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Loco-regional flaps are the method of choice for chest wall reconstruction. However there is a selected group of patients who require free flap reconstruction, when all other options are used up. A small subgroup of these patients was identified where the commonly used recipient vessels (Internal mammary A. + V., Thoraco-dorsal A. + V.) were no longer available.This group comprised 16 seriously ill patients in the period from 2000 to 2004. Underlying diseases were sternum osteomyelitis (10×), tumor (2×), and osteo-radionecrosis (4×). There were 10 women and 6 men with mean age 62.4 years. All patients were classified as ASA III and IV. Fourteen patients received a TFL flap, two patients a vertical rectus myocutaneuos flap (VRAM). Recipient vessels were created with a temporary A-V loop between the cephalic vein and the thoraco-acromial artery (CTA-loop).No flap was lost and two had to be revised successfully for thrombosis of the arterial anastomosis. Mean operation time was 6.1 (4.7–8.4) h. Average time for ventilatory support was 56 (4–338) h. Five patients died within 6 months postoperatively due their underlying advanced disease (n = 3) or multiple organ failure (n = 2).The new concept of creating recipient vessels for free flap reconstruction of complex thoracic wall defects proved to be safe and reliable. The CTA loop allowed for unhurried flap dissection, best possible flap positioning, and straightforward end-end anstomoses in these seriously sick patients. The outcome with respect to complications and survival justifies the operative effort.