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Free tissue flap transfer can be utilized for reconstruction following tumor resection. While flap failure occurs primarily within 72 h post-operation, late failure after day 7 is rare. We present the case of a 14-year-old with a late lower extremity free flap vascular compromise, along with the successful flap salvage.

ABSTRACT: Background: Free flap reconstructions are an important reconstructive option for soft tissue defects in mangled lower extremities. Microsurgery facilitates soft tissue coverage of defects that otherwise would result in amputation. However, the success rates of traumatic lower extremity free flap reconstructions remain lower than those in other locations. Nevertheless, post-free flap failure salvage strategies have rarely been addressed. Therefore, the current review aims to provide an overview of post-free flap failure strategies in lower extremity trauma and their subsequent outcomes. Methods: A search of Pubmed, Cochrane, and Embase databases was performed on June 9, June 2021 using the following medical subject headings (MeSH) search terms: ‘lower extremity’, ‘leg injuries’, ‘reconstructive surgical procedures’, ‘reoperation’, ‘microsurgery’ and ‘treatment failure’. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Partial and total free flap failures after traumatic reconstruction were included. Results: Twenty-eight studies with a total of 102 free flap failures fulfilled the eligibility criteria. Following the total failure, a second free flap is the predominant reconstructive strategy (69%). In comparison to the failure rate of a first free flap (10%), the fate of a second free flap is less favorable with a failure rate of 17%. The amputation rate following flap failure is 12%. The risk of amputation increases between primary and secondary free flap failures. After partial flap loss, the preferred strategy is a split skin graft (50%). Conclusion: To our knowledge, this is the first systematic review on the outcome of salvage strategies after free flap failure in traumatic lower extremity reconstruction. This review provides valuable evidence to take into consideration in the decision-making regarding post-free flap failure strategies.

Vasopressor use in patients undergoing autologous free tissue transfer is generally discouraged by surgeons perioperatively. This stems from concerns about the increased risk of flap failure with their use. The aim of this systematic review was to investigate the evidence and quantify any harm or benefits associated with vasopressor use. A systematic review of the literature was undertaken using OVID Medline to search 13 databases. The search strategy used Boolean operators, text word searches, truncation symbols, and adjacency searching. Terms such as "free flap," "free tissue graft," and "free tissue transfer" were used along with a list of appropriate vasopressors. The primary outcome was free flap failure, on which a meta-analysis was performed. The search initially identified 1029 unique articles, which after title and abstract screening was reduced to 112, of which 15 remained after full-text screening for inclusion in the review and analysis. We analyzed data from 8427 flaps, with 6695 having received a vasopressor. Meta-analysis demonstrated that vasopressor use reduced the relative risk (RR) of free flap failure (RR: 0.70; 95% CI: 0.50–0.97; p = 0.03) but did not affect rates of other adverse events (RR: 0.81; 95% CI: 0.63–1.05; p = 0.11). Vasopressor use appears beneficial for autologous free tissue transfer, with evidence that it reduced the risk of flap failure without impacting the rates of other adverse events. The use of vasopressors should, therefore, be encouraged on a case-by-case basis, depending upon the general physiological needs of the patient. [ABSTRACT FROM AUTHOR]

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction. [ABSTRACT FROM AUTHOR]

The commonest cause of microvascular free flap failure is thrombosis at the anastomosis. Pharmacological antithrombotic therapies have been used to mitigate this risk, but they carry the risk of bleeding and haematoma formation. To justify any intervention, it is necessary to evaluate the benefits and balance of risks. This meta-analysis aims to quantify the value of systemic anticoagulation during head and neck free tissue reconstruction. We performed a systematic review on the impact of additional prophylactic antithrombotic therapy on head and neck (H&N) free tissue transfer (on top and above the use of low molecular weight heparin to prevent deep vein thrombosis). We carried a PRISMA-guided literature review, following registration with PROSPERO. All studies analysing the possible impact of prophylactic anticoagulants on free flap surgery in the head and neck were eligible. The primary outcome was perioperative free flap complications (perioperative thrombosis, partial or total free flap failure, thrombo-embolic events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation or bleeding complications requiring further intervention. We identified eight eligible studies out of 454. These included 3531 free flaps for H&N reconstruction. None of the assessed interventions demonstrated a statistically significant improvement in free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated an increased relative risk of free flap complications [RR 1.54 (0.73–3.23)] compared to control albeit not statistically significant (p = 0.25). Pooled analysis from the included studies showed that the prophylactic use of therapeutic doses of anticoagulants significantly (p = 0.003) increased the risk of haematoma and bleeding requiring intervention [RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure. Additional anticoagulation does not reduce the incidence of free flap thrombosis and failure. Unfractionated heparin (UFH) consistently increased the risk of free flap complications. The use of additional anticoagulation as 'prophylaxis' in the perioperative setting, increases the risk of haematoma and bleeding. [ABSTRACT FROM AUTHOR]

Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps ("safe workhorses"). [ABSTRACT FROM AUTHOR]

The development of modern microvascular surgical techniques has enabled the reliable transfer of free vascularized tissue. This allowed for predictable reconstruction outcomes with excellent surgical success rates. However, devastating consequences of partial or total flap failure and subsequent loss may occur. This usually occurs in the first 48–72 h post-operatively. It is rare for flaps to fail in the late post-operative period and it remains poorly understood why flaps fail after day seven. We presented two patients in whom flap failure occurred after the seventh post-operative day (POD). Complete flap failure occurred after POD 9 and 27 in our cases. During the postoperative period, there was no evidence of early occlusion or insult to the vascular integrity such as venous/arterial compression. The cause of late flap failure was due to thrombophlebitis secondary to infection from the tracheostomy-neck fistula. This assumption was supported by recurrent failure of anastomoses revision. [ABSTRACT FROM AUTHOR]

Flow couplers for venous anastomosis, which enable the invasive monitoring of free flaps during the postoperative period with a continuous venous signal audible immediately after completion of the anastomosis, have been reported to be reliable, sensitive, and specific as anastomotic flap monitoring adjuncts. The purpose of this study was to evaluate the reliability, sensitivity, specificity, and outcomes of surgical exploration, and the impact on free-flap survival of the venous anastomotic flow coupler for microvascular head and neck reconstruction in a consecutive series of patients. This is a retrospective review of consecutive patients treated in the department of oral and maxillofacial surgery who underwent reconstruction of a head and neck defect using venous anastomosis with a flow coupler-vascularised free flap between October 2015 and December 2020. A total of 189 patients had free-flap reconstruction of head and neck defects. We compared the venous flow coupler group (n = 72) with patients who had free flaps with hand-sewn anastomoses over the same period (n = 117). There were no false positive/negatives associated with the flow coupler as an implantable flap monitor. The flow coupler cohort had a significantly higher flap salvage rate compared with free flaps that were monitored clinically (p = 0.04). The venous flow coupler has been shown to be a reliable microvascular anastomotic and invasive flap monitor that enables accurate and timely detection of flap compromise and prompt, successful free-flap salvage. [ABSTRACT FROM AUTHOR]

