Free Flap Take-Back following Postoperative Microvascular Compromise

Abstract

There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage, whereas intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies.

Vein grafting your way out of trouble: Examining the utility and efficacy of vein grafts in microsurgery

“…A recent examination of factors related to flap survival following operative take back demonstrated that vein grafts did not increase the likelihood of flap loss, and may have increased likelihood of flap salvage although this did not reach statistical significance. 16,17 Importantly, these studies did not find an increased rate of failure comparing vein grafted and non-vein grafted take back cases. The current study differs in focus as we attempt to clarify primary versus salvage vein grafting, where a differences does appear to exist, however not necessarily secondary to the graft itself.…”

“…Our take back protocol advocates for mechanical thrombectomy, resection of the thrombosed vessel to healthy intima followed by pharmacologic thrombolysis. 15,16 Although utilization of vein grafts in salvage procedures may be uncommon overall, 11 IVG may be necessary to enable a tension free anastomosis. In our hands, such grafts are typically 5 cm in length, but may be as short as 1 cm.…”

Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin

“…Although flap salvage techniques are documented in the literature [4][5][6][7], we feel that these simple reproducible steps emphasising the diluted concentration of tPA and the long dwell times adopted in this case are transferrable to many other cases of 'free flaps in difficulty'. This case also highlighted that salvage is still feasible at such a late presentation and that the plastic surgeon should not give up even in such dramatic scenarios where positive outcomes appear hopeless (Fig.…”

Quantitative assessment of the free jejunal graft perfusion

“…Using the monitor flap technique in which a portion of FJG is brought out, ICG fluorescence angiography can be applied postoperatively in the intensive care unit to check the perfusion status of the flaps. Furthermore, venous congestion resulting from failure of venous anastomosis is a common problem in other organ transplantation procedures, such as liver transplantation from living donor [26] or skin flap transfers [27]. Fluorescence angiography with chronological quantification of fluorescence intensity may also be useful to assess venous perfusion in various tissue transfers.…”