Postoperatives Monitoring freier Muskellappenplastiken mittels perforatorbasierten adipokutanen Monitorinseln: Ökonomie, Versorgungsqualität und Ästhetik

Zusammenfassung

Hintergrund Freie Muskellappenplastiken zur Rekonstruktion großer Weichteildefekte sind neben fasziokutanen Lappenplastiken etablierte mikrochirurgische Standardverfahren. Diese werden häufig mit adipokutanen Monitorinseln zur Durchblutungskontrolle geplant. In unserer Klinik werden sowohl konventionelle, breitbasig aufsitzende adipokutane Monitorinseln (random pattern), als auch perforatorbasierte Monitorinseln verwendet. Während konventionelle Monitorinseln in einer zweiten Operation abgetragen werden müssen und der verbliebene Defekt mit Spalthauttransplantaten versorgt werden muss, können perforatorbasierte Monitorinseln am Patientenbett mittels einfacher Ligatur entfernt werden. In der vorliegenden Studie sollen ökonomische, versorgungsqualitative und ästhetische Aspekte perforatorbasierter versus herkömmlicher adipokutaner Monitorinseln nach freiem Muskellappentransfer verglichen werden.

Patienten und Methoden Im Zeitraum von August 2014 bis Juli 2016 konnten anhand einer retrospektiven Datenanalyse 102 geeignete Patienten identifiziert werden. Patienten mit perforatorbasierter Monitorinsel (Gruppe A) wurden einem Kollektiv von Patienten mit breitbasig aufsitzender Monitorinsel (Gruppe B) gegenübergestellt. Patientencharakteristika, Operationszeiten, ökonomische Daten und ästhetische Ergebnisse wurden zwischen den Gruppen verglichen.

Ergebnisse Bei 72 Patienten wurden perforatorbasierte (Gruppe A, 71 %), bei 30 Patienten konventionelle (Gruppe B, 29 %) Monitorinseln gehoben. Patienten-, Defekt- und Lappencharakteristika waren in beiden Gruppen vergleichbar. Operations- und Säulenzeit waren in Gruppe B tendenziell kürzer, jedoch ohne statistische Signifikanz zu erreichen (p = 0,35; p = 0,28). Die Entfernung der Monitorinsel in Gruppe A erfolgte signifikant früher (p < 0,01). Sowohl die gesamtstationäre als auch die postrekonstruktive Verweildauer waren in Gruppe A signifikant kürzer (p = 0,03; p < 0,01). Personelle und materielle Ressourcen konnten in Gruppe A geschont und ein ästhetisch ansprechenderes Ergebnis erzielt werden.

Schlussfolgerung Mit perforatorbasierten Monitorinseln kann eine zweite Operation zur Monitorinselabtragung und Hauttransplantation vermieden werden. Hierdurch kann eine Reduktion der stationären Verweildauern mit Schonung der materiellen und personellen Ressourcen erreicht werden.

Abstract

Introduction Besides fasciocutaneous workhorse flaps, free muscle flaps for the reconstruction of large soft tissue defects are well-established standard microsurgical procedures. Random-pattern adipocutaneous skin paddles are often included for postoperative perfusion monitoring of the muscle flap. At our institution, both conventional broad-based and perforator-based adipocutaneous skin paddles are used. While conventional skin paddles have to be removed during a second operation, perforator-based skin paddles can be removed at the bedside by ligature. The present study aims to compare economic aspects, quality of care and aesthetic results of perforator-based versus conventional adipocutaneous skin paddles after free muscle flap transfer.

Methods 102 patients treated between August 2014 and July 2016 were identified and included in a retrospective data analysis. Patients with perforator-based skin paddles (group A) were compared with a population of patients with conventional skin paddles (group B). Patient characteristics, procedural characteristics, economic data and aesthetic results were compared between both groups.

Results Perforator-based skin paddles were raised in 72 patients (group A, 71 %), and conventional skin paddles were raised in the remaining 30 patients (group B, 29 %). Patient, defect, and flap characteristics were comparable in both groups. Operating times tended to be shorter in group B. Skin paddle removal was performed significantly earlier in group A (p < 0.01). Both overall and post-reconstructive length of hospital stay were significantly shorter in group A (p = 0.03; p < 0.01). Also, personnel and material resources were saved and more satisfactory aesthetic results were achieved in group A.

Conclusion Perforator-based monitor islands can help avoid secondary operations that would otherwise be necessary to remove monitoring skin paddles. Thus, the inpatient length of stay can be reduced while sparing material and human resources.

