Preoperative Platelet Count Predicts Lower Extremity Free Flap Thrombosis: A Multi-Institutional Experience

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures

BACKGROUND

 Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage.

METHODS

 A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed.

RESULTS

 From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique.

CONCLUSION

 Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis

BACKGROUND

 Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes.

METHODS

 A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status.

RESULTS

 Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts.

CONCLUSION

 Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.

Reevaluating Thrombocytosis as a Risk Factor in Free Flap Surgery: Does Timing Matter?

INTRODUCTION

Thrombocytosis, defined as a platelet count >400,000, has been implicated as a risk factor in free flap failure. Despite proposed mechanisms of pedicle thrombosis, recent studies have suggested that thrombocytosis has no effect on free tissue transfer viability. Risk factors that may compromise successful free tissue transfer should be understood and elucidated, with particular attention to thrombocytosis and its conflicting evidence in the literature. We hypothesize that thrombocytosis has no bearing on free flap success or the rates of pedicle thrombosis.

METHODS

Our institution performed a retrospective chart review on all patients who underwent free flap reconstruction over the past 6 years. Patient demographics, medical history, type and location of free tissue transfer, preoperative platelets, postoperative platelets, and flap outcomes and complications (wound dehiscence, infection, hematoma, seroma, and need for blood transfusion) were recorded. Independent t test, Mann-Whitney U tests, χ2 test, and Fisher exact tests were used to determine P values to compare flap outcomes in patients with thrombocytosis (platelet count >400,000) and those with platelet counts less than 400,000.

RESULTS

In our 502-patient cohort, 71 were found to have a platelet count >400,000 (35 preoperatively and 36 postoperatively) and 431 patients had platelet counts <400,000. There were 42 reconstructive failures (flap success rate of 91.6%) and 111 returns to the operating room (OR). For patients with postoperative thrombocytosis, 24 flaps returned to the OR (44.4%), whereas in patients without thrombocytosis, 87 flaps returned to the OR (19.4%; P < 0.001). In patients with postoperative thrombocytosis, 10 OR returns were due to pedicle venous thrombosis (18.5%), in comparison to 10 returns for venous thrombosis in those with normal platelets (2.2%; P < 0.001). There was a small difference in free flap success rates between those with postoperative thrombocytosis and normal platelets, 88.7% versus 92.11%; however, this was not statistically significant ( P = 0.71). The thrombocytosis group had a higher incidence of overall postoperative complications ( P = 0.002).

CONCLUSIONS

Thrombocytosis has historically been cited as a risk factor for free flap reconstruction failure with recent conflicting evidence in the literature. In patients with postoperative thrombocytosis, we found an increased risk of venous thrombosis; however, this did not result in increased flap failure. There was an increase in postoperative complications, which corresponds with National Surgical Quality Improvement Program data reported in the literature. We suspect that thrombocytosis is not a harbinger of free flap failure but rather a marker for overall inflammation, which may confer a higher rate of venous thrombosis requiring reoperation and postoperative complications.

Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) Score as a Predictive Model for the Success of Reconstruction of Head and Neck Defects with Free Microvascular Flaps

Significant advances in reconstructive head and neck surgery with free microvascular flaps have had a positive impact on esthetic outcomes and quality of life. However, complications still occur in some patients. This study investigated the influence of the Hemoglobin, Albumin, Lymphocyte, and Platelet Score (HALP score), an immunonutritive marker, on complications and flap success. The retrospective analysis included 194 patients who underwent reconstruction of head and neck defects with free microvascular flaps. The HALP score correlated strongly with overall complications, including flap necrosis, infection, fistula, and hematoma. Hemoglobin, albumin, lymphocytes, and platelets individually showed associations with specific complications. HALP score was an extremely strong predictor of complications (AUC = 0.85). HALP score may be valuable for assessing patient status and predicting complications in microvascular free-flap reconstruction to allow timely interventions and improve outcomes. Further research is needed to investigate additional predictors and improve postoperative care.

Reoperative Microsurgical Free Flap Surgery: Lessons Learned

ABSTRACT

Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.

Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery

This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.

