First Aid for Failing Flaps

Abstract

Wound coverage with pedicled (local, regional, or distant) or free flaps is commonplace throughout plastic surgery. However, irrespective of the method of tissue transfer or type of tissue being transferred, inflow and outflow remain key parameters for success. Much has been written detailing complex tissue transfers and delineating arterial and venous anatomy. Despite this, simple venous insufficiency causing venous congestion is common. In experimental models, when arterial inflow is impaired, even mild venous inadequacy affects flap survival. Furthermore, studies have shown that venous congestion is more detrimental to the rate and percentage of flap area surviving than arterial ischemia. Obviously, complete venous occlusion typically requires operative exploration and correction, but many instances occur when venous congestion occurs for reasons other than complete venous thrombosis. Here we detail the basic postoperative "first aid" techniques available to optimize venous drainage. Although these techniques are not a substitute for sound anatomic flap selection, good surgical technique, or re-operation when a significant underlying problem exists, they do offer additional options to improve flap outcomes.

What’s the remedy for the distal necrosis of DIEP flap, better venous drain or more arterial supply?

“…However, the relative importance of arterial versus venous supercharging in enhancing survival of the flap remains controversial. Some literatures presumed that the venous congestion is the main cause of the zone IV necrosis of DIEP or TRAM flaps [ 10 , 11 ], while other literatures demonstrated that the arterial inflow had a marked effect on the survival of the distal part of the flaps [ 12 , 13 ]. In order to explore the physiology and hemodynamics of the DIEP flap, a lot of experimental animal models have been developed, but the conclusions were still conflictive [ 7 , 14 – 17 ].…”

Quantitative Assessment of Free Flap Viability with CEUS Using an Integrated Perfusion Software

“…Besides closure of the anastomosis, an insufficient blood supply is frequently a progressive circulatory failure caused by a gradual reduction of the microcirculation. Most complications occur with 72 h after surgery, and salvage rates as high as 50 % are reported if the ischemia time is limited to 6 h [6]. However, clinical signs of compromised flap perfusion often only occur after the tissue has been irreversibly damaged [7].…”

Mandibular reconstruction with microvascular re-anastomosed fibular free flaps – Two complementary methods of postoperative transplant monitoring

“…Thrombosis of the anastomosed vessels with consecutive flap failure does not always occur suddenly. A more frequent occurrence is progressive circulatory failure caused by the gradual shutdown of microcirculation [40,42]. Clinical signs are not always evident and hardly detectable during gradual changes, delaying the diagnosis of beginning flap failure and the decision when to revise an anastomosis.…”