Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database

Analysis of Selection of Recipient Vein, Number of Outflows, Style and Technique in Head and Neck Venous Anastomosis and a Proposed Algorithm

Surgeons have preferential ways of performing venous anastomosis in head and neck microsurgery. However, controversies exist regarding the superiority of each method. This study aims to determine the effects of these variables on the rates of thrombosis and flap failure, and propose an algorithm to be used as a facilitator in the decision-making process. A total of 208 microsurgical reconstructions on 199 patients from a single surgeon's data were evaluated. Selection of recipient vein (superficial vs. deep), style of anastomosis (end-to-end vs. end-to-side), number of outflows (one vs. two) and technique of anastomosis (hand-sewn vs. coupler) were compared. Selection was done according to the pre- and intraoperative plan, as well as, surgeon's clinical judgement. Outcomes were determined as rates of venous thrombosis and flap failure. Five patients (2.4%) had venous problems, leading to two partial and three total flap failures. Selection of the recipient vein, style and number of outflows did not affect the outcomes, whereas coupler use decreased the rates of venous thrombosis and flap failure (p=0.008). Although it is difficult to set dogmatic criteria to achieve consistent outcomes, coupler use in this study prevented flap failure. An algorithmic approach was proposed with the results of the data and literature to increase the success in microsurgical anastomosis. Surgeons should use algorithms and sound judgement with adherence to microsurgical principles to obtain the best results for each patient.

Thromboelastometry for Assessing Risks of Free Flap Thrombosis in Patients Undergoing Microvascular Surgery

Introduction: Coagulation assessment is often missing in microvascular surgery. We aimed at evaluating the predictive value of thromboelastometry for free flap thrombosis in microvascular surgery patients. Materials and Methods: We enrolled 103 adult patients with traumatic injuries scheduled for microvascular free flap surgery into a prospective observational study. Thirty-six patients with recent trauma underwent surgery within 30 days (ES group), and were compared with 67 trauma patients who underwent surgery later than 30 days (late surgery, LS group) after the injury. Rotational thromboelastometry (RTE) was performed before surgery. Functional fibrinogen to platelet ratio (FPR) ≥ 42 was selected as the main hypercoagulability index. Free flap thrombosis was set as primary outcome. Thrombotic risk factors and duration of surgery related to free flap thrombosis were secondary outcomes. Statistical significance p < 0.05; not significant NS. Results: Six patients (16.7%) in the ES group and 10 (14.9%) in the LS group had free flap thrombosis (NS). In the entire cohort, free flap thrombosis rate increased in the presence of thrombogenic comorbidities (OR 4.059, CI 1.33-12.37; p = 0.014) and prolonged surgery times (OR 1.007, CI 1 - 1.012; p = 0.05). Although hypercoagulability occurred more frequently in the ES group (44.4%) than in the LS group (11.9%; p < 0.001), it was not associated with higher free flap thrombosis rate. In ES group patients with surgery times > 240 min, the risk of free flap thrombosis increased (OR 3.5, CI 1.16-10.6; p = 0.026) with 93.3% sensitivity and 86.7% specificity (AUC 0.85; p = 0.007). In contrast, in LS patients hypercoagulability increased the odds of free flap thrombosis (OR 8.83, CI 1.74-44.76; p = 0.009). Moreover, a positive correlation was found between FPR ≥ 42 and free flap thrombosis rate (r = 0.362; p = 0.003). In the LS group, the presence of thrombogenic comorbidities correlated with free flap thrombosis rate (OR 7, CI 1.591-30.8; p = 0.01). Conclusions: In LS patients with thrombogenic comorbidities, thromboelastometry supports the detection of hypercoagulability and predicts free flap thrombosis risk. In ES patients, postoperative hypercoagulability did not predict free flap thrombosis. Prolonged surgery time should be considered as a risk factor.

Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction

The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm³), with a PNI <40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p <0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 ± 55.5 days vs. 28.3 ± 24.4 days, p <0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.

[Reconstruction of lower limbs in old age-an interdisciplinary approach : Strategies for trauma surgery, vascular surgery and plastic surgery]

The treatment of complex injuries of the lower extremities in geriatric and/or multimorbid patients requires optimized preoperative and perioperative management as well as differentiated and interdisciplinary surgical approaches. Timely and definitive treatment should be strived for to avoid longer periods of immobilization. Temporary external stabilization of complex fractures, when necessary, should be followed by permanent loading stable internal osteosynthesis as soon as possible. Accompanying soft tissue defects are reconstructed after wound débridement using the full armamentarium of plastic and reconstructive surgical procedures, including microvascular free flap. In the context of perfusion compromised soft tissue situations, negative pressure wound therapy can provide sterile temporary defect coverage and aid in preconditioning poorly vascularized tissue before definitive reconstruction. A clarification of the vascular status in geriatric patients is paramount and relevant perfusion disorders should be treated either by intervention or open surgery before complex reconstructive interventions. Close interdisciplinary coordination of the various surgical procedures is imperative in order to guarantee an optimized stable reconstructive outcome with acceptable patient risk. Taking these principles into account, the reconstruction of complex trauma to the extremities can be carried out even in geriatric or multimorbid patients in specialized interdisciplinary surgical centers with excellent functional results.

