Breast reconstruction with free-tissue transfer

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the rationale for the use of free tissue transfer for breast reconstruction. 2. Understand the indications, advantages, and disadvantages of this method of reconstruction.The authors discuss the indications, advantages, and disadvantages of free-tissue transfer for breast reconstruction. The most common free flaps used today are individually discussed. Details about indications, contraindications, pertinent anatomy, pedicle characteristics, flap pliability, perfusion characteristics, advantages, and disadvantages for each of these flaps are presented. Details pertaining to the more common recipient vessels are presented. Future considerations are also briefly discussed.     

Limb reconstruction by free-tissue transfer combined with the Ilizarov method.

In four complex cases of extremity reconstruction, we have been able to overcome the problems of combined bone and soft-tissue loss and length discrepancy by a combination of free-tissue transfer and the Ilizarov method of slow distraction. It is our observation that gradual distraction of a free tissue is a safe and viable procedure; the free tissue tolerates the pins of the circular external fixator well, and there is an equal degree of distraction and regeneration of the transferred free tissue and the native recipient tissue without evidence of wound dehiscence. Corticotomy through free tissue and in close proximity to vascularized bone is safe, with the subsequent bone regeneration not unlike that of normal bone. Manipulation by slow distraction does not appear to compromise the vasculature of the recipient bed for later microsurgical procedures or endanger the axial flow pattern of the transferred free tissue.     

Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer

During a 2-year period, 15 lower and upper extremity amputees were treated by microsurgical free-tissue transfer in an effort to salvage their amputation stumps. Salvage of length and restoration of contour to aid in prosthetic rehabilitation were the two main indications for reconstruction. Included in the 15 transfers were 3 scapular free flaps, 11 latissimus dorsi musculocutaneous flaps, and 1 groin flap. Thirteen of the patients in this group were refitted with prostheses following reconstruction and did well with no pain or skin breakdown of the resurfaced stumps. The follow-up period on these patients averaged 16 months. One patient, in whom the flap succeeded, underwent stump soft-tissue revision and myodesis. One patient, in whom the flap failed, continued to develop recurrent ulceration in his stump. This clinical experience followed an extensive laboratory study of 12 above-knee amputation patients using noninvasive Doppler ultrasound measurements to determine weight-loading and interface-pressure distribution between the stump and the socket of the prostheses and their relation to stump length and circumference.     

Microvascular free-tissue transfer in children

We have reviewed our experience with 22 microvascular free-tissue transfers in children. Ages range from 2 to 14 years; the success rate was 96 percent. Two patients underwent reexploration for postoperative hemorrhage, possibly due to treatment with low-molecular-weight dextran. No vessel spasm was observed, compared with a 28 percent incidence in our adult series of 154 patients. The vessels were in pristine condition. Operative time was shorter (6.1 hours) than in our adult series (9.7 hours). Average hospital stay was 10 days (compared to 23 days for adults). All children have resumed almost normal activity within 2 months (4 months for adults). Results of this study indicate that microvascular free-tissue transfer can be accomplished safely and expeditiously in children. Care should be taken in preoperative and postoperative planning, however, especially concerning immobilization.     

The role of free-tissue transfers in lower-extremity reconstruction

Eighty-five free flaps were performed in 76 patients for defects in the lower extremity. A new classification of lower-extremity defects was devised to help define the role of free-tissue transfers: group 1, soft-tissue defects; group 2, soft-tissue and bone loss less than 8 cm; group 3, massive soft-tissue and bone loss greater than 8 cm; and group 4, bone defect only. Each group was further divided into clean (A) and infected (B) wounds. Our overall results include resolution of the presenting problem in 82 percent; there were 17 flap losses (20 percent), persistent osteomyelitis in 8, and 10 amputations. This review has prompted us to limit our indications for limb salvage, particularly in group 3B, in patients with compound injuries that include loss of plantar sensation, and in patients with large segments of infected bone.     

Microsurgical free-tissue transfer in the elderly patient.

During the 5-year period from July of 1984 to July of 1989, we performed 94 free-tissue transfers in 92 patients over the age of 50 whom we arbitrarily defined as "elderly." There were 32 patients in the age range between 50 and 59 years, 40 patients aged between 60 and 69 years, and 20 patients aged between 70 and 79 years. Seventy-one flaps were utilized for head and neck reconstruction, and 23 flaps were used in reconstruction of the trunk and extremities. There was 1 total flap loss, for a flap viability rate of 99 percent (93 of 94). Postoperative complications were classified into surgical (technical) and medical categories. There were 14 major surgical complications (15 percent) and 13 significant postoperative medical problems (14 percent). The majority of these complications occurred in head and neck cancer patients in the age group between 60 and 69 years, who had significant underlying medical problems and were preoperatively classified as ASA 3. There were 5 postoperative deaths, for a mortality rate of 5.4 percent (5 of 92 patients).     

