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Year : 2019  |  Volume : 27  |  Issue : 3  |  Page : 147-150

How reconstructive microsurgery can be performed in Nonurban State Hospitals: Experience and problems

Department of Plastic Surgery, Siirt Urban Hospital, Siirt, Turkey

Date of Web Publication4-Jul-2019

Correspondence Address:
Dr. Burak Sercan Ercin
Department of Plastic Surgery, Siirt Urban Hospital, Siirt
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_68_18

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How to cite this article:
Ercin BS, Yildirim K. How reconstructive microsurgery can be performed in Nonurban State Hospitals: Experience and problems. Turk J Plast Surg 2019;27:147-50

How to cite this URL:
Ercin BS, Yildirim K. How reconstructive microsurgery can be performed in Nonurban State Hospitals: Experience and problems. Turk J Plast Surg [serial online] 2019 [cited 2021 Oct 27];27:147-50. Available from: http://www.turkjplastsurg.org/text.asp?2019/27/3/147/262130

Dear Editor,

Reconstruction of surgical or traumatic defects requires extensive knowledge about all kinds of reconstructive options and a certain level of skills in implementing these options. While simple defects can be closed through healing by secondary intention, skin grafts or local flaps, complex defects may necessitate the use of higher level reconstructive procedures such as regional or free flaps. Free flaps are being used and improved since first experienced by Daniel and Taylor 45 years ago.[1] Today, free flaps are being widely used in suitable defects in centers both in Turkey and across the world.

Free flap procedures demand an experienced surgical team, a nurses' team experienced in flap surgery and postoperative monitorization, suitable microsurgical tools and threads, and intensive care unit (ICU) facilities to be used when necessary.[2]

Whereas these are the actual essentials, unfortunately, not all of these are available in secondary health-care facilities. Ironically, patient populations that often require serious reconstructive procedures mostly reside in the vicinity of such secondary health-care facilities.

As two plastic surgeons serving our compulsory medical service, in this study, we aim at presenting the establishment of microsurgical applications in peripheral regions, the challenges and the ways of coping with these challenges in light of the realities.

Patients who underwent a free flap procedure in the Siirt State Hospital in the months from March to September 2018 were examined based on variables including age, gender, duration of operation, number of anastomoses, hospitalization time, and flap failure.

Seven patients were examined in total [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]. Follow-up times of patients ranged from 20 days to 6 months. All patients were male. Mean patient age was 30.2 years (minimum 13 and maximum 48 years). Mean operating time was 280 min (minimum 195 and maximum 400 min). Patients 1–4 were administered 100 mg of oral acetylsalicylic acid and 0.01 cc/kg subcutaneous low molecular weight heparin for 15 days starting on postoperative day 1. Patients 5–7 did not receive any postoperative anticoagulation treatment. Mean hospitalization time was 24.5 days (minimum 13 and maximum 48 days). Two vein and one artery anastomoses were performed on six of the patients. Flap loss was not seen in any of the patients. One patient was transferred to the ICU due to the gastrointestinal system (GIS) bleeding on postoperative day 4. The patient underwent a selective duodenal artery embolectomy in an external center after which he healed and was discharged. In one case which joint transfer was performed tension-related partial necrosis developed in the monitor island because of erroneous planning. After wound care, the digit was reconstructed with a reverse cross-digit flap and graft.
Table 1: Demographic data of patients

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Figure 1: Severe contracture in the right axilla caused by boiling oil 3 years earlier in 13-year-old male patient

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Figure 2: Reconstruction was planned and performed with an anterolateral thigh flap. Keloid in the axillary region was almost entirely excised, and contracture bands were excised in full. The thoracodorsal nerve was preserved, and the subscapular vascular system was exposed

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Figure 3: As planned, an anterolateral thigh flap of 24 cm × 8 cm was lifted by including two septocutaneous perforators in the flap

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Figure 4: End-to-end vein anastomosis was performed to the two serratus branches of the thoracodorsal vein. End-to-end artery anastomosis was performed on the angular branch of the thoracodorsal artery. The donor site was primarily reconstructed. Total operating time was 195 min. No problems were identified in the patient's examination on day 20. Almost full shoulder joint abduction was achieved

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Figure 5: The 44-year-old patient was admitted to the ward with a tractor run-over injury in his right lower limb. Daily washing and debridement revealed a soft-tissue defect in the dorsum of the foot that exposed the ankle joint

