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N. Patel et al.
replantation [85], and the use of LMWH has been
described in salvage of free aps. Injection of
LMWH directly into areas of the congested ap in
a subcutaneous fashion has been described, with
the onset of action and time to visible effect
reported to be about 2h, with peak effect occurring
at about 4–5 h and duration of effect of about
12–24 h. It has been recommended that doses of
20–40mg every 4–6h should be implemented for
the rst 1–3days, decreasing to 10–20mg every
24 h around the 10–14-day mark [86]. Therapy
should be continued for a minimum of 10days, as
studies have identied the time frame for the reestablishment of neovascularization to be around
7–10days [87]. As with Rt-PA, the use of LMWH
can be useful in cases of thrombosis both at the
level of the pedicle and within the microcirculation
of the ap, which may not be amenable to surgical
exploration. In addition to its anticoagulant effects,
heparin has been shown to reduce endothelial dysfunction within the microcirculation of postischemic aps, thus providing a protection against
reperfusion injury that is independent of its systemic anticoagulant effects, though the exact mechanism of this effect is yet unknown. It has been
postulated to be linked to effects such as inhibition
of leukocyte adhesion to postischemic endothelium
via increases in nitric oxide synthesis, reduction of
free radicals due to its capacity to release superoxide dismutase from the endothelium, as well as
direct anti-inammatory effects [88–90].
Leeches (hirudotherapy) have shown promise
in the management of venous congested aps,
particularly as a bridge to formal surgical exploration and revision [91, 92]. Leech therapy is
only useful, however, in cases where arterial
inow is patent and sufcient, and therapy is targeted at decreasing the accumulating venous
pressure within the ap (Fig. 6.9). Leeches
secrete a non-heparin anticoagulant called hirudin, which aids in the feeding process. Leeches
are kept in refrigerated distilled water with
Hirudo salt. Prior to application, any blood clots
should be cleaned off with dry gauze (use of alcohol swabs may interfere with latching). The leech
is grasped with gloves or non-toothed forceps
and placed onto the ap. If the leech does not
latch, the ap can be pricked to induce bleeding
to encourage the leech to latch. The leech will
generally detach once it is fully distended and
must be monitored to prevent migration of the
leech to other areas, with treatment lasting anywhere from 30 min to 4–5 h. Leeches are then
euthanized in 70% isopropyl alcohol and discarded. All patients are placed on antibiotics prophylaxis for Aeromonas hydrophila for the
duration of leech therapy, which consists of doxycycline, ciprooxacin, ceftriaxone, or Bactrim,
with prophylaxis continuing for 14 days after
cessation of leech therapy. Furthermore, the
patient’s hemoglobin levels must be monitored
throughout the treatment period every 6h, and
transfusion should be considered if levels drop
below 10g/dL in symptomatic patients [93]. It
should be noted that leech therapy has not been
shown to help salvage all venous congested tissues and as such should not be used as a primary
method of ap salvage [94, 95].
HBOT has been shown to improve the survival of free ap failures in the setting of arterial,
venous, and combined arteriovenous insufciency; however, it has been validated primarily
in animal models [96]. In contrast to leech therapy, HBOT has been shown to impact ap survival greatest in cases of arterial insufciency,
secondary to its ability to enhance broblasts and
collagen synthesis, promote neovascularization,
and reduce local hypoxic insults [97, 98]. Further
Fig. 6.9 Use of
medicinal leeches on
venous congested ap.
Note the improvement
of central portion of
ap, with necrosis of
limited to lateral edge
and distal tip
6 Free Flap Considerations andComplications
107
investigation in human subjects is necessary at
this time to better evaluate the efcacy of HBOT
as an accepted mode of free ap salvage in head
and neck reconstructive surgery.
