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

Abstract

Background Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%–95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time—with salvage rates between 22% and 67%. There are limited data‐driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage. Methods A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi‐square tests and linear regression modeling was completed for analysis. Results The patient‐specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case‐specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure. Conclusions Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision‐making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post‐index operation are the best candidates for a salvage attempt.

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures

“…It is important to note that in previous studies, time is arguably the most well-known and important factor affecting flap salvage. 4 7 9 20 33 Although takeback procedures resulting in failure occurred a median of 5 days from initial operation as opposed to the 1 day observed for those salvaged, the difference was not statistically significant. The time between operations is often considered a proxy for ischemic time.…”

“…One potential explanation for this is the immediate ischemia induced by arterial occlusion as compared with the more insidious development of ischemia and arterial collapse in venous compromise. In addition, as described by Odorico et al, 9 venous outflow obstruction is often secondary to modifiable risk factors including extrinsic compression causing kinking and pedicle redundancy whereas arterial failure is attributable to patient-specific factors (e.g., atherosclerotic disease, vessel damage) that are more difficulty to correct during salvage procedures. As a result, despite use of more intense salvage techniques including mechanical thrombectomy and TPA infusion, arterial perfusion could not be restored.…”

“…The time between operations is often considered a proxy for ischemic time. 9 Through the inclusion of etiologies unrelated to microvascular compromise this data incorporates conditions that progressively develop without simultaneous tissue deoxygenation. As a result, time and ischemic time become uncoupled in our data analysis.…”

Postoperative Day 1 Discharge in Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction

“…Complications of microsurgical breast reconstruction can be devastating, including risk of hemorrhage and total flap loss due to vascular compromise. 23 DIEP flaps performed at our institution are monitored using ViOptix T.Ox Tissue oximeter, which has been shown to provide earlier detection of vascular compromise. 24 Monitoring is discontinued by 8:00 am on POD 1 if no issues have arisen.…”

Discussion: Optimal Timing for Secondary Reconstruction of Head and Neck Defects after Free Flap Failure

“…4 Although the authors attempt to provide guidance for a very important issue in microvascular head and neck reconstruction, the success rate of salvage free flaps is multifactorial, and the timing of a secondary free flap is only one factor that can influence the final outcome. [5][6][7] Given the high success rates of free flaps, it is difficult to provide large numbers to guide management in the setting of a flap loss. 8 As the authors note, it was not possible to perform multivariate analysis of their cohort, given the limited number of patients.…”