Evaluation von Sekundäreingriffen nach mikrochirurgischer Lappentransplantation zur Rekonstruktion der oberen Extremität

Zusammenfassung

Hintergrund Das primäre ästhetische und funktionelle Ergebnis nach freiem Gewebetransfer zur oberen Extremität kann suboptimal ausfallen und Folgeoperationen notwendig machen. Diese Studie soll erstmalig Art und Anzahl von Sekundäreingriffen evaluieren und prädiktive Faktoren hierfür identifizieren.

Patienten und Methoden Patienten, die im Zeitraum 2010–2017 eine freie Lappenplastik zur oberen Extremität erhielten, wurden in eine retrospektive Kohortenstudie eingeschlossen: Patienten mit einem oder mehreren Sekundäreingriffen zur Optimierung des funktionellen oder ästhetischen Lappendesigns (S-Kohorte) und Patienten ohne Sekundäreingriff, welche als Kontrolle (K-Kohorte) dienten. Prädiktoren für Sekundäreingriffe wurden mittels multivariater logistischer Regressionsanalyse identifiziert.

Ergebnisse Es konnten 128 Patienten eingeschlossen werden (S-Kohorte 36, K-Kohorte 92). Insgesamt erfolgten 56 Sekundäroperationen nach durchschnittlich 8 Monaten. Die S-Kohorte wies vermehrt Defekte an der Hand (53 %) auf und es erfolgte mehrheitlich eine Rekonstruktion mittels Faszio- bzw. Adipokutanlappen (89 %). Die häufigsten Sekundäreingriffe stellten die chirurgische Dermolipektomie/Teilexzision (61 %), gefolgt von der Liposuktion (16 %) und einer Kombination beider Eingriffe (17 %) dar. Zusätzlich erfolgten bei 64 % der Patienten aus der S-Kohorte im Rahmen der formverändernden Sekundäreingriffe weitere operative Interventionen zur Funktionsoptimierung. Patienten mit einer Defektlokalisation an der Hand erhielten 2,4-fach häufiger Sekundäroperationen (p = 0,05). Darüber hinaus war die Wahrscheinlichkeit für eine Korrekturoperation bei gutem Allgemeinzustand (ASA1/2) um das 6-Fache erhöht (p = 0,03).

Schlussfolgerung Sekundäreingriffe stellen häufige und sichere Verfahren dar, die häufig von Patienten in gutem Allgemeinzustand mit einer Defektrekonstruktion mittels freier Lappenplastik an der Hand gewünscht werden. Wir empfehlen daher die Implementierung von Sekundäreingriffen in den rekonstruktiven Plan, um die Patienten-Compliance und Zufriedenheit zu steigern.

Abstract

Background The primary cosmetic and functional outcome following successful upper limb salvage using free tissue transfer can often be unfavourable, which may motivate patients to undergo secondary procedures. In this study, we sought to identify predictors for secondary procedures and to analyse the type and number of these procedures.

Patients and methods Patients who underwent free tissue transfer to the upper extremity between 2010 and 2017 were included in a retrospective cohort study: patients with secondary procedures to optimise the functional and aesthetic flap design (S cohort) vs. control cohort (C cohort). A multivariate regression analysis was used to identify predictors for secondary procedures.

Results One hundred and twenty-eight patients were included in the study (S cohort 36, C cohort 92). All in all, 56 secondary refinement procedures were performed in a mean of eight months after the initial free flap reconstruction. Most of the defects in the S cohort were localised at the hand (53 %), and upper limb salvage was mostly accomplished by fasciocutaneous and adipocutaneous free flaps (S cohort 89 %). The most frequently performed secondary refinement procedures were direct partial flap excision (61 %), followed by liposuction (16 %) and the combination of both (17 %). Furthermore, 64 % of the secondary refinement procedures from the S cohort were combined with further surgical interventions to improve hand function, e. g. tenolysis and arthrolysis. Patients with defects of the hand received secondary procedures 2.4 times more frequently (p = 0.05). Also, patients with a good general health condition (ASA 1 and 2) were six times more likely to undergo a secondary procedure (p = 0.03).

Conclusion Secondary procedures are safe and frequently requested by patients following successful free flap upper limb salvage. In particular, this applies to patients who are in a good health condition and with free flaps to the hand. Therefore, we recommend the implementation of secondary refinement procedures in the reconstructive plan to increase patient compliance and satisfaction.

