliance can hamper flap success. Modifiable factors such as
smoking and patient weight should also be contemplated. If risk factors for flap failure are high, a simple
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method of wound closure may be better than complex multistage reconstruction.
In free tissue transfer, the presence of recipient vessels must be evaluated. Ideal recipient vessels are in
close proximity (either deep or adjacent) to the wound to be reconstructed. The quality of these vessels
should be assessed. If the planned recipient vessels appear injured either on preoperative angiogram or
during direct inspection intraoperatively, consider use of different vessels. Use of vessels outside the zone
of injury during free flap reconstruction leads to increased rates of lower extremity limb salvage. 32
Additionally, recipient vessels should be of adequate caliber to anastomose easily to the flap vessels and
provide adequate perfusion. If there are no adequate recipient vessels near the defect, consideration can
be given to vein grafts or creation of an AV loop from a regional blood supply source. 33 In the
extremities, flow-through flaps should be considered if perfusion of the hand or foot would otherwise be
compromised by anastomosis of a flap.
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Selection and Management of the Donor Site
The full extent of the reconstructive ladder is contemplated for each wound, preferably from simplest to
most complex. Local tissue will often provide better color match and appearance but may be limited
depending on the location of the wound. Many local, regional, and distant donor sites are available.
Consider the suitability of each donor site to fulfill the goals of reconstruction and the logistics and
positioning on the operating table, avoiding positional changes if possible. Attempt to minimize residual
donor site deformity.
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Site and Content Selection
In selecting the appropriate donor site, first consider the skin surrounding the defect. Color match,
texture, thickness, and special characteristics such as hair growth should be taken into account. Design
the flap to be slightly larger than the defect for adequate skin coverage. This will help account for the
thickness of the flap, avoid tight closure over the vascular pedicle, and facilitate donor site closure. Often
significant edema of the flap occurs during the procedure that will make closure tight if some excess
tissue is not included in flap design. After assessment of skin requirements, flap thickness and content
can be selected. Can adequate thickness be reconstructed with skin and subcutaneous fat? Is muscle bulk
needed to fill the defect, or is a functional muscle needed to restore movement? Is bone or cartilage
support of the soft tissues necessary? For complex reconstructions of the head and neck, lining may be
required in addition to external skin coverage. Mucosal lining can be fashioned from skin, skin graft,
mucosa, or raw muscle surface, which will mucosalize with time.
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Pedicle Considerations
Once content requirements of the flap have been determined, decisions can be made concerning the
pedicle. The surgeon should consider both caliber and length required, especially in the case of free tissue
transfer. The caliber should approximate that of the recipient vessels; however, if significant size
mismatch exists, end-to-side anastomosis is an option. 34 Concerning pedicle length, the surgeon should
consider the ergonomic constraints of microsurgical vessel anastomosis. Free tissue transfer can be made
significantly easier with slight slack in the pedicle for creation of a tension-free anastomosis that occurs in
an orientation that is comfortable for the operating surgeon’s hands. Appropriate length can be obtained
either by initial selection or by dissection proximally on the flap pedicle to its origin.
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Manipulation of Donor Site Tissue
Manipulation of donor site tissue at the time of flap transfer is utilized for complex reconstruction to
provide a better-tailored flap and minimize donor defects. For a complex wound, two (or more) flaps can
be carried on one pedicle. These flaps are known as compound or chimeric flaps. 35 An example is the
latissimus dorsi, parascapular, scapular bone, serratus anterior flap, which can be one complex
compound flap based on the subscapular vascular system (Figure 4.13).
FIGURE 4.13 Compound chimeric flap to heel defect. A. A young man with a medial foot wound with exposed calcaneus after
osteomyelitis. B. Compound flap design using the teres major muscle and fasciocutaneous parascapular flap harvested on the
subscapular vascular system. Note the intraoperative use of templates for better planning reconstruction of this three-
dimensional defect. C. The harvested flap. D. After inset and healing.
