Efficacy of the postoperative management after microsurgical free tissue transfer

Flying high?-Exploring the effect of red bull on blood pressure after microsurgical breast reconstruction in a randomized controlled trial

BACKGROUND

A sufficiently high blood pressure (BP) is essential for flap perfusion after microsurgical breast reconstruction. However, postoperative hypotension is common after these procedures. Perioperative volume overload may increase flap-related complications, and postoperative vasopressor use may be limited depending on institutions. Red Bull has been shown to increase BP in several studies. We aimed to evaluate the effect of Red Bull on perfusion-related variables after microsurgical breast reconstruction.

METHODS

We conducted a multicenter, prospective, randomized controlled trial. Female patients undergoing unilateral microsurgical breast reconstruction from June 2020 to October 2022 were randomly assigned to the intervention or control groups. The intervention group received 250 ml of Red Bull 2 h after surgery and twice on postoperative day (POD) 1. The control group received 250 ml still water at the respective intervals. BP was measured using a 24-hour monitoring device. Vasopressor use, fluid balance, and flap outcomes were compared.

RESULTS

One hundred patients were included in the study. Both groups were comparable concerning age, body mass index, and caffeine consumption. Mean arterial and diastolic BP were significantly higher in the Red Bull group after the second drink in the morning of POD1 (p-value = 0.03 and 0.03, respectively). Vasopressor use was similar, with a tendency for less postoperative etilefrine in the Red Bull group (p-value = 0.08). No flap loss was observed.

CONCLUSIONS

We observed increased mean arterial and diastolic BP in the Red Bull group after the second drink. Red Bull may be a useful adjunct after microsurgical breast reconstruction.

LEVEL OF EVIDENCE

I, therapeutic.

Evidence-Based Approaches to Anticoagulation in Reconstructive Microsurgery-A Systematic Literature Review

This systematic review addresses the crucial role of anticoagulation in microsurgical procedures, focusing on free flap reconstruction and replantation surgeries. The objective was to balance the prevention of thrombotic complications commonly leading to flap failure, with the risk of increased bleeding complications associated with anticoagulant use. A meticulous PubMed literature search following Evidence-Based-Practice principles yielded 79 relevant articles, including both clinical and animal studies. The full-texts were carefully reviewed and evaluated by the modified Coleman methodology score. Clinical studies revealed diverse perioperative regimens, primarily based on aspirin, heparin, and dextran. Meta-analyses demonstrated similar flap loss rates with heparin or aspirin. High doses of dalteparin or heparin, however, correlated with higher flap loss rates than low dose administration. Use of dextran is not recommended due to severe systemic complications. In animal studies, systemic heparin administration showed predominantly favorable results, while topical application and intraluminal irrigation consistently exhibited significant benefits in flap survival. The insights from this conducted systematic review serve as a foundational pillar towards the establishment of evidence-based guidelines for anticoagulation in microsurgery. An average Coleman score of 55 (maximum 103), indicating low overall study quality, however, emphasizes the need for large multi-institutional, randomized-clinical trials as the next vital step.

Efficacy of ultrasound guided superior laryngeal nerve block on sedation for delayed extubation in maxillofacial surgery with free flap reconstruction

OBJECTIVE

Superior laryngeal nerve block (SLNB) is a regional anesthesia technique for addressing airway response. However, SLNB on the efficacy of sedation in patients with delayed extubation is unknown, particularly for maxillofacial surgery (MS). The aim of the study was to assess whether ultrasound guided (UG) SLNB reduces the incidence of moderate to severe cough for delayed extubation in MS with free flap reconstruction.

METHODS

60 patients were randomly assigned to the GEA group (control group) and the SLNB group (UG-SLNB postoperatively, study group). During the initial two postoperative hours, the incidence of moderate and severe cough, agitation, and the number of patients requiring rescue propofol and flurbiprofen were recorded. Additionally, the time spent under the target level of sedation, postoperative hemodynamics, and the total does of propofol during the postoperative 24 h were recorded.