Head and Neck Reconstructive Surgery: Characterization of the One-Team and Two-Team Approaches

PURPOSE

To the best of our knowledge, no studies have compared the patient profiles for 1- versus 2-team surgery within head and neck oncosurgery.

PATIENTS AND METHODS

A retrospective study of the data from 2968 patients who had undergone concurrent head and neck extirpative and reconstructive surgery in the National Surgical Quality Improvement Program (2010 to 2017) was conducted. Patients were stratified into 1- and 2-team surgery groups, and the demographic data were compared. Univariate analyses of the outcomes before and after propensity score matching were conducted.

RESULTS

Most ablative and reconstructive head and neck procedures (68.5%) were performed using a 1-team approach. The patients who had undergone 2-team surgery were more likely to have a higher American Society of Anesthesiologists classification (P < .001), to require mandibulectomy (P < .001) or glossectomy (P < .001), and to receive a microvascular free flap (P < .001) but were less likely to require parotidectomy (P < .001) or to receive a rotational flap (P < .001). Before propensity score matching, the patients undergoing 2-team surgery had longer operative times (P < .001), longer postoperative stays (P < .001), greater rates of a return to the operating room (P = .001), and an increased rate of complications (P < .001). After propensity score matching, the 2-team approach continued to have longer operative times (P < .001) and an increased incidence of complications (P < .001) but no significant differences in the length of stay or rate of return to the operating room after Bonferroni's correction.

CONCLUSIONS

Nationally, most head and neck ablative and reconstructive surgeries were completed by 1 team. More complicated reconstructive procedures involving microvascular free flaps have been more commonly performed by 2 teams, resulting in slightly longer operative times and greater associated complication rates.

Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck

Importance

Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking.

Objective

To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck.

Design, Setting, and Participants

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016.

Exposures

Microvascular reconstructive surgery of the head and neck.

Main Outcomes and Measures

Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality.

Results

A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16).

Conclusions and Relevance

Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery.

Level of Evidence

3.

Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database

BACKGROUND

Lower extremity free flaps are a common way to treat both traumatic and oncologic lower extremity wounds. These patients often suffer postoperative complications. We sought to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify variables associated with postoperative complications.

METHODS

Patients who had free flap procedure and a primary diagnosis code for lower extremity pathology were identified in the NSQIP database from 2006 to 2017. NSQIP includes data on preoperative, intraoperative, and postoperative variables, including information up to 30 postoperative days. Current procedural terminology (CPT) codes for free flaps and international classification of diseases (ICD) 9 and 10 codes for lower extremity pathology were used for our cohort. We examined overall and major complication rates. Major complications were defined as reoperation, readmission, organ space infection, or death. Univariate and multivariate analyses were used to identify associations with complications.

RESULTS

Four hundred and eighty-three patients underwent lower extremity free flaps. Overall complication rate was 31.6% and major complication rate was 14.9%. Prolonged operative time (OR = 2.81, CI:1.76-4.48, p < .001), preoperative steroid use (OR = 3.04, CI:1.12-8.29, p = .030), and preoperative anemia (OR = 4.10, CI:2.00-8.41, p < .001) were independently associated with any complication. Diabetes (OR = 2.56, CI:1.24-5.29, p = .011) and prolonged operative time (OR = 3.75, CI:2.17-6.47, p < .001) were independently associated with major complications.

CONCLUSIONS

In lower extremity flap reconstruction, associations with overall complications include prolonged operative time, steroid use, and anemia. Associations with major complications included diabetes and prolonged operative time. These associations can be used to guide interventions on patients identified to have greater risk of complications.

Association between operation- and operator-related factors and surgical complications among patients undergoing free-flap reconstruction for head and neck cancers: A propensity score-matched study of 1,865 free-flap reconstructions

OBJECTIVE

Efforts have been devoted to clarify the possible factors related to postoperative complications in free-flap reconstruction. While patient-related factors have been widely discussed, studies regarding the operation/operator-related factors are rather limited in the literature. This study was designed to investigate the relationship between operation/operator-related factors and the surgical complications in free-flap reconstruction following head and neck cancer resection.

METHODS

Data of 1,841 patients with a total of 1,865 free-flap reconstructions (24 double free-flap reconstructions) between March 2008 and February 2017 were retrieved from the registered microsurgery database of the hospital. The association of operation/operator-related factors (including flap length and length-width ratio, flap types, use of vein graft, opposite side microanastomosis, number of microanastomoses, operators, operator experience, and operation time) with surgical complications was assessed by 1:1 propensity score-matched study groups.

RESULTS

After propensity score matching of the patient-related factors, the rate of vein grafting was significantly higher (0.6% vs. 2.2%, p = .038) and the operation time was longer (7.0 [5.8-8.5] vs. 7.4 [6.1-8.8] hr, p = .006) in the complication group. In addition, flap length and length-width ratio, flap types, opposite side microanastomosis, number of microanastomoses, operators, and operator experience were not associated with surgical complications.

