Anterolateral thigh flap donor-site complications and morbidity

The authors examined donor-site complications and morbidity in 37 patients after reconstruction with free or pedicled anterolateral thigh flaps. Intraoperative assessment included damage to the vastus lateralis muscle and whether the main pedicle of the rectus femoris muscle had been killed. Postoperative assessment of the donor site included wound healing, range of motion, muscle strength, gait, and sensation. Patients were surveyed with a questionnaire about fatigue in their activities of daily life and the appearance of the donor site. All 32 patients who underwent primary skin closure could perform activities of daily life normally, and most (87.5 percent) reported that donor-site appearance was satisfactory. However, the severity of donor-site dysfunction was related to the degree of damage to the vastus lateralis muscle, and most patients (87.5 percent) had some loss of sensation at the anterolateral aspect of the thigh. Because of adhesions between the meshed skin graft and the underlying fascia, range of motion at the hip and knee was limited in significantly more patients who had received split-thickness skin grafts (60 percent) than patients who had undergone primary skin closure (3.1 percent). Therefore, wider flaps or flaps harvested nearer the knee may increase donor-site morbidity. The authors concluded that the incidence of long-term morbidity with the anterolateral thigh flap is low, although it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site.     

Ankle-arm index versus angiography for the preassessment of the fibula free flap

Peripheral arterial occlusive disease or congenital anomalies of the major crural arteries may limit the use of the fibula free flap and should be detected preoperatively. Conventional selective angiography is the definitive standard imaging method for making this diagnosis, but it has drawbacks. A safer, cheaper, more accurate, and noninvasive alternative is desirable. The authors sought to test the hypothesis that the ankle-arm index of each of the three crural arteries, combined with pencil Doppler examination of the peroneal skin perforators, would provide adequate information to restrict the use of angiography to cases in which the outcomes of either or both of these options are insufficient. The ankle-arm index data of each of the three crural arteries, as well as pencil Doppler examination of the peroneal skin perforators of both legs of nine prospectively included patients and the nonoperated legs of 13 retrospectively included patients, were compared statistically in four different ways with the preoperative angiographic findings. A combined ankle-arm index and pencil Doppler examination is not accurate enough to detect legs or arteries with subclinical peripheral arterial occlusive disease or vascular variation and, hence, is not a sufficient basis on which to develop the surgical plan for a fibula free flap.     

Donor-site morbidity after free vascularized autogenous fibular transfer: subjective and quantitative analyses

The purpose of this study was to determine the subjective and quantitative donor-site morbidity after removal of a free vascularized fibula flap for autoreconstruction. Ten patients and six age-matched, healthy control subjects were included in this study. The postoperative periods ranged from 6 to 87 months. Subjective donor-site morbidity was assessed with a patient questionnaire and the Enneking system. For quantification of donor-site morbidity, gait was evaluated during normal walking, walking under visual and cognitive constraints, and walking at a velocity higher than the preferred one. In general, the patient perception of donor-site morbidity was low. Complaints were frequently mentioned, however, including pain (60 percent), dysesthesia (50 percent), a feeling of ankle instability (30 percent), and inability to run (20 percent). Gait analyses revealed that patients walked at a lower preferred velocity, compared with control subjects. Furthermore, they demonstrated significant increases in the coefficients of variation of stride time during walking under visual and cognitive loads and during walking at a velocity higher than the preferred one, compared with normal walking. These increases were not observed for control subjects. These findings suggest that the reautomatization of gait is affected among patients. This study demonstrates that fibula harvesting is associated with low subjective morbidity but frequent complaints. Walking during complex tasks and at high velocities reveals that restoration of gait is not complete after partial fibulectomy.     