Conversely, a very large flap may benefit from a double pedicle. A simple example of this is the
bipedicled advancement flap. However, in more complex cases, very large flaps, such as double pedicle
TRAM (transverse rectus abdominis myocutaneous) flaps, may be raised and left pedicled, or transferred
as a double pedicle free flap if the volume of tissue required exceeds the amount that can be transferred
on a single pedicle. 36,37
Flaps can be designed to be folded on themselves to create added bulk or can be employed in
reconstruction of a lamellar surface such as the lower lip. In this case, a donor site with a thin
subcutaneous layer should be selected. 38 Complex central facial defects often require reconstruction of
the multiple external and internal epithelial surfaces. As mentioned earlier, the use of a 3D intraoperative
alginate moulage to facilitate flap planning and folding to accurately repair the multiple epithelial defects
has been found to be very useful (see Figure 4.12).
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Management of the Donor Site
Inherent in flap design is management of residual donor site defects. Commonly the donor site of a flap is
repaired primarily, or in cases of undue tension, skin grafted. Attempts should be made to minimize
donor site deformity as much as possible. Consider the consequences of scar contracture such as
decreased range of motion and pain. When possible, orient incisions within resting skin tension lines.
Contour deformity may be considered cosmetic; however, functional issues with hygiene may occur in
severe cases. Functional loss from muscle or nerve transfer must be contemplated preoperatively and
discussed with the patient. Choose muscle flaps that have redundant function when possible. Revision of
donor site deformities should be offered when a functional problem exists and a solution is apparent.
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Staging Reconstruction in Complex Defects
Staged reconstructions are often required for complex defects. In such cases, it is important to plan ahead
and perform the best possible surgery at each stage, keeping in mind the opportunity cost of additional
procedures and time for maturation at each stage. Avoid burning bridges and consider adjunct
techniques, including delay, expansion, prelamination, and prefabrication.
Delay of a flap involves a preliminary surgical stage to partially raise the flap and divide a portion of the
blood supply. This allows for axialization of blood flow and conditioning of the flap tissues to low
oxygen levels in anticipation of flap transfer at a second stage. Delay can increase survival of a larger
surface area on a given pedicle. 28
As discussed previously, tissue expansion of the donor flap provides more tissue and a thinner flap and
alleviates tension at the donor site, resulting in easier closure and improved scarring.
Prefabrication of a flap involves transferring a vascular pedicle into a desired block of tissue, then waiting
8 weeks for spontaneous neovascularization, thus creating a new vascular territory not previously found
in nature. 39 After maturation, the neovascularized tissue is transferred based on the implanted pedicle.
This technique has been used to provide thin axial flaps and to transfer tissue with enhanced color and
texture match (Figure 4.14).
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FIGURE 4.14 Flap prefabrication. A. A 40-year-old man with hypertrophic burn scar contracture of the anterior neck. B. To
avoid areas of scarring on the thigh, a prefabricated flap is designed on the anteriomedial thigh using the descending branch of
the lateral femoral circumflex vessels. C. Vessels are transposed to the desired area; a tissue expander is also placed to
expand the new flap. D. After expansion and neovascularization of the tissue around the new pedicle. E. Flap inset. F. After flap
debulking the patient is left with a thin, pliable flap, excellent color match, functional improvement, and minimal scarring.
The technique of prelamination involves implantation of tissue (usually bone or cartilage) or an alloplastic
device into a vascular territory prior to transfer. It has been used mainly for reconstruction of complex
defects in the central third of the face. 40
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Options in Case of Flap Compromise
Despite the surgeon’s best efforts, some flaps will inevitably experience decreased arterial perfusion or
venous congestion after elevation and inset. In pedicled or free flaps, inadequate arterial flow is usually
recognized early and may be the result of poor flap design or pedicle kinking. In a free flap, the arterial
insufficiency represents thrombosis of the new anastomosis until proven otherwise. These cases require
revision on the table or urgent return to the operating room to revise the anastomosis.
