|Year : 2020 | Volume
| Issue : 2 | Page : 45-50
Clinical outcome of microsurgical free flap procedures in Lagos, Nigeria
Bolaji O Mofikoya1, Orimisan Belie2, Andrew O Ugburo1, Abdulwahab O Ajani3
1 Plastic Surgery Unit, Department of Surgery, College of Medicine, University Of Lagos/Lagos University Teaching Hospital, Idiaraba, Lagos, Nigeria
2 Plastic Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idiaraba, Lagos, Nigeria
3 Plastic Surgery Unit, Department of Surgery, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria
|Date of Submission||11-Apr-2020|
|Date of Acceptance||07-Aug-2020|
|Date of Web Publication||18-Dec-2020|
Dr. Orimisan Belie
Plastic Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idiaraba, Lagos
Source of Support: None, Conflict of Interest: None
Background: Reconstruction of complex defects following radical tumour excision and post-traumatic defects has been made possible with the use of microsurgical free tissue transfer. It is associated with less donor site morbidity and hence and good surgical outcome in the reconstructed area. It is a routine procedure in the developed countries, however it is gradually evolving in the developing nations. Method: The records of all patients who had free flap reconstruction of their defects were retrieved from the unit database. The demographic characteristics, indications for surgery, choice of flap and the complications were documented. The data were analysed using appropriate statistical tools. Results: Free flaps represent 1.7% of all major flap surgeries performed. Among these patients, those between the ages of 21 and 30 years had highest number of free flaps accounting for 26% of the study population. Anterolateral thigh flap (ALT) was the most common donor flap. Venous compromise was more common among patients who developed complications. Conclusion: Despite many challenges facing successful microvascular surgery in the developing nation, formation of dedicated team and institutional support will improve the outcome of these procedures.
Keywords: Complex defects, free flaps, microsurgical procedures
|How to cite this article:|
Mofikoya BO, Belie O, Ugburo AO, Ajani AO. Clinical outcome of microsurgical free flap procedures in Lagos, Nigeria. Nigerian J Plast Surg 2020;16:45-50
|How to cite this URL:|
Mofikoya BO, Belie O, Ugburo AO, Ajani AO. Clinical outcome of microsurgical free flap procedures in Lagos, Nigeria. Nigerian J Plast Surg [serial online] 2020 [cited 2022 May 19];16:45-50. Available from: https://www.njps.org/text.asp?2020/16/2/45/303838
| Introduction|| |
Reconstructive ladder has been known to the world of Plastic Surgery as a step by step means of re-surfacing soft tissue defect in different part of the body where the surgeon deploys the simplest technique and moves to a more complex method of wound cover as in ascending the rungs of a ladder. This however has been replaced with the reconstructive tool box where the most functionally and aesthetically suitable flap is used among many available options of reconstruction and this concept of “tool box” has been a great asset in the armamentarium of the reconstructive surgeons. Microsurgery affords the opportunity to cover complex defect, replace like with like, improve functionality and better cosmetic outcome in the reconstructed areas.
Complex defect in children can now be conveniently covered with free flap despite the sub-millimeter calibre of the perforating vessels in paediatric age group which was practically an uphill task before microsurgery was popularized, in the elderly age has been found not to contribute adversely to the outcome of microsurgical procedures., The recent development in bio-engineering has given rise to production of finer instruments which have enhanced the outcome of these procedures.
The need for microsurgical free tissue transfers has not parallel the availability of expertise for these procedures. When the expertise is available, supporting equipments are not available in many centres of developing countries. The supporting staffs with requisite skills and knowledge of flap monitoring and post-operative care are also very scarce. Lack of institutional support, high cost of material for patients and surgeons and very low surgeons to patients’ ratio make successful free tissue transfer an uphill task. These are some of the factors contributing to poor outcome in free flap procedures and these make microsurgeries unattractive to prospective microsurgeon in sub-Saharan Africa.
Nigeria is the most populous nation in Africa with a population of about two hundred million representing 2.6% of the world population. There are few reports and publications on free flaps from this part of the world. Microsurgery is still in its infancy stage in Nigeria despite many decades of progress in developed world. The procedure started actively at Lagos University Teaching Hospital more than 10 years ago and these procedures have since been employed in the coverage of complex defects.