CONCLUSIONS

In a hospital that consisted of surgeons with high-volume or very-high-volume experience, the operators or operation experience were not significantly associated with the surgical complications. Only a longer operation time was associated with surgical complications in the patients who underwent free-flap reconstruction for head and neck cancer.

Association between blood pressure and postoperative hematomas in the patients undergoing head and neck cancer reconstruction

BACKGROUND

Postoperative hematoma is one of the most common complications of free flap reconstruction and compromises the perfusion of pedicles and perforators. Therefore, we reviewed our patients to analyze the associated risk factors.

METHOD

This study involved a retrospective chart review from 2014 to 2016. We identified the patients undergoing free flap reconstructions for head and neck cancer. Patients with postoperative hematoma requiring surgical intervention were included.

RESULT

We enlisted 289 patients undergoing head and neck reconstructions. Eighteen patients (6.2%) had postoperative hematomas of which 12 hematomas occurred within the first 3 days and 9 in the first 24 hours. Elevated systolic blood pressure increased the risk of hematoma formation, but hematoma was not associated with higher failure rate. Tachycardia was observed in the patients with hematoma.

CONCLUSIONS

Transient elevated blood pressure increased the risk of hematoma. We suggest controlling systolic blood pressure below 150 mm Hg for prevention of hematoma.

Protective STA-MCA bypass to prevent brain ischemia during high-flow bypass surgery: case series of 10 patients

BACKGROUND

High-flow extracranial-intracranial bypass is associated with a significant risk of ischemic stroke. The goal of this study is to evaluate the effectiveness of STA-MCA bypass preceding a high-flow bypass as a means of protecting the brain from ischemia during the high-flow bypass anastomosis in patients with otherwise untreatable aneurysms.

MATERIALS AND METHOD

This prospective study included 10 consecutive patients treated for complex/giant aneurysm using a previous combined STA-MCA bypass and high-flow EC-IC bypass between June 2016 and January 2018 when classical endovascular or microsurgical exclusion was estimated too risky. Early cranial Doppler, MRI, CT scan, and conventional angiography were performed in each patient to confirm patency of bypasses, measure flow in the anastomoses, detect any ischemic lesions, and evaluate exclusion of the aneurysm.

RESULTS

The mean age at treatment was 55 years (range 34 to 67). The mean time of microsurgical procedure was 11 h (range 9 to 12). In all patients, the high-flow bypass was patent intraoperatively and complete occlusion of aneurysm was obtained. No ischemic lesions were noted on early MRI. One patient died from a large hemispheric infarction related to a common carotid artery dissection 10 days after the microsurgical procedure and immediate postoperative epidural hematoma was noted in one other patient.

CONCLUSION

In this study, we described the use of a protective STA-MCA bypass, performed prior to the high-flow bypass, in order to reduce the risk of perioperative ischemic lesions without increasing the morbidity of the surgical procedure. This treatment paradigm was feasible in all ten patients without complications related to the STA-MCA anastomosis.

Scoping Review of the National Surgical Quality Improvement Program in Plastic Surgery Research

Background

The National Surgical Quality Improvement Program (NSQIP) is a robust, high-quality surgical outcomes database that measures risk-adjusted 30-day outcomes of surgical interventions. The purpose of this scoping review is to describe how the NSQIP is being used in plastic surgery research.

Methods

A comprehensive electronic literature search was completed in PubMed, Embase, MEDLINE, and CINAHL. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. Articles were included if they utilized NSQIP data to conduct research in a domain of plastic surgery or analyzed surgical procedures completed by plastic surgeons. Extracted information included the domain of plastic surgery, country of origin, journal, and year of publication.

Results

A total of 106 articles met the inclusion criteria. The most common domain of plastic surgery was breast reconstruction representing 35% of the articles. Of the 106 articles, 95% were published within the last 5 years. The Plastic and Reconstructive Surgery journal published most of the (59%) NSQIP-related articles. All of the studies were retrospective. Of note, there were no articles on burns and only one study on trauma as the domain of plastic surgery.

Conclusion

This scoping review describes how NSQIP data are being used to analyze plastic surgery interventions and outcomes in order to guide quality improvement in 106 articles. It demonstrates the utility of NSQIP in the literature, however also identifies some limitations of the program as it applies to plastic surgery.

Free tissue transfer with the free rectus abdominis flap in high-risk patients above 65 years: A retrospective cohort study

BACKGROUND

Though technically feasible, free tissue transfer carries the risk of perioperative morbidity and mortality in elderly patients. To minimize the operative treatment time and complication rates, we choose the rectus abdominis muscle (RAM) flap.

METHODS

Between 2012 and 2017, 34 patients (mean age: 74±7 years, range: 65-89 years) with comorbidities underwent defect reconstruction with a free RAM flap. Recipient-sites were: lower extremity (65%), trunk (18%), upper extremity (12%), and head and neck (6%).

