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

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