Intraoperative Flussmessungen mittels Transit-Time Flowmetry und mikrovaskulärer Indocyaningrün Angiographie bei freien DIEP und ms-TRAM Lappenplastiken bei der autologen mikrochirurgischen Brustrekonstruktion

Background: Vascular patency is the key element for high flap survival rates. The purpose of this study was to assess and compare the blood flow characteristics of deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis musculocutaneous (ms-TRAM) flaps for autologous breast reconstruction. Methods: This prospective clinical study combined Transit- Time Flowmetry and microvascular Indocyanine Green Angiography for the measurement of blood flow volume, vascular resistance, and intrinsic transit time. Results: Twenty female patients (mean age, 52 years) received 24 free flaps (14 DIEP and 10 ms-TRAM flaps). The mean arterial blood flow of the flap in situ was 7.2 ± 1.9 mL/min in DIEP flaps and 11.5 ± 4.8 mL/min in ms-TRAM flaps (p < 0.05). After anastomosis, the mean arterial blood flow was 9.7 ± 5.6 mL/min in DIEP flaps and 13.5 ± 4.2 mL/min in ms-TRAM flaps (p = 0.07). The arterial vascular resistance of DIEP flaps was significantly higher than that of ms-TRAM flaps. The intrinsic transit time of DIEP flaps was 52 ± 18 s, and that of ms-TRAM flaps was 33 ± 11 s (p < 0.05). The flap survival rate was 100%. One DIEP flap with the highest intrinsic transit time (77 s) required surgical revision due to arterial thrombosis. Conclusion: In this study, we established the blood flow characteristics of free DIEP and ms-TRAM flaps showing different blood flow rates, vascular resistances, and intrinsic transit times. These standard values will help to determine the predictive values for vascular compromise, hence improving the safety of autologous breast reconstruction procedures.Intraoperative Flussmessungen mittels Transit-Time Flowmetry und mikrovaskulärer Indocyaningrün Angiographie bei freien DIEP und ms-TRAM Lappenplastiken bei der autologen mikrochirurgischen Brustrekonstruktion. 1.1 Hintergrund und Ziele Die suffiziente Blutversorgung ist ein entscheidender Faktor für die Überlebensrate freier Lappenplastiken. Das Ziel dieser Studie war es Blutflusseigenschaften der Anschluss- und Empfängergefäße bei freien DIEP (= Deep Inferior Epigastric Perforator) und ms-TRAM (= muscle-sparing Transverse Rectus Abdominis Muscle) Lappenplastiken im Rahmen autologer mikrochirurgischer Brustrekonstruktionen zu analysieren und miteinander zu vergleichen. 1.2 Methoden Diese prospektive klinische Studie kombiniert hierfür erstmals die Technologie der Ultraschall-basierten Transitzeit-Flussmessung (TTFM = Transit-Time Flowmetry) mit der mikrovaskulären Indocyaningrün Angiographie zur Messung des Blutflussvolumens, des Gefäßwiderstandes, sowie der intrinsischen Durchflussrate von Lappenplastiken (ITT = Intrinsic Transit Time) bei freien DIEP und ms-TRAM Lappenplastiken. 1.3 Ergebnisse 20 Patientinnen (Durchschnittsalter: 52 Jahre) mit 24 freien Lappenplastiken, wovon 14 DIEP und 10 ms-TRAM Lappenplastiken waren, wurden in diese Studie eingeschlossen. Das mittlere arterielle Blutflussvolumen vor Absetzen des Lappenstiels war mit 11.5 ± 4.8 ml/min bei ms-TRAM Lappenplastiken signifikant höher als bei DIEP Lappenplastiken mit 7.2 ± 1.9 ml/min (p < 0.05). Nach Anastomose mit der Arteria mammaria interna lag das durchschnittliche Blutflussvolumen von ms- TRAM Lappenplastiken bei 13.5 ± 4.2 ml/min und war somit ebenfalls höher als bei DIEP Lappenplastiken mit 9.7 ± 5.6 ml/min (p = 0.07). Im Gegensatz dazu zeigte sich der durchschnittliche arterielle Gefäßwiderstand bei DIEP Lappenplastiken sowohl vor Lappenhebung als auch nach Anastomosierung signifikant höher als bei ms-TRAM Lappenplastiken. Die Intrinsic Transit Time von DIEP Lappenplastiken war mit 52 ± 18 Sekunden signifikant länger als die von ms-TRAM Lappenplastiken mit 33 ± 11 Sekunden. Die Gesamtüberlebensrate aller Lappenplastiken betrug 100%. Die DIEP Lappenplastik mit der längsten Intrinsic Transit Time (77 Sekunden) musste jedoch aufgrund einer arteriellen Thrombose operativ revidiert werden. 1.4 Schlussfolgerung In dieser Studie konnten durch den Vergleich von Blutflusseigenschaften zwischen DIEP und ms-TRAM Lappenplastiken Unterschiede des Blutflussvolumens, dem arteriellen Gefäßwiderstand und der Intrinsic Transit Time erhoben werden. Diese Messungen zu definierten Zeitpunkten sollen als Normwerte und in weiterer Folge als Grundstein für die Erhebung positiv prädiktiver Werte von Durchblutungsstörungen im Rahmen autologer Brustrekonstruktionen mittels DIEP und ms-TRAM Lappenplastiken dienen

