Free Tissue Transfer In Patients Research Articles

Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction.

Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO. Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status. A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups. This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.

Free Tissue Transfer to the Lower Extremity in the Setting of Thrombocytosis and the Role of Antiplatelet Therapy: A Propensity Score-Matched Analysis.

Free tissue transfer (FTT) provides a versatile method to achieve successful lower limb salvage. Thrombocytosis in patients undergoing lower extremity (LE) FTT is associated with increased risk of complications. The aims of this study were to assess the feasibility of performing LE FTT in patients with preoperative thrombocytosis, and whether antiplatelet (AP) therapy on the day of surgery (DOS) affects outcomes. A retrospective review of thrombocytotic patients who underwent LE FTT between 2011 and 2022 was performed. Patients were stratified into groups based on the receipt of AP therapy on the DOS. Patients were propensity score matched for comorbidity burden and postoperative risk stratification. Outcomes of interest included perioperative transfusion requirements, postoperative flap-related complications, rates of flap success, limb salvage, and ambulatory status. Of the 279 patients who underwent LE FTT, 65 (23.3%) were found to have preoperative thrombocytosis. Fifty-three patients remained following propensity score matching; of which, 32 (60.4%) received AP therapy on the DOS and 21 (39.6%) did not. Overall flap success rate was 96.2% (n = 51). The likelihoods of thrombosis and hematoma development were similar between cohorts (p = 0.949 and 0.574, respectively). Receipt of DOS AP therapy was associated an additional 2.77 units and 990.10 mL of transfused blood (p = 0.020 and 0.018, respectively). At a mean follow-up of 20.7 months, overall limb salvage and ambulatory rates were 81.1% (n = 43) and 79.2% (n = 42), respectively, with no differences between cohorts. Preoperative thrombocytosis is not an absolute contraindication to LE FTT. DOS AP therapy may be protective in comorbid patients with elevated platelet counts but must be weighed against possible short-term bleeding as suggested by significant increases in postoperative transfusion requirements.

PC62. Impact of Area Deprivation Index and Distance from Hospital on Outcomes in Free Tissue Transfer Patients

PC62. Impact of Area Deprivation Index and Distance from Hospital on Outcomes in Free Tissue Transfer Patients

Free Tissue Transfer in Patients with Hematologic Malignancies: A Case Series

Introduction: Free tissue transfer performed in patients with hematologic malignancies has several considerable challenges. Studies that report the challenges and outcomes related to these patients have been rather limited. This study presents the outcome of free tissue transfer as the reconstructive option for patients with hematologic malignancies. This study reports our experience regarding the perioperative evaluation, management, and outcomes of five patients with hematological malignancies that underwent free tissue transfer at Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia. Case Presentation: Five patients with hematologic malignancies, aged 26 to 60 years, who underwent free tissue transfer at Dharmais Cancer Hospital-National Cancer Center, Jakarta, Indonesia from January 2017 to February 2020 were included. The outcomes such as flap survival, complications, and mortality were reviewed. There were three patients with NonHodgkin lymphoma (NHL), one patient with peripheral T-cell lymphoma, and one patient with acute myeloid leukemia (AML). All patients received free tissue transfer with flap modalities such as radial free forearm flap and anterolateral thigh. One patient had a postoperative complication of vein compromise and was treated with negative pressure wound therapy (NPWT), which resulted in partial flap necrosis. Dehiscence was also found in one patient, and the patient underwent reoperation. Then, a myocutaneous trapezius flap was applied. There was no total flap loss, no donor site morbidity, and no mortality. Conclusions: This study has shown that free tissue transfer was a reliable reconstructive option for patients with hematologic malignancies. Flap survival and minimal complications can be achieved by optimizing the patient’s condition preoperatively, performing the meticulous nontraumatic surgical technique, closely monitoring potential post-operative complications, and implementing a multidisciplinary approach with the hematooncologists.

Intensive care unit versus floor admission following lower extremity free flap surgery: Is there a difference in outcomes?

Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted toward admitting FTT patients to the floor postoperatively instead of the ICU. The purpose of this study is to compare surgical outcomes in patients admitted to the floor versus ICU immediately following LE free flap reconstruction. We retrospectively reviewed patients undergoing LE FTT reconstruction from 2011 to 2021. Flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or floor postoperatively. To ensure proper comparability between cohorts, we corrected for age, BMI and Charlson Comorbidity Index (CCI) using 1:2 propensity score matching (floor: ICU). Primary outcomes included early postoperative complications, flap takeback and salvage, flap success, and postoperative length of stay (LOS). A total of 252 patients were identified. Forty-five patients (17.9%) were admitted to the floor postoperatively and 207 patients (82.1%) to the ICU. Overall, microsurgical success rate was 97.2%, which was similar for floor and ICU patients. Flap takeback and salvage were similar between cohorts. Average postoperative LOS was significantly shorter in floor patients (15.7 vs. 19.1 days, p= 0.043). Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. In the ongoing era of health care cost containment, microsurgery centers should consider appropriate floor training to allow medically stable free flap patients to avoid an ICU stay.

QS27. Surgical Outcomes of Postoperative Intensive Care Unit Versus General Floor Management Following Lower Extremity Free Flap Reconstruction in the Comorbid Chronic Wound Population

Purpose: Free tissue transfer (FTT) lower limb salvage requires costly multidisciplinary care. Traditionally, patients who undergo FTT reconstruction for lower extremity (LE) wounds were admitted to the intensive care unit (ICU) in the immediate postoperative period for close monitoring. During the COVID-19 pandemic, our practice shifted towards admitting FTT patients to the general floor postoperatively instead of the ICU. This is the first study to compare surgical outcomes in patients admitted to the floor versus ICU immediately following free flap reconstruction for chronic LE wounds. Methods: A retrospective review was performed of patients undergoing FTT to LE from 2011 to 2021 by the senior author (K.K.E.). In March 2020, our institution began admitting our free flap patients to the general floor post-operatively. In patients admitted to the floor postoperatively, flap monitoring consisted of an implantable Cook-Swartz Doppler probe for muscle flaps and ViOptix tissue oximetry for fasciocutaneous flaps; clinical exam and hand-held dopplers were not the primary flap monitoring techniques. Patients were divided into two groups depending on whether they went to the ICU or specialty floor in the immediate postoperative period. Primary outcomes were postoperative complications, hospital length of stay (LOS), flap takeback and salvage, and flap success. Statistical significance was set at values of p < 0.05. Results: A total of 255 patients underwent FTT to LE during the 10-year period. Forty-two patients (16.5%) were admitted to the floor postoperatively and 213 patients (83.5%) went to the ICU. Average age and body mass index were 55.8 years and 29.4 kg/m2, respectively. Comorbidities among the two groups were similar, except floor patients had a higher prevalence of diabetes (69.0% vs. 49.3%, p=0.019). Overall microsurgical success rate was 97.3%, which was similar for floor and ICU patients (100% vs. 96.7%, p=0.604). Flap takeback occurred in 3 floor patients (1.2%) and 13 ICU patients (5.1%) (p=0.733). Flap salvage was higher in floor patients, although not statistically significant (7.1% vs. 3.3%, p=0.250). Average hospital LOS did not significantly differ among patients admitted to the floor versus ICU (16.1 vs. 17.7 days, p=0.628). Conclusion: Our findings suggest that postoperative floor admission does not decrease flap success rates and should be considered in patients who undergo FTT to LE reconstruction and are otherwise stable. Efforts should be focused on training floor nurses to use the Cook Doppler and ViOptix devices to monitor flaps. While we expect hospital costs to decrease with floor admission, future studies should focus on the cost impact of postoperative floor management in this patient population.