Venous insufficiency of a flap is more common and the onset more insidious than that of arterial
insufficiency. This phenomenon is multifactorial. In elevating a flap, longitudinal venous channels in the
flap are disconnected. Additionally, the low pressure in the venous system is more vulnerable to extrinsic
pressure because of compression from inset and flap edema. Numerous methods have been described to
improve flap survival in the case of venous congestion. First, the surgeon should attempt to release
insetting sutures causing tension or kinking. The flap may be pricked with a needle serially to reduce the
venous burden. Deepithelialization of a portion of the flap, or removal of the nail plate in the case of a
digit, with periodic application of heparin solution may increase venous outflow. Use of Hirudo
medicinalis or medicinal leeches can ensure ongoing flap outflow until venous microanastomoses form.
Finally, augmenting outflow by cannulation of a vein with an angiocatheter and periodically draining the
flap may be useful. 41
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Conclusion
Flaps are the mainstay of reconstructive surgery. In the words of Gillies, always consider “blood supply
before beauty.” 1 Remember to maintain adequate flap vascularity and plan for secondary revision to
improve contour and appearance. When performing staged reconstructions for complex defects, plan
ahead and do not burn bridges.
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Questions
1. A 62-year-old man with squamous cell cancer of the ear is treated with total auriculectomy
including burring of the mastoid bone. Flap reconstruction to close the wound is planned with a
pedicled supraclavicular flap. The blood supply to the supraclavicular flap is considered which of
the following?
a. Random
b. Free
c. Reverse flow
d. Axial
e. Perforator
2. A 45-year-old woman with recurrent breast cancer undergoes mastectomy and free deep inferior
epigastric artery perforator flap. Routine anastomoses of one artery and one vein are completed, and
the flap is inset. On the table, the flap appears congested. Insetting sutures are released with no
improvement. The arterial and venous anastomoses are visualized and noted to be patent. What is
the next best step to resolve the congestion?
a. Anastomose the superficial inferior epigastric vein (SIEV).
b. Revise the venous anastomosis.
c. Start leech therapy.
d. Administer systemic TPA.
e. Revise the arterial anastomosis.
3. A 70-year-old man is involved in a motor vehicle collision. A large portion of his scalp was avulsed
and could not be salvaged. After multiple debridements, the resultant defect comprises 70% of the
scalp with exposed calvarium at the base. Reconstruction is best achieved with which of the
following?
a. Split-thickness skin graft
b. Free omental flap with split-thickness skin graft
c. Wet-to-dry dressing changes with healing by secondary intention
d. Tissue expansion with staged advancement of flaps
e. Scalp flap with skin graft to the donor defect
4. A 13-year-old girl is diagnosed with rhabdomyosarcoma of the left orbit and face. Orbital
exenteration and radical en bloc resection including bone is planned followed by chemotherapy and
radiation. Which of the following best reconstructs the resulting 3D defect?
a. Dermal substitute
b. Skin graft
c. Local advancement flap including skin and subcutaneous fat
d. Free anterolateral thigh (ALT) flap including skin, subcutaneous fat, and fascia
e. Free ALT flap including skin, subcutaneous fat, fascia, and vastus lateralis muscle
5. A 65-year-old man is evaluated for reconstruction of a chronic wound to the lateral malleolus.
Because of medical comorbidities, he is a poor candidate for free tissue transfer. Reverse sural flap is
planned. On the evening of postoperative day zero, the patient has mild hypotension, and the flap is
noted to be dark and congested distal to a line of tension created by insetting sutures. What is the
next best step?
a. Apply moisturizer cream to the affected area.
b. Release insetting sutures at area of maximum tension.
c. Administer a fluid bolus.
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d. Elevate extremity.
e. Observe and reassure that this will likely improve with time.
6. An otherwise fit 30-year-old man, following a compound fracture of the distal third of the tibia,
previously treated by the orthopedist with open reduction and internal fixation, presents with a
small open wound breakdown (4 × 3 cm) with exposed hardware. He has good pulses. After further
debridement and removal of hardware and application of an external fixator, the soft tissue defect is
repaired with a local propeller perforator flap, based on a posterior tibial artery perforator. During
flap dissection and inset, the flap becomes progressively more congested along its entire length.
Which of the following is the most appropriate next step in management?
a. Observation
b. Application of nitropaste
c. Postoperative leech therapy
d. Proximal perforator dissection to source vessel
e. Free flap salvage
1. Answer: d. The supraclavicular flap is an axial flap based on axial blood flow through the
supraclavicular artery. 42 It is not considered a random flap, although random-pattern extensions can
be added to the distal aspect. 43 Blood flow in the supraclavicular artery is antegrade and not
considered a reverse-flow flap. As the flap is based on a named axial vessel, it is not a perforator flap.
