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J Reconstr Microsurg 2012; 28(04): 267-272
DOI: 10.1055/s-0032-1311681
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Viability of the Skin Paddle Does Not Predict the Functional Outcome in Free Muscle Transfers with a Second Ischemic Event: A Report of Three Cases

Chaitanya Dodakundi
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Kazuteru Doi
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Yasunori Hattori
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Soutetsu Sakamoto
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Yuki Fujihara
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Takehiko Takagi
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
,
Makoto Fukuda
1   Department of Orthopedic Surgery, Ogori Daiichi General Hospital, Yamaguchi, Japan
› Author Affiliations
Further Information

Publication History

17 July 2011

22 December 2011

Publication Date:
10 April 2012 (online)

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Abstract

Conventional skin flap monitoring is one of the widely used methods to assess postoperative circulation in innervated free muscle transfer (IFMT). However, following reexploration for vascular compromise and reestablishing circulation, functional recovery of the muscle despite surviving skin flap is not clear. The purpose of this article is to report three such cases and determine the reliability of viable skin flap in an IFMT with a second ischemic event. Long-term functional results were assessed in terms of reinnervation time, elbow range of motion, strength of elbow flexion, finger function in terms of total active motion, and power lifting with hook grip. These IFMTs developed complete or partial necrosis of the muscle and could not obtain satisfactory function. The conventional monitoring of the skin flap did not promptly reflect vascularity of IFMT, and a surviving skin flap after reexploration for compromised vascularity does not guarantee complete survival of the muscle. There is a need for earlier and rapid detection of vascular compromise in IFMTs.