Schlüsselwörter

Freie Lappenplastiken - freier Gewebetransfer - obere Extremität - Sekundäreingriff - Sekundäroperation

Key words

Free flap - free tissue transfer - secondary procedure - refinement procedure

Publication History

Received: 03 August 2020

Accepted: 14 October 2020

Article published online:
13 April 2021

• Literatur

• 1 Gupta A, Lakhiani C, Lim BH. et al. Free tissue transfer to the traumatized upper extremity: Risk factors for postoperative complications in 282 cases. J Plast Reconstr Aesthet Surg 2015; 68: 1184-1190
• 2 Kremer T, Bickert B, Germann G. et al. Outcome assessment after reconstruction of complex defects of the forearm and hand with osteocutaneous free flaps. Plast Reconstr Surg 2006; 118: 443-454 discussion 455–446
• 3 Sauerbier M, Ofer N, Germann G. et al. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007; 119: 605-615
• 4 Zhang Y, Gazyakan E, Bigdeli AK. et al. Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety. Microsurgery 2019; 39: 463-475
• 5 Kaempfen A, Daigeler A, Largo RD. et al. Report of the consensus workshop on microsurgical training at the 32nd annual meeting of the german-speaking group for microsurgery of the peripheral nerves and vessels in Basel 2010. Handchir Mikrochir Plast Chir 2011; 43: 262-265
• 6 Rehim SA, Kowalski E, Chung KC. Enhancing aesthetic outcomes of soft-tissue coverage of the hand. Plast Reconstr Surg 2015; 135: 413e-428e
• 7 Rumsey N, Harcourt D. Body image and disfigurement: issues and interventions. Body Image 2004; 1: 83-97
• 8 Kovacs L, Grob M, Zimmermann A. et al. Quality of life after severe hand injury. J Plast Reconstr Aesthet Surg 2011; 64: 1495-1502
• 9 Chung KC, Kotsis SV, Kim HM. et al. Reasons why rheumatoid arthritis patients seek surgical treatment for hand deformities. J Hand Surg Am 2006; 31: 289-294
• 10 Neumeister M, Hegge T, Amalfi A. et al. The reconstruction of the mutilated hand. Semin Plast Surg 2010; 24: 77-102
• 11 Parrett BM, Bou-Merhi JS, Buntic RF. et al. Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity. Plast Reconstr Surg 2010; 126: 1630-1638
• 12 Nasir S, Aydin MA. Upper extremity reconstruction using free SCIA/SIEA flap. Microsurgery 2010; 30: 37-42
• 13 Enajat M, Smit JM, Rozen WM. et al. Aesthetic refinements and reoperative procedures following 370 consecutive DIEP and SIEA flap breast reconstructions: important considerations for patient consent. Aesthetic Plast Surg 2010; 34: 306-312
• 14 Oni G, Saint-Cyr M, Maia M. et al. Dermolipectomy of the lateral thoracic fat compartment in secondary breast reconstruction revision: Anatomical and clinical results. J Plast Reconstr Aesthet Surg 2012; 65: 201-206
• 15 Gundeslioglu AO, Selimoglu N, Toy H. et al. Neo-vascularisation of musculocutaneous and muscle flaps after division of the major vascular supply: an experimental study. J Plast Reconstr Aesthet Surg 2013; 66: 978-986
• 16 Yoon AP, Jones NF. Critical time for neovascularization/angiogenesis to allow free flap survival after delayed postoperative anastomotic compromise without surgical intervention: A review of the literature. Microsurgery 2016; 36: 604-612
• 17 Hui-Chou HG, Sulek J, Bluebond-Langner R. et al. Secondary refinements of free perforator flaps for lower extremity reconstruction. Plast Reconstr Surg 2011; 127: 248-257
• 18 Kotsougiani D, Platte J, Bigdeli AK. et al. Evaluation of 389 patients following free-flap lower extremity reconstruction with respect to secondary refinement procedures. Microsurgery 2018; 38: 242-250
• 19 Hong JP, Choi DH, Suh H. et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30: 491-496
• 20 Yildirim S, Taylan G, Eker G. et al. Free flap choice for soft tissue reconstruction of the severely damaged upper extremity. J Reconstr Microsurg 2006; 22: 599-609
• 21 Nasir S, Baykal B, Altuntas S. et al. Hemodynamic differences in blood flow between free skin and muscles flaps: prospective study. J Reconstr Microsurg 2009; 25: 355-360
• 22 Paro J, Chiou G, Sen SK. Comparing Muscle and Fasciocutaneous Free Flaps in Lower Extremity Reconstruction – Does It Matter?. Ann Plast Surg 2016; 76 Suppl 3 S213-215
• 23 Kim JT, Kim SW, Youn S. et al. What Is the Ideal Free Flap for Soft Tissue Reconstruction?. A Ten-Year Experience of Microsurgical Reconstruction Using 334 Latissimus Dorsi Flaps From a Universal Donor Site. Ann Plast Surg 2015; 75: 49-54
• 24 Kauhanen MS, Salmi AM, von Boguslawsky EK. et al. Muscle fiber diameter and muscle type distribution following free microvascular muscle transfers: a prospective study. Microsurgery 1998; 18: 137-144