Purpose: Surgical site infection (SSI) frequently occurs in patients with head and neck cancer (HNC) after tumor resection and can lead to death in severe cases. Moreover, there is no definitive conclusion about the risk factors of SSI. Therefore, it is of great clinical significance to study the factors affecting the SSI. Methods: The HNC patients included in this study were all from the Department of Oral and Maxillofacial Surgery of the Second Xiangya Hospital of Central South University (CSU), and these patients received surgical treatment in the department from January 2018 to December 2019. The cross tabulation with chi-squared testing and multivariate regression analysis were applied to determine the risk factors of SSI. To identify the key risk factors of SSI, the caret package was used to construct three different machine learning models to investigate important features involving 26 SSI-related risk factors. Results: Participants were 632 HNC patients who underwent surgery in our department from January 2018 to December 2019. During the postoperative period, 82 patients suffered from SSI, and surgical site infection rate (SSIR) was about 12.97%. Multivariate logistic regression analysis shows that diabetes mellitus, primary tumor site (floor of mouth), preoperative radiotherapy, flap failure, and neck dissection (bilateral) are risk factors for SSI of HNC. Machine learning indicated that diabetes mellitus, primary tumor site (floor of mouth), and flap failure were consistently ranked the top three in the 26 SSI-related risk factors. Conclusion: Diabetes mellitus, primary tumor site (floor of mouth), flap failure, preoperative radiotherapy, and neck dissection (bilateral) are risk factors for SSI of HNC. [ABSTRACT FROM AUTHOR]

Objective: Investigate current practice patterns of head and neck microvascular reconstructive surgeons when removing an implantable Doppler after free flap surgery. Study Design: Cross‐sectional survey study. Methods: Survey distributed to head and neck microvascular reconstructive surgeons. Data regarding years performing free tissue transfer, case numbers, management of implantable Doppler wire, and complications were collected. Results: Eighty‐five responses were analyzed (38,000 cases). Sixty‐six responders (77.6%) use an implantable Doppler for postoperative monitoring, with 97% using the Cook‐Swartz Doppler Flow Monitoring System. Among this group, 65.2% pull the wire after monitoring was complete, 3% cut the wire, and 31.8% have both cut and pulled the wire. Of those who have cut and pulled the wire, 48% report cutting and pulling the wire with equal frequency, 43% formerly pulled the wire and now cut the wire, and 9% previously cut the wire but now pull the wire. Of those who pull the wire, there were two injuries to the pedicle requiring return to the operating for flap salvage, and one acute venous congestion. Of the nine who previously pulled the wire, six (67%) cited concerns with major bleeding/flap compromise as the reason for cutting the wire. Conclusion: In this study, most surgeons use an implantable Doppler for monitoring of free flaps postoperatively. In extremely rare instances, pulling the implantable Doppler wire has resulted in flap compromise necessitating revision of the vascular anastomosis. Cutting the wire and leaving the proximal portion in the surgical site has been adopted as a management option. Level of Evidence: 4 Laryngoscope, 132:554–559, 2022 [ABSTRACT FROM AUTHOR]

Background: Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success. Method: This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply. Result: A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs' vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP. Conclusion: In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome. [ABSTRACT FROM AUTHOR]

Background  The role of vasopressors has long been a subject of debate in microsurgery. Conventional wisdom dictates the avoidance of vasopressor use, due to concerns such as peripheral vasoconstriction, inducing vasospasm of the anastomoses, and leading to failure in perfusion. It has since become common practice in some centers to avoid intraoperative vasopressor use during free tissue transfer surgery. Recent studies have suggested that this traditional view may not be supported by clinical evidence. However, none of these studies have separated vasopressor use by method of administration. Methods  We conducted a retrospective review of our experience of vasopressor use in free flap surgery at a single high-volume center. The outcome measures were flap failure, flap-related complications and overall postoperative complications (reported using the Clavien–Dindo classification). Groups were compared using Chi-square or Fisher's Exact test where appropriate. Results  A total of 777 cases in 717 patients were identified. 59.1% of these had vasopressors administered intraoperatively. The overall failure rate was 2.2%, with 9.8% experienced flap-related complications. There was no difference in flap loss when vasopressors were administered, but an increased rate of microvascular thrombosis was noted (p  = 0.003). Continuous administration of vasopressors was associated with reduced venous congestion, whereas intermittent boluses increased risk of microvascular thrombosis. Conclusion  Our study confirms previous findings that intraoperative vasopressor use in free flap surgery is not associated with increased failure rate. Administering vasopressors continuously may be safer than via repeated boluses. [ABSTRACT FROM AUTHOR]

BackgroundVirtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.MethodThis retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.ResultA total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.ConclusionIn general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

Purpose: Free flap reconstruction is a valuable technique to preserve function in oncological head and neck surgery. Postoperative graft thrombosis is a dreaded risk. This study aims to compare low-dose unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) in perioperative thrombosis prophylaxis. Methods: This is a retrospective analysis of 266 free flaps performed at our academic center. A comparison was made between 2 patient groups, based on their respective postoperative prophylaxis protocols either with UFH (n = 87) or LMWH (n = 179). Primary endpoints were the frequency of transplant thrombosis and the number of flap failures. Secondary endpoints were the occurrence of peri- and postoperative complications. Results: The flap survival rate was 96.6% and 93.3% for the groups UFH and LMWH, respectively (P = 0.280). The rate of postoperative bleeding requiring revision was 4.6% and 6.7% for each group, respectively (P = 0.498). We found a hematoma formation in 4.6% and 3.9% (P = 0.792). Conclusion: The free-flap survival rate using low-dose UFH seems to be equivalent to LMWH regimens without compromising the postoperative outcome. Consequently, for risk-adapted thrombosis prophylaxis, either LMWH or UFH can be administrated. [ABSTRACT FROM AUTHOR]

Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications. Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index. A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p =0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p =0.001). If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy. [ABSTRACT FROM AUTHOR]

