Factors that influence the outcome of salvage in free tissue transfer

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Abstract

Introduction: The success of salvage techniques for free tissue transfer is well documented. The aim of this study was to identify factors that influenced the results of salvage operations in a group of patients who required early exploration. Methods: From a database survey of 408 patients who had a total of 427 free issue transfer reconstructions, 65 (16%) returned to the operating theatre within 7 days. A retrospective analysis of their progress was made from the case records. Results: The flap chart was found to be highly accurate for the 65 patients who had returned to the operating theatre, reporting two false positives and one false negative. Forty patients had compromised flaps and 25 had haematomas that required evacuation. The commonest problem with flaps was venous congestion (33/40, 83%), and 29 flaps were successfully salvaged (73%). Most successful salvage attempts were made within 24 hours of the end of the initial operation. The salvage rate was higher for the radial fasciocutaneous flaps (25/30, 83%), than for composite flaps (2/7, 29%). A total of 24/427 flaps failed (6%). Conclusions: We now recommend hourly observations of the flap for 24 hours followed by 4-hourly monitoring for 48 hours. Improved monitoring techniques for composite grafts may result in more being salvaged and a better overall survival.

Section snippets

INTRODUCTION

Microvascular free tissue transfer is now a reliable technique.1., 2., 3., 4., 5. Accurate monitoring of the flap permits the surgical team to have another chance of a successful transfer if the tissue becomes compromised in the early postoperative period. Successful salvage rates have been reported between 28 and 87.5%.6., 7., 8. Previous reports have confirmed the success of flap salvage techniques but there are few detailed data on the circumstances surrounding the decision to return to the

PATIENTS AND METHODS

A computerised database has been in regular use for patients with head and neck cancer who are operated on at the Regional Maxillofacial Unit in Liverpool, and data are available for analysis from January 1992. We analysed the database from January 1992 until October 1998, and identified 408 patients who had 427 free flap reconstructions. A detailed complication form indicated the early return to theatre (within 7 days), and flap compromise. Sixty-five patients were identified who required an

RESULTS

Sixty-five of 408 patients (16%) returned to the operating room within 7 days for further surgery as part of an early complication. Forty (10%) patients had flaps compromised by vascular thrombosis and 25 (6%) were not compromised but had a bleeding site or haematoma.

Table 1 shows the reasons for returning to the operating room as given on the flap chart. Of the 65 patients, 41 patients had a change in the flap chart although 5 of these also had a haematoma or bleeding as an additional reason

DISCUSSION

The rates of return to theatre have been reported between 139 and 20%,5 which are comparable with the 16% rate in this study. Operations specifically for compromised flaps has been reported in between 3.83 and 8%,5., 10. which is less than the overall result in this study of 10% (40/408). The flap salvage rate in this study of 73% (29/40) is comparable with other reports.5., 11.

The results show that for venous thrombosis an early return to theatre is essential if there is going to be a

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