Late spontaneous head and neck free flap failure: a case report

Perforator flaps should no longer be considered an exotic or complicated option for microsurgical tissue transfer. However, despite a proper design and attention to detail, as with any free flap, failure can be anticipated sometimes to occur. If a free flap is then still indicated, the big question is what to do next? In our series of 314 perforator free flaps over the past decade, 21 (7%) total failures occurred. A second free flap was attempted for 17 (81%) of these cases. Overall these were successful for 16 (94%) patients, including 11 perforator free flaps that were 100% successful. The anterolateral thigh (ALT) free flap proved to be the "workhorse" alternative. It can be concluded that if failure of a free flap can best be rectified by a second free flap, failure of a perforator free flap can also be reliably salvaged by a second perforator free flap.

The aim of the study is to assess the possible predictors of microvascular free flap failure and determine the critical postoperative timing of flap failure, thereby minimizing this adverse outcome. This is a retrospective single-institutional review of 1569 free flap operations. All free flaps with outcome status recorded were analyzed for possible predictors in the development of microvascular compromise. Compromised cases were then analyzed for differences in time to compromise and time to theater takeback between salvaged versus failed free flaps. Of the assessable 1569 free flaps, 31 developed microvascular compromise (2.0%); the salvage rate was 20.0%, and overall failure rate was 1.5%. Osteocutaneous free flaps in head and neck had increased risk of developing free flap failure compared to other flaps (odds ratio = 3.8, 95% confidence interval: 1.2-12.7). Among breast patients, previous radiotherapy had a significant association with flap failure ( P < 0.001). Free flap salvage rates dropped from 38.5% to 7.7% for compromises detected after 24 hours ( P = 0.160), and from 57.1% to 11.1% for free flaps taken back to theater greater than 3 hours after compromise detection ( P = 0.032). Delays in compromise detection and flap takeback to theater resulted in reduced salvage rates, with the critical timing of takeback being under 3 hours. Standardized flap monitoring protocols and incorporation of newer technologies could see faster detection and improved salvage rates. Additional care is required when reconstructing: osteocutaneous head and neck free flaps and previously irradiated breast patients.

Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: a systematic review and meta-analysis

Background:Severe acute burn injuries represent a challenge to the reconstructive surgeon. Free flap reconstruction might be required in cases of significant critical structure exposure and soft tissue deficits, when local options are unavailable. This study aimed to determine the free flap complication rate in acute burn patients.Methods:A systematic review and meta-analysis were conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and registered on the International Prospective Register of Systematic Reviews database (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was the free flap failure rate.Results:The study identified 31 articles for inclusion. A total of 427 patients (83.3% men, 16.7% women) accounting for 454 free flaps were included. The mean patient age was 36.21 [95% confidence interval (CI), 31.25–41.16]. Total free flap loss rate was 9.91% [95% CI, 7.48%–13.02%], and partial flap loss was 4.76% [95% CI, 2.66%–8.39%]. The rate of venous thrombosis was 6.41% [95% CI, 3.90%–10.36%] and arterial thrombosis was 5.08% [95% CI, 3.09%–8.26%]. Acute return to the operating room occurred in 20.63% [16.33%–25.71%] of cases. Stratified by body region, free flaps in the lower extremity had a failure rate of 8.33% [95% CI, 4.39%–15.24%], whereas in the upper extremity, the failure rate was 6.74% [95% CI, 3.95%–11.25%].Conclusion:This study highlights the high risk of free flap complications and failure in acute burn patients.

Objective: To report a case of late-onset anterolateral thigh free flap failure in reconstruction of a defect from excision of buccal carcinoma.&#x0D; Methods:&#x0D; Design: Case Report&#x0D; Setting: Tertiary Government Hospital&#x0D; Participant: One&#x0D; Results: Complete flap failure of the anterolateral thigh free flap used for reconstructing the defect from a buccal cancer excision was documented on the 29th post-operative day.&#x0D; Conclusion: Late-onset flap failure is mainly non-vascular in etiology. However, flap failure is more likely multifactorial. Frequent follow-up after hospital discharge is recommended to monitor flap viability.&#x0D; Keywords: free flap, anterolateral thigh flap, flap failure, microvascular surgery, head and neck reconstruction

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. 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. 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%). 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.

Staphylococcal scalded skin syndrome (SSSS) is a clinical term used for a spectrum of blistering skin conditions induced by the epidermolytic toxins of the Staphylococcus aureus bacteria. The complications of SSSS include thrombosis; however, the pathophysiology of this is still poorly understood. We present a case of free anterolateral thigh (ALT) flap failure in a patient as a result of widespread flap thrombosis associated with staphylococcalscalded skin syndrome (SSSS). This is the first reported case of free flap failure associated with SSSS.Free flap failure due to acquired prothrombotic conditions, such as infection, is a rare and potentially under-reported phenomenon. This article aims to further explore the role of both thrombophilias and provoked thrombotic events in free flap failure. A review of the literature will also be presented, and cases of free flap failure in patients with infection-induced vascular complications will be summarised.