RESULTS

The ASA status was 2 in 11 patients, 3 in 21 patients, and 4 in 2 patients. Twenty patients (59%) received additional vascular surgery. Three patients (9%) underwent simultaneous restoration of fractures. The mean operative time (OT) was 325±75 min. There was no total flap loss. Partial flap loss occurred in one patient (3%). The incidence of surgical and medical complications was 32% and 38%: 11 patients experienced a total of 22 surgical complications, of which 15 were major (requiring additional surgery) and 7 minor (conservative treatment). One patient died postoperatively because of progressive respiratory failure. Prolonged OT was highly associated with hematoma formation requiring re-operation (p = 0.01). ASA status was a significant predictor for postoperative critical care monitoring (p = 0.03). Reconstruction was successful in 31 out of 34 patients (91%) during a mean follow-up time of 17.7 ± 8.8 months (range: 2-51 months).

CONCLUSION

The free RAM flap has proven as a reliable and efficient tool in the armamentarium of reconstructive microvascular surgeons with some advantages in the treatment of multimorbid patients older than 65 years.

Unplanned Reoperations in Oral and Maxillofacial Surgery

PURPOSE

The purpose of this study was to determine the incidence of and reasons for unplanned reoperations in oral and maxillofacial surgery.

MATERIALS AND METHODS

During a 4-year period, a total of 169 patients undergoing reoperations were encountered. The clinical characteristics and causes were reviewed.

RESULTS

There were 11,151 patients who underwent surgery, and the incidence of unplanned reoperations was 1.52%. The male-to-female ratio was 2.45:1. The average age in this cohort was 51.5 years. Among the common causes of an unplanned return to the operating room, the most common were reoperations performed for postoperative bleeding, diagnostic issues, and vascular crisis (32.54%, 28.40%, and 29.59%, respectively).

CONCLUSIONS

The unplanned reoperation rate was 1.52%. The main causes were postoperative bleeding, diagnostic issues, and vascular crisis. Patients with malignant tumors or microvascular flaps were more likely to undergo unplanned reoperations. Improving perioperative management and diagnostic capability might reduce the incidence of unplanned reoperations.

Is quicker better? A NSQIP analysis of anesthesia time and complications following tracheostomy placement

BACKGROUND

Increased anesthesia time may lead to respiratory complications in patients receiving tracheostomy, which contributes to patient morbidity.

METHODS

The American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases of planned tracheostomy (CPT 31600) from 2005 to 2012. Patients were stratified into quintiles based on anesthesia duration. Pearson's chi square, Fischer's exact test, one-way ANOVA, and multivariate regression were used to determine the association between patient characteristics with pneumonia and ventilator dependence.

RESULTS

Out of 752 patients, 83 patients experienced post-operative pneumonia, and 166 experienced ventilator dependence. Following multivariate regression analysis, anesthesia quintiles were not significantly associated with pneumonia or ventilator dependence. Age (OR 1.03, 95% CI 1.00-1.05, P = .032), dyspnea (OR 2.21, 95% CI 1.18-4.13; P = .013), pre-operative ventilator dependence (OR 3.08, 95% CI 1.19-7.98; P = .020), and sepsis (OR 6.68, 95% CI 3.19-14.0; P < .001) remained as significant predictors of post-operative ventilator dependence.

CONCLUSIONS

Faster may not be better-- prolonged anesthesia time does not increase the risk of post-operative pneumonia or ventilator dependence in patients receiving a planned tracheostomy in the operating room.

Current practices in microvascular reconstruction in otolaryngology-head and neck surgery

OBJECTIVES/HYPOTHESIS

Despite major advances in the field of head and neck microvascular free tissue transfer (MFTT) over the past several decades, there are no standardized perioperative regimens for the care of patients undergoing free flap reconstructive surgery, and continued variation in practice exists. This study aimed to report current trends in the field of MFTT performed by otolaryngologists, including surgeon training, institutional operative practices, and perioperative management.

STUDY DESIGN

Cross-sectional survey.

METHODS

A survey of Accreditation Council for Graduate Medical Education-accredited residency programs and American Head and Neck Society fellowship sites was conducted.

RESULTS

Seventy-one (62.8%) programs responded, with 67 (94.4%) routinely performing MFTT and 23 (32.4%) having a dedicated microvascular fellowship program. Of institutions performing MFTT, 66 (98.5%) reported the use of a two-surgeon team, most commonly both otolaryngologists (76.3%). Institutional MFTT volumes and donor site frequency are reported. Postoperative care includes routine admission to the intensive care unit (75.2%), step-down unit (15.0%), or general care floor (8.1%). Postoperative flap monitoring practices, including modalities, personnel, and timing/frequency show institutional variation. Despite differences in postoperative monitoring regimen and management (sedation, anticoagulation, antibiotic use), surgeon-reported measures of flap success rate (95.7%, standard deviation [SD] 4.7%) and complication rate (6.8%, SD 2.4%) show little difference across institutions.

CONCLUSIONS

Many elements of MFTT perioperative care show continued variation at an institutional level. There is a notable shift toward the two-team approach within otolaryngology. Self-reported flap complication and success rates showed no significant differences based on perioperative care and monitoring regimen. Further study of perioperative practices should focus on standardization of care to improve overall outcomes in this complex patient population.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:138-145, 2019.

