Microsurgery Selected Readings Plastic Surgery

Volume 11 • Issue R4
MICROSURGERY
Kailash Narasimhan, MD
John R. Griffin, MD
James F. Thornton, MD
Reconstructive
www.SRPS.org
Editor-in-Chief Jeffrey M. Kenkel, MD
Editor Emeritus F. E. Barton, Jr, MD
Contributing Editors R. S. Ambay, MD 30 Topics

R. G. Anderson, MD
S. J. Beran, MD
Grafts and Flaps
S. M. Bidic, MD
Wound Healing, Scars, and Burns
G. Broughton II, MD, PhD
J. L. Burns, MD Skin Tumors: Basal Cell Carcinoma, Squamous Cell
J. J. Cheng, MD Carcinoma, and Melanoma
C. P. Clark III, MD Implantation and Local Anesthetics
D. L. Gonyon, Jr, MD Head and Neck Tumors and Reconstruction
A. A. Gosman, MD Microsurgery and Lower Extremity Reconstruction
K. A. Gutowski, MD Nasal and Eyelid Reconstruction
J. R. Griffin, MD Lip, Cheek, and Scalp Reconstruction
R. Y. Ha, MD Ear Reconstruction and Otoplasty
F. Hackney, MD, DDS Facial Fractures
L. H. Hollier, MD Blepharoplasty and Brow Lift
R. E. Hoxworth, MD Rhinoplasty
J. E. Janis, MD Rhytidectomy
R. K. Khosla, MD Injectables
J. E. Leedy, MD Lasers
J. A. Lemmon, MD Facial Nerve Disorders
A. H. Lipschitz, MD Cleft Lip and Palate and Velopharyngeal Insufficiency
R. A. Meade, MD
Craniofacial I: Cephalometrics and Orthognathic Surgery
D. L. Mount, MD
Craniofacial II: Syndromes and Surgery
J. C. O’Brien, MD
Vascular Anomalies
J. K. Potter, MD, DDS
Breast Augmentation
R. J. Rohrich, MD
M. Saint-Cyr, MD Breast Reduction and Mastopexy
M. Schaverien, MRCS Breast Reconstruction
M. C. Snyder, MD Body Contouring and Liposuction
M. Swelstad, MD Trunk Reconstruction
A. P. Trussler, MD Hand: Soft Tissues
R. I. S. Zbar, MD Hand: Peripheral Nerves
Hand: Flexor Tendons
Senior Manuscript Editor Dori Kelly Hand: Extensor Tendons
Hand: Fractures and Dislocations, the Wrist, and
Business Manager Becky Sheldon Congenital Anomalies
Corporate Sponsorship Barbara Williams
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SRPS • Volume 11 • Issue R4 • 2014
MICROSURGERY
Kailash Narasimhan, MD*

John R. Griffin, MD†
James F. Thornton, MD*
*University of Texas Southwestern Medical Center at Dallas,

Dallas, Texas
†Private Practice, San Mateo, California
HISTORY instrumentation and techniques presented by Smith10

