• Archives of Plastic Surgery
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• 제49권6호
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• pp.782-784
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• 2022

Diabetic foot ulcers are a severe complication of diabetes, and their management requires a multidisciplinary approach for optimal management. When treating these ulcers, limb salvage remains the ultimate goal. In this article, we present the "hanging" free flap for the reconstruction of chronic lower extremity diabetic ulcers. This two-staged approach involves standard free flap harvest and inset; however, following inset the "hanging" pedicle is covered within a skin graft instead of making extraneous incisions within the undisturbed soft tissues or tunnels that can compress the vessels. After incorporation, a second-stage surgery is performed in 4 to 6 weeks which entails pedicle division, flap inset revision, and end-to-end reconstruction of the recipient vessel. Besides decreasing the number of incisions on diabetic patients, our novel technique utilizing the "hanging" pedicle simplifies flap monitoring and inset and allows reconstruction of recipient vessels to reestablish distal blood flow.

• 대한두경부종양학회:학술대회논문집
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• 대한두경부종양학회 2001년도 제18차 학술대회
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• pp.276-276
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• 2001

• Archives of Plastic Surgery
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• 제36권5호
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• pp.555-558
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• 2009

Purpose: The high success rate of free flap transfers is well documented in previous literature, and is possible due to the early detection of vascular compromise and timely reoperation. We specifically analyzed the operative results of immediate and delayed reconstruction with free transverse rectus abdominis musculocutaneous(TRAM) flap respectively in order to reveal its distinctive features on timing and causes of vascular compromise. Methods: The senior author operated on 158 patients, 161 cases of free TRAM flap for breast reconstruction. 51 patients underwent delayed reconstruction, whilst immediate reconstruction was performed in the other 107 patients. All patients were monitored every 3 hours for the first 3 days. We reviewed medical records of all patients, and tested statistical significance with the Fisher's test. Results: Reoperation was performed in 20 cases, but the cases include hematoma with bleeding focus and arterial anastomosis site rupture due to abrupt arm abduction. We performed reoperation in 15 cases of suspicious vascular compromise. Flap compromise was noticed mostly within 24 hours, but not longer than 72 hours. Venous compromise was dominant by 11 cases (73.3%). There was difference in the timing of flap compromise between immediate and delayed reconstruction. All the cases of delayed reconstruction did not show signs of vascular compromise after 12 hours postoperatively. On the other hand, cases of vascular compromise were observed until 72 hours postoperatively in cases of immediate reconstruction. Conclusion: Delayed reconstruction showed vascular compromise within 12 hours postoperatively, while immediate reconstruction showed compromised until the 3rd postoperative day. If more aggressive monitoring is maintained during this period, we believe salvage of flaps may be increased with more efficiency.

• Archives of Plastic Surgery
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• 제48권4호
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• pp.457-461
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• 2021

Background Pedicled perforator flaps can present postoperative complications similar to those encountered in free flap surgery. Beyond a clinical evaluation, there is still no reliable technical aid for the early prediction of vascular issues. The aim of this study was to assess the support of near-infrared spectroscopy technology as an intraoperative tool to anticipate postsurgical flap ischemia. Methods We prospectively enrolled 13 consecutive patients who were referred to our hospital from March 2017 to July 2018 and required a reconstructive procedure with a pedicled fasciocutaneous perforator flap. We measured flap peripheral capillary oxygen saturation (SpO₂) in each patient with a Somanetics INVOS 5100C Cerebral/Somatic Oximeter (Medtronic), both before and after transposition. Patient demographics, operative data, and complications were then recorded during the following 6 months. We analyzed the data using the Wilcoxon signed-rank test and linear regression. Results The mean flap SpO₂ before and after transposition was 92%±3% and 78%±19%, respectively. The mean change in SpO₂ was 14%±17%, with a range of 0% to 55%. The change in saturation and mean saturation ratio were significantly different between patients with and without postoperative flap necrosis. Conclusions An immediate quantitative analysis of flap peripheral capillary SpO₂ after transposition has never before been described. In our experience, an intraoperative drop in SpO₂ equal to or greater than 15%-20% predicted vascular complications in pedicled perforator flaps. Conversely, flap size and rotation angle were not correlated with the risk of flap necrosis.