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Figure 6: The dorsalis pedis artery and concomitant veins in the dorsum of the foot were dissected and prepared for anastomosis. A free gracilis muscle flap was lifted from the other lower limb

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Figure 7: Two veins were end-to-end anastomosed to the concomitant veins. Recipient artery was anastomosed side-to-end with the arteria dorsalis pedis. On postoperative day 2, the upper part of the flap was reconstructed with a partial-thickness skin graft. Once the defect on the right leg granulated following negative pressure wound therapy, the site was reconstructed with a partial-thickness skin graft on day 24. No problems were identified in the flap on postoperative day 24

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Reconstructive microsurgery has been improved and continues to be improved every day since the free flap procedures performed by Daniel and Taylor.[1] Thanks to these advancements, today, free flaps are being routinely used in many large centers both in Turkey and around the world. Yet, however, presently, the need for free flaps cannot be met in the underdeveloped or developing countries where the number of cases requiring free flaps is higher than in the developed countries.[3]

In Turkey, plastic surgeons are legally required to fulfill a period of public service following 5 or 6 years of residency and are assigned by lottery for a period of 1–2 years to peripheral cities where there is need for specialists. Surgeons are often assigned to secondary health-care facilities in the Central and Southeastern regions of Anatolia, and typically, there will be no support staff experienced in microsurgery in these institutions.

Until the first case presented in this study, no free flap reconstruction procedures had been performed in the province of Siirt, and therefore, surgical nurses had limited knowledge about how to assist microsurgical procedures, about tissue management or microsurgical tools. Given these conditions, especially in the cases of the first few patients, we performed the procedures together as two surgeons, assisting one another. During these procedures, selected nurses were perioperative trained and equipped with fundamental skills.

  Technical Equipment Problems Top

The microscope available in the operating room (OR) was rather suitable for ear, nose, throat, or brain surgeries and did not have a bilaterally symmetric binocular design, particularly suitable for reconstructive microsurgery. Therefore, anastomosis was performed by one surgeon without assistance. Given that such conditions may be often encountered in places where microsurgeries are not usual, the surgeon has to be prepared and able to carry out the anastomosis procedure single-handedly. Alternatively, two surgeons can perform the anastomosis together using surgical loupes. Many studies report to have found no significant difference between using a loupe and a microscope in terms of a successful anastomosis.[4],[5]

Another major problem in a secondary health-care facility is the availability of suitable surgical tools. The microsurgical tools available in our hospital had been previously used by the physicians of other branches and hence were unusable. Therefore, procedures requiring microsurgery were performed using the personal microsurgical tools of the surgical team. These tools were not products of the top brands. Since the sterilization staff was not familiar with handling microsurgical tools, all tools were cleaned and maintained by the surgeons themselves after every procedure. Given the sensitive nature of microsurgical tools, well-maintained but lower-profile tools can sometimes be more useful than expensive but poorly maintained ones.

Another problem was the absence of a patient care staff experienced in monitoring the flap. Close follow-up within the first 48 h after a free flap surgery is crucial for salvaging the flap in the event of a vascular problem.[6] In large centers and training institutions, circulation of the flap is monitored by experienced nurses or surgical residents. This is often not possible in secondary health-care facilities. Given the absence of an on-call plastic surgeon and hence that the flap would not be monitored as desired, double vein anastomosis was used in six of the seven cases. As known, the most common cause of flap losses is thrombosis, which is most commonly seen in venous anastomosis.[7] There are studies which show that more than one venous anastomosis has no significant effect on flap survival.[8]

There are, however, studies that report reduced complication rates with dual venous anastomosis, especially in lower extremity reconstructions.[9],[10] We believe that in environments where circulation can be monitored only under suboptimal conditions, two venous anastomoses, whenever possible, one superficial and one of the deep systems, will be more reliable.

In most centers, the success rate of free flap reconstructions is above 95%.[11],[12],[13] In our study, this rate currently appears to be 100%; however, the low number of cases is a major restraining factor in this result. While flap necrosis was not seen in any of our patients, one patient had gastric ulcer bleeding, a rare complication which required massive transfusion. The patient healed following a selective duodenal artery embolectomy performed by an interventional radiology team in an external center. Severe GIS complications following a free flap surgery are rare. Mert report of mortality associated with gastric perforation following a free flap procedure.[14]

Since the patient had no history of GIS bleeding, the bleeding was deemed to be an outcome caused by the use of aspirin. Li et al. report that aspirin significantly reduced thrombus rates following anastomosis in their experimental study.[15] However, there are not enough randomized, double-blind, prospective studies examining antithrombotic regimens. In a study, Khouri et al. found that an antithrombotic regimen did not significantly affect flap loss.[16] Dhiwakar et al. found that anticoagulant treatment significantly increased the risk of hematoma in head-and-neck reconstruction.[17] Different antithrombotic regimens are used in many centers, but which should actually be used? Or should postoperative antithrombotics be at all used? There are no clear answers yet. Therefore, no postoperative anticoagulation was used in cases 5–7.

