Annals of the Royal College of Surgeons of England (1976) vol 58
Replantation and reconstructive microvascular surgery Part II B McC O'Brien
BSC MS FRCS FRACS FACS
Director, MicrosurgeryhResearch Unit, and Assistant Plastic Surgeon, St Vincent's Melbourne
Hospital,
Composite tissue transfer The second main clinical field of microvascular surgery is composite tissue transfer, involving free flap and omental transfers with microvascular anastomoses. Twenty-four such transfers have been performed at St Vincent's, the donor sites being the groin (mainly), forehead, digit, and omenttum. Harii, who performed the first microvascular free flap transfer in September I972, has also used the scalp, the deltopectoral area, and a compound skin-muscle flap involving the skin and underlying gracilis27". It would appear from anatomical dissections that the dorsum of the foot may also be a potential donor area"'29. Recipient sites have included the hand and forearm, head and neck, lower limb, and thorax. The indications have included reconstructive cancer surgery, traumatic skin losses, scar contractures following burns and other trauma, burn scar disfigurements'", adduction contractures of the thumb, and congenital abnormalities. Nineteen of the 24 transplants have survived, and one that failed was sticcessfully repeated. Although omental transfer based on a vascular pedicle has been described for covering chest defects, McLean and Buncke" were the first to use it as a free transfer with microvascular anastomoses to cover a large defect of the scalp with a free skin graft for final cover. This has been repeated on several occasions by Harii". I have used the omentum for the correction of bilateral facial atrophy in a 39-year-old man. The omentum was divided longitudinally and each segment transferred to the face with end-to-end anastomoses of the gastroepiploic vessels to the facial vessels. Sur-
vival of the right omentum was achieved, but partial necrosis of the left omentum developed at 6 months. A pulsating omentum was palpated on the right side, though it was slightly bulky. Normal tissue with patent vessels was confirmed on biopsy and a right carotid arteriogram revealed a patent anastomosis on the lower border of the mandible. The facial asymmetry was corrected by partial removal of the excess right omentum, transferring it to the left face as a free graft. This has given an almost symmetrical appearance with normal dentures. Fat from the groin based on its feeding vessels is suggested as an alternative for the correction of facial atrophy. In May 1973, at the meeting of the British Hand Surgery Society at Harrogate, I called the one-stage flap transfer 'free flap'. Hayhurst's" suggestion, 'microvascular flap', has much merit and perhaps the two names should be combined. The characteristics of a microvascular free flap considered to be important are adequate size, dispensable donor area with minimal or no defect, constant vessels of adequate size, and aesthetic qualities such as correct texture, minimal or no hair, and minimal thickness. Axial pattern flaps not only enable large areas to be transferred with microvascular anastomoses, but these can be extended significantly in width and/or length if there are adjacent axial pattern systems, and less so with adjacent random patterh systems. The groin flap of McGregor and Jackson9 has proved the most useful donor site, and in ioo cadaver dissections the superior circumflex iliac artery was always present within 2 cm of the inguinal ligament. The superficial inferior epigastric
172
B McC O'Brien the groin are available for virtually any large defect. The microvascular free flap is more advantageous when a direct or distant flap is impossible or too slow. Awkward postures are eliminated and earlier mobilization with decreased joint stiffness is possible. There is improved flap circulation with better use of the recipient vessels, and hospital stay is shorter. A preoperative arteriogram is useful only when clinical examination does not provide sufficient
a(
information.
f-)
FIG. I 9 (a) Congenital adduction deformity of thumb with absent digit in a io-year-old boy. (b) One-stage micro vascular free groin flap transferred into first web space with reconstruiction of ulnar collateral ligament of metacarpophalangeal joint of thumb; seen at 9 months.
artery is sometimes absent but often arises in common
with the superficial circumflex iliac
artery from the femoral artery, and this short
trunk should be used for anastomosis if available. The superficial circumflex iliac vein is usually single but sometimes drains via a common trunk with the superficial inferior epigastric vein into the saphenous vein. One artery and one superficial vein only are needed for anastomosis and the larger the diameter of the vessels, the more advantageous the situation. The vessels have always been large enough for anastomosis, varying from to 3 mm in diameter, and free flap transfers from i
Dissection of the donor groin area The donor flap is measured to the pattern of the recipient defect after the latter has been created. The groin dissection is performed simultaneously with the dissection at the recipient site unless there is doubt of the adequacy of the recipient vessels. Several points in the surgery of the groin flap need emphasis: i) An initial medial approach to the vessels, dissecting out to the medial border of the sartorius muscle, is recommended. The flap is centralized over the axial vessels. 2) The lateral dissection includes the deep fascia over the sartorius in order to preserve the axial vessels, which lie deeply in this area. A fat flap may be thinned laterally almost to the lateral sartorius border. The more heavily covered Caucasian presents more difficulties here than the Oriental. 3) The vessels are tagged with varying lengths of sutures to distinguish arteries from veins, and the groin defect, even though wide, is closed primarily except in the largest cases, when split skin graft cover is used. In some circumstances a bulky free flap is not applicable-for example, to correct an adduction contracture of the thumb.
Recipient area The recipient vesssels are located and prepared till they appear normal under the operating microscope and possess free flow. The free flap is then loosely sutured into place, the vessel repairs are performed, and the final suturing completed with a simple drainage tube inserted away from the anasto-
mosis.
