J Reconstr Microsurg 2010; 26(8): 513-515
DOI: 10.1055/s-0030-1261697
© Thieme Medical Publishers

First Aid for Failing Flaps

Simon G. Talbot1 , Julian J. Pribaz1
  • 1Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
Further Information

Publication History

Publication Date:
22 June 2010 (online)

ABSTRACT

Wound coverage with pedicled (local, regional, or distant) or free flaps is commonplace throughout plastic surgery. However, irrespective of the method of tissue transfer or type of tissue being transferred, inflow and outflow remain key parameters for success. Much has been written detailing complex tissue transfers and delineating arterial and venous anatomy. Despite this, simple venous insufficiency causing venous congestion is common. In experimental models, when arterial inflow is impaired, even mild venous inadequacy affects flap survival. Furthermore, studies have shown that venous congestion is more detrimental to the rate and percentage of flap area surviving than arterial ischemia. Obviously, complete venous occlusion typically requires operative exploration and correction, but many instances occur when venous congestion occurs for reasons other than complete venous thrombosis. Here we detail the basic postoperative “first aid” techniques available to optimize venous drainage. Although these techniques are not a substitute for sound anatomic flap selection, good surgical technique, or re-operation when a significant underlying problem exists, they do offer additional options to improve flap outcomes.

REFERENCES

  • 1 Taylor G I, Palmer J H. The vascular territories (angiosomes) of the body: experimental study and clinical applications.  Br J Plast Surg. 1987;  40 113-141
  • 2 Taylor G I, Caddy C M, Watterson P A, Crock J G. The venous territories (venosomes) of the human body: experimental study and clinical implications.  Plast Reconstr Surg. 1990;  86 185-213
  • 3 Tsuzuki K, Yanai A, Tange I, Bandoh Y. The influence of congestion and ischemia on survival of an experimental vascular pedicle island flap.  Plast Reconstr Surg. 1989;  84 789-793
  • 4 Yazar S, Chen H C, Mardini S. Augmentation of venous drainage by a venous anastomosis for pedicled flaps.  J Reconstr Microsurg. 2008;  24 369-376
  • 5 Kerrigan C L, Wizman P, Hjortdal V E, Sampalis J. Global flap ischemia: a comparison of arterial versus venous etiology.  Plast Reconstr Surg. 1994;  93 1485-1495 discussion 1496-1497
  • 6 Aydin M A, Mavili M E. Examining microcirculation improves the angiosome theory in explaining the delay phenomenon in a rabbit model.  J Reconstr Microsurg. 2003;  19 187-194
  • 7 Akan I M, Yildirim S, Gideroğlu K. Salvage of flaps with venous congestion.  Ann Plast Surg. 2001;  46 456
  • 8 Smoot III E C, Debs N, Banducci D, Poole M, Roth A. Leech therapy and bleeding wound techniques to relieve venous congestion.  J Reconstr Microsurg. 1990;  6 245-250
  • 9 Kubo T, Yano K, Hosokawa K. Management of flaps with compromised venous outflow in head and neck microsurgical reconstruction.  Microsurgery. 2002;  22 391-395
  • 10 Upton J. Leeches.  Plast Reconstr Surg. 1987;  79 311
  • 11 Utley D S, Koch R J, Goode R L. The failing flap in facial plastic and reconstructive surgery: role of the medicinal leech.  Laryngoscope. 1998;  108(8 Pt 1) 1129-1135
  • 12 Hartig G K, Connor N P, Heisey D M, Conforti M L. Comparing a mechanical device with medicinal leeches for treating venous congestion.  Otolaryngol Head Neck Surg. 2003;  129 556-564
  • 13 Wong C H, Tan B K. Intermittent short saphenous vein phlebotomy: an effective technique of relieving venous congestion in the distally based sural artery flap.  Ann Plast Surg. 2007;  58 303-307
  • 14 Gürsoy K, Kankaya Y, Uysal A, Koçer U. Dealing with the venous congestion of free flaps: venous catheterization.  J Craniofac Surg. 2008;  19 1645-1647
  • 15 Hartrampf Jr C R, Drazan L, Noel R T. A mechanical leech for transverse rectus abdominis musculocutaneous flaps.  Ann Plast Surg. 1993;  31 103-105
  • 16 Caplin D A, Nathan C R, Couper S G. Salvage of TRAM flaps with compromised venous outflow.  Plast Reconstr Surg. 2000;  106 400-401
  • 17 Stasch T, Goon P K, Haywood R M, Sassoon E M. DIEP flap rescue by venesection of the superficial epigastric vein.  Ann Plast Surg. 2009;  62 372-373
  • 18 Murphy A D, Conroy F J, Regan P J. A safety net for TRAM flaps with venous congestion.  J Plast Reconstr Aesthet Surg. 2009;  62 e114

Julian J PribazM.D. 

Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital

75 Francis Street, Boson, MA 02115

Email: jpribaz@partners.org)

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