An audit: Microvascular Free Flaps

Muralidhasan M¹, S Skanda²

¹Consultant-Plastic and Reconstructive Surgery, Kauvery Hospital, Cantonment, Trichy

²Guiding Consultant – HOD and Senior Consultant, Plastic and Reconstructive Surgery, Kauvery Hospital, Cantonment, Trichy

Background

Microvascular tissue transfer

A free flap is a tissue flap, including blood vessels, skin, fat, and sometimes muscle, bone, nerve that is detached from one part of the body and reattached to another part of the body. Anastomosis of the artery and veins is done at the recipient site. Good perfusion and an adequate drainage is ensured.

Fig: Flap

Methodology

A retrospective analysis of free flap patients over a period of 1 year at KMC Speciality Hospital, Cantonment, Trichy

Study period: July 2023 to July 2024
Data: Retrieved from electronic database
Sample: Total Number of free flaps done-66.

Results

Free Flaps in Diabetic foot Ulcers

Diabetic Wounds never heal if they are not treated appropriately; they need a critical evaluation and a multi-disciplinary approach.

Aim

Any major raw area needs functional and aesthetically acceptable wound coverage. Diabetic foot ulcers are no exception to this.
We need to give a stable and durable cover for the wound.
Prevent recurrences.
Treat and salvage the foot, the limb, and ultimately the patient
Give a better quality of life for our patients.

Challenges

Ischemic component
Surgical Site infection
Heavily Calcified vessels with chronic inflammatory peri vascular changes
MDR /Poly microbial colonisation
Break the myth
Cardiac/Renal Status

Results

Total number of free flaps in Diabetic Foot ulcers = 34

Outcomes

Diabetic plantar defect

Diabetic midfoot defect

Gracilis Muscle flap

Diabetic Heel pad defect

Heel pad reconstruction with gracilis muscle

Limb salvaged with Gracilis muscle flap

Diabetic Entire sole of the foot defect

Gracilis muscle with graft

Post Traumatic Defects – Challenges

Prothrombotic state
Need to go outside the zone of injury, hence long pedicle of the flaps
Good Quality Veins – We prefer deep veins
External Fixator device – Planned before fixing
Other injuries – Rib and long bone fractures, head injury

Other defects

Parameters assessed	Electrical Burns	Lymphedema	Oncoplastic reconstruction	Non diabetic infected wounds	Rhombergs disease
Total numbers	3	4	1	2	1
Muscle flap	0	0	0	1	0
Fasciocutaneous /Chimeric flaps	3	4	1	1	1
Complete Success	3	4	1	1	1
Re-exploration	0	1	1	1	0

Post Mastectomy Upper limb Lymphedema

Filarial Lower limb Lymphedema

Pediatric Post Electrical Burns raw area

Pediatric post high voltage electrical burns fasciotomy, early flap cover

Limb Salvaged

Post Traumatic soft tissue defect

Pediatric post-traumatic soft tissue Defect

Parameter	DFU	Trauma	Lymphedema	Others
Intraop blood loss	< 100ml	< 200 ml	< 100ml	< 100ml
Immediate post op Reexploration	12%	15%	33.3%	11.11%
Surgical donor site infection	5.88%	-	-	-
Abandoned intraop	5.88%	-	-	-
Intraop Switch over to alternate flap	8.82%	10%	33.33%	22.22%
Long term flap related complications	14.70%	5%	-	11.11%
Operating time	3 to 4 hr	3 to 5 hr	3 to 4 hr	3 to 5 hr
Average stay in hospital	6.5 days	9 days	5 days	11 days

Discussion

Travelling along the reconstructive ladder, provides us various options in reconstruction. Free microvascular tissue transfer helps us in early wound cover. Transferred tissues provide a durable long-term cover, avoiding further compromise in the crippled limb

When no local options are available, free flaps are the lifeboat. We did have complication, but identifying it at the earliest and salvaging the flap was crucial for our success

We are heading towards bringing down the donor site related complications to zero

Reasons for Complete Loss

Polymicrobial infection
Prothrombotic state
Venous insufficiency

Reasons for Partial Loss

Positional Changes
Inadequate venous Drainage
Violating the angiosome or Perforosome territory
Hypoperfusion due to hypotension
Vessel spasm (Pediatric population

How did we overcome the challenges?

Critical pre op assessment – Multidisciplinary approach
Preoperative counselling of the patient
Radical debridements
Critical assessment of wounds
Preoperative Vascular assessment and Revascularization if needed
Early flap cover in traumatic / Burns wounds
Avoiding the zone of injury for the recipient vessels
Meticulous dissection of pedicle
Neurotising the flap

How did we overcome the challenges?

No heparin in post op period
Avoiding hypotension in post op period
Warmer support
Adequate positional support
Regular Follow up to avoid flap related complications
And now , we have come up with Surgical Offloading for diabetic patients post salvage with free flaps
Expenses for long term dressings is much more compared to microvascular procedure, which gives a durable long term cover
Now being covered under many private insurance policies and schemes, so surgical cost is taken care.
Surgical timing reduced by two team approach – one team for recipient site and other for flap harvest, working simultaneously

Acknowledgment

Skilled Microsurgical team
Multidisciplinary supportive Speciality Team
Well-trained staffs

Dr. Muralidhasan M
Consultant-Plastic and Reconstructive Surgery

Dr. S. Skanda
Guiding Consultant – HOD and Senior Consultant

An audit: Microvascular Free Flaps

An audit: Microvascular Free Flaps

Muralidhasan M1, S Skanda2

Journals

Muralidhasan M¹, S Skanda²