The acquisition of requisite microsurgical skills requires steep learning curve. Many hours of practise are required to achieve improved surgical skills. We document our experience and outcome of microsurgical free tissue transfer highlighting the successes and failures achieved over 5 year duration.
| Methods|| |
The records and clinical photographs of patients who had free tissue transfer in Lagos University Teaching Hospital (LUTH) for various pathologies over a 5-year period (from January 2015 to December 2019) were retrieved from our unit database. The clinical and demographic data were analysed using SPSS 20. Age, gender, region, donor/recipient sites, indications, outcome were documented
Patients were prepared pre-operatively as it is done routinely for major surgeries. Computerised tomographic angiography were done routinely, the perforators were also located using the handheld doppler. Intra-operatively we avoided hypotensive anaesthesia and vasopressors. Dilute heparin solution, 2% lidocaine (lignocaine) dissolved in normal saline solution were used to gently flush the vessels ends to dislodge any clot and relieve spasm respectively.
The flaps were raised incorporating the perforators and dissected proximally along the main vessels as the pedicle. The pedicles were divided off its origin. The recipient vessels were prepared and the anastomoses done using single layer prolene 8/0 BV sutures either as end to side or end to end.
Post-operatively the flaps were monitored according to unit protocol using 5 parameters which are colour change, flap tension comparable with surrounding tissues, pin prink, Doppler auscultation and differential temperature. Each parameter is scored from 0 to 2. Loose dressings, warm intravenous fluids and analgesia were administered.
| Results|| |
A total of 1,118 flap surgeries was performed over the study period, out of these 19 (1.7%) patients had free tissue transfer. There were 11 female 8 male (F: M = 1.4:1). The minimum age was two years and maximum was 59 years. Mean Age±SEM = 28.32±3.98. The age range of 21–30 years had the highest number of patients [Figure 1] having 26.3% of all the study population.
The commonest indication for microsurgery was tissue replacement following tumor excision. A total of 11 (57.9%) patients had free tissue transfer following tumour excision while 8 (42.1%) patients had this procedure following traumatic injury [Figure 2]. Among the anatomic regions ten free flaps were transferred to the head and neck [Figure 3] whiles the lower limbs were the recipient region in nine patients.
|Figure 3 A patient with locally advanced right hemifascia cancer. A. Marking for wide local excision and neck dissection. B. Donor site marking for ALT. C. Defect after tumour excision. D. Immediate post-operative photograph. E. One month post-operative photograph in preparation for adjuvant radiotherapy.|
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The most common donor flap was the anterolateral thigh flap (ALT) which was used to cover defects in 58% of the study population, while free fibular flaps were used in 31.6% of patients as the second commonest flap used as a donor flap [Figure 4].
Arterial anastomoses were done first in 7 patients, while venous anastomoses were performed as the first anastomoses in 12 patients and there was no statistical significant difference in the outcome of surgery among those who had either artery or vein as the first vessel anastomosed (P value = 0.071). Fifteen (79%) patients had end to end anastomoses, while 4 (21%) patients had end to side anastomoses with no statistically significant difference between the two techniques in relation to outcome (P = 0.648).
| COMPLICATION/REVISION SURGERY|| |
Three (15.8%) patients had venous congestion, and re-exploration was performed on them within the first 24 hours by suture removal, evacuation of haematoma and elevation, with complete flap survival. Three other (15.8%) patients had arterial insufficiency (2 ALT flaps and 1 fibular flap). One of the failed ALT was replaced with radial forearm flap, other ALT could not be salvage despite intervention, and the wound was allowed to granulate and was subsequently skin grafted. The failed free fibular flap was excised and the patient refused secondary procedure, discharged herself against medical advice and travelled to Cameroon from where she was referred. All the patients with venous congestion had 100% salvage rate, however those with arterial compromise could not be salvaged with simple re-exploration. The remaining 13 (68.2%) patients had complete flap survival and required no re-exploration.
| Discussion|| |
Despite the steep learning curve, the major breakthrough in successful microsurgical procedures comes by daring to start, loupe only microsurgery, overcoming barriers, training (local and international), flap monitoring. In our study though trauma is the single commonest indication for free flaps transfer, reconstruction following oncological surgeries were more than surgeries due to trauma. In larger studies reconstruction following tumour excision remains the commonest indication, which is in tandem with our study where 57.9% of the free flaps were done following tumour excision. Patients in the third decade of life were the highest age group that benefited from the procedure. This is most likely due to the fact individuals in this age group are more adventurous and are more likely to engage in dangerous activities.