A supraclavicular flap is typically left pedicled and rotated to fill defects of the head and neck. It is
particularly useful in patients who are not good candidates for free flaps. In this question, a pedicled
flap is desired and therefore the tissue is not harvested as a free flap.
2. Answer: a. In this case, the best course of action is to locate the SIEV at the edge of the flap and
create a second venous anastomosis, thereby supercharging venous outflow. 44,45 Some surgeons
routinely preserve the SIEV during dissection in case of need for added venous drainage. Revision of
the existing venous and arterial anastomoses would likely provide no benefit if each is already a
visibly patent anastomosis, as mentioned in the question stem. Leech therapy is useful in smaller,
thin flaps; however, in this bulky high-flow flap, the small amount of venous outflow leech therapy
provides would be negligible. Systemic use of tissue plasminogen activator would not improve
venous outflow and could increase the risk of hemorrhagic complications.
3. Answer: b. The omental free flap is an excellent option in large defects of the calvarium and can be
easily skin grafted for ultimate coverage. A skin graft alone would be inadequate coverage for
exposed bone as graft take would be limited because of a poorly vascularized wound bed. Wet-to-dry
dressing changes may be considered as a temporizing measure to help debride devitalized tissue and
prepare the wound for coverage; secondary intention healing would progress very slowly and leave
the patient at risk for infection and desiccation of bone. Tissue expansion is an appropriate option for
defects comprising up to 50% of the hair-bearing scalp, but would be insufficient for a 70% defect. A
scalp flap with skin grafting of the donor defect is also not appropriate for near total scalp loss. 46
4. Answer: e. Three-dimensional contour deformities are best reconstructed using a flap that contains
muscle, which can conform to the defect and fill dead space. The same flap without muscle would
not be the best option. 47 A skin graft would likely not vascularize over exposed bone. Dermal
substitutes would likewise be unsatisfactory coverage in this complex defect. Local flaps may play a
role in coverage of a large wound; however, insufficient local tissue exists to fill a defect this large
and would likely lead to unsightly scarring and additional deformity.
5. Answer: b. The flap described is likely suffering from impaired venous outflow distal to the area
of tension. Release of insetting sutures in this area will likely improve outflow at this site. 41
Moisturizing cream is unlikely to improve venous outflow. Mild hypotension postoperatively is not
ideal for flap survival and would be more likely to impair arterial inflow. Augmentation of blood
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pressure with a fluid bolus would not reliably improve venous outflow. Elevation of the extremity
may decrease flap edema and offer some mild improvement in venous outflow but would not solve
the issue of a specific line of tension across the flap. Observation is incorrect, as the congestion will
likely progress if left unrevised.
6. Answer: d. Propeller flaps, which are single perforator flaps, are being used more commonly in
reconstruction of small defects that had previously been treated with free flaps. However, proper
dissection of the pedicle is mandatory in this type of flap which usually has to rotate 180°. The most
common complication associated with propeller flap dissection is venous congestion. This is usually
due to impaired venous outflow through the very thin and fragile comitant veins running with the
perforating artery. This is more likely to happen if there is a bulky pedicle due to additional soft
tissue and fascia, which makes kinking of these small veins more likely when the flap and pedicle is
twisted 180°. The best way to minimize this is to fully dissect the pedicle and free it from
surrounding soft tissue and fascia. 48,49 If venous congestion persists, this suggests injury to the
draining veins; the flap can be returned to its initial position, and venous leeching from a distended
vein within the flap may be used to salvage the flap. This is much more effective than topical leech
therapy. Nitropaste therapy is not effective with venous congestion. Traditionally, free flap salvage
was the preferred choice of treatment for distal third leg defects and may be required should the
perforator flap fail, but one should try to salvage the problem at hand before proceeding to another
method of repair.
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References
Gillies, H, Millard, D. The Principles and Art of Plastic Surgery. Boston: Little and Brown; 1957.
