Factors impacting successful salvage of the failing free flap

Abstract

Background: Understanding factors impacting successful salvage of a compromised free flap. Methods: Multi-institutional review of free flap reconstructions for head and neck defects (n = 1764). Results: Free flap compromise rate: 9% (n = 162); 46% salvaged (n = 74). Higher salvage rates in initial 48 hours (64%) vs after (30%; P < .001). Greater compromise (14%) and failure (8%) if inset challenging vs straightforward (6% compromise, 4% failure; P = .035). Greater compromise (23%) and failure (17%) following intraoperative anastomosis revision vs no revision (7% compromise, 4% failure; P < .0001). Success following arterial insufficiency was lower (60% failed, 40% salvaged) vs venous congestion (23% failed, 77% salvaged) (P < .0001). Greater flap salvage following thrombectomy (66%) vs no thrombectomy (34%; P < .0001). Greater flap salvage if operative duration ≤8 hours (57%), vs >8 hours (40%) (P = .04). Conclusions: There were higher rates of free flap salvage if the vascular compromise occurred within 48 hours, if due to venous congestion, if operative duration ≤8 hours, and if the anastomosis did not require intraoperative revision. K E Y W O R D S free flap, free flap salvage, head and neck reconstruction, outcomes, surgical complications 1 | INTRODUCTION Microvascular free flap reconstruction of head and neck defects was first introduced in the 1970s and has resulted in superior aesthetic and functional results and improved patient quality of life. 1-3 Free flap survival rates in recent years are consistently cited as greater than 95%, 4-10 with still a small percentage of free flaps experiencing vascular compromise. Salvage of a compromised free flap is often attempted as complete failure of a free flap results in significant morbidity for the patient, increased length of hospitalization, and increased health care cost. 7,11-15 The ability to salvage a compromised free flap has been cited as high as 60% to 80%. 9,16-19 Therefore, great efforts are undertaken to salvage a compromised free flap. Most academic centers, which perform high volume free tissue transfer, are prepared to rapidly intervene once a compromised free flap is identified. A timely recognition of a

Surgical and demographic predictors of free flap salvage after takeback: A systematic review

“…While a history of radiation therapy was not significantly correlated with failed salvage, it did approach significance ( p = .06), and was significantly associated with failed salvage in the head and neck population ( p = .028). The impact of radiation on free flap reconstruction is well‐documented (Onoda et al, 2014 ; Sweeny et al, 2020 ), and the association with failed salvage likely stems from recipient vessel friability and inflammation creating an overall pro‐thrombotic microenvironment. In general, patients with assumed vessel friability and fragility make nonideal candidates for salvage attempt.…”

Microvascular free flap for head and neck reconstruction: our experiences with 218 free flaps for head and neck reconstructions

“…According to various literatures successful flap salvage rate generally ranges from over 25% to over 90%. 14,23,[25][26][27][28] In our series, RFF was the most common flap performed 112/218 (51.3%). There were 15 vascular complications with RFF and 7 vascular compromised flaps could be salvaged by re-exploration.…”

Reconstruction of Oral Cavity Defects with Free Flaps After Ablation of Intraoral Cancers

“…Tüm bu komplikasyonların erken tespiti ve tedavisi için sık flep takibi mutlak gereklidir. 19 Pedikül çevresine yerleştirilen penröz drenlerin ve pedikülden uzak flep altına dren yerleştirilmesini, pediküle baskı yapacak koleksiyonların oluşmaması için önemli olduğunu düşünüyoruz. Bunlara rağmen boyun diseksiyonu alanında hematom gelişen bir hastamızda, flepte herhangi bir soruna neden olmadan hematom boşaltılmış ve flep kaybı yaşanmamıştır.…”