• Archives of Plastic Surgery
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• v.34 no.4
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• pp.432-435
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• 2007

Purpose: The jejunal free flap has the shorter ischemic time than other flap and requires a laparotomy to harvest it. As the evaluation of the perfusion the buried flap is very important, the perfusion of the buried jejunal free flap requires monitoring for its salvage. We tried to improve the monitoring flap method in the jejunal free flap and examined its usefulness. Methods: From March 2002 to March 2006, the monitoring flap method was applied to 4 cases in 8 jejunal free flaps for the pharyngeal and cervical esophageal reconstructions. The distal part of the jejunal flap was exposed without suture fixation through cervical wound for monitoring its perfusion. The status of perfusion was judged by the color change of jejunal mucosa and mesentery. If necessary, pin prick test was performed. Doppler sonography was applied to mesenteric pedicle of the monitoring flap in case of suspicious abnormal circulation. Results: The monitoring flap shows no change in 3 cases, but the congestion happened in one case at the 12 hours after the operation. This congestion was caused by the twisting or kinking of the mesenteric pedicle of the monitoring flap. So, we fixed up the monitoring flap close to adjacent cervical skin for prevention of rotation. Finally, the main part of transferred jejunal flap was intact. Conclusion: The success of a jejunal free flap depends on close postoperative monitoring and early detection of vascular compromise. So, various monitoring methods have been tried, for instance, direct visualization using a fiberoptic pharyngoscope, through a Silastic window placed in the neck flap, or external surface monitoring with an Doppler sonography, use of a buried monitoring probe. But, all of the above have their own shortcomings of simplicity, non-invasiveness, reliability and etc. In our experience, monitoring flap can be a accurate and reliable method.

• Archives of Reconstructive Microsurgery
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• v.21 no.1
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• pp.14-20
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• 2012

Purpose: Defect after ablation of hypopharyngeal cancer often requires reconstruction by free tissue transfer. Since neo-hypopharynx is totally buried, various methods have been suggested for monitoring. We propose a modified design of anterolateral thigh (ALT) free flap for reconstruction of pharyngolaryngectomy defect, which has an exteriorized part for clinical monitoring and allows for primary closure. Materials and Methods: Three consecutive patients with hypopharyngeal cancer were reconstructed with ALT flap with modified design: 1) distal part of flap was elongated into fusiform shape and used as exteriorized monitoring segment with a deepithelized bridge and 2) proximal part was designed as curve so the maximum width of the flap was reduced to less than 10 cm. Results: Patient 1, 2 had uneventful postoperative course with healthy skin color and fresh pin prick bleeding. In patient 3, defect after cancer ablation was shorter than usual and deepithelized bridge was longer. When the general hemodynamic status of the patient was aggravated in postoperative course, the color of monitoring skin was changed. Viability of the whole flap was confirmed by endoscopy. However, leakage developed after 3 weeks and repair was necessary. In all patients the donor sites were closed primarily. Conclusion: By the modified design of ALT flap, clinical monitoring can be possible by examining exteriorized monitoring flap and also donor site can be closed primarily. However possibility of false positive exists and technical caution and patient selection is needed because of danger of leakage.

• Archives of Reconstructive Microsurgery
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• v.13 no.1
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• pp.82-85
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• 2004

Flap monitoring is important for flap salvage. Although there are many methods to observe the flap, practical methods mostly used are subjective methods. Recording flap surface temperature is one of the objective methods of flap monitoring. We used an infra-red thermometer to simplify monitoring of the flap temperature. 60 groin flaps of SD rats are used in the experiment. Artificial arterial or venous insufficiency was made and the surface temperature was checked and compared with body temperature. In the results, the temperature of the arterial clamped flaps was lower than that of body and the mean difference was $0.3^{\circ}C$ after 20 minutes of clamping. In the vein-clamped flaps, the mean decrease was $0.4^{\circ}C$ after 30 minutes of clamping. The all difference of the temperature between the flaps and body was statistically significant. Our results suggest that flap monitoring by infra-red thermometer is simple, useful and helpful to evaluate the flap status.