One Versus 2 Venous Anastomoses in Free Flap Surgery: A Systematic Review and Meta-Analysis

Background

The necessity of a second venous anastomosis in free flap surgery is controversial. The purpose of this systematic review is to determine whether venous flap failure and reoperation rates are lower when 2 venous anastomoses are performed. The secondary objective is to determine whether venous flap failure and reoperation rates are lower when the 2 veins are from 2 different drainage systems.

Methods

A comprehensive search of the literature identified relevant studies. Investigators independently extracted data on rates of flap failure and reoperation secondary to venous congestion. A meta-analysis was performed; odds ratios (ORs) were pooled using a random-effects model and 95% confidence intervals (CIs).

Results

Of 18 190 studies identified, 15 were included for analysis. The mean sample size was 287 patients (minimum = 102, maximum = 564). No statistically significant difference in venous flap failure was found when comparing 1 versus 2 venous anastomoses (OR: 1.35; 95% CI: 0.46-3.93). A significant decrease in reoperation rate due to venous congestion was shown (OR: 3.03; 95% CI: 1.64-5.58). The results favor using 2 veins from 2 different systems over veins from the same system (OR: 0.16; 95% CI: 0.02-1.27).

Conclusions

There is low-quality evidence suggesting that the use of 2 venous anastomoses will lower the rate of reoperation due to venous congestion. There are insufficient data published to meaningfully compare outcomes of flaps with 2 venous anastomoses from different systems to flaps with anastomoses from the same system.

Does Hormone Therapy Use Increase Perioperative Complications in Abdominally Based Microsurgical Breast Reconstruction?

BACKGROUND

The use of hormone therapy (tamoxifen and aromatase inhibitors) has been shown to increase venous thromboembolism. As breast cancer patients undergoing microsurgical breast reconstruction are often receiving hormone therapy, it is unclear whether this increased thrombotic risk is associated with increased flap loss.

METHODS

A retrospective review was performed on patients undergoing abdominally based microsurgical breast reconstruction at an academic institution from 2004 to 2015. Patients were divided by use of hormone therapy at the time of surgery. Complication rates, including complete or partial flap loss and overall complications, were compared and analyzed using univariate and logistic regression models.

RESULTS

Among a total of 853 patients (1253 flaps), 193 patients (269 flaps) were receiving hormone therapy and 660 patients (984 flaps) were not. Patients on hormone therapy had higher rates of previous breast surgery, advanced cancer stage, chemoradiation before reconstruction, and delayed and unilateral reconstruction. There were no statistically significant differences between hormone therapy patients and nontherapy patients in complete flap loss (1.0 percent versus 1.1 percent) and partial flap loss (2.2 percent versus 1.5 percent). Hypertension and previous breast surgery were the only independent risk factors for minor complications (adjusted OR, 2.1; 95 percent CI, 1.3 to 3.6; p = 0.005; and adjusted OR, 1.8; 95 percent CI, 1.2 to 2.7; p = 0.009, respectively) and overall complications (adjusted OR, 2.2; 95 percent CI, 1.3 to 3.7; p = 0.004; and adjusted OR, 1.9; 95 percent CI, 1.3 to 3.0; p = 0.003, respectively).

CONCLUSIONS

Hormone therapy was not associated with a higher incidence of complete or partial flap loss or overall complications. The authors propose an individualized approach to the preoperative cessation of tamoxifen or aromatase inhibitors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

It Takes Two: One Resects, One Reconstructs

Care of patients with advanced head and neck cancer is a multidisciplinary effort through all phases of care. Head and neck cancer surgery involves balancing oncologic control, functional preservation, and aesthetics. Given the advances in free tissue reconstruction, the majority of defects can be reconstructed using free tissue transfer flaps. A 2-team approach allows for early, continual communication and meticulous operative planning. Operations can be combined into a single effort. This approach maximizes efficiency and enables multidisciplinary collaboration for comprehensive surgical treatment. We present our experience and an outline of how responsibilities between the ablative and reconstructive teams are shared.

Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the ACS-NSQIP database

BACKGROUND

Diabetes affects a significant proportion of the population in the United States. Microsurgical procedures are common in this patient population, and despite many conflicting reports in the literature, there are no large studies evaluating the direct association between diabetes and outcomes, specifically failure, following free flap reconstruction. In this study, we sought to determine the impact of diabetes on postoperative outcomes following free flap reconstruction using a national multi-institutional database.

METHODS

We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients undergoing free flap reconstruction from 2010 to 2015. Preoperative variables and outcomes were compared between diabetic and nondiabetic patients. Univariate and multivariate analyses were performed to control for confounders.

RESULTS

We identified 6030 eligible patients. No significant difference in flap failure rates was observed. However, diabetic patients presented significantly higher rates of wound complications, including deep incisional surgical site infection (SSI) (OR = 1.35; P = .01) and wound dehiscence (OR = 1.17; P = .03). Diabetic patients also presented a significantly longer hospital length of stay (LOS) (β = .62; P < .001).

CONCLUSIONS

Our study evaluated the largest national cohort of free flap procedures. These results suggest that diabetes is not associated with increased rates of flap failure. However, diabetic patients are at significantly higher risk of postoperative deep incisional SSI, wound dehiscence, and longer LOS. Our findings provide the most concrete evidence to date in support of free flap reconstruction in diabetic patients, but highlight the need for heightened clinical vigilance and wound care for optimal outcomes.

