Advanced Microcirculatory Parameters of Lower Extremity Free Flaps during Dangling and Their Influencing Factors

Jonas Kolbenschlag; Pascal Bredenbroeker; Marcus Lehnhardt; Adrien Daigeler; Sebastian Fischer; Kamran Harati; Andrej Ring; Ole Goertz

doi:10.1055/s-0035-1554940

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2015; 31(07): 500-507
DOI: 10.1055/s-0035-1554940

Original Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Advanced Microcirculatory Parameters of Lower Extremity Free Flaps during Dangling and Their Influencing Factors

Authors

Jonas Kolbenschlag

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Pascal Bredenbroeker

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Marcus Lehnhardt

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Adrien Daigeler

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Sebastian Fischer

²Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
Kamran Harati

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Andrej Ring

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany
Ole Goertz

¹Department of Plastic Surgery, Burn Center, Sarcoma Center, BG University Hospital, Ruhr University, Bochum, Germany

Abstract

Background Dangling of the leg to habituate a free flap to the lower extremity is common practice. However, little is known about the microcirculatory changes in free flaps and the influence of comorbidities.

Methods Tissue oxygen saturation (StO₂) and hemoglobin content (tissue hemoglobin index [THI]) of 39 lower extremity free flaps was measured during dangling on postoperative days (PODs) 6 to 9. We assessed the maximal desaturation during dangling and re-elevation and the maximal increase in THI as well as the time required to reach a stable plateau during dangling, among others.

Results All parameters showed significant changes during dangling (desaturation during dangling: 0.23 ± 10.7 vs. − 4.66 ± 12.6%, p = 0.001 for POD 6 vs. 7; further desaturation after re-elevation: − 11.1 ± 7.4 versus − 14.5 ± 7.8%, p = 0.001 for POD 6 vs. 9; THI increase during dangling: from 3.4 ± 1.6 to 4.2 ± 1.8 AU, p = 0.008, time to THI plateau: 1.7 ± 1.2 vs. 2.5 ± 1.7 minutes, p = 0.004 for POD 6 vs. 7). Age, gender, and smoking did not influence the mentioned parameters. Nondiabetic patients showed a significant increase of baseline StO₂, whereas diabetic patients did not (p = 0.009 vs. 0.11). For THI, both diabetic and hypertensive patients showed a lower increase in THI on the first day of dangling (p = 0.056; p = 0.009) and significantly lower baseline values on the last day (0.046 for both).

Conclusion Duration of dependency seems to have the greatest impact on microcirculation during dangling, although comorbidities may interfere with the adaptive processes. An earlier start of dangling could safely be applied in most patients. Special care needs to be taken in diabetic and hypertensive patients.

Keywords

free flap - dangling - lower extremity - reconstruction - microcirculation

Full Text

References

References
1 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109 (7) 2219-2226 , discussion 2227–2230
2 Kolbenschlag J, Hellmich S, Germann G, Megerle K. Free tissue transfer in patients with severe peripheral arterial disease: functional outcome in reconstruction of chronic lower extremity defects. J Reconstr Microsurg 2013; 29 (9) 607-614
3 Jokuszies A, Neubert N, Herold C, Vogt PM. Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome. J Reconstr Microsurg 2013; 29 (1) 27-32
4 Kolbenschlag J, Bredenbroeker P, Daigeler A , et al. Changes of oxygenation and hemoglobin-concentration in lower extremity free flaps during dangling. J Reconstr Microsurg 2014; 30 (5) 319-328
5 Ridgway EB, Kutz RH, Cooper JS, Guo L. New insight into an old paradigm: wrapping and dangling with lower-extremity free flaps. J Reconstr Microsurg 2010; 26 (8) 559-566
6 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008; 61 (3) 280-284
7 Rohde C, Howell BW, Buncke GM , et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg 2009; 25 (1) 15-19
8 Keller A. Noninvasive tissue oximetry for flap monitoring: an initial study. J Reconstr Microsurg 2007; 23 (4) 189-197
9 Keller A. A new diagnostic algorithm for early prediction of vascular compromise in 208 microsurgical flaps using tissue oxygen saturation measurements. Ann Plast Surg 2009; 62 (5) 538-543
10 Lin SJ, Nguyen MD, Chen C , et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (3) 1080-1085
11 Thorniley MS, Sinclair JS, Barnett NJ, Shurey CB, Green CJ. The use of near-infrared spectroscopy for assessing flap viability during reconstructive surgery. Br J Plast Surg 1998; 51 (3) 218-226
12 Vargas CR, Nguyen JT, Ashitate Y , et al. Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: A pilot study in a porcine model. Microsurgery 2015;
13 Goertz O, Kapalschinski N, Skorzinski T , et al. Wound healing complications in smokers, non-smokers and after abstinence from smoking [in German]. Chirurg 2012; 83 (7) 652-656
14 Rahmanian-Schwarz A, Gonser P, Willkomm L , et al. Dermal perfusion of common donor sites free flaps in chronic smokers and nonsmokers. Eplasty 2011; 11: e52
15 Schiffrin EL. Remodeling of resistance arteries in essential hypertension and effects of antihypertensive treatment. Am J Hypertens 2004; 17 (12, Pt 1) 1192-1200
16 Rosado P, Cheng HT, Wu CM, Wei FC. Influence of diabetes mellitus on postoperative complications and failure in head and neck free flap reconstruction: A systematic review and meta-analysis. Head Neck 2015; 37 (4) 615-618
17 Liu Z, Tian Z, Zhang C, Sun J, Zhang Z, He Y. Microvascular reconstruction in elderly oral cancer patients: does diabetes status have a predictive role in free flap complications?. J Oral Maxillofac Surg 2015; 73 (2) 357-369