Some illustrative cases are shown in Figures
19-2 1.
.:s,e
Replantation and reconstructive microvascular surgery
.N. A.,
it.:i.,,
;
ow
As .:
17 3
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. 20 (a) In filtrating basal cell carcinoma of nose. (b) Microvascular free frorehead flap following excision of carcinoma. (c) Same patient at 6 months. (d) Anastomosis of anterior superficial temporal artery to su,perior labial artery and supraorbital and anterior temporal reins to external an,gular andn n aso facial reins. (Re produiced by peermissiotn from the British Journal of IP1avtic Surgerv.`
(b)
I74
B McC O'Brien
~~ ~ .: .:Nf~ ~(b) (a) Extensire rhabdomyoof deltoid (after wide irradiation.. (b) Outline of largue microv)ascular free groin flaP 31 X 22 CM. (c) Radical excision of malignancy with exposure of head of humerus. (d) Six months after application of
FIG. 21 sarcoma
flap.
the thickened medial end of the free flap cannot be inserted satisfactorily into an area possessing a thin layer of subcutaneous tissue. This has led to kinking of the artery with arterial thrombosis in 2 cases. In another case an irradiated artery was used, with loss of the flap, but this was suiccessfully repeated io days later using a groin flap from the opposite side to thrombosis. joining to normal vessels outside the irradiated region. In a further case an atherosclerotic secCauses of failure The single cause of fail- tion of an artery in an elderly patient was used ure has been arterial thrombosis and this is at the recipient site and this led to arterial considered correctable. In well-covered pati.ents thrombosis and loss of the flap. The final cause
Postoperative management In the uncomplicated case the postoperative managemnt is minimal. The part is mildly elevated where possible and antibiotics are given but no anticoagulants. The flap is left exposed and half-hourly observations are made of blo-od pressure, pulse rate, colour, and capillary retur. Hypotension is avoided as this may lead
Replantation and reconstructive microvascular surgery of the flap failure was arterial thrombosis following hypotension and excessive postoperative elevation. Venous thrombosis has been observed in a further 2 cases and arterial thrombosis also in 2 other cases, but these were successfully corrected by reanastomosis. These vascular complications require urgent reoperation as the flaps do not wNithstand secondary ischaemia well. A microvascular free flap transfer can be carried out in the uncomplicated case within 4-6 h and its safety is steadily improving. More donor sites are necessary. Harii" has reported promising results using the deltopectoral flap based on the second (preferably) or third perforating branches of the internal mammary vessels. There is, however, need for thin flaps and in cadaver dissections the dorsum of the foot based on the dorsalis pedis vessels may provide such a flap, though limited in area'1. The microvascular free flap has a definite place in reconstructive surgery and for some has displaced the tube pedicle and many distant flaps. One-stage toe-to-hand transfer This is an area of microvascular development pioneered by Cobbett" in I969 and used since that time in small numbers of cases in the United States by Buncke et al."4 and in Japan by Tamai". Reports from these small numbers have indicated technical difficulties and concern for the microvascular anastomoses in the postoperative period. These difficulties have been resolved by using the dorsalis pedis artery and the great saphenous vein with their continuations into the hallux or second toe'6. The plantar vessels are not necessary for the circulation of the large or second toe, and 30 cadaver dissections have confirmed the constant presence of dorsal digital vessels of adequate size.
Two operating teams work simultaneously the hand and the foot, locating the respective vessels, tendons, and nerves. A generous amount of skin is taken with the toe. The extensor hallucis longus or the extensor digitorum longus of the second toe is divided at the ankle area and the flexor hallucis longus above the medial malleolus or the flexor digitorum longus to the second toe on the plantar aspect. The level of section of the toe is deter-
on
17 5
mined by the length of the digit missing. However, retention of the metatarsophalangeal joint means careful dissection of muscle from the toe in situ to reduce the bulk of the transplant. An intramedullary bone graft may be taken from the residual toe bone. The dorsal vessels are traced under the extensor retinaculum, which is partly divided, but are not sectioned until the hand and foot dissections have been completed. After definition of the vessels, nerves, and tendons in the hand the bone is shaved and prepared for the bone graft. The toe is transfixed to the hand and the bones fixed with oblique Kirschner pins after the insertion of the intramedullary bone graft. The flexor tendon and the two digital nerves are joined and then the volar wound is closed. The extensor hallucis longus or extensor digitorum longus is sutured to the extensor pollicis longus or extensor indicis. The great saphenous vein and the dorsalis pedis artery are anastomosed end-to-end to the cephalic vein or one of its tributaries and to the radial artery just before the latter disappears into the first intermetacarpal cleft (Figs 22 and 2 3). The technique of transfer of the first and second toes is comparable. The toe transfers provide a pinch mechanism on the radial aspect of the hand. The second toe may be used for reconstruction of the index finger or middle finger when all 4 fingers are absent or only the little finger is present. There are skin deficiencies on each side of the second toe when it is used for transfer, and these require split skin graft cover. The plantar pad is unduly thick and is now thinned in situ before transfer. Similar vascular anastomoses are made for the hallux and second toe. The moderately large vessel size and the superficial position of the microanastomoses have contributed to the success and safety of this procedure. No anticoagulants are required and postoperative progress is uncomplicated. One great toe transfer and 3 second toe transfers have been performed. A protective degree of sensibility is achieved in the transfers and the difficult deep dissection of the sole is avoided. Not only does this method provide a safe toe transfer for acquired severely disabled hands. but it appears
applicable to severe congenital abnormalities.
