Fatal complications in reconstructive plastic surgery and ways of their prevention

Abstract

The world experience and experience of the Institute of Microsurgery (Tomsk, Russia) in rescuing dying free flaps are summarized in the paper. The issues related to the prevention of vascular disorders, which in 85–95% of cases lead to fatal complications in the form of total necrosis of the reperfused flap, are discussed. We are talking about the immediate, early and late complications due to the compromise of blood flow along the vascular pedicle (arterial, venous, arterial-venous). Unlike irreversible disorders, temporary disturbances in blood supply in free flaps are caused by the consequences of primary ischemia and reperfusion. Their duration and reversibility depend on the tissue composition, i.e. from the anoxic resistance of the tissues constituting the flap and, of course, the structures that form the wall of the flap vessels themselves. With a short duration of primary ischemia (up to 1 hour) and compensated reperfusion syndrome, temporary vascular disorders are manifested by flap skin flushing and metabolic edema of its tissues, which disappear 10-40 minutes after reperfusion. The indications for revision of the vascular pedicle are doubts about the adequacy of blood flow in the flap due to the appearance of the first signs of anastomotic thrombosis. The highest rates of flap rescue are achieved after revision of the vascular pedicle no later than 90 minutes after the first signs of thrombosis appear. It is important that the surgeon performing these microvascular anastomoses does the revision. The development of technologies for rescuing a perishing flap has become especially relevant in the last decade. This is due to the rapid development of reconstructive microsurgery of head and neck tumors. In such patients, there is practically no alternative to free transplantation of tissue complexes for the reconstruction of the lower jaw, tongue, soft tissue defect of the lower face and neck. The main technical problem leading to fatal complications after transplantation of a radial, peroneal, anterolateral femur flap is the difficulty of finding recipient vessels suitable for revascularization in soft tissues previously exposed to radiation. The search for alternative recipient vessels during the primary reconstruction of defects, for example, in the oral cavity, is accompanied by a significant increase in the duration of primary ischemia (up to 3–4 hours) and the death of flaps. The preservation of the viability of such free flaps is possible only by their temporary extracorporeal perfusion with extracorporeal membrane oxygenation. It is possible to preserve the viability of free flaps for 2 weeks (without microvascular anastomoses) during tertiary reconstruction of head and neck defects by continuous extracorporeal perfusion of the flap until it is completely engrafted in the recipient area. There is experience of using a tubular non-free radial flap on the long vascular pedicle of the radial vascular bundle (from the wrist to the ulnar fossa) in tertiary tissue reconstruction after removal of head and neck tumors.