• 대한미세수술학회:학술대회논문집
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• 1997.10a
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• pp.137-137
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• 1997

• Archives of Reconstructive Microsurgery
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• v.5 no.1
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• pp.70-79
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• 1996

From January 1980 to May 1995, ninety-six patients had been treated by free-flap transfer for the soft tissue defects of the extremities. Ninety-eight cases of free-tissue transfer were reviewed to evaluate the clinical reliability in terms of survival and quality of long-time function after reconstructive surgery. Among these 98 cases(27 cases in latissimus dorsi myocutaneous flap, 25 in dorsalis pedis flap, 20 in forearm fasciocutaneous flap, 9 in groin flap, 7 in gracilis myocutaneous flap, 6 in 1st web space flap of foot and 4 cases in tensor fascia lata flap), 92 cases of then were survived. 7 cases were performed with vein grafts. We ananalyzed the reconstruction of the extremities on 98 cases with the soft tissue defects which had been reconstructed free-flap transfer and followed for minimum 1 year period at Korea University Hospital. 1. 92 cases(93.9%) of the total 98 cases were successful and can be obtained the excellent results in soft tissue free-flap transfer. 2. While there were no clinically significant differences in survival rate of flaps transferred from different potential flap donor sites,3 cases of 9 groin flaps were showed higher failure rate due to the complications such as arterial thrombosis, infection and anatomical variation of vessels. 3. Postoperative thrombectomy was performed in 30 cases to be occured in the arterial and venous thrombosis. The revision was failed in 2 cases due to persistent arterial thrombosis and infection, then treated with skin graft. 4. Vein graft was frequently required in severely compromised-soft tissue defects resulted from high-energy trauma. The vein graft was not stitistically significant on the frequency of flap failure rate(P<0.04). 5. Meticulous monitoring, careful planning, early revision and technical considerations will provide for a high clinical success of the free-flap transfer.

• Archives of Plastic Surgery
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• v.45 no.1
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• pp.45-50
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• 2018

Background Free muscle flaps are a mainstay for reconstruction of distal third leg wounds and for large lower extremity wounds with exposed bone. However a major problem is the significant postoperative flap swelling, which may take months to resolve. We studied the efficacy and safety of immediate application of a vacuum assisted closure (VAC) dressing after a free muscle flap to the lower extremity. Methods Over a 19 months period, all consecutive free muscle flaps for lower extremity reconstruction at a Level I trauma center were evaluated prospectively for postoperative flap thickness, complications and flap survival. Immediate application of a VAC dressing was performed in 9 patients, while the flap was left exposed for monitoring in 8 patients. Results There was no statistically significant difference in flap survival between both cohorts. Mean flap thickness at postoperative day 5 for the VAC group was $6.4{\pm}6.4mm$, while flap thickness for the exposed flap group was $29.6{\pm}13.5mm$. Flap thickness was significantly decreased at postoperative day 5 for the VAC dressing group. Conclusions Immediate application of VAC dressing following free muscle flaps to the lower extremity does not compromise flap survival or outcomes and results in decreased flap thickness and a better aesthetic outcome.

• Korean Journal of Head & Neck Oncology
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• v.23 no.1
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• pp.26-31
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• 2007

Background and Objectives：Microvascular free flap reconstruction has been revolutionized in last two decades, and became a standard option in the reconstruction of head and neck defects. We intended to review our experiences of 51 microvascular free flap for head and neck defects during 5-year period and to analyze the types of flaps according to primary sites, success and complication rates. Subjects and Methods：From Oct. 2001 through Dec. 2005, fifty one free flap reconstructions were performed in forty nine patients at ENT department of Soonchunhyang university bucheon hospital. Primary sites, pathology, T-stage, operative time, time interval of oral feeding, and various reconstructive factors such as recipient and donor vessels, free flap related complications, failure rates and salvage rates were retrospectively analyzed. The relation between complication rates and preoperative risk factors were statistically analyzed. Results：Methods of reconstruction were radial forearm free flap(RFFF)(n=28, 54.9%), anterolateral thigh free flaps(n=9, ALTFF)(17.6%), rectus abdominis free flap(n=7, RAFF)(13.7%), jejunal free flap(n=5, JFF)(9.8%), and miscellanous(n=2, 4.0%) in order. In free flap related complications, failure of free flap occurred in seven cases(13.7%) and pharyngocutaneous fistula occurred in five cases(9.8%) among fifty one free flaps. The overall success rate of free flaps was 86.3%. Salvage of free flaps was possible only one among eight cases(12.5%). In positive preoperative risk factor groups, failure of free flap was higher than in negative risk factor group. However, it was not statistically significant. Conclusion：We confirmed that free flap reconstructions are highly versatile and reliable options for use in the reconstruction of various soft tissue defects of the head and neck. Free flaps have gained great popularity given its versatility, ability for a two-team approach, and minimal donor site morbidity. However, complications related to microvascular surgery may be overcome by increased surgical experience and by intensive flap monitoring in early postoperative period.

