Semin Plast Surg 2020; 34(04): 314-320
DOI: 10.1055/s-0040-1721766
Review Article

Flap Failure and Salvage in Head and Neck Reconstruction

Weitao Wang
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Adrian Ong
2   Department of Otolaryngology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
,
Aurora G. Vincent
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Tom Shokri
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Britney Scott
3   Department of Otolaryngology – Head and Neck Surgery, Kettering Health Network, Dayton, Ohio
,
Yadranko Ducic
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
› Author Affiliations

Abstract

With advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.



Publication History

Article published online:
24 December 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Forner D, Williams BA, Makki FM, Trites JR, Taylor SM, Hart RD. Late free flap failure in head and neck reconstruction: a systematic review. Ear Nose Throat J 2018; 97 (07) 213-216
  • 2 Eskander A, Kang S, Tweel B. et al. Predictors of complications in patients receiving head and neck free flap reconstructive procedures. Otolaryngol Head Neck Surg 2018; 158 (05) 839-847
  • 3 Hyodo I, Nakayama B, Kato H. et al. Analysis of salvage operation in head and neck microsurgical reconstruction. Laryngoscope 2007; 117 (02) 357-360
  • 4 Brady JS, Desai SV, Crippen MM. et al. Association of anesthesia duration with complications after microvascular reconstruction of the head and neck. JAMA Facial Plast Surg 2018; 20 (03) 188-195
  • 5 Findlay G, Goodwin A, Protopapa K, Smith N, Mason M. Knowing the Risk: A Review of the Perioperative Care of Surgical Patients. London, UK: National Confidential Enquiry into Patient Outcome and Death; 2011
  • 6 Las DE, Jong T, Zuidam JM, Verweij NM, Hovius SE, Mureau M. Identification of independent risk factors for flap failure: a retrospective analysis of 1530 free flaps for breast, head and neck and extremity reconstruction. J Plast Reconstruct Aesthetic Surg 2016; 69: 894-906
  • 7 Seidenstuecker K, Munder B, Mahajan AL, Richrath P, Behrendt P, Andree C. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg 2011; 127 (03) 1086-1092
  • 8 Serletti JM, Higgins JP, Moran S, Orlando GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg 2000; 106 (01) 66-70
  • 9 Howard MA, Cordeiro PG, Disa J. et al. Free tissue transfer in the elderly: incidence of perioperative complications following microsurgical reconstruction of 197 septuagenarians and octogenarians. Plast Reconstr Surg 2005; 116 (06) 1659-1668 , discussion 1669–1671
  • 10 Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 2009; 31 (01) 45-51
  • 11 Choi S, Schwartz DL, Farwell DG, Austin-Seymour M, Futran N. Radiation therapy does not impact local complication rates after free flap reconstruction for head and neck cancer. Arch Otolaryngol Head Neck Surg 2004; 130 (11) 1308-1312
  • 12 Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg 2006; 59 (07) 737-742
  • 13 le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of complications of free flap reconstruction in head and neck surgery: analysis of 304 free flap reconstruction procedures. Laryngoscope 2012; 122 (05) 1014-1019
  • 14 Eckardt A, Meyer A, Laas U, Hausamen JE. Reconstruction of defects in the head and neck with free flaps: 20 years experience. Br J Oral Maxillofac Surg 2007; 45 (01) 11-15
  • 15 Tan NC, Lin PY, Chiang YC. et al. Influence of neck dissection and preoperative irradiation on microvascular head and neck reconstruction-analysis of 853 cases. Microsurgery 2014; 34 (08) 602-607
  • 16 Valentini V, Cassoni A, Marianetti TM. et al. Diabetes as main risk factor in head and neck reconstructive surgery with free flaps. J Craniofac Surg 2008; 19 (04) 1080-1084
  • 17 Zhou W, Zhang WB, Yu Y. et al. Risk factors for free flap failure: a retrospective analysis of 881 free flaps for head and neck defect reconstruction. Int J Oral Maxillofac Surg 2017; 46 (08) 941-945
  • 18 Granzow J, Li AI, Caton A, Boyd JB. Free flap survival following failure of the vascular pedicle. Ann Plast Surg 2015; 75 (01) 44-48