176
B McC O'Brien
(b
(ef,.:.::. ... :.{~.~ ~ ~ ~ ~ ~ ~ ~.~ .~ .
(a) Amputation of left thumb in 6 i- ear-old man through base of proximal Phalanx. (b) Reconstructed thumb 3 months after toe-tohand transfer. (c) Comparison of transplanted halluix on left hand and normal right thuimb. (Reproduced by permission from The Hand.) FIG. 22
Microlymphatic surgery This new field of microsirgery is the epitome of microvascular surgery. It is fascinating to read some oif the history of lymphatics, for the Hunter brothers, William and John, investigated this system. They injected lymph nodes, mapped out many lymphatic vessels, and demonstrated their valves. Their work resulted in one of the greatest surgical controversies of its time, delightfully described in the Bulletin of the New York Academy of Medici'ne (6th August 1974) by Mark M Ravich in a pub-
lication entitled 'Invective in surgery, William Hunter versus Monroe Primus, Monroe Secondus and Percival Pott'. Lymphaticovenous end-to-side communications have been observed under normal conditions",'3 and in abnormal circumstances"-"3. Lamne and Howard"4 conducted experimental end-to-side lymphaticovenous anastomoses to canine femoral veins over a temporary polyethylene splint which was then removed through a lateral ve-notomy. A patency Of 4004 was obtained between 3 weeks and 3 months
Replantation and reconstructive micro vascular surgery
17 7
(b)
FIG. 23 Toe-to-hand transfer (a) Diagrammatic representation of dorsal anatomy; sites of division of tendons and vessels are marked. (b) Diagrammatic representation of vascular anastomoses and tendon repairs. in 15 such anastomoses. In a second series of I5 anastomoses a 'shirt-tail' form of union, as used in ureterovesical anastomoses, with only one suture gave a patency rate of 20o%, after 3 months. The patency was observed by direct anastomosis and cannulation. It was noted that there was nearly always some stenosis at or near the anastomosis. Emphasis since that time has been placed on the anastomosis of transected lymph nodes to veins because of the technical difficulties involved in lymphaticovenous union. Niebulowicz and Olszewski45 and Politowski and Bortowski"6 claimed clinical improvement in patients with secondary lymphoedema using lymphonodovenous communications. Firica et al.47 demonstrated evidence of lymphovenous flow experimentally. Rivero et al.48 obtained ioo% patency at i month in dogs, but all the anastomoses were closed by fibrous tissue at 3 months38. However, these last observations were made in dogs without established secondary lymphoedema. Calderon et al.49 implanted lymphatics into veins and also performed direct end-to-end lymphaticovenous anastomoses but could not demonstrate the flow of lymph through these
anastomoses have been few. Cockett and Goodwin50, Mistillis and Skyring5", and Sedlacek5'2 have performed anastomoses for the treatment of chyluria and intestinal lymphangiectasia and for elephantiasis, with reasonable clinical results. However, in these conditions the anastomoses had been performed on large, dilated lymph vessels considerably removed from the size of normal lymphatics. Yamada53 succeeded in anastomosing lymph vessels to veins at the ankle of dogs with microvascular techniques, using a polyethylene catheter as a temporary internal splint. All the branches entering the saphenous veins between it and the nearest venous valvc were divided to protect the anastomoses, thus decreasing the venous pressure and avoiding back-flow across the anastomosis.
Personal experience: experimental In I969 many lymphaticovenous anastomoses were carried out to canine femoral vessels, joining the lymphatic obliquely to the femoral vein with 4 or 5 metallized nylon microsutures. However, the primary patency was inconsistent and subsequently a microsurgery technique junctions. Clinical trials of direct lymphaticovenous was evolved joining the lymphatic end-to-end
178
B McC O'Brien
to a similar-sized branch of the femoral vein over a Silastic splint, which was removed through the femoral vein wall after completion of the anastomosis. Angiography, re-exploration, and histopathological examination were used to follow the progress of the anastomoses. Most of the anastomoses were blocked within 24 h; hence postoperative heparin calcium (Calciparine) (700 mg/kg) was used subcutaneously twice daily for 7 days in the remaining group of I 5 dogs. Some improvement in patency rates was achieved up to I3 days. Then a technique in adult greyhounds was developed by Gilbert et al.54 anastormosing femoral lymphatics directly to small neighbouring veins away from the arterial pulsation. The diameter of the veins and lymphatic vessels ranged from 0.3 to I.2 mm. The vein was occluded with a soft clamp and the vein segment irrigated with heparinized saline (io 000 U/1) (Fig. 24). The lymphaticovenous anastomoses were performed without tension with i9-ptm metallized nylon sutures"9. The lymphatic flow was not interrupted and after the first few sutures the lymph helped to balloon up the vein. Repair is easier when the sutures are pas-sed through the vein walls first. Immediate patency of all anastomoses was obtained. The surrounding lymphatics were divided and ligated. It was possible by raising venous pressure to demonstrate venous backflow across the anastomosis and then to clear the anastomosis with lymph by squeezing the limb to elevate the lymphatic pressure. In assessing results lymphangiography was not found reliable and the best evidence of patency was by surgical exploration after the injection of patent blue dye into the paw. Proximal occlusion, emptying, and release also demonstrated distal-to-proximal flow. In these non-lymphoedematous models a patency rate at I week of 78% (14/I8) was obtained. Between 6 and 8 weeks the patency rate was 73O/ (24/33) and at 6 months 83% (IO/I2). In a second series the thoracic duct was ligated and at I month 7 out of II anastomoses (64%/,) were patent. Histologically in the patent anastomoses a thin circumferential luminal thrombus was present in continuity with the fibrinous coagulum between the tissue gaps and the suture track (Fig. 25). The prime determining factor
in the success of the anastomosis was achievement of correct apposition of the vessel edges without distortion, and this was dependent upon the number and placement of sutures as well as the tension applied when they were tied. When an occlusion occurred it stemmed in every case from the venous component. Lymph has very little coagulation potential. It was noted that where tissue disruption was greatest the luminal thrombus was most prominent (Fig. 24). Further experiments are now being carried out using lymphaticovenous anastomoses in dogs with experimental obstructive
(a;
4
(b)
FIG. 24 (a) Lymphatic above and vein below (already clamped); vessels approximately 0.5 mm diameter. (b) Completed anastomosis of lymphatic above and vein below with I 9-,ILm metallized microsutures; anastomosis is patent and lymph is flowing across it.
