Floor plan - 2013 Annual Meeting - American Association for Hand ...

A Reconstruction Algorithm to Encounter No Sizable Skin Perforator during Anterolateral
Thigh Flap Dissection
Institution where the work was prepared: Chang Gung Memorial Hospital - Kaohsiung Medical Center, Kaohsiung, Taiwan
Ching-Hua Hsieh, MD1; Seng -Feng Jeng, MD2; Yur-Ren Kuo, MD, PhD, FACS3; Pao-Yuan Lin, MD1; Johnson C. Yang,
MD4; (1)Chang Gung Memorial Hospital in Kaohsiung, (2)Chang Gung Memorial Hospital - Kaohsiung Medical Center,
Chang Gung University, (3)Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University,
(4)Chang Gung Memorial Hospital at Kaohsiung
PURPOSE:
The free anterolateral thigh (ALT) flap is becoming the preferred option for soft-tissue reconstruction in most clinical situations. If no sizable
skin perforators are found or if they are inadvertently divided during flap dissection in the ALT region, we propose a reconstruction
algorithm with modified options to facilitate a successful reconstruction.
MATERIALS & METHODS:
A Doppler flowmeter was used preoperatively to detect the location of the perforator. After incision being made down to the deep fascia,
the perforator to the skin was visualized first to determine which perforator was preferred for skin perfusion. If there was no sizable
skin perforator at all, the reconstruction algorithm was followed in this order: 1. More proximal exposure of the lateral circumflex femoral
artery system to harvest a tensor fascia lata flap. 2. Detection of a promising skin vessel medial to the incision with audible Doppler, and
proceeded dissection in a medial direction to elevate an anteromedial thigh flap. 3. Elevation of a free vastus lateralis muscle with coverage
of full-thickness skin graft (FTSG) harvested from ALT skin portion. 4. Abandon the donor site and sought for another donor region.
RESULTS:
Between August of 1995 and December of 2006, 923 patients received ALT flaps elevation at Chang Gung Memorial Hospital in
Kaohsiung. There were ten patients had no any adequate skin perforator in the ALT region during the initial dissection. There were three
patients, who had no perforator in one thigh, received dissection in contralateral thigh but still had no any sizable perforator for reconstruction.
In total, four patients received reconstruction with a free tensor fascia lata flap, three with an anteromedial thigh flap, two with
a free muscle flap and FTSG, and one with a radial forearm flap. There was one postoperative venous thrombosis in a tensor fascia lata
flap which was finally salvaged.
DISCUSSION:
With sizable perforator in 99% of the designed area, ALT flap is a very reliable flap for reconstruction. If there is no adequate skin perforator
in one thigh, dissection performed in another thigh is not suggested, because similarity of the vascular condition would be
encountered. When there is no sizable skin perforator in ALT dissection, an acceptable successful rate to complete the reconstruction
could be achieved by following the above algorithm according to our experience, which might be the largest series in dealing with such
kind of problem.
Early Results of a Prospective, Randomized Cost and Outcome Analysis of ICU vs. Surgical
Floor Monitoring in Free Flap Breast Reconstruction
Institution where the work was prepared: University of Chicago Medical Center, Chicago, IL, USA
Charles Y. Tseng, MD; David H. Song, MD; University of Chicago Medical Center
PURPOSE:
At present, it is standard practice to admit all patients who undergo free flap reconstruction to the ICU or an equivalent flap recovery
unit for monitoring on an hourly basis. The ICU remains a large user of hospital resources, accounting for 25% to 30% of total hospital
costs, despite the fact that these beds represent only 5 to 10% of total hospital beds. To date, there have been no studies documenting
an improvement in free flap outcomes or cost-savings based solely on ICU level flap monitoring. The purpose of this study is to perform
a cost comparison of free flap monitoring in the ICU versus surgical floor using standard clinical criterion, external Doppler probe,
and Near Infrared Spectroscopy (NIRS) in patients who have undergone free flap breast reconstruction.
METHODS:
Since August 2006, 14 patients underwent free flap breast reconstruction using MS-TRAM, DIEP, or SIEA free flaps. 8 patients (10 flaps)
were randomized to the ICU and 6 patients (7 flaps) to the standard surgical floor for post-operative monitoring using standard clinical
criteria, external Doppler probe, and continuous NIRS monitoring. Patient demographics, procedure type, diagnosis, adjuvant treatment,
and complications were recorded.
RESULTS:
6 MS-TRAM, 6 DIEP, and 5 SIEA free flaps breast reconstructions were performed. There was no difference in flap loss, fat necrosis, or
venous congestion. Average total length of stay (LoS) and cost of stay (CoS) in patients randomized to recover in the ICU was 4.25 days
and $18,122. Average LoS and CoS in patients recovering on the surgical floor was 4 days and $7,564.
CONCLUSION:
This randomized, prospective study compares the cost and early (30-day) results of post-operative recovery and free-flap breast reconstruction
monitoring in an ICU versus surgical floor setting at a single institution using external doppler probe and near-infrared spectroscopy
(NIRS) as adjunctive monitoring devices. Current monitoring devices fall short of the ideal and none have gained widespread
acceptance. A monitoring tool that could detect disturbances in vascular flow early, reliably, and independent of level of care and experience
of nursing staff could potentially generate tremendous cost savings to both the institution and to the patient. Easy to use and
accurate, NIRS technology has the potential to lower hospital costs by allowing patients to recover on a standard surgical floor while
receiving continuous free flap monitoring. Long term outcomes data are needed to corroborate our early findings.
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