Management of venous thrombosis in fibular free osseomusculocutaneous flaps used for mandibular reconstruction: clinical techniques and treatment considerations
© Draenert et al; licensee BioMed Central Ltd. 2010
Received: 2 November 2009
Accepted: 7 June 2010
Published: 7 June 2010
Mandibular 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.
Methods 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.
The 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.
Rescue of fibular flaps is possible even in patients with massive thrombosis if surgical revision is done quickly.
Mandibular and maxillary reconstruction with fibular osseomusculocutaneous free flaps represents a common procedure that is often applied in primary and secondary reconstructions of large bony defects in these areas [1, 2]. A possible complication of free flap procedures is venous failure of the anastomosis , which demands immediate revision surgery involving clot removal and anticoagulation therapy. We avoid the reopening of the arterial anastomosis by injecting the necessary rinsing with heparin in the arterial vessel with a small syringe.
We apply standard anti-thrombosis prophylaxis with low molecular weight heparin, for instance, Fragmin P, but do not preoperatively use any further anti-coagulatives, such as ASS or high dose heparin. Signs of venous failure after flap surgery, which becomes visible by livid skin color, represent a peracute indication for revision surgery. Therefore, nursing staff in the intensive care unit control the flap every 2 hours within the first 72 hours after initial surgery. This procedure includes visual control of the flap color, refill control by mild compression, and palpation of the flap consistence. The revision procedure includes opening of the venous anastomosis, clot removal, and flap perfusion with 3 ml heparin solution (5000 I.E./ml). This solution is injected in the pedicle artery three times, resulting in high frequency coagulation of the punctual bleeding. In this technique, the arterial anastomosis is not opened but anticoagulation is injected in the pedicle artery. The venous vessel is re-anastomozed after several minutes of continuous blood flow from the venous pedicle vessel. Post-surgical treatment includes the use of leeches applied three times a day (four to six leeches on the skin island) until return of normal skin color.
Results and discussion
Free fibula osseomusculocutaneous flaps with venous thrombosis treated following the described regiment.
radiatiotherapy before flap surgery
result of revision
squamous cell carcinoma
squamous cell carcinoma
no, but chemotherapy
Late bony reconstruction after radiotherapy is still widely applied in Germany, even though early bony reconstruction has promised some advantages . Patients with osteoradionecrosis and large bony defects require microvascular bony flaps, such as fibula or scapula transplants [4, 5]. After radiotherapy, the number of venous vessels suitable for microsurgical re-anastomosis of the flap is often limited to jugular veins [6–8]. Compromised venous vessels in the donor region may lead to venous failure . A further risk of thrombus formation is the higher prethrombotic activity in irradiated vessels . Imaging techniques, such as angiography, can be applied to evaluate the vascular situation in advance . We keep to the recommended practice of a minimum surveillance time of 45 min after the anastomosis of flap vessels .
Our described monitoring regiment includes visual control, palpation, and a manual refill test that is also described by other authors . Further methods, such as a Doppler probe, are not applied . Intensive care unit personnel densely control during the first 72 postoperative hours. The surgeons of our clinic additionally check the flap at least twice a day.
We immediately revise venous complications. This regiment is also described by other authors [13–16]. Local heparin injection is a well-known procedure in the management of venous thrombosis . We avoid the opening of the artery by injecting high dose heparin into the pedicle artery.
Adjuvant therapy with leeches is also common practice [13, 17]. Flap survival after venous thrombosis in fibula flaps is possible in most patients, but the survival rate of flaps with a bony component is lower . The presented technique is one possible regiment in patients with venous thrombosis after mandibular reconstruction by means of fibular free osseomusculocutaneous flaps. We did not apply lysis therapy and never did it. However this is also a known practice with good results in several publications [18–21].
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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