Free‐flap salvage: muscle only versus skin paddle – an Australian experience

Dat, Anthony; Loh, Ian; Bruscino-Raiola, Frank

doi:10.1111/ans.13522

Cited by 15 publications

(20 citation statements)

References 17 publications

(17 reference statements)

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“…The Doppler ultrasound showed regular findings during the entire observation period, as the monitoring is limited to arterial feedback. Arterial thrombosis is significantly less frequent in free tissue transfer [25,40], which also emphasizes the advantages of HSI technology in detecting venous and arterial vascular compromises. Not only does it indicate a vascular problem, but it is also able to distinguish venous from arterial compromise by pattern differentiation as Holmer et al have already described [38].…”

Section: Discussionmentioning

confidence: 91%

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Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study

et al. 2021

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Objectives Free flap surgery is an essential procedure in soft tissue reconstruction. Complications due to vascular compromise often require revision surgery or flap removal. We present hyperspectral imaging (HSI) as a new tool in flap monitoring to improve sensitivity compared to established monitoring tools. Methods We performed a prospective observational cohort study including 22 patients. Flap perfusion was assessed by standard clinical parameters, Doppler ultrasound, and HSI on t0 (0 h), t1 (16–28 h postoperatively), and t2 (39–77 h postoperatively). HSI records light spectra from 500 to 1000 nm and provides information on tissue morphology, composition, and physiology. These parameters contain tissue oxygenation (StO2), near-infrared perfusion- (NIR PI), tissue hemoglobin- (THI), and tissue water index (TWI). Results Total flap loss was seen in n = 4 and partial loss in n = 2 cases. Every patient with StO2 or NIR PI below 40 at t1 had to be revised. No single patient with StO2 or NIR PI above 40 at t1 had to be revised. Significant differences between feasable (StO2 = 49; NIR PI = 45; THI = 16; TWI = 56) and flaps with revision surgery [StO2 = 28 (p < 0.001); NIR PI = 26 (p = 0.002); THI = 56 (p = 0.002); TWI = 47 (p = 0.045)] were present in all HSI parameters at t1 and even more significant at t2 (p < 0.0001). Conclusion HSI provides valuable data in free flap monitoring. The technique seems to be superior to the gold standard of flap monitoring. StO2 and NIR PI deliver the most valuable data and 40 could be used as a future threshold in surgical decision making. Clinical Trial Register This study is registered at the German Clinical Trials Register (DRKS) under the registration number DRKS00020926.

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Section: Discussionmentioning

confidence: 91%

“…The skin is missing as a reliable predictor of possible vascular complications. In the case of venous thrombosis, for example, Doppler ultrasound continues giving regular sound feedback and abnormal tissue configuration can be prolonged [25,26].…”

Section: Introductionmentioning

confidence: 99%

Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study

et al. 2021

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“…Objective evaluations were also absent in the literature mentioning benefits of monitoring skin flap. 40 Dat et al 18 reported that muscle only free-tissue transfer flaps have a lower salvage rate compared with flaps with an overlying skin paddle. In their report, the time to reexploration of the muscle flap was shorter than that of the flap containing the skin paddle muscle flap but it was not significantly different.…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, as the skeletal muscle is more active in metabolism than that of other tissues, it is more vulnerable to tissue ischemia. Therefore, difficulties in flap monitoring can be a major drawback of this reconstruction method …”

Section: Introductionmentioning

confidence: 99%

“…Therefore, difficulties in flap monitoring can be a major drawback of this reconstruction method. 17,18 Currently, these challenges are rarely discussed, and the impact of flap monitoring through the skin paddle has not been objectively evaluated, particularly in the absence of adjunctive monitoring devices. To overcome these disadvantages of free muscle flaps, we included a small skin paddle in the flap.…”

Section: Introductionmentioning

confidence: 99%

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Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction

et al. 2018

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Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

Slijepcevic

Young

Shinn

et al. 2022

JAMA Otolaryngol Head Neck Surg

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free flap compromise is low, with successful salvage in up to 70%. When the flap is compromised a second time, the value of intervening is unknown.OBJECTIVE To assess the outcomes of a second revascularization attempt for compromised free flaps. DESIGN, SETTING, AND PARTICIPANTSThis multicenter retrospective medical record review included patients undergoing head and neck reconstruction with free flaps at 6 US medical centers from January 1, 2000, through December 30, 2020. Patients were 18 years or older with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. MAIN OUTCOME AND MEASUREFlaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts.RESULTS A total of 79 patients (mean age, 64 years; 61 [77%] men) were included in the analysis. Of the 79 flaps undergoing second salvage attempts, 24 (30%) survived while 55 (70%) demonstrated necrosis. Arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38; 95% CI, 1.21-9.47). When venous compromise was encountered, changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps); vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08; 95% CI, 0.00-0.60). Factors that were not associated with flap survival following second salvage attempts included flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage. CONCLUSIONS AND RELEVANCEIn this cohort study, second salvage was successful in 30% of free flaps. Flaps that underwent arterial or venous thrombectomy demonstrated better survival, while vein revision to neighboring branch veins was associated with worse flap outcomes.

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Free‐flap salvage: muscle only versus skin paddle – an Australian experience

Abstract: While timely recognition and re-exploration of the compromised free flap in the early postoperative setting is important in determining the flap salvage success, it is demonstrated that salvage rates are poorer for muscle only flaps compared with flaps with a skin paddle.

Cited by 15 publications

References 17 publications

Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study

Hyperspectral Imaging (HSI) as a new diagnostic tool in free flap monitoring for soft tissue reconstruction: a proof of concept study

Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction

Success and Outcomes Following a Second Salvage Attempt for Free Flap Compromise in Patients Undergoing Head and Neck Reconstruction

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