To conclude, we believe that free flap procedures can be reliably performed in secondary health-care facilities by plastic surgeons experienced in microsurgery when appropriate equipment is available. We believe that this study will encourage young plastic surgeons who will serve in secondary health-care facilities as part of their compulsory medical service, and thereby help reduce the burden on large centers, and with the availability of treatment options in their own regions will increase patient comfort.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses. A clinical technique. Plast Reconstr Surg 1973;52:111-7.  Back to cited text no. 1
Serafin D, Sabatier RE, Morris RL, Georgiade NG. Reconstruction of the lower extremity with vascularized composite tissue: Improved tissue survival and specific indications. Plast Reconstr Surg 1980;66:230-41.  Back to cited text no. 2
Nangole WF, Khainga S, Aswani J, Kahoro L, Vilembwa, A. Free flaps in a resource constrained environment: A five-year experience—outcomes and lessons learned. Plastic surgery international, 2015.  Back to cited text no. 3
Serletti JM, Deuber MA, Guidera PM, Reading G, Herrera HR, Reale VF, et al. Comparison of the operating microscope and loupes for free microvascular tissue transfer. Plast Reconstr Surg 1995;95:270-6.  Back to cited text no. 4
Ross DA, Ariyan S, Restifo R, Sasaki CT. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: A retrospective comparison. Arch Otolaryngol Head Neck Surg 2003;129:189-93.  Back to cited text no. 5
Cho BC, Shin DP, Byun JS, Park JW, Baik BS. Monitoring flap for buried free tissue transfer: Its importance and reliability. Plast Reconstr Surg 2002;110:1249-58.  Back to cited text no. 6
Novakovic D, Patel RS, Goldstein DP, Gullane PJ. Salvage of failed free flaps used in head and neck reconstruction. Head Neck Oncol 2009;1:33.  Back to cited text no. 7
Khaja SF, Rubin N, Bayon R. Venous complications in one versus two vein anastomoses in head and neck free flaps. Ann Otol Rhinol Laryngol 2017;126:722-6.  Back to cited text no. 8
Stranix JT, Lee ZH, Anzai L, Jacoby A, Avraham T, Saadeh PB, et al. Optimizing venous outflow in reconstruction of gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one? Microsurgery 2018;38:745-51.  Back to cited text no. 9
Stranix JT, Anzai L, Mirrer J, Hambley W, Avraham T, Saadeh PB, et al. Dual venous outflow improves lower extremity trauma free flap reconstructions. J Surg Res 2016;202:235-8.  Back to cited text no. 10
Hanasono MM, Friel MT, Klem C, Hsu PW, Robb GL, Weber RS, et al. Impact of reconstructive microsurgery in patients with advanced oral cavity cancers. Head Neck 2009;31:1289-96.  Back to cited text no. 11
Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free flaps for oncologic surgical defects: Refinement in donor-site selection and technique. Plast Reconstr Surg 1998;102:722-32.  Back to cited text no. 12
Blackwell KE. Unsurpassed reliability of free flaps for head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1999;125:295-9.  Back to cited text no. 13
Demirel M, Karadayi K, Serel S, Emiroǧlu M. An unusual localization of spontaneous gastric perforation: A case report. Ankara Üniversitesi Tıp Fakültesi Mecmuası 2011;64:101-3.  Back to cited text no. 14
Li X, Cooley BC. Effect of anticoagulation and inhibition of platelet aggregation on arterial versus venous microvascular thrombosis. Ann Plast Surg 1995;35:165-9.  Back to cited text no. 15
Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al. Aprospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998;102:711-21.  Back to cited text no. 16
Dhiwakar M, Khan NA, McClymont LG. Surgical resection of cutaneous head and neck lesions: Does aspirin use increase hemorrhagic risk? Arch Otolaryngol Head Neck Surg 2006;132:1237-41.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]

  [Table 1]


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