Replantation and reconstructive microvascular surgery
(a) Transverse section of patent lymphatic near a lymphaticovenous anastomoszs at I month; a mild luminal thrombus is present. Gomori aldehyde fuchsin. (b) Thrombosed lymphaticovenous anastomosis with some recanalization at 3 months. Gomori aldehyde fuchsin. (Reproduced by permission from the British Journal of Plastic Surgery.) FIG. 25
lymphoedema established by the method described by Clodius and Wirth55. There is a difference of pressure within the peripheral veins and the lymphatics, the lymphatic pressure being higher than the venous, during active muscular contraction53. In obstructive lymphoedema the pressure gradient between the lymphatics and the veins is probably higher still. Clinical experience Microlymphaticovenous have its main application in the treatment of secondary obstructive lymphoedema, as in primary lymphoedema there are usually few lymphatic vessels and little evidence of obstruction. In secondary lymphsurgery appears to
I179
oedema microsurgical treatment should ideally be instituted before the peripheral lymphatics have been substantially destroyed by increasing pressure and repeated infections. Preoperative lymphangiography has caused some worsening of the lymphoedema. The arm is elevated for approximately a week before operation and a compression pump applied daily for several hours until the arm volume is constant. In io cases of secondary obstructive lymphoedema in the upper limb treated by microvascular surgery 2-7 lymphaticovenous anastomoses, at the elbow and/or the middle of the medial aspect of the upper arm, have been performed. Postoperative elevation and compression are continued for a week after surgery, but no anticoagulant therapy is used. There has been significant reduction of limb volume, greater in the hand and forearm than in the upper arm. The isolation of the lymphatics after injection of patent blue dye into, the web space on the dorsum of the hand has been tedious, particularly when the lymphatics are only lightly stained. However, all sizeable lymphatics demonstrable by preoperative lymphangiography are usually located, and also a neighbouring vein of similar diameter. In most cases it has been assumed that there has been a valve in the vein distal to the main vein. Obstructive lymphoedemas of short and long duration have been treated. The earlier the patient is seen after onset of the oedema, the greater should be the chance of anastomosing larger numbers of lymuhatics to veins, but no known method is available yet of detecting those cases in which obstructive lymuhoedema will develop, nor is there any reliable method of estimation of lymphatic clearance by radioactive means or otherwise. There is a need for an accurate method of determining the lymph flow from a limb. A reduction in volume of 2 % of the limb has been observed at i month (Figs. 26 and 27), but some of this improvement has been lost with ambulation and dependency and failure to use conservative measures. Elevation at night assisted by pump compression and the wearing of an elastic stocking are needed, but these supportive mea'ures were not used in some of the early cases. Lvmuh can be expressed more quickly from a limb with multiple lymphaticovenous communications. Greater
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FIG. 26 (a) Obstructive lymphoedema of left.upper limb of 6 years duration following radical mastectomy an:d irradiation (b) Lymphangiogram showing obstructed lymphatics in elbow area. (c) Stained tortuous lymphatic in wound in cubital fossa. comfort and increasing softness of the limbs nature of obstructive lymphoedema, observahave been evident and clothes have fitted tion over a period of years is indicated. These~ morereadly ihcniudspotv e microsurgical methods are equally applicable ures it is possible that permanent improvement to the upper and lower limbs and to cases of may be obtained: as it may take some time ,ructive for the lymphaticovenous communication to loaie obtuiv lypodm flown l
take effect. However in view of the latent
trauma
lymphoedema
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I?eplantation and reconstructive microvascular surgery
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* Conclusion The role of microvascular surgery in replantation and reconstruction is established. Careful case selection is emphasized and there is a need for restructuring surgical units to incorporate this development. Many tissues can be transferred with the aid of microvascular surgery, including free muscle transplant and large bone grafts, which we are actively investigating at experimental and clinical levels. Further, the application to clinical allograft transplantation is not far distant. Microvascular surgery has had a brief yesterday, for it is the surgery of today and certainly of tomorrow. Many trusts and foundations in Australia and other countries assisted with this programme and their support is gratefully acknowledged. St Vincent's Hospital is thanked, with much appreciation for the provision and maintenancc of the surgical research theatres. The Sccretary and staff of the Royal College of Surgeons of England were unfailing in
an
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Replantation and reconstructive microvascular surgery Part II B McC O'Brien
BSC MS FRCS FRACS FACS
Director, MicrosurgeryhResearch Unit, and Assistant Plastic Surgeon, St Vincent's Melbourne
Hospital,