Identification of Independent Risk Factors for Complications: A Retrospective Analysis of 163 Fibular Free Flaps for Mandibulofacial Reconstruction

PURPOSE

Fibular free flap transfer is a powerful tool available to the reconstructive surgeon when treating oral and maxillofacial defects, but complications still occasionally occur and predictive analysis focusing on this specific flap is limited in terms of risk factors for complication. The purpose of this study was to identify key variables associated with complications in patients undergoing fibular free flap transfer.

PATIENTS AND METHODS

The data of 163 consecutive patients who underwent fibular free flap surgery at the Department of Oral and Maxillofacial Surgery, Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University, between 2012 and 2015 were reviewed retrospectively. Patient demographic data, laboratory data, surgical data, and fluid infusion-related data that may have an influence on free flap outcomes were recorded. Univariate and multivariate logistic regression analyses were used to identify relevant risk factors.

RESULTS

A total of 163 fibular free flaps were transferred for mandibulofacial reconstruction in 163 patients with a mean age of 50.9 years. Postoperative complications developed in 33 (20.2%). Multivariate analysis showed that free flap complications were significantly associated with radiotherapy history (odds ratio [OR], 5.12; P = .001), postoperative anemia (OR, 1.048; P = .041), postoperative hypoalbuminemia (OR, 0.844; P = .002), and prolonged operative time (OR, 1.005; P = .004).

CONCLUSIONS

Radiotherapy history, decreased postoperative hemoglobin and albumin levels, and prolonged operative time are potential predictors of postoperative complications after fibular free flap reconstruction for mandibulofacial defects.

Applicability of quantitative optical imaging techniques for intraoperative perfusion diagnostics: a comparison of laser speckle contrast imaging, sidestream dark-field microscopy, and optical coherence tomography

Patient morbidity and mortality due to hemodynamic complications are a major problem in surgery. Optical techniques can image blood flow in real-time and high-resolution, thereby enabling perfusion monitoring intraoperatively. We tested the feasibility and validity of laser speckle contrast imaging (LSCI), optical coherence tomography (OCT), and sidestream dark-field microscopy (SDF) for perfusion diagnostics in a phantom model using whole blood. Microvessels with diameters of 50, 100, and 400  μm were constructed in a scattering phantom. Perfusion was simulated by pumping heparinized human whole blood at five velocities (0 to 20  mm/s). Vessel diameter and blood flow velocity were assessed with LSCI, OCT, and SDF. Quantification of vessel diameter was feasible with OCT and SDF. LSCI could only visualize the 400-μm vessel, perfusion units scaled nonlinearly with blood velocity. OCT could assess blood flow velocity in terms of inverse OCT speckle decorrelation time. SDF was not feasible to measure blood flow; however, for diluted blood the measurements were linear with the input velocity up to 1  mm/s. LSCI, OCT, and SDF were feasible to visualize blood flow. Validated blood flow velocity measurements intraoperatively in the desired parameter (mL·min-1·g-1) remain challenging.

A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation

PURPOSE

The present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur.

METHODS

Twelve patients (aged 15-58 years) with infected bone defects of the femur (between 6.0 and 18.0cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1-2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site.

RESULTS

Mean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7-15cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9-72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%.

CONCLUSIONS

Free vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.

Reconstruction of the Foot and Ankle Using Pedicled or Free Flaps: Perioperative Flap Survival Analysis

Objective

The purpose of this study is to determine the correlation between non-technical risk factors and the perioperative flap survival rate and to evaluate the choice of skin flap for the reconstruction of foot and ankle.

Methods

This was a clinical retrospective study. Nine variables were identified. The Kaplan-Meier method coupled with a log-rank test and a Cox regression model was used to predict the risk factors that influence the perioperative flap survival rate. The relationship between postoperative wound infection and risk factors was also analyzed using a logistic regression model.

Results

The overall flap survival rate was 85.42%. The necrosis rates of free flaps and pedicled flaps were 5.26% and 20.69%, respectively. According to the Cox regression model, flap type (hazard ratio [HR] = 2.592; 95% confidence interval [CI] (1.606, 4.184); P < 0.001) and postoperative wound infection (HR = 0.266; 95% CI (0.134, 0.529); P < 0.001) were found to be statistically significant risk factors associated with flap necrosis. Based on the logistic regression model, preoperative wound bed inflammation (odds ratio [OR] = 11.371,95% CI (3.117, 41.478), P < 0.001) was a statistically significant risk factor for postoperative wound infection.

Conclusion

Flap type and postoperative wound infection were both independent risk factors influencing the flap survival rate in the foot and ankle. However, postoperative wound infection was a risk factor for the pedicled flap but not for the free flap. Microvascular anastomosis is a major cause of free flap necrosis. To reconstruct complex or wide soft tissue defects of the foot or ankle, free flaps are safer and more reliable than pedicled flaps and should thus be the primary choice.

