From the Plastic and Jaw Department, United She3~eM Hospitals.

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1 THE " BLUE FLAP ": A METHOD OF TREATMENT By WILFRED HYNES, F.R.C.S. From the Plastic and Jaw Department, United She3~eM Hospitals. THE " blue flap," one of the most difficult problems in surgery, is apt to occur with long and otherwise heroic flaps which frequently perish from intravascular thrombosis. Many of these catastrophes can be avoided by a more careful designing of local flaps, or, in the case of tubed pedicles or direct flaps, by testing the circulation through their pedicles before each stage of their transfer. The remarks which follow apply particularly to tubed pedicles, but are equally relevant to direct flaps, and describe an effort to stem the relentless daily advance of necrosis which is such a constant feature of the "blue flap." VASCULAR CHANGES WHEN A LONG FLAP IS RAISED OR WHEN ONE END OF A LONG TUBED PEDICLE IS DIVIDED Immediately after a badly designed flap is raised, or one end of a long tubed pedicle is divided, the skin at its distal end becomes white ; this is slowly replaced by a spreading bluish colour which, however long the flap, eventually reaches its distal extremity, which then blanches on pressure. The small vessels on the distal cut surface of the flap ooze dark-coloured blood. When these vessels thrombose in the course of the next few hours, blood can no longer escape from the flap and the sluggish blood stream in the end of the flap is completely stopped. This circulation cannot be resumed as the visa tergo provided by the arterial blood entering the flap at its pedicle is insufficient to propel the stagnant blood out of the flap and so back into the general circulation (Hynes, 195o). Within a few hours this stagnant blood thromboses and the skin at the extremity of the flap assumes an irreversible dark blue colour, that is, it no longer blanches on pressure. This intravascular thrombosis spreads relentlessly backwards, and within three to four days the distal third or more of the flap becomes black and is unmistakably dead. A TREATMENT FOR THE " BLUE FLAP " The aim is to avoid stagnation-of blood by keeping it moving in and out of the distal end of the flap. This prevents thrombosis and ensures survival of the tissues by the constant supply of fresh blood. As will be described below, gravity can be used to allow blood both to enter and to leave the end of the flap, and this may suffice in mild cases. In more severe cases, however, this is not enough, and more active measures must be used to drive the blood in and out of the flap--this process, which acts as an artificial heart to the flap, therefore consists of an emptying and a filling mechanism. 166

2 THE c, BLUE FLAP " " A METHOD OF TREATMENT 16 7 I. Methods which empty the Flap of Blood : the Emptying ~VIechanism.--This can be carried out passively or actively. (a) Passive Emptying.--Gravity can move blood passively out of (and into) a flap and this suffices for mild cases. The blood-vessels at the free end of a flap are wide, toneless channels, and blood can therefore be made to flow along them in either direction by gravity (Hynes, 195o). Thus, if the distal end of the flap is raised above the level of its pedicle, blood flows passively out of the flap, which becomes white ; and, conversely, if the distal end of the flap is lowered below the level of its pedicle, blood passively enters the flap and reaches its free extremity, however long the flap may be, and the flap becomes blue. FIG. I FIG. 2 Active expression of blood from the wrist inset of an abdominal tubed pedicle, Method of driving blood into a tubed pedicle which is carried on the right wrist and has been inset on the left leg. (b) Active Expression of Blood from the End of a Flap.--In more severe cases blood can be actively driven out of the flap as follows : a soft, thin-walled rubber bag, resembling a sphygmomanometer cuff, is strapped in position over the distal end of the flap or the tubed pedicle inset and is big enough to overlap it a little on all sides. The bag is connected by pressure tubing to an intermittent venous occluder (Fig. I)Pan instrument which raises the pressure in the bag to any desired level for two minutes, after which the pressure is automatically released for two minutes. This raising and release of pressure in the bag continues every two minutes day and night for as long as required. By using a pressure of about 30 to 40 ram. Hg in the rubber bag, the stagnant blood in the dilated vessels in the end of the flap or tubed pedicle is expressed every two minutes. 2. Methods to fill the Flap with Blood: the Filling Mechanism.- This can be carried out passively or actively. (a) Passive Filling by Gravity.--As described above, blood can be made to flow passively into the dilated, toneless vessels at the end of a flap by simply