Endovascular Interventions and Flap Outcomes in Peripheral Arterial Disease Patients Undergoing Fasciocutaneous Versus Muscle Free Tissue Transfer in Lower Extremity Reconstruction

Endovascular Interventions and Flap Outcomes in Peripheral Arterial Disease Patients Undergoing Fasciocutaneous Versus Muscle Free Tissue Transfer in Lower Extremity Reconstruction

724 Role of synthetic dermal matrix for reconstruction of complex non-graftable wound defects

IntroductionThe aim of this study was to investigate the role of a synthetic dermal matrix, Biodegradable Temporising Matrix (BTM), for coverage of complex wounds. The authors defined complex wounds as wounds not amenable to reconstruction with skin grafting alone due to an inherent avascularity of the wound bed, such as the presence of exposed bone, tendinous or neural structures.MethodsA retrospective review of a prospectively maintained database of complex wounds as defined above was carried out. Clinical and operative notes were reviewed along with review of an extensive photographic database demonstrating wound healing progress using staged dermal matrix (BTM) and autologous skin graft reconstruction.Results55 patients were identified who underwent staged dermal matrix and autologous skin graft reconstruction for complex wounds affecting a wide variety of patient demographics, treatment indications and body sites. Wound aetiology varied between burn injury, non-burn related trauma including degloving injury and infective complications. We discuss caveats relating to successful application of a dermal matrix, technique tips, prevention and management of complications.Dermal substitutes play an integral role in providing biological wound cover for avascular wound beds which may otherwise require complex distant flap or microsurgical free flap reconstruction. BTM is a completely synthetic dermal matrix comprised of a 2-mm-thick sheet of biodegradable polyurethane foam bonded to a non-biodegradable polyurethane sealing membrane. Our department has developed significant expertise in the use of BTM throughout its development from initial animal studies through to recent human clinical trials. The synthetic composition of BTM does not require rapid neo-vascularisation for its integrity or survival. As such, two-stage BTM reconstruction has proven robustness in the face of unfavourable wounds compared with other popular dermal matrices, physiologically covering avascular structures, allowing for early graft take, expediting rehabilitation and mobilisation with excellent scar cosmesis and limited contracture formation.ConclusionsDermal matrices such as BTM play an important role in complex wound healing, frequently achieving excellent results with a low complication profile. BTM has been used successfully in cases where biological matrices would not routinely be considered as demonstrated by this clinical series. It has provided a valuable alternative to free-tissue transfer in patients with significant co-morbidities, vascular insufficiency and/or those for whom long operations are undesirable.

Association between hypertension requiring medication and 30-day outcomes in head and neck microvascular surgery.

Hypertension has been shown to be both a protective factor and a risk factor for complications in head and neck reconstructive surgery. Retrospective analysis of microvascular free tissue transfer patients using the National Surgical Quality Improvement Program database. Hypertensive patients (n=1598; 46.9%) had a significantly higher rate of complications, including pneumonia (p < 0.001), myocardial infarction (p=0.003), and intra/post-operative transfusion (p < 0.001). In a multivariable model, hypertension was associated with returning to the operating room (OR=1.45 [95% CI 1.20, 1.76], p < 0.001), post-operative medical complications (OR=1.53 [95% CI 1.24, 1.90], p < 0.001), and surgical complications (OR=1.17 [95% CI 1.00, 1.37], p=0.047). However, no difference in 30-day readmission was found (p > 0.05). Hypertension is a modifiable risk factor for post-operative complications in head and neck free tissue transfer, in which prospective studies are required to establish causation. This study may serve as an impetus for proactive recommendations to manage hypertension before undergoing head and neck microvascular surgery.

Microsurgical Head and Neck Reconstruction in Patients With Fanconi Anemia.

Patients with Fanconi anemia (FA) are at increased risk for head and neck cancers that often necessitate extensive reconstructions. Such patients have multiple comorbidities including anemia and thrombocytopenia frequently requiring bone marrow transplant, and they are at an increased risk of cancer recurrence and need for further extirpation. in the present study, charts from 3 patients with FA who underwent microvascular free tissue transfer by the senior author were retrospectively reviewed for pertinent pre- and peri-operative details in addition to functional and cosmetic outcomes. Two of these patients ultimately required metachronous free flap reconstructions for recurrence. All patients had acceptable functional and cosmetic outcomes following each instance of free flap reconstruction, thereby demonstrating the utility of microvas- cular free tissue transfer in patients with FA. The authors herein present each patient's clinical history in addition to a discussion of the current literature and an outline of our approach to these challenging cases.

