Reconstructive microsurgery

What is microsurgical free tissue transfer ?

In modern Plastic and Reconstructive surgery, free tissue transfer is used to

a)close or fill soft tissue defects following trauma, burns or tumor resection
b)Reconstruct organs (breast reconstruction following cancer or congenital anomalies, tongue reconstruction) also f.i. phalloplasty in transgender surgery
c)Reconstruct muscle function (functional muscle transfer following facial palsy)
d)Reimplantation of severed extremities

When is microsurgical soft tissue transfer carried out ?

Guidelines are the so called “ladder of repair”, which recommends that surgeons should always endeveaour to first embark on any procedure that is easier and more straightforward than microsurgical free tissue transfer.
The  “ladder of repair” has to be followed under consideration of comparable results, which have to be adequate or not inferior with view to form , function and aesthetic outcome.
In other words, sometimes a solution using local, pedicled tissue transfer may be possible , but in the long-term the patient may benefit more from the more extensive solution of microsurgical free tissue transfer.

In summary, the expected result bot with view to form and function have to be superior when microsurgical free tissue transfer is used, as compared to local, pedicled transfer.

Who is suitable ?

Generally everybody with a reasonable indication. Medically, microsurgical free tissue transfer is an extensive operation. Therefore patients must be fit to undergo such extensive surgery. This is normally a mutual decision between anestesist and surgeon.

What are the risks ?

Whenever free tissue is harvested for transfer as a so called “free flap”, there is a certain donor-site morbidity.
Ideally this is only a scar.

Some donor site scars are better and easier to hide than others, this depends on the case.
If muscle is harvested, there maybe functional deficits, which are held as small as possible by selecting muscle tissue which anatomically results in small donor site defects.
There is always the risk of flap loss, this may be technical (failure of anastomisis of vessel), or patient related ( smoker, small vessel disease, extended trauma zone, irradiation f.e. in breast reconstruction). There is no absolute percentage since preconditions depend on very individual factors.
A surgeon who performs many “free flaps” f.e. to cover lower extremity defects in acute trauma patients will lose more flaps than a surgeon performing rather selective breast reconstruction in well-conditioned patients.

Smoking is a key risk factor, especially in microsurgical breast reconstruction. Excessive smokers face a high risk of complete or partial flap failure. Long term smoking may leave vessels irreversably damaged, which may make any microsurgical procedure very hazardous.

What are the benefits ?

Microsurgical free tissue transfer enables surgeons to select optimum tissue for optimum form and function. In the ideal case, the donor site morbidity adds up to an aesthetic benefit for the patient.
An example is free tissue transfer harvesting tissue from the abdomen (TRAM, DIEP flaps) which is used for breast reconstruction.
The donor site closure results in a situation very comparable to an abdominoplasty, therefore the patient seeking breast reconstruction via this operation has actually got an aesthetic benefit from harvesting the flap.

This results in very high satisfaction rates with this kind of flap in breast reconstruction.

Other common options for harvest of tissue for microsurgical transfer in breast reconstruction are the thighs and the buttocks.

These breast reconstruction are mainly used when there is not enough tissue excess available to harvest as a flap.

Is it true that microsurgical breast reconstruction needs to be carried out in multiple stages ?

Normally yes. Again there is a certain range of opinion as to whether to perform an additional, adjusting procedure on the contralateral “healthy” breast, frequently a breats uplift. I mostly prefer to leave that for a second step because the results are more predictable once the reconstructed breats has fully settled.

Reconstruction in one session is fully acceptable, but from my view and experience at the price of a higher revision rate for the adjusting breast uplift.

Also, there may be requirement for additional nipple reconstruction in an additional session.

Dr.Alexander Amir  Aslani, MD, EBOPRAS

Hospital:

Director and Chief Surgeon
Department of Plastic, Aesthetic and Reconstructive Surgery
Hospital Quiron Malaga
Avda.Imperio Argentina, 1
E-29004 Malaga
Spain
www.quiron.es