Failure of a microvascular free flap remains rare, yet multiple failures can occur, particularly in the presence of hypercoagulable conditions. This case series highlights our experience with a rare hypercoagulable state: hyperhomocysteinemia. We present two cases of patients with hyperhomocysteinemia in this report. High-dose heparinization was administered to both patients, resulting in successful salvage of one flap and failure of the other. Notably, one patient had a history of prior free flap failures. However, after correcting hyperhomocysteinemia, subsequent free flaps were successful. In cases of detected complications, a coagulability study is warranted, and adjustments to anticoagulation treatment may be necessary. Furthermore, when a history of flap failures is evident, screening for hyperhomocysteinemia may be warranted, with correction made prior to reconstruction.

Over the past two decades, microvascular free tissue transfer has become a common procedure, usually with predictable results. The overall success rate of free flap surgery has gradually improved, and most recent reviews document an overall success rate between 90% and 95%. The goal of this study was to determine the outcome of those patients who underwent unsuccessful free microvascular tissue transfer. An extensive chart review was carried out on all those patients who underwent free microvascular tissue transfer at the Queen Elizabeth II Health Sciences Centre from 1988 to 1999. One hundred and forty-eight patients underwent free tissue transfer. A total of 164 free flaps were carried out, with an overall success rate of 92%. Free flap failure was defined as complete necrosis of the flap. There were 13 documented flap failures with complete necrosis of the flap requiring debridement. Seven patients underwent repeat free microvascular tissue transfer. These procedures were carried out by the same surgeon or surgical team 12 to 52 days after the first surgery. These secondary microvascular procedures were all successful. Of the remaining patients, five had either debridement and split-thickness skin grafting or regional flap coverage. One patient went on to lower limb amputation. This study reaffirms the success rates of free microvascular tissue transfer. In addition, the success rates of repeat free flaps were evaluated. It appears that patients undergoing repeat microvascular tissue transfers have no innate propensity for flap failure.

INTRODUCTION: The use of microvascular free tissue transfer has steadily increased over the years, due to the ability to reconstruct complex defects.1–4 Fortunately, failure rates have decreased over the past few years, with improvements in surgical technique combined with better pre- and post-operative assessments, including patient selection.5–7 The viability of free flaps depends upon various patient-based factors. The objective of this study was to further identify risk factors that are associated with increased incidence of flap failure, especially with regards to specific types of free flaps based on anatomic location. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (ACS-NSQIP) was queried for all patients who underwent microvascular free tissue transfer from 2005 through 2012. Patients were identified based upon the following CPT codes: 15756, 15757, 15758, and 19364. Univariate analysis was performed to identify the association between free flap failure and the following factors: age, gender, race, body mass index (BMI), diabetes, smoking, alcohol, hypertension, intraoperative transfusion, functional health status, American Society of Anesthesiologists classification, operative time, and flap location. Factors yielding a significance of p <0.20 were included in multivariate logistic regression models in order to identify independent risk factor significance for flap failure. Furthermore, cases were stratified based upon recipient site (Breast, Head and Neck, Trunk, or Extremity), and analysis was repeated in order to identify risk factors specific to each location. RESULTS: 1921 of 2103 patients who underwent microvascular free flap reconstruction met inclusion criteria (Table 1). Multivariate logistic regression identified BMI (AOR = 1.07, p=0.004) and male gender (AOR = 2.16, p=0.033) as independent risk factors for flap failure. Among the “Breast Flaps” subgroup, BMI (AOR=1.075, p=0.012) and smoking (AOR=3.35, p=0.02) were independent variables associated with flap failure. In “Head and Neck Flaps,” operative time (AOR = 1.003, p=0.018) was an independent risk factor for flap failure. No independent risk factors were identified for the “Extremity Flaps” or “Trunk Flaps” subtypes (Table 2).Table 1: Frequency of Microvascular Free Flaps Among Each Flap Category.Table 2: Multivariate Analysis Indicated Adjusted Odds Ratios for Flap Failure.CONCLUSION: BMI was identified as an independent risk factor for flap failure among all microvascular free flaps and within the “Breast Flaps” subcategory. Smoking additionally was identified as an independent risk factor within “Breast Flaps.” Finally, increased operative time was a risk factor for flap failure among “Head and Neck Flaps.”