In the late 1890s and early 1900s, surgeons began and Cobbett11 in the 1960s, suture technology has
approximating blood vessels, both in laboratory progressed to 50-mm needles with 12-0 suture.
animals and in human patients, without the aid Per Gallico,12 in 1963, surgeons in China
of magnification.1,2 In 1902, Carrel3 described successfully reattached a patient’s hand that had been
the technique of triangulation for blood vessel amputated at the wrist. The radial and ulnar arteries
anastomosis and advocated end-to-side anastomosis were anastomosed with short links of 2.5-mm-
for blood vessels of disparate size. Nylén4 first used a diameter polyethylene tubes. Also in 1963, Kleinert
monocular operating microscope for human eardrum and Kasdan13 described their experience with digital
surgery in 1921. Soon after, as reported by Mudry,5 amputations and near-amputations. The authors
Holmgren used a stereoscopic microscope for were unable to successfully replant digits but did
otolaryngological procedures.
revascularize nearly amputated digits. They used
In 1960, Jacobson et al.6 working with loupe magnification and emphasized the importance
laboratory animals, reported microsurgical of using vein grafts if vessel anastomosis was under
anastomoses with 100% patency in carotid arteries tension. In 1964, Malt and McKhann14 described the
as small as 1.4 mm in diameter. In 1965, Jacobson first successful clinical replantations in two patients
and Katsumura7 were able to suture 1-mm- who had undergone arm amputations.
diameter vessels with 100% patency in laboratory
animals. The authors emphasized the importance of Also in 1964, Nakayama et al.15 reported
avoiding intimal trauma and precise intima-intima what is most likely the first clinical series of free
reapproximation. In 1966, Green et al.8 used 9-0 tissue microsurgical transfers. The authors brought
nylon suture on rat aortae (average diameter, 1.3 vascularized intestinal segments to the neck for
mm) and vena cavae (average diameter, 2.7 mm) and cervical esophageal reconstruction in 21 patients.
reported anastomotic patency in 37 of 40 animals The intestinal segments were attached by direct
at 21 days. Acland,9 in 1972, presented a series that microvascular anastomoses in vessels that were 3 to
showed 95% patency in anastomosed rat superficial 4 mm in diameter. Sixteen patients had a functional
epigastric arteries. Since the reviews of microsurgical esophagus at follow-up of at least 1 year.
1
Two separate articles published in the mid- reconstruction of the thumb and finger extension in
1960s described the successful experimental patients with C7−T1 brachial plexus root avulsion.35
replantation of rabbit ears and rhesus monkey Currently, new studies indicate the long-term
digits.16,17 In 1965, Krizek et al.18 reported the first sequelae involved with upper limb transplantation.
successful series of experimental free flap transfers in Jensen et al.36 noted that although most patients
a dog model. In 1968, Komatsu and Tamai19 used who undergo hand transplant achieve improved
a surgical microscope to aid in the first successful social, functional, cosmetic, and sensory outcomes,
replantation of a completely amputated digit. In measurements of quality of life are limited. Chang
1969, Cobbett20 transferred a great toe to the hand. and Mathes37 reported that although more than 65
In 1971, Antia and Buch21 reported successful hand transplants have been performed and favorable
free transfer of a superficial epigastric artery skin flap outcomes have been reported, to achieved optimal
to the face. The authors anastomosed the superficial outcomes, the transplant must be performed at
epigastric artery and vein to the common carotid a dedicated center that facilitates integration of
artery and internal jugular vein to repair a cheek multiple specialists, ethicists, pharmacists, and
defect. In 1972, McLean and Buncke22 transferred the rehabilitation professionals.
omentum to the scalp via microvascular anastomoses. As the results of surgery became more
In 1973, Daniel and Taylor23 and O’Brien et al.24 predictable and the number of available free flaps
independently reported the free tissue transfer of grew, efforts shifted to minimizing donor site
groin flaps for lower extremity reconstruction. morbidity. Clinical applications and choices of
Since the beginning of clinical microvascular perforator flaps continue to change. In the hands
surgery in the early 1970s, donor sites for free tissue of experienced operators, loupe magnification now
transfer have multiplied and microsurgical tools seems to be as effective as the operating microscope
and techniques have been expanded and refined. As in certain cases. Free flap selection for specific defects
microsurgery became more prevalent and experience is becoming more standardized, and technological
with free tissue transfer mounted, the success rates innovations in anastomotic techniques and devices
of microvascular procedures also climbed. Current hold promise for the future of microsurgery.
success rates are higher than 90% (Table 1).25−31
Khouri32 presented a survey of nine microsurgeons
and reported that operative experience is the most BASIC SCIENCE CONCEPTS IN
critical factor related to improved success rates. MICROSURGERY
In 1990, O’Brien33 reviewed the strides made In addition to possessing the appropriate technical
in microvascular surgery during the 1970s and 1980s skills, the microvascular surgeon needs to understand
and looked to the future for new applications of the mechanisms of vessel injury, repair, and
microsurgery. New areas of microsurgical interest regeneration; be familiar with the processes of
have evolved during the last 21 years. In 2000, vasospasm and thrombosis and their pharmacological
Whitworthm and Pickford34 reported good results at control; and be aware of the effects of ischemia and
30 years for the patient with the first toe-to-thumb hypoxia on revascularized tissue.
transfer. Clinicians continue to refine techniques
for salvage of severely injured upper extremities,
including the scenario of failed replantation. Vessel Injury and Regeneration
Functional free muscle transfer is an active area of Microvascular anastomoses inevitably disturb the
research, with new applications being discovered. endothelium and subendothelium of the vessel walls.
Recently, functional free gracilis has been described as Exposure of the underlying subendothelium to the
being reinnervated by the nerve to the supinator for bloodstream results in platelet aggregation, which is
2
TABLE 1
Free Flap Success Rate and Learning Curve
Study Experience Success Rate (%)
Serafin, 198025 First 25 cases 72
Last 25 cases 96
Godina, 198626 First 100 cases 74
Last 100 cases 96
Harashina, 198827 First 3 years 75
Last 5 years 97
Khouri and Shaw, 198929 First 100 cases 91
Last 100 cases 97
Canales et al., 199128 First 3 years 83
Last 3 years 97
Selber et al., 201230 Review of nearly 5,000 cases (4,965) 99
Holom et al., 201331 Review 143 head and neck cases 92
the first step in the formation of a thrombotic plug. endothelium covers the anastomotic site. At the
time of anastomosis, a layer of platelet covers the
Among the multiple connective tissue
denuded endothelium of the vessel wall. This layer
components of the blood vessel wall, collagen
of platelet cells does not progress to fibrin deposition
stimulates the greatest amount of platelet clumping.
and thrombosis if it is not exposed to the media and
Weinstein et al.38 effectively showed blood vessel
the lumen is not injured. During the next 24 to 72
injury and repair processes through scanning electron
hours, the platelets gradually disappear. Platelets
microscopy (SEM) of anastomoses. Full-thickness show little affinity for exposed surfaces of sutures
sutures that afforded intimal continuity provoked the within the vessel lumen.38,39 The disappearance of
least amount of anastomotic bleeding and platelet platelets within the lumen and the formation of
aggregates. “Far worse damage” occurred with partial- pseudointima correlate well with previous clinical and
thickness bites of the vessel wall than with properly experimental observations and lead to the conclusion
placed full-thickness sutures. In a separate study that the critical period of thrombus formation in the
using SEM, Harashina et al.39 noted no difference in anastomosis occurs during the first 3 to 5 days.40,41
patency (94%) of 1-mm-diameter rat femoral
The mechanism of endothelial regeneration
vessels anastomosed with either adventitial or full-
depends on the presence or absence of mechanical
thickness sutures.
injury to the subendothelial structures. If the
During healing of the vessel wall, a endothelial layer alone is damaged, it is reconstituted
pseudointima forms within the first 5 days.39 from surrounding cells and regeneration is complete
Approximately 1 to 2 weeks after injury, new in 7 to 10 days. With damage of the underlying
3
subendothelial structures, media and adventitia, of the drug in the study patients were well below
regeneration of damaged epithelium occurs by toxic levels, suggesting that most of the topically
migration and differentiation of myoendothelial cells applied lidocaine is not fully absorbed. Nevertheless,
from the cut vessel ends.42 The remaining layers of the the standard pharmacology references list the
vessel wall regenerate via proliferation of fibroblasts maximum safe dose of injectable lidocaine as ≤500
with collagen deposition and myointimal thickening mg for the average adult patient. Ohta et al.47
at the anastomotic site.43 The elastic and muscular showed experimentally that Xylocaine (AstraZeneca,
elements of the vessel wall fail to regenerate to the Wilmington, DE) has its optimum spasmolytic and
same degree as the endothelium, and the layers do not antispasmodic effects at a concentration of 20%.
return to their preinjury state. Clinically, 2% lidocaine also has a beneficial effect on
These findings led to an emphasis on gentle moist vessels.
dissection of all vessels and careful controlled Injury to the endothelium from microvascular
placement of sutures through vessel walls. Simple clips is directly related to clip pressure.48 Weinstein
dissection and exposure of vessels from their beds was et al.38 noted that curved or angled clips cause
shown by Margić44 to result in significant endothelial more damage than do flat clips. Closing pressures
loss, although the vessels maintained flow. Also, of vascular clips should remain <30 gm/mm2 to
to avoid damage to vessels during dissection, side minimize damage to vessels.49 O’Brien et al.50
branches should be tied or coagulated using bipolar presented a discussion of the currently available
electrocoagulation. Improper bipolar coagulation can clamps and clamp approximators and provided
result in endothelial damage and platelet aggregation examples of each. El-Shazly51 described a new double
if the current passes too close to the branch origin. transverse microvascular clamp that can be applied
Caffee and Ward45 described the safe and effective use simultaneously as one clamp to both the artery and
of bipolar electrocautery in small vessels. The authors the vein, allowing anastomosis to be performed more
reported that the side branch must be treated with easily by rendering the working environment
electrocautery at the lowest setting possible to achieve less crowded.
coagulation and that this must be done well away
The most significant damage to vessel walls is
from its junction with the main vessel.
from needle and suture penetration and technique
Special attention should be given to small of placement. Large needles and obliquely placed
vessels, which if desiccated can lose their endothelial sutures cause major endothelial lacerations, exposing
cell layer and trigger diffuse platelet aggregation. subendothelium and inducing platelet aggregation.
It is important that all exposed vessels be kept in a Repeat needle puncture for suture placement
moist environment to prevent desiccation. Prolonged produces large platelet plugs at bleeding sites.
vasospasm can also cause endothelial sloughing, and
Unequal inter-suture distances can result
vessels experimentally subjected to vasospasm for
in endothelial gaps, distortion, constriction, and
longer than 2 hours lose most of their
exposed intimal flaps. Loosely tied sutures can expose
endothelial layer.38
subendothelial elements to the bloodstream and
Topical lidocaine often is used in microvascular allow excessive anastomotic bleeding and subsequent
surgery to prevent vasospasm. The safe maximum platelet plug formation. Too many sutures or sutures
dose of lidocaine for topical application has not that are tied too tightly can trigger endothelial
been established. Johnstone et al.46 reported using slough.38 Excessive trauma to vessel walls, undue
4% lidocaine in doses of up to 2000 mg with no tension on suture lines, and loosely approximated
adverse effects. The anesthetic was applied topically sutures can produce medial discontinuity and result
to arteries and veins being anastomosed during free in pseudoaneurysms or aneurysms at the
tissue transfer. The measured serum concentrations anastomotic site.38,39
4
Chow et al.52 subjected microanastomoses in which eventually reach a critical mass that can cause
the animal model to various levels of tension and thrombus formation by either occluding the vessel or
found a greater tolerance for microanastomotic initiating the classic extrinsic pathway
tension than had been previously surmised. of coagulation.58
Acland and Trachtenberg53 used SEM to evaluate Multiple steps in the clotting mechanism
microanastomoses in rats at intervals ranging from have been manipulated pharmacologically with the
1 hour to 21 days after anastomosis. Their findings aim of reducing platelet aggregation and release.59
paralleled those of Weinstein et al.38 in that intimal Johnson and Barker60 presented a discussion of
loss occurred below the site of clamp pressure and current antithrombotic therapy in microvascular
medial necrosis occurred at the anastomosis proper. surgery. Heparin has been used for years as an
Despite the noted changes, the patency rate was anticoagulant. Heparin acts primarily to increase
100%, indicating that some tissue damage is tolerated the action of antithrombin-3, which inactivates
without untoward consequences. thrombin. Heparin has also been shown to decrease
Lidman and Daniel54 investigated the reasons platelet adhesion61,62 and to hamper the conversion
why clinical microvascular anastomoses failed and of fibrinogen to fibrin.63 Greenberg et al.64 showed
found that anastomoses performed in the zone of in a rabbit model that low-dose heparin infusion
injury were most often implicated. Another common significantly prevented anastomotic occlusion for 72
problem leading to surgical failure was external hours after surgery in the arterial inversion model. A
compression of the anastomosis by hematoma. recent review presented by Froemel et al.65 indicates
that no consensus has been reached regarding which
prophylactic antithrombotic agents can be routinely
Clotting Mechanism used. Current regimens continue to use aspirin,
Johnson55 detailed the biochemical and physical heparin, and colloids (dextran). Good surgical
aspects of the process of platelet-mediated thrombosis technique, however, remains one of the
in vessels. Platelets do not adhere to undamaged, best prophylactics.
healthy intimal surfaces, but when the intima is Khouri et al.66 studied the effect of heparin on
injured in any fashion, exposed collagen triggers rat femoral artery anastomoses and noted that a single
platelet adhesion to the vessel surfaces.56 Once these bolus dose of heparin administered before blood flow
platelets are activated by collagen, platelet granules was reestablished inhibited thrombus formation by
are released, which in turn attract more platelets—a preventing the conversion of fibrinogen to fibrin.
process known as aggregation. The activated platelets Treatment with dazmegrel, a selective thromboxane
have stimulated receptor sites to which fibrinogen synthetase and platelet aggregation inhibitor, was
adheres, and fibrinogen then forms proteinaceous only partly successful in improving the patency rate at
bridges between platelets. As platelets become the anastomoses. Fibrin could still form an occlusive
activated, they also promote the change of fibrinogen thrombus even in the absence of aggregating platelets.
to fibrin. The fibrin in turn promotes “red clot” and The authors concluded that at least in their model,
further strengthens the growing clot. fibrin mesh deposition contributed more to the
Platelets contain two types of granules: alpha pathogenesis of thrombotic occlusion of traumatized
granules and dense granules. Alpha granules contain arteries than did platelet aggregation. The incidence
von Willebrand factor and fibrinogen. Dense granules of hematomas in the animals treated with heparin was
contain adenosine diphosphate, calcium ions, and 12.5% (three of 24 rats).
serotonin.57 The secreted adenosine diphosphate, In the clinic, heparin is administered by direct
calcium, fibrinogen, and von Willebrand factor continuous infusion to save free flaps.67 Some
all contribute to ongoing recruitment of platelets, surgeons think that heparin does not improve
5
patency in cases of uncomplicated repairs and that have shown that dextran improves microvascular
the associated risk of bleeding outweighs the potential patency.73−78 A study in the rabbit model by Rothkopf
benefit of heparin as an anticoagulant.55,60 Perhaps et al.72 showed patency of microanastomoses and
paradoxically, the slow oozing that accompanies arterial inversion grafts at 7 days to be 85% in
injudicious heparin use in free flaps can result in large the dextran group and 48% in the control group.
clots around the small vessels, ultimately causing Clinically, a 10% solution of dextran-40 usually
occlusion and thrombosis of outflow or inflow. For is administered as a loading dose of 40 to 50 mL;
this reason, heparin infusion is used sparingly by a continuous infusion of 25 to 50 mL/h is then
most microsurgeons. intravenously administered. Because of reports of
allergic reactions to dextran,60 a test dose should be
When administered intraoperatively at a dose
administered first. Dextran can also cause bleeding
of 325 mg, aspirin inhibits initial platelet aggregation
and subsequent vessel occlusion problems, similar to
at the anastomotic site. This action was thought
heparin. Acute renal failure occurring secondary to
to be mediated by the endothelial cyclooxygenase
dextran use has also been reported.79
pathway with subsequent blockage of thromboxane
A2. Even at low doses, however, aspirin inhibits release Proteolytic enzymes such as streptokinase
of prostacyclin, a potent vasodilator and platelet and urokinase are being evaluated as lytic agents in
inhibitor.68 Newly created anastomoses show a loss thrombosed vessels and might find a place in the
of endothelium for several millimeters from the prevention of microvascular thrombosis, especially
suture line,53 and the mechanism for prostacyclin in traumatized vessels.80,81 Streptokinase was
production was thought to be absent. Contrary administered to four patients and urokinase to two,
to previous expectations, Restifo et al.69 found a resulting in a 100% success rate. Streptokinase is
clear increase in prostacyclin production at the produced by group C beta-hemolytic streptococci,
anastomosis. The authors speculated that the rising and urokinase is produced by human kidney cells.
levels of prostacyclin stemmed from smooth muscle Both can convert plasminogen into plasmin, a
or fibroblasts in the subendothelium or from an highly specific fibrinolytic enzyme.82−85 Goldberg
up-regulation of prostacyclin synthetase triggered by et al.80 presented a report of the salvage of six of
cytokines released after vessel injury. They concluded seven thrombosed free flap vessels by infusion of
that the thrombogenic tendency of the anastomosis streptokinase or urokinase. A sub-flap hematoma
was not explained by a decrease in the antithrombotic developed postoperatively in one of the six cases.
agent. Prostacyclin itself as a topical agent in Currently, these enzymes are used in the salvage of
microvascular surgery is not effective.70 flaps and not for preventive purposes. Trussler et
Dextran is a polysaccharide that is clinically al.86 used catheter-directed thrombolysis with tissue
plasminogen activator (tPA) to salvage two free flaps.
available in molecular weights of 40,000 (dextran-40)
and 70,000 (dextran-70). Dextran was first used tPA is produced by human vascular
as a volume expander but was later found to have endothelium and is responsible for activating
numerous effects on the microvascular clotting plasminogen, the inactive precursor to plasmin.
scheme, with both antiplatelet and antifibrin Apparently, tPA is rapidly bound by specific
functions. Several pathways have been theorized inhibitors. However, in the presence of high amounts
for the observed decrease in platelet adhesion noted of fibrin, a shift occurs in the activator-inhibitor
after dextran administration, including elevated complex and tPA, plasminogen, and plasmin are
negative electric charge on platelets and inactivation released, with consequent fibrinolysis.81,87 Levy et al.88
of von Willebrand factor, a major contributor to compared the effects of urokinase and tPA in the rat
platelet aggregation and adhesion to vessel wall model and found no statistical difference between the
collagen.59,60,71,72 Multiple experimental studies two substances with respect to lysis of microsurgical
6
thrombosis. In 1989, Fudem and Walton89 reported information that is currently available regarding
salvage of a free flap with a 15-minute infusion of the benefits of anticoagulation in microsurgery, the
high-dose tPA and concomitant heparin. Arnljots et following conclusions seem warranted:
al.81 significantly improved patency of traumatized
1. Indications have not been defined
microvessels with low-dose tPA infusion for 2 hours.
for anticoagulation or antifibrinolytic
Romano and Biel90 showed statistically significant
therapy when mechanical and vascular
improvement in patency rates of microanastomoses
factors are optimal (e.g., during elective
in animals treated with low-dose tPA infusion over 48
free flap transfers).
hours. Stassen et al.91 reported successful dissolution
of arterial thrombosis with selective infusion of 2. When evidence of thrombosis is
recombinant tPA during digital revascularization. present in postoperative microvascular
Selective infusion reduces the risk of systemic anastomosis, flap reexploration and
complications from tPA administration. treatment with fibrinolytic therapy and
anticoagulation seem prudent. Flap
Several authors stress the importance of using
reexploration is the essential step.
anti-coagulants along with fibrinolytic therapy in
microsurgery.60,85,92 The next horizon in manipulating 3. Anticoagulation or fibrinolytic therapy
the clotting mechanism to prevent microvascular might be indicated in clinical situations
thrombosis is through monoclonal antibody in which mechanical or metabolic
regulation of platelet aggregation. Gold et al.93 factors are not favorable and cannot
showed profound inhibition of platelet function in be improved.
humans after administration of murine monoclonal In general, the standard treatment for
antibodies directed against human platelet threatened flaps is reexploration. Trussler et al.97
glycoprotein IIb/IIIa receptor, which mediates
reported the cases of two patients who presented with
platelet aggregation and contributes to
late occlusions to their free flaps, one at postoperative
thromboembolic disorders.
day 6 and the other at postoperative day 12. Both
Lan et al.94 suggested another strategy for patients underwent flap salvage with highly selective
salvage of thrombosed microvascular anastomoses. catheter-directed thrombolysis. This option deserves
The authors argued for anastomotic resection and further study, especially in select cases of delayed or
replacement of thrombosed veins with vein grafts, late pedicle thrombosis in free flaps.
together with systemic heparin administration. In the
rat femoral vein model, a high rate of recanalization
was noted when this protocol was implemented. Tissue Response to Ischemia and Hypoxia
Davies95 surveyed the practice of anticoagulation The transfer of tissues by microvascular anastomoses
in clinical microvascular surgery. On the basis of requires a period of tolerance to ischemia by the
responses he received from 73 centers in 22 countries, donor tissue. Skin and subcutaneous tissue are
the author was able to document equal success relatively resistant to the effects of anoxia, and
rates (89%) for free flap procedures performed intracellular pH changes are reversible for up to 24
with anticoagulation (691 cases) and without hours.98 Mammalian skeletal muscle is much less
anticoagulation (134 cases). For limb replantation, tolerant to ischemia than is skin.99,100 Irreversible
the overall success rate was lower with anticoagulation damage to the microcirculation of skeletal muscle
(76%) than without anticoagulation (89%). in man begins at approximately 6 hours.99 As
Veravuthipakorn and Veravuthipakorn96 reported very documented by nuclear magnetic resonance
good results achieved when using no antithrombotics spectroscopic studies,101 irreversible damage to
in free flaps or in replants. Considering the energy metabolism occurs after 4 hours of ischemia.
7
In contrast, connective tissue rich in fibroblasts, response of the vascular endothelium to ischemia.
chondroblasts, or osteoblasts is relatively resistant While studying the effects of ischemia on rabbit
to prolonged hypoxia.102 In peripheral nerves, the brains in 1968, Ames et al.118 noted that some
neuromuscular junctions are most sensitive ischemic organs failed to reperfuse after their blood
to ischemia.103 supply had been reestablished. The authors called this
the no-reflow phenomenon.
Cooling prolongs tolerance to ischemia in all
types of tissues.102−110 Muscle and fat cells show a The mechanism of no-reflow is thought to
marked increase in histological changes with duration involve cellular swelling in the vascular endothelium
of cold ischemia, whereas skin and small vessels with subsequent intravascular platelet aggregation
remain relatively free of abnormality after circulation and leakage of intravascular fluid into the interstitial
is restored to the tissue.109 Donski et al.109 studied the space. This hypothesis correlates well with clinical
effect of cooling on the survival of free groin flaps in observations of excellent blood flow immediately after
the rabbit: 86% of flaps that were cooled for 1 to 3 anastomosis that decreases shortly after the no-reflow
days survived. Anderl111 stored a human groin flap for phenomenon takes effect, at which point the
24 hours and reported complete flap survival; in the low-flow state triggers intravascular thrombosis
rat, maximum ischemia time was 6 hours at normal and flap ischemia.
body temperatures and 48 hours if cooled.108 Reus May et al.107 investigated no-reflow in
and Schlenker110 suggested rewarming of arterial flaps denervated free epigastric flaps in the rabbit, which
before circulation is reestablished to ensure adequate closely approximates the clinical situation. The
blood flow during the ensuing hyperemic period. authors observed mild obstruction to blood flow as
Takayanagi and Tsukie112 reported survival early as 1 hour after ischemia, increasing in severity at
of at least the skin portion of a latissimus dorsi 8 and 12 hours. Histological changes were reversible
musculocutaneous free flap after 15 to 17 hours of at 4 and 8 hours but became incontrovertible at 12
cold ischemia. May et al.107 noted 100% survival of hours, culminating in death of the flaps.
rabbit free flaps at 4 hours of normothermic ischemia, Zdeblick et al.119 studied the no-reflow effect
decreasing to 80% at 8 hours. Berggren et al.102 in replanted rat hind limbs. Predictors of no-
showed complete survival of bone grafts preserved reflow were an increased number of red blood cell
in Collins-Terasaki solution at 5°C after 25 hours of aggregates 5 minutes after replantation and changes
ischemia, provided that the medullary nutrient blood in tissue pH values persisting for longer than 1 hour
supply was later reconstituted. Chinese investigators after replantation. Clearance of H+ and lactate is
successfully replanted limbs in animals after 108 associated with improved flow. The authors’ findings
hours of cold ischemia.106 Baek and Kim113 reported support the concept of ongoing arterial obstruction,
successful replantation of two fingers after 42 hours arteriovenous shunting, and an altered thrombogenic
of warm ischemia. Walkinshaw et al.114 showed that fibrinolytic system as the mechanisms of the no-
proximal bowel segments are more resistant to warm reflow phenomenon.
ischemia than are distal small bowel segments and Jacobs et al.120 noted an inversely proportional
suggested using proximal bowel for free transfer. relationship between warm ischemia time and
Based on a review of the literature, we have compiled fibrinolytic activity. The greatest decrease in
estimates of tissue tolerance to ischemia, which we fibrinolysis occurred at 0 to 6 hours of warm
present in Table 2.115−117 ischemia. Suval et al.121,122 showed that changes in
microvascular permeability occur during reperfusion
after 30 minutes or 2 hours of ischemia. The first
Reperfusion Injury and the No-Reflow Effect
manifestations of tissue damage in reperfusion
Success in the clinical setting often depends on the injury are caused by leukocytic and endothelial cell
8
TABLE 2
Ischemic Tolerance of Various Tissues
Tissue Warm (h) Cold (h)
Skin and subcutaneous tissue115 4−6 ≤10
Muscle116 <2 8
Bone117 <3 24
interactions. No-reflow occurred in 30% of the prolonged. In the short term, anticoagulants serve to
muscle tissue regardless of ischemia time. decrease inflammation associated with the clotting
cascade and potentially help salvage the watershed
Russell et al.123 and Manson et al.124 presented
areas of significant but reversible ischemia.125
discussions of the mechanisms of ischemia-induced
injury to cells and the role of oxygen free radicals Several authors76,82 have shown the effect of
in the reperfusion of ischemic tissue. Reperfusion thrombolytic agents in reversing ischemic changes
of muscle is followed by a local response and an in human and rat myocardium. Others80,83,126 have
inflammatory response. The local response consists reported salvage of flaps in the clinical situation
of swelling (i.e., the muscle flap or replanted limb with the administration of thrombolytic drugs when
grows in size at the time of reperfusion). Therefore, the no-reflow phenomenon was likely in effect.
fasciotomies are prudent in most cases and mandatory Nonsteroidal anti-inflammatory agents inhibit cyclo-
in all except those with the shortest ischemia times. oxygenase and block the effects of thromboxane A2,
The swelling might also be evident in buried such as vasoconstriction and microvascular thrombus
muscle flaps. formation. Douglas et al.127 showed that ibuprofen-
treated flaps survive longer periods of ischemia. The
The inflammatory response parallels ischemia ibuprofen-treated flaps had accelerated fluorescein
time up until cell death begins to occur. When cell uptake that suggested reversal of thrombosis
death is diffuse, such as after very long ischemia and vasoconstriction. Feng et al.128 postulated
times, the no-reflow phenomenon is essentially that the ratio of vasoconstricting to vasodilating
immediate and very little inflammatory response prostaglandins might be responsible for the
ensues. Areas of muscle that have slight ischemic microcirculatory changes that result in the no-reflow
damage will therefore generate few inflammatory phenomenon. Schmid-Schönbein,129 on the other
mediators at the time of reperfusion. For instance, hand, stated that capillary plugging by granulocytes
muscle flaps that are appropriately cooled and flaps seems to be the mechanism underlying no-reflow.
that were reperfused in less than 1 hour generate
much less inflammation than does muscle that was The actual number of platelets in the
not cooled or was exposed to longer ischemia times. circulation might not affect microvascular patency
Intermediate zones in replanted muscle or transferred in routine microsurgery cases. Kuo et al.130 studied
muscle flaps after 2 or more hours of warm ischemia microanastomoses in splenectomized rats with
produce high levels of inflammatory mediators thrombocytosis versus rats with normal platelet
and eventually show the worst cell damage. Thus, counts and found similar patency rates.
in a replanted limb, certain areas suffer more than In summary, the common denominator in
do other areas, and surgeons might choose to be failure of microvascular anastomoses is endothelial
more liberal with anti-coagulants when ischemia is disruption with exposure of subendothelial collagen-
9
containing surfaces to which platelets adhere.131 If Magnification