Daniel, RK, Kerrigan, CL. Skin flaps: an anatomical and hemodynamic approach. Clin Plast Surg. 1979;6(2):181-200.
Taylor, GI, Palmer, JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg.
1987;40(2):113-141.
Taylor, GI, Corlett, RJ, Ashton, MW. The functional angiosome: clinical implications of the anatomical concept. Plast Reconstr Surg.
2017;140(4):721-733.The authors review data from experimental work of other researchers on vascular imaging of skin flaps in various animal models.
The study then used a rabbit model to focus on the role of anastomotic vessels between angiosome territories in tissue perfusion. Using fluorescein
infusion, rabbit perforator flaps showed conversion of choke vessels to true anastomoses by 7 days, allowing distal territory survival in 95% of flaps.
This highlights the dynamic, functional nature of anastomotic vessels as they can control flow between territories. The functional angiosome is thereby
defined as the volume of tissue that clinically can be isolated on a source vessel. The area extends beyond its anatomical territory to capture an adjacent
territory if connections are by choke anastomoses, or more if they are by true anastomoses.
Saint-Cyr, M, Wong, C, Schaverien, M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg.
2009;124(5):1529-1544.
Converse, JM. Introduction to Plastic Surgery. Reconstructive Plastic Surgery. 2nd ed, vol. 1. Philadelphia, PA: WB Saunders; 1977:3-68.
Cormack, GC, Lamberty, BG. Fasciocutaneous vessels. Their distribution on the trunk and limbs, and their clinical application in tissue
transfer. Anat Clin. 1984;6(2):121-131.
Cormack, GC, Lamberty, BG. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg.
1984;37(1):80-87.
Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg.
1981;67(2):177-187.The authors summarize data from previous studies involving vascular injections of latex solutions into muscle of cadavers. They
determine the pattern of blood supply to each muscle establishes the extent of safe transposition and usefulness in reconstruction. A classification
system is suggested based on the blood supply of each muscle. This classification of vascular anatomy is shown clinically to predict arcs of rotation and
ultimate muscle flap survival after elevation.
Cho, EH, Shammas, RL, Carney, MJ, et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a
multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191-199.
McLean, DH, Buncke, HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg.
1972;49(3):268-274.
Moradi, P, Glass, GE, Atherton, DD, et al. Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience
from a single reconstructive center. Plast Reconstr Surg. 2010;126(6):1960-1966.
Filatov, V. Plastic procedure using a round pedicle. McDowell F, trans. Vestnik Oftalmol. 1917;34:149-158.
Gillies, H. The tubed pedicle in plastic surgery. N Y Med J. 1920;111:1.
Stell, PM. The viability of skin flaps. Ann R Coll Surg Engl. 1977;59(3):236-241.
Milton, SH. Pedicled skin-flaps: the fallacy of the length : width ratio. Br J Surg. 1969;56(5):381.
McGregor, IA, Morgan, G. Axial and random pattern flaps. Br J Plast Surg. 1973;26(3):202-213.
Taylor, GI, Daniel, RK. The free flap: composite tissue transfer by vascular anastomosis. Aust N Z J Surg. 1973;43(1):1-3.
Morris, SF, Tang, M, Almutari, K, Geddes, C, Yang, D. The anatomic basis of perforator flaps. Clin Plast Surg. 2010;37(4):553-570, xi.
Behan, FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73(3):112-120.
Hyakusoku, H, Yamamoto, T, Fumiiri, M. The propeller flap method. Br J Plast Surg. 1991;44(1):53-54.
Teo, TC. The propeller flap concept. Clin Plast Surg. 2010;37(4):615-626, vi.
Timmons, MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg. 1986;77(1):80-92.
Fukui, A, Inada, Y, Maeda, M, et al. Venous flap: its classification and clinical applications. Microsurgery. 1994;15(8):571-578.
Tan, O, Atik, B, Bekerecioglu, M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery.
2005;25(1):36-43.
Zhou, XT. Effects of tissue expansion on the ratio of length to width of random-pattern skin flaps. Zhonghua Wai Ke Za Zhi. 1989;27(7):417-
418, 445.