A Myocutaneous Latissimus Dorsi Propeller Flap Based on a Single Dorsal Intercostal Perforator

This study presents a novel surgical technique for the reconstruction of highly challenging large lower back defects. In this case, a 72-year-old man initially diagnosed with renal cell carcinoma received nephrectomy followed by the dissection of an iliac crest metastasis and repeated high-dose irradiation therapy. Several years later, an osteocutaneous fistula at the right caudal posterior trunk made the reconstruction of the lower back defect necessary. High-dose irradiation of the lower back and poor vascular conditions at the pelvic region disqualified the patient for previously published local or free flap options. The initial strategy of an arteriovenous loop anastomosed to the femoral vessels and a free latissimus dorsi flap transfer had to be withdrawn due to repeated intraoperative loop thrombosis. For that reason, the entire latissimus dorsi muscle was used as a myocutaneous propeller flap receiving its blood supply solely through a single dorsal intercostal artery perforator. The flap survived completely and no fistulous formation occurred postoperatively. The time to complete wound healing was 4 months. This new technique is considered a valuable addition for the reconstruction of challenging posterior caudal trunk defects

Intraoperative Blood Flow Analysis of DIEP vs. ms-TRAM Flap Breast Reconstruction Combining Transit-Time Flowmetry and Microvascular Indocyanine Green Angiography

Background: Vascular patency is the key element for high flap survival rates. The purpose of this study was to assess and compare the blood flow characteristics of deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis musculocutaneous (ms-TRAM) flaps for autologous breast reconstruction. Methods: This prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the measurement of blood flow volume, vascular resistance, and intrinsic transit time. Results: Twenty female patients (mean age, 52 years) received 24 free flaps (14 DIEP and 10 ms-TRAM flaps). The mean arterial blood flow of the flap in situ was 7.2 &plusmn; 1.9 mL/min in DIEP flaps and 11.5 &plusmn; 4.8 mL/min in ms-TRAM flaps (p &lt; 0.05). After anastomosis, the mean arterial blood flow was 9.7 &plusmn; 5.6 mL/min in DIEP flaps and 13.5 &plusmn; 4.2 mL/min in ms-TRAM flaps (p = 0.07). The arterial vascular resistance of DIEP flaps was significantly higher than that of ms-TRAM flaps. The intrinsic transit time of DIEP flaps was 52 &plusmn; 18 s, and that of ms-TRAM flaps was 33 &plusmn; 11 s (p &lt; 0.05). The flap survival rate was 100%. One DIEP flap with the highest intrinsic transit time (77 s) required surgical revision due to arterial thrombosis. Conclusion: In this study, we established the blood flow characteristics of free DIEP and ms-TRAM flaps showing different blood flow rates, vascular resistances, and intrinsic transit times. These standard values will help to determine the predictive values for vascular compromise, hence improving the safety of autologous breast reconstruction procedures

Protocol for a systematic review of venous coupler devices versus hand-sewn anastomosis for microsurgical free flap reconstruction

Abstract Background A patent microvascular anastomosis is of paramount importance in free tissue transfer. Anastomotic coupler devices provide an alternative to technically demanding hand-sewn venous anastomosis. Various advantages of these devices have been discussed but previous systematic reviews had methodological flaws or did not perform a meta-analysis. This review aims to evaluate the quality of the evidence and quantify the efficacy and safety of venous couplers compared to hand-sewn anastomosis. Methods A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive search strategy has been developed and will be applied to the databases MEDLINE and Embase from inception to October 2018. All clinical studies using anastomotic coupler devices for venous anastomoses in free tissue transfer will be eligible for inclusion. Screening of studies and data extraction will be performed independently by two authors. Our primary outcome is anastomotic venous thrombosis. Secondary outcomes will include time to complete the venous anastomosis, tearing of veins, anastomotic leakage, flap loss/failure and fiscal outcomes. The risk of bias for included studies will be assessed by using the ROBINS-I tool, and recommendations based on the evidence will be made using the GRADE approach. Descriptive statistical analyses will be used and if two or more studies report the same outcome, data will be pooled for comparative analysis. A direct comparison meta-analysis will be performed if possible. Discussion There has been no comparison of coupled and hand-sewn venous anastomoses using a robust and validated methodology preceded by a protocol and performing meta-analysis. Included studies are expected to be mainly observational and prone to bias; however, there is value in summarising the evidence, assessing its risk of bias and performing meta-analysis to guide clinicians. By using a broad approach including all types of flaps, we foresee inherent differences regarding the unit of analysis and different anatomic sites. This will limit the validity of our conclusions but is unavoidable. We will seek unpublished data from authors and perform subgroup analysis where appropriate. Limitations and areas of uncertainty will be discussed to guide future research. Systematic review registration PROSPERO CRD4201811011

