Outcomes Of Free Tissue Transfer Research Articles

P43. Outcomes of Free Tissue Transfer in Lower Extremity Soft Tissue Sarcoma Reconstruction: An Analysis at a Quaternary Cancer Center

P43. Outcomes of Free Tissue Transfer in Lower Extremity Soft Tissue Sarcoma Reconstruction: An Analysis at a Quaternary Cancer Center

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.

The impact of COVID-19 pandemic on free tissue transfer outcomes: A NSQIP analysis

The COVID-19 pandemic significantly impacted hospital resources and patient care, although its effect on free tissue transfer procedures is poorly understood. We conducted the current study to investigate the potential impact of COVID-19 and its accompanying system shut-downs on the surgical outcomes of patients undergoing free flap procedures. Patients undergoing free tissue transfer procedures were identified from the National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2020. We used 2016-2019 as baseline (pre-pandemic) data to compare with 2020 (peri-pandemic). We divided the patients into the following 3 groups: all patients undergoing free tissue transfer, breast reconstruction free tissue transfer, and non-breast free tissue transfer cases. Outcomes of interest included patient morbidity/mortality, time to surgery, time to takeback, and length of hospital stay. We used Pearson's chi-square and Fisher's exact tests to assess categorical variables. Wilcoxon's ranked sign tests and ANOVA tests were used for non-parametric and parametric continuous variables, respectively. Significance was set at alpha <0.05. When comparing peri-pandemic to pre-pandemic rates, patient morbidity and mortality and unplanned primary or secondary takeback operations were both significantly higher in all 3 groups peri-pandemic. Median time to primary or secondary takeback operation was also significantly greater peri-pandemic. Patients undergoing flap procedures peri-pandemic had an overall increase in median morbidity and mortality, unplanned primary or secondary takebacks, and median number of days to takebacks compared to the pre-pandemic period. This is concerning given that any future protocols instituted can have detrimental effects on patients who receive a free tissue transfer procedure.

Evaluating the impact of hemodynamic support measures on head and neck free tissue transfer outcomes: A population-based analysis

ObjectivesThis study sought to analyze the effects of perioperative blood transfusions and vasopressors on 30-day surgical complications and 1-year mortality after reconstructive surgery in head and neck free tissue transfer (FTT) and to identify predictors of administration of perioperative blood transfusions or vasopressors. Materials and MethodsTriNetX (TriNetX LLC, Cambridge, USA), an international population-level electronic health record database, was queried to identify subjects that underwent FTT requiring perioperative (intraoperative to postoperative day 7) vasopressors or blood transfusions. Primary dependent variables were 30-day surgical complications and 1-year mortality. Propensity score matching was used to control for population differences, and covariate analysis was used to identify preoperative comorbidities associated with perioperative vasopressor or transfusion requirements. Results7,631 patients met inclusion criteria. Preoperative malnutrition was associated with increased odds of perioperative transfusion (p = 0.002) and vasopressor requirement (p < 0.001). Perioperative blood transfusion (n = 941) was associated with increased odds of any surgical complication (p = 0.041) within 30 days postoperatively and specifically increased odds of wound dehiscence (p = 0.008) and FTT failure (p = 0.002), respectively. Perioperative vasopressor was (n = 197) was not associated with 30-day surgical complications. Vasopressor requirement was associated with increased hazards-ratio of mortality at 1-year (p = 0.0031). ConclusionPerioperative blood transfusion in FTT is associated with increased odds for surgical complications. Judicious use as a hemodynamic support measure should be considered. Perioperative vasopressor use was associated with an increased risk of one-year mortality. Malnutrition is a modifiable risk factor for perioperative transfusion and vasopressor requirement. These data warrant further investigation to assess causation and potential opportunity for practice improvement.

The Impact of Venous Anastomosis Technique on Outcomes of Free Tissue Transfer to the Head and Neck.

Objectives: To evaluate the impact of different techniques of microvascular venous anastomosis on the outcome of free tissue transfer to the head and neck. Methods: Retrospective case series of patients undergoing microvascular free tissue transfer (MFTT) from January 2006 to September 2021. Chi-square tests and t-tests were utilized to identify differences in flap outcomes by technique, and log-binomial regression analyses were utilized to identify differences in flap outcomes by technique. Results: A total of 1055 consecutive MFTTs were analyzed. One hundred four cases required a return to the operating room for any reason, and 19 were attributed to venous compromise (18.0%). Ultimately, there were 22 FTT failures requiring complete revision (2.1%). In total, 1055 MFTTs involved 1352 venous anastomoses, ranging from 1 to 3 anastomoses in each case. End-to-end (ETE) was used 1040 times (76.9%) and end-to-side (ETS) 204 times (15.0%). The calculated risk ratio for venous complication for ETS compared with ETE was 1.17 (0.34-3.98). A microvascular coupler was used in 355 cases (33.6%). The calculated risk ratio for coupler compared with suture anastomoses was 0.92 (0.35-2.39). Conclusions: There were no significant difference in regard to outcomes of MFTT when comparing ETE with ETS, nor when comparing coupler with suture anastomoses.