platelet aggregation reaches a certain mass, it will Daniel and Terzis133 recounted the evolution of
trigger fibrin deposition that leads to vasospasm, operative magnification. Hoerenz,134−136 Nunley,137
stenosis, and eventual thrombosis of the vessel. As the and O’Brien et al.50 comprehensively reviewed the
blood flow rate through the anastomosis falls below operating microscope. Shenaq et al.138 recounted
a critical level, the flap fails. When this happens an 8-year experience with loupe magnification for
in enough of the watershed areas, it can propagate free tissue transfer. Among 251 free tissue transfers
to other potentially salvageable but nevertheless performed during the time of the study period using
vulnerable areas of the muscle. a 5.5× loupe, 97.2% were successful. The partial
Free flap failure is not necessarily an all-or-none flap necrosis rate was 1.2%, and the revision rate
phenomenon. Although thrombosis at the arterial for anastomoses was 8.3%, which compares well
or venous anastomosis with cessation of blood flow with surgery performed with the guidance of an
to a flap often results in complete flap loss, free flaps operating microscope. The most favorable results were
occasionally experience a slow, progressive, and partial achieved with free flaps (98.5% success) and toe-to-
death that is potentially reversible. Weinzweig and hand transfers (96.4% success). Digital replantation
Gonzalez131 reported their experience with 10 patients was less successful (79.2% success). The authors
in whom free flap failure was not an all-or-none supported the use of loupes for vessels ≥1.0 mm in
phenomenon. The authors discussed their experience diameter. Loupes are cost-effective and portable, and
they free the operator’s position.
with these failing flaps and stated that with dressing
changes, judicious débridement, and skin grafts or Serletti et al.139 compared loupe versus
other local flaps, the dying flaps often can be salvaged microscope visualization in a series of 200 free flaps.
without resorting to other free tissue transfer. The authors conducted a retrospective review with
an inherent bias in that at the time of flap transfer,
the choice of magnification was influenced by the
TECHNICAL FACTORS size of the vessels encountered, the anatomic area of
surgery, and patient factors. In general, the authors
Many factors contribute to the success of a
chose loupe magnification for adult head and neck
microvascular procedure. Among technical
and breast reconstruction. The microscope was used
variables are instruments and sutures used for the
more often for children and for vessels ≤1.5 mm
anastomosis and the technique of anastomosis.
in diameter. The findings support the use of loupe
Other miscellaneous considerations influencing
magnification for selected microsurgical cases in the
the outcome of free tissue transfer are the choice
hands of experienced microsurgeons.
of donor and recipient vasculature, whether the
anastomosis is performed outside the “zone of Ross et al.140 assessed the results of a large
injury,” technical expertise of the surgeon, and series of free flaps transferred to the head and neck
patient history of tobacco smoking. One of the most with the aid of loupe versus the microscope. Similar
important prerequisites for success in microsurgery complications occurred in the two groups, and
is organization. The operating room, staff, and shorter operating times were required in the
equipment must be well prepared for microsurgery. loupe group.
The surgeons must be organized in their planning Head-mounted magnification devices that have
and execution, and the hospital unit itself must be more power and field of vision than do standard
organized. Postoperative care is as important as all the loupes are being developed. Chiummariello et al.141
steps that come before the recovery room. Germann reported their experience with the Varioscope M5
et al.132 offered concise and useful principles for (Life Optics, Chicago, IL) device. The authors
organization of and preparation for microsurgery. remarked that the device offers increased freedom of
10
movement over the operating microscope. Another mechanical endurance with polyglycolic acid or
potential advantage is variable magnification range. polyglactin sutures. Chen et al.148 used an interrupted,
Devices such as this continue to be explored. They non-absorbable suture technique for anastomosis
have not yet supplanted the operating microscope for in young rat femoral arteries. The vessels were later
most surgeons. examined when the rats were adults and had gained
Microsurgical instruments should be few weight. Evidence indicated growth at the anastomotic
in number and high in quality. Acland142 and sites without stenosis or hyperplasia. The authors
O’Brien et al.50 listed the essential instruments concluded that the use of an interrupted, non-
for any microsurgical setup and their proper use. absorbable suture technique in small vessels that are
The instruments include magnification loupes of expected to grow over time is safe in rats and might
at least 2.5 or a microscope with 200 to 250 focal be safe in children requiring microvascular surgery.
length, jewelers’ forceps, microscissors, a vessel Currently, most practitioners use non-absorbable
dilator, a needle holder, irrigation, cellulose sponges, (Prolene [Ethicon, Somerville, NJ] or nylon) sutures
microscopic hemoclips, and Merocel (Medtronic, in their clinical cases.
Minneapolis, MN).
Anastomotic Techniques: Interrupted, Continuous,
Number of Sutures Sleeve, and Adhesive
The number of sutures used in the anastomosis Techniques of microvascular anastomosis with
is critical: too few and excessive bleeding and interrupted sutures have been modified from the
thrombus formation can occur; too many and triangulation method presented by Carrel.3 Daniel
the increased damage to the endothelium risks and Terzis133 illustrated the basic microsurgical
intravascular thrombosis. The goal is to achieve a anastomotic techniques in their text. Mechanical
well-approximated, sealed, nonbleeding union with a factors in certain clinical settings sometimes dictate
minimum number of sutures. departure from or modification of the conventional
triangulation or bicentric angulation methods,
Colen et al.143 studied the relationship but patency rates must not suffer in the process.
between the number of sutures and the strength of a The surgeon’s expertise and time required for the
microvascular anastomosis in rat femoral vessels. The anastomosis should be considered when formulating
authors determined that an eight-suture anastomosis the operative plan.
most closely paralleled the control state in this animal
model. Zhang et al.144,145 reported achieving excellent Various methods have been described for
patency in rat femoral vessels when using a four- microvascular anastomosis. Simple interrupted
stitch sleeve anastomosis. The authors also described a full-thickness sutures are preferred and are the
three-suture sleeve technique. standard with which all new anastomotic techniques
are compared.
Anastomoses performed with continuous
Type of Sutures sutures are no different from those performed with
Both absorbable and nonabsorbable sutures have interrupted sutures regarding patency rates and blood
been used for microanastomosis. Mii et al.146 noted velocity profiles,149,150 but they can be performed
faster and smoother endothelial regeneration with much faster.151,152 Patency rates in the rabbit are 92%
polyglycolic acid absorbable material than with arterial and 84% venous. In the rat carotid artery,
nonabsorbable suture. Thiede et al.147 showed no Firsching et al.153 showed 100% patency at 2 to 4
increased aneurysm or pseudoaneurysm formation months with continuous sutures. The main argument
and no vascular ruptures caused by decreased against the use of continuous suture is that it can
11
narrow the caliber of the vessel lumen.152 Suture with the telescoping technique compared with the
entrapment in vessel clamps and suture breakage have conventional interrupted suture technique (98%)
also been reported.154 Cordeiro and Santamaria155 in the rat femoral artery model. O’Brien et al.50
reported their experience with continuous suture confirmed the findings presented by Sulley et al. and
anastomosis in 200 consecutive free flaps. The did not recommend sleeve anastomosis because of its
authors’ success rate was similar to that of other overall lower patency rate.
large series that used interrupted sutures. In contrast,
Turan et al.164 extended the concept of
Chase and Schwartz156 reported better results with
fish-mouthing the vessel ends and applied it
simple interrupted sutures than with
to microsurgery. In a controlled animal study,
continuous sutures.
the authors compared traditional interrupted
Chen and Chiu157 described a spiral interrupted anastomoses with their four-suture everted, fish-
suture technique that combines elements of the mouthed anastomoses. The patency and anastomotic
continuous and interrupted suture techniques. The complication rates were similar in the two groups.
authors noted that the technique is faster than a The time needed for anastomosis was shorter with the
simple interrupted suture but is frequently associated everted technique.
with a purse-string-like constriction of end-to-end
Early experimental studies of vascular repairs
venous anastomoses.
with synthetic adhesives yielded less than satisfactory
Man and Acland158 described a refined results.165,166 Occasionally, the adhesive penetrated
continuous suture technique and reported a 14- into the vessel lumen and caused instant thrombosis.
day patency rate of 85% in the rat femoral artery, In 1977, Matras et al.167 proposed the use of
compared with 80% patency for interrupted sutures. fibrin tubes for vascular end-to-end anastomosis.
The authors suggested that the overriding advantage Other authors have used fibrinogen adhesive to
of the continuous technique is that it decreases the augment techniques such as conventional suture
anastomotic time by half. anastomosis,168 a coupling technique,169 and the sleeve
The sleeve technique originally described method,170 with variable results. Despite patency
by Lauritzen159 and Lauritzen and Hansson160 rates similar to those achieved with conventional
is said to be faster and simpler to perform, and anastomoses,171,172 fibrinogen adhesive is not as
suture placement causes less trauma to the vessels. versatile as suturing and might not be applicable to
Lauritzen159 described a precise technique and noted end-to-end anastomoses or anastomoses in which the
that endothelialization of the anastomosis takes 1 vessels are of different caliber.
week, or half the time needed with conventional
suture anastomoses. Clinically, the telescoped
End-to-End, End-to-Side, and End-in-End Sleeves and
technique is hampered by difficulty in anastomosing
Arteriovenous Loops
veins and other vessels of various diameters.
Duminy,161 however, altered the technique and End-to-end vessel anastomosis is most common
achieved a high patency rate and easier anastomosis of in microvascular surgery. When a size discrepancy
different-sized vessels. exists between the donor and recipient vessels, a
decision must be made regarding the type of repair.
Krag and Holck162 compared the telescoped
A difference of 2:1 or less can be handled by gently
anastomotic technique with the traditional end-to-
dilating the smaller vessel and not dilating the larger
end method in the femoral arteries and veins of rats.
one.173 Another option in dealing with vessel size
They found less risk of late thrombus deposition with
discrepancy is to cut the end of the smaller vessel at a
the sleeve technique (13% versus 41%), although
slightly oblique angle to increase its diameter.174
the patency rates at 1 week were the same (88%).
Sully et al.163 reported a lower patency rate (84%) One must be extremely wary of a significant
12
mismatch when performing end-to-end venous Another option to consider when recipient
anastomosis.175 If the discrepancy is such that vessels are compromised is the arteriovenous loop.
the anastomosis would be compromised, end-to- This technique is particularly useful when the zone of
side anastomosis should be considered. If a limb injury is difficult to determine, in severe trauma, and
or appendage depends on only a single vessel for in irradiated zones. The loops can be immediate or
perfusion, an end-to-side repair must also delayed. With this technique, one creates an extension
be performed. of the arterial pedicle with a looped vein graft. The
Godina176 reported his clinical experience flap or replanted tissue is supplied via end-to-side
with microvascular transplantation and showed a anastomoses off the loop. Revisions are facilitated as
higher failure rate with end-to-end anastomoses. He long as the loop remains patent. Cavadas187 described
subsequently proclaimed the end-to-side technique his experience with 56 arteriovenous loops in the
as his preferred choice for lower extremity free flaps. upper and lower extremities (Fig. 1). The author
In contrast, Samaha et al.177 found no statistical achieved excellent success rates.
differences in the patency rates in 1051 consecutive
tissue transplants as long as good clinical judgment
was used in the choice of recipient vessels.
Animal experiments have failed to show a
difference in patency rates between end-to-end and
end-to-side techniques when repairing vessels of
similar diameter.178 When size-discrepant vessels are
involved, end-to-side venous repairs have proved to
be significantly better.179 The dynamics of flow in
end-to-side arterial repairs are favorable.180,181
In 1978, Lauritzen182 described the sleeve
anastomosis or end-in-end anastomosis, an
invaginating technique with far fewer sutures
than those required for the end-to-end method.
Experimental studies showed patency rates similar to Figure 1. Long arteriovenous loop can be constructed using
those achieved with conventional end-to-end sutures the contralateral saphenous vein graft connected proximally
to the popliteal artery and distally to the ipsilateral in situ
plus significant time savings and minimal intimal saphenous vein at the malleolar region. This construct
trauma.159−163,182,183 Nakayama et al.184 presented a is especially useful in diabetic patients. (Reprinted with
report of 15 free flap transfers using sleeve vascular permission from Cavadas.187)
anastomoses, with only one failure occurring. The
authors suggested that this technique is best indicated
if a favorable size discrepancy exists between donor
and recipient vessels (small caliber upstream end to Cuffs, Couplers, Staplers, and Automatic
large caliber downstream end). Suturing Devices
The sleeve technique has not been widely The use of cuffs and stents to simplify and expedite
adopted by surgeons because of reports of microvascular anastomoses has been touted as an
stenosis.163,185,186 The choice of technique should alternative to conventional methods. McLean and
be secondary to the choice of recipient vessels. In Buncke,188 in 1973, suggested reducing the number
single-vessel limbs and when anastomosing vessels of of sutures during microanastomosis by means of a
considerable size mismatch, thrombus, and aneurysm Saran Wrap (S. C. Johnson & Son) cuff. Tschoff,189
formation, the end-to-side technique is preferred. in 1975, used a lyophilized dural cuff for the same
13
purpose. Harris et al.190 presented a basic autogenous the disadvantages of stapling techniques include the
cuff technique consisting of six sutures. Modifications following: 1) the necessity to mobilize the vessels to
involving fewer sutures,191,192 fat wraps,193 polythene evert them; 2) shortening of the vessel through loss
cuffs,194 silicone rubber cuffs,195 external absorbable of the everted cuff; 3) the need to precisely match
splints,196 stents,197 intravascular stents,198 and metallic the bushing size with the vessel; 4) less flexibility in
circles199 in experimental models have been described. “tailoring” the anastomosis when discrepancy in vessel
However, most of these techniques are difficult to size is present; and 5) limited availability of
implement and present new problems, and very few the apparatus.
have been applied clinically.200
Shennib et al.212 studied the use of an automatic
Connectors have been proposed to facilitate vascular suturing device in a pig model. The average
microvascular anastomoses and improve reliability. anastomotic time was 22 minutes with 7-0 suture,
The first ring device was introduced in 1962 by and patency rates were good. Devices such as these
Nakayama et al.201 In 1986, Ostrup and Berggren202 might find future applications in microvascular
introduced a modification of this device (called surgery. Of course, they will provide a benefit only if
Unilink) that subsequently evolved into the they serve to shorten operating time, improve patency
microvascular anastomotic coupler manufactured rates, and/or make the anastomosis technically easier.
by 3M (Saint Paul, MN). Clinical series of vessels Arterial coupling devices have been used in more
anastomosed with the mechanical device have shown recent studies. In a recent study by Spector et al.,213
equal or greater patency rates and faster anastomosis in 80 flaps (including DIEP, TRAM, and superior
of either normal or irradiated vessels.203−205 gluteal flaps), arterial coupling was used and resulted
Histological studies showed the same healing in a 100% success rate. The authors concluded that
process whether the anastomosis was performed although not commonly used, in properly selected
with conventional sutures or mechanically.206 At 16 patients, coupling the artery can prove expeditious
weeks after repair, coupled anastomoses are 50% and improve efficiency.
stronger than are sutured vessels.207 Biodegradable
ring devices do not seem to have any advantage over
nonabsorbable devices208 and might cause thrombosis Laser Anastomosis
because of the inflammatory response to the ring Laser-assisted microvascular anastomoses have been
during absorption.204 evaluated.214,215 The associated patency rates compare
Some authors204,205 find mechanical favorably with those achieved with conventional
coupling devices to be especially useful for end- manual sutures and have the advantage of shorter
to-end anastomosis in veins and soft arteries. The operative times, limited endothelial trauma with small
applicability of these devices in thick-walled arteries, thrombogenic risk, and no suture material to trigger a
in vessels with diameters <1.0 mm, and for end- foreign-body reaction.
to-side anastomosis is less convincing and seems A wide range of laser wavelengths has been
limited.205,209 used, including those emitted by carbon dioxide,216,217
Zeebregts et al.210 compared a standard suture argon,218 neodymium-doped yttrium aluminium
technique with nonpenetrating vascular closure staple garnet,219 potassium titanyl phosphate,220 and diode221
clips and with Unilink rings. The authors noted lasers. The adjunctive use of photosensitizing dyes
excellent patency with all three methods. The devices makes low-energy discharges possible and minimizes
can reduce anastomotic time in experienced hands. collateral tissue damage.222
Cope et al.211 reported the successful use of a The mechanism of tissue fusion through laser
microvascular stapling device that can be used for energy is still undefined. The initial strength of such
end-to-side and end-to-end anastomoses. In general, a bond depends on physical factors (collagen coiling
14
and crosslinking and coagulum formation) rather Temperature monitoring is a widely used
than biological processes such as inflammation and measure of flap circulation. May et al.228 described the
healing.223 The tissue-welding phenomenon might be experimental evolution and clinical application of an
caused by heat generated by the laser energy or might implantable thermocouple to monitor patency of the
be wavelength-dependent. microvascular pedicle.
To date, laser-assisted microvascular anastomosis The surface temperature measurements
is considered to be investigational. Difficulties with presented by Acland229 have proven most useful for
aneurysm formation,224 low breaking and tensile monitoring replanted digits. However, Kaufman et
strength during the early postoperative period,225 and al.230 found that, in muscle free flaps, temperature
the cumbersome size and high maintenance cost of monitoring is labile and easily changed by
conventional lasers have delayed full acceptance into environmental manipulation and as such is unreliable
clinical practice. On the other hand, miniature diode in assessing the vascular status.
lasers with fiberoptic delivery systems and selective
Khouri and Shaw231 presented their series of
photo-welding techniques seem promising to the
600 consecutive free flaps monitored by surface
future of microsurgery.
temperature recordings. They specifically monitored
the difference in temperature between the flap and
MONITORING PERFUSION a control site on the patient’s normal skin. After
10,000 temperature readings, the authors found only
Salvage of a failing free flap requires timely one temperature difference >1.8°C that failed to
recognition of inadequate flow and prompt show microvascular thrombosis. Seventeen readings
intervention to correct the problem. To be effective, were false-positive. Khouri and Shaw detected
clinical assessment of skin color, temperature, and 52 thrombosed flaps using surface temperature
capillary refill must be performed by a knowledgeable monitoring and were able to salvage 45 of the free
and experienced observer. Other, more sophisticated flaps by reexploration.
methods of evaluating circulation after free tissue
transfer have been proposed. Some are In a discussion of the article by Khouri and
reviewed below. Shaw,231 Jones232 noted that he had discontinued
the use of surface temperature monitoring in
Devices to monitor blood flow in flaps should
replantation and toe-to-thumb transfers and preferred
be relatively inexpensive, highly reliable, and simple
using the pulse oximeter instead. Jones also noted
to operate and interpret. The monitoring technique
that differential surface temperature monitoring
should be continuous and applicable to many kinds
is not sufficiently sensitive to monitor free muscle
of flaps.
flaps covered with split-thickness skin grafts. In his
The Doppler ultrasound flowmeter is the most opinion, the only clinical applicability of surface
common means for gauging circulation after free temperature recordings is in skin or skin island flaps,
tissue transfer.226 It can be used to monitor both and even those can be clinically monitored more
arterial and venous blood flow in flaps. The laser easily by means of capillary refill and Doppler probes.
Doppler has the additional advantage that it can
Jones and Gupta233 expanded on the topic
continuously record the microcirculatory flow in all
and reported efficacy of differential oximetry to
types of cutaneous and musculocutaneous free flaps
assess perfusion in pediatric toe-to-hand transfers.
and replanted limbs. Nevertheless, Walkinshaw et
Continuous pulse oximetry of a normal digit is the
al.227 found the laser Doppler to be unable to predict
baseline reference.
future clinical events and to be no more accurate than
clinical assessment in pointing to the need for Roberts and Jones234 described direct
clinical intervention. monitoring of microvascular anastomoses with
15
an implantable ultrasonic Doppler probe. Those through action on the dermal microvasculature, blood
authors and Swartz et al.235 noted that the Doppler constituents, and vasoconstricting prostaglandins.
probe can recognize and distinguish between arterial
Nolan et al.,244 Gu et al.,245 and van Adrichem
and venous occlusion and that in doing so, it is
et al.246 showed, in experimental studies, that
more reliable than a thermocouple probe. Venous
smoking was detrimental to microvascular surgery
occlusion can be difficult to detect by Doppler probe,
in terms of delayed anastomotic healing and free
especially in large muscle flaps.235 Fernando et al.236
flap failure. Surprisingly, large clinical series and
implanted a laser Doppler probe directly into muscle
some experimental studies have failed to show any
or subcutaneous tissue distal to the vascular pedicle.
damaging effects of cigarette smoking on free tissue
The Doppler recordings correlated with blood flow
transfers.247−249 Arnez et al.250 reported no difference
in the flap, and arterial compromise was readily
in flap loss or vascular thrombosis rates in smokers
detected. Rothkopf et al.237 assessed the patency rates
compared with nonsmokers in 50 free transverse
of microvascular anastomoses in the upper extremity
rectus abdominus muscle (TRAM) flap breast
by using color Doppler ultrasonographic imaging.
reconstructions. Reus et al.251 reported no difference
Whitney et al.238 reported significantly in anastomotic patency or overall survival of 162 free
higher salvage rates (86%) of transplanted toes flaps in smokers and non-smokers. Chang et al.249
and cutaneous flaps that were reexplored based on reviewed 963 free tissue transfers and showed no
quantitative fluorometry findings compared with statistically significant difference in vessel patency,
similar microvascular transplants that were not flap survival, or reoperation rate between smokers and
monitored with fluorescein (56%). The overall nonsmokers. Smokers did show a higher incidence of
accuracy of quantitative fluorometry in their 8-year healing complications at the flap interface and at the
experience with 23 transplants was 91%. Jones et donor site wound.249,251
al.239 described remote monitoring of free flaps with
telephonic transmission of photoplethysmographic Cigarette smoking seems to adversely affect
waveforms, which theoretically would facilitate the outcome of digital replantation surgery. van
surveillance of the flap by the operating surgeon. Adrichem et al.252 showed that tobacco smoking
decreases microcirculatory blood flow in replanted
Based on type and location of vascularized digits compared with healthy digits. Chang et al.249
tissue, monitoring of flaps and anastomoses should be observed that 80% to 90% of smokers ultimately
individualized.240 Replants and toe-to-thumb transfers lose their replanted digits if they smoke during the
can be effectively monitored by pulse oximetry, 2 months before or after surgery. Smoking is not
whereas free flaps often are monitored with Doppler an absolute contraindication to digital replantation
handheld pencil probes for several days after surgery, according to Buncke who stated that it is imperative
along with clinical observation.240 The implantable for patients not to smoke postoperatively. The reason
venous Doppler probe is used by many modern why cigarette smoking has a greater adverse effect
microsurgeons. Some clinicians evaluate perfusion by on digital replantations than on free flaps is unclear.
clinical examination alone. Digital blood flow is under much stronger vasomotor
control than are other areas in the body and is more
sensitive to the vasoconstrictive effects of nicotine.
INFLUENCE OF PATIENT FACTORS
Tobacco Use
Patient Age
Cigarette smoking has been shown to affect cutaneous
blood flow,241 wound healing,241,242 and survival of Parry et al.253 reported a 96% success rate with free
pedicled flaps.243,244 The overall effect of byproducts tissue transfer in children. Canales et al.29 echoed
of cigarette smoke is to produce a thrombogenic state the findings in 106 pediatric patients operated on
16
between 1973 and 1989. Their success rate (93% also increased as operative times increased. Higher
in the last 5 years reported) and complications were rates of reconstructive failure were noted in cases of
similar in their pediatric and adult patients. No attempted limb salvage in patients with peripheral
growth-related complications were noted at either the vascular disease.
recipient or donor sites.
To summarize, comorbidities and type
Yücel et al.254 reported no significant vessel of reconstruction must be taken into account
spasm and a 95% overall success rate in 20 pediatric when evaluating elderly patients for free tissue
free flaps. Clarke et al.255 reported a 99% flap survival transfer. However, patient age should not deter the
rate in pediatric microvascular cases despite frequent experienced microsurgeon.
but manageable complications. Vessel spasm was
not a significant problem. Duteille et al.256 reported
achieving excellent results with 22 pediatric free flaps. Systemic Disease
The authors noted that children have a greater risk Banis et al.260 showed that microsurgery can be
of vasospasm that is compounded by small vessel size a valuable tool in the salvage of ischemic lower
and recommended great care with vessel dissection. extremities from atherosclerosis of diabetic
Regional and local anesthesia is used to enhance microangiopathy. Karp et al.261 reported their
vessel dilation, and fat cells are left around the vessels. experience with 21 free flaps in 19 diabetic patients
Lidocaine 2% is used around the vessels at the time and documented only one flap loss, with all patients
of anastomosis. able to ambulate on their flaps. Nevertheless, five of
Patients older than 65 years can also undergo 19 original patients needed eventual amputation at 6
successful free tissue transfers.257 Chick et al.257 noted to 37 months after surgery.
a successful outcome in 30 of 31 free flaps transferred Moran et al.262 reviewed a large number of flaps
in patients older than 65 years. The complications comprising their 10-year experience with free flaps
associated with wound healing were the same in the in the context of lower extremity peripheral vascular
65 and older group and in the the younger-than-65 disease. The perioperative mortality rate was 5%;
group. The authors concluded that age alone is 5-year flap survival rate was 77%; limb salvage rate
not a factor in success or failure of free flaps when was 63%; and patient 5-year survival rate was 67%.
preexisting medical conditions are factored out Clearly, peripheral vascular disease is a significant
of the equation. Advanced age alone was not a risk factor for any long surgery. It is also a known
factor in morbidity or mortality from the risk factor for early death. Many of the amputations
microsurgical procedure. and patient deaths had nothing to do with the free
Shestak and Jones258 reported successful free tissue transfer, but peripheral vascular disease as a
tissue transfer in 93 of 94 flap procedures performed comorbidity must be weighed when considering free
in patients who were 50 to 79 years old, for a free flap flaps in this patient population.
viability rate of 99%. Fourteen (15%) major surgical Moran et al.263 also identified patients with
complications and 13 (14%) substantial postoperative renal insufficiency who underwent free tissue transfer.
medical problems occurred. The mortality rate Renal disease seems to be a stronger predictor than
was 5.4%. peripheral vascular disease of reconstructive failure
Serletti et al.259 reported a series of free flaps and major medical complications, including death.
in elderly patients (average age, 72 years). Success Fifty-two percent of the patients in the study by
rates were excellent and in line with other age Moran et al. suffered major morbidity or mortality
groups. The higher rate of medical complications during postoperative year 1. Among those who
was associated with patient comorbidities but not survived the first year, reconstruction was successful
with age as an independent factor. Complications in 55%.
17
For a more complete review of peripheral PTFE microvascular prostheses. In some series,
vascular disease, renal disease, and other the early patency rates were adequate, but in time,
comorbidities in reconstructive microsurgery of the neointimal hyperplasia and subsequent anastomotic
lower extremity, the reader is referred to the Lower narrowing were noted and led to concern regarding
Extremity Reconstruction issue of Selected Readings in long-term patency rates. Shen et al.274 noted
Plastic Surgery.264 significant thrombosis and occlusion when 2-mm
expanded PTFE grafts were used in low-flow free
flaps in rabbits.
MICROVASCULAR GRAFTS AND
van der Lei and Wildevuur275 reported poor
PROSTHESES
neoendothelialization in PTFE grafts, although
When it is not possible to repair a vessel by patency was high in the high-flow, short-segment
anastomosing the cut ends, such as in cases of grafts. Samuels et al.,276 on the other hand, noted
traumatic loss or when additional vessel resection that short-segment PTFE microvascular grafts were
is needed, grafts of autogenous veins are the most covered with a layer of endothelium. The authors
common substitute circulatory conduit used in reported a long-term patency rate of 80% and no
humans. Vein grafts are readily available and can be evidence of excessive neointimal hyperplasia.
harvested in predetermined lengths and diameters to
match as closely as possible the caliber of the recipient Yeh et al.277 described the use of human
vessel(s). Autogenous vein grafts are reversed for umbilical artery grafts as a microvascular substitute.
spanning intra-arterial gaps and placed directionally Although early patency of the grafts was good,
for bridging intravenous gaps. with time, marked degeneration of the vessel walls
occurred. Subsequently, Roberts et al.278 reported that
The histological changes that take place in vein the technique of glutaraldehyde tanning of human
grafts after placement in the arterial system have been chorionic veins seemed to be responsible for the low
well described in the literature.265,266 Mitchell et al.267 patency rate of the grafts, rather than fibrosis from
studied the long-term fate of microvenous autografts. the immunological reaction.
The patency of intra-arterial vein grafts was 98%. The
patency of intravenous vein grafts was 100%. Intra-
arterial vein grafts were modified by the ingrowth of MICROANASTOMOSES OF IRRADIATED
smooth muscle cells from the recipient artery, and the VESSELS
influx of smooth muscle cells created a neointima that Radiotherapy is known to impair wound healing by
considerably thickened the walls of the vein graft. In decreasing the number of blood vessels in tissue by
contrast, intravenous vein grafts maintained normal progressive thrombosis, resulting in tissue ischemia;
vein morphology. An unexplained loss in length of by decreasing fibroblast proliferation and production
the grafts of approximately 30% occurred, which led of collagen; and by destroying epithelial cells.
to the recommendation that vein grafts should be Patency in experimental microvascular anastomoses
35% longer than the measured gap. performed after irradiation has been highly variable.
Despite the success achieved with autogenous Earlier studies showed that it is significantly lower
vein grafts, experimental investigation of synthetic than in nonirradiated vessels.279-281 Other series, both
materials to replace small vessels continues.268-273 The experimental203,282 and clinical,283-288 showed high flap
most common materials tested for this purpose are success rates and low morbidity in irradiated beds.
fibrous polyurethane and microporous or expanded
Mulholland et al.284 compared free flap survival
polytetrafluoroethylene (PTFE).
rates in 226 irradiated and 108 nonirradiated head
O’Brien et al.271 and Hess et al.272,273 presented and neck reconstructions and reported similar failure
reviews of the experimental results obtained with rates for both groups. Reece et al.285 presented a
18
report of 66 elderly cancer patients who underwent was in the hands of a few pioneers; 20 years ago, free
tumor resection and free tissue transfer after previous tissue transfer was primarily practiced at university
radiotherapy. The authors found no significant centers. Today, free tissue transfer is fully entrenched
differences for flap failure or wound healing problems as a technique that nonacademic private practitioners
when compared with a similar group of patients who readily adopt in the treatment of their patients.
had not received radiotherapy. Similarly, Bengston Free flaps currently are being performed at an ever-
et al.286 and Schusterman et al.287 showed, in large increasing rate and for ever-expanding indications.
clinical series, that previous radiotherapy does not Microsurgical procedures are now used with
predispose patients to a higher rate of acute free flap confidence in situations that were previously thought
loss or wound complications. Kroll et al.288 reviewed to present high risk of failure, such as in irradiated
854 consecutive free flaps and concluded that fields,284 elderly patients,257,258 and those with
previous irradiation had no significant effect on flap occlusive peripheral vascular disease from generalized
failure rates. A prospective survey of 493 free flaps by arteriosclerosis or diabetes mellitus.260 Shestak and
the International Microvascular Research Group289 Jones258 reported successful free tissue transfer in 93
suggested that more caution should be exercised of 94 flaps in patients who were 50 to 79 years old,
in performing free flap transfer in patients with an for a free flap viability rate of 99%. Complications
irradiated recipient bed. were primarily nonsurgical and averaged 30%.
Guelinckx et al.290 proposed the following Mortality was 5.4%. Chick et al.257 noted successful
guidelines for anastomosis of irradiated recipient free flap transfers in 30 of 31 patients who were older
vessels: than 65 years. The wound healing complications
were the same as in a younger cohort. The authors
• limit dissection of recipient vessels to
concluded that age alone is not a factor in the success
reduce manipulation and injury
or failure of free tissue transfers when preexisting
• restrict electrocoagulation of arterial medical conditions are factored out of the equation.
side branches
The reported success rates of microvascular
• use small-gauge needles and suture transfers rose as experience with the procedures
materials (e.g., 10-0 nylon sutures mounted. Approximately 10 years ago, success rates
swaged on 70-mm needles) were in the 90% to 94% range, with 10% incidence
• pass the microneedle from inside of thrombosis. In the survey by Khouri et al.,289
to outside to minimize intramural encompassing data from nine microsurgical centers,
dissection and injury the combined success rate of microvascular flap
transfers was 98.8%, and only 3.7% of flaps were
• shorten the period of vessel cross- reexplored for thrombosis. Moreover, an esthetic final
clamping to minimize stasis and result is what most plastic surgeons currently strive
microthrombi for and expect from microvascular surgery, not just
• flush vessels with a heparinized simply a cover for the wound.
solution during the anastomosis and Failure of free tissue transfers is most often
before restoring blood flow caused by technical factors. Khouri et al.289 presented
a discussion of the reasons why free flaps fail and
suggested ways to avoid them. In the authors’
FREE FLAPS
extensive review, most free flap procedures were
It has been more than 2 decades since the first reports performed for posttraumatic indications and to treat
of human composite tissue transfers by microvascular extremity defects, cases in which the overwhelming
anastomoses. Twenty-five years ago, free tissue transfer majority of complications occurred. Apparently,
19
the magnitude of the traumatic insult is the single descriptions of a flap do not always mirror the
most important factor influencing the subsequent individual clinical situation. Therefore, alternative
development of microvascular thrombosis. Khouri sources of donor tissue should always be kept in
et al emphasized that one should always seek the
vascular pedicle of largest diameter, considering mind. In an excellent review, Pederson291 detailed the
failures are more likely when small-diameter pedicles principles of free tissue transfer in the upper extremity
are used, especially diameters <1 mm. Published (Figs. 2−4).
A B
C D
E F
Figure 2. A, Degloving injury to the thumb of a 23-year-old man. B, Cloth is used for template for lateral arm flap. C, Flap is
marked on lateral upper arm. D, Flap is placed. Seam is placed dorsally with anastomosis of lateral cutaneous nerve of the
arm to the ulnar digital nerve of the thumb. E, Results at 8 months postoperatively. Protective sensation had returned. F,
Flexion at 8 months postoperatively. (Reprinted with permission from Pederson.291)
20
A B
C D
Figure 3. A, Intraoperative view of the forearm of a 12-year-old boy after a propeller injury. Note the disrupted median
nerve. B, Intraoperative view after innervated gracilis transfer. Skin paddle for monitoring is over proximal muscle. C, Exten-
sion at 8 months postoperatively. D, Flexion at 8 months postoperatively. (Reprinted with permission from Pederson.291)
Skin, Fascia, and Perforator Flaps