Background: Studies carried out in 1998 by Khouri et al. established a benchmark for free flap survival. Whilst individual factors related to free flap survival have been examined since, there has been little contemporaneous data re-examining overall flap survival rates and factors related to complications to assess progress in the field and specifically European or UK practice. Methods: Six plastic surgery units from four regions within the South West UK regional collaboration group prospectively collected data on all free flap surgery performed in a 6-month period between October 2013 and April 2014. Results: Data on 264 free flaps were prospectively collected. Total flap failure was 2.7% and partial flap failure was 4.5%. Regression analysis identified obesity and previous recipient site radiotherapy as the most important factors in flap failure. The rate of intra-operative and post-operative flap thrombosis was 3.8% and 6.4%, respectively, and was associated with lower limb recipient site and surgeon grade. Post-operative haematoma occurred in 4.2%, associated with recipient site radiotherapy. Conclusions: Our study establishes a UK baseline for standards in free flap surgery. With the recent introduction of a UK Free Flap Surgery Registry, this baseline will support unit audit and improvements in free flap surgery. Level of evidence: Level III, risk/prognostic study. [ABSTRACT FROM AUTHOR]

Rapid identification of possible vascular compromise in free flap reconstruction to minimize time to reoperation improves achieving free flap salvage. Subjective clinical assessment, often complemented with handheld Doppler, is the golden standard for flap monitoring; but this lacks consistency and may be variable. Non-invasive optical methods such as near-infrared spectroscopy (NIRS) and hyperspectral imaging (HSI) could facilitate objective flap monitoring. A systematic review was conducted to compare NIRS with HSI in detecting vascular compromise in reconstructive flap surgery as compared to standard monitoring. A literature search was performed using PubMed and Embase scientific database in August 2021. Studies were selected by two independent reviewers. Sixteen NIRS and five HSI studies were included. In total, 3662 flap procedures were carried out in 1970 patients using NIRS. Simultaneously; 90 flaps were performed in 90 patients using HSI. HSI and NIRS flap survival were 92.5% (95% CI: 83.3–96.8) and 99.2% (95% CI: 97.8–99.7). Statistically significant differences were observed in flap survival (p = 0.02); flaps returned to OR (p = 0.04); salvage rate (p < 0.01) and partial flap loss rate (p < 0.01). However, no statistically significant difference was observed concerning flaps with vascular crisis (p = 0.39). NIRS and HSI have proven to be reliable; accurate and user-friendly monitoring methods. However, based on the currently available literature, no firm conclusions can be drawn concerning non-invasive monitoring technique superiority

• Pedicled flap reconstruction in the head and neck is still an alternative if free flaps are not possible. • Angiography of the subclavian artery is not a standard procedure in the surgical planning of pedicle flap harvesting. • In exceptional cases, we recommend angiography of the neck and thoracic vessels. • The application of a temporary pharyngostoma is still an option in extraordinary circumstances. Pedicled flap reconstruction still plays an essential role in head and neck surgery as an alternative to free grafts. Two standard methods are the pectoralis major and the deltopectoral flap, which are generally characterized by their reliable perfusion. This case describes bilateral arteriosclerosis of the subclavian artery as a possible cause of flap failure. We report on a 65-year-old patient with a multilevel carcinoma of the right pharynx. Due to the unique patient history, a free flap reconstruction was not possible. After resection of the primary, we performed reconstruction with a pedicled pectoralis major flap. Postoperatively, we observed necrosis of the pectoralis major flap. Secondary defect reconstructions were performed with a deltopectoral flap first from the right and then, in the case of necrosis, from the left side. Stenosing arteriosclerotic plaques of the subclavian artery on both sides were the cause of flap failure. Preoperative angiography of the subclavian artery is not a standard diagnostic procedure in the surgical planning of pedicled flap reconstruction in the head and neck region. In exceptional cases, we recommend angiographic imaging of the supplying vessels to make a more precise flap selection and avoid complications. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Microvascular free tissue transfer is a reliable method for reconstructive surgery. However, pedicle thrombosis remains a serious complication following free tissue transfer as no consensus has been reached on the optimal management of failing flaps. The purpose of this systematic review is to examine the current evidence on the use of thrombolytic drugs and their effects on microvascular flap salvage rates. A systematic literature search was performed using Medline, Embase, and, PubMed databases to identify scientific literature published between January 1987 and January 2019. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles of English language studies reporting on free flap salvage procedures or protocols using thrombolytic drugs were included and reviewed by one author. Of 105 articles screened, 27 studies and case reports were included and qualified for data extraction. Overall, the level of evidence of the current literature is low. Thirteen retrospective studies tried to demonstrate a systemic approach for thrombolysis in flap salvage. The other 14 case reports presented clinical use of thrombolytic drugs to salvage free flaps. None of the thrombolytic agents presented had superior salvage outcomes. A review on the current literature did not provide satisfactory and consistent evidence for the optimal management of patients with microvascular thrombosis, since no consensus has been reached on the optimal management of failing flaps. Prospective randomized studies are needed regarding their indications, dosages, and methods of administration, efficacy, and safety. [ABSTRACT FROM AUTHOR]

Abstract Background A 67-year-old man presented with abrupt failure of a pedicled vertical rectus abdominus myocutaneous (VRAM) flap 13 days postoperatively. Methods The patient underwent pelvic reconstruction with a pedicled VRAM flap following sacral chordoma and abdominoperineal resection. The flap remained well perfused and viable until postoperative day 13, at which point the patient was noted to become systemically unwell with fever, chills, and abdominal pain. This clinically coincided with prompt arterial and venous insufficiency of the VRAM flap. Results Computed tomography of the abdomen was ordered to rule out a pelvic collection and revealed an inflated Foley catheter in the bulbar urethra. This was associated with marked distention of the bladder and bilateral hydronephrosis. Direct compression of the deep inferior epigastric pedicle by the bladder neck was noted. Conclusion The case highlights the importance of considering bladder outlet obstruction and subsequent distention as a cause of pedicle compression and VRAM flap failure following pelvic reconstruction.