Osteotomy to treat malocclusion following reconstruction of the mandible with the free fibula flap

Malocclusion may result after free fibula flap reconstruction of the mandible, because of inadequate positioning of the temporomandibular joint, inaccurate contouring of the reconstruction plate, or subsequent fracture of a miniplate. Factors that alter the vascularity of the transplanted fibula may also result in a delayed presentation of malocclusion. Seven cases are presented, in which primary surgical treatment consisted of segmental mandibulectomy and reconstruction with a free fibula osteoseptocutaneous flap. Fixation was achieved with a reconstruction plate in five cases and a miniplate in two cases. Malocclusion was corrected with an osteotomy performed at the junction of the fibula and the native mandible. The new osteotomy sites were fixed with miniplates and maintained with intermaxillary fixation. Complete bony union was achieved at the osteotomy sites. The correction of malocclusion was successful in all cases, and all patients have resumed a normal diet. This report demonstrates that osteotomy and realignment of the mandible are effective for the secondary correction of malocclusion after mandibular reconstruction with the free fibula osteoseptocutaneous flap.     

Effect of obesity on flap and donor-site complications in free transverse rectus abdominis myocutaneous flap breast reconstruction

The purpose of this study was to assess the effect of obesity on flap and donor-site complications in patients undergoing free transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. All patients undergoing breast reconstruction with free TRAM flaps at our institution from February 1, 1989, through May 31, 1998, were reviewed. Patients were divided into three groups based on their body mass index: normal (body mass index <25), overweight (body mass index 25 to 29), obese (body mass index > or =30). Flap and donor-site complications in the three groups were compared. A total of 936 breast reconstructions with free TRAM flaps were performed in 718 patients. There were 442 (61.6 percent) normal-weight, 212 (29.5 percent) overweight, and 64 (8.9 percent) obese patients. Flap complications occurred in 222 of 936 flaps (23.7 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall flap complications (39.1 versus 20.4 percent; p = 0.001), total flap loss (3.2 versus 0 percent; p = 0.001), flap seroma (10.9 versus 3.2 percent; p = 0.004), and mastectomy flap necrosis (21.9 versus 6.6 percent; p = 0.001). Similarly, overweight patients had a significantly higher rate of overall flap complications (27.8 versus 20.4 percent; p = 0.033), total flap loss (1.9 versus 0 percent p = 0.004), flap hematoma (0 versus 3.2 percent; p = 0.007), and mastectomy flap necrosis (15.1 versus 6.6 percent; p = 0.001) compared with normal-weight patients. Donor-site complications occurred in 106 of 718 patients (14.8 percent). Compared with normal-weight patients, obese patients had a significantly higher rate of overall donor-site complications (23.4 versus 11.1 percent; p = 0.005), infection (4.7 versus 0.5 percent; p = 0.016), seroma (9.4 versus 0.9 percent; p <0.001), and hernia (6.3 versus 1.6 percent; p = 0.039). Similarly, overweight patients had a significantly higher rate of overall donor-site complications (19.8 versus 11.1 percent; p = 0.003), infection (2.4 versus 0.5 percent; p = 0.039), bulge (5.2 versus 1.8 percent; p = 0.016), and hernia (4.3 versus 1.6 percent; p = 0.039) compared with normal-weight patients. There were no significant differences in age distribution, smoking history, or comorbid conditions among the three groups of patients. Obese patients, however, had a significantly higher incidence of preoperative radiotherapy and preoperative chemotherapy than did patients in the other two groups. A total of 23.4 percent of obese patients had preoperative radiation therapy compared with 12.3 percent of overweight patients and 12.4 percent of normal-weight patients; 34.4 percent of obese patients had preoperative chemotherapy compared with 24.5 percent of overweight patients and 17.7 percent of normal-weight patients. Multiple logistic regression analysis was used to determine the risk factors for flap and donor-site complications while simultaneously controlling for potential confounding factors, including the incidence of preoperative chemotherapy and radiotherapy. In summary, obese and overweight patients undergoing breast reconstruction with free TRAM flaps had significantly higher total flap loss, flap hematoma, flap seroma, mastectomy skin flap necrosis, donor-site infection, donor-site seroma, and hernia compared with normal-weight patients. There were no significant differences in the rate of partial flap loss, vessel thrombosis, fat necrosis, abdominal flap necrosis, or umbilical necrosis between any of the groups. The majority of overweight and even obese patients who undertake breast reconstruction with free TRAM flaps complete the reconstruction successfully. Both such patients and surgeons, however, must clearly understand that the risk of failure and complications is higher than in normal-weight patients. Patients who are morbidly obese are at very high risk of failure and complications and should avoid any type of TRAM flap breast reconstruction.     