It has been well documented that low threshold for re-exploration will salvage more flaps with compromised flap circulation. Bui et al. in a retrospective study of 1193 patients conducted at Memorial Sloan-Kettering cancer centre found out that the commonest reason for re-exploration were venous problems which include venous thrombosis and haematoma compression of the pedicle. Flap with venous complications were also found to survive more than those with arterial problems. In this study, all patients with venous congestion had 100% salvage rate, however the flaps with arterial problems could not be salvaged with simple re-exploration requiring replacement with another free flap.
Rai et al. in Nepal reported free radial forearm flap as the commonest donor flap among 56 patients studied over seven years. Elgohary et al. used 11 free RFF to cover heel defect among 25 patients while free ALT flap was used for the remaining patients. The free RFF and free ALT flaps are one of the commonest free flaps used routinely to cover large defects. The free RFF provide a long pedicle of up to 20cm and a larger calibre of up to 2.5mm that makes anastomoses easier, it however leaves a scarred forearm as the secondary defect which must be skin grafted. This area usually is an exposed part of the body which unlike the donor site of the free ALT flap is relatively hidden. An adequate pedicle length is usually harvested in free ALT flap, the calibre however may not be as big as in RFF. Free Latissimus Dorsi (LD) flap, and groin flaps are among other flaps that are transferred as free tissue flaps for covering large defects. Regarding technique of vascular anastomosis, there is no documented advantage of end to end anastomosis over end to side. The technique used depends on the orientation of the recipient vessels and the calibre of both recipient and donor vessels. In our study we were able to salvage all the flaps with venous compromise because we had developed a protocol for free flap monitoring post-operatively.
Nangole et al. have proven that the challenges of lack of operating microscope and other materials can be surmounted by the use of loupe to provide magnification. He performed microsurgery on 120 patients in Kenya over a five year duration using loupe as the source of magnification. This means where surgeons are motivated microsurgery can be successfully carried out in resource poor environment. In our centre the procedure are performed using operating microscope
| Conclusion|| |
Despite the challenges facing microsurgeons in the developing world, determination can make microvascular surgery a reality. Institutions need to assist the surgeon in provision of microscope and other needed materials. Dedicated team needs to be raised and protocols formed for flap monitoring to achieve success.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mofikoya BO, Ugburo AO, Iduwe GL, Belie O. Complex lower extremity reconstruction with free perforator flap in a 20 month old child. 2017;9(2), 61-9.
Jubbal KT, Zavlin D, Suliman A. The effect of age on microsurgical free flap outcomes: An analysis of 5, 951 cases. Microsurgery 2017;37:858-64.
Ferrari S, Copelli C, Bianchi B, Ferri A, Poli T et al.
Free flaps in elderly patients: Outcomes and complications in head and neck reconstruction after oncological resection. J Craniomaxillofac Surg 2013;41:167-71.
Mofikoya BO, Ugburo AO, Belie OM. Clinical assessment score for monitoring free flaps in the dark skin. AJMHS 2018;49:18-22
Mofikoya BO, Ugburo AO, Bankole OB. Microvascular anastomosis of vessels less than 0.5mm in diameter: a supermicrosurgery training model in Lagos, Nigeria. J Hand Microsurg 2011;3:16-7
Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A et al.
Free flap re-exploration: indications, treatment, and outcomes in1193 free flaps. Plastic and Reconstructive Surgery 2007;119:2092-100
Rai SM, Grinsell D, Hunter-smith D, Corlett R, Nakarmi K et al.
Microsurgical free flaps at Kathmandu Model Hospital. J Nepal Health Res Counc 2014;12:100-3
Elgohary H, Ahmed M., Nawar AM, Zidan A, Shoulah AA, Younes MT. Functional and aesthetic outcomes of reconstruction of soft-tissue defects of the heel with free flap. JPRAS 2019;19:35-44
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. Plast Surg Int 2015;2015:194174.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]