Faculty Bibliography

BACKGROUND:Microvascular free tissue transfer is a reliable method for reconstruction of complex surgical defects. However, there is still a small risk of flap compromise necessitating urgent reexploration. A comprehensive study examining the causes and methods of avoiding or treating these complications has not been performed. The purpose of this study was to review the authors' experience with a large number of microvascular complications over an 11-year period. METHODS:This was a retrospective review of all free flaps performed from 1991 to 2002 at Memorial Sloan-Kettering Cancer Center. All patients who required emergent reexploration were identified, and the incidence of vascular complications and methods used for their management were analyzed. RESULTS:A total of 1193 free flaps were performed during the study period, of which 6 percent required emergent reexploration. The most common causes for reexploration were pedicle thrombosis (53 percent) and hematoma/bleeding (30 percent). The overall flap survival rate was 98.8 percent. Venous thrombosis was more common than arterial thrombosis (74 versus 26 percent) and had a higher salvage rate (71 versus 40 percent). Salvaged free flaps were reexplored more quickly than failed flaps (4 versus 9 hours after detection; p = 0.01). There was no significant difference in salvage rate in flaps requiring secondary vein grafting or thrombolysis as compared with those with anastomotic revision only. CONCLUSIONS:Microvascular free tissue transfer is a reliable reconstructive technique with low failure rates. Careful monitoring and urgent reexploration are critical for salvage of compromised flaps. The majority of venous thromboses can be salvaged. Arterial thromboses can be more problematic. An algorithm for flap exploration and salvage is presented.

Smoking is universally considered to be a risk factor for surgical complications. The incidence of complications following tissue expander/implant breast reconstruction in patients who smoke has not been previously evaluated.A review of complications following tissue expander/implant reconstruction in 515 patients was performed. Patients who had 2-stage, tissue expander/implant reconstruction at Memorial Sloan-Kettering Cancer Center between May 2002 and December 2003 were included. Complications in smokers (n=132) and nonsmokers (n=383) were compared. The rate of overall complications, reconstructive failure, mastectomy flap necrosis, and infectious complications was significantly higher in smokers compared with nonsmokers. The rate of complications in ex-smokers was also higher than in nonsmokers. Using multivariate statistical analysis to adjust for confounding variables, smoking was identified as independent predictor of postoperative complications.A significant association between smoking status and postoperative complications exists. Thus, smokers who undergo postmastectomy expander/implant reconstruction should be informed of the increased risk of surgical complications and should be counseled on smoking cessation.

The timing of percutaneous endoscopic gastrostomy (PEG) tube placement in patients who undergo cervical esophageal reconstruction using free jejunal transfer is controversial. The purpose of this study was to review the authors' experience with pharyngeal reconstruction using free jejunal transfer to establish useful guidelines for enteral tube placement. A retrospective analysis of all patients treated with free jejunal autografts for reconstruction of cervical esophageal defects during a 12-year period was performed. A total of 105 patients underwent 108 esophageal reconstructions using these techniques. Sixty-three patients (60%) did not have enteral tube placement at any time, whereas 42 patients had gastrostomy or PEG tubes placed preoperatively (n = 12), intraoperatively (n = 8), or postoperatively. The majority of patients were able to resume per-oral feeds and avoid long-term tube feeds (86.7%). Most patients who underwent preoperative or intraoperative enteral tube feed placement had them removed postoperatively (82%). Only patients who required postoperative placement of feeding tubes required prolonged feeding tube support. In conclusion, most patients who undergo esophageal reconstruction using free jejunal transfer recover the ability to swallow and maintain adequate nutrition without supplemental enteral tube feeds. Preoperative gastrostomy tube placement is not necessary in most patients unless severe preoperative nutritional compromise is present.

There are many technical considerations in patients who require radiotherapy after oncologic reconstruction. A traditional tenet is to avoid skin grafts in this setting. However, this is not always avoidable. Therefore, the objective of this study was to evaluate the wound healing and functional outcome of patients in the authors' institution whose skin grafts were subsequently irradiated. A retrospective analysis of all patients treated with split-thickness skin grafts and postoperative radiotherapy at Memorial Sloan-Kettering Cancer Center from 1995 to 2002 was performed. Parameters evaluated included indications for skin graft, defect size, time to postoperative radiotherapy, total radiotherapy dose, delays and interruptions in radiotherapy, wound complications, and the need for further skin grafting. There were 30 patients (23 men, 7 women) with a mean defect size of 152 +/- 132 cm2. All split-thickness skin grafts were placed on healthy vascular tissue beds. In most instances (67%) skin grafts were used to cover muscle flaps. Median time to initial radiotherapy after grafting was 8 weeks (range, 4-60 weeks). There was 1 delay and 4 interruptions in radiotherapy treatment. There were 2 partial skin graft losses (<20%) after radiation that healed with conservative treatment. There was 1 complete skin graft loss after radiotherapy that required regrafting. Split-thickness skin grafts can tolerate postoperative radiotherapy without significant complications. Postoperative external beam radiation can begin as early as 6 to 8 weeks after skin grafting. If the requirement for postoperative radiotherapy is known, split-thickness grafts should ideally be placed on well-vascularized muscle beds. Minor skin graft loss resulting from postoperative radiotherapy can usually be treated conservatively without the need for additional surgery.

A number of patients with free tissue transfer require secondary revision to improve contour and regional definition to maximize function or appearance. However, there is controversy with regard to whether irradiated free flaps can be revised safely using liposuction. The purpose of this study was to compare the outcomes of revisionary procedures requiring liposuction in irradiated versus nonirradiated flaps. From December 1992 to July 2001, office and hospital records were reviewed retrospectively to identify patients who had undergone free tissue transfer and subsequent flap revision at a single institution. The number of revisions, amount of fat aspirated, timing of revision and the postoperative complications including infection, hematoma, wound dehiscence, and flap loss were reviewed. A total of 41 flap revisions using liposuction alone or with direct excision were performed on 33 free flaps (31 head and neck, 1 chest wall, and 1 extremity). The rectus musculocutaneous flap was the most commonly revised (88%). The average length of time to secondary revision of patients who had received postoperative radiotherapy to their flaps was significantly higher that those whose flaps had not been irradiated (P < 0.05). There were no postoperative complications except for 1 partial (20%) flap loss in a patient whose flap was irradiated. The difference in complication rates between the irradiated and nonirradiated group was not statistically significant. Secondary free flap revision using liposuction and direct excision is a safe technique for recontouring free flaps. There was no significant difference in complication rates for irradiated and nonirradiated flaps. Postoperative radiation therapy is therefore not a contraindication to secondary revision. However, these procedures should be delayed for several months after the acute effects of radiation have resolved.