  • 19 Schramm S, Wettstein R, Wessendorf R, Jakob SM, Banic A, Erni D. Acute normovolemic hemodilution improves oxygenation in ischemic flap tissue. Anesthesiology 2002; 96 (06) 1478-1484
  • 20 Erni D, Wettstein R, Schramm S. et al. Normovolemic hemodilution with Hb vesicle solution attenuates hypoxia in ischemic hamster flap tissue. Am J Physiol Heart Circ Physiol 2003; 284 (05) H1702-H1709
  • 21 Motakef S, Mountziaris PM, Ismail IK, Agag RL, Patel A. Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines. Plast Reconstr Surg 2015; 135 (01) 290-299
  • 22 Massey MF, Gupta DK. The effects of systemic phenylephrine and epinephrine on pedicle artery and microvascular perfusion in a pig model of myoadipocutaneous rotational flaps. Plast Reconstr Surg 2007; 120 (05) 1289-1299
  • 23 Hwang JH, Mun GH. An evolution of communication in postoperative free flap monitoring: using a smartphone and mobile messenger application. Plast Reconstr Surg 2012; 130 (01) 125-129
  • 24 Engel H, Huang JJ, Tsao CK. et al. Remote real-time monitoring of free flaps via smartphone photography and 3G wireless Internet: a prospective study evidencing diagnostic accuracy. Microsurgery 2011; 31 (08) 589-595
  • 25 Sweeny L, Topf M, Wax MK. et al. Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction. Laryngoscope 2020; 130 (02) 347-353
  • 26 Salgado CJ, Smith A, Kim S, Higgins J, Behnam A, Herrera HR, Serletti JM. Effects of late loss of arterial inflow on free flap survival. J Reconstr Microsurg 2002; 18 (07) 579-584
  • 27 Wax MK, Rosenthal E. Etiology of late free flap failures occurring after hospital discharge. Laryngoscope 2007; 117 (11) 1961-1963
  • 28 Jorgensen S, Bascom DA, Partsafas A, Wax MK. The effect of 2 sealants (FloSeal and Tisseel) on fasciocutaneous flap revascularization. Arch Facial Plast Surg 2003; 5 (05) 399-402
  • 29 Wise SR, Harsha WJ, Kim N, Hayden RE. Free flap survival despite early loss of the vascular pedicle. Head Neck 2011; 33 (07) 1068-1071
  • 30 Yoon AP, Jones NF. Critical time for neovascularization/angiogenesis to allow free flap survival after delayed postoperative anastomotic compromise without surgical intervention: a review of the literature. Microsurgery 2016; 36 (07) 604-612
  • 31 Barrera-Ochoa S, Gallardo-Calero I, Lopez-Fernandez A. et al. Effect of previous irradiation on vascular thrombosis of microsurgical anastomosis: a preclinical study in rats. Past Reconstr Srug Glob Open 2016; 4: e1073
  • 32 Tall J, Björklund TC, Skogh AC, Arnander C, Halle M. Vascular complications after radiotherapy in head and neck free flap reconstruction. Ann Plast Surg 2015; 75 (03) 309-315
  • 33 Herle P, Shukla L, Morrison WA, Shayan R. Preoperative radiation and free flap outcomes for head and neck reconstruction: a systematic review and meta-analysis. ANZ Journal of Surgery 2015; 85 (03) 121-127
  • 34 Wolff K-D, Stiller D. Ischemia tolerance of free-muscle flaps: an NMR-spectroscopic study in the rat. Plast Reconstr Surg 1993; 91 (03) 485-491
  • 35 Griffin JR, Thornton JF. Microsurgery: free tissue transfer and replantation. Selected Readings Plast Surg 2005; 10 (05) 1-39
  • 36 Herlin C, Bertheuil N, Bekara F, Boissiere F, Sinna R, Chaput B. Leech therapy in flap salvage: systematic review and practical recommendations. Ann Chir Plast Esthet 2017; 62 (02) e1-e13
  • 37 Harun A, Kruer RM, Lee A, Boahene K, Byrne PJ, Richmon JD. Experience with pharmacologic leeching with bivalirudin for adjunct treatment of venous congestion of head and neck reconstructive flaps. Microsurgery 2018; 38 (06) 643-650
  • 38 Wei FC, Demirkan F, Chen HC. et al. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?. Plast Reconstr Surg 2001; 108 (05) 1154-1160 , discussion 1161–1162
  • 39 Fearon JA, Cuadros CL, May Jr JW. Flap failure after microvascular free-tissue transfer: the fate of a second attempt. Plast Reconstr Surg 1990; 86 (04) 746-751
  • 40 Baumeister S, Follmar KE, Zenn MR, Erdmann D, Levin LS. Strategy for reoperative free flaps after failure of a first flap. Plast Reconstr Surg 2008; 122 (03) 962-971