Nutritional markers for predicting lower extremity free tissue transfer outcomes in the chronic wound population.

Optimizing nutritional status is critical to maximize flap success and healing. Prealbumin and albumin have been utilized as easily obtained proxies for overall nutritional status. The aim of this study was to investigate whether these markers are correlated with healing time and overall flap healing after lower extremity (LE) free tissue transfer (FTT) in the chronic wound population. A retrospective review of LE chronic wound FTT patients treated by a single surgeon at our institution from 2011 to 2020 was performed. Data collected included demographics, comorbidities, flap characteristics, and perioperative labs. The outcomes of interest were flap healing (FH) and time to flap healing (TFH). We identified 69 patients undergoing LE FTT for limb salvage meeting our inclusion criteria. When using a threshold of <3.5g/dl for low albumin and < 20 mg/dl for low prealbumin, no significance was found between FH or TFH and preoperative albumin or preoperative prealbumin. With low albumin defined as <2.7g/dl with the prealbumin threshold unchanged, TFH was significantly increased, and FH was significantly decreased compared with the defined normal preoperative albumin group. Low preoperative albumin, when defined as <3.5g/dl, and prealbumin did not correlate with TFH or FH. Contrarily, when defined as <2.7g/dl, low preoperative albumin correlated significantly with increased TFH and decreased FH rates. Further investigation into validated biomarkers and their thresholds is needed to assess the effect of nutritional status on wound healing and guide perioperative optimization.

The Utility of Dermal Wound Matrices Compared With Local-Tissue Rearrangement and Free-Tissue Transfer for Scalp Wounds: A Multidisciplinary Dual Matched-Pair Analysis

BACKGROUND: Scalp reconstruction can pose significant challenges due to a lack of native tissue mobility and/or tissue damage secondary to radiation. Local tissue rearrangement (LTR), free-tissue transfer (FTT), and Bilayer Wound Matrix (BWM) (Integra; Integra LifeSciences, Princeton, NJ) are frequently employed for wound coverage of the scalp. We present the first comparative study to evaluate the optimal treatment modality. METHODS: A retrospective chart review was conducted from January 2008 to June 2019 encompassing all patients requiring soft-tissue reconstruction (BWM, LTR, and FTT) to scalp wounds. Patients were matched into each group based upon patient age, wound defect size, and wound age. Patient demographics, comorbidities, wound characteristics, and postoperative healing outcomes were all recorded. Outcomes including 90-day exposure rates, reoperative rates, hospital length of stay, operative times, and wound complications were examined and compared between the modalities. RESULTS: A total of 361 patients undergoing scalp soft-tissue reconstruction with either FTT, LTR, or BWM were identified. Following patient matching, 126 patients were deemed appropriate for inclusion in the LTR/BWM cohort, whereas 56 were examined in the FTT/BWM groups. The mean defect size of the LTR/BWM group was 45 cm2. LTR provided significantly better wound coverage at 90 days (95.2%), compared with BWM (84.1%) (P = 0.040), although reoperative rates (7.9% versus 15.9%) did not differ significantly (P = 0.271). The total mean defect size in the FTT/BWM groups was 129.1 cm2. Wound coverage success rates at 90 days were similar for the FTT group (92.9%) compared with the BWM group (96.4%) (P = 1.00). Reoperative rates (14.3% FTT, 3.6% BWM) were also not significantly different (P = 0.352). However, operative time for FTT patients was significantly greater (389.9 minutes) compared with BWM patients (87.2 minutes) (P < 0.001), as well as mean hospital length of stay (5.5 versus 1.2 days, respectively, P < 0.001). CONCLUSIONS: LTR is a more durable option for moderately size wounds when compared with BWM. BWM may be as efficacious as FTT for wound coverage of uncomplicated larger defects and may be more cost-efficient, given the obvious greater technical difficulty, operative time, and length of stay associated with FTT.