Head and Neck Reconstruction in Patients with Polycythemia Vera: Case Series and Literature Review

Background  Polycythemia vera (PV) is a myeloproliferative disease with overproduction of erythrocytes, leukocytes, and platelets causing an increased risk of both thrombosis and hemorrhage. There are limited reports and no established guidelines for managing such patients undergoing reconstructive surgery. Methods  We present four patients with PV and head and neck cancer who required reconstruction after resection and provide a review of the current literature. Results  Preoperatively, patients on cytoreductive therapy continued with their treatment throughout their hospital course and had hematologic parameters normalized with phlebotomy or transfusions if needed. Two patients who underwent free flap surgery (cases 1 and 2) had postoperative courses complicated by hematoma formation and persistent anemia, requiring multiple transfusions. Cases 3 and 4 (JAK2+ PV and JAK2- PV, respectively) underwent locoregional flap without postoperative complications. Conclusion  Concomitant presentation of PV and head and neck cancer is uncommon and presents unique challenges for the reconstructive surgeon. Overall, we recommend that patients should have hematologic parameters optimized prior to surgery, continue ruxolitinib or hydroxyurea, and hold antiplatelet/anticoagulation per established department protocols. It is essential to engage a multidisciplinary team involving hematology, head and neck and reconstructive surgery, anesthesia, and critical care to develop a standardized approach for managing this unique subset of patients.

Preoperative Predictors of Free Flap Failure

OBJECTIVE

Microvascular free tissue transfer is an important reconstructive option for defects of the head and neck. The present study aims to identify preoperative patient- and tumor-specific characteristics, laboratory values, and other risk factors associated with early free flap failure.

STUDY DESIGN

Retrospective cohort study of 1070 patients.

SETTING

Head and neck surgical oncology service at a tertiary care center from 2005 to 2019.

METHODS

Demographics, comorbidities, preoperative laboratory values, treatment history, and cancer stage were collected for consecutive patients who underwent free flap reconstruction of the head and neck and experienced early free flap failure (<8 days from surgery).

RESULTS

In 1070 patients, the prevalence of early free flap failure was 3.8% (n = 41). Female sex (odds ratio [OR], 2.58; 95% CI, 1.36-4.99), presence of peripheral vascular disease (OR, 2.78; 95% CI, 1.05-6.57), and elevated preoperative platelet count (OR, 2.67; 95% CI, 1.20-5.47) were independently associated with risk of early free flap failure.

CONCLUSION

Female sex, peripheral vascular disease, and preoperative thrombocytosis are all strong predictors of early free flap failure. This suggests that hypercoagulability and poor vessel quality may predispose patients to flap loss. Patients with elevated platelets or peripheral vascular disease warrant careful reconstructive decision making and close monitoring in the perioperative period.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Rotational Thromboelastometry Derivative Fibrinogen-Platelet Ratio Predicts Thrombosis in Microsurgery

BACKGROUND

 Early detection of thrombotic events is of paramount importance for microsurgical procedures. Here, we present findings that underscore the value of rotational thromboelastometry (ROTEM) to aid in decision-making for pre- and postoperative anticoagulation, as well for patients with suspected hypercoagulability.

METHODS

 We prospectively collected pre- and postoperative ROTEM values on all free flap cases at the University of California, San Francisco, from 2015 to 2016. Patient age, body mass index, comorbidities, operative reports, risk factors, thrombotic complications, and outcomes were collected from electronic medical records. Two-sample t-tests were used to compare ROTEM values between cohorts. Modeling for sensitivity, specificity, and accuracy was done for threshold fibrinogen-to-platelet ratio (FPR).

RESULTS

 Of 52 patients who underwent free-tissue transfer, 15 had a thrombotic event either intraoperatively or postoperatively that required revision of the vascular anastomosis. Eight patients were clinically hypercoagulable preoperatively, seven of which had a thrombotic event. Several pre- and postoperative ROTEM values differed significantly between thrombotic and nonthrombotic cases. Preoperative (p = 0.027) and postoperative (p = 0.013) FPR were statistically significant when comparing the thrombotic to the nonthrombotic cohort. Threshold FPR ≥ 30 was the most sensitive and FPR ≥ 40 was the most specific.

CONCLUSION

 Our study affirms other studies that established ROTEM as an effective predictive tool for thrombotic events during free-tissue transfer. However, a lower threshold for FPR improves catchment of thrombotic events and flap failure with acceptable sensitivity. Our results support the routine use of ROTEM for detecting hypercoagulability in patients who would potentially benefit from intervention to prevent thrombotic complications.

A scoring system to predict a prolonged length of stay after surgery for Crohn's disease

AIM

Many factors influence the postoperative length of stay (LOS) in Crohn's disease (CD). This study aims to identify the factors associated with a prolonged LOS after ileocolic resection (ICR) for CD and to develop a scoring system to predict the postoperative LOS in CD.

METHOD

Patient data were collected from St Marks Hospital, London, UK, and the Humanitas Clinical and Research Center Milan, Italy, for all patients who underwent an ICR for CD from 2005 to 2017. Logistic regression was used for multivariate analysis. The scoring system was developed from the logistic regression model. The performance of the scoring system was evaluated using the area under the receiver operating characteristic curve (AUROC).

