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Free Flap Take-Back following Postoperative Microvascular Compromise: Predicting Salvage versus Failure

Mirzabeigi, Michael N. M.D.; Wang, Theresa M.D.; Kovach, Stephen J. M.D.; Taylor, Jesse A. M.D.; Serletti, Joseph M. M.D.; Wu, Liza C. M.D.

Plastic & Reconstructive Surgery: September 2012 - Volume 130 - Issue 3 - p 579–589
doi: 10.1097/PRS.0b013e31825dbfb7
Reconstructive: Trunk: Original Article

Background: The purpose of this study is twofold: (1) to stratify preoperative risk factors that predict successful free flap salvage and (2) to identify perioperative strategies that correlate with successful salvage.

Methods: A retrospective chart review was performed on all free flaps performed from January of 2005 to April of 2011. The time until salvage was defined as the end of the initial procedure until the initiation of the salvage attempt. The primary endpoint, successful salvage, was defined as any flap that did not result in total loss.

Results: A total of 2260 free flaps were reviewed, and 47 take-backs for delayed microvascular compromise were identified. Twenty-three of 47 flaps (49 percent) were salvaged. The mean time until take-back, presence of thrombophilia, and preoperative platelet counts were factors predictive of unsuccessful salvage. Preoperative platelet counts above 300 were associated with the lowest rates of salvage. Intraoperative maneuvers were examined, and surgeon experience (defined as >5 years in practice) was the only factor that was significant; however, intraoperative heparin anticoagulation and complete mechanical thrombectomy trended toward significance. The type of thrombolytic agent used was not found to result in a statistically significant difference.

Conclusions: There is evidence to suggest that there may be preoperative factors predictive of flap salvage success, including thrombophilia and routine preoperative platelet values. Shorter time to take-back and surgeon experience may improve salvage, whereas intraoperative heparin anticoagulation and complete mechanical removal of the thrombus demonstrate preliminary evidence as effective intraoperative strategies.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Philadelphia, Pa.

From the Division of Plastic Surgery, University of Pennsylvania Health System.

Received for publication November 10, 2011; accepted March 13, 2012.

Presented at the 28th Annual Meeting of the Northeastern Society of Plastic Surgeons, in Amelia Island, Florida, October 20 through 23, 2011, and the 91st Annual Meeting and Symposium of the American Association of Plastic Surgeons, in San Francisco, California, April 14 through 17, 2012.

Disclosure: No author of this article has any financial interests or commercial associations to disclose.

Liza C. Wu, M.D.; Division of Plastic Surgery, 10 Penn Tower, 3400 Spruce Street, Philadelphia, Pa. 19104, liza.wu@uphs.upenn.edu

©2012American Society of Plastic Surgeons