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

The Use of Thromboelastography as a Guide to Tailor the Anticoagulation Management in
the Microvascular Surgical Patient
Institution where the work was prepared: The Methodist Hospital, Institute for Reconstructive Surgery, Houston, TX, USA
Aldona J. Spiegel, MD; The Methodist Hospital; Hector Salazar-Reyes, MD; Baylor College of Medicine / The
Methodist Hospital, Institute for Reconstructive Surgery
PURPOSE:
Thrombo-embolic events are among the most feared complications in plastic surgery. Deep venous thrombosis (DVT) and pulmonary
embolism (PE) remain a small (Incidence: 0.35%-1.4%; 0.02%-1.4%, respectively) but real life-threatening risk in plastic surgery. In
microvascular breast reconstruction DVT incidence ranges from 0.87% -5%. Additionally, flap loss incidence due to local thrombosis
varies from 1%-10%. Microvascular surgeons have to balance thrombo-embolic events and flap losses on one side, and postoperative
bleeding complications on the other. Currently employed tests for assessing patients' coagulation status do not reflect the dynamic
process of hemostasis and offer a limited perspective. Assessing patients' hemostasis globally, allows the microsurgeon to promptly
implement preventive measures. Thromboelastography (TEG) monitors hemostasis as well as platelet interaction by measuring the viscoelastic
properties of blood, by assessing the clotting cascade and by evaluating the strength and stability of the newly formed clot.
In the last nine months, we have routinely used in our microsurgical practice the TEG as tool to manage the anticoagulation therapy
and to monitor patients' overall coagulation status. Additionally, an algorithm for patient management based on the TEG results has
been developed. The purpose of this work is to retrospectively review the outcome in our microsurgical practice, following the proposed
algorithm and to evaluate the impact that TEG had in complication rates.
METHODS:
A retrospective chart review was performed in all patients who underwent autologous breast reconstruction (DIEaP and SIEA flaps) by the
senior author (AJS). Special attention was placed on patients' risk factors for developing thrombo-embolic and hemorrhagic events, type
and timing of reconstruction, outcome, complications and their correlation with the TEG values obtained before, during and after surgery.
RESULTS:
Forty-seven DIEaP and 9 SIEA flaps were performed in 34 patients. Age ranged from 34 to 64 years. The data analysis will be presented
and shows encouraging results in the treatment of these patients. Since TEG has been implemented on routine basis, no thromboembolic
events have occurred; flap loss index has been reduced to zero and hematoma formation has been present only in one case;
drainage of the hematoma was not necessary.
CONCLUSION:
A thorough coagulation evaluation must be performed to avoid complications and guarantee surgical success. In the quest for the ideal
test to evaluate the coagulation status in microvascular patients, TEG has demonstrated to be a valuable element, and may have the
potential to become the cornerstone to assess these patients' coagulation status.
Free-style Proximal Lateral Leg Perforator Flaps for Head and Neck Reconstruction
Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan, Taiwan
Wei-Chao Huang1; Christopher Glenn Wallace1; Robert EH Ferguson, MD2; Fu-Chan Wei1; Jeng-Yee Lin1; (1)Chang
Gung Memorial Hospital, (2)University of Kentucky
INTRODUCTION:
Free-style perforator flap surgery represents a relatively new concept in reconstructive microsurgery that brings potential benefits of
reduced donor site morbidity and improved flexibility in customization of, for example, flap orientation, dimensions and composition.
We report harvesting techniques, anatomic variations encountered and clinical applications of free-style proximal lateral leg perforator
(PLLP) flaps in head and neck reconstruction.
MATERIAL:
From January 2000 through May 2007, 17 patients (15 males, 2 females; age range: 32 to 80 years) underwent head and neck reconstruction
with free-style PLLP flaps. Dimensions of skin islands ranged between 4x7 cm and 6.5x18 cm. Three flaps included a small portion of
soleus muscle to provide bulk for reconstructing tongue or through-and-through cheek defects. Mean follow-up was 13.6 months.
RESULTS:
Vascular origins of free-style PLLP flaps were noted as follows: 11.7 % from the posterior tibial system, 11.7 % from the common popliteal
system, 76.6 % from the peroneal system. Five flaps were re-explored for compromised circulation, of which four required venous reanastomosis
for venous thrombosis. Three of these flaps recovered with no sequelae, but one failed completely and required replacement
with a radial forearm free flap. The fifth flap suffered arterial pedicle disruption due to accidental forceful hyperextension of the
neck 5 days postoperatively. Revascularization with a 1.5 cm vein graft was performed, but the flap still underwent partial necrosis which
required resection and reconstruction with a pedicled deltopectoral flap. Overall, 15 flaps survived completely, one flap had partial
necrosis and one flap failed completely.
CONCLUSIONS:
When applying the concept of free-style harvest, we were able to exercise considerable flexibility intraoperatively, such as when changing
flap design and when incorporating intraoperatively identified and more substantial perforators to supply the PLLP flap, allowing us
to overcome potential problems of limited pedicle length, vascular variations and small diameter pedicle vessels. Free-style PLLP flaps
offer many advantages, such as versatility in design, appropriate tissue volume, superior texture, diverse tissue types available on one
pedicle, feasibility for a two-team approach and negligible donor site morbidity, and we recommend it as a useful addition to the Plastic
Surgeon's armamentarium for head and neck reconstruction.
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