The free groin flap was the first flap to be successfully
transferred by direct microvascular anastomoses.
Currently, it rarely is used in free tissue transfers
because of the anatomic variability of the donor
vascular pedicle. One of the most common and
versatile skin flaps for microvascular transfer is the
radial forearm flap,292-295 particularly in head and
neck reconstruction. Other reliable options are the
scapular,296-298 parascapular,299 lateral arm,300 and
dorsalis pedis free flaps.301,302
Free fascial transfers are useful in reconstructions
Figure 4. Great toe wrap-around flap in a case of partial
thumb amputation. Patient is shown 1 year after great toe
for which thin, well-vascularized cover is needed
wrap-around reconstruction of the left thumb. (Reprinted and to provide for gliding of tendons in the hand.
with permission from Pederson.291) The free temporoparietalis (TP) fascial flap has a
21
consistent vascular anatomy and a pedicle of fairly “with increasing knowledge of perforator flap
large caliber.303-305 The TP fascial flap is a versatile flap entity and refinements of surgical techniques, the
with many applications. The free fascial forearm306 anterolateral thigh perforator flap reconstruction can
and scapular flaps299,307 offer similar versatility for be as reliable as other types of cutaneous flaps.”
thin, well-vascularized tissue.
On rare occasions, the surgeon explores the flap
The anterolateral thigh (ALT) flap has become and finds no dominant or workable artery and vein
a major workhorse in numerous anatomic regions,
to the flap. Some time is wasted, and the surgeon is
including extremity, head and neck, and perineal
frustrated. Wei and Celik315 provided an excellent
reconstruction (Figs. 5 and 6).308,309 It offers hardy
yet thin skin and fascia. It can be deepithelialized review of the principles and application of perforator
or harvested directly as a fascia-fat flap. The flaps and relevant anatomy. Work continues to
donor site often can be closed primarily. Donor help delineate perforator flap dissection for specific
site complications are not absent, however. Many dermatomes.316 Better understanding of the cutaneous
patients notice some sensation loss at the lateral thigh patterns of perforator locations will likely help
postoperatively. Some patients notice thigh weakness surgeons to select, tailor, and successfully dissect these
caused by the dissection through the vastus and/ flaps (Fig. 8).317
or rectus femoris. Flaps that require skin grafts to
close the donor site might be associated with stiffness
during hip motion or knee flexion because of scar
adherence of the graft to muscle fascia.310 Engel et
al.311 advocated the use of the ALT flap at their center
as the first choice free flap for multiple applications.
Rodriguez et al.312 presented a report of multiple ALT
flaps used for trauma reconstruction and described
similar virtues regarding the ALT.
Novak et al.313 compared the donor site
morbidity of the ALT flap with that of the radial
A
forearm flap. Interestingly, the radial forearm flap
donor site seemed to generate more cold intolerance
and possibly had a poorer cosmetic appearance.
The blood supply of the ALT flap can be from
septocutaneous and intermuscular perforators or
from direct intramuscular perforators. If the flap is
harvested and found to have muscular perforators,
it is termed a perforator flap proper. If the blood
supply arrives via septal vessel, it is probably more
correct to term the flap a fasciocutaneous free flap. B
This is a semantic distinction that adds little to our
understanding of flap elevation in that the surgeon
follows the perforators down to their source regardless Figure 5. A, Intramuscular dissection of a perforator
of the path they take. Celik et al.314 described through vastus lateralis muscle to anterolateral thigh flap.
Arrowheads indicate musculocutaneous perforator. B,
technical pearls for ALT flap harvest, including
Septocutaneous vessels to anterolateral thigh flap. Arrow-
preservation of a fascial cuff around the pedicle heads indicate septocutaneous vessel. RF, rectus femoris; VL,
during dissection (Fig. 7). The authors concluded, vastus lateralis. (Reprinted with permission from Pederson.291)
22
A A
B B
C
Figure 7. A, Anterolateral thigh musculocutaneous
perforator flap. One musculocutaneous perforator
dissected free from the vastus lateralis. B, Dissection of two
intramuscular perforators. (Reprinted with permission from
Celik et al.314)
frequency. Perforator variants are being derived from

