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J Reconstr Microsurg 2022; 38(08): 637-646
DOI: 10.1055/s-0042-1742733
Original Article

The 72-Hour Microcirculation Dynamics in Viable Free Flap Reconstructions

Nicholas Moellhoff
1   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Clara Gernert
1   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Konstantin Frank
1   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Riccardo E. Giunta
1   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
,
Denis Ehrl
1   Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
› Institutsangaben Funding The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with the methods applied or the results presented in this article.
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Abstract

Background The risk for vascular complications is the highest within the first 24 hours after free flap transfer. Clinical signs of critical perfusion are often recognized with time delay, impeding flap salvage. To detect failing flaps as soon as possible and to prevent persisting microvascular impairments, knowledge of physiological perfusion dynamics in free flaps is needed. Aim of this study was to investigate the physiological perfusion dynamics of viable free flaps using the Oxygen to See (O2C) device for continuous monitoring.

Methods Microcirculation was continuously monitored in 85 viable free flaps over a period of up to 72 hours following microvascular anastomosis using tissue spectrophotometry and laser Doppler flowmetry (O2C, LEA Medizintechnik, Gießen, Germany). The parameters investigated included capillary-venous blood flow (flow), oxygen saturation (SO2), and relative amount of hemoglobin (rHB).

Results Microcirculatory blood flow increased significantly overall, especially within the first 18 hours after microsurgical anastomosis, after which peak formation was occurred. Mean values of SO2 showed a decreasing trend and the steepest decrease of SO2 (slope: 1.0) occurred during the steepest increase of flow between 3 and 6 hours (slope: 4.7) postanastomosis. The rHB values remained fairly constant throughout the study period.

Conclusion Hyperemia after free flap transfer accounts for a significant increase of microvascular flow. Tissue oxygenation is reduced, likely due to an increase of oxygen consumption after anastomosis. A better understanding of physiological perfusion dynamics in free flaps can aid surgeons in recognizing compromised vasculature earlier and improve free flap salvage.

