Download PDF
J Reconstr Microsurg 2017; 33(03): 179-185
DOI: 10.1055/s-0036-1594296
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Perfusion Controlled Mobilization after Lower Extremity Free Flaps—Pushing the Limits of Time and Intensity

Ulf Dornseifer
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Technische Universität München, Munich, Germany
2   Department of Experimental Plastic Surgery, Clinic for Plastic and Hand Surgery, Technische Universität München, Munich, Germany
,
Charlotte Kleeberger
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Technische Universität München, Munich, Germany
,
Lukas Kargl
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Technische Universität München, Munich, Germany
,
Markus Schönberger
3   Institute of Medical and Polymer Engineering, Technische Universität München, Garching, Germany
,
Daniel Rohde
3   Institute of Medical and Polymer Engineering, Technische Universität München, Garching, Germany
,
Milomir Ninkovic
1   Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Hospital, Technische Universität München, Munich, Germany
,
Arndt Schilling
2   Department of Experimental Plastic Surgery, Clinic for Plastic and Hand Surgery, Technische Universität München, Munich, Germany
4   Clinic for Trauma Surgery, Orthopaedic Surgery and Plastic Surgery, University Medical Center Göttingen, Göttingen, Germany
› Author Affiliations
Further Information

Publication History

14 August 2016

08 October 2016

Publication Date:
28 November 2016 (online)

    Permissions and Reprints

Abstract

Background The current standard to gradually adapt the fragile perfusion in lower extremity free flaps to an upright posture is the dangling maneuver. This type of flap training neither fits the orthostatic target load of an upright posture, nor does it assist in mobilizing the patients effectively. In this study, we quantitatively analyzed training effects of an early and full mobilization on flap perfusion.

Methods A total of 15 patients with gracilis flaps for distal lower extremity reconstruction were included. Flap training was performed daily by mobilizing the patients on a tilt table into a fully upright posture for 5 minutes between the third and fifth postop days (PODs). Changes in micro- and macrocirculation were analyzed by laser Doppler flowmetry, remission spectroscopy, and an implanted Doppler probe.

Results All flaps healed without complications. Yet, in three patients, the increased orthostatic load required an adjustment of the training duration due to a critical blood flow. The others showed an increasing compensation in the microcirculation. When tilting the patients, blood flow and oxygen saturation dropped significantly less on POD5 than on POD3. Furthermore, a significant increase of the blood flow was noted after an initial decrease during the mobilization on all days. An increasing compensation in the macrocirculation could not be determined.

Conclusion Full mobilization of patients with lower extremity free flaps can be performed safely under perfusion monitoring, already starting on POD3. Additionally, monitoring allows a consideration of the individual orthostatic competence and therefore, exploitation of the maximum mobilization potential.