the thoracodorsal system and the gluteal vessels.319-321
Kim et al.319 described a thin latissimus dorsi
perforator-based flap (Figs. 9−11).
Figure 6. A, Cutaneous anterolateral thigh flap dissected
suprafascially. B, Fasciocutaneous anterolateral thigh flap. The deep inferior epigastric perforator (DIEP),
C, Musculocutaneous anterolateral thigh flap with part of
superior gluteal artery perforator,322 superficial
vastus lateralis muscle. (Reprinted with permission
from Pederson.291) inferior epigastric artery (SIEA), and gracilis flaps
are all being used for breast reconstruction. The
The future of flap harvest might include the results and donor morbidities associated with these
new “free style” free flap concept. Mardini et al.318 flaps are being compared with those associated with
used color Doppler to guide harvest of free style free free TRAM and pedicled TRAM flaps. Large series
flaps from many areas around the body. The thigh of successful breast reconstructions with SIEA and
is being used as the model donor site for flaps with DIEP flaps have been published in recent years.323,324
this retrograde technique. Other perforator flaps and The DIEP flap might be as cost-effective as the free
perforator-type flaps are being used with increasing TRAM flap in this scenario.325
23
Chevray323 compared SIEA and DIEP flaps

with each other and with TRAM flaps. Operative
times were similar. The author noted the advantage of
non-violation of the abdominal wall when the SIEA is
used. Unfortunately, the SIEA pedicle often is absent
or not substantial enough for flap transfer. When
the vessel is present and usable, it frequently is small
and has a short pedicle. Hospital stays were slightly
shorter in the SIEA group.
The SIEA flap generally is considered safe,
primarily for hemi-flaps, whereas the DIEP and free
TRAM flaps generally have reliable flow across the
abdominal midline. SIEA transfer has drawbacks,
which are the hemi-flap size limitation, the small
vessel size with short pedicle, and time spent
intraoperatively looking for SIEA when they might
not be present. Occasionally, however, one side of the
lower abdominal skin is SIEA-dominant, with respect
to arterial and venous flow, or just venous outflow.
For this reason, we advocate looking at the SIEA
and superficial inferior epigastric vein on all patients
before performing DIEP dissection.
Figure 8. Locations of the 16 skin perforators. Circle If blood flow, pedicle length, and adequate
represents 3-cm-diameter circle that is centered on the harvest size are available for an SIEA, the patient has
first anatomic landmark. Each black dot represents one the advantage of not having to undergo abdominal
skin perforator, and each black triangle represents two
fascial opening and muscle dissection. Considering
skin perforators. P, posterior axillary fold; S, scapular tip;
L, latissimus dorsi muscle; I, iliac crest. (Reprinted with that both DIEP and SIEA flap transfers purport to
permission from Lin et al.317) have decreased abdominal wall morbidity relative to
the free TRAM, further studies comparing these flaps
will be instructive.
Muscle and Musculocutaneous Free Flaps