Radiotherapy as a risk factor for free flap failure has been widely debated. The purpose of this study was to investigate vascular complications in free flap surgery at a center advocating preoperative radiotherapy. On the basis of previous experimental studies, we also aimed to investigate temporal aspects of vascular complications in both arteries and veins. Furthermore, we aimed to study the effect of tissue plasminogen activator (tPA), because irradiated microvascular recipient vessels are associated with impaired fibrinolysis.A retrospective review was conducted for 344 consecutive head and neck microvascular reconstructions. Radiotherapy was administered previously in 283 (82%) of the cases, median dose 64 Gy. Flap outcome, vascular complications, and salvage attempts were identified, along with time elapsed from completed radiotherapy, described as early (<6 weeks), delayed (6-15 weeks) and late (>15 weeks) reconstructions.Total flap loss was more common in irradiated cases (P = 0.035), among which flap failure increased with time elapsed from the last radiotherapy session to surgery (P = 0.021). Among 30 registered vascular complications, venous thrombosis was the most common type and increased in delayed, compared to early, reconstructions (P = 0.012). Increased salvage rates were observed when tPA was administered intraoperatively (P = 0.015).The present study indicates that previous radiotherapy is a risk factor for head and neck free flap failure, especially in delayed reconstructions. This may be linked to previous findings of impaired fibrinolysis in irradiated microvascular recipient veins, which is further supported by the beneficial effect of tPA during salvage surgery. We emphasize the importance of early reconstruction after radiotherapy and suggest that there is a role for fibrinolytic agents during free flap salvage surgery in previously irradiated subjects.

A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement’s, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.

Sir: We appreciate the letter by Dr. Al-Benna regarding our article, “Failure of Free Flaps in Head and Neck Oncology Surgery in COVID-19 Patients.”1 The author states that preexisting endothelial dysfunction can explain the failure of free flaps in head and neck oncology patients. There is absolutely no doubt that endothelial dysfunction by itself can result in flap failure, but the aim of this article1 was to identify the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) as an independent risk factor for free flap failure. At the time it was written (accepted in April of 2020 and published in August of 2020), no data existed in the literature. It therefore seemed necessary to share our experience with the international community of reconstructive surgeons. Between 150 and 200 free flaps per year are performed at our center (Gustave Roussy Cancer Campus, Villejuif, France) for head and neck oncology. It is considered a tertiary referral care center in France and in Europe. During the endemic period, we received many referrals, as in some areas, where the number of cases was elevated, many centers had to stop or suspend this type of surgery.2 Our free flap activity did not stop during this period. Risk factors for free flap failure, such as obesity, hypertension, diabetes, cardiovascular disease, advancing age, and other factors, are well known and are considered in the interpretation of our failures. The case presented in our article was of a patient who did not have any risk factor except for the cancer. In contrast, we subsequently had a similar case with concomitant SARS-CoV2 and failure of free flap without other risk factors. In the meantime, numerous articles detailing the thromboembolic mechanisms of SARS-CoV2 have emerged, and anticoagulation has been widely proposed. In keeping with the recent literature, we consider there to be a high risk of thromboembolism complications when the following laboratory values are present: D-dimer greater than 3 μg/ml; fibrinogen greater than 8 g/liter; body mass index greater than 30 kg/m2; oxygen therapy greater than 5 liters/minute, and active cancer less than 6 months. We propose a heparin treatment dosage that takes into account these factors. The goal of our article is to inform our community of coronavirus disease of 2019 as a potential independent risk factor for free flap failure. In particular, if a patient had a positive polymerase chain reaction SARS-CoV2 test and the operation cannot be delayed for oncologic reasons, curative heparin therapy can be administered or nonmicrosurgical reconstruction (pedicled flaps) can be considered in this case. DISCLOSURE The authors have no conflict of interest with regard to this communication. No funding was received for this work. Nadia Benmoussa, M.D., Ph.D.Department of Head and Neck Oncology Heba Alkhashnam, M.D.Department of Plastic SurgeryGustave RoussyParis-Saclay UniversityVillejuif, France

Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction. Retrospective multi-institutional review of prospectively collected databases at tertiary care centers. Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history. Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002). This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures. 4 Laryngoscope, 130:347-353, 2020.

Hemoglobinopathies such as sickle cell disease (SCD) are traditionally considered a relative contraindication to free tissue transfer, due to concerns that erythrocyte sickling will increase the risk of microvascular thrombosis and flap failure. This article describes a case report with the successful use of free tissue transfer in a patient with SCD and provides a systematic literature review on free tissue transfer in SCD. A retrospective chart review was performed of a patient with SCD who underwent free tissue transfer at the authors' institution. A systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed using the keywords "free tissue transfer," "free flap," or "microsurgery" and "sickle cell" on PubMed, Ovid/Medline, and Scopus. A 29-year-old male with delayed presentation of an electrical burn to the face and scalp underwent wound closure with a free anterolateral thigh flap. Key management principles included red blood cell transfusion to keep hemoglobin S under 30% and hemoglobin greater than 10 g/dL, maintenance of hydration, normothermia, adequate analgesia, and postoperative anticoagulation. Systematic literature review identified 7 articles describing 13 cases of free tissue transfer in 10 patients with SCD, with combined complete free flap success in 10 of the 13 flaps. Free tissue transfer can be successfully performed in patients with SCD. However, evidence on the optimal management of this unique patient population in the perioperative period after free tissue transfer is limited to case reports in the literature.