Leighton, WD, Russell, RC, Feller, AM, et al. Experimental pretransfer expansion of free-flap donor sites: II. Physiology, histology, and
clinical correlation. Plast Reconstr Surg. 1988;82(1):76-87.The authors endeavor to evaluate the changes in blood flow and tissue histology that occur
with tissue expansion. Using pig models, flaps are designed, expanded, and elevated. Blood flow and angiography were recorded and tissue samples
were examined and compared with a nonexpanded control site. The authors found the vascular trees within flaps enlarge following expansion, and
pronounced neovascularization is seen in the papillary dermis and capsular layers. There is thinning of all the tissue layers except for the epidermis.
Successful clinical application of these principles in humans is depicted.
Taylor, GI, Corlett, RJ, Caddy, CM, Zelt, RG. An anatomic review of the delay phenomenon: II. Clinical applications. Plast Reconstr Surg.
1992;89(3):408-416.
Kane, WJ, Olsen, KD. Enhanced bone graft contouring for mandibular reconstruction using intraoperatively fashioned templates. Ann Plast
Surg. 1996;37(1):30-33.
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Toto, JM, Chang, EI, Agag, R, et al. Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computer-
guided preoperative planning. Head Neck. 2015;37(11):1660-1664.
Breidenbach, WC, Trager, S. Quantitative culture technique and infection in complex wounds of the extremities closed with free flaps. Plast
Reconstr Surg. 1995;95(5):860-865.
Stranix, JT, Lee, ZH, Jacoby, A, et al. Not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast
Reconstr Surg. 2017;140(5):1033-1041.
Atiyeh, BS, Sfeir, RE, Hussein, MM, Husami, T. Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot. Plast
Reconstr Surg. 1995;95(6):1062-1069.
Ikuta, Y, Watari, S, Kawamura, K, et al. Free flap transfers by end-to-side arterial anastomosis. Br J Plast Surg. 1975;28(1):1-7.
Hallock, GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast
Surg. 1991;27(2):126-131.The authors endeavor to differentiate a chimeric flap from the previously described compound or composite flaps. A chimeric
flap is defined as a flap in which more than one tissue type is linked together, but tissue components may be independently maneuvered while remaining
attached by a common regional source vessel. They describe specific surgical dissection technique of the ALT and rectus femoris muscle chimeric flap
and offer a case report of a patient treated with this method.
Wagner, DS, Michelow, BJ, Hartrampf, CR Jr. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg.
1991;88(6):987-997.
Agarwal, JP, Gottlieb, LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction.
Ann Plast Surg. 2007;58(4):359-363.
Jeng, SF, Kuo, YR, Wei, FC, et al. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series.
Plast Reconstr Surg. 2004;113(1):19-23.
Khouri, RK, Upton, J, Shaw, WW. Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical
study. Plast Reconstr Surg. 1991;87(1):108-115.
Pribaz, JJ, Fine, NA. Prelamination: defining the prefabricated flap : a case report and review. Microsurgery. 1994;15(9):618-623.
Talbot, SG, Pribaz, JJ. First aid for failing flaps. J Reconstr Microsurg. 2010;26(8):513-515.The authors present a descriptive article on the possible
etiologies of arterial and venous insufficiency in flaps. Based on their experience and expertise, they highlight surgical techniques that can prevent blood
flow compromise before it occurs. Citing other studies, they propose an algorithm for assessing and treating a flap that is experiencing venous
insufficiency or congestion.
Pallua, N, Machens, HG, Rennekampff, O, et al The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal
contractures. Plast Reconstr Surg. 1997;99(7):1878-1884; discussion 1885-1876.
Ross, RJ, Baillieu, CE, Shayan, R, Leung, M, Ashton, MW. The anatomical basis for improving the reliability of the supraclavicular flap. J
Plast Reconstr Aesthet Surg. 2014;67(2):198-204.
Vijayasekaran, A, Mohan, AT, Zhu, L, et al. Anastomosis of the superficial inferior epigastric vein to the internal mammary vein to augment
deep inferior artery perforator flaps. Clin Plast Surg. 2017;44(2):361-369.
