Second Salvage successful in 30% of Free Flaps in Head & Neck Reconstruction Surgery: JAMA
Functional rehabilitation following composite ablative procedures in the head and neck may be reconstructed with composite free tissue grafts. Free tissue transfer has the potential to provide reliable results; however, vascular compromise in the perioperative period can occur in up to 10% to 15% of cases. A recent study suggests that a second revascularization attempt for compromised free flaps increased rates of survival in 30% of patients undergoing head and neck reconstruction surgery. The study findings were published in the JAMA Otolaryngol Head Neck Surgery on April 27, 2022.
While the initial salvage rate of compromised free flaps demonstrates a high measure of success, there exists a small number of flaps that will develop vascular compromise a second time. In these cases, the rate of second successful revascularization is unknown. Therefore, Dr Allison A. Slijepcevic and her team conducted a study to assess the outcomes of a second revascularization attempt for compromised free flaps.
In a multicenter retrospective medical record review, the researchers included patients undergoing head and neck reconstruction with free flaps at 6 US medical centres from January 1, 2000, through December 30, 2020. Of 3510 flaps identified, 79 were successfully salvaged once, became compromised a second time, and underwent attempted salvage. The major outcome assessed was the flaps with a history of initial compromise and successful revascularization demonstrating second episodes of compromise followed by second salvage attempts.
Key findings of the study:
- Among 79 flaps undergoing second salvage attempts, the researchers found that 24 (30%) survived while 55 (70%) demonstrated necrosis.
- They noted that the arterial or venous thrombectomy was performed in 17 of the 24 (71%) flaps that survived and 23 of the 55 (42%) flaps demonstrating necrosis (odds ratio, 3.38).
- When the venous compromise was encountered, they observed that changing the anastomotic vein was associated with decreased survival compared with not changing the vein (29 of 55 [53%] flaps vs 10 of 24 [42%] flaps).
- They reported that vein revision to an alternative branch was completed in 1 of the 24 (4%) flaps that survived and 19 of the 55 (35%) flaps with necrosis (odds ratio, 0.08).
- They further noted that flap type, cause of flap failure, postoperative complications, patient comorbidities, and heparin administration after second salvage does not associate with flap survival following second salvage attempts.
The authors concluded, "In this cohort study, second salvage surgeries successfully perfused 30% of flaps. Thrombectomy of isolated thrombi was associated with flap success following second salvage surgeries. Flap failure associated with venous compromise demonstrated worse outcomes."
They further added, "Second salvage procedures may improve flap survival in a small number of patients with flaps compromised by pedicle thrombi and may be advantageous when secondary free flaps or locoregional flap reconstructions are not preferred."
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Keywords:
Head and neck reconstruction, free flap, survival rate, compromised free flaps, initial salvage, Second salvage attempts, vascular compromise, successful revascularization, thrombectomy, thrombus, anastomotic vein, isolated thrombi, JAMA Otolaryngol Head Neck Surgery.