RESULTS

A total of 628 surgeries were included in the analysis. Eighty eight surgeries were excluded due to missing data. The remaining 543 were divided into two cohorts for the development (n = 418) and validation (n = 125) of the scoring system. The regression model was statistically significant (p < 0.0001). The statistically significant independent variables included the time since diagnosis, American Society of Anesthesiologists (ASA) grade, perioperative use of steroids, surgical access, strictureplasty and platelet count. The AUROCs for the development and validation cohorts were 0.732 and 0.7, respectively (p < 0.0001). The cut-off score suggested by Youden's index was 50, with a sensitivity of 65.6% and a specificity of 73.3%.

CONCLUSION

The time since diagnosis, ASA grade, steroid use, surgical access, strictureplasty and platelet count were associated with a prolonged LOS and were used to develop a scoring system. The calculator is available online at https://rebrand.ly/Crohnscal.

Correlation between Venous Thromboembolism Risk and Venous Congestion in Microvascular Reconstruction of the Lower Extremity

BACKGROUND

Risk for venous thromboembolism formation and the relationship to postoperative free flap venous congestion and flap failure have not been adequately evaluated in a trauma population. The authors aim to use the Caprini Risk Assessment Model to evaluate the association between venous thromboembolism risk and postoperative flap venous congestion following lower extremity free tissue transfer.

METHODS

A retrospective analysis was conducted of all patients who underwent lower extremity free flap reconstruction of traumatic defects at a single institution between 2007 and 2016. A Wilcoxon rank sum test was used for nonparametric analysis of aggregate Caprini Risk Assessment Model scores and flap outcomes. Flap venous congestion and failure rates as associated with the categorical variables underlying the Caprini Risk Assessment Model were further studied. Logistic regression was used to evaluate each of these outcomes and other flap-related covariates relative to the Caprini Risk Assessment Model categorical variables that had the greatest effect on our patient sample.

RESULTS

One hundred twelve patients underwent lower extremity free flap reconstruction. One hundred eight free flaps were analyzed. Eight patients were excluded. The majority of patients were male (75.9 percent) and required reconstruction because of acute trauma (68.1 percent versus 31.9 percent for chronic wounds). There was no statistically significant association found between age, body mass index, or timing of trauma versus venous congestion, flap failure, or other flap-related covariates.

CONCLUSION

In patients with significantly elevated Caprini Risk Assessment Model scores, there was no significant association between venous thromboembolism risk and flap failure following free tissue reconstruction of lower extremities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

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.

Reoperation of Lower Extremity Microsurgical Reconstruction When Facing Postsplenectomy Thrombocytosis

Patients who sustain high-energy polytrauma are a unique population in that their mechanism of injury may induce multiorgan damage requiring immediate interventions such as splenectomy and bony fixation for mangled extremities. This results in the intersection of certain conditions, such as postsplenectomy thrombocytosis with the need for soft tissue reconstruction, often with free tissue transfer, for limb salvage after severe trauma to the lower extremity. However, there are no treatment guidelines in the management of postsplenectomy thrombocytosis in the setting of a lower extremity free flap reconstruction. We present a patient who had initial free tissue transfer to the lower extremity complicated by delayed microvascular thrombosis at postoperative day 4, during which time his platelet count exceeded more than 1,000,000/mm³. However, a successful second lower extremity free tissue transfer was achieved after platelet-reductive treatment with platelet apheresis during the perioperative period. Our patient went on to heal from his second free flap without further complications. Thus, thrombocytosis in the setting of free tissue transfer requires perioperative intervention to correct this hematologic condition. An innovative utilization of platelet apheresis may ensure the success of free tissue transfer by addressing the thrombocytosis in microsurgical patients after splenectomy.

Polymorphism rs2066865 in the Fibrinogen Gamma Chain (FGG) Gene Increases Plasma Fibrinogen Concentration and Is Associated with an Increased Microvascular Thrombosis Rate

