Venous Free Flap with Interposition Bypass Graft for Arteriovenous Fistula Preservation: A Case Report.

Cutaneous squamous cell carcinoma (CSCC) overlying an arteriovenous fistula (AVF) is rare and presents unique challenges. This case report describes a method of fistula preservation after CSCC excision using a flow-through venous free flap. The saphenous vein of the venous flap was used as flow-through segment for AVF preservation. The flap was inserted along the dorsal aspect of the forearm wound and microvascular anastomosis of the arterial inflow was completed using a vein just proximal to the radiocephalic fistula anastomosis. Venous outflow was established by creating an end-to-end vascular anastomosis between the cephalic vein and the greater saphenous vein. A separate subcutaneous vein was used to provide a low-pressure outflow for the flap to avoid congestion. This case demonstrates an option for AVF preservation that has not been previously described. It also highlights the importance of a multidisciplinary approach for the safe treatment of CSCCs overlying AVFs.

Staged Mastopexy Before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Implant-Based and Autologous Breast Reconstruction.

BACKGROUND: Breast reconstruction following nipple sparing mastectomy in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS: A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before nipple sparing mastectomy and reconstruction in our institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS: In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3 percent) were reconstructed with free abdominal flaps, 6 (7.1 percent) with tissue expanders and 66 (78.6 percent) with permanent subpectoral implants and acellular dermal matrix. There was one postoperative superficial nipple areolar complex epidermolysis (1.2 percent), and two partial mastectomy skin flap necrosis (2.4 percent). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION: Mastopexy or breast reduction before nipple sparing mastectomy and reconstruction is a safe procedure with a low risk of ischemic complications.

Head and Neck Reconstruction with Venous Flap: A Case Report.

Venous flaps are nonphysiologic flaps in which the venous system replaces the vascular circuit found in conventional flaps, serving as inflow as well as outflow. Although a main concern with venous flaps has been their reliability, this can be improved by manipulating their physiology using shunt restriction. The soft, pliable tissue provided by venous flaps coupled with the low donor site morbidity and ease of flap harvest make them ideal for coverage of moderate-sized facial defects, which may be too large for local options yet too small for conventional free flaps. We report the use of a large, 70 cm2 arterialized venous free flap to reconstruct a complex forehead deficit after basal cell carcinoma resection. Furthermore, we present the first report of the successful use of valvulotomes in the case of a large, reverse flow arterialized venous flap where several in-series valves were found to prevent adequate perfusion of the flap. Upon removal of the valves, complete perfusion of the flap was achieved.

Preshaping DIEP Flaps: Simplifying and Optimizing Breast Reconstruction Aesthetics.

SUMMARY: One key component of a successful autologous breast reconstruction is insetting the flap to accurately resemble an aesthetic breast. The authors describe a novel technique used to shape a deep inferior epigastric artery perforator flap into a coned breast mound before introducing it into the breast pocket. With the flap perfusing on the chest wall, an area of skin estimating the size and location of the skin paddle is marked. The skin to be buried is then deepithelialized. Once hemostasis is ensured, the shaping is performed. Two 2-0 polydioxanone sutures are anchored in the Scarpa fascia at the 10- and 2-o'clock positions and then run at the level of the Scarpa fascia to the 6-o'clock position. The two sutures are then cinched together to achieve the desired shape and then tied. The flap is then placed in the breast pocket and secured into place at the inferomedial and inferolateral corners, and at its cranial aspect. The size of the skin paddle can then be finalized. In the authors' series of 21 breast reconstructions in 11 patients using flap preshaping, they have not seen any compromise in flap perfusion, with one patient showing a small area of secondary fat necrosis. In addition, the flaps maintained their aesthetic breast shape throughout follow-up. The authors believe this technique for shaping inferior epigastric artery perforator flaps before inset into the breast pocket to be both safe and predictable, simplifying one of the more tedious aspects of autologous breast reconstruction.

High-Fidelity Microsurgical Simulation: The Thiel Cadaveric Nerve Model and Evaluation Instrument.

With surgical education moving from a time-based to a competency-based model, developing high-fidelity simulation models has become a priority. The Thiel cadaveric model has previously been used for a number of medical and surgical simulations, including microvascular simulation. We aim to investigate the use of the Thiel model in peripheral nerve simulation and validate a novel evaluation instrument. Sixteen residents ranging from postgraduate years 1 to 6 participated in the study. Their nerve coaptations using Thiel cadaveric nerves were video recorded and evaluated by 5 fellowship-trained microsurgeons using the Micro-Neurorrhaphy Evaluation Scale (MNES). The intraclass correlation among the 5 evaluators was 0.75, revealing excellent interrater reliability. The Cronbach α was .77, underlining the internal consistency of the test items. Bivariate analysis revealed a significant association between the MNES scores and the participants' self-declared level of experience. This correlation was confirmed by mixed modeling. Our results validate the MNES and underscore the utility of the Thiel nerve tissue for peripheral nerve surgical simulation.