A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer

Composite free tissue transfer has an established role in head and neck oncology for the reconstruction of the bony defect following tumor ablation, and while donor-site morbidity is variably reported, there is little consensus on the most favorable donor site. The fibula and deep circumflex iliac artery have distinct advantages in terms of the volume and length of bone in mandibular reconstruction. Few studies have compared their donor-site morbidity. The aim of this study was to compare the fibula and deep circumflex iliac artery flaps using a review of the case notes and cross-sectional review of patients attending a research clinic for validated orthopedic examination and completion of health-related quality-of-life questionnaires. Between February of 1993 and May of 2001, 44 fibula free flaps and 73 deep circumflex iliac artery free flaps were performed. Ninety-nine case notes and 36 patients were available for review of donor-site morbidity. Sixteen patients with fibula flaps and 20 patients with deep circumflex iliac artery flaps took part in the clinical examination component of the study, which was composed of a clinical examination by an orthopedic surgeon using the American Orthopedic Foot and Ankle Society ankle scoring system and the Harris hip scoring system, and two patient-completed questionnaires, the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. Subjective and objective markers of morbidity related to both flaps were similar in most parameters. However, fibula flaps were associated with more problems with donor-site healing, reduced power, and sensation. Poor orthopedic scores for both flaps were associated with notably poor scores on the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. The study would suggest that both deep circumflex iliac artery and fibula donor sites result in an acceptable and comparable morbidity for most patients, but in cases in which significant donor-site morbidity is encountered, health-related quality of life is significantly compromised.     

The radial forearm flap: a biomechanical study of donor-site morbidity utilizing sheep tibia.

The use of vascularized bone grafts to reconstruct extremity and mandibular defects is now commonplace in reconstructive surgery. Fibula, scapula, iliac crest, rib, and metatarsal as well as the radial forearm osseocutaneous flaps have all been utilized for this purpose. Troublesome spiral fractures of the distal radius are the most common fractures associated with the use of the distal radius as a vascularized bone-graft donor site. This study was proposed to investigate the effect of donor-site bone loss on the strength of the radius under torsional (rotational) loading. Previous clinical series and experimental studies have not examined this aspect of distal radius loading after harvesting the bone graft. Fifty pairs of sheep tibiae were utilized in the experiment. Five pairs were used in a pilot study and 45 pairs were used in the main experiment. Five pairs of human radii were used for the control in the pilot study. The pilot study attempted to make a comparison between the human radius and the sheep tibia for experimental purposes. For the biomechanical study of donor-site defects, four study groups were examined with random assignment and matched pairs. The control group (group 1) had no alteration to the bone. Each test condition included five matched pairs of sheep tibiae. Experiment 1 compared the difference in the depth of the osteotomy defect. In doing this, one-third of the total length of the bone was removed in each of the following specimens to include (1a) 30 percent of the cross-sectional area of the total bone, (1b) 37 percent of the cross-sectional area of the total bone, and (1c) 50 percent of the cross-sectional area of the total bone. In experiment 2, the osteotomy shape was varied. Instead of the ends of the cuts being squared, the ends were beveled or rounded. Experiment 3 compared different lengths of bone removed in the osteotomy defect and included the following: In experiment 3a the diameter of the sheep tibia was measured at the incisura fibularis. This dimension was one diameter of bone, and a one-diameter length of bone was removed. In experiment 3b, a two-diameter length of bone was removed. In experiment 3c, a three-diameter length of bone was removed. In experiment 3d, a four-diameter length of bone was removed.(ABSTRACT TRUNCATED AT 400 WORDS)