Hematomas
The formation of hematomas not only compromises tissues by the extrinsic pressure effect they
elicit, but they also induce a complex sequence of
interrelated biochemical and cellular events,
including neutrophil inltration, cytokinemediated inammation, and a prothrombotic
state, which leads to synthesis of reactive oxygen
species and activation of the complement system,
resulting in tissue injury, as well as vascular
thrombosis [99, 100]. Sources of bleeding may
include the vascular pedicle, tissue bed, as well
as bleeding from ap edges. Postoperative
hematoma formation (Fig. 6.10) accounts for
anywhere between 0.2% and 30% [101] of postoperative complications relating to free aps in
head and neck reconstruction, representing the
second most common postoperative complication in free aps, just behind vascular thrombosis
[102]. This is higher than other regions of the
body, likely relating to increased dead space in
the head and neck with more anatomical constraints, more complex vascular anatomy, as well
as difculty in immobilization and autonomic
reexes such as gagging and coughing, as well as
vomiting, resulting in inadvertent pedicle disruption or vascular leakage [103]. Studies have
shown that free aps are compromised by hematomas 2–4% of the time within this cohort, most
commonly resulting from compromise of venous
outow and ap congestion [104]. As such, early
recognition of hematoma formation and management are crucial to free ap salvage. A study by
Chen etal. concluded that if return to the OR for
re-exploration and salvage was within 36h, salvage rates were signicantly higher at 84% as
compared to 50% if return to OR was after this
time frame, with salvage rates especially higher
in cases where there was an absence of thrombosis [105]. Other studies have shown salvage rates
of 93.3% if return to OR was within 5h of detection, and 100% in the absence of thrombosis, as
compared to 58.3% in the presence of vascular
thrombosis [106]. The use of postoperative anticoagulation to decrease vascular thrombosis rates
in free aps remains a debated topic with no consensus as of yet. Studies have shown that in cases
where no anticoagulation therapy was used, rates
of free ap failure, thrombosis, as well as rates of
hematoma formation were similar to rates of various anticoagulation therapies [107, 108].
However, a study by Kroll etal. demonstrated a
statistically signicant increase in rates of hematoma formation in patients who received highdose heparin for pedicle thrombosis prophylaxis
at 20% [109]. Moreover, other studies have
shown that the use of NSAIDs postoperatively
has been associated with higher rates of hematoma formation in this cohort, with aspirin showing the lowest rates of hematomas [110, 111]. All
this may suggest that anticoagulation postoperatively offers no or minimal improvement in ap
survival and minimal effect on ap-related complications in the postoperative setting [112].
Despite this, patients often require chemoprophylaxis for reasons other than prevention of ap
thrombosis, such as prevention of VTE, and thus
Fig. 6.10 Formation of
postoperative
hematomas in free ap
patients
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N. Patel et al.
this should be taken into consideration. It has
also been suggested that postoperative blood
pressure control can inuence rates of hematoma
formation and should ideally be <150 mmHg
systolic, as rates of hematoma formation can
increase with even transient increases of about
165mmHg systolic [113]. Despite this, maintaining a high enough blood pressure to maintain
good ap perfusion and avoiding signicant periods of hypotension are essential, with systolic
blood pressure ideally maintained above
100mmHg for this purpose [114].
Signs of the presence of a hematoma can
sometimes be subtle, with just the localized
development of ecchymosis in the cervical region
or just the presence of a mild amount of edema.
Other times, evidence of hematoma formation is
more obvious, with the presence of a large swelling, ecchymosis, bleeding from between sutures,
compression of the vascular pedicle, and venous
outow blockage.
One method by which to manage hematoma
formation is the removal of sutures at bedside
with evacuation of the hematoma. Some authors
however have stated that given the cytotoxic
nature of the effects of a hematoma, as well as the
potential for incomplete hematoma evacuation,
performing this maneuver is not sufcient and
return to the OR for exploration and formal evacuation is recommended (Fig. 6.11) [115].
Additionally, formal exploration is often warranted in order to identify and obtain surgical
control of bleeders if present, and to examine the
vascular pedicle for potential thrombosis. If reexploration is performed prior to the formation of
vascular thrombosis, salvage rates are signicantly higher, underscoring the importance of
early detection.