Intraoperative Blood Flow Analysis of Free Flaps with Arteriovenous Loops for Autologous Microsurgical Reconstruction

Background: Arteriovenous (AV) loops help to overcome absent or poor-quality recipient vessels in highly complex microvascular free flap reconstruction cases. There are no studies on blood flow and perfusion patterns. The purpose of this study was to evaluate and compare intraoperative hemodynamic characteristics of AV loops followed by free tissue transfer for thoracic wall and lower extremity reconstruction. Methods: this prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the assessment of blood flow volume, arterial vascular resistance and intrinsic transit time at the time of AV loop construction and on the day of free flap transfer. Results: A total of 11 patients underwent AV loop creation, of whom five required chest wall reconstruction and six required reconstruction of the lower extremities. In seven of these cases, the latissimus dorsi flap and in four cases the vertical rectus abdominis myocutaneous (VRAM) flap was used as a free flap. At the time of loop construction, the blood flow volume of AV loops was 466 ± 180 mL/min, which increased to 698 ± 464 mL/min on the day of free tissue transfer (p > 0.1). After free flap anastomosis, the blood flow volume significantly decreased to 18.5 ± 8.3 mL/min (p p < 0.05). Conclusion: This is the first study to perform intraoperative blood flow and hemodynamic measurements of AV loops followed by free tissue transfer. Our results show hemodynamic differences and contribute to deeper understanding of the properties of AV loops for free flap reconstruction

Is Instillational Topical Negative Pressure Wound Therapy in Peri-Prosthetic Infections of the Breast Effective? A Pilot Study

Peri-prosthetic breast infections pose a risk of severe complications after breast implant surgery. The need to remove the breast implant, control the infection and perform additional surgical procedures are the consequences. Reimplantation of an alloplastic implant is only appropriate after an infection-free interval. In this retrospective cohort study, we investigated the effectiveness of negative pressure wound treatment with instillation and dwell time (NPWTi-d) on peri-prosthetic breast infections in combination with implant removal and antibiotic therapy. Twelve patients treated with NPWTi-d due to breast implant infection were included in the study. The bacterial burden was analyzed using wound swabs before and after NPWTi-d. Additionally, laboratory values were determined before NPWTi-d and immediately before wound closure. A total of 13 peri-prosthetic breast infections in 12 patients were treated using implant removal and NPWTi-d. In 76.9% (n = 10) of the cases, the patients had undergone alloplastic breast reconstruction following cancer-related mastectomy, whereas 23.1% (n = 3) of the patients had undergone breast augmentation for cosmetic reasons. The bacterial burden in the breast pocket decreased statistically significant after implant removal and NPWTi-d. No shift from Gram-positive to Gram-negative bacteria was observed. Inflammatory markers rapidly decreased following treatment. NPWTi-d had a positive impact on the healing process after peri-prosthetic breast infections, leading to a decrease in bacterial burden within the wounds and contributing to uneventful healing. Therefore, secondary reimplantation of breast prostheses might be positively influenced when compared to conventional implant removal and simple secondary closure. Further studies are required to conclusively establish the beneficial long-term effects of using NPWTi-d for the treatment of peri-prosthetic breast infections

Analysis of laboratory markers in body contouring procedures after bariatric surgery does not indicate particular risks for perioperative complications

Abstract Background Body contouring surgery after massive weight loss is associated with different risk factors. Wound healing disorders and seromas commonly occur postoperatively. Bariatric interventions lead to massive weight loss with excess skin and soft tissue. In this study, perioperatively collected laboratory markers of this special patient population were analyzed. Methods Fifty-nine patients were analyzed retrospectively regarding bariatric surgery, weight loss, body contouring surgery, laboratory markers, and complication rates. Results Body contouring surgery (n = 117) was performed in 59 patients. Weight loss was achieved after gastric bypass (40.1%), gastric banding (33.9%), or sleeve gastrectomy (26.0%), with an average of 69.2 kg. The most common body contouring procedure included abdominoplasty (n = 50), followed by thigh lift (n = 29), mammaplasty (n = 19), brachioplasty (n = 14), and upper body lift (n = 5). Analysis of laboratory markers revealed no exceptional and clinically relevant variations. Correlation analysis revealed associations between resection weight, amount of drain fluid, and particular laboratory markers. Conclusion Analysis of perioperative laboratory markers in this special patient population after massive weight loss did not indicate clinically relevant risk factors regardless of the type of bariatric or body contouring surgery. Body contouring surgeries after bariatric interventions prove to be safe and low risk concerning perioperative laboratory markers and postoperative hospitalization