Factors affecting outcome in free-tissue transfer in the elderly

Free-tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free-flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free-tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free-flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free-tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free-tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free-tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process.     

Intraarterial chemotherapy: the effects on free-tissue transfer

Multimodal therapy including intraarterial chemotherapy is recognized as state-of-the art therapy for soft-tissue cancer. Multimodal therapy often involves regional limb perfusion followed by sarcoma surgery with reconstruction of the resulting defect. This study was performed in an effort to evaluate the potential of free flap reconstruction after intraarterial therapy. A retrospective chart review of 52 patients who had undergone limb perfusion between 1988 and 1998 at the University of Texas M. D. Anderson Cancer Center and the Division of Plastic Surgery, University of Bochum, Germany, identified 16 patients who had undergone intraarterial limb perfusion that was then followed by surgical resection and free flap reconstruction. There were seven women and nine men, with an average age of 37.9 years. All sixteen patients had received preoperative adjuvant systemic chemotherapy. Reconstruction of the lower extremity was performed most commonly with rectus abdominis and latissimus dorsi free flaps. All vessels used for donor recipient anastomosis had been previously perfused. A vein graft was used in one case. Split-thickness skin grafting over the free flaps was used in four cases. The average length of hospitalization was 21.75 days, with an average follow-up of 20 months. No flap loss or infection was observed. Two flaps demonstrated partial edge necrosis. Three patients developed partial split-thickness skin graft loss and one developed a seroma that required no treatment. A draining sinus tract required resection in one patient. The overall flap success rate was 100 percent, with no flap failures. The overall surgical outcome was considered to be good in 12 patients on the basis of improved function and ambulation, and fair in four who had limitations in function and/or ambulation on the basis of both the patient self-evaluation and the physical therapy evaluation. Seven patients had recurrence of their disease. The overall mean survival time after surgery was 20.6 months. Currently, 10 patients are alive and six have died from their disease. The results of this study indicate that preoperative intraarterial chemotherapy does not significantly increase the risk of immediate free flap complications. Although our numbers are small, we believe that there is no clinical evidence justifying hesitation or refusal of free flap reconstruction after limb perfusion and intraarterial chemotherapy. Routine care in vessel selection and microsurgical technique should be performed to maximize favorable outcomes. Vessels should be inspected for their suitability before undertaking any free flap reconstruction.     

Flap failure after microvascular free-tissue transfer: the fate of a second attempt

In most cases, the loss of a free-tissue transfer is a disaster for both the patient and the surgeon. Seven patients received a second microvascular free-tissue transfer after loss of the first. The indications for free-tissue transfer included chronic osteomyelitis of the lower leg (four patients), acute traumatic defect of the leg (one patient), acute traumatic defect of the arm (one patient), and esophageal defect after surgical excision (one patient). In three patients, the interval between the first and second procedures was less than 2 weeks. The remaining four patients had their second free-tissue transfer performed 5 weeks to 21 months after the first. Six of the seven free flaps were successful. Two patients with venous obstruction occurring after the second free-tissue transfer were salvaged by reexploration. Partial loss of the flap was noted in one of these patients. It is concluded from this select group of patients that failure of a free-tissue transfer does not contraindicate a second microtissue transfer does not contraindicate a second microvascular free-tissue transfer.     

The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases

One-hundred and fifty consecutive free-tissue transfers were reviewed to evaluate the role of emergent exploration in flap survival. Eleven flaps exhibited signs of circulatory failure between 1 hour and 6 days postoperatively and required return to the operating room. In eight patients the preoperative diagnosis was venous thrombosis, and in three patients it was arterial thrombosis. The average time from the first abnormal examination to exploration was 1.5 hours. There were no false-positive explorations. All 11 flaps were salvaged following correction of the cause of circulatory compromise. In eight patients this was due to inflow or outflow obstruction in the recipient vessels proximal to the anastomosis, in two patients it was due to extrinsic compression of the flap from a tight wound closure, and in one patient it was due to obstruction of the recipient vein by a drain. Primary anastomotic thrombosis was not encountered as the cause of circulatory compromise in any patient. An aggressive approach to exploration was responsible for an increase in flap survival in the entire series from 90 to 98 percent. The results of this study demonstrate the efficacy of clinical monitoring, the role of early exploration, and the durability of microvascular anastomoses.     

Streptokinase salvage of a free-tissue transfer: case report and review of the literature

Postoperative thrombosis is a devastating complication after a microvascular free-tissue transfer. We are reporting the case of a clinical free osteomyocutaneous flap (fibula, peroneal, and soleus muscle, and skin) which suffered recalcitrant postoperative venous thrombosis and was salvaged only after isolated selective infusion of streptokinase. The use of a fibrinolytic agent or plasminogen activator for this purpose in humans has not previously been reported.