In 1970, Tamai326 first reported free transplantation
of vascularized skeletal muscle with his account of
a rectus femoris muscle transfer in dogs. At biopsy
5 months later, muscle fibers and motor nerve
action potentials were almost normal. Harii et
al.327 transferred the gracilis muscle, in 1973, for
facial reanimation in a patient with long-standing
Bell palsy. At about the same time, a surgical team
Figure 9. Illustration shows cross-section of thin latissimus in China328 transferred the lateral portion of the
dorsi perforator-based flap and dissection plane through pectoralis major muscle to the forearm to replace the
superficial fascial layer. SAL, superficial adipose layer; finger flexor musculature destroyed in a Volkmann
DAL, deep adipose layer; LD, latissimus dorsi muscle; TDV,
thoracodorsal vessels. (Reprinted with permission from contracture. Ikuta et al.329 repeated this operation
Kim et al.319) in 1976.
24
A B
C D
Figure 10. A, Post-burn scar contracture on the right wrist of a 5-year-old girl creates limited range of motion.
B, Thin 8 × 4.5 cm latissimus dorsi perforator-based free flap was designed on the patient’s back near the scars.
C, Flap with pedicles that were dissected to the main muscular branch under the muscle to gain proper vein
diameter for anastomosis. Underlying muscle was not included in this flap. D, Postoperative results. (Reprinted with
permission from Kim et al.319)
A B
C Figure 11. A, Diabetic, cellulitic foot

of a 53-year-old man has extensive
defect after undergoing débridement.
B, Thin 20 × 10 cm latissimus dorsi
perforator-based free flap containing
thin superficial adipose layer was
elevated for covering the defects in
the foot dorsum, lateral foot, and
plantar areas. C, Appearance at 1
month postoperatively. (Reprinted with
permission from Kim et al.319)
25
Today, the transfer of skeletal muscle as a to replace lost muscle and tendon-unit function.
free flap is a common operation in plastic surgery. Functional muscle has particular application in
The vast majority of these free muscle transfers are restoration of finger flexion and extension in cases
performed to provide bulk and soft-tissue coverage of severe posttraumatic loss or Volkmann ischemic
in cases of traumatic losses or osteomyelitis. The contracture and for facial reanimation. Both topics
most common muscle flaps are the latissimus dorsi are covered extensively in Selected Readings in Plastic
and rectus abdominis muscle flaps, which offer the Surgery issues dealing with facial nerve disorders338
advantages of reliable, large-caliber, long vascular and hand surgery.339,340 In an interesting report, Lin et
pedicles and relatively low donor site morbidity. al.341 described use of the soleus, latissimus, gracilis,
Salgado et al.330 reported an alternative method and rectus femoris muscles in functional free muscle
for harvesting the rectus muscle via a Pfannenstiel transplantation to restore finger flexion and extension
incision. This approach might offer the advantage of and in the repair of biceps defects to provide
a more esthetic donor scar. Other refinements have functional elbow flexion and lifting power. It is worth
evolved out of consideration for donor site morbidity noting that in that series, the youngest patient was 16
caused by muscle harvest. Brooks and Buntic331 and years old. The authors reported M4 return of function
Buntic et al.332 reported their first 100 cases of partial in most of their transfers.
superior latissimus flaps and partial medial rectus
Selection of a donor muscle for transplantation
flaps. The authors noted that the partial latissimus
must be based on the functional requirements of
preserves function of the bulk of the muscle, as the
the patient and the dynamic characteristics of the
motor nerve, or the relevant portion, is preserved.
The partial rectus preserves lateral muscle function muscle. The working strength of a skeletal muscle
(Fig. 12).332 is directly proportional to the cross-sectional area of
the contracting muscle fibers, whereas the range of
The concept of transplanting a tissue unit muscle contraction is a factor of fiber length. The
composed of skin and muscle for reconstruction neuronal mesh of the available donor muscle should
originated with Tanzini333 who, in 1906, used the match the anatomy of the recipient nerve branch as
latissimus dorsi musculocutaneous flap to build much as possible. Many muscles have been tried, but
a breast mound. The work conducted by Tanzini the gracilis muscle is emerging as the clinical favorite
was initially accepted, subsequently ignored, and for many applications. Harvest and inset of the
then forgotten for three generations. McCraw and functional gracilis muscle is generally straightforward
Dibbell334 rediscovered the concept originated by in experienced hands. Several articles detail the
Tanzini when they transferred a number of free operative technique of gracilis harvest and anatomic
musculocutaneous flaps in dogs, which led to their variations of the muscle (Figs. 13−16).342-344 Hasen
landmark work on human island musculocutaneous et al.343 described wide elevation of the adductor
flaps.335 Most of the independent musculocutaneous longus on both sides of the vascular pedicle (Figs. 17
territories described by McCraw et al.335 are potential and 18). Lin et al.345 harvested the gracilis through a
sources of free flaps, and numerous others have since shorter incision without the endoscope.
been identified and successfully transferred.
Functional free muscle transplantation involves
Maxwell336 listed several musculocutaneous the transfer of skeletal muscle by microvascular
free flaps and described their history and anatomy. anastomoses and reinnervation by microsurgical
Maxwell credited Fujino et al.337 with the first clinical technique, suturing an undamaged motor nerve
free transfer of a musculocutaneous unit, in 1975; in the recipient site to the motor nerve in the
this was a deepithelialized gluteus maximus flap used transplanted muscle. The ultimate success of a
for reconstruction in a patient with an aplastic breast. free innervated muscle transfer depends not only
Functional free muscle transfer is performed on survival of the muscle but also on function of
26
the part. Histologically, muscle fibers that are not

reinnervated gradually degenerate and are eventually
replaced by fat cells. The question of whether
muscle fibers survive in their original state and are
reinnervated or whether they first degenerate and
subsequently regenerate remains unanswered.
Many factors are important to the outcome of
any procedure: effective tenotomy in reestablishing
proper muscle resting tension, amount and quality of
donor nerve tissue and of the anastomosis, quality of
donor and recipient vasculature, and other anatomic
conditions at the recipient site. In a rabbit rectus
femoris muscle model, Terzis et al.346 showed that
despite 100% patency of the anastomosis, maximum
working capacity after reimplantation was only one- Figure 12. Illustration shows the partial superior latissimus
fourth of normal. Still, revascularized free muscle flap (PSL Flap) isolated on the transverse arterial branch of
transplants can be expected to at least partially replace the latissimus muscle. Additional pedicle length is gained
by harvest of the thoracodorsal artery (TDA) and vein, with
the function of lost muscles in various areas.
or without the subscapular system. Lateral descending
Some authors347-351 have emphasized the branch (DB) has been ligated. Flap is harvested with the
transverse branch (TB) of the artery and the transverse
importance of reestablishing correct resting tension
nerve branch that accompanies it. Remaining latissimus
of muscle transplants. Small decreases in resting muscle is innervated by the intact descending branch
muscle tension can markedly reduce the power of the thoracodorsal nerve (not pictured). Vascularity of
and amplitude of a contracture. A recent article352 the remaining muscle is preserved through intercostal
perforators and perforators of the thoracolumbar fascia.
advocates the importance of early passive motion for (Reprinted with permission from Buntic et al.332)
these functional transfers in the upper extremity. Doi
et al.352 reported that early motion might help with
excursion and prevent adhesions.
On average, muscle transplants have
significantly less functional recovery than do controls,
although 100% of the control maximum tetanic
tension has been noted in several transplanted
muscles.353 A study by Kuzon et al.353 involved
orthotopically replanting gracili on 15 dogs and
comparing twitch, tension, and maximal tetanic
contraction with contralateral leg gracilis controls.
In several individual replants, 100% of control
maximal tetanic tension was observed. Kuzon et al.
concluded that intraoperative ischemia, if less than
4 hours, does not affect functional recovery of a free Figure 13. Potential arc of rotation of the distally based
gracilis pedicles flap based on the proximal secondary
muscle transfer and that the observed variability in pedicle. Distal to the patella, the reach of the flap depends
functional outcome must be caused by other, still on the exact location of the proximal secondary pedicle
undetermined, factors. and might not be reliable. (Reprinted with permission from
Cavadas et al.342)
27
A B
C D
Figure 14. Pedicled reverse gracilis muscle flap. A, Chronic infected suprapatellar defect with missing quadricipital tendon. B,
Ipsilateral gracilis muscle is dissected based on the proximal secondary pedicle. C, Muscle is turned over to allow access to the
patella and reconstruction of the quadricipital tendon. D, Result after skin grafting of the muscle. (Reprinted with permission
from Cavadas et al.342)
Osseous and Osteocutaneous Free Flaps second metatarsal, radius, calvaria, and scapula as
Free osteocutaneous flaps evolved from the need common sources of vascularized bone and have cited
for both vascularized skin and bone in some early reports of microsurgical transfer of the respective
reconstructions. Ostrup and Fredrickson354 pioneered flaps.297,301,354,355,359−366 Vascularized bone autografts
the free transfer of vascularized bone in 1974. have been shown to be superior to nonvascularized
Shortly thereafter, Taylor et al.355 and O’Brien356 bone grafts regarding early incorporation, bone
were instrumental in defining the advantages, risks, hypertrophy, mechanical strength to failure, and
and limitations of the technique. Buncke et al.357 osseous mass retention.367,368 The rate of graft union
transferred a free rib osteocutaneous flap to the lower is affected not only by the graft itself but also by
leg for tibial pseudarthrosis in 1977. That same year, the condition of the recipient bone ends. When
Serafin et al.358 used a rib osteocutaneous free flap for bone defects are large or the recipient bed is poorly
mandibular reconstruction. vascularized, clinical evidence suggests that osteocyte
Several authors have listed rib, fibula, iliac crest, survival is greater in free vascularized bone grafts.369
28
Berggren et al.374 compared medullary and

periosteally supplied costal grafts in dogs. Grafts that
were revascularized through their periosteal vessels
A
showed less resorption, albeit with some marrow
necrosis and partial loss of osteocytes. Grafts with
both medullary and periosteal blood supply survived
completely but were partially resorbed with time.
Both types of grafts healed to their recipient site
equally well.
Vascularized rib grafts can be harvested either
via an anterior approach, preserving periosteal blood
supply, or posteriorly, conserving primarily medullary
blood supply. Serafin et al.375 summarized the benefits
and limitations of both approaches. Georgescu
B and Ivan376 showed successful use of the serratus-rib
composite free flap for upper and lower
extremity reconstruction.
In 1979, Taylor377 was the first to report transfer
of a free vascularized graft of fibular bone beneath a
previously implanted groin flap for repair of a tibial
defect. In 1983, the author369 recommended free
fibular grafts to repair bony defects >8 cm, whereas
ilium (straightened by an osteotomy) or fibula can be
used for defects 6 to 8 cm. Defects <6 cm long can be
repaired by conventional nonvascularized bone grafts.
Figure 15. A, Intraoperative view of dissected proximal These data are mainly applicable to mandible defects;
secondary pedicle up to its origin from the superficial
other osseous defects might have variability. Taylor369
femoral vessels. B, Intraoperative view of segmental gracilis
flap fully dissected and ready for free transfer. The gracilis also described various techniques of harvesting
muscle has not been divided. (Reprinted with permission vascularized fibular grafts and has proposed helpful
from Cavadas et al.342) refinements. Most recently, Taylor378 described
a novel technique of free vascularized fibula flap
Trauma and irradiation hamper bone healing
reconstruction of the clavicle combined with biceps
in conventional nonvascularized bone grafts,370
tendon for repair of the coronoid ligaments and plate
whereas vascularized bone grafts seem to better
stabilization of the acromioclavicular joint (Fig. 19).
tolerate irradiation of the recipient bed.371 Moreover, Hidalgo379,380 reported extensive experience with free
vascularized bone grafts seem to heal more rapidly, fibular transfers in mandibular reconstruction.
even in the presence of an infected wound.372,373 In
Many practitioners think it is prudent to
short, the technique of vascularized free bone grafts
perform bilateral lower extremity angiography before
is the standard against which emergent technologies,
fibula harvest to rule out peronea magna. Peronea
such as Ilizarov distraction osteogenesis, must be magna is an anatomic variation with which the
measured. See the Selected Readings in Plastic Surgery peroneal artery is dominant and provides significant
Lower Extremity Reconstruction issue264 for a more arterial flow to the foot along with the posterior
detailed discussion of bony reconstruction in the tibial artery. With this variant, the anterior tibial
lower extremity. artery is hypoplastic or nonexistent. Harvesting
29
A B
C D
Figure 16. A, Crush injury of the first web of the right (dominant) hand in a 22-year-old man. B, All nonviable muscles
underwent débridement. The resultant defect was filled with a segmental gracilis free transfer based on the proximal
secondary pedicle and revascularized to the radial vessels. C, Absence of adduction retraction. D, Good opposition because of
the remaining abductor pollicis brevis muscle. (Reprinted with permission from Cavadas et al.342)
the fibula in such a case can leave the patient with Taylor and Watson362 described the free
a single-vessel-foot or worse. Angiography has transfer of vascularized ilium on the deep circumflex
its own associated risks, however, including renal iliac vessels. Taylor et al.363,383 later expanded the
failure, contrast material allergy, bleeding, and applications of the technique and suggested further
pseudoaneurysm of the cannulated access artery. surgical refinements. Shenaq384 reported less
As imaging technology improves, our reliance on
morbidity with the classic iliac crest free flap when
angiography will likely wane. Magnetic resonance
using the inner cortex of the bone, but a study by
angiography and computed tomographic angiography
are useful tools.381 Duymaz et al.382 noted that Mirovsky and Neuwirth385 disputed that conclusion.
computed tomographic angiography has provided Mialhe and Brice386 presented a report of a posterior
excellent visualization of the lower extremity and can iliac crest osteomusculocutaneous free flap that is
be used for planning purposes in cases of free tissue based on a superficial branch of the superior
reconstruction of the lower extremity (Fig. 20). gluteal artery.
30
Figure 17. Illustration shows that

after division of the intramuscular
branches to the adductor longus
muscle, the gracilis muscle is
divided distally and proximally
and the adductor longus muscle
is mobilized on both sides of the
pedicle. (Reprinted with permission
from Hasen et al.343)
Figure 18. Illustration shows