Pilot of the Patient Concerns Inventory – Ward Discharge in Patients following major reconstructive surgery for head and neck cancer

Planning discharge from hospital following microvascular free-tissue surgery can be complex and challenging. Planning involves the patient, carers, and multiple health professionals. Poor communication and expectations can delay discharge or give a suboptimal discharge process. It was hypothesised that prompt-list modelled along the principals of the Patient Concerns Inventory (PCI) could be help in discharge planning. The aim of this study was to define the items and format of a PCI-Ward Discharge (PCI-WD) and undertake a small pilot. Items appropriate for the PCI-WD were formulated through discussion with patients, carers, ward staff, Head and Neck Clinical Nurse Specialists, and clinicians. The pilot took place over three months from December 2019 through to February 2020. Audit approval was given by the hospital Audit Department. The PCI-WD comprises 43 items. Items from existing PCIs for use at diagnosis and follow-up consultations were reduced in number and 38 new or modified items added; six treatment related, five social care and social well-being, four psychological, emotional, and spiritual well-being, seven physical and functional well-being, and 16 discharge related. The pilot involved 14 free-tissue transfer patients, seven male, seven female, with an age range of 57 to 87 and a mean age of 72. Eight PCI-WD were returned. PCI-WD items identified most frequently were ‘surgery site other than head/neck’, ‘when do I come back to hospital’, ‘dental check-up/oral health care’ and ‘diet/eating’. Early findings suggest that PCI-WD could be a useful tool in aiding the discharge process. Further evaluation is required.

Free Tissue Transfer Using End-to-side Arterial Anastomosis for Limb Salvage in Patients With Lower Extremity Arterial Disease

Free tissue transfer (FTT) is an invaluable component of functional limb salvage in patients with large lower extremity wounds for whom limb amputation is the only alternative. The traditional FTT technique involves a donor vessel anastomosed in an end-to-end fashion to the recipient vessel. End-to-side anastomosis has rarely been utilized due to perceived technical difficulty with vessel size mismatch. In patients with single vessel runoff, an end-to-end anastomosis is contraindicated. Given our focus on limb salvage in patients with LEAD, we have almost exclusively utilized the end-to-side arterial anastomosis, and herein present our experience. A retrospective review of all patients undergoing FTT at a single institution from 2012 to 2020 was performed. All patients underwent preoperative arteriogram, and LEAD was defined as abnormal tibial runoff of any degree. All patients with evidence of LEAD were included for this analysis. Our operative approach has been previously described and involves a longitudinal arteriotomy in the inflow vessel. The flap donor artery is then sutured from heel to toe in an interrupted fashion under microscopic visualization. There were 141 free flaps performed during this period using an end-to-side anastomosis; 67 patients had evidence of LEAD by arteriography. Average age was 59 years (range, 19-87 years); 54% had diabetes; 18% had one vessel runoff to the foot; 58% had two vessel runoff to the foot; and 19% required preoperative endovascular intervention. Technical success of FTT was achieved in 97% of patients. At 30 days, the limb salvage rate was 96%. No patients died in the perioperative period. At a mean follow-up of 1.1 years, the overall limb salvage rate was 79%. Free flap survival rate was 92%. 83% of patients were ambulatory independently or with an assistive device on most recent follow-up. FTT in patients with LEAD and large wounds is a reasonable approach to limb salvage. End-to-side anastomosis is a feasible technique that allows free flap survival with preservation of distal flow.

Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population.

Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. Therapeutic, IV.

The impact of a post-operative clinical care pathway on head and neck microvascular free tissue transfer outcomes.