Objective: To examine the effects of vasopressors on free flap outcomes. Background: Most micro-surgeons avoid the use of vasopressors during free flap surgery due to concerns of vasoconstriction, which could potentially lead to vascular thrombosis and flap failure. Previous studies lack the statistical power to draw meaningful conclusions. Methods: All free flaps between 2004 and 2014 from a single institution were reviewed retrospectively. Vasopressors were given intraoperatively as an intravenous bolus when blood pressure dropped >20% from baseline. The timing of intraoperative vasopressor administration was divided into 3 phases: from anesthesia induction to 30 minutes before the start of flap ischemia (P1); end of P1 to 30 minutes after revascularization (P2); end of P2 to end of surgery (P3). Agents included phenylephrine, ephedrine and calcium chloride. Results: A total of 5671 free flap cases in 4888 patients undergoing head and neck, breast, trunk, or extremity reconstruction were identified. Vasopressors were used intraoperatively in 85% of cases. The overall incidence of pedicle compromise was 3.6%, with a flap loss rate of 1.7%. A propensity score matching analysis showed that intraoperative use of any agents at any time of surgery was not associated with increased overall pedicle compromise [51/ 1584 (3.2%) vs 37/792 (4.7%); P = 0.074] or flap failure rates [26/1584 (1.6%) vs 19/792 (2.4%); P = 0.209]. Rather, there was less risk of venous congestion [33/1584 (2.1%) vs 31/792 (3.9%); P = 0.010]. Conclusions: Intraoperative use of phenylephrine, ephedrine, or calcium chloride as an intravenous bolus does not increase flap compromise and failure rates in cancer patients. [ABSTRACT FROM AUTHOR]

Background: The lack of uniformity of criteria for defining recipient-site infection after oral oncologic surgery with simultaneous reconstruction is problematic despite numerous studies on this issue. This study aimed to investigate the difference in the criteria for defining recipient-site infection after oral oncologic surgery with reconstruction.Methods: A Medline search was performed via PUBMED using the following combinations of key terms that were tagged in the title, abstract, or both: "surgical site infection-head neck," "surgical site infection-oral cancer," "antibiotic prophylaxis-head neck," and "surgical site infection-oral carcinoma." Search results were filtered between 2005 and 2017. Articles in which there was no mention of the criteria for definition of surgical-site infection were excluded.Results: The number of articles that met the inclusion criteria was 24. The lack of uniformity in the criteria for defining recipient-site infection in each article appeared to be attributable mainly to differences in whether an orocutaneous fistula and superficial incisional infection were regarded as recipient-site infection.Conclusion: Reconsideration of the categorization of orocutaneous fistula as infection, regardless of the etiology, and differentiation of superficial and deep incisional infections are necessary for correct assessment of recipient-site infection in oral oncologic surgery. [ABSTRACT FROM AUTHOR]

Summary Autologous microsurgical flap reconstruction has become commonplace in most plastic surgery units, and the success rates of this procedure have markedly increased over recent years. However, the possibility of flap failure still needs to be considered. A review of the literature reveals that the critical period for flap-threatening complications is the first 24–48 post-operative hours; however, the window for the onset of these complications remains open for up to 7 days post-operatively. In this study, we focus on the timing of flap complications, aiming to elucidate the time period over which meticulous flap monitoring can positively contribute to flap salvage rates. The relevant literature on the study topic was collated and reviewed in conjunction with the senior author's case series, which consisted of a total of 335 free flaps used during a 2-year period for breast and head and neck reconstruction or limb trauma. Patients' series were then divided into groups according to the complications timing. The correlation between the timing of complications and the flap salvage rate was investigated among the groups. Overall analysis of both the literature and our own data on 335 free flaps showed a progressive reduction in flap salvage rate during post-operative days; the correlations between the times of complication onset and the flap salvage rates in all groups were significant up to the third post-operative day. The correlations between salvage rates and later complications were not significant. Our results suggest that hourly flap monitoring should be compulsory during the first 48 post-operative hours, but clinical monitoring four times daily should be sufficient thereafter. [ABSTRACT FROM AUTHOR]

The reporting of the outcomes of flap reconstruction is often based on numerical success rates. Whilst this remains a useful variable with which to measure success, it is limited in its ability to reflect the complex processes involved. The lack of consistency in the categorisation of outcomes of flap reconstruction in the head and neck could potentially lead us to lose the opportunity to fully capture the implications of its success or failure, or both. We propose a classification that moves away from primarily reporting the results of its binary nature, and focuses more on the process of reconstruction, particularly in the head and neck. [ABSTRACT FROM AUTHOR]

Presentamos una complicación muy poco frecuente en una paciente mastectomizada y reconstruida con un colgajo DIEP que se necrosó a los 12 días de la intervención, sin apreciarse ninguna causa precipitante. La paciente había sido sometida a radioterapia, que es una causa conocida de retraso en la neovascularización del colgajo. Consideramos que en este tipo de pacientes las medidas dirigidas a la protección del colgajo deben mantenerse durante un período de tiempo mayor que en ausencia de radioterapia.We present an unusual complication suffered by a patient who received a DIEP flap for breast reconstruction and suffered necrosis 12 days after surgery, without existing an objective reason. Patient had been submitted to radiotherapy, that it´s a known reason for delaying in neovascularización of the flap, so we consider that in this patients, measures directed to protect the flap must be extended in time, if compared with those patients without radiotherapy.

Background: Free flap reconstructions are an important reconstructive option for soft tissue defects in mangled lower extremities. Microsurgery facilitates soft tissue coverage of defects that otherwise would result in amputation. However, the success rates of traumatic lower extremity free flap reconstructions remain lower than those in other locations. Nevertheless, post-free flap failure salvage strategies have rarely been addressed. Therefore, the current review aims to provide an overview of post-free flap failure strategies in lower extremity trauma and their subsequent outcomes., Methods: A search of Pubmed, Cochrane, and Embase databases was performed on June 9, June 2021 using the following medical subject headings (MeSH) search terms: 'lower extremity', 'leg injuries', 'reconstructive surgical procedures', 'reoperation', 'microsurgery' and 'treatment failure'. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Partial and total free flap failures after traumatic reconstruction were included., Results: Twenty-eight studies with a total of 102 free flap failures fulfilled the eligibility criteria. Following the total failure, a second free flap is the predominant reconstructive strategy (69%). In comparison to the failure rate of a first free flap (10%), the fate of a second free flap is less favorable with a failure rate of 17%. The amputation rate following flap failure is 12%. The risk of amputation increases between primary and secondary free flap failures. After partial flap loss, the preferred strategy is a split skin graft (50%)., Conclusion: To our knowledge, this is the first systematic review on the outcome of salvage strategies after free flap failure in traumatic lower extremity reconstruction. This review provides valuable evidence to take into consideration in the decision-making regarding post-free flap failure strategies., (© 2023 The Authors.)