Keywords

free muscle transfer - vascular compromise - reexploration
 

  • References

  • 1 Doi K, Sakai K, Ihara K, Abe Y, Kawai S, Kurafuji Y. Reinnervated free muscle transplantation for extremity reconstruction. Plast Reconstr Surg 1993; 91: 872-883
    CrossrefPubMedGoogle Scholar
  • 2 Chuang DC, Hattori Y, Ma And HS, Chen HC. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy. Plast Reconstr Surg 2002; 109: 116-126 ; discussion 127–129
    CrossrefPubMedGoogle Scholar
  • 3 Bishop AT. Functioning free-muscle transfer for brachial plexus injury. Hand Clin 2005; 21: 91-102
    CrossrefPubMedGoogle Scholar
  • 4 Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg 2005; 13: 382-396
    CrossrefPubMedGoogle Scholar
  • 5 Manktelow RT, Anastakis DJ. Free functioning muscle transfers. In: Green D, Hotchkis RN, Pederson WC, Wolfe SW, eds. Green's Operative Hand Surgery. 5th ed. Philadelphia: 2005: 1757-1776
    Google Scholar
  • 6 Smit JM, Zeebregts CJ, Acosta R, Werker PM. Advancements in free flap monitoring in the last decade: a critical review. Plast Reconstr Surg 2010; 125: 177-185
    CrossrefPubMedGoogle Scholar
  • 7 Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg 2009; 124 (6, Suppl) e295-e302
    CrossrefPubMedGoogle Scholar
  • 8 Kerrigan CL, Daniel RK. Critical ischemia time and the failing skin flap. Plast Reconstr Surg 1982; 69: 986-989
    CrossrefPubMedGoogle Scholar
  • 9 Picard-Ami Jr LA, Thomson JG, Kerrigan CL. Critical ischemia times and survival patterns of experimental pig flaps. Plast Reconstr Surg 1990; 86: 739-743 ; discussion 744–745
    CrossrefPubMedGoogle Scholar
  • 10 Willms-Kretschmer K, Majno G. Ischemia of the skin. Electron microscopic study of vascular injury. Am J Pathol 1969; 54: 327-353
    PubMedGoogle Scholar
  • 11 Selye H. Ischemic necrosis: prevention by stress. Science 1967; 156: 1262-1263
    CrossrefPubMedGoogle Scholar
  • 12 May Jr JW, Chait LA, O'Brien BM, Hurley JV. The no-reflow phenomenon in experimental free flaps. Plast Reconstr Surg 1978; 61: 256-267
    CrossrefPubMedGoogle Scholar
  • 13 Allen BS, Okamoto F, Buckberg GD , et al. Immediate functional recovery after six hours of regional ischemia by careful control of conditions of reperfusion and composition of reperfusate. J Thorac Cardiovasc Surg 1986; 92 (3 Pt 2) 621-635
    PubMedGoogle Scholar
  • 14 Harman JW. A histological study of skeletal muscle in acute ischemia. Am J Pathol 1947; 23: 551-565
    PubMedGoogle Scholar
  • 15 Harman JW, Gwinn RP. The recovery of skeletal muscle fibers from acute ischemia as determined by histologic and chemical methods. Am J Pathol 1949; 25: 741-755
    PubMedGoogle Scholar
  • 16 Adams JE, Kircher MF, Spinner RJ, Torchia ME, Bishop AT, Shin AY. Complications and outcomes of functional free gracilis transfer in brachial plexus palsy. Acta Orthop Belg 2009; 75: 8-13
    PubMedGoogle Scholar
  • 17 Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Double free-muscle transfer to restore prehension following complete brachial plexus avulsion. J Hand Surg Am 1995; 20: 408-414
    CrossrefPubMedGoogle Scholar
  • 18 Doi K, Muramatsu K, Hattori Y , et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am 2000; 82: 652-666
    CrossrefPubMedGoogle Scholar
  • 19 Chen KT, Mardini S, Chuang DC , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120: 187-195
    CrossrefPubMedGoogle Scholar
  • 20 Gabriel A, Chaney N, Stephenson LL, Zamboni WA. Effect of total venous occlusion on capillary flow and necrosis in skeletal muscle. Plast Reconstr Surg 2001; 108: 430-433
    CrossrefPubMedGoogle Scholar
  • 21 Hölzle F, Loeffelbein DJ, Nolte D, Wolff KD. Free flap monitoring using simultaneous non-invasive laser Doppler flowmetry and tissue spectrophotometry. J Craniomaxillofac Surg 2006; 34: 25-33
    PubMedGoogle Scholar
  • 22 Smit JM, Werker PM, Liss AG , et al. Introduction of the implantable Doppler system did not lead to an increased salvage rate of compromised flaps: a multivariate analysis. Plast Reconstr Surg 2010; 125: 1710-1717
    CrossrefPubMedGoogle Scholar
  • 23 Swartz WM, Jones NF, Cherup L, Klein A. Direct monitoring of microvascular anastomoses with the 20-MHz ultrasonic Doppler probe: an experimental and clinical study. Plast Reconstr Surg 1988; 81: 149-161
    CrossrefPubMedGoogle Scholar
  • 24 Swartz WM, Izquierdo R, Miller MJ. Implantable venous Doppler microvascular monitoring: laboratory investigation and clinical results. Plast Reconstr Surg 1994; 93: 152-163
    CrossrefPubMedGoogle Scholar
  • 25 Whitaker IS, Smit JM, Acosta R. A simple method of implantable Doppler cuff attachment: experience in 150 DIEP breast reconstructions. J Plast Reconstr Aesthet Surg 2008; 61: 1251-1252
    CrossrefPubMedGoogle Scholar
  • 26 Oliver DW, Whitaker IS, Giele H, Critchley P, Cassell O. The Cook-Swartz venous Doppler probe for the post-operative monitoring of free tissue transfers in the United Kingdom: a preliminary report. Br J Plast Surg 2005; 58: 366-370
    CrossrefPubMedGoogle Scholar
  • 27 Bill TJ, Foresman PA, Rodeheaver GT, Drake DB. Fibrin sealant: a novel method of fixation for an implantable ultrasonic microDoppler probe. J Reconstr Microsurg 2001; 17: 257-262
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Serafin D, Shearin JC, Georgiade NG. The vascularization of free flaps: a clinical and experimental correlation. Plast Reconstr Surg 1977; 60: 233-241
    CrossrefPubMedGoogle Scholar
  • 29 Salgado CJ, Smith A, Kim S , et al. Effects of late loss of arterial inflow on free flap survival. J Reconstr Microsurg 2002; 18: 579-584
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Hoopes JE. Pedicle flaps: an overview. In: Krizek TJ, Hoopes JE. eds. Symposium on Basic Science in Plastic Surgery. Vol. 15. St. Louis, MO: Mosby; 1976: 241-259
    Google Scholar
  • 31 Black MJM, Chait L, O'Brien BM, Sykes PJ, Sharzer LA. How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs. Br J Plast Surg 1978; 31: 295-299
    CrossrefPubMedGoogle Scholar
  • 32 Fasching MC, Van Beek AL. Monitoring muscle viability using evoked M waves. Plast Reconstr Surg 1985; 75: 217-222
    CrossrefPubMedGoogle Scholar