RESULTS

The data showed the SLNB group had a significantly lower incidence of moderate to severe cough and agitation (p < 0.05), and a longer sedation time (p < 0.05). The number of patients required rescue propofol and flurbiprofen, as well as the hemodynamic changes, were significantly different between the two groups (p < 0.05).

CONCLUSION

The use of UG-SLNB is associated with reduced incidence of postoperative cough. Moreover, SLNB can enhance the efficacy of postoperative sedation with need of fewer agents postoperatively.

CLINICAL TRIAL REGISTRATION

ChiCTR2000039982.

From Risk Assessment to Intervention: A Systematic Review of Thrombosis in Plastic Surgery

Thromboembolism is a feared complication in plastic surgery and is linked to higher rates of morbidity and mortality. Despite extensive research, there is a lack of consistency between recommendations and clinical protocols to be implemented pre and post-surgery to reduce the incidence of thromboembolism. A systematic literature review was conducted using Pubmed and Scopus databases to determine the risk factors, screening methods, and existing treatment models for thromboembolism prevention. Articles in non-English languages were excluded. Analysis indicated that predominant risk factors include age (>35), elevated body mass index, coagulation disorders, smoking, estrogen therapies, genetic predisposition, vascular endothelium damage, stasis, and use of general anesthesia in patients with a history of cancer. Implementation of a proper prophylactic protocol is dependent on understanding the interplay between the aforementioned risk factors and the utilization of well-defined, evidence-based guidelines, such as the 2005 Caprini Risk Assessment Model and ultrasound surveillance. The literature review revealed that mechanical prophylaxis is the primary prevention method, followed by thromboprophylaxis for patients with higher Caprini scores. Plastic surgeons often underestimate the present risk stratification tools available for the prophylactic intervention of thromboembolism due to the fear of bleeding or hematoma complications postoperatively. In summary, this literature review emphasizes the importance of plastic surgeons selecting protocols that is inclusive of the patient's risk profile to yield a reduced risk of thromboembolism.

Post-reconstruction Free Flap Complications After Oral Cancer Ablation

Introduction

Microvascular free flap transfer is considered a standard reconstruction after the ablation of oral cancer. Although the success rate is high, flap complications occasionally occur. This study investigated the reasons for and local factors involved in complications of free flap transfer and explored how to salvage the flaps.

Patients and Methods

The cases of 53 patients who underwent a free flap transfer [radial forearm flaps (n = 36), abdominis musculocutaneous flaps (n = 6), scapular osteocutaneous flaps (n = 10), and fibular osteocutaneous flap (n = 1)] were analyzed: flap complications were observed in five of the cases.

Results

In the all five cases, a salvage operation was performed under general anesthesia. The flap complications occurred within 33 h after anastomosis. In the salvage operation, thrombotic occlusion in veins of flap feeders was observed in three of the five cases. The possible reasons for flap complications were a twisting of the anastomosed vein where two veins were united, pressure to the feeder due to subcutaneous hematoma, and edema of adjacent tissue and/or drain tube; the reason was not clear in one case. The flaps were successfully salvaged in four cases by thrombectomy in veins, release of pressure at the veins, and/or interposition of the vein graft.

Conclusion

Surgeons should pay close attention to the pressure and/or twisting in the feeder as well as the hemostasis in the surgical field, and a salvage operation should be carried out immediately when a flap complication is identified.