To study the impact of a clinical care pathway and computerised order set on short-term post-operative outcomes for patients undergoing head and neck free tissue transfer. In this retrospective cohort study, patients who underwent head and neck free tissue transfer by a single reconstructive surgeon between January 2007 and July 2009 were assigned to one of two cohorts based on the timing of their surgery: pre- or post-clinical care pathway implementation. Measured outcomes included peri-operative complications and mortality, length of hospital stay and costs, unplanned reoperations, and readmissions within 30 days of discharge. The pre-clinical care pathway cohort included 81 patients and the post-clinical care pathway cohort comprised 46. Implementation of the clinical care pathway was associated with decreased variability in length of hospital stay (median (interquartile range) = 8 (6, 11) vs 7 (6, 9) days). The post-clinical care pathway cohort also had a significantly lower unplanned reoperation rate (15.2 vs 35.8 per cent, p = 0.01). A clinical care pathway is a successful means of standardising and improving complex patient care. In this study, care pathway implementation in head and neck free tissue transfer patients improved efficiency and the quality of patient care.

Does Anticoagulation Improve Flap Outcomes in Hypercoagulable Patients? A Systematic Review.

Despite improvements in microsurgical techniques, hypercoagulable patients remain a reconstructive challenge. Thrombophilias are a relatively common problem with potentially catastrophic results including free flap loss. The aim of this study was to assess the available literature on free tissue transfer in patients with known hypercoagulability to develop recommendations for management. A systematic review of the PubMed, EBSCO, and Cochrane databases was performed in June 2018. Inclusion criteria were assessment of outcomes of free tissue transfer in patients with established hypercoagulability. Exclusion criteria were review articles, case reports, and studies lacking detailed discussion of anticoagulation regimens and surgical outcomes. Data collected included the number of hypercoagulable patients, anticoagulation regimens, thrombotic complications, flap success, and bleeding complications. Statistical analysis was performed using independent samples t-tests. Of 147 total results, four articles were included for analysis. One relevant article published after search completion was included. In total, 185 free tissue transfers were performed in 155 thrombophilic patients. Anticoagulation regimens varied widely but often included intraoperative continuous heparin, with or without additional bolus, followed by postoperative and outpatient anticoagulation. Hypercoagulable patients often developed late postoperative thromboses. Of the intraoperative thromboses, 36.4% were successfully salvaged. No flaps with postoperative thrombosis were salvaged. Preemptive therapeutic anticoagulation improved outcomes but increased the bleeding risk. Free tissue transfer may be successful in hypercoagulable patients. High-risk patients identified preoperatively should receive therapeutic anticoagulation initiated intraoperatively unless contraindicated. Salvage after postoperative thrombosis is poor. Ultimately, the benefits of free tissue transfer must be considered with the potential morbidity of bleeding complications on a case-by-case basis when developing a reconstructive plan. Initiating anticoagulation based on the presence of intraoperative risk factors may prevent unnecessary intervention.

Mild hypothermia is associated with improved outcomes in patients undergoing microvascular head and neck reconstruction.

Microvascular free tissue transfer has become the standard for reconstruction for large defects. With long operative times and an increased surface area exposed, transient hypothermia is common, but it is unclear how this impacts surgical outcomes. This study evaluated the impact of core body temperature on free tissue flap outcomes in patients undergoing microvascular reconstruction. Retrospective data analysis. Mount Sinai Hospital; NYC, NY; 2007-2016. Demographic information, mean/minimum/maximum body temperatures, and the presence of flap complications (venous thrombosis, arterial insufficiency, flap death, wound infection/dehiscence, fistula, chyle leak, hematoma/seroma) of 519 free tissue transfer patients were documented. Binomial logistic regression was used to examine associations between the presence of flap complications and mean temperature. Statistical analysis used SPSS, with p-values ≤0.05 deemed statistically significant. 393 soft-tissue and 125 osteocutaneous flaps were included. 19.8% (n = 103) patients had the presence of ≥1 flap complication, while 80.2% (n = 416) did not. Average temperature for all patients was 36.12 ± 0.84 °C, with minimum at 34.43 ± 0.97 °C and maximum at 37.24 ± 1.23 °C. After controlling for several factors including: tumor stage, radiation, diabetes, BMI, age, sex, and flap type, there was a significant association between flap complications and mean intraoperative temperature (Exp(B) = 1.559, p = 0.004). Higher intraoperative temperatures were associated with worse outcomes. A mild relative hypothermia may improve flap outcomes in this population. This represents the largest study to date evaluating the impact of intraoperative temperature on free tissue transfer outcomes.