Outcomes of perioperative vasopressor use for hemodynamic management of patients undergoing free flap surgery: A systematic review and meta-analysis.

This systematic review and meta-analysis investigates the objective evidence regarding outcomes in head and neck free flap surgeries using vasoactive agents in the perioperative period. A search was performed in PubMed, Cochrane, Web of Science, and Scopus databases. Inclusion criteria were clinical studies in which vasopressors were used in head and neck free flap surgery during the intraoperative and perioperative period. Eighteen studies (n=5397) were included in the qualitative analysis and nine (n=4381) in the meta-analysis. There was no difference in flap failure outcomes with perioperative vasopressor use in head and neck free flap surgery (n=4015, OR=0.93, 95% CI [0.60, 1.44]). When patients received vasopressors perioperatively, there was an associated decrease in flap-specific complications (n=3881, OR=0.69, 95% CI [0.55, 0.87]). Intraoperative vasopressor use does not negatively impact free tissue transfer outcomes in head and neck surgery and may reduce overall free flap complications.

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.

Usefulness of Interposition Arteriovenous Bundle Grafts in Free Flap Surgery: A Case Series and Systematic Review.

The paucity of reliable recipient vessels adjacent to defects poses a great challenge in free flap reconstruction. Although the use of interposition vein grafts to cover the vascular gap is common, its potential association with higher risks of flap compromise is often reported. Interposition arteriovenous bundle grafts have been introduced as an alternative. This study aimed to evaluate the outcomes of free tissue transfer using interposition arteriovenous bundle grafts and to conduct a systematic review of studies that reported the use of the technique. Patients who underwent free tissue transfer using the interposition arteriovenous bundle graft technique were assessed for flap perfusion-related complications. A systematic review of literature was performed using pooled analysis to calculate the rate of perfusion-related complications. Overall, 14 cases of free flap reconstruction used the interposition arteriovenous bundle graft technique to cover vascular gaps in diverse regions. The most common donor vessel of this graft was the descending branch of the lateral circumflex femoral vessels (mean length, 6.9 cm). All flaps survived except for 1 case of partial flap loss, showing a flap compromise rate of 7.1%. A systematic review identified 13 studies that represented 78 cases using this technique. In the pooled analysis, including the current series, the overall flap survival rate was 95.7%, reporting 4 of 92 cases of flap compromise. The interposition arteriovenous bundle graft technique may help overcome the challenges of pedicle shortage or lack of adjacent recipient vessels in free flap reconstruction.

Eight Tales of Cervical Necrotizing Fasciitis and Free Tissue Transfer.

Aggressive surgical debridement is required in cervical necrotizing fasciitis, and in severe defects, subsequent free tissue transfer might be necessary. However, there is concern that the inflammatory environment of the infection site may threaten free flap viability, particularly with concerns for thrombosis of feeding vessels and compromised tissue integration. Cases in the head and neck area are rare, so there are limited data regarding outcomes of free tissue transfer in these patients. A retrospective chart review assessed patients with cervical necrotizing fasciitis treated at an academic tertiary hospital between 2015 and 2021. Twenty-five patients were identified, and eight required free tissue transfer after adequate surgical debridement. Treatment, hospital course, and demographic data were collected on these eight patients. All flaps had full survival at follow up (median follow up 3 months, range 1-39 months) without concerns for vascular compromise. These data suggest that in patients with large soft tissue defects due to cervical necrotizing fasciitis, free tissue transfer may be a safe treatment modality.

Free Tissue Transfer during the COVID-19 Pandemic: A Proposed Evidence-Based Protocol for Early Discharge.

