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      Ferulización de la microanastomosis arterial tras elongar el pedículo con injerto venoso. Caso clínico Translated title: Splinting the arterial microanastosis with vein graft after elongation of the pedicle. Case report

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          Abstract

          Resumen La ferulización arterial es una modificación de la técnica de envoltura del sitio de aneurisma en aorta que se realiza en cirugía cardiotorácica. En microcirugía, modificamos la técnica sin envolver completamente el sitio de anastomosis cuando se presenta una angulación, sino solo ferulizándolo para disminuir la angulación de la anastomosis arterial causada por la turbulencia del paso del flujo sanguíneo y el alargamiento del pedículo empleando un injerto de vena como puente entre el vaso receptor y el pedículo del colgajo. Presentamos un caso de resección de carcinoma mandibular y reconstrucción con colgajo libre de tensor de fascia lata que a las 32 horas de la cirugía sufre sangrado profuso por avulsión de la microanastomosis arterial. Utilizamos 16 cm de vena safena para reconstruir el desgarro en el pedículo arterial y elongarlo, de cara a disminuir la tensión en la microanastomosis del vaso receptor y el pedículo del colgajo libre. Tras la microanastomosis se presenta angulación del pedículo y retardo de 10 segundos en el llenado capilar tras punción con aguja del colgajo libre. Reservamos 4 cm del injerto de vena para ferulizar el sitio de angulación de la microanastomosis arterial con el injerto de vena, observando disminución del ángulo de la microanastomosis y llenado capilar de 2 a 3 segundos, mejorando así la perfusión del colgajo libre.

          Translated abstract

          Abstract Arterial splinting is a modification of the aortic aneurysm site wrapping technique performed in cardiothoracic surgery. In microsurgery, we modify the technique without completely wrapping the anastomosis site when angulation occurs, but only splinting it to decrease angulation of the arterial anastomosis caused by turbulence in the passage of blood flow and lengthening of the pedicle using a vein graft such as bridge between the recipient vessel and the flap pedicle. We present a case of resection of mandibular carcinoma and reconstruction with fascia lata tensor free flap that, 32 hours after surgery, suffered profuse bleeding due to avulsion of the arterial microanastomosis. We used 16 cm of the saphenous vein to reconstruct the tear in the arterial pedicle and lengthen it in order to decrease the tension in the microanastomosis of the recipient vessel and the pedicle of the free flap. After microanastomosis, angulation of the pedicle occurs and noticed a 10-second delay in capillary filling after needle puncture of the free flap. We reserved 4 cm of the vein graft to splinting the angulation site of the arterial microanastomosis with the vein graft, achieving a decrease in the angle of the microanastomosis and a capillary filling of 2 to 3 seconds, thus improving the perfusion of the free flap

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          Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.

          Microvascular free tissue transfer is a reliable method for reconstruction of complex surgical defects. However, there is still a small risk of flap compromise necessitating urgent reexploration. A comprehensive study examining the causes and methods of avoiding or treating these complications has not been performed. The purpose of this study was to review the authors' experience with a large number of microvascular complications over an 11-year period. This was a retrospective review of all free flaps performed from 1991 to 2002 at Memorial Sloan-Kettering Cancer Center. All patients who required emergent reexploration were identified, and the incidence of vascular complications and methods used for their management were analyzed. A total of 1193 free flaps were performed during the study period, of which 6 percent required emergent reexploration. The most common causes for reexploration were pedicle thrombosis (53 percent) and hematoma/bleeding (30 percent). The overall flap survival rate was 98.8 percent. Venous thrombosis was more common than arterial thrombosis (74 versus 26 percent) and had a higher salvage rate (71 versus 40 percent). Salvaged free flaps were reexplored more quickly than failed flaps (4 versus 9 hours after detection; p = 0.01). There was no significant difference in salvage rate in flaps requiring secondary vein grafting or thrombolysis as compared with those with anastomotic revision only. Microvascular free tissue transfer is a reliable reconstructive technique with low failure rates. Careful monitoring and urgent reexploration are critical for salvage of compromised flaps. The majority of venous thromboses can be salvaged. Arterial thromboses can be more problematic. An algorithm for flap exploration and salvage is presented.
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            The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?

            The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.
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              Arteriovenous loop grafts for free tissue transfer.

              Arteriovenous (AV) loop grafts are a type of vascular conduit that can be used to support free tissue transfer. Wounds of various etiologies may require free tissue transfer, and the AV loop graft is a useful adjunct when adjacent blood supply is inadequate. Here we present 2 cases and review the technique and published literature.
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                Author and article information

                Journal
                cpil
                Cirugía Plástica Ibero-Latinoamericana
                Cir. plást. iberolatinoam.
                Sociedad Española de Cirugía Plástica, Reparadora y Estética (SECPRE) (Madrid, Madrid, Spain )
                0376-7892
                1989-2055
                December 2020
                : 46
                : 4
                : 471-474
                Affiliations
                [2] Taiwan orgnameChina Medical University Hospital Taichung China
                [1] Taiwan orgnameHospital Taichung orgdiv1China Medical University orgdiv2Departamento de Cirugía Plástica y Microcirugía Reconstructiva China
                Article
                S0376-78922020000500011 S0376-7892(20)04600400011
                10.4321/s0376-78922020000500011
                38b61f3a-8dab-4048-833d-ccdb05fa782c

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

                History
                : 10 March 2020
                : 09 April 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 11, Pages: 4
                Product

                SciELO Spain

                Categories
                Reconstructiva

                Microanastomosis vascular,Vascular pedicle,Microcirugía,Vascular splinting,Vascular microanastomosis,Microsurgery,Pedículo vascular,Ferulización vascular

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