BACKGROUND: Connective tissue or collagen vascular disorders affect multiple organ systems through a variety of mechanisms: the presence of vasospasm; autoimmunoglobulin deposition along vascular basement membranes; activation of inflammatory cells; and intravascular thrombosis. As a result, patients often exhibit manifestations of their disease with vasculitis and soft tissue pathology. Some may suggest that the inherent risks for thrombosis and wound healing complications deem these patients unsuitable candidates for free tissue reconstruction. We present our series of connective tissue disorder patients who underwent successful free flap reconstruction. This represents the first reported series in the literature.
METHODS: A prospective chart review was conducted of all free flap reconstruction within the Division of Plastic Surgery at University of Pennsylvania. A total of 1284 free flaps were performed between February 2005 and February 2009. Twenty-five (2%) patients with diagnosis of connective tissue disorders were identified with some having concomitant diseases. Diagnoses included Sjogren’s syndrome (3), Raynaud’s phenomenon (8), rheumatoid arthritis (7), systemic lupus erythematosus (4), sarcoidosis (4), limited scleroderma (CREST syndrome) (1), and multicentric reticulohistiocytosis (1). Data were evaluated based on operative, inpatient and outpatient clinical records.
RESULTS: All 25 patients were females. Mean age was 51 years (37 to 72). The average BMI was 28.1 kg/m² (16.6 to 38.8). Average length of hospital stay was 4 days (3 to 8). Seven patients (28%) were on chronic immunosuppressive therapy for their diseases. A total of 32 free flap reconstructions were performed which included 23 breast patients (7 DIEP, 21 TRAM, 1 gluteal) and 2 head and neck patients (1 ALT, 2 radial forearm). In the breast patients, six flaps were delayed reconstruction, and 17 were immediate. All free flaps were performed with a single arterial and venous anastomosis. There were no intraoperative or postoperative microvascular complications. Postoperatively, each patient received the standard anticoagulation according to independent surgeon protocol. There was 1 case of lower extremity deep vein thrombosis on postoperative day 15 that was managed with coumadin. There were 3 cases of wound dehiscence, all of which healed secondarily with local wound care.
CONCLUSIONS: In connective tissue disorder, the hallmark is inflammation of the soft tissues and blood vessels. Because of these inherent risks, free tissue transfer may carry an increased risk of wound healing complications or flap loss/thrombosis. We demonstrate from our series, however, that it is safe, and there is no increased morbidity in vascular compromise and the types of postoperative complications in this population. Connective tissue disorders should not preclude patients from free flap reconstruction.