Composite tissue transfer The second main clinical field of microvascular surgery is composite tissue transfer, involving free flap and omental transfers with microvascular anastomoses. Twenty-four such transfers have been performed at St Vincent's, the donor sites being the groin (mainly), forehead, digit, and omenttum. Harii, who performed the first microvascular free flap transfer in September I972, has also used the scalp, the deltopectoral area, and a compound skin-muscle flap involving the skin and underlying gracilis27". It would appear from anatomical dissections that the dorsum of the foot may also be a potential donor area"'29. Recipient sites have included the hand and forearm, head and neck, lower limb, and thorax. The indications have included reconstructive cancer surgery, traumatic skin losses, scar contractures following burns and other trauma, burn scar disfigurements'", adduction contractures of the thumb, and congenital abnormalities. Nineteen of the 24 transplants have survived, and one that failed was sticcessfully repeated. Although omental transfer based on a vascular pedicle has been described for covering chest defects, McLean and Buncke" were the first to use it as a free transfer with microvascular anastomoses to cover a large defect of the scalp with a free skin graft for final cover. This has been repeated on several occasions by Harii". I have used the omentum for the correction of bilateral facial atrophy in a 39-year-old man. The omentum was divided longitudinally and each segment transferred to the face with end-to-end anastomoses of the gastroepiploic vessels to the facial vessels. Sur-
vival of the right omentum was achieved, but partial necrosis of the left omentum developed at 6 months. A pulsating omentum was palpated on the right side, though it was slightly bulky. Normal tissue with patent vessels was confirmed on biopsy and a right carotid arteriogram revealed a patent anastomosis on the lower border of the mandible. The facial asymmetry was corrected by partial removal of the excess right omentum, transferring it to the left face as a free graft. This has given an almost symmetrical appearance with normal dentures. Fat from the groin based on its feeding vessels is suggested as an alternative for the correction of facial atrophy. In May 1973, at the meeting of the British Hand Surgery Society at Harrogate, I called the one-stage flap transfer 'free flap'. Hayhurst's" suggestion, 'microvascular flap', has much merit and perhaps the two names should be combined. The characteristics of a microvascular free flap considered to be important are adequate size, dispensable donor area with minimal or no defect, constant vessels of adequate size, and aesthetic qualities such as correct texture, minimal or no hair, and minimal thickness. Axial pattern flaps not only enable large areas to be transferred with microvascular anastomoses, but these can be extended significantly in width and/or length if there are adjacent axial pattern systems, and less so with adjacent random patterh systems. The groin flap of McGregor and Jackson9 has proved the most useful donor site, and in ioo cadaver dissections the superior circumflex iliac artery was always present within 2 cm of the inguinal ligament. The superficial inferior epigastric
172
B McC O'Brien the groin are available for virtually any large defect. The microvascular free flap is more advantageous when a direct or distant flap is impossible or too slow. Awkward postures are eliminated and earlier mobilization with decreased joint stiffness is possible. There is improved flap circulation with better use of the recipient vessels, and hospital stay is shorter. A preoperative arteriogram is useful only when clinical examination does not provide sufficient
a(
information.
f-)
FIG. I 9 (a) Congenital adduction deformity of thumb with absent digit in a io-year-old boy. (b) One-stage micro vascular free groin flap transferred into first web space with reconstruiction of ulnar collateral ligament of metacarpophalangeal joint of thumb; seen at 9 months.
artery is sometimes absent but often arises in common
with the superficial circumflex iliac
artery from the femoral artery, and this short
trunk should be used for anastomosis if available. The superficial circumflex iliac vein is usually single but sometimes drains via a common trunk with the superficial inferior epigastric vein into the saphenous vein. One artery and one superficial vein only are needed for anastomosis and the larger the diameter of the vessels, the more advantageous the situation. The vessels have always been large enough for anastomosis, varying from to 3 mm in diameter, and free flap transfers from i
Dissection of the donor groin area The donor flap is measured to the pattern of the recipient defect after the latter has been created. The groin dissection is performed simultaneously with the dissection at the recipient site unless there is doubt of the adequacy of the recipient vessels. Several points in the surgery of the groin flap need emphasis: i) An initial medial approach to the vessels, dissecting out to the medial border of the sartorius muscle, is recommended. The flap is centralized over the axial vessels. 2) The lateral dissection includes the deep fascia over the sartorius in order to preserve the axial vessels, which lie deeply in this area. A fat flap may be thinned laterally almost to the lateral sartorius border. The more heavily covered Caucasian presents more difficulties here than the Oriental. 3) The vessels are tagged with varying lengths of sutures to distinguish arteries from veins, and the groin defect, even though wide, is closed primarily except in the largest cases, when split skin graft cover is used. In some circumstances a bulky free flap is not applicable-for example, to correct an adduction contracture of the thumb.
Recipient area The recipient vesssels are located and prepared till they appear normal under the operating microscope and possess free flow. The free flap is then loosely sutured into place, the vessel repairs are performed, and the final suturing completed with a simple drainage tube inserted away from the anasto-
mosis.
Some illustrative cases are shown in Figures
19-2 1.