Puisque l'enseignement de la chirurgie passe d'un modèle axé sur le temps à un modèle axé sur les compétences, il est devenu prioritaire de créer des modèles de simulation haute fidélité. La méthode cadavérique de Thiel a déjà été utilisée pour plusieurs simulateurs médicaux et chirurgicaux, y compris la simulation microvasculaire. Les chercheurs ont l'intention de l'explorer pour la simulation des nerfs périphériques et de valider un nouvel instrument d'évaluation. Seize résidents de première à sixième année ont participé à l'étude. Leur coaptation nerveuse à l'aide des nerfs cadavériques de Thiel a été enregistrée sur vidéo et évaluée par cinq microchirurgiens possédant un postdoctorat à l'aide de l'échelle d'évaluation de la microneurorraphie (ÉÉMN). La corrélation intraclasse entre les cinq évaluateurs était de 0,75, révélant une excellente fiabilité interévaluateur. Le coefficient alpha de Cronbach était de 0,77, soulignant la cohérence interne des éléments à l'essai. L'analyse bivariée a révélé une association significative entre les scores d'ÉÉMN et le taux d'expérience déclaré par les participants. Cette corrélation a été confirmée par modélisation mixte. Les résultats des chercheurs valident l'ÉÉMN et soulignent l'utilité des tissus nerveux de Thiel pour la simulation chirurgicale des nerfs périphériques.

High Fidelity Microsurgical Simulation: The Thiel Model and Evaluation Instrument.

BACKGROUND: The Thiel embalmment method has recently been used in a number of medical simulation fields. The authors investigate the use of Thiel vessels as a high fidelity model for microvascular simulation and propose a new checklist-based evaluation instrument for microsurgical training. METHODS: Thirteen residents and 2 attending microsurgeons performed video recorded microvascular anastomoses on Thiel embalmed arteries that were evaluated using a new evaluation instrument (Microvascular Evaluation Scale) by 4 fellowship trained microsurgeons. The internal validity was assessed using the Cronbach coefficient. The external validity was verified using regression models. RESULTS: The reliability assessment revealed an excellent intra-class correlation of 0.89. When comparing scores obtained by participants from different levels of training, attending surgeons and senior residents (Post Graduate Year [PGY] 4-5) scored significantly better than junior residents (PGY 1-3). The difference between senior residents and attending surgeons was not significant. When considering microsurgical experience, the differences were significant between the advanced group and the minimal and moderate experience groups. The differences between minimal and moderate experience groups were not significant. Based on the data obtained, a score of 8 would translate into a level of microsurgical competence appropriate for clinical microsurgery. CONCLUSIONS: Thiel cadaveric vessels are a high fidelity model for microsurgical simulation. Excellent internal and external validity measures were obtained using the Microvascular Evaluation Scale (MVES).

HISTORIQUE: La méthode d'embaumement Thiel a récemment été utilisée dans divers domaines de simulation médicale. Les auteurs explorent l'utilisation des vaisseaux Thiel comme modèle haute-fidélité pour la simulation microvasculaire et proposent un nouvel instrument d'évaluation de formation à la microchirurgie reposant sur une liste de vérification. MÉTHODOLOGIE: Treize résidents et deux microchirurgiens traitants ont effectué des anastomoses microvasculaires sur des artères embaumées Thiel. Quatre microchirurgiens surspécialisés en ont évalué l'enregistrement à l'aide d'un nouvel instrument (échelle de simulation microchirurgicale en dix étapes). Ils ont évalué la validité interne au moyen du coefficient de Cronbach et vérifié la validité externe à l'aide de modèles de régression. RÉSULTATS: L'évaluation de fiabilité a révélé une excellente corrélation intraclasse de 0,89. Lorsqu'on compare les scores obtenus par des participants de divers niveaux de formation, les chirurgiens et les résidents seniors (de quatrième ou cinquième année) ont obtenu des résultats significativement supérieurs à ceux des résidents juniors (de première à troisième année). La différence entre les résidents seniors et les chirurgiens traitants n'était pas significative. Les différences d'expérience microchirurgicale étaient significatives entre le groupe avancé et les groupes ayant une expérience minime ou modérée. D'après les données obtenues, un score de 8 désignerait un niveau de compétence microchirurgicale acceptable pour la microchirurgie clinique. CONCLUSIONS: Les vaisseaux cadavériques Thiel sont un modèle haute-fidélité de simulation microchirurgicale. D'excellentes mesures de validité interne et externe ont été obtenues au moyen de l'échelle de simulation microchirurgicale en dix étapes.

