Perioperative Management for Microsurgical Free Tissue Transfer: Survey of Current Practices with a Comparison to the Literature

Motakef, Saba; Mountziaris, Paschalia M.; Ismail, Inzhili K.; Agag, Richard L.; Patel, Ashit

doi:10.1055/s-0035-1546422

Cited by 27 publications

(25 citation statements)

References 71 publications

(80 reference statements)

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“…Though intraoperative use of pressors has recently been reported to have no impact on flap success or on incidence of complications, [22][23][24][25][26][27] and this was not true in our study. Though there was no effect on flap loss, we found that those with intraoperative microvascular arterial complications were approximately three times more likely to require emergent return to the OR for a flap complication than those without arterial complications (41.7 vs. 13.8%).…”

Section: Discussioncontrasting

confidence: 72%

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Chang

Chu

Nelson

et al. 2017

J reconstr Microsurg

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Microvascular anastomotic patency is fundamental to head and neck free flap reconstructive success. The aims of this study were to identify factors associated with intraoperative arterial anastomotic issues and analyze the impact on subsequent complications and cost in head and neck reconstruction. A retrospective review was performed on all head and neck free flap reconstructions from 2005 to 2013. Patients with intraoperative, arterial anastomotic difficulties were compared with patients without. Postoperative outcomes and costs were analyzed to determine factors associated with microvascular arterial complications. A regression analysis was performed to control for confounders. Total 438 head and neck free flaps were performed, with 24 (5.5%) having intraoperative arterial complications. Patient groups and flap survival between the two groups were similar. Free flaps with arterial issues had higher rates of unplanned reoperations (< 0.001), emergent take-backs ( = 0.034), and major surgical ( = 0.002) and respiratory ( = 0.036) complications. The overall cost of reconstruction was nearly double in patients with arterial issues ( = 0.001). Regression analysis revealed that African American race (OR = 5.5, < 0.009), use of vasopressors (OR = 6.0, = 0.024), end-to-side venous anastomosis (OR = 4.0, = 0.009), and use of internal fixation hardware (OR =3.5, = 0.013) were significantly associated with arterial complications. Intraoperative arterial complications may impact complications and overall cost of free flap head and neck reconstruction. Although some factors are nonmodifiable or unavoidable, microsurgeons should nonetheless be aware of the risk association. We recommend optimizing preoperative comorbidities and avoiding use of vasopressors in head and neck free flap cases to the extent possible.

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Section: Discussioncontrasting

confidence: 72%

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Chang

Chu

Nelson

et al. 2017

J reconstr Microsurg

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“…Motakef et al distributed an online survey consisting of questions regarding perioperative management for free tissue transfer and evaluated microsurgeons' approach to perioperative temperature control. 36 According to their data, intraoperative core temperature was assessed most commonly using an esophageal probe (69%), followed by the use of a Foley's catheter (35%). Unfortunately, their data provided no insight into the clinical pathways applied for patient temperature control or specific temperature goals.…”

Section: Discussionmentioning

confidence: 99%

Impact of Intraoperative Hypothermia on Microsurgical Free Flap Reconstructions

Moellhoff

Broer

Heidekrueger

et al. 2020

J Reconstr Microsurg

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Background Patients requiring microsurgical defect reconstruction are highly susceptible to intraoperative hypothermia, given oftentimes long operative times and exposure of large skin surface areas. While the impact of hypothermia has been extensively studied across various surgical fields, its role in the setting of microsurgical free flap reconstruction remains elusive. This study evaluates the effects of hypothermia on outcomes of free flap reconstructions. Methods Within 7 years, 602 patients underwent 668 microvascular free flap reconstructions. The cases were divided into two groups regarding the minimal core body temperature during free flap surgery: hypothermia (HT; < 36.0°C) versus normothermia (NT; ≥36.0°C). The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. Results Our data revealed no significant difference with regard to the rate of major and minor surgical complications, or the rate of revision surgery between both groups (p > 0.05). However, patients in the HT group showed significantly higher rates of total flap loss (6.6% [HT] vs. 3.0% [NT], p < 0.05) and arterial thrombosis (4.6% [HT] vs. 1.9% [NT], p < 0.05). This translated into a significantly longer hospitalization of patients with reduced core body temperature (HT: mean 16.8 days vs. NT: mean 15.1 days; p < 0.05). Conclusion Hypothermia increases the risk for arterial thrombosis and total flap loss. While free flap transfer is feasible also in hypothermic patients, surgeons' awareness of core body temperature should increase. Taken together, we suggest that the mean intraoperative minimum temperature should range between 36 and 36.5°C during free flap surgery as a pragmatic guideline.

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“…Our result is in line with the study of Motakef et al after conducting questionnaires to ask Hb threshold for intraoperative blood transfusion, showing that 63% of responders have answered that 7 to 8 g/dL is their limit. 8 Excluding intraoperative surgical problem such as anastomosis leakage and hematoma that can directly lead to flap failure, obtaining adequate Hb level as an active transfusion strategy in perioperative flap period is essential. Although the universal recommendation is to reduce blood transfusion, the correlation between perioperative Hb levels and other clinical parameters with flap failure supports a welltimed request for transfusion to provide permissive normovolemic status since decreased perioperative Hb value might increase the risk of flap failure.…”

Section: Discussionmentioning

confidence: 99%

“…Sometimes it is common for microsurgeons to manage patients according to their mentors' beliefs or anecdotal facts in free flap patients. 8 To address such knowledge gap, the objective of this study was to perform a comprehensive analysis to determine whether blood transfusion could impact microsurgical outcome or flap-related complications and find evidence-based points of transfusion in free flap patients.…”

mentioning

confidence: 99%

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion

Kim

Woo

Park

et al. 2018

J reconstr Microsurg

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A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.

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Perioperative Management for Microsurgical Free Tissue Transfer: Survey of Current Practices with a Comparison to the Literature

Cited by 27 publications

References 71 publications

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Complications and Cost Analysis of Intraoperative Arterial Complications in Head and Neck Free Flap Reconstruction

Impact of Intraoperative Hypothermia on Microsurgical Free Flap Reconstructions

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion

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