3 168 BRITISH JOURNAL OF PLASTIC SURGERY lowering its distal end below the level of its pedicle. The flap can therefore be filled and emptied by raising and then lowering its free extremity every ten to fifteen minutes, and this will suffice for a mild case of "blue flap" (Case I below). (b) Active Filling of the Flap with Blood.--In more severe cases of" blue flap," blood must be actively driven into the flap, and this is possible with flaps and tubed pedicles in certain situations by using the following method : If the pedicle of the flap or tube lies on a limb (e.g., a cross-leg flap or a Stage 3 abdominal tubed pedicle, where the tube, carried on the wrist, has been inset into a leg defect), blood can be driven forcibly into its very end by placing a sphygrnomanometer cuff round the limb above the level of the pedicle of the flap or tube and raisingthe pressure in the cuff to 3o to 60 mm. Hg (Fig. 2). This raises the venous pressure and therefore the capillary pressure in the limb below the cuff, and the flap or tubed pedicle becomes engorged with blood and assumes a high colour (Hynes, 195o). Release of the pressure in the cuff allows the blood to leave the flap or tube. This method of forcing blood into a "blue" flap or tube is extremely effective and, used alone, is the most certain method of saving it, even if necrosis has already started. By attaching the cuff to an intermittent venous occluder, this application and release of pressure in the cuff can be carried on automatically every two minutes for as long as required. If an intermittent venous occluder is not available, the same effect can be produced by using an ordinary sphygmomanometer, the cuff of which, placed round the limb proximal to the level of the pedicle of the flap or tube, is blown up to a pressure of 30 to 40 ram. Hg by using the hand bulb. This cannot conveniently be done every two minutes, but its occasional use for a few minutes will " boost" the blood supply to the tube or flap, and this, in many cases, will be enough to save it. There is one precaution to be observed in using this method. If it is applied in the first twenty-four hours after the end of a flap or tubed pedicle has been sutured over a defect, the forcible entry of blood causes bleeding under the inset. The method, therefore, should not be applied for the first twenty-four hours after the operation ; it can then be safely used, starting with a pressure of 2o to 30 ram. Hg in the cuff for twenty-four hours and increasing it to 4o to 50 mm. Hg for the subsequent duration of the treatment. THE USE OF THESE METHODS IN PRACTICE A combination of the above methods, depending on the site of the flap and the severity of the case, will be required, one or other method of filling the flap with blood being used in conjunction with one or other method of emptying it (Fig. 3). The following case records illustrate the way in which these combinations can be applied in practice. Case x.--a " blue flap " treated by passive emptying of the flap by gravity alternating with passive filling of the flap by gravity. Mrs E. K., aged 69 years. Case of gross lympheedema of right arm of nine years" duration following radical mastectomy and radiotherapy. This patient was faced with the l~ossibility of amputation of the right arm, and an effort was therefore made to save the limb by making a long tubed pedicle on the back of the right chest and flank ; later, its lower end was divided and inset into the back of the elbow region of the affected arm so as to provide a path for the escape of the tissue fluid from the swollen limb.

4 THE ~' BLUE FLAP ~ : A METHOD OF TREATMENT 169 I7th January I95o.--A tubed pedicle 22 by IO cm. was raised on the back and right side of the trunk. 27th February I95o.--Flap 8 by IO cm. delayed on the lower end of the skin tube-- the tube together with the flap on its end was therefore 3 by IO cm. FIG. 3 Method of driving blood in and out of an abdominal tubed pediclc which is carried on the right wrist and has been inset on the left leg. The apparatus on the patient's right actively fills the tube with blood and that on the patient's left then expresses the blood from the inset. FIG. 4 Case I. Survival of the inset of a long tubed pedicle. Photograph taken one month after operation. 6th March I95o.--The lower end of the tubed pedicle with the flap on its end was finally raised, and the flap was inset into a defect created just above the back of the right elbow. The flap was of a deep blue colour, though it blanched readily on pressure ; its colour was ominous and strongly suggested the early loss of the flap.

5 I70 BRITISH JOURNAL OF PLASTIC SURGERY As soon as the patient was returned to bed, her position was altered every fifteen minutes so that the inset of the tube was alternately below and then above the level of its pedicle, and this was continued for eighteen hours ; in this way the blood was kept moving in and out of the flap by gravity. Eighteen hours after operation the flap had a bright pink-blue colour and was very obviously alive, and the treatment was stopped. The whole flap survived (Fig. 4). While it may be suggested that the flap may have survived without this treatment, it was considered very unlikely at the time in view of the length of the tube, its site, the deep blue colour of its inset, and the age of the patient. Incidentally, the oedema of" the arm subsided until the limb, though bigger than its fellow, remains permanently about half its original diameter. Fie. 5 Case 2. Photograph of the tubed pedicle taken fifteen days after its inset into the arm. It shows survival of the bulk of the inset with the exception of an area which was dead before treatment by expression was started. Case 2.--A " blue flap " treated by passive filling of the flap by gravity alternating with active emptying of the flap by expression. Mrs E. L., aged 49 years. Case of gross cedema of the left arm following radical mastectomy and radiotherapy nine years ago. The plan of treatment was to inset the lower end of a tubed pedicle, raised on the back of the left side of the chest, as low down the arm as possible, and was similar to that described in Case I. I7th March I95o.--Tubed pedicle 25 by IO cm. raised on a fat left lateral chest wall. 4th July I95o.--Flap Io by IO cm. delayed on the lower end of the tube. Further operation was postponed for five months owing to sepsis under the delayed flap. 29th December I95o.--Withont a further delaying operation, the lower end of the tube with the flap on its end (overall combined dimensions 35 by IO cm.) was raised from the chest wall and inset into a defect created just above the back of the left elbow. At the end of this operation the flap was in a poor way--it was blue and blanched very slowly on pressure. On return to bed the patient was nursed in a position which allowed the blue inset to lie above the level of its pedicle in an effort to encourage venous drainage. 3oth December I95o (one day after operation).--the terminal I to 2 cm. of the inset was deep blue, and did not blanch on pressure--it was obviously irretrievably lost. The