.:s,e
Replantation and reconstructive microvascular surgery
.N. A.,
it.:i.,,
;
ow
As .:
17 3
..
..
:::
j_ i-
Supraorbital v:
..
..........Ex
1a....
:Extang.v.-.r Ant temp.v. Supoacia.l att S"p Ialsse z ._bii 'SU"p.
.
.tp a
htsuperoop. cort.
. 20 (a) In filtrating basal cell carcinoma of nose. (b) Microvascular free frorehead flap following excision of carcinoma. (c) Same patient at 6 months. (d) Anastomosis of anterior superficial temporal artery to su,perior labial artery and supraorbital and anterior temporal reins to external an,gular andn n aso facial reins. (Re produiced by peermissiotn from the British Journal of IP1avtic Surgerv.`
(b)
I74
B McC O'Brien
~~ ~ .: .:Nf~ ~(b) (a) Extensire rhabdomyoof deltoid (after wide irradiation.. (b) Outline of largue microv)ascular free groin flaP 31 X 22 CM. (c) Radical excision of malignancy with exposure of head of humerus. (d) Six months after application of
FIG. 21 sarcoma
flap.
the thickened medial end of the free flap cannot be inserted satisfactorily into an area possessing a thin layer of subcutaneous tissue. This has led to kinking of the artery with arterial thrombosis in 2 cases. In another case an irradiated artery was used, with loss of the flap, but this was suiccessfully repeated io days later using a groin flap from the opposite side to thrombosis. joining to normal vessels outside the irradiated region. In a further case an atherosclerotic secCauses of failure The single cause of fail- tion of an artery in an elderly patient was used ure has been arterial thrombosis and this is at the recipient site and this led to arterial considered correctable. In well-covered pati.ents thrombosis and loss of the flap. The final cause
Postoperative management In the uncomplicated case the postoperative managemnt is minimal. The part is mildly elevated where possible and antibiotics are given but no anticoagulants. The flap is left exposed and half-hourly observations are made of blo-od pressure, pulse rate, colour, and capillary retur. Hypotension is avoided as this may lead
Replantation and reconstructive microvascular surgery of the flap failure was arterial thrombosis following hypotension and excessive postoperative elevation. Venous thrombosis has been observed in a further 2 cases and arterial thrombosis also in 2 other cases, but these were successfully corrected by reanastomosis. These vascular complications require urgent reoperation as the flaps do not wNithstand secondary ischaemia well. A microvascular free flap transfer can be carried out in the uncomplicated case within 4-6 h and its safety is steadily improving. More donor sites are necessary. Harii" has reported promising results using the deltopectoral flap based on the second (preferably) or third perforating branches of the internal mammary vessels. There is, however, need for thin flaps and in cadaver dissections the dorsum of the foot based on the dorsalis pedis vessels may provide such a flap, though limited in area'1. The microvascular free flap has a definite place in reconstructive surgery and for some has displaced the tube pedicle and many distant flaps. One-stage toe-to-hand transfer This is an area of microvascular development pioneered by Cobbett" in I969 and used since that time in small numbers of cases in the United States by Buncke et al."4 and in Japan by Tamai". Reports from these small numbers have indicated technical difficulties and concern for the microvascular anastomoses in the postoperative period. These difficulties have been resolved by using the dorsalis pedis artery and the great saphenous vein with their continuations into the hallux or second toe'6. The plantar vessels are not necessary for the circulation of the large or second toe, and 30 cadaver dissections have confirmed the constant presence of dorsal digital vessels of adequate size.
Two operating teams work simultaneously the hand and the foot, locating the respective vessels, tendons, and nerves. A generous amount of skin is taken with the toe. The extensor hallucis longus or the extensor digitorum longus of the second toe is divided at the ankle area and the flexor hallucis longus above the medial malleolus or the flexor digitorum longus to the second toe on the plantar aspect. The level of section of the toe is deter-
on
17 5
mined by the length of the digit missing. However, retention of the metatarsophalangeal joint means careful dissection of muscle from the toe in situ to reduce the bulk of the transplant. An intramedullary bone graft may be taken from the residual toe bone. The dorsal vessels are traced under the extensor retinaculum, which is partly divided, but are not sectioned until the hand and foot dissections have been completed. After definition of the vessels, nerves, and tendons in the hand the bone is shaved and prepared for the bone graft. The toe is transfixed to the hand and the bones fixed with oblique Kirschner pins after the insertion of the intramedullary bone graft. The flexor tendon and the two digital nerves are joined and then the volar wound is closed. The extensor hallucis longus or extensor digitorum longus is sutured to the extensor pollicis longus or extensor indicis. The great saphenous vein and the dorsalis pedis artery are anastomosed end-to-end to the cephalic vein or one of its tributaries and to the radial artery just before the latter disappears into the first intermetacarpal cleft (Figs 22 and 2 3). The technique of transfer of the first and second toes is comparable. The toe transfers provide a pinch mechanism on the radial aspect of the hand. The second toe may be used for reconstruction of the index finger or middle finger when all 4 fingers are absent or only the little finger is present. There are skin deficiencies on each side of the second toe when it is used for transfer, and these require split skin graft cover. The plantar pad is unduly thick and is now thinned in situ before transfer. Similar vascular anastomoses are made for the hallux and second toe. The moderately large vessel size and the superficial position of the microanastomoses have contributed to the success and safety of this procedure. No anticoagulants are required and postoperative progress is uncomplicated. One great toe transfer and 3 second toe transfers have been performed. A protective degree of sensibility is achieved in the transfers and the difficult deep dissection of the sole is avoided. Not only does this method provide a safe toe transfer for acquired severely disabled hands. but it appears
applicable to severe congenital abnormalities.
