Objective: Free tissue transfer is a highly reliable procedure for the reconstruction of head and neck defects. However, the most common cause of failure is secondary to microvascular compromise. As such, it's critical to understand the implications of intraoperative anastomotic revision on free flap survival. This study provides a detailed analysis of free-flap survival outcomes following intraoperative anastomotic revision and the implementation of additional salvage techniques during surgery.
Method: CPT codes were used to identify all patients who underwent free flap reconstruction at a single tertiary institution from January 2013 to August 2023. Retrospective chart review was performed to obtain demographics, history of radiation, nutrition status, comorbidities, tumor characteristics, surgical technique, and post-operative course.
Results: A total of 305 free flaps in 296 patients were identified and reviewed. A total of 32 out of the 305 free flaps (10.5%) required intraoperative revision of the anastomosis. Mean age of the 32 patients requiring intraoperative anastomosis revision was 62.5 ± 14.6 years old, 62.5 % male, and had a mean follow-up time of 24.6 ± 31.0 months. Indication for free flap reconstruction included reconstruction after oncologic resection (87.5%), repair of an esophageal perforation (3.1%), chronic wound infection (6.3%), and chondronecrosis of the larynx (3.1%). Table 1 summarizes the most common intraoperative indications for anastomotic revision and salvage techniques used. The most common indication for intraoperative anastomosis was arterial thrombosis (n = 22, 68.8%) followed by arterial spasm (n = 7, 21.9%). Most patients only required one revision (n = 20, 62.5%) and the maximum number was three (n = 2, 6.3%). The most frequently employed salvage techniques, in addition to revising the anastomosis, included using different recipient vessels (n = 14, 43.8%), initiating an intraoperative heparin infusion (n = 7, 21.9%), and administering TPA through injections into the flap (n = 4, 12.5%). Only 12.5% (n = 4) required a return to the operating room due to a free flap complication and the overall free flap survival rate was 93.8% (n = 30).
Conclusion: This retrospective review reveals that intraoperative revision is associated with a free flap failure rate of 6.2% (n = 2/32), which is notably lower than the failure rate reported in the literature for intraoperative anastomotic revision, which is as high as 20%. This study demonstrates the successful salvage of free flaps through strategic intraoperative techniques, offering promising ways to enhance and optimize free flap survival.
Table 1: Summary of intraoperative techniques | Characteristic | No.% |
| Indication for intra-op reanastamosis | |
| Arterial thrombosis | n=22(69) |
| Arterial spasm/congestion | n=7(22) |
| Venous congestion | n=2(6) |
| Number of revisions | |
| x 1 | n=20(63) |
| x 2 | n=10(31) |
| x 3 | n=2(6.3) |
| Salvage technique in addition to re-anastamosis | |
| Different recipient vessels | n=14(44) |
| TPA | n=4(13) |
| Heparin infusion | n=7(22) |