Intraoperative Hemodynamic Evaluation of the Latissimus Dorsi Muscle Flap: A Prospective Study

Abstract

The aim of this study was to assess intraoperatively the hemodynamic changes in the donor vessel of free latissimus dorsi (LD) flap before and after denervation and to analyze flow changes after flap transfer. Twenty-seven patients underwent LD muscle microvascular reconstruction for lower-limb soft tissue defects. Measurements of blood flow were performed intraoperatively by using a 2- to 5-mm probe ultrasonic transit-time flowmeter around the dissected vessels. Registrations were made in the thoracodorsal artery before and after harvesting the flap, after compressing and cutting the motor nerve, and after anastomosis. Mean blood flow of in situ harvested thoracodorsal artery as measured intraoperatively by transit-time flowmeter was (mean ± standard deviation) 16.6 ± 11 mL/min and was significantly increased after raising the flap to 24.0 ± 22 mL/min (p <0.05); it was 25.6 ± 23 mL/min after compressing the motor nerve and was significantly increased after cutting the motor nerve to 32.5 ± 26 mL/min (p <0.05). A significant increase of blood flow to 28.1 ± 19 mL/min was also detected in the thoracodorsal artery after flap transplantation with end-to-side anastomosis (p <0.05). Vascular resistance in the thoracodorsal artery significantly decreased after flap raising and anastomosis (from 7.5 ± 3.4 to 4.0 ± 1.9 and to 4.5 ± 2.4, respectively, p <0.05). LD flap harvesting increases blood flow and decreases resistance in the thoracodorsal artery, especially after denervation.

Keywords

latissimus dorsi muscle - free flap - microvascular flap - blood flow - hemodynamics - intraoperative