BACKGROUNDAs free tissue transfer outcomes improve, institutions are examining early discharge protocols. “Early” is generally defined as between one and five days postoperatively, which correlates with the timing of most major complications and most opportunities for flap salvage. Given the trend towards early discharge, the need for healthcare cost reductions and shortage of ICU beds during a viral pandemic, we aimed to propose an evidence-based protocol to select patients for discharge within 72 h of free tissue transfer. METHODSA retrospective review of all patients who underwent free tissue transfer at Vanderbilt University Medical Center, Tennessee, USA since the onset of the COVID-19 (2020-2021) pandemic was performed. Patients were included for review if they were discharged within 72 h of surgery. Literature relating to expedited discharge after free tissue transfer was also reviewed. RESULTSSix patients met inclusion criteria for retrospective review. None suffered intraoperative or postoperative inpatient complications and all were discharged within 72 h postoperatively. There were no flap failures within 30 d of reconstruction. CONCLUSIONThis study reviews a patient cohort undergoing free tissue transfer during the COVID-19 pandemic. These cases were reviewed for factors that may have contributed to their postoperative success after discharge within 72 hours. These data points were combined with published evidence on risks for failure after free flap reconstruction to design a protocol to select patients for early discharge. The benefits of early discharge include reducing healthcare costs, risks of inpatient hospitalization, and ICU utilization, which is of paramount importance in the midst of a global pandemic..

Impact of perioperative vasopressors on lower extremity free flap reconstruction.

Free tissue transfer is a treatment option for soft tissue defects of the lower extremity. For a successful outcome, it is necessary to evaluate the vessel condition and blood flow patency. The administration of a vasopressor could impact the survival rate of free tissue transfer; however, there is a lack of studies on vasopressor use and lower extremity reconstruction. This study aimed to investigate the relationship between the use of a vasopressor and outcomes of free tissue transfer in lower extremity reconstruction. This retrospective, observational study was conducted between March 2010 and February 2019. Data were divided into intraoperative and postoperative variables according to the administration time. Data on patient demographics, risk factors, details of reconstruction, flap outcomes, and duration of intensive care unit (ICU) stay were obtained. Binary logistic regression models were computed to determine the association between flap outcome and vasopressor administration. Of the 338 patients, 186 were administered a vasopressor. Intraoperative and postoperative vasopressor use was not related to the overall complication rate (odds ratio, 1.547; 95% confidence interval, 0.830-2.882; p=.169). Low-intraoperative levels of hemoglobin were associated with the overall complication rate. Postoperative vasopressor administration was associated with prolonged ICU stay. Our results showed that the intraoperative and postoperative use of vasopressors was not significantly associated with the success rate of free flaps. Future studies investigating the relationship between the dose, type, and duration of vasopressors and the complication rate following free tissue transfer are warranted.

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.

Day-of-Free Tissue Transfer Qualitative Cultures Do Not Predict Limb Salvage Outcomes.

Successful free tissue transfer is critical for lower extremity salvage in the chronic wound population. The rates of lower extremity free tissue transfer success lag behind those for other anatomical sites. The aim of this study was to evaluate whether positive qualitative day-of-free tissue transfer cultures or pathogen virulence negatively impacts short- and long-term outcomes of lower extremity free tissue transfer. Between April of 2011 and January of 2018, 105 lower extremity free tissue transfer procedures were performed. Growth level and speciation were identified from qualitative cultures taken during free tissue transfer. The relationship between demographics, comorbidities, culture data, postoperative infection, free tissue transfer survival, and long-term limb salvage was examined using logistic regression. The median Charlson Comorbidity Index was 3. Intraoperative free tissue transfer cultures were positive in 39.1 percent. Flap survival was 93.3 percent. Postoperative infection developed in 12.4 percent. The limb salvage rate was 81.0 percent. Positive culture was not significant for flap survival, postoperative infection, or amputation. Cultures positive for Enterococcus species had a significant relationship with flap success (OR, 0.08; p = 0.01) and amputation (OR, 7.32; p = 0.04). Insufficient antimicrobial coverage had a significant relationship with postoperative infection (OR, 6.56; p = 0.01) despite the lack of pathogen concordance. On multivariate analysis, postoperative infection (OR, 12.85; p < 0.01) and Charlson Comorbidity Index were predictive of eventual amputation (OR, 1.44; p = 0.01). Positive day-of-free tissue transfer cultures, regardless of pathogen, had limited predictive value for short- and long-term outcomes of free tissue transfer in the authors' cohort. These findings call for a broader multicenter prospective analysis and consideration of health care-associated infections and their impact on limb salvage outcomes. Risk, III.

Anastomotic Revision in Head and Neck Free Flaps.