Keywords

microsurgery - monitoring - O2C - microcirculation - perfusion - free flap


Publikationsverlauf

Eingereicht: 18. Juni 2021

Angenommen: 27. Dezember 2021

Artikel online veröffentlicht:
14. Februar 2022

© 2022. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Lin CH, Lin YT, Yeh JT, Chen CT. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007; 119 (07) 2118-2126
    CrossrefPubMedGoogle Scholar
  • 2 Lorenzo AR, Lin CH, Lin CH. et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthet Surg 2011; 64 (05) 649-655
    CrossrefPubMedGoogle Scholar
  • 3 Heidekrueger PI, Heine-Geldern A, Ninkovic M. et al. Microsurgical reconstruction in patients greater than 80 years old. Microsurgery 2017; 37 (06) 546-551
    CrossrefPubMedGoogle Scholar
  • 4 Klein HJ, Fuchs N, Mehra T. et al. Extending the limits of reconstructive microsurgery in elderly patients. J Plast Reconstr Aesthet Surg 2016; 69 (08) 1017-1023
    CrossrefPubMedGoogle Scholar
  • 5 Khouri RK, Cooley BC, Kunselman AR. et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102 (03) 711-721
    Google Scholar
  • 6 Chen KT, Mardini S, Chuang DC. et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
    Google Scholar
  • 7 Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol 2009; 1: 33
    CrossrefPubMedGoogle Scholar
  • 8 Bigdeli AK, Gazyakan E, Schmidt VJ. et al. Long-term outcome after successful lower extremity free flap salvage. J Reconstr Microsurg 2019; 35 (04) 263-269
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 9 Siemionow M, Arslan E. Ischemia/reperfusion injury: a review in relation to free tissue transfers. Microsurgery 2004; 24 (06) 468-475
    CrossrefPubMedGoogle Scholar
  • 10 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (07) 1230-1233
    CrossrefPubMedGoogle Scholar
  • 11 Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique. Plast Reconstr Surg 1998; 102 (03) 722-732 , discussion 733–734
    CrossrefPubMedGoogle Scholar
  • 12 Abdel-Galil K, Mitchell D. Postoperative monitoring of microsurgical free tissue transfers for head and neck reconstruction: a systematic review of current techniques–part I. Non-invasive techniques. Br J Oral Maxillofac Surg 2009; 47 (05) 351-355
    CrossrefPubMedGoogle Scholar
  • 13 Abdel-Galil K, Mitchell D. Postoperative monitoring of microsurgical free-tissue transfers for head and neck reconstruction: a systematic review of current techniques–part II. Invasive techniques. Br J Oral Maxillofac Surg 2009; 47 (06) 438-442
    CrossrefPubMedGoogle Scholar
  • 14 Smit JM, Zeebregts CJ, Acosta R, Werker PMN. Advancements in free flap monitoring in the last decade: a critical review. Plast Reconstr Surg 2010; 125 (01) 177-185
    CrossrefPubMedGoogle Scholar
  • 15 Rothenberger J, Amr A, Schaller HE, Rahmanian-Schwarz A. Evaluation of a non-invasive monitoring method for free flap breast reconstruction using laser doppler flowmetrie and tissue spectrophotometry. Microsurgery 2013; 33 (05) 350-357
    CrossrefPubMedGoogle Scholar
  • 16 Hölzle F, Loeffelbein DJ, Nolte D, Wolff KD. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg 2006; 34 (01) 25-33
    CrossrefPubMedGoogle Scholar
  • 17 Hölzle F, Rau A, Loeffelbein DJ, Mücke T, Kesting MR, Wolff KD. Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. Int J Oral Maxillofac Surg 2010; 39 (01) 21-28
    CrossrefPubMedGoogle Scholar
  • 18 Mücke T, Wolff KD, Rau A, Kehl V, Mitchell DA, Steiner T. Autonomization of free flaps in the oral cavity: a prospective clinical study. Microsurgery 2012; 32 (03) 201-206
    CrossrefPubMedGoogle Scholar
  • 19 Rahmanian-Schwarz A, Schiefer JL, Amr A, Rothenberger J, Schaller HE, Hirt B. Thermoregulatory response of anterolateral thigh flap compared with latissimus dorsi myocutaneous flap: an evaluation of flaps cutaneous flow and velocity due to thermal stress. Microsurgery 2011; 31 (08) 650-654
    CrossrefPubMedGoogle Scholar
  • 20 Gandjbakhche AH, Bonner RF, Arai AE, Balaban RS. Visible-light photon migration through myocardium in vivo. Am J Physiol 1999; 277 (02) H698-H704
    PubMedGoogle Scholar
  • 21 Lorenzetti F, Salmi A, Ahovuo J, Tukiainen E, Asko-Seljavaara S. Postoperative changes in blood flow in free muscle flaps: a prospective study. Microsurgery 1999; 19 (04) 196-199
    CrossrefPubMedGoogle Scholar
  • 22 Siemionow M, Andreasen T, Chick L, Lister G. Effect of muscle flap denervation on flow hemodynamics: a new model for chronic in vivo studies. Microsurgery 1994; 15 (12) 891-894
    CrossrefPubMedGoogle Scholar
  • 23 Chen LE, Seaber AV, Bossen E, Urbaniak JR. The effect of acute denervation on the microcirculation of skeletal muscle: rat cremaster model. J Orthop Res 1991; 9 (02) 266-274
    CrossrefPubMedGoogle Scholar
  • 24 Rosenberry R, Chung S, Nelson MD. Skeletal muscle neurovascular coupling, oxidative capacity, and microvascular function with ‘one stop shop’ near-infrared spectroscopy. J Vis Exp 2018; (132) 57317
    PubMedGoogle Scholar
  • 25 Nasir S, Baykal B, Altuntaş S, Aydin MA. Hemodynamic differences in blood flow between free skin and muscles flaps: prospective study. J Reconstr Microsurg 2009; 25 (06) 355-360
