Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 28:
Multiple Microvascular Transplants
  In our experience, approximately 25% of all patients receiving microvascular transplants of skin, muscle, bone, or a combination of these require a preliminary procedure to resurface the recipient area or prepare it in some way for later microsurgical reconstruction. An additional 25% of patients who receive a microvascular transplant require additional reconstruction with other flaps to complete their reconstruction. We have learned from our experience with emergency replantation of multiple traumatic amputations that 8 to 10 fingers can be successfully replanted by teams of surgeons working simultaneously and in sequence. As pointed out in Chapter 29, the team approach to microvascular replants in the emergency setting can be transferred directly to elective transplantation of multiple microvascular flaps. Many centers, including our own, have reported transplantation of multiple microvascular transplants within a single operation or multiple operations, particularly for reconstruction of functional digits in the severely injured hand.1-6 Simultaneous transplantation of multicomponent flaps has also been described for reconstruction of the head and neck and the lower extremity.7-11

Our general approach to complex problems is to provide cover with a microvascular transplant in the recipient area at the same time as the definitive transplant. In an organized center, with a number of trained personnel available, reconstruction of complex defects can now be performed with careful preoperative planning and coordination of multiple-team transplantation of separate tissues within a single operation. Anesthesia time, blood loss, and duration of hospitalization can be reduced. Although we have performed two microvascular transplants at the same time, it is conceivable that three or more free transplants could be accomplished using these principles.6 In addition to elective reconstruction, this multiple-team approach can be used in the reconstruction of acute injuries in which unreplantable parts from one or more extremities are replaced by the immediate transfer of multiple microvascular transplants to restore length and function of hands and digits.12 This approach is similar to that used in immediate reconstruction of breast or head and neck after malignancies requiring ablative surgery. 7,13


One of the great advantages of the multiple microvascular transplant approach is that the dissection in the recipient area, in both the acute and elective setting, provides a unique opportunity to develop recipient structures from bone, muscle, nerve, and blood vessels that cannot be duplicated at subsequent operations, when scar tissue has obliterated normal tissue planes and structures. The transplants themselves can be revascularized by a variety of internal shunts available only at this initial dissection. In a sense, everything is open and available at this crucial time. In addition, recovery time is reduced by permitting nerve regeneration and bone healing to occur simultaneously, rather than after two or more separate operations.

In our experience with over 50 simultaneous microvascular transplants, a variety of tissue combinations have been transplanted (Table 28-1). The majority have been used to provide functional digits and restore coverage in the same procedure. Survival rates are comparable to single transplants and have been 100% successful over the last 14 months.

Simultaneous transplantation of bilateral second toes has been the most commonly performed procedure, with excellent success and rare loss of the transplant.4-6

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