Predictors of free tissue transfer (FTT) failure and the need for postoperative revision (POR) have been extensively studied; however, there are little data evaluating outcomes when intraoperative revision (IOR) at initial surgery is required. This study seeks to better understand the impact IOR of the pedicle has on FTT outcomes. Retrospective review of 2482 consecutive patients across three tertiary institutions. Adult patients (>18) who received a FTT and underwent anastomotic revision from 2006 to 2019 were included. Logistic regression was performed to predict revision, and recursive partitioning was performed to classify risk of failure based on type of revision and vessels revised. Failure rates for IOR (19%) and POR (27%) were higher compared to a nonrevised failure rate of 2% (P < .01 and P < .01, respectively). Intraoperative venous revision (IORv, n = 13), arterial (IORa, n = 114), and both (IORb, n = 11) were associated with failure rates of 8% (odds ratio [OR] 3.5, P = .23), 18% (OR = 9.0, P < .01), 45% (OR = 35.3, P = <.01), respectively. Arterial revision was most common among IOR (83%, P < .01). Postoperative venous revision (PORv, n = 35), arterial (PORa, n = 36), and both (PORb, n = 11) were associated with failure rates of 20% (OR = 15.7, P < .01), 27% (OR = 10.6, P < .01), and 39% (OR = 27.0, P < .01), respectively. Failure rate for flaps that had POR after IOR (PORi, n = 11) was 45% (OR = 18.2, P < .01). Diabetes predicted IOR (P = .006); tobacco use, heavy alcohol use, and prior radiation predicted POR (P = .01, P = .05, and P = .01, respectively). Both IOR and POR were associated with increased failure compared to nonrevised flaps. The risk of failure increases sequentially with intraoperative or POR of the vein, artery, or both vessels. Revision of both vessels and POR after IOR are strongly predictive of failure. 3 Laryngoscope, 131:1035-1041, 2021.

Pediatric Microsurgery in the Reconstruction of Complex Posttraumatic Foot and Ankle Defects: A Long-Term Follow-Up with a Comprehensive Review of the Literature.

Lower limb reconstruction is a well-recognized challenge to the trauma or plastic surgeon. Although techniques and outcomes in the adult population are well documented, they are less so in the pediatric population. Here, we present our experience in the management of posttraumatic foot and ankle defects with free tissue transfer in children. We performed a retrospective analysis of 40 pediatric patients between the ages of 3 and 16 from 2008 to 2016 who underwent foot and ankle soft tissue reconstruction. Any patient who underwent reconstruction for any reason other than trauma was excluded. Data were collected on operative time, free tissue transfer type, use of vein grafts, length of hospital stay, and postoperative morbidity. Also, a comprehensive systematic literature review was completed according to the PRISMA protocol for all previous reports of foot and ankle reconstruction in the young age group with free tissue transfer. Of our 40 patients, 23 were males and 12 females, free tissue transfer was used to reconstruct primarily the dorsum (71%), heel (11%), medial (9%), and lateral (3%) aspect of the foot. The anterior tibial artery was the predominant recipient vessel for anastomosis (77%). Mean inpatient stay was 9 days and our complication rate was 20%, primarily of superficial infection treated with antibiotic therapy. The review of the literature articles is completely analyzed in detail. The need for durable coverage of exposed joints, tendons, fractures, or hardware makes the free flap particularly well suited to trauma reconstruction of the foot and ankle. The lack of underlying vascular disease in this patient group allows for low complication rates. Our study evidences the safety and positive long-term outcomes of free tissue transfer for the reconstruction of huge sized-soft tissue defects of the foot and ankle in children.

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.

Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: A matched‐pair analysis

Limb salvage in patients with peripheral vascular disease (PVD) and soft tissue defects often requires both a restoration of blood flow to the lower extremity and soft tissue coverage. Outcomes of free tissue transfer may be affected by vein grafts, which can be used for the placement of an autologous venous bypass or an arteriovenous (AV) loop leading to different hemodynamic situations. The purpose of this study was to investigate whether free flap anastomosis to a bypass or an AV loop can be performed with comparable results. We performed a matched-pair analysis of 22 patients with PVD undergoing free flap reconstructions of the lower extremity with end-to-side anastomosis to an autologous venous bypass (n = 11, 1 female and 10 male patients) or an AV loop (n = 11, 2 female and 9 male patients). Defects caused by trauma, infection, ulcer, or fasciotomy were reconstructed in each group with 5 muscle-based flaps, 3 parascapular flaps, 2 anterolateral thigh (ALT) flaps, and 1 conjoined latissimus dorsi and parascapular flap. Postoperative complications including thromboses, flap failures, wound complications, and hematomas were compared. Postoperative complication rates including 1 venous pedicle thrombosis (9%vs. 0%, P = 1.0), minor (18% vs. 9%, P = 1.0) and major wound complications (45% vs. 27%, P = .69) as well as hematomas (27% vs. 36%, P = 1.0) did not show relevant differences between the groups. Flap failures were absent in both groups. In patients with PVD, autologous venous bypass grafts may be used for end-to-side anastomoses of free flaps, with postoperative outcomes being comparable to AV loop reconstructions.