Lee, KT, Mun, GH. Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: a systematic review and meta-analysis.
Microsurgery. 2017;37(1):75-83.
Leedy, JE, Janis, JE, Rohrich, RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. 2005;116(4):54e-72e.
Simsek, T, Engin, MS, Yildirim, K, et al. Reconstruction of extensive orbital exenteration defects using an anterolateral thigh/vastus lateralis
chimeric flap. J Craniofac Surg. 2017;28(3):638-642.
D’Arpa, S, Cordova, A, Pignatti, M, Moschella, F. Freestyle pedicled perforator flaps: safety, prevention of complications, and management
based on 85 consecutive cases. Plast Reconstr Surg. 2011;128(4):892-906.
Maciel-Miranda, A, Morris, SF, Hallock, GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast
Reconstr Surg. 2013;131(6):896e-911e.
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C H A P T E R 5
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Principles of Microsurgery
Sarah E. Sasor and Kevin C. Chung
Key Points
Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; applications
include free tissue transfer, nerve repair, replantation, and transplantation.
Surgical precision is the key factor in anastomotic patency.
There is no difference in patency rate based on suture technique (simple interrupted versus
continuous) or anastomotic technique (end-to-end versus end-to-side).
Routine use of antithrombotic agents in the postoperative period is optional.
Thrombosis is most common within 24 hours of surgery. Early failure is often related to anastomotic
imperfections or pedicle positioning. If a problem is detected early, the flap can be salvaged by
exploration and revision of the anastomosis.
Microsurgery is a discipline that requires magnification, precision instruments, and specialized surgical
techniques. Magnification, using surgical loupes or an operating microscope, makes it possible to repair
tiny, delicate structures that exceed the limits of normal human eyesight. Microsurgical techniques are
used to repair blood vessels, nerves, and lymphatics; transplant tissue from one area of the body to
another; and reattach amputated parts.
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History
The origin of microsurgery can be traced back to the late 1890s when surgeons began repairing blood
vessels both in laboratory animals and humans without the use of magnification. The first successful end-
to-end anastomosis was performed on the carotid artery of a sheep in 1889 by Jassinowski. 1 In 1902,
Carrel described the triangulation method of anastomosis that is still routinely used today. 2 The
following year, Höpfner performed the first experimental extremity replantation on a canine hind limb. 3
The introduction of the operating microscope in Sweden by Nylen 4 and Holmgren 5 in the early 1920s
revolutionized the field of microsurgery; it was used successfully in ear and eye procedures in centers
throughout Europe. Fine surgical instruments specifically designed for use under magnification were
adapted from those used by watchmakers and jewelers. The development of fine sutures swaged on
suitably fine needles followed thereafter.
Jacobson and Suarez are credited with the first successful microsurgical anastomosis using an operating
microscope on a canine carotid artery in 1960. 6 They encountered significant difficulty while attempting
the procedure with the unaided eye, and after trying multiple forms of magnification, were successful
with a microscope previously used in otology.
Throughout the 1960s, Buncke experimented with replantation and transplantation in laboratory animals.
In 1966, he performed rabbit ear replantation with the anastomosis of vessels approximately 1 mm in
diameter. Buncke developed many important principles and techniques and is often called the founding
father of microsurgery. 7
Technological improvements such as coaxial illumination, motorized and optical zoom, binocular
viewing, and independent focus controls made small anastomoses more reliable. With flap failure rates
less than 2%, 8 microsurgical techniques are now used with confidence.
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Basic Science Concepts in Microsurgery
To optimize outcomes, microsurgeons must understand the basic mechanisms of vessel injury and
regeneration, the clotting mechanism, and how tissues respond to ischemia and reperfusion.