Perioperative Glycemic Control in Plastic Surgery: Review and Discussion of an Institutional Protocol

Perioperative hyperglycemia is a well-known risk factor for surgical morbidity such as wound healing, infection, and prolonged hospitalization. This association has been reported for a number of surgical subspecialties, including plastic surgery. Specialty-specific guidelines have become increasingly available in the literature. Currently, glucose management guidelines for plastic surgery are lacking. Recognizing that multiple approaches exist for perioperative glucose, protocol-based models provide the necessary structure and guidance for approaching glycemic control. In this article, we review the influence of diabetes on outcomes in plastic surgery patients and propose a practical approach to perioperative blood glucose management based on current Endocrine Society and Mayo Clinic institutional guidelines.

Is obesity a predisposing factor for free flap failure and complications? Comparison between breast and nonbreast reconstruction: Systematic review and meta-analysis

Obesity is a risk factor for postoperative morbidity in breast reconstruction. Although existing studies about nonbreast reconstruction are limited, previous research has demonstrated that obesity is not an important factor in poor outcomes in nonbreast reconstruction. Our study evaluates the effects of obesity on postoperative morbidity in nonbreast reconstruction in comparison to breast reconstruction. A systematic literature review and meta-analysis was performed using Medline, EMBASE, and Cochrane databases. Obesity was extracted for predictor variables and partial, total loss of flap, and complication were extracted for outcome variables. Subgroup analyses were performed according to reconstruction site. The Newcastle-Ottawa scale (NOS) was used to assess the quality of the studies, and the Cochrane risk of bias tool was used. Publication bias was evaluated using funnel plots. The search strategy identified 944 publications. After screening, 19 articles were selected for review. Partial flap loss, total flap loss, and complications in breast reconstruction occurred significantly more often in obese patients in comparison to nonobese patients (OR = 2.479, P = 0.021 for partial loss, OR = 3.083, P = 0.002 for total loss, OR = 2.666, P = 0.001 for complications). In contrast, partial flap loss, total flap loss, and complications in nonbreast reconstruction were not significantly different in obese patients in comparison to nonobese patients (OR = 0.786, P = 0.629 for partial loss, OR = 0.960, P = 0.961 for total loss, and OR = 1.009, P = 0.536 for complications). In contrast to the relationship between obesity and poor outcomes in breast reconstruction, our study suggests the obesity is not a predisposing factor for poor outcomes in nonbreast reconstruction. Long-term studies are needed to confirm these findings.

Benefits of two or more senior microsurgeons operating simultaneously in microsurgical breast reconstruction: Experience in a swedish medical center

BACKGROUND

The aim of this study is to evaluate how the number of senior microsurgeons, performing autologous microvascular breast reconstruction together, influences operating time and postoperative complications.

METHODS

A retrospective study was carried out in one hundred consecutive patients who underwent unilateral delayed deep inferior epigastric perforator flap reconstruction at a single institution. All patients followed our institution's surgical protocol and were divided into groups depending on the number of senior microsurgeons that simultaneously performed the procedure. Operating time and complications were compared between the groups.

RESULTS

Sixteen of the patients were operated by one single microsurgically trained specialist, 64 by two and 20 by three specialists. The mean operating time for the one microsurgeon's group was 286 ± 84 min, for the two-microsurgeons' group 265 ± 57 min and for the three-microsurgeons' group 251 ± 59 min. There was a trend of decreasing operating times when more microsurgeons performed surgery together, however the difference between groups was not statistically significant (P = 0.251). Total flap failure rate was 2% (2/100). Both cases occurred in the group operated by one single microsurgeon (2/16) compared with two microsurgeon's group (0/64) and three microsurgeon's group (0/20; P < 0.005).

CONCLUSIONS

By optimising the surgical experience available during microvascular breast reconstruction, operating time can be reduced and efficiency improved. In the current setting, two microsurgically trained surgeons achieved optimal operation flow with the lowest complication rate. © 2016 Wiley Periodicals, Inc. Microsurgery 37:416-420, 2017.

Identification of independent risk factors for flap failure: A retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction

Reconstructive microsurgery is a powerful method of treating various complex defects. However, flap loss remains a possibility, leading to additional surgery, hospitalisation and costs. Consequently, it is important to know which factors lead to an increased risk of flap failure, so that measures can be undertaken to reduce this risk. Therefore, we analysed our results over a 20-year period to identify risk factors for flap failure after breast, head and neck and extremity reconstruction. The medical files of all patients treated between 1992 and 2012 were reviewed. Patient characteristics, surgical data and post-operative complications were scored, and independent risk factors for flap loss were identified. Reconstruction with a total of 1530 free flaps was performed in 1247 patients. Partial and total flap loss occurred in 5.5% and 4.4% of all free flaps, respectively. In all flaps, signs of compromised flap circulation were a risk factor for flap failure. More specifically, the risk factors for flap failure in breast reconstruction were previous radiotherapy, venous anastomosis revision, gluteal artery perforator (GAP) flap choice and post-operative bleeding. In head and neck reconstruction, pulmonary co-morbidity and anastomosis to the lingual vein or superficial temporal artery were risk factors, whereas a radial forearm flap reduced the risk. In extremity reconstruction, diabetes, prolonged anaesthesia time and post-operative wound infection were risk factors. Independent pre-, intra- and post-operative risk factors for flap failure after microvascular breast, head and neck and extremity reconstruction were identified. These results may be used to improve patient counselling and to adjust treatment algorithms to further reduce the chance of flap failure.