Geometric Three-Dimensional End-to-Side Microvascular Anastomosis: A Simple and Reproducible Technique.

End-to-side (ETS) anastomoses are useful when preservation of distal vascularity is critical. The ideal ETS microanastomosis should maintain a wide aperture and have a smooth take-off point to minimize turbulence, vessel spasm, and thrombogenicity of the suture line. We have developed a unique, dependable, and reproducible geometric technique for ETS anastomoses, and analyze its efficacy in our series of patients. The geometric ETS technique involves creating a three-dimensional (3D) diamond-shaped defect on the recipient vessel wall, followed by a slit incision of the donor vessel to create a "spatula" fitting this defect. This technique removes sutures from the point of most turbulent blood flow while holding the recipient vessel open with a patch vesselplasty effect. We perform a retrospective review of a single surgeon's experience using this technique. The geometric 3D ETS technique was used in 87 free flaps with a total of 102 ETS anastomoses in a wide range of cases including head and neck, trunk and genitourinary, and extremity reconstruction. Overall, free flap success rates were 98%. The geometric 3D ETS technique creates a wide anastomosis, minimizes turbulence-inducing thrombogenicity, and mechanically holds the recipient vessel open. It is reliable and reproducible, and when performed properly has been shown to have high rates of success in a large group of free tissue transfer patients.

Use of Incisional Negative Pressure Wound Therapy in Skin-Containing Free Tissue Transfer.

Negative pressure wound therapy (NPWT) was initially introduced for wound management, but its benefits have stimulated the investigation of its use in new clinical scenarios. Most recently, incisional NPWT has been shown to be a benefit. Incisional NPWT applied to skin-containing free tissue transfer has not been well defined. This may originate from concerns of dressing material obscuring frequent examination of the newly transferred tissue or risk of pedicle compression and potential for increased risk of tissue loss. We aim to describe incisional NPWT in cutaneous free tissue transfer. An institutional review board-approved retrospective review of consecutive free tissue transfer patients was completed over a 3-year period. Free tissue transfer procedures were performed in standard manner. After fixation of the flap to the donor site with interrupted sutures, one or two drainage tubes were inserted in the subflap position. The surface of the flap was protected with Vaseline gauze followed by a 1 cm thick layer of sterile cotton. The vacuum-assisted closure (VAC) sponge (KCI, TX) was then placed in the standard fashion and negative pressure at -125 mm Hg was initiated in a continuous mode. A window was routinely made over the flap's distal region to allow for serial flap examination. For extremity procedures, no splints were utilized, and patients were limited to motion in the hospital bed. NPWT was employed continuously for 7 days and subsequently removed along with operative drains. A total of 24 consecutive patients underwent free tissue transfer. The average patient age was 39.8 years with a mean body mass index of 23. Tobacco use was noted in 58% of patients in the series. The indication for the free tissue transfer included trauma (N = 21), malignancy (N = 2), and burn reconstruction (N = 1). The areas of reconstruction included scalp (N = 5), lower extremity (N = 11), and upper extremity (N = 8). Skin-containing free flaps employed consisted of the latissimus dorsi myocutaneous free flap (N = 16), anterolateral thigh free flap (N = 6), thoracodorsal artery perforator free flap (N = 1), and radial forearm free flap (N = 1). The average defect size reconstructed was 238.3 cm2 with a mean operative time of 501 minutes. Postoperatively, patients remained in the hospital an average of 15.5 days (range: 9-32 days) with a mean follow-up of 8.1 months. No hematomas, seromas, surgical-site infections, or deep vein thrombosis/pulmonary embolism occurred in the series. None of the flaps required return to the operating room. There were no documented cases of partial or complete flap loss. NPWT may be employed in a fashion similar to the standard incisional application. With this technique, serial flap examination remains possible and is not associated with pedicle compression or increased rates of flap loss. Interestingly, no splints were utilized with the VAC device which itself may serve as a relative immobilizer of an extremity.