Hemodynamic alterations in the transferred tissue to lower extremities

Sakurai, Hiroyuki; Yamaki, Takashi; Takeuchi, Masaki; Soejima, Kazutaka; Kono, Taro; Nozaki, Motohiro

doi:10.1002/micr.20570

Cited by 14 publications

(18 citation statements)

References 25 publications

(28 reference statements)

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“…The venoarteriolar response mechanism reportedly continues within tissues even after free-flap transfer. 6,8,9 Ridgway et al 8 have demonstrated that after dangling for 5 minutes on the seventh postoperative day, tissue oxygenation in a lower-extremity free flap decreases significantly and does not return to the baseline value for as long as 44 minutes. These findings support the common perception of many surgeons, who, therefore, start postoperative mobilization between 1 and 3 weeks after the transfer of free flaps to the lower extremity.…”

Section: Discussionmentioning

confidence: 99%

“…6 To enable early mobilization, the standard methods of anastomosis might need to be abandoned in favor of a new approach, such as flow-through anastomosis, that can stabilize the circulation of flaps in the acute phase. 7 Therefore, in this study, we attempted to mobilize patients early after free-flap transfer, with flow-through anastomosis for both arteries and veins, to the lower extremity to repair oncologic defects.…”

mentioning

confidence: 99%

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Early Mobilization after Free-flap Transfer to the Lower Extremities

Miyamoto¹,

Kayano²,

Fujiki³

et al. 2014

Plastic and Reconstructive Surgery Global Open

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Background:Prolonged bed rest and elevation have traditionally been considered necessary after free-flap transfer to the lower extremities. In this retrospective study, we tried to mobilize patients early after free-flap transfer to the lower extremity by means of flow-through anastomosis for both arteries and veins.Methods:This study included 13 consecutive patients who underwent immediate free-flap transfer after wide resection of soft-tissue tumors of the lower extremity from March 2012 through July 2013. The defects were above the knee in 5 patients and below the knee in 8 patients. In all patients, flow-through anastomosis was used for both arteries and veins. The patients were mobilized starting on the first postoperative day, and their activities of daily life were gradually expanded, depending on the wound conditions. Postoperative complications and the progression of their activities of daily life were investigated retrospectively.Results:No anastomotic failure or take back occurred. Partial flap necrosis occurred in 1 patient because of a poor perforator but was unrelated to early mobilization. All patients could move to wheelchairs on the first postoperative day. Within 1 week, 12 of 13 patients could start dangling and 10 of 13 patients could start ambulating.Conclusions:This study demonstrates that early mobilization after free-flap transfer to the lower extremity is made possible by flow-through anastomosis for both arteries and veins. Flow-through flaps have stable circulation from the acute phase and can tolerate early dangling and ambulation.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Early Mobilization after Free-flap Transfer to the Lower Extremities

Miyamoto¹,

Kayano²,

Fujiki³

et al. 2014

Plastic and Reconstructive Surgery Global Open

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“…This is thought to be one reason that free flaps transferred to the lower extremities have a higher loss rate. 23 Based on this evidence, one could infer that any practice that promotes increased blood velocity, such as limiting venous anastomosis to a single vena comitans, would be preferable because blood flow and velocity may be reduced as a result of increased vascular resistance. However, further investigation is needed before definite conclusions can be drawn.…”

Section: Discussionmentioning

confidence: 99%

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

Hanasono

Kocak

Ogunleye

et al. 2010

Plastic and Reconstructive Surgery

107

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Background The authors’ goal was to determine whether one or two venous anastomoses results in superior blood flow through microvascular free flaps. Methods During flap harvest, blood velocity was measured in each of two venae comitantes using Doppler ultrasonography. Next, one of the two veins was occluded with a microvascular clamp and blood velocity was measured in the open vein. The clamp was then removed and placed on the other vein, and blood velocity was measured in the first vein. The pedicle was divided and microvascular anastomosis of either one or two veins was performed. Venous blood velocity was then compared between flaps with one versus two venous anastomoses. Results Eighty-one free flaps were performed. Before pedicle division, the peak venous blood velocity in each of the two venae comitantes averaged 6.3 ± 4.8 cm/second. When one of the veins was occluded, the peak venous blood velocity increased to 19.5 ± 17.3 cm/second (p <0.00001). One venous anastomosis was performed in 69 flaps and two venous anastomoses were performed in 12 flaps. The mean blood velocity in flaps in which one venous anastomosis was performed was greater than the mean blood velocity in either vein when two venous anastomoses were performed (13.1 ± 7.3 cm/second versus 7.5 ± 4.3 cm/ second, respectively; p = 0.001). Conclusions When one vena comitans is occluded, blood velocity in the second vena comitans increases significantly. Venous blood velocity is significantly greater after a single venous anastomosis than in either of two veins when two venous anastomoses are performed. These results argue against routinely performing two venous anastomoses.

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“…3 As a result of this change, a disproportionate stress to the perfusion can lead to a partial or total flap loss. 2 Correspondingly, a gradual increase of the gravitational challenge has been enforced to avoid perfusion disorders. The great number of varying flap training protocols (starting point, intensity, frequency) 4,5 illustrates the uncertainty in this area due to a lack of data.…”

mentioning

confidence: 99%

Perfusion Controlled Mobilization after Lower Extremity Free Flaps—Pushing the Limits of Time and Intensity

Dornseifer

Kleeberger

Kargl

et al. 2016

J reconstr Microsurg

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The current standard to gradually adapt the fragile perfusion in lower extremity free flaps to an upright posture is the dangling maneuver. This type of flap training neither fits the orthostatic target load of an upright posture, nor does it assist in mobilizing the patients effectively. In this study, we quantitatively analyzed training effects of an early and full mobilization on flap perfusion. A total of 15 patients with gracilis flaps for distal lower extremity reconstruction were included. Flap training was performed daily by mobilizing the patients on a tilt table into a fully upright posture for 5 minutes between the third and fifth postop days (PODs). Changes in micro- and macrocirculation were analyzed by laser Doppler flowmetry, remission spectroscopy, and an implanted Doppler probe. All flaps healed without complications. Yet, in three patients, the increased orthostatic load required an adjustment of the training duration due to a critical blood flow. The others showed an increasing compensation in the microcirculation. When tilting the patients, blood flow and oxygen saturation dropped significantly less on POD5 than on POD3. Furthermore, a significant increase of the blood flow was noted after an initial decrease during the mobilization on all days. An increasing compensation in the macrocirculation could not be determined. Full mobilization of patients with lower extremity free flaps can be performed safely under perfusion monitoring, already starting on POD3. Additionally, monitoring allows a consideration of the individual orthostatic competence and therefore, exploitation of the maximum mobilization potential.

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Hemodynamic alterations in the transferred tissue to lower extremities

Cited by 14 publications

References 25 publications

Early Mobilization after Free-flap Transfer to the Lower Extremities

Early Mobilization after Free-flap Transfer to the Lower Extremities

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

Perfusion Controlled Mobilization after Lower Extremity Free Flaps—Pushing the Limits of Time and Intensity

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