Multidisciplinary Practice Variations of Anti-Thrombotic Strategies for Free Tissue Transfers

Background: Venous thrombosis, the leading cause of free flap failure, may have devastating consequences. Many anti-thrombotic agents and protocols have been described for prophylaxis and treatment of venous thrombosis in free flaps. Methods: National surveys were distributed to microsurgeons (of both Plastics and ENT training) and hematology and thrombosis specialists. Data were collected on routine screening practices, perceived risk factors for flap failure, and pre-, intra-, and post-operative anti-thrombotic strategies. Results: There were 722 surveys distributed with 132 (18%) respondents, consisting of 102 surgeons and 30 hematologists. Sixty-five surgeons and 9 hematologists routinely performed or managed patients with free flaps. The top 3 perceived risk factors for flap failure according to surgeons were medical co-morbidities, past arterial thrombosis, and thrombophilia. Hematologists, however, reported diabetes, smoking, and medical co-morbidities as the most important risk factors. Fifty-four percent of physicians routinely used unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) as a preoperative agent. Surgeons routinely flushed the flap with heparin (37%), used UFH IV (6%), or both (8%) intra-operatively. Surgeons used a range of post-operative agents such as UFH, LMWH, aspirin, and dextran while hematologists preferred LMWH. There was variation of management strategies if flap thrombosis occurred. Different strategies consisted of changing recipient vessels, UFH IV, flushing the flap, adding post-operative agents, or a combination of strategies. Conclusions: There are diverse practice variations in anti-thrombotic strategies for free tissue transfers and a difference in perceived risk factors for flap failure that may affect patient management.

Astragaloside IV improves angiogenesis under hypoxic conditions by enhancing hypoxia‑inducible factor‑1α SUMOylation

Improving angiogenic capacity under hypoxic conditions is essential for improving the survival of skin grafts, as they often lack the necessary blood supply. The stable expression levels of hypoxia‑inducible factor‑1α (HIF‑1α) in the nucleus directly affect the downstream vascular endothelial growth factor (VEGF) signaling pathway and regulate angiogenesis in a hypoxic environment. Astragaloside IV (AS‑IV), an active component isolated from Astragalus membranaceus, has multiple biological effects including antioxidant and anti‑diabetic effects, and the ability to provide protection from cardiovascular damage. However, the mechanisms underlying these effects have not previously been elucidated. The present study investigated whether AS‑IV promotes angiogenesis via affecting the balance between ubiquitination and small ubiquitin‑related modifier (SUMO) modification of HIF‑1α. The results demonstrated that persistent hypoxia induces changes in expression levels of HIF‑1α protein and significantly increases the proportion of dysplastic blood vessels. Further western blotting experiments showed that rapid attenuation and delayed compensation of SUMO1 activity is one of the reasons for the initial increase then decrease in HIF‑1α levels. SUMO1 overexpression stabilized the presence of HIF‑1α in the nucleus and decreased the extent of abnormal blood vessel morphology observed following hypoxia. AS‑IV induces vascular endothelial cells to continuously produce SUMO1, stabilizes the HIF‑1α/VEGF pathway and improves angiogenesis in hypoxic conditions. In summary, the present study confirmed that AS‑IV stimulates vascular endothelial cells to continuously resupply SUMO1, stabilizes the presence of HIF‑1α protein and improves angiogenesis in adverse hypoxic conditions, which may improve the success rate of flap graft surgery following trauma or burn.

Administration of intravenous iron and tranexamic acid in the management of postoperative iron deficiency anaemia following free flap reconstruction: re-audit

Following free tissue transfer, intravenous iron (IVI) has a role in reducing the rates of blood transfusion and more rapidly restoring haemoglobin (Hb) levels. Anaemia has a detrimental effect on survival, postoperative complications, fatigue, and health-related quality of life, therefore early correction is recommended. The aim of this re-audit is to assess the use of IVI, of tranexamic acid intraoperatively, and of perioperative blood transfusions. A total of 148 consecutive patients who underwent ablative surgery and free flap reconstruction between May 2018 and September 2019 were audited. The median (IQR) age was 66 (59,72) years and 36% were female. For two-thirds, surgery was for cancer located in the oral cavity and two-thirds of the free flaps were soft tissue. Tranexamic acid (TXA) was used intraoperatively for 30%, red blood cells (RBC) were transfused for 20% and 55 patients (37%) received IV iron. This compares with 4%, 26%, and 0, respectively, in the initial audit. Those having IVI were more likely (56%) to have had a composite flap, a lower postoperative haemoglobin and lower discharge Hb. The Hb between four and twelve weeks' follow up, known for 40, was a median (IQR) of 122 (104,138). There were no adverse reactions to IV iron. Although it is straightforward to administer IVI postoperatively, this re-audit demonstrates that it can be a challenge to embed change in protocols. Through raised awareness of the benefits of IVI, lack of adverse events and clarification of selection criteria, it is hoped that rates of IVI use will increase.