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(a) Amputation of left thumb in 6 i- ear-old man through base of proximal Phalanx. (b) Reconstructed thumb 3 months after toe-tohand transfer. (c) Comparison of transplanted halluix on left hand and normal right thuimb. (Reproduced by permission from The Hand.) FIG. 22
Microlymphatic surgery This new field of microsirgery is the epitome of microvascular surgery. It is fascinating to read some oif the history of lymphatics, for the Hunter brothers, William and John, investigated this system. They injected lymph nodes, mapped out many lymphatic vessels, and demonstrated their valves. Their work resulted in one of the greatest surgical controversies of its time, delightfully described in the Bulletin of the New York Academy of Medici'ne (6th August 1974) by Mark M Ravich in a pub-
lication entitled 'Invective in surgery, William Hunter versus Monroe Primus, Monroe Secondus and Percival Pott'. Lymphaticovenous end-to-side communications have been observed under normal conditions",'3 and in abnormal circumstances"-"3. Lamne and Howard"4 conducted experimental end-to-side lymphaticovenous anastomoses to canine femoral veins over a temporary polyethylene splint which was then removed through a lateral ve-notomy. A patency Of 4004 was obtained between 3 weeks and 3 months
Replantation and reconstructive micro vascular surgery
17 7
(b)
FIG. 23 Toe-to-hand transfer (a) Diagrammatic representation of dorsal anatomy; sites of division of tendons and vessels are marked. (b) Diagrammatic representation of vascular anastomoses and tendon repairs. in 15 such anastomoses. In a second series of I5 anastomoses a 'shirt-tail' form of union, as used in ureterovesical anastomoses, with only one suture gave a patency rate of 20o%, after 3 months. The patency was observed by direct anastomosis and cannulation. It was noted that there was nearly always some stenosis at or near the anastomosis. Emphasis since that time has been placed on the anastomosis of transected lymph nodes to veins because of the technical difficulties involved in lymphaticovenous union. Niebulowicz and Olszewski45 and Politowski and Bortowski"6 claimed clinical improvement in patients with secondary lymphoedema using lymphonodovenous communications. Firica et al.47 demonstrated evidence of lymphovenous flow experimentally. Rivero et al.48 obtained ioo% patency at i month in dogs, but all the anastomoses were closed by fibrous tissue at 3 months38. However, these last observations were made in dogs without established secondary lymphoedema. Calderon et al.49 implanted lymphatics into veins and also performed direct end-to-end lymphaticovenous anastomoses but could not demonstrate the flow of lymph through these
anastomoses have been few. Cockett and Goodwin50, Mistillis and Skyring5", and Sedlacek5'2 have performed anastomoses for the treatment of chyluria and intestinal lymphangiectasia and for elephantiasis, with reasonable clinical results. However, in these conditions the anastomoses had been performed on large, dilated lymph vessels considerably removed from the size of normal lymphatics. Yamada53 succeeded in anastomosing lymph vessels to veins at the ankle of dogs with microvascular techniques, using a polyethylene catheter as a temporary internal splint. All the branches entering the saphenous veins between it and the nearest venous valvc were divided to protect the anastomoses, thus decreasing the venous pressure and avoiding back-flow across the anastomosis.
Personal experience: experimental In I969 many lymphaticovenous anastomoses were carried out to canine femoral vessels, joining the lymphatic obliquely to the femoral vein with 4 or 5 metallized nylon microsutures. However, the primary patency was inconsistent and subsequently a microsurgery technique junctions. Clinical trials of direct lymphaticovenous was evolved joining the lymphatic end-to-end
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to a similar-sized branch of the femoral vein over a Silastic splint, which was removed through the femoral vein wall after completion of the anastomosis. Angiography, re-exploration, and histopathological examination were used to follow the progress of the anastomoses. Most of the anastomoses were blocked within 24 h; hence postoperative heparin calcium (Calciparine) (700 mg/kg) was used subcutaneously twice daily for 7 days in the remaining group of I 5 dogs. Some improvement in patency rates was achieved up to I3 days. Then a technique in adult greyhounds was developed by Gilbert et al.54 anastormosing femoral lymphatics directly to small neighbouring veins away from the arterial pulsation. The diameter of the veins and lymphatic vessels ranged from 0.3 to I.2 mm. The vein was occluded with a soft clamp and the vein segment irrigated with heparinized saline (io 000 U/1) (Fig. 24). The lymphaticovenous anastomoses were performed without tension with i9-ptm metallized nylon sutures"9. The lymphatic flow was not interrupted and after the first few sutures the lymph helped to balloon up the vein. Repair is easier when the sutures are pas-sed through the vein walls first. Immediate patency of all anastomoses was obtained. The surrounding lymphatics were divided and ligated. It was possible by raising venous pressure to demonstrate venous backflow across the anastomosis and then to clear the anastomosis with lymph by squeezing the limb to elevate the lymphatic pressure. In assessing results lymphangiography was not found reliable and the best evidence of patency was by surgical exploration after the injection of patent blue dye into the paw. Proximal occlusion, emptying, and release also demonstrated distal-to-proximal flow. In these non-lymphoedematous models a patency rate at I week of 78% (14/I8) was obtained. Between 6 and 8 weeks the patency rate was 73O/ (24/33) and at 6 months 83% (IO/I2). In a second series the thoracic duct was ligated and at I month 7 out of II anastomoses (64%/,) were patent. Histologically in the patent anastomoses a thin circumferential luminal thrombus was present in continuity with the fibrinous coagulum between the tissue gaps and the suture track (Fig. 25). The prime determining factor
in the success of the anastomosis was achievement of correct apposition of the vessel edges without distortion, and this was dependent upon the number and placement of sutures as well as the tension applied when they were tied. When an occlusion occurred it stemmed in every case from the venous component. Lymph has very little coagulation potential. It was noted that where tissue disruption was greatest the luminal thrombus was most prominent (Fig. 24). Further experiments are now being carried out using lymphaticovenous anastomoses in dogs with experimental obstructive
(a;
4
(b)
FIG. 24 (a) Lymphatic above and vein below (already clamped); vessels approximately 0.5 mm diameter. (b) Completed anastomosis of lymphatic above and vein below with I 9-,ILm metallized microsutures; anastomosis is patent and lymph is flowing across it.