• Archives of Craniofacial Surgery
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• v.15 no.3
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• pp.121-124
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• 2014

The use of the implantable Doppler device eases the burden of free flap monitoring, and allows caregivers to notify healthcare personnel of a potential vascular event. A 24-year-old female patient underwent anterolateral thigh adipofascial flap surgery to provide a buried flap on the left temporal area for a depressed and infected skull wound. The author was able to salvage the flap from two venous occlusions, which was made possible by early notifications from the caregiver who reported changes in the Doppler signal.

• Archives of Plastic Surgery
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• v.42 no.6
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• pp.741-745
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• 2015

Background Microvascular complications after free-flap breast reconstructions are potentially devastating problems that can increase patient morbidity and lead to flap loss. To date, no comprehensive study has examined the rates of salvage and the methods of microvascular revision in breast reconstruction. We reviewed the treatment of microvascular complications of free-flap breast reconstruction procedures over a seven-year period. Methods A retrospective review of all patients who underwent microvascular breast reconstruction at our institution between April 2006 and December 2013 was conducted. Based on their surgical records, all patients who required emergency re-exploration were identified, the rate of flap salvage was determined, the factors associated with flap salvage were evaluated, and the causes and methods of revision were reviewed. Results During the review period, 605 breast reconstruction procedures with a free lower abdominal flap were performed. Seventeen of these flaps were compromised by microvascular complications, and three flaps were lost. The overall salvage rate was 82.35%. No significant differences between the salvaged group and the failed group were observed with regard to age, BMI, axillary dissection, number of anastomotic arteries and veins, recipient vessel types, or use of the superficial inferior epigastric vein in the revision operation. Successful salvage of the flap was associated with a shorter time period between recognizing the signs of flap compromise and the take-back operation. Conclusions The salvage rate of compromised lower abdominal flaps was high enough to warrant attempting re-exploration. Immediate intervention after the onset of flap compromise signs is as important as vigilant postoperative monitoring.

• Archives of Reconstructive Microsurgery
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• v.9 no.1
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• pp.15-22
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• 2000

One hundred & seventy four consecutive free-flap transfers were reviewed to analyze distribution of the type of reconstructions, kinds of donor flaps as well incidence of complications. The role of emergent exploration and the effect of preoperative wound conditions in flap survival were evaluated. Free flap transfer for head and neck reconstruction was most common as 93 cases, followed by for upper extremity of 30 cases, for lower extremity 30 cases, 18 penile reconstructions and for trunk & breast 3 cases. Nine flaps exhibited signs of ciruclatory insufficiency between 5 hours and 7 days. Three were managed conservatively with ultimate partial necrosis of the flaps. Eight flaps required return to the operating room. On exploration, early arterial occlusion was revealed in 1 flap, late arterial occlusion in 2 flaps, early venous occlusion in 1 flap, late venous thrombosis in 2 flaps, prolonged venous spasm in 1 and hematoma in 1 flap. The average time from the first abnormal examination to exploration was 2.6 hours. There were no false-positive explorations. Four free flaps failed in spite of the correction of the cause of circulatory compromise. The remaining 4 flaps were salvaged following the correction the casuse. Recipient vessel problems such as irradiation and infection were the most common cause of circulatory crisis. Among the eight flaps requiring return to the operating room, single vein was anastomosed in three flaps and two veins in the remaining five. In the totally failed four flaps only single vein was anastomosed in three cases. The results of this study demonstrate the efficacy of clinical monitoring and the role of early exploration. Precautious selection of recipient vessels and two vein anastomosis are recommended for safe and better prognosis.