Selective and Continuous Transarterial Heparin Infusion: Postmicrosurgical Therapy of Lower Leg Reconstruction for Cases with Recipient Artery Damage

BACKGROUND

Microsurgical lower extremity reconstruction is challenging because of high incidence of vascular thrombosis compared to microsurgical head and neck reconstruction. The risk of vascular pedicle thrombosis increases, if patients have arterial sclerosis or intimal dissection at the recipient artery. We performed selective and continuous transarterial heparin infusion for postoperative anticoagulant therapy.

METHODS

Fifteen patients (10 men and 5 women; mean age of 55.1 years; range of 16-86 years) received lower leg reconstruction using free flap. Postoperatively, a catheter was inserted into the femoral artery during surgery. Heparin infusion was performed through the catheter as a postoperative therapy for patients who had a risk factor of vascular pedicle thrombosis. Until two days post-operation, heparin was started between 5,000 and 10,000 IU per day. In postoperative days 3 and 4, half of the initial dose of heparin was administered. In postoperative days 5 and 6, 25% of the initial dose of heparin was administered.

RESULTS

Recipient arteries were the posterior tibial (n=11), anterior tibial (n=2), lateral circumflex femoral (n=1), and medial sural (n=1) arteries. Thirteen of the 15 cases showed arterial sclerosis or intimal dissection at the recipient artery. There was no case of vascular thrombosis. Hematoma formation at flap recipient was observed in four cases. Their initial heparin dose was than 8.5±1.7 U/kg/h.

CONCLUSION

Continuous transarterial heparin infusion was an effective anticoagulant therapy for the patients who had received free tissue transfer to a lower extremity. The initial dose of heparin should not exceed 6.5 U/kg/h.

Controversies in free tissue transfer for head and neck cancer: A review of the literature

BACKGROUND

Microvascular free tissue transfer provides superior functional outcomes when reconstructing head and neck cancer defects. Careful patient selection and surgical planning is necessary to ensure success, as many preoperative, intraoperative, and postoperative patient and technical factors may affect outcome.

AIMS

To provide a concise, yet thorough, review of the current literature regarding free flap patient selection and management for the patient with head and neck.

MATERIALS AND METHODS

PubMed and Cochrane databases were queried for publications pertaining to free tissue transfer management and outcomes.

RESULTS

Malnutrition and tobacco use are modifiable patient factors that negatively impact surgical outcomes. The use of postoperative antiplatelet medications and perioperative antibiotics for greater than 24 hours have not been shown to improve outcomes, although the use of clindamycin alone has been shown to have a higher risk of flap failure. Liberal blood transfusion should be avoided due to higher risk of wound infection and medical complications.

DISCUSSION

There is a wide range of beliefs regarding proper management of patients undergoing free tissue transfer. While there is some data to support these practices, much of the data is conflicting and common practices are often continued out of habit or dogma.

CONCLUSION

Free flap reconstruction remains a highly successful surgery overall despite as many different approaches to patient care as there are free flap surgeons. Close patient monitoring remains a cornerstone of surgical success.

