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A Single Institutional Analysis of 5,000 Flaps: An Evaluation of Microsurgical Free Flap Salvage Predictors and Take-Backs Following Microvascular Compromise
Jason M. Weissler, M.D., Martin J. Carney, B.S., Michael G. Tecce, D.O., Ari M. Wes, B.S., Joshua Fosnot, M.D., Suhail K. Kanchwala, M.D., David W. Low, M.D., Stephen J. Kovach, M.D., Liza C. Wu, M.D., Joseph M. Serletti, M.D..
University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Microvascular compromise remains a devastating complication following free tissue transfer. The purpose of this study is to identify preoperative risk factors and perioperative strategies predictive of successful flap salvage.
METHODS: A retrospective chart review was conducted for all breast, head/neck, and lower extremity free flaps performed at a single-institution between 2005-2015. The primary endpoint, successful salvage, was defined as any flap that did not result in complete flap loss. Univariate analysis was performed using Chi-squared, Wilcoxon rank-sum, and Fisher’s exact test. Lastly, a multivariate logistic regression was performed.
RESULTS: Of the first consecutive 5,000 free flaps performed by 6 surgeons, 4,847 free flaps were analyzed. 74 take-backs for delayed microvascular compromise were identified. The overall mean take-back rate was 1.53%. Fifty flaps (67.6%) were salvaged. Factors predictive of successful salvage included: no thrombotic event during index reconstruction (OR=19.6; p=0.016) and revision of index anastomosis during take-back (OR=6.48; p=0.014). Chemical thrombectomy use (OR=12.2; p=0.096) and non-existence of thrombophilic abnormalities (OR=8.2; p=0.054) trended towards significance.
CONCLUSION: This study represents the largest take-back series in the published literature. There is evidence to suggest that certain preoperative comorbidities and identifiable intraoperative maneuvers are predictive of flap salvage success. Effective operative strategies are available to the surgeon to mitigate thrombotic complications, arguing for a standardized approach to microvascular compromise.


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