Closer to an Understanding of Fate - The Role of Vascular Complications in Free Flap Breast Reconstruction
Joshua Fosnot, Shareef Jandali, MD, Stephen J. Kovach, III, MD, Liza C. Wu, MD, Joseph M. Serletti, MD.
The University of Pennsylvania Health System, Philadelphia, PA, USA.
BACKGROUND: The catastrophic outcome of flap loss in autologous breast reconstruction can be devastating to both the patient and surgeon alike. Flap loss is almost invariably a result of a vascular complication, yet not all complications portend the same fate. The purpose of this study was to determine if intraoperative complications and technical variation are associated with subsequent delayed vascular problems and eventual flap loss.
METHODS: This was a retrospective review of all free flaps performed at Penn between 2005 and 2010 by the senior authors. Details of intraoperative and delayed vascular complications were recorded after scrutinizing medical records and operative reports. Simple statistical methods such as Chi-square or Fischer exact testing were used for analysis.
RESULTS: Overall, 1173 free flaps were performed in 804 patients. Of these, 1.2% (n=14) resulted in complete flap loss while an additional 0.9% (n=10) were partially lost. Intraoperative complications arose in 9.6% of flaps (n=113): 38 arterial thromboses, 6 venous thromboses and 71 other technical challenges. Delayed complications occurred in 2.6% of flaps (n=31): 14 arterial thromboses, 14 venous thromboses and 5 congested flaps. Intraoperative arterial thrombosis was not associated with a subsequent delayed arterial thrombosis (2.6% vs. 1.1%, p = 0.37). There was a trend toward higher delayed venous thrombosis with a preceding intraoperative venous thrombosis (16.7% vs. 1.1%, p = 0.07). Technical difficulties were associated with a higher rate of delayed arterial thrombosis (4.2% vs. 1.0%, p = 0.05), but not delayed venous thrombosis (2.8% vs. 1.1%, p = 0.21). In total, a flap with any intraoperative vascular issue was associated with both delayed arterial (4.4% vs. 0.8%, p < 0.01) and venous thrombosis (3.5% vs. 0.9%, p = 0.04). Intraoperative arterial thrombosis was not associated with either partial (2.6% vs. 0.8%, p = 0.28) or complete flap loss (2.6% vs. 1.1%, p = 0.37). Intraoperative venous thrombosis was not associated with higher partial flap loss (0.0% vs. 0.9%, p = 1.0), but did result in a trend toward higher complete flap loss (16.7% vs. 1.1%, p = 0.07). Intraoperative technical difficulties were associated with a higher rate of partial flap loss (4.2% vs. 0.6%, p = 0.02), but not complete flap loss (2.8% vs. 1.1%, p = 0.21). Taken in aggregate, there was a higher rate of complete flap loss (3.5% vs. 0.9%, p = 0.04) with any intraoperative problem and a trend toward higher partial flap loss (2.7% vs. 0.7%, p = 0.06). Overall, delayed arterial thromboses were salvaged from complete flap loss 64.3% of the time; whereas, delayed venous thromboses only 50% of the time.
CONCLUSIONS: In free flap breast reconstruction, when a vascular problem is encountered in the operating room, there is an associated higher delayed vascular complication rate and subsequent flap loss. Given that flaps with delayed vascular complications are only salvaged about half the time, further research is needed to determine if those with an intraoperative issue should be treated differently in the post operative period to minimize risk.
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