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

Partial Muscle Transplantation: Strategy for Preservation of Form and Function at the Donor Site
Institution where the work was prepared: California Pacific Medical Center, San Francisco, CA, USA
Darrell Brooks; Rudolf F. Buntic; Buncke Clinic
INTRODUCTION:
Selection of the best tissue transplant requires striking a balance between the potential benefit for the recipient site and risk to the
donor site. There has been a recent trend towards transplantation of perforator flaps and away from muscle flaps given the attendant
loss of function with muscle harvest. Although we acknowledge the attributes of the perforator flap, we continue to recognize significant
advantages of muscle transplantation in selected patients.
PURPOSE:
The purpose of this study is to describe the design and transplantation of the partial superior latissimus dorsi(PSL) and partial medial
rectus abdominis(PMR) muscle flaps while preserving form and function at the donor sites.
METHODS:
A retrospective review of partial muscle flaps transplanted between 2003-2006 was conducted. Charts were reviewed to define indications
for tissue transplantation, characteristics of transplanted tissue, outcome analysis, maintenance of donor site form/function, as well
as, patient satisfaction. The PSL flap is designed along the superior edge of the latissimus dorsi muscle, medial or lateral depending
on recipient site requirements such as pedicle length and flap dimension. The descending branch of the thoracodorsal nerve is preserved
maintaining function in the residual latissimus. The majority (>70%) of the latissimus muscle is left intact with adequate blood
supply and persistent innervation from the descending branch of the thoracodorsal nerve. Depending on the required pedicle length
and flap dimension, the PMR flap is designed up or down the medial edge of the muscle. Care is taken to protect the arcade of intercostal
nerves and arteries. Branches from the deep inferior epigastric vessels (DIEVs) going to the medial aspect of the rectus muscle
are identified and followed back to the DIEVs. The majority (>50%) of the rectus width is preserved with adequate blood supply and
innervation by intercostals arteries and nerves.
RESULTS:
Thirty-seven PSL muscle flaps were performed for arm/hand(12), leg/foot(16), and head/neck(9) defects. Twenty-five PMR muscle flaps
have been performed for chest wall(1), arm/hand(11), and leg/foot(13) defects. All flaps survived. Examination revealed preservation of
function of the residual muscle without associated hernia after PMR or early arm fatigue or changes in strength related to activities
involving arm extension after PSL harvest. The lateral thoracic silhouette was maintained in all PSL cases.
CONCLUSION:
The partial latissimus dorsi and rectus abdominis muscle flaps are reliable techniques for muscle transplantation. The minimal donor
site morbidity and versatility in flap design make them excellent options in reconstructing a range of defects.
Microvascular Venous Coupler Reduces the Rate of Venous Anastomosis Failure
Institution where the work was prepared: University of Manitoba, Winnipeg, MB, Canada
Matthew Choi, MD; Edward Wayne Buchel; Thomas E.J. Hayakawa; University of Manitoba
PURPOSE:
To compare venous anastomosis complication rates between hand sewn anastomoses and those using a venous coupler device.
METHODS:
We retrospectively reviewed a single surgeon experience using Deep Inferior Epigastric Perforator (DIEP) flaps and Superficial Inferior
Epigastric Artery (SIEA) free flaps for breast reconstruction. The surgeon performed hand-sewn venous anastomoses exclusively in his
practice before changing his technique to using a venous coupler exclusively (Synovis coupling device). The consecutive series of handsewn
cases was then compared to the consecutive series where the venous coupling device was used. Only DIEP and SIEA free flaps
were considered for this analysis. In all cases, end-to-end anastomosis were performed to internal mammary vessels, with one exception
where these recipient vessels were matted down by diseased lymph nodes and the thoracodorsal vessels were used instead.
Outcomes measured were takebacks to the operating room for venous insufficiency or venous occlusion.
RESULTS:
A total of 141 cases of DIEP and SIEA free flaps were performed with the hand-sewn technique. Bilateral surgeries were performed in
60 cases totaling 201 flaps. Fifteen (7.4%) patients were taken back to the operating room for venous congestion or venous occlusion.
A total of 81 cases of DIEP and SIEA free flaps were performed using a venous coupler. Bilateral surgeries were performed in 29 cases
totaling 110 flaps. One (0.9%) patient was taken back to the operating room for venous occlusion. This significant difference in anastomosis
complication rate (p = 0.036) represents an absolute risk reduction of 6.5% and a relative risk reduction of 88%.
DISCUSSION:
Published series of coupler experiences to date have reviewed cases where the authors have selected cases as appropriate for coupler
use. This exposes results to a bias which may reflect the use of the coupler in ideal circumstances. Furthermore, reported series do not
have direct comparison of failure rates to hand-sewn controls. Our study addresses these shortcomings by reporting large consecutive
cohorts where the same operative technique is used repeatedly without a decision to abandon the coupler in favor of hand-sewing, or
vice versa. By reviewing a single surgeon experience performing a single operative procedure, we also achieve reasonable comparison
to a hand-sewn control group.
CONCLUSION:
The use of a venous coupler reduces the complication rate associated with the venous anastomosis.
DISCLOSURE:
The authors have no conflicts of interest.
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