Microsurgical Reconstruction in Large Vascular Malformations

Serious complications have been frequently observed after surgery in large or extensive venous malformations (VM), lymphatic malformations (LM) or extensive arteriovenous malformations (AVM). A large or deep defect might be caused by radical resection of the lesion, and its ischemic bed could stimulate the reactivation of remnant lesion or aggravated recurrence of the lesion. Sometimes, destruction of normal structures seems unavoidable, such as in the lip or ear, and important structures, such as the facial nerve or feeding vessel, may be exposed with radical resection of the lesion. Normal vascular patency can be sacrificed during surgery, especially in lesions of the extremities. To prevent these sequelae, microsurgical reconstruction is recommended for reconstruction of normal structures or resurfacing of defects.

Surgical treatments in 79 cases of large or extensive vascular malformations have been performed: VM (42), LM (17), AVM (9), and other extensive or combined vascular malformations (11). Microsurgical reconstruction has been applied in 52 cases for the reconstruction of defects after radical resection of lesions, such as vein graft for vascular patency, free flap reconstruction for filling the defect, free flap for vascular rebuilding, resurfacing with free flap for covering the important structure exposed, and so on. These treatment modalities were compared with other conventional treatments in 27 cases, including resection only without any microsurgical reconstruction.

A significant decrease in the recurrence rate was observed in the group with microsurgical reconstruction; on the contrary, the group without microsurgical reconstruction showed various postoperative problems, such as recurrence, pain, deformity, leakage of seroma, and functional problems.

Accurate diagnosis of vascular malformations is important for their complete remission. Later recurrence would be expected in incomplete resection or radical resection only in the treatment of large or extensive AVM, LM, and VM, because insufficient resection can stimulate the remnant lesion to activate a new ischemic bed and hemodynamic alteration. However, if the lesion or defect is reconstructed with well-vascularized tissue such as a free flap, the bed and peripheral dormant lesion can subside over time. Furthermore, a more challenging procedure can be planned because coverage by microsurgical reconstruction would be available in any defect after radical or sufficient resection of a vascular lesion, and the additional well-vascualrized tissue in the flap would prevent recurrence.