Management of venous thrombosis in fibular free osseomusculocutaneous flaps used for mandibular reconstruction: clinical techniques and treatment considerations

Abstract

BackgroundMandibular reconstruction by means of fibula transplants is the standard therapy for severe bone loss after subtotal mandibulectomy. Venous failure still represents the most common complication in free flap surgery. We present the injection of heparine into the arterial pedicle as modification of the revising both anastomoses in these cases and illustrate the application with a clinical case example.MethodsMethods consist of immediate revision surgery with clot removal, heparin perfusion by direct injection in the arterial vessel of the pedicle, subsequent high dose low-molecular weight heparin therapy, and leeches. After 6 hours postoperatively, images of early flap recovery show first sings of recovery by fading livid skin color.ResultsThe application of this technique in a patient with venous thrombosis resulted in the complete recovery of the flap 60 hours postoperatively. Other cases achieved similar success without additional lysis Therapy or revision of the arterial anastomosis.ConclusionRescue of fibular flaps is possible even in patients with massive thrombosis if surgical revision is done quickly.

Resurrection of an ALT flap with recombinant tissue plasminogen activator and heparin

“…Although flap salvage techniques are documented in the literature [4][5][6][7], we feel that these simple reproducible steps emphasising the diluted concentration of tPA and the long dwell times adopted in this case are transferrable to many other cases of 'free flaps in difficulty'. This case also highlighted that salvage is still feasible at such a late presentation and that the plastic surgeon should not give up even in such dramatic scenarios where positive outcomes appear hopeless (Fig.…”

Determining the appropriate number and duration of leech therapy in congested tissues using tissue spectrophotometry and laser Doppler flowmetry

“…Its usage dates back to ancient Egypt and has increased in the past few decades . Leech therapy received official FDA approval in 2004 and is used in plastic surgery, maxillofacial surgery, dermatologic surgery and urology to temporarily improve the venous outflow of pedicle flaps, nipples, ears, noses, and microvascular free flaps until graft neovascularization takes place.…”