Various composite free flaps are available for reconstruction of bony head and neck defects. The aim of this study was to compare the relative success of four different bony free flaps. One hundred and seventy-three microvascular composite free flap reconstructions for bony defects of the head and neck region, performed over the period April 2008 to April 2015, were reviewed retrospectively. The type of free flap, indication for free flap reconstruction, age at harvesting of the free flap, use of pre- or postoperative radiotherapy, and free flap failure were examined. For the 173 reconstructions performed, 84 fibula free flaps, 43 iliac crest free flaps, 32 scapula free flaps, and 14 osteocutaneous radial forearm free flaps were harvested. The mean age at time of harvesting was 40.7 years for the iliac crest, 57.3 years for the fibula, 64.3 years for the scapula, and 73.9 years for the osteocutaneous radial forearm free flap. No complete free flap failure was documented, nor was there any failure of bony segments. Three fibula flap skin paddles did not survive. No returns to theatre for salvage were required. This study showed no difference in the survival rates of these four types of composite free flap. [ABSTRACT FROM AUTHOR]

Microvascular free flaps are preferred for most major head and neck reconstruction surgeries because of better functional outcomes, improved esthetics, and generally higher success rates. Numerous studies have investigated measures to prevent flap loss, but few have evaluated the optimal treatment for free flap complications. This study aimed to determine the complication rate after free flap reconstructions and discusses our management strategies. Medical records of 260 consecutive patients who underwent free flap reconstructions for head and neck defects between July 2006 and June 2010 were retrospectively reviewed for patient and surgical characteristics and postoperative complications. The results revealed that microvascular free flaps were extremely reliable, with a 3.5 % incidence of flap failure. There were 78 surgical site complications. The most common complication was neck wound infection, followed by dehiscence, vascular congestion, abscess, flap necrosis, hematoma, osteoradionecrosis, and brisk bleeding. Twenty patients with poor wound healing received hyperbaric oxygen therapy, which was ineffective in three patients who eventually experienced complete flap loss. Eleven patients with vascular congestion underwent medicinal leech therapy, which was effective. Among the 78 patients with complications, 44 required repeat surgery, which was performed for postoperative brisk bleeding in three. Eventually, ten patients experienced partial flap loss and nine experienced complete flap loss, with the latter requiring subsequent pectoralis major flap reconstruction. Microvascular free flap reconstruction represents an essential and reliable technique for head and neck defects and allows surgeons to perform radical resection with satisfactory functional results and acceptable complication rates. [ABSTRACT FROM AUTHOR]

Purpose: There are many options for breast reconstruction following a mastectomy, and data on outcomes are greatly needed for both the patient and the care provider. This study aims to identify the prevalence and predictors of adverse outcomes in autologous breast reconstruction in order to better inform patients and surgeons when choosing a surgical technique. Methods: This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified each autologous breast reconstruction performed between 2005 and 2012. Of the 6855 autologous breast reconstructions, there were 2085 latissimus dorsi (LD) flap procedures, 2464 pedicled transverse rectus abdominis myocutaneous (TRAM) flap procedures, and 2306 free flap procedures that met the inclusion criteria. The prevalence of complications in each of the three procedures was calculated and compared using χ analysis for binomial categorical variables. Univariate and multivariate logistic regression analyses identified independent risk factors for adverse outcomes in autologous reconstruction as a whole. Results: The prevalence of general complications was 10.8 % in LD flaps, 20.6 % in TRAM flaps, and 26.1 % in free flaps for autologous breast reconstruction ( p < 0.001). The prevalence of wound complications was 4.3 % in LD flaps, 8.1 % in TRAM flaps, and 6.2 % in free flaps for autologous breast reconstruction ( p < 0.001). The prevalence of flap failure was 1.1 % in LD flaps, 2.7 % in TRAM flaps, and 2.4 % in free flaps for autologous breast reconstruction ( p < 0.001). Multivariate regression analysis showed that obesity [odds ratio (OR) 1.495, p = 0.024], hypertension (OR 1.633, p = 0.008), recent surgery (OR 3.431, p < 0.001), and prolonged operative times (OR 1.944, p < 0.001) were independently associated with flap failure in autologous breast reconstruction procedures. When controlling for confounding variables, TRAM flaps were twice as likely (OR 2.279, p = 0.001) and free flaps were three times as likely (OR 3.172, p < 0.001) to experience flap failure when compared to LD flaps. Conclusions: Latissimus dorsi flaps are associated with the fewest short-term general complications and free flaps are associated with the most short-term general complications in autologous breast reconstruction. Free flaps are the most likely to experience flap failure, though there is no significant difference when compared to pedicled TRAM flaps. Free and TRAM flaps remain as the widely acceptable forms of breast reconstruction in the patient without many risk factors for flap failure or wound complications. The identified risk factors will aid in surgical planning and risk adjustment for both the patient and the care provider. Though many other factors will be taken into consideration with surgical planning of autologous breast reconstruction, the presence of these identified risk factors may encourage the use of a surgical technique associated with fewer adverse outcomes, like the LD flap. Level of Evidence III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors . [ABSTRACT FROM AUTHOR]

Summary Background The quality of head and neck cancer reconstruction in England is not known. Hospital administrative data provides details of treatment within the English National Health Service and may be used for national outcomes analysis. Methods An algorithm for identifying head and neck surgery with flap-based reconstruction from administrative data was constructed and validated against information from three cancer units. The validated algorithm was applied to 2003–2013 national activity. Results The algorithm was 91% sensitive and over 99% specific. Its application to administrative data identified 11,841 patients and demonstrated an increase of 52% in reconstruction-containing head and neck cancer surgery in the past decade. There were 7776 males and mean treatment age was 62 years. Oral cavity was the commonest primary site ( n = 7567; 64%) and 7575 patients (64%) underwent primary surgery. The commonest procedure was floor-of-mouth excision ( n = 3614) and 9749 patients had a neck dissection. The most commonly used flap was the radial forearm ( n = 4429). Flap failure occurred in 496 (4.2%) patients. It increased the mean length of stay from 22 to 41 days ( P < 0.00001), and the odds ratio of in-hospital death to 2.37 [95% confidence interval 1.66–3.38; P < 0.0001]. Lethality of reconstructive failure was not uniform and was highest when a pharyngolaryngeal flap failed. Conclusions Reconstructive surgery is central to the multidisciplinary management of head and neck cancer. Its quality directly influences patient morbidity and survival. We recommend that analysis of hospital administrative data should be periodically carried out as part of an over-arching quality assurance programme and, particularly for pharyngolaryngeal reconstructions, surgery should be undertaken in units with the best reconstructive outcomes. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess the effectiveness of early exploration of anterolateral thigh (ALT) free flap compromise in head and neck reconstruction and to correlate this with the salvage success rate. The perioperative data of 1051 patients with 1072 ALT flap reconstructions were reviewed retrospectively for the period January 2002 to December 2012. Outcome measures included ethnicity, defect type, incidence and timing of flap compromise, type of flap compromise, causes of vascular occlusion, and salvage rate. The success rate of free flap reconstruction was 97.3% (1043/1072). Of the 29 failures, 21 were complete and eight were partial failures (10-40% of the flap). Venous occlusions occurred in 39 flaps (83.0%) and arterial occlusions in five flaps (17.0%). Six cases were detected within 8h postoperatively, 13 at 8-16h postoperatively, seven at 16-24h postoperatively, and 18 at 24-48h postoperatively, with respective salvage rates of 66.7%, 61.5%, 28.6%, and 22.2%; three cases detected after 48h failed. The salvage rate at ↜16h (62.2%) was much higher than that at >16h (21.4%, P=0.0039). Early detection, re-exploration, and effective handling of the flap crisis increases the rate of flap salvage tremendously. [ABSTRACT FROM AUTHOR]