Salvage Reconstruction
Unfortunately, there are the rare instances where
ap salvage appears to be unlikely, and surgeons
are left to make a tough decision, namely when to
terminate salvage efforts and what steps to take
next. In the case of partial ap failure, options for
management depend primarily on the amount of
residual defect after partial ap debridement or
excision, location of the defect, as well as tissue
availability. In cases where a small defect
remains, local tissue rearrangement sometimes
sufces for the purposes of wound coverage,
whereas larger defects may necessitate the use of
a regional ap. If the defect involves a communication of the oral cavity to the neck, salivary leak
into the cervical tissues becomes a signicant
consideration, given the increased risk of infection and stula formation. In the setting of total
ap failure, one must balance the needs of the
wound or defect for reconstruction with a goal of
restoring form and function, with the ability of
the patient to tolerate another extensive procedure and to decide what additional procedure
should be undertaken. The reconstructive options
remain similar, a second free tissue transfer,
regional ap, or local tissue rearrangement
(Fig.6.12) [4]. In addition to the tolerance of a
secondary procedure, consideration should be
made for extended hospital stay with potential for
Fig. 6.11 Complete
evacuation of hematoma
during exploratory
surgery in OR
6 Free Flap Considerations andComplications
109
Fig. 6.12 Unsalvageable necrotic free ap with removal of ap, and salvage supraclavicular ap performed for cheek
reconstruction
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Fig. 6.12 (continued)
additional morbidity, as well as the timing of
radiation, if applicable, as a delay in this treatment modality is not favorable. The decision of
what type of secondary reconstruction should be
done at this time depends on several factors,
including the type and location of the original
defect, number and amount of available tissues or
ap options, and patient comorbidities and stability. The simplest reconstruction should be undertaken, one that has the highest chance of success
and the minimum amount of additional patient
morbidity. For example, in the case of maxillomandibular reconstruction with a free osteocutaneous bula ap, in the event of bula ap failure,
the ideal salvage ap would be a second free bula ap, as that has the highest chance of meeting
the reconstructive requirements. However, if a
second bula ap cannot be harvested due to anatomic restrictions (lack of adequate three-vessel
runoff), or due to the patient’s fragility or inability to tolerate a second lengthy procedure, one
should consider a soft tissue ap such as an
anterolateral thigh ap or radial forearm free ap
to obtain wound coverage, which would provide
a shorter procedure and thus less morbidity for
the patient. If the patient will be obtaining dental
implants, secondary bone grafting can be considered at a later stage. Another option in this case
can be a pedicled ap, such as a pectoralis myocutaneous ap if the surgeon chooses to avoid
N. Patel et al.
another free ap procedure because of a vesseldepleted neck, patient stability issues, diagnosis
of thrombophilic disorder, severe infection, etc.
Salvage reconstruction often presents a challenge
as it occurs in a previously operated wound bed,
often contaminated or infected, and the ideal ap
has already been utilized. As such, success rates
in the salvage setting often drop as compared to
the primary reconstruction setting. Bozikov and
Arnez found that ap failures in the salvage operation were 4.6× more likely, with a success rate
of only 53.3% [116]. Salvage reconstruction can
be done either in the immediate setting or in a
delayed fashion, depending on these factors,
though most surgeons will opt to perform it
immediately. In the head and neck, this presents a
particular challenge as specic issues come into
consideration, such as dealing with vesseldepleted necks, salivary contamination/leak if a
composite defect of the oral cavity is involved,
patients having a history of prior radiation,
patients with head and neck cancer who are often
malnourished with poor wound healing, and need
for coverage of the great vessels, among others
[117]. In cases of limited availability of adequate
vessels for anastomosis, due to radiation damage
or depletion from previous free ap surgery, surgeons can consider options such as vein grafting;
use of the internal mammary, thoracoacromial
vessels, or transverse cervical vessels; and use of
the contralateral neck vessels, or end-to-side
anastomoses, in particular with the internal jugular vein, as this provides reliable drainage, good
caliber, and consistent anatomy [118–121].
Though surgeons often desire to provide patients
with the best reconstructive option possible, one
must also consider that sometimes the best reconstruction … is no reconstruction. The use of synthetic prostheses, when available, often can
represent excellent alternatives as prosthetic
reconstruction, for patients in whom surgical
reconstruction is not an option. A wide variety of
options exist for orbital, nasal, maxillary, and
auricular reconstruction, with or without implants
for support and retention [122].
6 Free Flap Considerations andComplications
111
Conclusion
Free ap reconstruction of the head and neck represents a complex surgical endeavor and can be
wrought with complications at any stage of
patient care. Surgeons must be mindful and must
employ careful patient selection and workup, as
well as demonstrate excellent surgical technique,
and patients should be carefully and constantly
monitored in the immediate postoperative period
to help mitigate, and ideally avoid, these complications. Surgeons must be adept at recognizing
issues early that could potentially compromise
ap viability and be prepared to perform additional salvage procedures to maximize success
rates.
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Part III
Post-operative Considerations
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