Replantation and reconstructive microvascular surgery
(a) Transverse section of patent lymphatic near a lymphaticovenous anastomoszs at I month; a mild luminal thrombus is present. Gomori aldehyde fuchsin. (b) Thrombosed lymphaticovenous anastomosis with some recanalization at 3 months. Gomori aldehyde fuchsin. (Reproduced by permission from the British Journal of Plastic Surgery.) FIG. 25
lymphoedema established by the method described by Clodius and Wirth55. There is a difference of pressure within the peripheral veins and the lymphatics, the lymphatic pressure being higher than the venous, during active muscular contraction53. In obstructive lymphoedema the pressure gradient between the lymphatics and the veins is probably higher still. Clinical experience Microlymphaticovenous have its main application in the treatment of secondary obstructive lymphoedema, as in primary lymphoedema there are usually few lymphatic vessels and little evidence of obstruction. In secondary lymphsurgery appears to
I179
oedema microsurgical treatment should ideally be instituted before the peripheral lymphatics have been substantially destroyed by increasing pressure and repeated infections. Preoperative lymphangiography has caused some worsening of the lymphoedema. The arm is elevated for approximately a week before operation and a compression pump applied daily for several hours until the arm volume is constant. In io cases of secondary obstructive lymphoedema in the upper limb treated by microvascular surgery 2-7 lymphaticovenous anastomoses, at the elbow and/or the middle of the medial aspect of the upper arm, have been performed. Postoperative elevation and compression are continued for a week after surgery, but no anticoagulant therapy is used. There has been significant reduction of limb volume, greater in the hand and forearm than in the upper arm. The isolation of the lymphatics after injection of patent blue dye into, the web space on the dorsum of the hand has been tedious, particularly when the lymphatics are only lightly stained. However, all sizeable lymphatics demonstrable by preoperative lymphangiography are usually located, and also a neighbouring vein of similar diameter. In most cases it has been assumed that there has been a valve in the vein distal to the main vein. Obstructive lymphoedemas of short and long duration have been treated. The earlier the patient is seen after onset of the oedema, the greater should be the chance of anastomosing larger numbers of lymuhatics to veins, but no known method is available yet of detecting those cases in which obstructive lymuhoedema will develop, nor is there any reliable method of estimation of lymphatic clearance by radioactive means or otherwise. There is a need for an accurate method of determining the lymph flow from a limb. A reduction in volume of 2 % of the limb has been observed at i month (Figs. 26 and 27), but some of this improvement has been lost with ambulation and dependency and failure to use conservative measures. Elevation at night assisted by pump compression and the wearing of an elastic stocking are needed, but these supportive mea'ures were not used in some of the early cases. Lvmuh can be expressed more quickly from a limb with multiple lymphaticovenous communications. Greater
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FIG. 26 (a) Obstructive lymphoedema of left.upper limb of 6 years duration following radical mastectomy an:d irradiation (b) Lymphangiogram showing obstructed lymphatics in elbow area. (c) Stained tortuous lymphatic in wound in cubital fossa. comfort and increasing softness of the limbs nature of obstructive lymphoedema, observahave been evident and clothes have fitted tion over a period of years is indicated. These~ morereadly ihcniudspotv e microsurgical methods are equally applicable ures it is possible that permanent improvement to the upper and lower limbs and to cases of may be obtained: as it may take some time ,ructive for the lymphaticovenous communication to loaie obtuiv lypodm flown l
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* Conclusion The role of microvascular surgery in replantation and reconstruction is established. Careful case selection is emphasized and there is a need for restructuring surgical units to incorporate this development. Many tissues can be transferred with the aid of microvascular surgery, including free muscle transplant and large bone grafts, which we are actively investigating at experimental and clinical levels. Further, the application to clinical allograft transplantation is not far distant. Microvascular surgery has had a brief yesterday, for it is the surgery of today and certainly of tomorrow. Many trusts and foundations in Australia and other countries assisted with this programme and their support is gratefully acknowledged. St Vincent's Hospital is thanked, with much appreciation for the provision and maintenancc of the surgical research theatres. The Sccretary and staff of the Royal College of Surgeons of England were unfailing in
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