• Archives of Plastic Surgery
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• 제40권5호
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• pp.505-509
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• 2013

Background The aim of this study was to collect important data on the time of oxygen saturation change in relation to skin flap color alteration using non-invasive pulse oximetry to evaluate its ability to provide continuous monitoring of skin flap perfusion. Methods An experimental study on the monitoring of blood perfusion of 20 tube-island groin flaps of 10 male New Zealand rabbits was performed using pulse oximetry. The animals were randomly assigned to one of two groups representing a blockage of either arterial or venous blood flow. The oxygen saturation change and clinical color alteration were monitored from the beginning of vessel clamping until the saturation became undetectable. The result was analyzed by the t-test using SSPS ver. 10.0. Results The mean times from the vessel clamping until the saturation became undetectable were $20.19{\pm}2.13$ seconds and $74.91{\pm}10.57$ seconds for the artery and vein clamping groups, respectively. The mean time of the clinical alteration from the beginning of vein clamping was $34.5{\pm}11.72$ minutes, while the alteration in flaps with artery clamping could not be detected until 2.5 hours after clamping. Conclusions The use of neonate-type reusable flex sensor-pulse oximetry is objective and effective in early detection of arterial and vein blockage. It provides real-time data on vessel occlusion, which in turn will allow for early salvaging. The detection periods of both arterial occlusion and venous congestion are much earlier than the color alteration one may encounter clinically.

• Archives of Plastic Surgery
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• 제32권4호
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• pp.503-510
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• 2005

If we could predict the necrosis of the flap caused by reperfusion injury, we can minimize the necrosis of the flap by taking appropriate action before necrosis begins. In this study, we examined whether we can predict the survival of flap under reperfusion injury or not, by measuring laser doppler flow meter values. We divided the group into the control and experimental groups corresponding to 6, 8, 9, 10, and 12hours after reperfusion(hours after ligation of auricular central artery). In each group, we examined necrotic change, perfusion unit (PU), serum superoxide dismutase (SOD), glutathione peroxidase, angiography and pathologic findings. No necrosis was observed in the 6 and 8 hours group but 8, 18, 20 hours after ligation, necrosis was observed, Also in each of 9, 10 and 12 hours group (each group consisted of 20 flaps), necrosis were noted. According to the above data, the critical time of necrosis in the auricular skin flap model lies between about 8 to 9 hours. Comparing the PU between the necrosis and non-necrosis groups, the former group showed a mean 39.57 PU increase after 60 min of reperfusion, and the latter group showed a mean increase of 21.21 PU. We can conclude that better flow can dilute oxygen free radical into systemic circulation, and this means less injuries are caused on vessels. Our study implies that if blood flow increase is less than 30 PU, intensive care is needed to save the flap. Additionally, we found significant decrease of serum SOD and glutathione peroxidase in the necrotic group. Therefore, monitoring these serum markers will be helpful in predicting reperfusion injury and supplementing these enzymes could be helpful to save the flap. The laser doppler flow meter is thought to be helpful in clinical circumstances for evaluating the circulation of the flap after the operation. However, more accumulation of clinical studies should be necessary establishing useful clinical data.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• 제33권4호
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• pp.340-349
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• 2007

Free flap transplantation with microvascular anastomosis has been successfully performed by development of surgical technique, materials and postoperative monitoring equipments of flap. But success rate of microvascular anastomosis is influenced by various factors, and failure rate is about 5-10%. The most influential factor for success rate is surgical technique and other factors that influence failure of microvascular anastomosis are ischemic time of free flap, thrombus formation of anastomosis region and vascular spasm. In this study, vascular patency and thrombus formation in experimental micro-venous anastomosis, and endothelial repair were observed with histologic analysis, scanning electron microscopy, transmission electron microscopic examination. The results were obtained as follows: 1. In vascular patency test in 30 minute and 7 days after micro-venous anastomosis with heparin irrigation, all of 12 anastomosis site were good vascular patency. 2. In thrombus formation in 2 weeks group(Experimental I), 2 site of 6 cases were observed thrombus, and in 4 weeks group(Experimental II), 1 site of 6 cases were observed thrombus. 3. In histologic examination, normal vein(Control Group) showed continued internal elastic lamina, well formed thick smooth muscle layer and connective tissue. The group of 2 weeks after microvenous anastomosis(Experimental I) showd locally recovered internal lamina, discontinued internal lamina, disorganized smooth muscle cells and granulation tissue around suture silk. In the group of 4 weeks after micro-venous anastomosis(Experimental II), anastomosis site showed almostly continued internal lamina, disorganized smooth muscle cells and cicartrized tissue around suture silk. 4. In scanning electron microscope examination in 2 weeks(Experimental I) after micro-venous anastomosis, mesh fibrin formation showed near to endothelial cells, and in 4 weeks after micro-venous anastomosis(EXperimental II), numerous blood cells and fibrin mesh formation was seen associated with irregular endothelial cell arrangement. 5. In transmission electron microscope examination in 2 weeks after micro-venous anastomosis(Experimental I), irregular arrangement of smooth muscle cells was seen adjacent to collagenized tissue around suture silk. In 4 weeks after micro-venous anastomosis(Experimental II), denuded venous wall composed of relatively well arranged smooth muscle cells was covered by endothelial cells, but fibroblast cells and foreign body giant cells near to suture silk was remained. From the results obtained in this study, results of good vascular patiency and anti-thrombotic effect of heparin were obtained as a local irrigation solution, and repair of venous endothelial cell was observed in 2 weeks after micro-venous anastomosis.