• References

• 1 Salmi AM, Tierala EK, Tukiainen EJ, Asko-Seljavaara SL. Blood flow in free muscle flaps measured by color Doppler ultrasonography. Microsurgery 1995; 16: 666-672
• 2 Lorenzetti F, Suominen S, Tukiainen E , et al. Evaluation of blood flow in free microvascular flaps. J Reconstr Microsurg 2001; 17: 163-167
• 3 Lorenzetti F, Salmi A, Ahovuo J, Tukiainen E, Asko-Seljavaara S. Postoperative changes in blood flow in free muscle flaps: a prospective study. Microsurgery 1999; 19: 196-199
• 4 Hanasono MM, Ogunleye O, Yang JS, Hartley CJ, Miller MJ. Changes in blood velocity following microvascular free tissue transfer. J Reconstr Microsurg 2009; 25: 417-424
• 5 Machens HG, Pallua N, Pasel J, Mailaender P, Liebau J, Berger A. Persistence of pedicle blood flow up to 10 years after free musculocutaneous tissue transfer. Plast Reconstr Surg 1998; 101: 719-726
• 6 Machens HG, Mailänder P, Pasel J , et al. Flap perfusion after free musculocutaneous tissue transfer: the impact of postoperative complications. Plast Reconstr Surg 2000; 105: 2395-2399
• 7 Lorenzetti F, Giordano S, Suominen E, Asko-Seljavaara S, Suominen S. Intraoperative hemodynamic evaluation of the radial and ulnar arteries during free radial forearm flap procedure. J Reconstr Microsurg 2010; 26: 73-77
• 8 McGillivray-Anderson KM, Faber JE. Effect of acidosis on contraction of microvascular smooth muscle by alpha 1- and alpha 2-adrenoceptors. Implications for neural and metabolic regulation. Circ Res 1990; 66: 1643-1657
• 9 Hjortdal VE. Microcirculatory profile in myocutaneous island flaps. An experimental study in pigs. Scand J Plast Reconstr Surg Hand Surg Suppl 1992; 24: 1-40
• 10 Chen LE, Seaber AV, Bossen E, Urbaniak JR. The effect of acute denervation on the microcirculation of skeletal muscle: rat cremaster model. J Orthop Res 1991; 9: 266-274
• 11 Siemionow M, Andreasen T, Chick L, Lister G. Effect of muscle flap denervation on flow hemodynamics: a new model for chronic in vivo studies. Microsurgery 1994; 15: 891-894
• 12 Wang WZ, Anderson G, Firrell JC. Arteriole constriction following ischemia in denervated skeletal muscle. J Reconstr Microsurg 1995; 11: 99-106
• 13 Banbury J, Siemionow M, Porvasnik S, Petras S, Zins JE. Muscle flaps' triphasic microcirculatory response to sympathectomy and denervation. Plast Reconstr Surg 1999; 104: 730-737
• 14 Nasir S, Baykal B, Altuntaş S, Aydin MA. Hemodynamic differences in blood flow between free skin and muscles flaps: prospective study. J Reconstr Microsurg 2009; 25: 355-360
• 15 Figus A, Mosahebi A, Ramakrishnan V. Microcirculation in DIEP flaps: a study of the haemodynamics using laser Doppler flowmetry and lightguide reflectance spectrophotometry. J Plast Reconstr Aesthet Surg 2006; 59: 604-612 ; discussion 613
• 16 Kim JT, Kim CY, Kim YH. T-anastomosis in microsurgical free flap reconstruction: an overview of clinical applications. J Plast Reconstr Aesthet Surg 2008; 61: 1157-1163
• 17 Ichinose A, Tahara S, Terashi H, Yokoo S. Reestablished circulation after free radial forearm flap transfer. J Reconstr Microsurg 2004; 20: 207-213
• 18 Heitland AS, Markowicz M, Koellensperger E, Schoth F, Feller AM, Pallua N. Duplex ultrasound imaging in free transverse rectus abdominis muscle, deep inferior epigastric artery perforator, and superior gluteal artery perforator flaps: early and long-term comparison of perfusion changes in free flaps following breast reconstruction. Ann Plast Surg 2005; 55: 117-121
• 19 Kurita M, Takushima A, Shiraishi T, Okazaki M, Ozaki M, Harii K. Alteration of arterial blood flow after free muscle transfer. Ann Plast Surg 2010; 64: 477-481
• 20 Gürlek A, Schusterman MA, Evans GR, Gherardini G. Blood flow and microcirculatory changes in an ischemia-reperfusion injury model: experimental study in the rabbit. J Reconstr Microsurg 1997; 13: 345-349
• 21 Jokuszies A, Niederbichler A, Meyer-Marcotty M, Lahoda LU, Reimers K, Vogt PM. Influence of transendothelial mechanisms on microcirculation: consequences for reperfusion injury after free flap transfer. Previous, current, and future aspects. J Reconstr Microsurg 2006; 22: 513-518
• 22 Nasir S, Aydin MA, Sonmez E, Baykal B. Flow-through free latissimus dorsi flap for reconstruction of injured limbs: evaluation of hemodynamic effects on extremity circulation. Ann Plast Surg 2010; 65: 164-169
• 23 Hartman JC, Olszanski DA, Hullinger TG, Brunden MN. In vivo validation of a transit-time ultrasonic volume flow meter. J Pharmacol Toxicol Methods 1994; 31: 153-160
• 24 Matre K, Birkeland S, Hessevik I, Segadal L. Comparison of transit-time and Doppler ultrasound methods for measurement of flow in aortocoronary bypass grafts during cardiac surgery. Thorac Cardiovasc Surg 1994; 42: 170-174
• 25 Tukiainen E, Kallio M, Lepäntalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: long-term outcome. Ann Surg 2006; 244: 949-957 ; discussion 957–958
• 26 Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. J Reconstr Microsurg 2006; 22: 173-181
• 27 Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg 2010; 125: 582-588
• 28 Halperin TJ, Fox SE, Caterson SA, Slavin SA, Morris DJ. Delayed division of the thoracodorsal nerve: a useful adjunct in breast reconstruction. Ann Plast Surg 2007; 59: 23-25