Abstract: In head and neck microvascular reconstruction, a proportion of patients are at a higher risk of flap failure. These include salvage surgery after chemoradiotherapy, reconstruction for osteoradionecrosis and when difficulty is encountered in achieving flap perfusion intraoperatively. Several studies have shown that the Cook-Swartz Doppler (Cook Medical Inc, Bloomington, USA) enabled earlier detection of a compromised flap. We retrospectively reviewed microvascular reconstructions monitored with the Cook-Swartz implantable Doppler (2006–2012) and included patients’ characteristics, comorbidity (American Society of Anesthesiologists’ (ASA) grade), indication for operation, type of reconstruction, and indication for implantable Doppler. We also included details of surgical exploration, free flap salvage, and outcomes of flap salvage. These outcomes were compared with a group of low-risk patients (2005–2009) whose flaps were monitored clinically. A total of 75 free flaps in 73 patients were monitored with the implantable Doppler: 40 (53%) were in cases which required reconstruction following previous surgery/radiotherapy or flap perfusion difficulties, 10 (13%) buried flaps, 13 (17%) as routine flap monitors and 12 (17%) for other indications. The false negative rate was 5%, sensitivity 67%, the false positive rate was 25%, and specificity was 95%. Higher risk flaps monitored with the doppler had a higher return to theatre rate, 21% compared with 4% (p <0.001) and flap failure rate, 7% compared with 1% (p =0.002). Salvage rates for free flaps were similar in both groups (62% compared with 60%, p =1.0). There is not enough evidence to suggest that the implantable doppler reduces the rate of failed flaps in routine low-risk cases, and its value in monitoring high-risk reconstructions require evaluation in a prospective randomised study. [Copyright &y& Elsevier]

Objectives/Hypothesis Free tissue transfer has success rates greater than 95%. Approximately 10% will require reexploration for vascular compromise. Return to the operating room within 48 hours yields the highest rate of successful salvage. Our aim was to determine whether an implantable Doppler used for intraoperative/postoperative monitoring would 1) alter the pattern of detecting flap failure and 2) alter the overall incidence of flap survival. Study Design Prospective analysis. Methods Generic and study specific data was collected. Note was made at the end of the case if revision of the vascular anastomosis was performed. Data was collected for flap outcomes in the postoperative period. Results A total of 1,236 free tissues transfers from 2001 through 2011 were analyzed. Ninety-four were outside the head and neck or the Doppler was not used/inadvertently discontinued. A total of 1,142 flaps make up the study cohort. One hundred thirty-four (11.7%) intraoperative flow problems were detected, all successfully revised. Of these, 15 (11%) required postoperative revision and five (33%) were successfully salvaged, with an overall survival 93%. A total of 1,008 flaps did not require intraoperative revision, 62 required reexploration (6.1%), and 38 (61%) were salvaged. The overall survival was 97.6%. There were eight false positive (no intervention) and 10 false negatives. Sensitivity was 87% with specificity 99%. Conclusion Intraoperative Doppler's increase the detection of immediate/incipient vascular problems. Patients requiring revision in the operating room require revision more often in the postoperative period ( P = .03) and are less likely to have successful salvage and a lower flap survival rate ( P = .05). Level of Evidence N/A. Laryngoscope, 124:S1-S12, 2014 [ABSTRACT FROM AUTHOR]

Tobacco cigarette smoking remains a serious risk factor for necrosis of local facial skin flaps. To date, no pharmacological therapies exist for cigarette smoke-induced impairment of skin flap tissue survival. Accumulating evidence suggest that phosphodies-terase-5 (PDE-5) inhibitor therapy may counteract the negative effects of cigarette smoke on flap survival. Here, we evaluate skin flap survival in a series of consecutive tobacco cigarette users treated with the PDE-5 inhibitor, sildenafil, who underwent local flap facial reconstruction. We included 11 patients (5 females; median age: 64) with a significant smoking history. Seventeen facial flaps were performed for 14 defects. All patients received sildenafil in the postoperative setting. One complication of necrosis of the flap distal margin was encountered. Follow-up was available for all patients. Our results demonstrate that facial reconstruction in tobacco cigarette smokers can be performed with improved success and that sildenafil therapy may mitigate the deleterious effects of smoking on flap survival. [ABSTRACT FROM AUTHOR]

Abstract: Reconstruction of surgical defects in the head and neck using microvascular free tissue transfer is reliable with success rates in excess of 95%. Our previous audit (1992–1998) showed that 16% of patients required an early return to theatre, and the overall free flap salvage rate was 73%. The medical records of 37 patients who had required early return to theatre (within 7 days) after free tissue transfer were analysed to ascertain the indication for reoperation, and whether surgical intervention had been successful, taking into account the timing and cause of compromise. The results of a retrospective re-audit (1999–2004 and 2005–2009) showed that the return to theatre rate had reduced to 4% overall because of a reduction in the number of cases: those that required evacuation of a neck haematoma, and venous compromise of fasciocutaneous or perforator free flaps. Salvage of flaps was most successful when done within the first 24h, and in cases of venous compromise. Three percent of free flaps failed without attempted salvage; most were late failures. Overall survival (1992–2009) for composite free flaps (93%) was lower than for fasciocutaneous or perforator free flaps (96%). Between 2005 and 2009 our overall free flap survival rate was 98%. [Copyright &y& Elsevier]

Abstract: The radial forearm free flap (RFFF) is well-established in head and neck reconstruction, but early potential failure may necessitate a contingency plan, which could include the opposite RFFF if cannulation of the relevant artery at the time of the first operation did not influence its patency. We prospectively studied patients listed for major operations who required radial artery cannulation. They all had perioperative imaging of the radial artery with colour flow duplex before cannulation and at intervals after the cannula had been removed (2h–7 days). Forty patients were recruited (mean age 65 years, range 32–91). Thirty-three had patent vessels within 2h of the cannula being removed, and 39/40 at 24h. Patency after removal of the cannula returns rapidly, and is almost always complete by 24h. In most people the contralateral radial forearm could therefore be used to mode of salvage reconstruction if the flap failed early. [ABSTRACT FROM AUTHOR]