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Vessel Injury and Regeneration
Microvascular anastomoses disrupt all three layers of a vessel wall. Exposure of subendothelial collagen
to the bloodstream results in platelet aggregation and the formation of thrombotic plugs. Full-thickness
sutures provide intimal continuity at the anastomosis site and result in the highest rates of patency. 9
Soon after anastomosis, a layer of platelets adhere to the denuded endothelium at the suture line—
provided there is no exposed media or extensive vessel damage, fibrin deposition and thrombosis will
not occur. Platelets gradually dissipate over the next 24 to 72 hours. As the vessel wall heals, a
pseudointima forms. Dissipation of platelets in the vessel lumen and formation of the pseudointima
correlates clinically with the critical period of thrombus formation within the first 3 to 5 days. 10
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Clotting Mechanism
Platelet adherence and aggregation is the first step in thrombus formation. Platelets do not adhere to
undamaged endothelium; however, collagen within the subendothelium is highly thrombogenic. If the
intima is damaged, exposed collagen within the media triggers platelet adhesion to the vessel wall.
Platelets contain alpha and dense granules that secrete von Willebrand factor, fibrinogen, ADP
(adenosine diphosphate), calcium, and serotonin. Together, these factors promote the recruitment and
adherence of additional platelets through the formation of proteinaceous bridges. Activated platelets
stimulate the conversion of fibrinogen to fibrin to strengthen the growing clot. Eventually, a critical mass
is reached, resulting in thrombus formation by either occlusion of the vessel lumen or activation of the
extrinsic pathway of coagulation. 11
Antithrombotic drugs intervene at various steps in the clotting cascade with the aim to reduce platelet
aggregation and clot formation. Heparin increases antithrombin-3 activity, which inactivates thrombin.
Aspirin causes irreversible inactivation of cyclooxygenase (COX) and, subsequently, blocks the formation
of thromboxane A2. Dextran decreases red blood cell aggregation through both antiplatelet and antifibrin
effects; its exact mechanism of action is unknown. Despite widespread use, evidence on the benefit of
antithrombotics in microsurgery is equivocal. 12 Dextran has been shown to have no effect on flap
survival but a 3.9- to 7.2-fold increase in systemic complications including renal failure, pulmonary
edema, and congestive heart failure. 13 Heparin and aspirin continue to be commonly used.
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Tissue Response to Ischemia and Hypoxia
Free tissue transfer requires a period of flap ischemia while the vascular anastomosis is performed. The
main mechanism of ischemic injury is hypoxia, which leads to anaerobic glycolysis. Cellular acidosis is
particularly severe because the absence of blood flow results in the accumulation of local metabolic by-
products (lactic acid). Coagulative necrosis will ensue if ischemia is not promptly reversed.
Tissues have varying levels of tolerance to ischemia based on their composition and metabolic
requirements. Skin and subcutaneous tissue remain viable for approximately 24 hours. 14 Muscle is less
tolerant; irreversible damage to the microcirculation occurs at approximately 6 hours without blood flow.
15 Connective tissue has very low metabolic requirements and can withstand prolonged periods of
hypoxia. 16 Cooling prolongs tolerance to ischemia for all types of tissues. 17
Restoration of blood flow to ischemic tissues may cause additional damage owing to the production of
free radicals and reactive oxygen species. The localized inflammatory response leads to leakage of
intravascular fluid into the interstitial space and cellular swelling. Despite excellent anastomotic
technique, it may be difficult or impossible to restore flow in flaps subjected to prolonged ischemia. Brisk
inflow immediately after the anastomosis is followed by a sharp decline in flow rate shortly thereafter.
The low flow state triggers intravascular thrombosis and flap ischemia. The process is termed the no-
reflow phenomenon. 18
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Technical Factors
Many variables contribute to the success of a microvascular anastomosis: patient selection, operative
planning, and technical setup, including magnification, instrumentation, and exposure. Meticulous
technique and surgeon experience play the greatest role in success.
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Equipment
Instrumentation
Basic microsurgical instruments include jeweler’s forceps, smooth-tipped dilating forceps, micro needle
drivers, straight and curved microscissors, and single and double microvascular clamps. Instruments
should be of the highest quality—glare-free, nonmagnetic, and ergonomic. Heparinized saline irrigation
should be available in a 3 mL syringe with a 26-gauge angiocatheter tip. A microsurgical background of
contrasting color (yellow, blue, or green) provides improved visualization. Additional necessary
instruments include bipolar electrocautery, micro clips and appliers, suction, and a sterile Doppler
ultrasound (Figure 5.1).
FIGURE 5.1 Microinstrumentation.
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