Background and Objective: Thrombosis due to inherited hypercoagulability is an issue that has been raised in microvascular flap surgery previously. We analyzed the association of a single nucleotide polymorphism (SNP) in rs2066865 in the fibrinogen gamma chain (FGG) gene, alteration in plasma fibrinogen concentration, and presence of microvascular flap thrombosis. Materials and Methods: A total of 104 adult patients with microvascular flap surgery were subjected to an analysis of the presence of SNP rs2066865 in the FGG gene. Alterations in plasma fibrinogen concentration according to genotype were determined as a primary outcome, and flap thrombosis was defined as a secondary outcome. Results: Flap thrombosis was detected in 11.5% of patients (n = 12). Successful revision of anastomosis was performed in four patients, resulting in a microvascular flap survival rate of 92.3%. We observed an increase in plasma fibrinogen concentration in genotype G/A and A/A carriers (G/G, 3.9 (IQR 4.76-3.04); G/A, 4.28 (IQR 5.38-3.18); A/A, 6.87 (IQR 8.25-5.49) (A/A vs. G/A, p = 0.003 and A/A vs. G/G, p = 0.001). Within group differences in microvascular flap thrombosis incidence rates were observed—G/G 6/79 (7.59%); G/A 5/22 (22.7%); A/A 1/3 (33.3%) (OR 0.30 95%; CI 0.044 to 0.57), p = 0.016; RR 3.2—when G/G versus G/A and A/A were analyzed respectively. Conclusions: A/A and G/A genotype carriers of a single nucleotide polymorphism in rs2066865 in the fibrinogen gamma chain gene had a higher plasma fibrinogen concentration, and this might be associated with an increased microvascular flap thrombosis incidence rate. Determined polymorphism could be considered as a genetic marker associated with microvascular flap thrombosis development. To confirm the results of this study, the data should be replicated in a greater sample size.

Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis

BACKGROUND

Clinical indications are expanding for the use of fasciocutaneous free flaps in lower extremity traumatic reconstruction. The authors assessed the impact of muscle versus fasciocutaneous free flap coverage on reconstructive and functional outcomes.

METHODS

A multicenter retrospective review was conducted on all lower extremity traumatic free flaps performed at Duke University (1997 to 2013) and the University of Pennsylvania (2002 to 2013). Muscle and fasciocutaneous flaps were compared in two subgroups (acute trauma and chronic traumatic sequelae), according to limb salvage, ambulation time, and flap outcomes.

RESULTS

A total of 518 lower extremity free flaps were performed for acute traumatic injuries (n = 238) or chronic traumatic sequelae (n = 280). Muscle (n = 307) and fasciocutaneous (n = 211) flaps achieved similar cumulative limb salvage rates in acute trauma (90 percent versus 94 percent; p = 0.56) and chronic trauma subgroups (90 percent versus 88 percent; p = 0.51). Additionally, flap choice did not impact functional recovery (p = 0.83 for acute trauma; p = 0.49 for chronic trauma). Flap groups did not differ in the rates of flap thrombosis, flap salvage, flap loss, or tibial nonunion requiring bone grafting. Fasciocutaneous flaps were more commonly reelevated for subsequent orthopedic procedures (p < 0.01) and required fewer secondary skin-grafting procedures (p = 0.01). Reconstructive and functional outcomes remained heavily influenced by injury severity.

CONCLUSIONS

Muscle and fasciocutaneous free flaps achieved comparable rates of limb salvage and functional recovery. Flap selection should be guided by defect characteristics and reconstructive needs.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Postoperative anticoagulation after free flap reconstruction for head and neck cancer: A systematic review

OBJECTIVE

Postoperative use of anticoagulation after free tissue transfer in head and neck ablative procedures is common practice, but a clear protocol has not been well established. The outcome measures including total flap failure, thrombosis, and hematoma formation for different anticoagulation regimens in free tissue transfer in the head and neck were reviewed.

DATA SOURCES

PubMed, Ovid, and Cochrane databases were examined for patients who underwent free tissue transfer following head and neck ablative procedures.

REVIEW METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were utilized to identify English-language studies reporting anticoagulation regimens following free tissue transfer in head and neck ablative procedures. Outcomes included total flap failure, thrombosis, and hematoma formation. Two independent reviewers assessed the quality of the articles by using the Methodological Index for Non-Randomized Studies.

RESULTS

A total of 368 articles were identified. An additional 36 articles were identified through screening of reference lists. Twenty-one of these studies met final inclusion criteria for qualitative analysis. Outcome data on total flap failure, thrombosis, and hematoma formation were extracted and analyzed for comparison against all anticoagulation regimens. Total flap failure, thrombosis, and hematoma formation rates were 4.4%, 4.5%, and 2.2%, respectively. Individual study rates ranged from 0.0% to 10.7%, 0.0% to 10.4%, and 0.6% to 7.2%, respectively.

CONCLUSIONS

There is not adequate evidence to develop a standardized anticoagulation protocol for head and neck free flap procedures. Comparable flap complications were reported between all the employed anticoagulation methods studied, though significant variability in study design among articles existed. Prospective, randomized studies are warranted to determine the optimal postoperative anticoagulation regimen following free tissue transfer of the head and neck. Laryngoscope, 128:412-421, 2018.