passage of the gracilis muscle into
the space created between the
adductor longus and sartorius
muscles for final proximal pedicle
dissection. (Reprinted with
permission from Hasen et al.343)
Figure 19. Patient is a 42-year-

old man with a 5-cm recurrent
dermatofibrosarcoma adherent to
the periosteum of the lateral third of
the left clavicle shown by magnetic
resonance imaging 9 years after initial
resection. Left inset, Wide tumor excision
with 3-cm skin margins and 9.5 cm of
the clavicle was performed sparing
adjacent neurovascular structures and
a ligamentous acromioclavicular joint
cuff. Arrow indicates the site of the bone
section. Center inset, Left osseocutaneous
fibular flap was raised on the peroneal
vessels and was transferred. a. & v., artery
and vein. Right image, In a separate
operation, the acromioclavicular joint
dislocation was reduced and held by
fixing the modified clavicular plate with
unicortical screws and positioning the
hook beneath the acromion laterally. a.,
artery; v., vein. (Reprinted with permission
from Taylor et al.378)
31
tissue options and the need for laparotomy to harvest

the omentum, its popularity has waned considerably.
Nevertheless, after latissimus, and latissimus-serratus,
the omentum remains a reliable option for large scalp
defect reconstruction. In addition, the omentum can
be used for wound coverage in the lower extremity,
and the gastroepiploic system is used simultaneously
for lower limb revascularization in the context of
peripheral vascular disease and ischemic wounds.264
REPLANTATION
A
The first end-to-end anastomosis between vessels
of disjoined parts was performed by Murphy1 in
1896. According to Kleinert et al.,396 a few years
later, the German surgeon Hoepfner successfully
replanted limbs in dogs. Working independently
during the first years of the century, Guthrie2 and
Carrel3 transplanted kidneys, blood vessels, and
composite tissues in lambs and dogs. In 1902,
Carrel experimentally showed the feasibility of limb
replantation, although his heterotransplant ultimately
failed. Ten years later, the author received the Nobel
Prize for his contribution to the science of vascular
B anastomosis and organ transplantation.
In 1921, Nylén and Holmgren first described
Figure 20. Computed tomographic angiography scans the use of a microscope during surgery for
of a 54-year-old man with a comminuted tibial fracture otosclerosis.4 In 1950, Perritt397 sutured a human
and anterior soft-tissue defect over the right leg. A, cornea under an operating microscope.
Patent anterior tibial arterial and venous comitantes at
the proximal margin of the injury site (arrow) are shown. Malt and McKhann14 replanted the arm of
B, Image obtained 4 cm distal to the image shown in A a 12-year-old boy who had suffered an above-
shows occlusion of anterior tibial vessels, evidenced by the elbow amputation in 1962. In 1963, Kleinert et
absence of contrast (arrow). (Reprinted with permission from
Duymaz et al.382)
al.398 presented a report on vessel repair techniques
to revascularize near-complete severed limbs. In
1965, Kleinert and Kasdan399 reported the first
Free Flaps of Viscera and Omentum
revascularization of human digits and Komatsu and
Microvascular transfers of bowel segments, primarily Tamai19 performed the world’s first replantation of a
of the proximal jejunum, are widely used for human digit.
reconstruction in the oral cavity, pharynx, and As the 20th century progressed, surgeons
cervical esophagus.387-393 The greater omentum is attempted to operate on increasingly finer structures
an excellent source of donor tissue and has been of the body, and reports of successful reattachment of
transferred by microanastomoses for multiple severed extremities became commonplace. Today, the
reconstructive problems in the past.394,395 Today, feasibility of human limb replantation is no longer in
because of the increasing abundance of other free question. The reader is referred to an excellent article
32
by Kleinert et al.400 for a history of replantation and although proven for many years in major organ
an overview of popular techniques. transplants, has not been conclusively shown in limb
replantation.356,409 Usui et al.410 and Smith et al.411
noted some benefit from fluorocarbon perfusion of
Arm and Forearm Replants amputated extremities, with less alteration of lactate,
Upper extremity replantation has evolved rapidly pH, and creatine kinase levels. This improvement was
since the report presented by Malt and McKhann.14 offset by loss of capillary endothelium and
Survival rates have improved significantly during increased edema.
the last 30 years, and the ultimate success of a Fukui et al.412 described their experience with
replantation attempt is now judged by functional and continuous postoperative infusion of urokinase,
cosmetic parameters. prostaglandin E, heparin, and low-molecular-weight
Unlike distal amputations, the proximal limb dextran. In the 13 cases reported, no instances of
has a large muscle mass that renders it vulnerable arterial thrombosis occurred, and the authors noted
to ischemic degeneration. Nerve injuries to the significant differences in platelet count, fibrinogen,
proximal limb are associated with a high risk of loss of and antithrombin III in the patients receiving the
function. Review articles by Morrison et al.,401 Wilson drug infusion compared with the control group.
et al.,402 O’Brien,403 and Whitney et al.404
offer different perspectives on the subject of major Indications and Contraindications
limb replantation.
Meyer et al.413 stated that patients with amputations
In the rat, muscle necrosis and permanent proximal to the wrist joint but close to it are good
breakdown of biochemical systems occur within 4 candidates for replantation, as evidenced by Chen
hours of ischemia.405 In man, muscle necrosis has grade I or II recovery in 80%. In general, upper
been documented after only 2.5 hours of tourniquet extremities amputated proximal to the midforearm
ischemia.406 Metabolic parameters correlate with should not be replanted if the warm ischemia time
histological evidence of extensive cellular damage. is longer than 6 hours.402 The following are universal
With increasing ischemic times, the histological contraindications to replantation:402
appearance does not return to normal even after
perfusion is restored. Cooling theoretically prolongs • concomitant life-threatening injury
the safe ischemic period, although Muramatsu • multiple segmental injuries in the
et al.407 noted that even when cooled, muscle amputated part
enzymes (creatine kinase, serum glutamic-oxalacetic
• severe crushing or avulsion of the tissues
transaminase) continued to leak out of the replanted
dog hind limb after 6 hours of ischemia. • extreme contamination
Nunley et al.408 described the technique of • inhibiting systemic illness (e.g., small-
arterial and venous shunting as an aid to rapidly vessel disease, diabetes mellitus)
perfuse the upper limb during lengthy replantation • previous surgery or trauma to the
operations. The shunt allows adequate time amputated part precluding replantation
for thorough débridement, appropriate bony
stabilization, and identification of anatomic
structures. The authors concluded that the Functional Recovery
arteriovenous shunt improved their operative
Return of function in cases of forearm replantations
technique without jeopardizing muscle viability.
depends largely on two factors: the degree of nerve
The value of tissue perfusion in replantation, regeneration and the hand rehabilitation program.414
33
Russell et al.415 reported their results in cases of upper Replantation is controversial in the following clinical
limb replantation and revascularization. The most situations:
frequent complication of surgery was infection (29%) • loss of a single digit other than the
compounded by inadequate débridement, which led thumb, especially the index and small
to four failures. Nonunion occurred in 13%, and fingers, even when the amputation
intrinsic muscle function was weak or absent in all level is proximal to the flexor digitorum
patients. Excellent or good results were noted in eight superficialis tendon insertion
of 19 patients; all had clean, guillotine-type distal
amputations or incomplete proximal amputations • single-digit amputations distal to the
with intact nerves. Fair and poor results were digitorum superficialis insertion
associated with crush or avulsion injuries. The authors • ring finger avulsion injuries
concluded that the potential for functional recovery is
proportional to the amount of viable
tissue remaining. Level and Type of Injury
Tsai et al.421 described their technique for
replantation of the fingertip at the level of the distal
Hand and Digit Replants
interphalangeal joint or distally. They noted a 69%
Weiland et al.416 charted the progress of digital and survival rate, and 25% of patients had 2-point
hand replantation efforts at their institution over discrimination <5 mm. Clean, minimally crushed
a 7-year period. Survival of the replanted limbs amputations yield the best results after replantation.356
increased from 32% in 1970, to 74% in 1975, to Avulsion injuries, severely contaminated wounds,
more than 90% in 1976. As survival of the replanted and amputations with multiple levels of injury are
extremity climbed, clinical emphasis shifted to secondary choices for replantation.409,420,422 The
considerations of long-term functional results. severity of the damage often necessitates dissection
of a large area to escape the zone of injury, and repair
Strauch et al.417 offered an excellent review of
of injuries such as ring avulsions, for example, might
the problems and complications encountered in
not revascularize the flexor tendons and proximal
replantation surgery in the hand. Waikakul et al.418
interphalangeal (PIP) joint.400 Microsurgical repair
presented a large series of more than 1000 digital
in cases in which the entire finger has been degloved
replantations for which the functional results were
does not result in good function.415,420
generally good, with a replant viability rate of 93%.
Zone 2 replants experienced the worst outcomes. Ring avulsions are a special case. With ring
avulsions, the zone of injury varies by level and
by actual severity of the soft-tissue injury and
Indications and Contraindications devascularization. In general, avulsion injuries fare
significantly worse than do sharp injuries regarding
All other criteria being favorable, few surgeons
recovery of range of motion.423 Adani et al.424 reported
would argue against replantation in the
achieving acceptable results after complete ring
following circumstances:
avulsion replants.
• multiple finger amputations
• thumb amputations
Patient Age
• complete amputations of the hand at
O’Brien356 stated that any limb amputation in a child
the palm or wrist356,419,420
merits an attempt at replantation as long as the part
• all amputations in children is not severely crushed. Kleinert et al.400,420 stated that
34
age alone is not a contraindication to replantation person in Japan who is missing a finger can be labeled
but that it must be considered in the decision- as a gangster and might not be able to get a job.
making process. Microsurgical repair of the tiny
May et al.427 documented excellent survival and
vessels of infants renders the operation technically
good aesthetic results in a series of 24 digits replanted
difficult; on the other hand, functional return after
distal to the PIP joint, which prompted them to
replantation of digits in small children often is good.
advocate the procedure in selected cases. Wilson et
Useful functional recovery cannot be expected with
al.402 suggested a role for single-digit replantation
any reliability in the elderly. Thus, any attempt at
when adjacent fingers are severely injured and the
replantation should be carefully weighed against the
cut is clean. Waikakul et al.418 also advocated single-
potential systemic insult from the anesthesia
and operation. digit replantation. Kleinert et al.400,420 discouraged
single-digit replantation, although the results he has
achieved with the procedure have been impressive.
Length of Warm Ischemia Time O’Brien356 weighed the merits of single-digit
replantation based on patient sex, occupation, and
Kleinert et al.400,420 asserted that >12 hours of warm
expected functional result. Jones et al.428 compared
ischemia is a relative contraindication to digital
hand function in patients who had received single-
replantation, although survival of the replanted part
digit replants and those who had been amputated
has been documented after as long as 42 hours of
and concluded that there is little functional need to
warm ischemia.113 Prompt cooling of the amputated
replant a single digit except the thumb. Ultimately,
digit to 4°C prolongs the acceptable ischemic period
the discussion regarding single-digit replantation in
to approximately 24 hours, with a good chance of
adults remains a philosophical one, and each surgeon
complete survival and full functional return.
must come to his or her own conclusion based on the
situation at hand.
Patient Selection
A patient’s occupation, economic and social statuses, Secondary Procedures
nationality, mental health, and cooperativeness must
all be taken into account when deciding whether to Most replanted digits that include at least one joint
attempt replantation.425 Patients in occupations such in the replanted part experience significant stiffness
as manual labor might value gross motor skills and after healing, and secondary procedures often are
strength with rapid recovery, as opposed to a violinist needed. In addition, replanted digits might require
who values manual dexterity and fine motor skills. further soft-tissue coverage. Ross et al.423 reported the
Economics is important because some patients need best range of motion in zone 1 and zone 5 replants.
to return to work sooner and cannot sacrifice the time Interestingly, two-tendon replanted digits had better
and expense to undergo the rigorous rehabilitation range of motion than did one-tendon fingers. Early
required after digital or extremity replantation. motion protocols were advocated. Yu et al.429 reviewed
79 replanted digits that underwent a total of 102
secondary procedures. Flexor tenolysis was used often
Single-Digit Amputations with good results.
Urbaniak426 is a proponent of replantation in single-
digit amputations distal to the superficialis insertion
Replants of Miscellaneous Body Parts
if no crush injury is present. Tamai419 also replants
single digits when local wound conditions are Although the vast majority of reported surgical
favorable and if the patient desires the procedure. reattachments are in the upper extremity,
However, his recommendation is influenced in that a successful replants have been achieved in the lower
35
extremity,430 scalp,431-434 ear,435-439 penis,440,441 testes,441 Operative Technique

