LANDMARK: Analysis of Complications in Head and Neck Microvascular Reconstruction

Article: Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction.

Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction.Arch Otolaryngol Head Neck Surg. 2004 Aug;130(8):962-6. 


Take Home Points: 

  • Microvascular flap reconstruction is a reliable reconstructive technique that enables immediate primary closure and infrequently leads to flap failure. 
  • Approximately ⅓ of patients in this series had a significant perioperative complications with increased complications associated with > ASA Class III and age.

 The Details: 

  • Prospective cohort study of 400 free flaps in 388 patients for head and neck reconstruction over 7 years performed by single senior academic surgeon. 
  • 37% of patients with a history of high dose RT to reconstruction site
  • Flaps: 183 radial forearm, 145 fibula, 38 abdominus rectus, 28 subscapular system, 5 iliac crest, 1 jejunal. 
  • Patient characteristics analyzed: age; sex; American Society of Anesthesiology (ASA) comorbidity status; path diagnosis; history of radiation, neck dissection, or chemotherapy; tumor T and N stage; defect classification; and free flap type. 
  • The main outcome measures were complications occurring within 30 days of surgery. 
    • Complications were further sub categorized as reconstructive complications (direct impact on donor or flap site) or medical complications (categorized by organ system).
  • 30-day mortality rate was 1.3% (5/399)
    • Causes of death: intraoperative tension pneumothorax, liver failure, myocardial infarction, pulmonary embolism and tracheostomy tube mucus plug. 
  • Flap Complications: 7 flaps surgically re-explored, 4 of 7 (57%) were salvaged. Overall flap failure due to microvascular compromise was 0.8% (3 of 400 cases, all fibula).
    • Failed: 
      • 2 cases of venous anastomotic thrombosis (POD2 and POD4)
      • 1 case of arterial anastomotic thrombosis (POD1)
    • Salvaged: 
      • 3 cases of venous congestion- 2 from hematoma on POD2 and POD5, 1 by compression of drain on POD4
      • 1 case of arterial insufficiency (POD4)
  • Perioperative complications occurred in 144 (36.1%) of 399 surgical procedures.
    • Reconstructive complications occurred in 76 (19.0%) of 399 surgical procedures. 
      • Delayed healing from partial skin graft failure at the donor sites of radial forearm and fibula flaps was most common.
    • Medical complications occurred in 82 of 399 surgical procedures (20.6%).
      • Respiratory, cardiac, and infectious complications predominated, with pulmonary edema and supraventricular tachycardia being most common. 
    • On multivariate analysis, only history of previous surgery was only significant risk factor for perioperative complications
      • Age and ASA status were risk factors for medical complications
  • Limitations: 
    • Lacks some generalizability as this is a single surgeon’s results
    • Several flap types commonly used in head and neck reconstruction are under-represented (scapular system) or not represented (ALT) in this cohort
    • Overwhelming majority (85%) were for OC/OPx
    • Surprising that radiation history was not significant risk factor for flap compromise, however complication rate is low and therefore perhaps not enough power to expose if there is a relationship

Contributed by Andrew Goates, MD

Editor: Eric Lee, MD