Keywords

free flap - dangling - flap training
 

  • References

  • 1 Allen C, Glasziou P, Del Mar C. Bed rest: a potentially harmful treatment needing more careful evaluation. Lancet 1999; 354 (9186) : 1229-1233
    CrossrefPubMedGoogle Scholar
  • 2 Sakurai H, Yamaki T, Takeuchi M, Soejima K, Kono T, Nozaki M. Hemodynamic alterations in the transferred tissue to lower extremities. Microsurgery 2009; 29 (2) 101-106
    CrossrefPubMedGoogle Scholar
  • 3 Ridgway EB, Kutz RH, Cooper JS, Guo L. New insight into an old paradigm: wrapping and dangling with lower-extremity free flaps. J Reconstr Microsurg 2010; 26 (8) 559-566
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Rohde C, Howell BW, Buncke GM , et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg 2009; 25 (1) 15-19
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg 2008; 61 (3) 280-284
    CrossrefPubMedGoogle Scholar
  • 6 Isenberg JS, Siegal A, Sherman R. Quantitative evaluation of the effects of gravity and dependency on microvascular tissue transfer to the lower limb, with clinical applications. J Reconstr Microsurg 1997; 13 (1) 25-29
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Kolbenschlag J, Bredenbroeker P, Daigeler A , et al. Changes of oxygenation and hemoglobin-concentration in lower extremity free flaps during dangling. J Reconstr Microsurg 2014; 30 (5) 319-328
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Neubert N, Vogt PM, May M , et al. Does an early and aggressive combined wrapping and dangling procedure affect the clinical outcome of lower extremity free flaps?-a randomized controlled prospective study using microdialysis monitoring. J Reconstr Microsurg 2016; 32 (4) 262-270
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Hölzle F, Rau A, Loeffelbein DJ, Mücke T, Kesting MR, Wolff KD. Results of monitoring fasciocutaneous, myocutaneous, osteocutaneous and perforator flaps: 4-year experience with 166 cases. Int J Oral Maxillofac Surg 2010; 39 (1) 21-28
    CrossrefPubMedGoogle Scholar
  • 10 Nilsson GE, Tenland T, Oberg PA. Evaluation of a laser Doppler flowmeter for measurement of tissue blood flow. IEEE Trans Biomed Eng 1980; 27 (10) 597-604
    PubMedGoogle Scholar
  • 11 Nilsson GE, Tenland T, Obert PA. A new instrument for continuous measurement of tissue blood flow by light beating spectroscopy. IEEE Trans Biomed Eng 1980; 27 (1) 12-19
    PubMedGoogle Scholar
  • 12 Thorne ML, Poepping TL, Rankin RN, Steinman DA, Holdsworth DW. Use of an ultrasound blood-mimicking fluid for Doppler investigations of turbulence in vitro. Ultrasound Med Biol 2008; 34 (7) 1163-1173
    CrossrefPubMedGoogle Scholar
  • 13 Jokuszies A, Neubert N, Herold C, Vogt PM. Early start of the dangling procedure in lower extremity free flap reconstruction does not affect the clinical outcome. J Reconstr Microsurg 2013; 29 (1) 27-32
    PubMedGoogle Scholar
  • 14 Miyamoto S, Kayano S, Fujiki M, Chuman H, Kawai A, Sakuraba M. Early mobilization after free-flap transfer to the lower extremities: preferential use of flow-through anastomosis. Plast Reconstr Surg Glob Open 2014; 2 (3) e127
    CrossrefPubMedGoogle Scholar
  • 15 Bogin B, Varela-Silva MI. Leg length, proportion, health and beauty: a review. Anthropol Anz 2009; 67 (4) 439-459
    CrossrefPubMedGoogle Scholar
  • 16 Eisenhardt SU, Schmidt Y, Thiele JR , et al. Negative pressure wound therapy reduces the ischaemia/reperfusion-associated inflammatory response in free muscle flaps. J Plast Reconstr Aesthet Surg 2012; 65 (5) 640-649
    CrossrefPubMedGoogle Scholar
  • 17 Isogai N, Kamiishi H, Chichibu S. Re-endothelialization stages at the microvascular anastomosis. Microsurgery 1988; 9 (2) 87-94
    CrossrefPubMedGoogle Scholar
  • 18 Strecker WB, Wood MB, Schroeder AR. Stasis-induced thrombosis of rat microvascular anastomosis. J Reconstr Microsurg 1987; 4 (1) 69-73
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Guba Jr AM. Arteriovenous shunting in the pig. Plast Reconstr Surg 1980; 65 (3) 323-327
    CrossrefPubMedGoogle Scholar
  • 20 Hjortdal VE, Hansen ES, Henriksen TB, Kjølseth D, Søballe K, Djurhuus JC. The microcirculation of myocutaneous island flaps in pigs studied with radioactive blood volume tracers and microspheres of different sizes. Plast Reconstr Surg 1992; 89 (1) 116-122 , discussion 123–124
    CrossrefPubMedGoogle Scholar
  • 21 Kerrigan CL. Skin flap failure: pathophysiology. Plast Reconstr Surg 1983; 72 (6) 766-777
    CrossrefPubMedGoogle Scholar
  • 22 Pang CY, Forrest CR, Morris SF. Pharmacological augmentation of skin flap viability: a hypothesis to mimic the surgical delay phenomenon or a wishful thought. Ann Plast Surg 1989; 22 (4) 293-306
    CrossrefPubMedGoogle Scholar
  • 23 Reinisch JF. The pathophysiology of skin flap circulation. The delay phenomenon. Plast Reconstr Surg 1974; 54 (5) 585-598
    CrossrefPubMedGoogle Scholar
  • 24 Sakai T, Hosoyamada Y. Are the precapillary sphincters and metarterioles universal components of the microcirculation? An historical review. J Physiol Sci 2013; 63 (5) 319-331
    CrossrefPubMedGoogle Scholar
  • 25 Kolbenschlag J, Bredenbroeker P, Lehnhardt M , et al. Advanced microcirculatory parameters of lower extremity free flaps during dangling and their influencing factors. J Reconstr Microsurg 2015; 31 (7) 500-507
    Article in Thieme ConnectPubMedGoogle Scholar