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Interposition Vein Grafting in Head and Neck Free Flap Reconstruction

Maricevich, Marco, M.D.; Lin, Lawrence O., B.S.; Liu, Jun, Ph.D.; Chang, Edward I., M.D.; Hanasono, Matthew M., M.D.

Plastic and Reconstructive Surgery: October 2018 - Volume 142 - Issue 4 - p 1025-1034
doi: 10.1097/PRS.0000000000004770
Reconstructive: Head and Neck: Original Articles
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Background: Many surgeons are hesitant to use interposition vein grafting in head and neck microvascular free flap surgery because of concerns for elevated risk of flap loss.

Methods: The authors conducted a review of patients who underwent head and neck free flap reconstruction between 2005 and 2015. The effect of vein grafts on flap compromise and flap loss was analyzed using univariate and multivariate models.

Results: A total of 3240 free flaps were performed. Vein grafts were used in 241 flaps (7.4 percent). The free flap compromise rate was 14.5 percent with vein grafts and 3.4 percent without vein grafts (p < 0.001). The free flap loss rate was 6.4 percent with vein grafts and 1.1 percent without vein grafts (p < 0.001). Radiation therapy, chemotherapy, prior neck dissection, prior free flap, osteoradionecrosis, and multiple free flap surgery were more frequent within the vein graft group (all p < 0.001). Despite this, vein grafting was associated with an increased risk of flap compromise (adjusted OR, 4.8; 95 percent CI, 3.2 to 7.3; p < 0.001) and flap loss (adjusted OR, 5.5; 95 percent CI, 3.0 to 10.2; p < 0.001) on multivariable analysis. Individual review of each flap loss within the vein graft group identified no cases of thrombosis caused by anastomotic technical errors, arguing against the requirement of an additional anastomosis as a cause for loss of vein-grafted free flaps.

Conclusions: An increased risk of free flap compromise and loss is associated with use of vein grafts. However, a 93.4 percent success rate was still achieved in notably more challenging cases where vein grafting was deemed necessary taking into consideration the pertinent risks and benefits.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

This and Related “Classic” Articles Appear on Prsjournal.com for Journal Club Discussions.Coding Perspective for this Article is on Page 1033.

Houston, Texas

From the Division of Plastic Surgery, Baylor College of Medicine; and the Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center.

Received for publication October 20, 2017; accepted March 27, 2018.

Disclosure:The authors have no financial interest to declare in relation to the content of this article. No funding was received for this study.

Matthew M. Hanasono, M.D., Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 443, Houston, Texas 77030, mhanasono@mdanderson.org

Copyright © 2018 by the American Society of Plastic Surgeons