Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan.
Division of Plastic Surgery, Department of Surgery, Far Eastern Memorial Hospital, Taipei, Taiwan.
Microsurgery. 2024 Jan;44(1):e31041. doi: 10.1002/micr.31041. Epub 2023 Apr 3.
Arteriovenous (AV) looping prior to the lower extremity free flap reconstruction enables better venous drainage in flap circulation, leading to less flap complications and better survival. A two-staged reconstruction including free tissue transfer after AV looping ensures a robust venous drainage of the flap. Arterialization of the AV loop results in less venous problems after the free flap reconstruction. However, major problems of this staged operation include AV loop kinking, heavy compression and loop exposure, leading to AV graft failure and interruption of surgical planning. The purpose of this article is to summarize probable flaws we noticed in conventional two-stage lower limb reconstruction and overcome those problems using the skin paddle-containing vein graft.
Eight patients with lower limb defects underwent lower limb reconstruction surgery using this technique at our institute. The mean age was 52 years old. Of the eight patients, three of them have the defect due to infection. Three of them was due to trauma and three of them was due to full-thickness burn. Five of the defects located at foot. The other three defects located at heel, knee, and pretibial region. All of them require AV looping because of unavailability of nearby recipient vessels. They all received a two-stage operation, including the first stage AV looping with a skin paddle-containing vein graft and the second stage definite free tissue transfer.
The mean defect size was 140 cm (72-225). The mean length of AV loops was 17.1 cm (8-25). The mean size of skin paddles for vein grafts was 19.4 cm (15-24). The mean size of free ALT flaps 154.4 cm (105-252). All eight patients experienced a smooth postoperative course with no major or minor complications. There were no graft thrombosis or graft rupture complications during the vascular maturation period. All eight AV loops survived during maturation. All eight patients progressed to the second stage surgery. Maturation time ranged from 5 to 7 days. Free ALT flap was employed during the second stage reconstruction. All flaps survived at the last follow-up visit. There was no partial flap loss and complications. The mean follow-up time was 12.25 months, ranging from 8 to 17 months.
The skin paddle-containing vein graft is an effective modification of the regular vein graft for AV looping procedure. The skin paddle prevents the underlying AV loop from compression, kinking and twisting during maturation. It also aids assessing patency of the AV loop and avoids the formation of adhesion between the AV loop and the surrounding tissue.
动静脉（AV）环提前于下肢游离皮瓣重建，可改善皮瓣循环中的静脉引流，减少皮瓣并发症，提高成活率。包括游离组织转移后的两期重建，可确保皮瓣有强大的静脉引流。AV 环的动脉化可减少游离皮瓣重建后的静脉问题。然而，这种分期手术的主要问题包括 AV 环扭结、严重压迫和环暴露，导致 AV 移植物失败和手术计划中断。本文的目的是总结我们在常规下肢两期重建中发现的可能缺陷，并使用含皮瓣静脉移植物克服这些问题。
本研究所在我院对 8 例下肢缺损患者采用该技术行下肢重建手术。平均年龄 52 岁。8 例患者中，3 例因感染导致缺损，3 例因创伤导致缺损，3 例因全层烧伤导致缺损。5 例缺损位于足部，3 例位于足跟、膝部和胫骨前区。由于附近无受区血管，所有患者均需行 AV 环。他们均接受两期手术，一期行含皮瓣静脉移植物的 AV 环，二期行确定性游离组织移植。
平均缺损大小为 140cm（72-225cm），AV 环平均长度为 17.1cm（8-25cm），含皮瓣静脉移植物的平均皮瓣大小为 19.4cm（15-24cm），游离 ALT 皮瓣的平均大小为 154.4cm（105-252cm）。8 例患者术后均顺利康复，无严重或轻微并发症。血管成熟期间无移植物血栓或破裂并发症。所有 8 个 AV 环在成熟过程中均存活。8 例患者均进展至二期手术。成熟时间为 5-7d。二期重建时采用游离 ALT 皮瓣。末次随访时所有皮瓣均存活，无部分皮瓣坏死和并发症。平均随访时间为 12.25 个月，8-17 个月。
含皮瓣静脉移植物是 AV 环成形术常规静脉移植物的有效改良。皮瓣可防止 AV 环在成熟过程中受压、扭结和扭曲。它还有助于评估 AV 环的通畅性，并避免 AV 环与周围组织形成粘连。