6 THE ~c BLUE FLAP ~ " A METHOD OF TREATMENT 171 patient was then rolled on her side so that the blue inset was below the level of its pedicle, to encourage the passive entry of blood into the flap by gravity. At the same time a thin rubber bag was strapped over the inset, connected to an intermittent venous occluder which provided a pressure of 4 ram. Hg in the bag every two minutes, and this treatment was continued for two days. xnd January 1951 (four days after operation).--although the terminal i to 2 cm. of the inset was now black and obviously dead, there had been no extension of the necrosis. The rest of the inset, however, showed a high pink-blue colour, except for two small patches of superficial skin necrosis at its middle. i3th January 1951 (fifteen days after operation).--this flap survived in its entirety~ except for the loss of its terminal I to 2 cm. and two small patches of skin at its centre (Fig. 5). This case is of interest in that death of the terminal part of the flap was obvious in twenty-four hours, and it seemed quite clear that with such a long skin flap in a fat patient it was only a matter of a few days beforc the whole inset would have perished~ Once treatment was applied the process of necrosis was arrested. FIG. 6 Case 3. Condition of the inset two and a half days after operation showing extent of necrosis. FIG. 7 Case 3- Condition of inset fourteen days after operation--there has been no extension of the area of necrosis. Case 3.--A " blue flap " treated by active filling alternating with active emptying of the flap. H. T., aged 33. Had an unstable adherent scar on the lower third of the left leg following a compound fracture, and was treated by an abdominal tubed pedicle carried on the right wrist in a four-stage operation. 27th November 195o.--Stage 3 of the transfer was carried out, that is, an abdominal tube 30 by IO cm., carried on the right wrist, was inset on the left leg after the scar in that region had been excised. At the end of the operation the inset appeared satisfactory, though it was a little cyanosed. 29th November 195o (two days after operation).--the inset was cyanosed though it blanched on pressure, but its extreme distal edge was irreversibly blue for 3 to 4 ram. along its whole width, i.e., it was deep blue and did not blanch on pressure. Twelve hours later (that is, two and a half days after operation) this irreversibly blue area had more than doubled in width to form a deep-blue band about 1 cm. broad all round the three free edges of the inset (Fig. 6). Progress of the necrosis was so rapid that the following treatment was applied: (a) blood was actively driven into the flap by placing a sphygmomanometer cuff round the right upper arm and connecting it to an intermittent venous occluder which alternately inflated the cuff to a pressure of 3 ram. Hg and then

7 172 BRITISH JOURNAL OF PLASTIC SURGERY released this pressure every two minutes ; (b) at the same time, a thin rubber bag was strapped over the blue tubed pedicle inset and was connected to a second intermittent venous occluder which raised the pressure in the bag to 30 ram. Hg for the two minutes during which the arm cuff was deflated and which allowed its bag to deflate during the two minutes the arm cuff was blown up to a pressure of 30 ram. Hg (Fig. 3)- In this way blood was actively forced into the tubed pedicle inset for two minutes and then actively expressed for the next two minutes, and this was continued for the next two days. ist December 195o (four days after operation).--treatment discontinued. The inset, apart from its necrosing end, was a bright pink-blue and the area of necrosis had not extended. This is shown in Fig. 7, which was taken on the fourteenth post-operative day. CONCLUSIONS By keeping the blood in a " blue flap " on the move, intravascular thrombosis can be prevented and the flap saved. Treatment on the lines indicated should be initiated as soon as the patient is returned to bed from the operating theatre in all cases where the inset of a long flap or tubed pedicle is blue or looks in any way doubtful. Even if necrosis of part of a flap has already started, one should not stand helplessly by and watch its inevitable progress day by day. If active treatment is started at any stage, there is every likelihood that further extension of necrosis will be prevented. I woum like to thank John Needham & Co. (8heffieM) Ltd., who supplied the rubber bags. REFERENCE HYNES, W. (195o). Brit. J. Plastic Surg., 3, 165.

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