Reply: Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer: Review of the Literature and Evidence-Based Guidelines.

Abstract

Sir: We would like to thank Drs. Eid and Ver Halen for their astute commentary on our recent article, “Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer: Review of the Literature and Evidence-Based Guidelines.” Several salient points were highlighted regarding emerging paradigms in microsurgical perioperative care. Specifically, the authors requested our commentary on the effect (or lack thereof) of specific anticoagulation regimens, operative time, radiotherapy, and food products on postoperative outcomes in free flap surgery. Drs. Eid and Ver Halen cited a number of recent studies that noted no difference in postoperative outcomes in patients that received either aspirin or heparin. The study by Enajat et al. identified no significant difference between patients that received low-molecular-weight heparin either alone or in combination with aspirin daily, although there was a higher rate of hematoma formation requiring reoperation in the combination low-molecular-weight heparin and aspirin group.1 Lighthall et al. compared aspirin daily, subcutaneous heparin or low-molecular-weight heparin, heparin drip, aspirin and heparin or low-molecular-weight heparin, and no anticoagulation.2 The authors here noted that there was a higher rate of total complications in all groups compared with no anticoagulation, although there was no increase in bleeding complications in those who received aspirin alone, or in combination with heparin. As a retrospective, uncontrolled case series, this study is of a much lower quality than the studies on which our recommendations were based. Ashjian et al. demonstrated equivalent outcomes in patients receiving either aspirin or low-molecular-weight heparin.3 In our article, we noted that a review of the available literature suggests that there appears to be no difference between these agents when used as a single agent for postoperative anticoagulation for flap management. The overwhelming majority of patients undergoing free flap reconstruction meet criteria for unfractionated subcutaneous heparin or low-molecular-weight heparin thromboprophylaxis according to guidelines by the American Society of Plastic Surgeons and the American College of Chest Physicians,4,5 and this is also sufficient, according to the available data, for postoperative free flap anticoagulation. We do agree with the statement that the addition of aspirin to low-molecular-weight heparin or heparin is likely an unnecessary practice. This has shown no benefit to patients and may in fact predispose them to complications. At our institution, patients receive either unfractionated subcutaneous heparin or low-molecular-weight heparin for thromboprophylaxis, depending on the clinical scenario. In their correspondence, Drs. Eid and Ver Halen also highlighted the importance of operative time in flap outcomes. The analysis by Wong et al. of data from the American College of Surgeons National Surgical Quality Improvement Program database demonstrated that prolonged operative time was associated with flap failure, such that the risk for flap failure was more than doubled in patients whose operative time was in the top quartile (>625.5 minutes).6 Similarly, Kim et al.7 and others8,9 have noted that prolonged operative time was a significant risk factor for postoperative complications. On the basis of findings such as these, we feel that it is essential that every effort be made to complete free flap procedures efficiently. We have a relatively unique perspective at Albany Medical Center with regard to operative time. In 2011, with a nascent microsurgical program, the attending surgeons had limited experience. The operating room staff, anesthesia, postoperative care, and infrastructure all needed to be developed from the ground up. Within 3 years, our program has grown to perform over 150 free flaps per year and have dedicated operating room staff, anesthesiologists, a postoperative unit, and an infrastructure conducive to efficiency. With this model, and the increased experience of the surgeons performing these procedures, we have seen improved efficiency and decreased operative times, which has led to fewer complications and improved outcomes for our patients. The timing of surgery also becomes important with regard to preoperative radiation therapy. Halle et al. studied three groups of patients undergoing head and neck free flap reconstruction—patients operated on within 4 weeks, 4 to 6 weeks, and more than 6 weeks after radiotherapy—and noted an increased risk for partial and complete flap failure, infections, and delayed wound healing when free flap reconstruction was performed more than 6 weeks after the patient’s last radiotherapy session.10 Schultze-Mosgau et al. examined head and neck reconstruction patients operated on a mean of 1.3 months after radiotherapy and patients operated on a mean of 71.8 months after radiotherapy. They demonstrated that vascularization of the irradiated site was diminished in the patients operated on 71.8 months after radiotherapy.11 They postulated that this may be because of microvascular occlusion and fibrous transformation. Although these studies suggest that the insult of radiation is potentiated over an increased period following radiotherapy, they examined only a limited number of time points. Thus, it is difficult to specify a specific time point following radiation therapy before which microsurgical reconstruction should occur. At the senior authors’ (A.P., R.L.A.) institution, head and neck cancer reconstruction is rarely delayed following radiation therapy. Breast reconstruction, in contrast, is delayed for 6 months after the conclusion of radiation therapy. This practice is not related to the flap survival rate. Rather, this delay allows for the changes seen in acute radiodermatitis to resolve, resulting in decreased edema and improved pliability of the irradiated breast skin. The senior authors feel that this allows for improved aesthetic outcomes in delayed breast reconstruction. Finally, Drs. Eid and Ver Halen requested our opinion on the restriction of certain food products and herbal supplements following flap reconstruction. Although certain food products and over-the-counter supplements may indeed have an impact on patient outcomes, there are no definitive data that suggest that coffee, tea, and chocolate may compromise patient outcomes. Until such data emerge, these beliefs are little more than superstitions, as Drs. Eid and Ver Halen described them, and represent the oftentimes dogmatic beliefs that can guide practices. We appreciate the authors’ commentary on our article. Much work remains to be performed to elucidate best practices in perioperative management for microsurgical patients. It is our hope that this dialogue continues, by means of various media, to facilitate the advancement of patient care and outcomes following microsurgical reconstruction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Ashit Patel, M.B.Ch.B. Department of Surgery Division of Plastic Surgery Albany Medical Center Albany, N.Y. Saba Motakef, M.D. Department of Plastic Surgery Loma Linda University Medical Center Loma Linda, Calif. Richard L. Agag, M.D. Department of Surgery Division of Plastic Surgery Albany Medical Center Albany, N.Y.