Arteriovenous fistulas for microvascular head and neck reconstruction.

BACKGROUND: In head and neck cancer patients, multiple surgeries and radiation can leave the neck depleted of recipient vessels appropriate for microvascular reconstruction. The creation of temporary arteriovenous fistulas using venous interposition for subsequent microvascular reconstruction has rarely been reported in the head and neck. The authors report the largest series of temporary arteriovenous loops for head and neck reconstruction in vessel-depleted necks. METHODS: The authors performed a case series of major head and neck reconstructions using temporary arteriovenous fistulas with a saphenous vein graft. A subclavian surgical approach was used. All reconstructions were performed at least two weeks after the creation of the initial fistula. RESULTS: The authors have performed nine reconstructive cases for malignancy using five different free flaps. The subclavian and transerve cervical arteries were used, and the subclavian, internal jugular and cephalic veins were used for microanastomosis. Two cases of flap hematoma and one case of venous pedicle compression were recorded. No cases of flap failure were reported. CONCLUSIONS: Reconstruction using temporary arteriovenous fistulas is a reliable technique that can be used in the vessel-depleted neck, with excellent outcomes in experienced hands.

HISTORIQUE: Chez les patients atteints d'un cancer de la tête et du cou, les multiples opérations et la radiothérapie peuvent expurger le cou des vaisseaux receveurs convenant à la reconstruction microvasculaire. La création de fistules artérioveineuses temporaires par interposition veineuse en vue d'une reconstruction microvasculaire a rarement été signalée sur la tête et le cou. Les auteurs rendent compte de la plus vaste série de cas de boucles artérioveineuses temporaires sur des cous expurgés de vaisseaux receveurs lors de la reconstruction de la tête et du cou. MÉTHODOLOGIE: Les auteurs ont procédé à une série de cas de reconstructions majeures de la tête et du cou au moyen de fistules artérioveineuses temporaires par greffe de la veine saphène, en privilégiant un abord par la sous-clavière. Ils ont effectué toutes les reconstructions au moins deux semaines après la création de la fistule initiale. RÉSULTATS: Les auteurs ont effectué neuf reconstructions au moyen de cinq lambeaux libres différents après un cancer. Ils ont utilisé les artères sous-clavière et cervicale transverse ainsi que les veines sous-clavière, jugulaire interne et céphalique pour la micro-anastomose. Ils ont enregistré deux cas d'hématome du lambeau et un cas de compression du pédicule, mais aucun cas d'échec du lambeau. CONCLUSIONS: Entre des mains expérimentées, la reconstruction au moyen de fistules artérioveneuses temporaires est une technique fiable qui peut être utilisée dans le cou expurgé de vaisseaux receveurs et donner d'excellents résultats.

Horizontal mattress technique for anastomosis of size-mismatched vessels.

OBJECTIVE: To evaluate the horizontal mattress technique in microvascular anastomosis for size-mismatched vessels. METHODS: The present study involved cadaveric simulation using size-mismatched (1.5:1) Thiel-embalmed cadaveric arteries. The authors performed horizontal mattress anastomoses using 9-0 nylon suture and recorded the procedure. Vessel patency was evaluated by saline infusion. Vessels were cut open and photographed; histological slides were prepared and stained with hematoxylin and eosin. RESULTS: Four anastomoses were performed. Vessels were found to be patent in all cases, with grade 0 leaks. Intima-on-intima apposition with no intraluminal exposure of muscularis nor adventitia were observed. CONCLUSION: The present cadaveric study supports the technical feasibility of using horizontal mattress sutures in size-mismatched end-toend anastomoses.

OBJECTIF: Évaluer la technique de suture matelassée horizontale pour l'anastomose microvasculaire de vaisseaux de différentes dimensions. MÉTHODOLOGIE: La présente étude par simulation cadavérique portait sur des artères cadavériques de différentes dimensions (1,5:1), embaumées selon la méthode de Thiel. Les auteurs ont effectué des anastomoses par suture matelassée horizontale au moyen d'un fil de nylon 9-0 et ont vidéo-enregistré l'intervention. Ils ont évalué la perméabilité des vaisseaux au moyen d'une infusion de solution saline. Ils ont ouvert et photographié les vaisseaux et préparé des lames histologiques qu'ils ont colorées à l'hématoxyline et à l'éosine. RÉSULTATS: Quatre anastomoses ont été effectuées. Dans tous les cas, les vaisseaux étaient perméables et les fuites, de grade 0. Les chercheurs ont observé une apposition intima-sur-intima sans exposition intraluminale de la musculeuse ou de la séreuse. CONCLUSION: La présente étude cadavérique corrobore la faisabilité technique des sutures matelassées horizontales pour les anastomoses terminoterminales d'artères de dimensions différentes.

