M. Blessmann, R. Schmelzle

In modern medicine, corrective plastic surgery is mainly indicated for reconstruction of cutaneous defects caused by accidents, burns, tumor resection, and postoperative wound-healing disorders. Reconstructive plastic surgery is also frequently required for elimination of functional deficits associated with scar contracture. The range of corrective surgery includes repairs using local skin flaps (proximal flaps), such as advancement and rotation flaps. Reconstructive surgery, on the other hand, encompasses the use of local skin flaps with a vascularized pedicle (e.g., pectoralis major flaps and latissimus dorsi flaps), as well as microsurgical tissue transfers using graft material from adjacent and distant sites.

Unlike the other techniques, microsurgical tissue transfer and replantation surgery require a complete interruption of blood flow to the vascularized tissue pedicle. In some cases, the blood supply must be interrupted for several hours. The blood vessels (arteries and veins) that supply the grafted tissues must therefore be reconnected by microscopic anastomosis. Latissimus dorsi flaps are frequently employed as microsurgical transplants, especially in plastic reconstruction of large defects.

If arterial complications occur, revision of the vascular anastomosis must be performed as quickly as possible. Ischemia is frequently caused by insufficiency of the reconnected vessels, but may also be due to vessel wall injury or trauma-related vasospasm. Since hypoxia and electrolyte imbalances may also induce vasospasms, electrolyte testing should be performed regularly during the postoperative period. However, in many cases the exact cause cannot be determined. Patients at risk for these complications should be monitored in the intensive care unit (ICU). Hemoglobin levels should also be measured to ensure adequate oxygen transport and to determine whether a blood transfusion is required. Oxygen tissue pressure in the transplant should be monitored by intravital microscopy.

In pedicle flaps, perfusion problems may develop, but imbalances between arterial supply and venous drainage are more common. Deficient venous return leads to venous congestion or—in the worse case–thrombosis. Blue discoloration of a transplant is the classic sign of venous congestion. The skin becomes increasingly mottled, especially in areas with the worst blood drainage, which is usually along the edges of the transplant. If the drainage problem persists, discoloration increases, and the transplant changes from violet to blue to black. Significant volume enlargement of the transplant further aggravates the venous insufficiency problem.

Transplant patients should therefore be monitored at frequent intervals (in the ICU), particularly in the first few hours and days after surgery. Potential complications can then receive immediate and continuous attention.