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 26 Cai ZG, Zhang J, Zhang JG. et al. Evaluation of near infrared spectroscopy in monitoring postoperative regional tissue oxygen saturation for fibular flaps. J Plast Reconstr Aesthet Surg 2008; 61 (03) 289-296
    CrossrefPubMedGoogle Scholar
  • 27 Mücke T, Rau A, Merezas A. et al. Identification of perioperative risk factor by laser-doppler spectroscopy after free flap perfusion in the head and neck: a prospective clinical study. Microsurgery 2014; 34 (05) 345-351
    CrossrefPubMedGoogle Scholar
  • 28 Nelson JA, Kim EM, Eftakhari K. et al. Late venous thrombosis in free flap breast reconstruction: strategies for salvage after this real entity. Plast Reconstr Surg 2012; 129 (01) 8e-15e
    CrossrefPubMedGoogle Scholar
  • 29 Brown JS, Devine JC, Magennis P, Sillifant P, Rogers SN, Vaughan ED. Factors that influence the outcome of salvage in free tissue transfer. Br J Oral Maxillofac Surg 2003; 41 (01) 16-20
    CrossrefPubMedGoogle Scholar
  • 30 Rahmanian-Schwarz A, Rothenberger J, Amr A, Jaminet P, Schaller HE. A postoperative analysis of perfusion dynamics in deep inferior epigastric perforator flap breast reconstruction: a noninvasive quantitative measurement of flap oxygen saturation and blood flow. Ann Plast Surg 2012; 69 (05) 535-539
    CrossrefPubMedGoogle Scholar
  • 31 Patel UA, Hernandez D, Shnayder Y. et al. Free flap reconstruction monitoring techniques and frequency in the era of restricted resident work hours. JAMA Otolaryngol Head Neck Surg 2017; 143 (08) 803-809
    CrossrefPubMedGoogle Scholar
  • 32 Kneser U, Beier JP, Schmitz M. et al. Zonal perfusion patterns in pedicled free-style perforator flaps. J Plast Reconstr Aesthet Surg 2014; 67 (01) e9-e17
    CrossrefPubMedGoogle Scholar
  • 33 Lorenzetti F, Suominen S, Tukiainen E. et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg 2001; 17 (03) 163-167
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 34 Bégué T, Masquelet AC, Nordin JY. Anatomical basis of the anterolateral thigh flap. Surg Radiol Anat 1990; 12 (04) 311-313
    CrossrefPubMedGoogle Scholar
  • 35 Yamada S, Okamoto H, Sekiya I. et al. Anatomical basis of distally based anterolateral thigh flap. J Plast Surg Hand Surg 2014; 48 (03) 197-200
    CrossrefPubMedGoogle Scholar
  • 36 Deng C, Nie K, Wei Z. et al. Is the oblique branch a preferable vascular pedicle for anterolateral thigh free flaps?. J Reconstr Microsurg 2018; 34 (07) 478-484
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 37 Mücke T, Rau A, Merezas A. et al. Changes of perfusion of microvascular free flaps in the head and neck: a prospective clinical study. Br J Oral Maxillofac Surg 2014; 52 (09) 810-815
    CrossrefPubMedGoogle Scholar
  • 38 Figus A, Ramakrishnan V, Rubino C. Hemodynamic changes in the microcirculation of DIEP flaps. Ann Plast Surg 2008; 60 (06) 644-648
    CrossrefPubMedGoogle Scholar
  • 39 Ozturk CN, Ozturk C, Ledinh W. et al. Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction. Microsurgery 2015; 35 (02) 123-128
    CrossrefPubMedGoogle Scholar
  • 40 Ehrl D, Heidekrueger PI, Haas EM. et al. Does cigarette smoking harm microsurgical free flap reconstruction?. J Reconstr Microsurg 2018; 34 (07) 492-498
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 41 Ehrl D, Heidekrueger PI, Ninkovic M, Broer PN. Impact of duration of perioperative ischemia on outcomes of microsurgical reconstructions. J Reconstr Microsurg 2018; 34 (05) 321-326
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 42 Ehrl D, Heidekrueger PI, Ninkovic M, Broer PN. Effect of preoperative medical status on microsurgical free flap reconstructions: a matched cohort analysis of 969 cases. J Reconstr Microsurg 2018; 34 (03) 170-175
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 43 Ehrl D, Haas E, Baumbach S. et al. Is it sensible to use fix and flap also in old age? [in German]. Unfallchirurg 2019; 122 (06) 483-489
    PubMedGoogle Scholar
  • 44 Daigeler A, Kneser U, Fansa H, Riester T, Uder M, Horch RE. Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße. Reconstruction of the vascular compromised lower extremity - report of the consensus workshop at the 35. Meeting of the DAM (Deutschsprachige Gemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße) 2013 in Deidesheim [in German]. Handchir Mikrochir Plast Chir 2014; 46 (04) 248-255
    PubMedGoogle Scholar
  • 45 Yao ST. Haemodynamic studies in peripheral arterial disease. Br J Surg 1970; 57 (10) 761-766
    CrossrefPubMedGoogle Scholar
  • 46 Saad N, Wang H, Karamanos E. Tissue oximetry readings accurately predict late complications in patients undergoing free flap breast reconstruction: exploring the optimal cut point value. J Reconstr Microsurg 2020; 36 (07) 534-540
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 47 Koolen PGL, Vargas CR, Ho OA. et al. Does increased experience with tissue oximetry monitoring in microsurgical breast reconstruction lead to decreased flap loss? the learning effect. Plast Reconstr Surg 2016; 137 (04) 1093-1101
    CrossrefPubMedGoogle Scholar
  • 48 Wickham Hadley. ggplot2: Elegant Graphics for Data Analysis. Journal of Statistical Software 2010;35(01).
    PubMedGoogle Scholar