Intra-arterial Thrombolysis for Postoperative Digital Ischemia: A Case Report.

OBJECTIVE: Surgical repair of digital flexion deformities can result in vascular injuries threatening the viability of the affected digit. While uncommon, these injuries are reported to have a rate as high as 0.8% following palmo-digital fasciectomy for Dupuytren's disease. Late presentation of such vascular events pose a challenge, since taking the patient to the operating room does not guarantee success. METHODS: We report a case of subacute digital ischemia that presented 10 days following correction of a boutonniere deformity treated with intra-arterial thrombolysis. There were no particular intraoperative complications. The thrombolytic regimen consisted of Alteplase (Roche, Mississauga, Canada) 2 mg bolus and 1 mg per hour (total 30 mg received over 28 hours) and intravenous heparin with a subtherapeutic target partial thromboplastin time of 40 to 50 seconds. RESULTS: Thirty hours after the initiation of thrombolysis, an angiography confirmed complete reperfusion of the digital arteries at the distal interphalangeal joint that correlated with the clinical appearance of the digit. Thrombolysis was interrupted and therapeutic intravenous heparin was maintained. Bridging to warfarin was started 6 days postthrombolysis with a target international normalized ratio of 2 to 3. Unfortunately, she was weaned from the heparin while her international normalized ratio was not yet in the therapeutic range and the vessels rethrombosed. This was confirmed by angiography, and intra-arterial thrombolysis was performed with successful revascularization. The patient was restarted on therapeutic dose of heparin and carefully bridged to Coumadin. CONCLUSIONS: For traction injuries, thrombolytic therapy can be a viable option although we should keep in mind that it could provoke severe adverse events.

A new microsurgical research model using Thiel-embalmed arteries and comparison of two suture techniques.

PURPOSE: To assess the utility of the Thiel arterial model in microsurgical research, we compared interrupted horizontal mattress (HM) sutures to simple interrupted (SI) sutures in human vessels. METHODS: A microsurgical set-up using an operating microscope and Thiel-embalmed arteries was used to practice ten SI and HM anastomoses. Vessel patency, leak and stricture were evaluated using angiography, and vessel wall architecture was evaluated using light microscopy and scanning electron microscopy (SEM). The technique speed was also assessed. RESULTS: We have successfully evaluated all outcomes. All anastomoses were patent. The stricture rate was higher with HM than with SI (60% vs. 35% surface area reduction). Three minor leaks occurred with HM sutures versus one with SI sutures. Edges were evenly everted without any intimal flaps with HM compared to SI. The anastomoses were performed faster using HM than SI sutures (7:58 min vs. 12:41 min, respectively). CONCLUSION: This is the first study to evaluate the feasibility of a Thiel-embalmed artery model for research purposes. The HM microvascular suture is a promising technique that requires further in vivo validation.

Monitoring buried jejunum free flaps with a sentinel: a retrospective study of 20 cases.

OBJECTIVES/HYPOTHESIS: The free jejunum transfer has become a widely used reconstruction option after total laryngopharyngectomy. The aim of this study was to evaluate the effectiveness of using an exteriorized jejunal segment for flap monitoring. STUDY DESIGN: Case series. METHODS: Twenty patients with tumors involving the pharynx, larynx, or cervical esophagus were subjected to total laryngopharyngectomy and neck dissection. The resulting esophageal defect was reconstructed with a free jejunal flap based on a major branch of the superior mesenteric artery and vein. After completion of anastomoses with the recipient vessels, the flap was divided into two segments of common vascular supply. The smaller segment was exteriorized in the cervical region for direct monitoring of serosal color, temperature, peristalsis, and bleeding during the postoperative period. This sentinel was resected once the viability of the flap was judged appropriate. RESULTS: Of the 20 patients who had free jejunum transfers for pharyngoesophageal reconstruction, 14 had an uneventful postoperative course, and six needed re-exploration due to signs of arterial insufficiency in the sentinel segment. On re-exploration, four flaps were found to have arterial thrombosis and two had no abnormality at the anastomotic site. One of the flaps that developed thrombosis was subsequently lost. CONCLUSIONS: Monitoring of buried free jejunal flap with a sentinel is an effective method of assessing flap viability after total laryngopharyngectomy and guides re-exploration in cases of anastomotic complications.