Schlüsselwörter

Freie Muskellappenplastik - Monitorinsel - Hautinsel - mikrochirurgisches Lappenmonitoring - Lappenperfusion

Key words

Free muscle flap - skin paddle - free flap monitoring - flap perfusion

• Literatur

• 1 Gorschlüter P. Versorgungssicherung unter DRG-Bedingungen. Trauma Berufskrankheiten 2004; 6: 321-323
• 2 Vetter SY, Studier-Fischer S, Wentzensen A. et al. [The challenge of auditing by medical health insurance inspectors: development of individual case inspections according to 275ff SGB V]. Unfallchirurg 2009; 112 (08) 756-758
• 3 Kroll SS, Schusterman MA, Reece GP. et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plastic and reconstructive surgery 1996; 98 (07) 1230-1233
• 4 Hirigoyen MB, Urken ML, Weinberg H. Free flap monitoring: a review of current practice. Microsurgery 1995; 16 (11) 723-726 discussion 727
• 5 Kohlert S, Quimby AE, Saman M. et al. Postoperative Free-Flap Monitoring Techniques. Semin Plast Surg 2019; 33 (01) 13-16
• 6 Tsuzuki K, Yanai A, Bandoh Y. A contrivance for monitoring skin flaps with a Doppler flowmeter. J Reconstr Microsurg 1990; 6 (04) 363-366
• 7 Concannon MJ, Stewart DH, Welsh CF. et al. Impedance plethysmography: a new method for continuous muscle perfusion monitoring. Plastic and reconstructive surgery 1991; 88 (02) 292-298
• 8 Graham BH, Gordon L, Alpert BS. et al. Serial quantitative skin surface fluorescence: a new method for postoperative monitoring of vascular perfusion in revascularized digits. The Journal of hand surgery 1985; 10 (02) 226-230
• 9 Graham B, Paulus DA, Caffee HH. Pulse oximetry for vascular monitoring in upper extremity replantation surgery. The Journal of hand surgery 1986; 11 (05) 687-692
• 10 Jenkins SD, Sepka RS, Barwick WJ. et al. Routine clinical use of laser Doppler flowmeter to monitor free tissue transfer: preliminary results. J Reconstr Microsurg 1987; 3 (04) 281-283
• 11 Scheker LR, Slattery PG, Firrell JC. et al. The value of the photoplethysmograph in monitoring skin closure in microsurgery. J Reconstr Microsurg 1985; 2 (01) 1-5
• 12 Doyle DJ, Eng P. A microminiature photoplethysmograph probe for microvascular surgery. Microsurgery 1984; 5 (02) 105-106
• 13 Sudarsky LA, Salomon J. Liquid crystal temperature monitoring for microsurgery. J Reconstr Microsurg 1991; 7 (01) 13-14
• 14 Raskin DJ, Erk Y, Spira M. et al. Tissue pH monitoring in microsurgery: a preliminary evaluation of continuous tissue pH monitoring as an indicator of perfusion disturbances in microvascular free flaps. Ann Plast Surg 1983; 11 (04) 331-339
• 15 Serafin D, Lesesne CB, Mullen RY. et al. Transcutaneous PO2 monitoring for assessing viability and predicting survival of skin flaps: experimental and clinical correlations. J Microsurg 1981; 2 (03) 165-178
• 16 Smith AR, Sonneveld GJ, Kort WJ. et al. Clinical application of transcutaneous oxygen measurements in replantation surgery and free tissue transfer. The Journal of hand surgery 1983; 8 (02) 139-145
• 17 Davison PM, Batchelor AG, Wilson GR. et al. The muscle twitch monitor: a rapid unequivocal method of monitoring free muscle transfers. Br J Plast Surg 1986; 39 (03) 356-360
• 18 Aygit AC, Sarikaya A. Technetium 99 m sestamibi scintigraphy for noninvasive assessment of muscle flap viability. Ann Plast Surg 1999; 43 (03) 338-340
• 19 Lenz Y, Gross R, Penna V. et al. Evaluation of the Implantable Doppler Probe for Free Flap Monitoring in Lower Limb Reconstruction. J Reconstr Microsurg 2018; 34 (03) 218-226
• 20 Walkinshaw M, Holloway A, Bulkley A. et al. Clinical evaluation of laser Doppler blood flow measurements in free flaps. Ann Plast Surg 1987; 18 (03) 212-217
• 21 Cervenka B, Bewley AF. Free flap monitoring: a review of the recent literature. Curr Opin Otolaryngol Head Neck Surg 2015; 23 (05) 393-398
• 22 Dat AD, Loh IW, Bruscino-Raiola F. Free-flap salvage: muscle only versus skin paddle – an Australian experience. ANZ journal of surgery 2017; 87 (12) 1040-1043
• 23 Park SO, Son Y, Kim IK. et al. Effectiveness of small monitoring skin paddle in free muscle flap for scalp reconstruction. Head Neck 2018; 40: 2399-2408
• 24 Beier JP, Horch RE, Dragu A. et al. Perforator-based monitoring skin islands in free muscle flaps: teaching old dogs new tricks. Plastic and reconstructive surgery 2012; 129 (03) 586e-587e
• 25 Nagel SS, Thomas B, Fischer S. et al. Random-pattern versus perforator-based adipocutaneous skin paddles for postoperative monitoring of free muscle flaps-a comparative retrospective cohort study. J Plast Reconstr Aesthet Surg 2020; 74: 747-754
• 26 Charlson ME, Pompei P, Ales KL. et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (05) 373-383
• 27 Thomas B, Warszawski J, Falkner F. et al. A comparative study of preoperative color-coded Duplex ultrasonography versus handheld audible Dopplers in ALT flap planning. Microsurgery 2020; 40: 561-567
• 28 Vonlanthen R, Lodge P, Barkun JS. et al. Toward a Consensus on Centralization in Surgery. Ann Surg 2018; 268 (05) 712-724