• Journal of the Korean Association of Oral and Maxillofacial Surgeons
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• 제32권2호
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• pp.117-128
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• 2006

Free flap transplantation with microvascular anastomosis has been successfully performed by development of surgical technique, materials and postoperative monitoring equipments of flap. But success rate of microvascular anastomosis is influenced by various factors, and failure rate is about 5-10%. The most influential factor for success rate is surgical technique and other factors that influence failure of microvascular anastomosis are ischemic time of free flap, thrombus formation of anastomosis region and vascular spasm. Many studies has been published in microvascular anastomosis with histologic effect for irrigating solution. But local irrigation solution has been used clinically in microvascular anastomosis, the comparison with each solution, microhistological study for endothelial cell repair and vascular patency has not been reported. The heparin which is anti-thrombotic agent, and urokinase which is fibrinolytic agent are used for this study. Vascular patency and thrombus formation in experimental micro-arterial anastomosis, and endothelial repair were observed with histologic analysis, scanning electron microscopy, transmission electron microscopic examination. The results were obtained as follows: 1. In vascular patency test in 30 minute and 7 days after micro-arterial anastomosis, equal effects of good vascular patency were obtained in group of local irrigation with heparin and urokinase. 2. In thrombus formation in 7 days after micro-arterial anastomosis, equal effects of minimal thrombus formation were obtained in group of local irrigation with heparin and urokinase. 3. In toluidin blue staining in 7 days after micro-arterial anastomosis, local destruction of endothelial cell and inner elastic lamina were seen and endothelial repair was not seen. 4. In scanning electron microscope examination in 7 days after micro-arterial anastomosis, endothelial cell was not seen in peripheral to suture materials, thrombus associated fibrin network was observed. 5. In transmission electron microscope examination in 7 days after micro-arterial anastomosis, inflammatory cell was seen within smooth muscle cells in site of endothelial cell destruction, smooth muscle cell around suture material were arranged irregularly, some collagenous change were seen. From the results obtained in this study, same results of good vascular patency and anti-thrombotic effect of heparin and urokinase were obtained as a local irrigation solution, and repair of endothelial cell was not seen in 7 days after micro-arterial anastomosis.

• Archives of Plastic Surgery
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• 제32권4호
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• pp.461-466
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• 2005

Despite the major advances in the microvascular surgery with success rates of up to 98%, failure and vascular complications still remain even in the experienced hands. Failure of blood to flow across an anastomosis is usually caused by three factors: (1) Technical errors; (2) Undetected damage more proximally or via vasospasm; or (3) A clot or a thrombus. The success of a microvascular surgery depends on the severity of the vascular injury and, proper debridement of an injured vessel, and the failure rate of microvascular anastomosis in cases of trauma is higher as the thrombogenic possibility is increased by the endothelial damage. From January to November in 2003, 460 patients were underwent microvascular surgery(270 replantations and 190 free flap transfers) and re-operations were performed in 15 cases. Cases were reviewed by clinical and operative records. In these cases, causes of post-operative circulation insufficiency were identified as 9 vascular spasms and 6 thromboses at the previous anastomotic site. The average of re-operative success rate was 73%(60% in replantations and 100% in free flaps). In conclusion, through precise postoperative monitoring and assessment, immediate surgical re-exploration could be performed when a vascular complication is suspicious, the success rate of microvascular surgery would be increased more.

• Archives of Plastic Surgery
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• 제38권6호
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• pp.791-797
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• 2011

Purpose: Angiosarcoma is a rare and aggressive malignant soft tissue tumor. Due to a lack of the established optimal treatment modalities, however, an extensive resection followed by an early detection has been reported to be the best treatment of choice. We analyzed the clinical course of six patients, hence attempted to contribute to making a treatment plan for patients with angiosarcoma. Methods: Six patients who have been surgically treated between 2005 and 2010 are included. Through a retrospective analysis of the medical records, we evaluated the pattern of disease detection, a past history, time span between the detection and the primary surgery, surgical treatment modalities, time span between the primary surgery and the recurrence/metastasis, the sites of metastasis and the secondary treatment modalities. Results: The mean age of patients was 70.5 years; all male; and the sites were the scalp. Four patients underwent the reconstruction using a local flap with a skin graft and two patients using a free flap. The mean period elapsed until the primary operation since the identification was 7.3 months and until a recurrence or a metastasis occurred following the primary operation was 12 months. Four patients had pulmonary metastasis. As a secondary therapy, four patients underwent the radiotherapy and one was treated with the chemotherapy. At the present, five patients died and one undergoes a monitoring of the clinical course. Conclusion: It would be mandatory to shorten the length of hospital stay and to return patients to their daily lives as the earliest as possible using relatively simpler surgical methods, thus attempting to give them opportunity to resume their previous normal life.