The Role of Virtual Surgical Planning in the Era of Robotic Surgery

Among various surgical methods introduced to optimize esthetic results, robotic surgery has gradually expanded in scope. As incision, approach, and operation view in robotic surgery differ from existing surgical methods, we should consider reconstruction from a different perspective. We recently experienced two mandibular reconstruction cases after tumor ablative surgery with robotic neck dissection using the conventional reconstruction method and virtual surgical planning (VSP), respectively. We found that the conventional reconstruction method is inappropriate in modified facelift incision in robotic neck dissection because it provides limited surgical scope, restricts access to the defect area, and therefore, consumes considerable time before anastomosis. For these reasons, the authors consider VSP far more viable in the era of robotic surgery.

The Development of a Wireless Implantable Blood Flow Monitor

Microvascular anastomotic failure remains an uncommon but devastating problem. Although the implantable Doppler probe is helpful in flap monitoring, the devices are cumbersome, easily dislodged, and plagued by false-positive results. The authors have developed an implantable wireless Doppler monitor prototype from off-the-shelf components and tested it in a swine model. The wireless probe successfully distinguished between femoral vein flow, occlusion, and reflow, and wirelessly reported the different signals reliably. This is the first description of a wireless implantable blood flow sensor for flap monitoring. Future iterations will incorporate an integrated microchip-based Doppler system that will decrease the size to 1 mm, small enough to fit onto an anastomotic coupler.

Near-infrared imaging for the assessment of anastomotic patency, thrombosis, and reperfusion in microsurgery: a pilot study in a porcine model

BACKGROUND

Advances in microsurgical techniques have increased the use of free tissue transfer. Methods of intraoperative flap perfusion assessment, however, still rely primarily on subjective evaluation of traditional clinical parameters. Anastomotic thrombosis, if not expeditiously identified and revised, can result in flap loss with significant associated morbidity. This study aims to evaluate the use of near-infrared (NIR) fluorescence imaging in the assessment of microsurgical anastomotic patency, thrombosis, and vascular revision.

MATERIALS AND METHODS

A model of pedicle thrombosis was created using bilateral abdominal flaps isolated on deep superior epigastric vascular pedicles in four Yorkshire pigs. Following flap elevation, microvascular arterial and venous anastomoses were performed unilaterally, preserving an intact contralateral control flap. Thrombosis was induced at the arterial anastomosis site using ferric chloride, and both flaps imaged using NIR fluorescence angiography. The thrombosed vascular segments were subsequently excised and new anastomoses performed to restore flow. Follow-up imaging of both flaps was then obtained to confirm patency using fluorescence imaging technology.

RESULTS

Pedicled abdominal flaps were created and successful anastomotic thrombosis was induced unilaterally in each pig. Fluorescence imaging technology identified large decreases in tissue perfusion of the thrombosed flap within 2 minutes. After successful revision anastomosis, NIR imaging demonstrated dramatic increase in flow to the reconstructed flap, but intensity did not return to pre-thrombosis levels.

CONCLUSIONS

Early identification of anastomotic thrombosis is important in successful free tissue transfer. Real-time, intraoperative evaluation of flap perfusion, anastomotic thrombosis, and successful revision can be performed using NIR fluorescence imaging.

The efficacy of the Cook-Swartz implantable Doppler in the detection of free-flap compromise: a systematic review protocol

INTRODUCTION

The Cook-Swartz implantable Doppler monitors venous or arterial blood flow from free flaps and can detect free-flap compromise. Previous studies have shown that the use of this Doppler can improve detection and salvage rates as it provides an earlier warning than the current method of clinical assessment. Such studies assert that the implantable Doppler is of great value in monitoring free flaps in current microsurgical units. This systematic review aims to compare the efficacy of the Cook-Swartz implantable Doppler in monitoring free-flap compromise against conventional clinical free-flap monitoring techniques.

METHODS AND ANALYSIS

Various electronic databases will be systematically searched for studies that compare the use of Cook-Swartz implantable Doppler with clinical assessment. The selected studies will then have their titles and abstracts screened by two authors. Articles selected after title and abstract screen will have full text downloaded and the complete article will be assessed for suitability. Once the articles have been selected for inclusion, data extraction will take place. For data analysis, the outcomes of the studies will be tabulated, with descriptive statistics performed as appropriate and the detection rate of the Doppler and clinical assessment will be compared and synthesised where possible.

ETHICS AND DISSEMINATION

The authors hope to disseminate the findings as widely as possible. This systematic review will be published in a peer-reviewed journal and include a number of recommendations as its conclusion based on the evidence contained within. Given the wide range of specialties now utilising flaps, it will be presented at a wide range of national and international conferences.

PROTOCOL REGISTRATION IN PROSPERO

CRD42013005818 The literature search and data extraction went on until 28 January 2014. These steps were revised in line with peer review comments.