scrotum,441,442 upper and lower lips,443,444 tongue,445
The surgical principles of microvascular repair
nose,446 and face-scalp composite.447
have been previously discussed. When performing
Scalp replantation is one of the most critical replantation, one must be particularly careful to place
problems the plastic surgeon can encounter. Despite the anastomoses outside the zone of injury and to
appropriate efforts in experienced hands, scalp incorporate only undamaged vessel ends. Excessive
replants do not always survive nor are the parts always shortening of replanted parts results in muscle-tendon
replantable to begin with. Nahai et al.431 presented imbalance and dysfunction.
a discussion of the appropriate management of
The operative sequence for replantation varies
extensive scalp avulsions. Should replantation be
according to the clinical situation and preference
deemed too risky, the latissimus and the combined
of the surgeon. A common approach involves the
latissimus-serratus free flaps are excellent salvage
following steps:
options for subtotal and total scalp avulsions.448
Omentum is also an excellent option for scalp salvage. • preoperative patient evaluation and
preparation
Ademoğlu et al.449 discussed whether amputated
great toes should be replanted. Even though load • identification of structures in amputated
distribution is altered after amputation of a great part
toe, the gait is not significantly affected. The
• identification of structures in
authors stopped short of recommending great
amputation stump
toe replantation. A more recent study by Lin et
al.450 showed that great toe replantation should be • bone shortening (minimal) and bony
restricted to traumatic amputations in children and fixation
incomplete amputations in adults. This is especially • arterial repair (with or without
true at the level proximal to the interphalangeal joint. recirculation)
Complete amputation of the great toe with injuries
of the lateral toes portends a poor prognosis for the • venous repair
survival of replanted toes. Kutz et al.430 stated that • muscle-tendon unit repair
lower extremity replantation might be indicated in
cases of distal, clean, sharp amputations in young • nerve repair419,451
patients. For a more extensive discussion on lower • skin closure or soft-tissue coverage
extremity replantation, see the Selected Readings in
Plastic Surgery Lower Extremity Reconstruction
issue.264 Adjuncts to Microvascular Anastomoses in
Replantation
Mutimer et al.436 reported successful
microsurgical reattachment of totally amputated Internal Fixation
ears. Turpin437 described the evolving technique for Internal fixation techniques allow early mobilization
successful ear replantation. The author noted that while maintaining bony stability. Fixation can
vein grafts usually are required and that postoperative be accomplished with crossed K-wires,452 a single
venous congestion is a frequent problem. Turpin intramedullary K-wire,453 interosseous wiring,454
suggested that all patients should receive heparin intramedullary screws,417 or bone plates and external
anticoagulation and noted that medicinal leeches fixation devices. Arata et al.455 described the use of
or frequent abrasion might be necessary to control absorbable poly-l-lactide rods in digit replants. No
venous congestion. nonunions were noted. The type of fixation used is
based on considerations of fragment stability, early
36
mobilization, patient reliability and compliance, and points. Distal injuries were worse and more frequent
surgeon’s preference. than proximal injuries. Buncke et al.462 reviewed the
applications and long-term results of vein grafts in
replantation surgery.
Free Vascularized Joint Transfers
Tsai et al.456 described the immediate free transfer of
Arteriovenous Fistulae
a second toe joint for replacement of an index finger
PIP joint at the time of replantation when other Working in the rabbit ear replantation model,
methods of bony stabilization were unsatisfactory. Nichter et al.463 created an efferent arteriovenous
Nunley et al.457 reported 92% of normal growth fistula by anastomosing a distal artery to a proximal
in epiphyses transferred either by replantation or vein. Heparin in Ringer solution frequently is used to
free tissue transfer. Bowen et al.458,459 presented a flush the vessel ends before and during anastomosis.356
report of the vascularity and feasibility of growth Topical application of lidocaine or papaverine can
plate transfer and noted that both epiphyseal and relieve and sometimes avoid vasospasm during the
metaphyseal circulations must be revascularized to dissection.356
obtain adequate growth and structural integrity. Chen
et al.460 reported performing 29 vascularized toe joint
transfers to hand and finger joints and achieving Nerve Repair or Graft
good results. The outcomes of these joint flaps must Twenty-five years after its publication, the excellent
be compared with arthrodesis and well-functioning review of microneural repair techniques presented by
metallic or Silastic (Dow Corning Corporation, Terzis464 is still valid. Nerve grafting in replantation
Midland, MI) arthroplasties. With some complex surgery is an option when primary approximation is
hand joint injuries, a vascularized toe joint might be still impossible after adequate débridement. Donor
preferred to these other options. nerves can be harvested from other amputated and
non-replanted parts;419 a simple epineural technique
usually is best. If both ends of the nerves being
Vein Grafts sutured are well vascularized, complete reinnervation
Most replantation attempts fail because of venous is expected. Schultes et al.465 compared vascularized
insufficiency. In the absence of venous repair, versus nonvascularized nerve graft transfers in a rat
replantation is successful in fewer than 20% of model and found significant histological differences,
cases.451 The ideal is two or three venous repairs with less fibrosis and myelin degeneration in
per finger, but this might be impossible in cases of vascularized grafts.
distal amputations, amputations in children, injuries
that have severe dorsal components, or post-replant
venous thrombosis. Heparin
Vein grafts are routinely performed when Gordon et al.466 reported a 71% clinical success rate
the vessel ends are short and when tension at the in digital replantation without venous anastomoses
anastomosis is present. Mitchell et al.461 studied by systemic infusion of heparin and removal of the
avulsion injuries in rat limb arteries and veins. As nail plate.
seen through the operating microscope, the damage
to the vessels averaged 0.8 cm from the rupture site,
and serial histological examination revealed marked Leeches
injury for up to 4 cm. Arteries were more severely Multiple reports confirm the usefulness of medicinal
damaged than were veins, especially at bifurcation leeches in salvaging failing flaps or replants.467-473
37
Leeches typically are applied to the area of functional results obtained in their series as ranging
anastomosis to relieve venous congestion in flaps from grade I to grade IV. Patients who achieve grade
or in appendages through vasodilation and vascular I return (34%) are able to resume their original work
decompression.473 The key to the benefit of leeches and have at least 60% range of motion. Patients with
lies with hirudin, a selective thrombin inhibitor that grade IV functional results (4%) have negligible
leeches secrete and inject into the host tissue as they function of their replanted limbs.
feed on the host’s blood.
Matsuda et al.481 reported achieving effective
Anthony et al. used quantitative fluorometry
470
recovery of pinch, grasp, and sensation in 60% of
to study the effects of leeches on a replanted ear. The their replants. Schlenker et al.482 found 2-point
authors noted immediate benefits from leeching, discrimination of <10 mm in only nine of 20
namely evacuation of the pooled blood and relief of replanted thumbs. The average active range of motion
venous congestion. Later, bleeding continued from for the interphalangeal joint was 35% of normal and
the bite sites as a result of the injected hirudin. for the metacarpophalangeal joint was 29%. Most
Prophylactic antibiotics usually are patients were able to return to work after a mean
recommended when leeches are used because of interval of 7 months.
reports of infection with Aeromonas hydrophila,471 The results presented by Tamai451 in a report
which often is insensitive to ampicillin and of 293 upper extremity replants are listed in Table
cephalothin but consistently sensitive to 3. Excellent or good results were achieved in 72%
ciprofloxacin, tetracycline, and trimethoprim- of the cases. Table 4 lists limb survival results after
sulfamethoxazole.472 Oral administration of one of replantation surgery as reported by some major
these drugs is recommended when using leeches. centers.416,419,420,426,482−484
The reader is referred to an article by Valauri473
that describes the technical aspects and clinical
applications of medicinal leeches in microsurgery. Alternatives to Replantation: Salvage Procedures
For failed digital replants and non-replantable
Tissue Expansion injuries, toe-to-hand transplants can restore function.
Leung485 and Frykman et al.486 described the
As described by various authors,474-478 free flaps technique and functional results of these transfers.
can be modified in size and contour by using tissue
expanders before transfer. The field of toe-to-hand transfers continues to
be refined. Williamson et al.487 Yu and Huang,488 and
Chung and Kotsis489 reported achieving adequate
Analysis of Results reconstruction with toe transfers after multiple-finger
loss. The rate of return to work was satisfactory.
There are as many different standards for evaluating
In their review, Wei et al.490 discussed technical
functional recovery after replantation as there are
refinements and donor site considerations. They
reporting surgeons. Gelberman et al.479 correlated
reported excellent functional and aesthetic results.
sensory recovery of replanted parts with arterial pulse
pressure and concluded that two-point discrimination Buncke et al.491 reported their accumulated
reached normal levels (<6 mm) only when pulse experience of 40 years of toe-to-thumb
pressure in the replanted digit was at least 86% of reconstruction. The authors reviewed their technical
normal, as measured by the contralateral digit. Two- refinements and results. Emphasis was placed on low
point discrimination was worse in replanted digits donor site morbidity and excellent functional results.
than in isolated nerve injuries. Wei et al.492 also reported limited sensory
Zhong-Wei et al.480 categorized the various recovery after toe-to-finger transfer, perhaps curtailed
38
TABLE 3
Functional Results after 181* Upper Extremity Replants451
Replant Excellent Good Fair Poor
n % n % n % n %
Arm 0/5 0 1/5 20 3/5 60 1/5 20
Forearm 2/10 20 3/10 30 2/10 20 3/10 30
Hand 3/14 20 6/14 43 3/14 20 2/14 14
Digit 60/152 39 55/152 36 20/152 13 17/152 11
Total 65/181 36 65/181 36 28/181 15 23/181 13

*181 of 293 replants were followed for more than 1 year and are thus included in the table.
TABLE 4
Clinical Results after Replantation
Study Number Complete (% Viable) Number Incomplete (% Viable)
Sixth People’s Hospital, 1975483 320 (54) 53 (57)
Weiland, before 1976416 86 (39) N/A
Weiland, 1976416 50 (90) N/A
Tamai, 1978419 102 (86) 61 (93)
Urbaniak, 1979426 107 (82) 80 (94)
Hamilton et al., 1980484 83 (65) 77 (84)
Kleinert et al., 1980420 243 (49) 347 (70)
Schlenker et al., 1980482 51 (71) 13 (77)
at the outset by the relatively low density of sensory advocated earlier toe-to-hand transfers in cases of
receptors in toe glabrous skin. The authors described non-replantable digit loss. Yim et al.495 compared
their method of pulp reduction (Fig. 21). As outcomes of “primary” toe-to-hand transfers with
determined by patient questionnaire, toe transfers to those of delayed transfers. Primary transfers are
the hand produced minimal lower limb morbidity in defined as those performed during the acute period
a series presented by Chung and Wei.493 Beyaert et or within a mean 7 days after injury. No significant
al.494 noted some disturbance of gait after second toe differences were shown in intraoperative difficulty,
transfer in children. early technical outcome, or early functional results.
To decrease the time of disability, potentially Primary reconstruction seemed to require fewer
ameliorate soft-tissue coverage problems, and secondary procedures, such as tenolysis, but the
facilitate earlier return to work, many surgeons have difference was not statistically significant.
39
be satisfactorily addressed by local flaps or grafts.

Some avulsion and devascularization injuries might
need additional soft-tissue coverage. A 2002 article by
De Lorenzi et al.496 recounted the authors’ experience
with arterialized venous free flaps in such cases. These
flaps, like full-thickness skin grafts, are thin and
supple and can be tailored to precisely fit the defect
and Brunner lines. An insightful discussion and
informative review of arterialized venous flaps was
presented by Brooks.497
Hand Transplant and Composite Tissue Transfer

Transplantation of composite tissue allografts, such as
the hand, offers immense potential in reconstructive
surgery. Experimental studies of limb transplantation
in rodents have shown the efficacy of combination
therapy using multiple immunosuppressants.
By 2002, 14 human hand transplants had been
Figure 21. Toe-to-hand transplantation after traumatic digit performed. A review of the current replantation
loss. A, Pulp reduction was performed at least 9 months literature forecasts significant functional return after
after toe transplantation. Palmar surface of a transplanted hand transplantation, provided patient selection is
digit is shown with the ellipse of skin excised and marked
with a suture before fixation. B, Preparations of sections.
appropriate and allograft rejection can be prevented.37
Oblong piece of tissue was obtained from the distal part of Jones498 updated the status of limb
the pulp reduction specimen, embedded in paraffin, and
allograft transplantation in 2002. In general,
sectioned transverse to the epidermal ridges. Every fifth
section was mounted and stained with Masson trichrome immunosuppression has been well tolerated in
(30 sections per specimen). (Reprinted with permission from human recipients, although considerable risk of
Wei et al.492) posttransplant diabetes and chronic infections still
exists. Transplanted hands show good mechanical
motor function but poor sensory return. Patients
In conclusion, no medical or surgical reason need to be followed for the long term to fully assess
to wait several months for toe-to-hand transfer whether the risk was worth the reward, as many organ
is apparent, particularly when the thumb needs transplants have half-lives shorter than 10 years.
functional reconstruction. On the other hand, the
It needs to be considered whether hand
need for urgency in this setting has yet to be defined.
amputees should put their long-term health at
A person who has just lost a thumb is in a particularly
risk for a hand allograft that might fail long before
vulnerable emotional state, and it would be rash to
the patient’s expected death. Psychological trauma
attach a sense of urgency to what is essentially an
might ensue for a patient who regains use of a hand
elective reconstruction. Some patients might not be
for several years only to lose it again to chronic
psychologically ready for primary toe transfer during
rejection. The prospect for a second allograft
the early posttraumatic period, whereas others might
exists. Considering the long-term potential for
benefit from an earlier return of hand function and
organ failure, opportunistic infection, allograft
no additional hospitalizations.
rejection, and malignancy resulting from long-
It is sometimes the case that the digit is term immunosuppression, the risk:benefit ratio of
replantable but an associated soft-tissue defect cannot hand transplantation must be carefully weighed.
40
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58
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Microsurgery Selected Readings Plastic Surgery

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Volume 11 • Issue R4

Editor-in-Chief Jeffrey M. Kenkel, MD

Editor Emeritus F. E. Barton, Jr, MD

Contributing Editors R. S. Ambay, MD 30 Topics

Corporate Sponsorship Barbara Williams

Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs

Kailash Narasimhan, MD*

James F. Thornton, MD*

*University of Texas Southwestern Medical Center at Dallas,

†Private Practice, San Mateo, California

HISTORY instrumentation and techniques presented by Smith10

Study Experience Success Rate (%)

Serafin, 198025 First 25 cases 72

Godina, 198626 First 100 cases 74

Last 100 cases 96

Harashina, 198827 First 3 years 75

Khouri and Shaw, 198929 First 100 cases 91

Last 100 cases 97

Canales et al., 199128 First 3 years 83

Selber et al., 201230 Review of nearly 5,000 cases (4,965) 99

Holom et al., 201331 Review 143 head and neck cases 92

Tissue Warm (h) Cold (h)

Skin and subcutaneous tissue115 4−6 ≤10

containing surfaces to which platelets adhere.131 If Magnification

Skin, Fascia, and Perforator Flaps

frequency. Perforator variants are being derived from

Chevray323 compared SIEA and DIEP flaps

Muscle and Musculocutaneous Free Flaps

C Figure 11. A, Diabetic, cellulitic foot

the part. Histologically, muscle fibers that are not

Berggren et al.374 compared medullary and

Figure 17. Illustration shows that

Figure 18. Illustration shows

Figure 19. Patient is a 42-year-

tissue options and the need for laparotomy to harvest

extremity,430 scalp,431-434 ear,435-439 penis,440,441 testes,441 Operative Technique

Replant Excellent Good Fair Poor

Arm 0/5 0 1/5 20 3/5 60 1/5 20

Forearm 2/10 20 3/10 30 2/10 20 3/10 30

Hand 3/14 20 6/14 43 3/14 20 2/14 14

Digit 60/152 39 55/152 36 20/152 13 17/152 11

Total 65/181 36 65/181 36 28/181 15 23/181 13

Sixth People’s Hospital, 1975483 320 (54) 53 (57)

Weiland, before 1976416 86 (39) N/A

Weiland, 1976416 50 (90) N/A

Tamai, 1978419 102 (86) 61 (93)

Urbaniak, 1979426 107 (82) 80 (94)

Hamilton et al., 1980484 83 (65) 77 (84)

Kleinert et al., 1980420 243 (49) 347 (70)

Schlenker et al., 1980482 51 (71) 13 (77)

be satisfactorily addressed by local flaps or grafts.

Hand Transplant and Composite Tissue Transfer

REFERENCES rabbit utilising microminiature vascular anastomoses. Br J

findings in replanted rat hind limbs using various 1978;5:195–209.

Now Indexed in MEDLINE!

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