Management of anaemia and blood in patients having neck dissections or free flaps for head and neck cancer

Our main aims were to assess haemoglobin (Hb) concentrations from preoperative assessment to discharge from hospital, and to review which patients had blood transfusions and compliance with national transfusion guidelines. We studied a consecutive series of 131 patients between October 2016 and September 2017 who had either neck dissection or resection and free microvascular tissue transfer. Half the patients had soft tissue free flaps (n = 65), 26% had composite free flaps (n = 34), and 24% neck dissection only (n = 32). Using the WHO definition of anaemia, 4% (1/28) of patients who had neck dissections and 19% (16/85) of those who had free flaps were anaemic preoperatively. The median (IQR) Hb at discharge was 131 (119-144) g/L for patients who had neck dissections, 103 (95-114) g/L for those who had soft free flaps, and 95 (90-104) g/L for those who had composite free flaps. No patients who had neck dissection were given a red blood cell (RBC) transfusion, whereas they were given to 26/99 (26%) of those who had free flaps. Hb concentrations were checked after each unit in 31/39 transfusions (79%). Concentrations for those who had free flaps fell by about 30 g/L from admission to operation, and only four patients were given tranexamic acid peroperatively. Postoperatively Hb remained at similar concentrations until discharge, with 23/98 (24%) given iron orally on discharge. In terms of compliance with blood transfusion guidelines there was a notable absence of the use of tranexamic acid and of iron intravenously. An increase in their use could potentially reduce the number of blood transfusions required and the postoperative incidence of anaemia, and have a favourable effect on outcomes such as complications, fatigue, and overall quality of life.

Unfavorable outcomes in microsurgery: possibilities for improvement

The main aim of the present report is to describe our learning curve in microsurgery and how we solved the problems that frequently occur during the first phases of this learning curve. We analyzed the medical records of 69 patients that underwent head and neck reconstruction with free flaps in our department. The patients were divided into two groups. Group 1 included the patients reconstructed between January 2011 and June 2017, whilst Group 2 included those reconstructed between July 2017 and August 2018. A χ² test was used to compare the differences between the two groups in terms of flap failure (failure and partial failure) and eventual clinical errors. The p value was set at 0.05. Flap failure and clinical errors were most frequently observed in Group 1 (p < 0.05). Greater awareness of the need for proper functioning of the anastomosis during surgery, along with more exhaustive postoperative monitoring might explain the lower number of failures and signs of vascular compromise observed in Group 2. A number of variables may influence flap survival. Postoperative care, head position, kinking, body temperature, blood pressure and the ability to recognize the sign of vascular compromise all play a fundamental role following surgery. However, microsurgery is not just a routine type of surgery, and a properly trained team with several types of professionals must be adequately prepared to obtain acceptable results.

Use of omental free flap for craniofacial reconstruction in unfavorable wound bed: A case report

INTRODUCTION

The omental free flap is an effective tool for craniofacial reconstruction. However it is generally under-utilised by a large number of practitioners. This paper's goal is to increase awareness of this free flap's accessibility and to demonstrate that it can be an attractive option for reconstructive surgery.

CLINICAL REPORT

This article outlines the details of a 57-year-old patient who required coverage of a fronto-parietal wound with dura mater exposure. After previous failed conventional free flap attempts, a procedure using the omental free flap was finally performed on this severe wound. The omentum was harvested via a 8cm laparotomy and anastomosed to the temporal vessels. The final result was successful, with a favorable aesthetic result.

DISCUSSION

The omental free flap has many advantages: the pedicle length is long, it allows coverage of a large wound, it can be applied to a wound bed previously irradiated and infected, it has a low morbidity rate to the donor site, the surgical technique of harvesting is easy, the aesthetic result is satisfactory. However, the absence of skin slice is a disadvantage of the omental free flap because it makes monitoring difficult and it requires a skin graft in a second procedure. Laparoscopic harvest of omentum free flaps is a safe and effective tool in the reconstructive armamentarium. Every maxillofacial and plastic surgeon should aim to master and use this method as a legitimate option in some infrequent but appropriated cases.