We sought to determine the effect of ischemic preconditioning (IPC) on secondary ischemia in myocutaneous flaps in a rat model. Forty rectus abdominis myocutaneous flaps were elevated in 40 rats, and the animals were randomized into control or IPC groups (20 flaps each group). All flaps were then subject to primary ischemia for 2 hours via pedicle clamping. Twenty-four hours later, the control and IPC flaps were randomized to two groups each of 1 or 2 hours of secondary ischemia (4 groups, 10 flaps per group). Flap survival was evaluated on postoperative day 5 by measuring the percentage area of flap survival by a blinded observer. Mean flap survival area and total necrosis rates were compared between the groups. In the 1-hour secondary ischemia groups, IPC improved mean flap survival area from 11 � 7% to 36 � 22%, and the total necrosis rates from 40 to 0%. These differences were statistically significant (p < 0.006, p < 0.05, respectively). In the 2-hour secondary ischemia groups, differences were not statistically significant (p = 0.2, p = 0.4, respectively). IPC improves the survival of myocutaneous flaps subjected to secondary ischemia of 1 hour in this rat free flap model. [ABSTRACT FROM AUTHOR]

Background. Venous anastomotic failure is the primary reason for microvascular free tissue transfer failure. Donor and recipient veins can be oriented in the same longitudinal axis (end-to-end anastomosis), or the donor vein can be anastomosed to the internal jugular vein in an end-to-side configuration. No consensus on the optimal anastomosis configuration exists. We sought to evaluate whether type of venous anastomosis impacts flap survival rate. Methods. Data were collected on all patients undergoing microvascular free flap reconstruction of head and neck defects at the University of Washington between August 1993 and April 2007. Flaps with a single venous anastomosis were analyzed. Flaps were stratified into those with end-to-end and end-to-side anastomoses. Survival rates were compared between groups using bivariate and multivariate techniques. Results. Inclusion criteria were met by 786 free flaps; 87% performed in an end-to-end and 13% in an end-to-side configuration. Flap re-exploration and failure rate were 4.3% and 1.1%, respectively. In multivariate analysis, there was no difference in odds of flap re-exploration (OR .70, 95% CI .23–2.18) or flap failure whether or not an end-to-end or end-to-side anastomosis was performed (OR 2.09, 95% CI .38–11.5). Conclusions. In this large cohort of patients, we found no difference in the odds of flap re-exploration or failure based on venous anastomotic configuration. Reconstructive surgeons should have both anastomotic techniques in their repertoire to optimize the success of every flap. © 2009 Wiley Periodicals, Inc. Head Neck, 2009 [ABSTRACT FROM AUTHOR]

Rapid identification of possible vascular compromise in free flap reconstruction to minimize time to reoperation improves achieving free flap salvage. Subjective clinical assessment, often complemented with handheld Doppler, is the golden standard for flap monitoring; but this lacks consistency and may be variable. Non-invasive optical methods such as near-infrared spectroscopy (NIRS) and hyperspectral imaging (HSI) could facilitate objective flap monitoring. A systematic review was conducted to compare NIRS with HSI in detecting vascular compromise in reconstructive flap surgery as compared to standard monitoring. A literature search was performed using PubMed and Embase scientific database in August 2021. Studies were selected by two independent reviewers. Sixteen NIRS and five HSI studies were included. In total, 3662 flap procedures were carried out in 1970 patients using NIRS. Simultaneously; 90 flaps were performed in 90 patients using HSI. HSI and NIRS flap survival were 92.5% (95% CI: 83.3–96.8) and 99.2% (95% CI: 97.8–99.7). Statistically significant differences were observed in flap survival (p = 0.02); flaps returned to OR (p = 0.04); salvage rate (p < 0.01) and partial flap loss rate (p < 0.01). However, no statistically significant difference was observed concerning flaps with vascular crisis (p = 0.39). NIRS and HSI have proven to be reliable; accurate and user-friendly monitoring methods. However, based on the currently available literature, no firm conclusions can be drawn concerning non-invasive monitoring technique superiority [ABSTRACT FROM AUTHOR]

Background. The purpose of this study was to analyze the causes of flap compromise and failure in head and neck free flap reconstruction. Methods. We retrospectively reviewed 1310 free flap reconstructions for head and neck defects performed between July 1995 and June 2006. Results. Forty-nine cases of flap compromise due to vascular obstruction (3.7%) were identified, and 27 flaps were lost (2%). Arterial occlusions occurred in 12 flaps, with a salvage rate of 33%. Eight flaps failed within the first 24 hours, and only 1 of these was salvageable. Five of the 8 flaps had intraoperative thrombosis due to technical difficulties. Venous occlusions occurred in 31 flaps, with a salvage rate of 58%. Twenty-two venous occlusions occurred within the first 72 hours. The main reason for venous failure was mechanical obstruction due to compression, twisting, kinking, or stretching of the vein. The most common cause of late failures (after 7 days) was unrecognized failure of a buried flap owing to the lack of reliable monitoring. Overall, there was no correlation between surgeon experience and flap failure, but the flap failure rate was lower in surgeons who had performed more than 70 free flap procedures. Conclusion. Precise surgical techniques, avoidance of mechanical obstruction, and better monitoring of buried flaps may further improve the success rate of free tissue transfer in complex head and neck reconstruction. © 2008 Wiley Periodicals, Inc. Head Neck, 2009 [ABSTRACT FROM AUTHOR]

Summary: Reconstruction of the post-oncologic defect of the lower limb frequently requires free tissue transfer and these often extensive bone and soft tissue resections can occasionally be compounded by the presence of a deep venous thrombosis (DVT). We describe two patients in whom free tissue transfer was attempted, following extensive resection of a sarcoma in the thigh. Both patients had been diagnosed with DVT prior to surgery and received therapeutic low molecular weight heparin preoperatively. In the first patient, flap failure occurred due to venous congestion initially resulting from poor flow in the reconstructed femoral vein and then thrombosis and failure of the vascular reconstruction. In the second patient the superficial venous system was used for successful microvascular anastomosis leading to survival of the flap. Therefore, patients undergoing lower extremity free tissue transfer who are at high risk of DVT, or when there is a clinical suspicion of DVT, thorough preoperative assessment of the deep and superficial venous system is warranted for reconstruction planning. [Copyright &y& Elsevier]

We present an unusual complication suffered by a patient who received a DIEP flap for breast reconstruction and suffered necrosis 12 days after surgery, without existing an objective reason. Patient had been submitted to radiotherapy, that it's a known reason for delaying in neovascularización of the flap, so we consider that in this patients, measures directed to protect the flap must be extended in time, if compared with those patients without radiotherapy. [ABSTRACT FROM AUTHOR]

Summary: Background: Flap failure is a major complication in reconstructive plastic surgery. One of the most frequent etiologies of flap failure is venous thrombosis. However, infrequent causes also need to be explored, especially when faced with recurrent thrombosis. Heparin is frequently used in the prevention of venous thrombosis; however, the use of the medication itself may cause a serious thromboembolic state via an immune-related pathophysiological process. This adverse reaction to heparin may be life threatening. Case presentation: We present two cases, one pedicled and one free flap, with venous congestion concomitant to heparin-induced thrombocytopenia syndrome, in conjunction with severe life-threatening sequelae. Conclusions: Heparin-induced thrombocytopenia syndrome can be the cause of postoperative venous congestion. It is necessary to be alert for this syndrome in the presence of recurrent unexplained venous thrombosis or thrombocytopenia in patients receiving anticoagulation therapy. [Copyright &y& Elsevier]

Background: Microvascular tissue reconstruction is a well-established, commonly used technique for a wide variety of the tissue defects. However, flap failure is associated with an additional hospital stay, medical cost burden, and mental stress. Therefore, understanding of the risk factors associated with this event is of utmost importance., Aim: To develop machine learning-based predictive models for flap failure to identify the potential factors and screen out high-risk patients., Methods: Using the data set of 946 consecutive patients, who underwent microvascular tissue reconstruction of free flap reconstruction for head and neck, breast, back, and extremity, we established three machine learning models including random forest classifier, support vector machine, and gradient boosting. Model performances were evaluated by the indicators such as area under the curve of receiver operating characteristic curve, accuracy, precision, recall, and F1 score. A multivariable regression analysis was performed for the most critical variables in the random forest model., Results: Post-surgery, the flap failure event occurred in 34 patients (3.6%). The machine learning models based on various preoperative and intraoperative variables were successfully developed. Among them, the random forest classifier reached the best performance in receiver operating characteristic curve, with an area under the curve score of 0.770 in the test set. The top 10 variables in the random forest were age, body mass index, ischemia time, smoking, diabetes, experience, prior chemotherapy, hypertension, insulin, and obesity. Interestingly, only age, body mass index, and ischemic time were statistically associated with the outcomes., Conclusion: Machine learning-based algorithms, especially the random forest classifier, were very important in categorizing patients at high risk of flap failure. The occurrence of flap failure was a multifactor-driven event and was identified with numerous factors that warrant further investigation. Importantly, the successful application of machine learning models may help the clinician in decision-making, understanding the underlying pathologic mechanisms of the disease, and improving the long-term outcome of patients., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: To review the use of the medicinal leech, Hirudo medicinalis, in salvaging the failing, venous-congested flap. A protocol for the use of leeches is presented. Four illustrative cases of failing flaps (pectoralis major, midline forehead, and temporalis) are presented. Study Design: Literature review comprised of MEDLINE search 1965 to present. Retrospective review of four cases involving the management of the failing, venous-congested flap. Methods: A retrospective review of four cases of failing, venous-congested flaps was performed. Results: The authors' experience, as well as the data from the reviewed medical literature, demonstrates the importance of early intervention in order to salvage the failing, venous-congested flap. Leeches are an immediate and efficacious treatment option. Conclusions: 1. Review of the literature indicates that the survival of the compromised, venous-congested flap is improved by early intervention with the medicinal leech. H medicinalis injects salivary components that inhibit both platelet aggregation and the coagulation cascade. The flap is decongested initially as the leech extracts blood and is further decongested as the bite wound oozes after the leech detaches. 2. When a flap begins to fail, salvage of that flap demands early recognition of reversible processes, such as venous congestion. The surgeon must be familiar with the use of leeches and should consider their use early, since flaps demonstrate significantly decreased survival after 3 hours if venous congestion is not relieved. In the four cases presented, a standardized protocol facilitated early leech use and provided for the psychological preparation of the patient, availability of leeches, and an antibiotic prophylaxis regimen. 3. The complications associated with leech use can be minimized with antibiotic therapy, wound care, and hematocrit monitoring. 4. The use of the medicinal leech for salvage of the venous-congested flap is a safe, efficacious, economical, and well-tolerated intervention. [ABSTRACT FROM AUTHOR]

Microvascular free flap reconstruction is a routine option for coverage of a variety of tissue defects. Accurate monitoring in the postoperative period is a crucial part of successful flap surgery allowing early detection of vascular compromise and prompt intervention in flap salvaging. Despite that many safety procedures to assess flap viability have been developed, flap failure is consistently seen in 2-5% of free tissue transfers. In addition, great progress is being made in relation to various state-of-the-art technologies for flap monitoring. However, the gold standard still remains clinical monitoring at most institutions even though there is no standardized management protocol. The review should present a prospective optimal monitoring protocol and introduce some of the latest monitoring devices based on the recent literature and personal experience.

The fibula free flap (FFF) has been a workhorse in maxillofacial reconstruction. High success rates of this technique are reported. However, identifying risk factors for flap failure and analyzing complications can open the way to better patient care. A retrospective analysis was conducted of all FFFs performed over a 20-year period at a low-volume single tertiary center to identify risk factors and postoperative complications. A total of 129 FFFs were included (122 mandible, 7 maxilla). Complete flap failure occurred in 12.4% and partial flap failure in 7.8% of patients. A significant relation was found between younger age and flap failure, and most failures were associated with venous thrombosis. In-hospital surgical complications occurred in 60.5%, in-hospital medical complications in 49.6%, and out-of-hospital complications in 77.5% of patients. The in-hospital reintervention rate was 27.1%, and including salvaged flaps, flap survival rate was 87.6%. Osteomyocutaneous FFF failure (complete 12.4%; partial 7.8%) is an important clinical reality in a low-volume head and neck reconstruction center resulting in an in-hospital reintervention rate of 27.1%. Postoperative complications are frequent, both surgical and out-hospital complications. These results provide a better understanding of the limitations of the FFF in a low-volume center and can be used to optimize care in this kind of setting.

Objective: To review our experience with infrahyoid myocutaneous flap in reconstruction after oral cancer resection., Methods: Chart reviews were completed for all patients who underwent oral reconstruction with an infrahyoid myocutaneous flap by a single surgeon in the Department of Otolaryngology at Chonburi Cancer Hospital from 2011 to 2017. Characteristics of the patients and postoperative complications were analyzed., Results: Of the 34 patients in the study, 10 (29.4%) developed partial flap loss and 1 (2.9%) developed total flap loss. All cases of partial flap loss resolved with conservative treatment. Apparent cancer involvement of a cervical lymph node was significantly associated with flap failure ( odds ratio : 5.0, 95% CI : 1.03-24.28)., Conclusions: The infrahyoid myocutaneous flap is a fairly reliable reconstruction method. The flap should be performed with caution in cases with gross lymph node involvement.