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Semin Plast Surg 2003; 17(3): 267-274
DOI: 10.1055/s-2004-815683
Copyright © 2003 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Avoiding and Dealing with Complications after Head and Neck Microvascular Reconstruction

Babak J. Mehrara, Peter G. Cordeiro
  • Division of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
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Publication History

Publication Date:
23 January 2004 (online)

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ABSTRACT

Recent advances in microsurgical techniques and equipment have significantly improved success rates of head and neck reconstruction. In this manuscript we review the methods commonly used by high-volume microsurgery centers to minimize postoperative complications. In addition, we describe our techniques for postoperative management, flap monitoring, and pharmacological prophylaxis for thrombosis. Finally, we discuss methods to salvage compromised flaps.

KEYWORDS

Microsurgery - complications - prophylaxis - flap salvage

REFERENCES

  • 1 Cordeiro P G, Disa J J, Hidalgo D A, Hu Q Y. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients.  Plast Reconstr Surg . 1999;  104 1314-1320
    CrossrefPubMedGoogle Scholar
  • 2 Disa J J, Cordeiro P G. Mandible reconstruction with microvascular surgery.  Semin Surg Oncol . 2000;  19 226-234
    CrossrefPubMedGoogle Scholar
  • 3 Disa J J, Pusic A L, Hidalgo D H, Cordeiro P G. Simplifying microvascular head and neck reconstruction: a rational approach to donor site selection.  Ann Plast Surg . 2001;  47 385-389
    Google Scholar
  • 4 Hidalgo D A, Disa J J, Cordeiro P G, Hu Q Y. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique.  Plast Reconstr Surg . 1998;  102 722-733
    CrossrefPubMedGoogle Scholar
  • 5 Khouri R K. Free flap surgery. The second decade.  Clin Plast Surg . 1992;  19 757-761
    PubMedGoogle Scholar
  • 6 Serletti J M, Moran S L, Orlando G S, O'Connor T, Herrera H R. Urokinase protocol for free-flap salvage following prolonged venous thrombosis.  Plast Reconstr Surg . 1998;  102 1947-1953
    CrossrefPubMedGoogle Scholar
  • 7 Serletti J M, Higgins J P, Moran S, Orlando G S. Factors affecting outcome in free-tissue transfer in the elderly.  Plast Reconstr Surg . 2000;  106 66-70
    CrossrefPubMedGoogle Scholar
  • 8 Synderman C. The pathogenesis of vascular thrombosis and its impact in microvascular surgery.  Head Neck . 1999;  21 355-359
    CrossrefPubMedGoogle Scholar
  • 9 Wax M K, Quraishi H, Rodman S, Granke K. Internal jugular vein patency in patients undergoing microvascular reconstruction.  Laryngoscope . 1997;  107 1245-1248
    CrossrefPubMedGoogle Scholar
  • 10 Blackwell K E, Brown M T, Gonzalez D. Overcoming the learning curve in microvascular head and neck reconstruction.  Arch Otolaryngol Head Neck Surg . 1997;  123 1332-1335
    CrossrefPubMedGoogle Scholar
  • 11 Blackwell K E. Donor site evaluation for fibula free flap transfer.  Am J Otolaryngol . 1998;  19 89-95
    CrossrefPubMedGoogle Scholar
  • 12 Singh B, Cordeiro P G, Santamaria E, Shaha A R, Pfister D G, Shah J P. Factors associated with complications in microvascular reconstruction of head and neck defects.  Plast Reconstr Surg . 1999;  103 403-411
    Google Scholar
  • 13 Yaffe B, Cushin B J, Strauch B. Effect of cigarette smoking on experimental microvascular anastomoses.  Microsurgery . 1984;  5 70-72
    CrossrefPubMedGoogle Scholar
  • 14 Towler J. Cigarette smoking and its effects on wound healing.  J Wound Care . 2000;  9 100-104
    PubMedGoogle Scholar
  • 15 Shin V Y, Liu E S, Koo M W, Wang J Y, Matsui H, Cho C H. Cigarette smoke extracts delay wound healing in the stomach: involvement of polyamine synthesis.  Exp Biol Med (Maywood) . 2002;  227 114-124
    PubMedGoogle Scholar
  • 16 Campanile G, Hautmann G, Lotti T. Cigarette smoking, wound healing, and face-lift.  Clin Dermatol . 1998;  16 575-578
    CrossrefPubMedGoogle Scholar
  • 17 Jones J K, Triplett R G. The relationship of cigarette smoking to impaired intraoral wound healing: a review of evidence and implications for patient care.  J Oral Maxillofac Surg . 1992;  50 237-239
    CrossrefPubMedGoogle Scholar
  • 18 Sherwin M A, Gastwirth C M. Detrimental effects of cigarette smoking on lower extremity wound healing.  J Foot Surg . 1990;  29 84-87
    PubMedGoogle Scholar
  • 19 Siana J E, Rex S, Gottrup F. The effect of cigarette smoking on wound healing.  Scand J Plast Reconstr Surg Hand Surg . 1989;  23 207-209
    PubMedGoogle Scholar
  • 20 Reus III F W, Colen L B, Straker D J. Tobacco smoking and complications in elective microsurgery.  Plast Reconstr Surg . 1992;  89 490-494
    PubMedGoogle Scholar
  • 21 Esclamado R M, Carroll W R. The pathogenesis of vascular thrombosis and its impact in microvascular surgery.  Head Neck . 1999;  21 355-362
    CrossrefPubMedGoogle Scholar
  • 22 Goldminz D, Bennett R G. Cigarette smoking and flap and full-thickness graft necrosis.  Arch Dermatol . 1991;  127 1012-1015
    CrossrefPubMedGoogle Scholar
  • 23 Merli G J. Prophylaxis for deep venous thrombosis and pulmonary embolism in the surgical patient.  Clin Cornerstone . 2000;  2 15-20
    CrossrefPubMedGoogle Scholar
  • 24 Kroll S S, Schusterman M A, Reece G P. et al . Choice of flap and incidence of free flap success.  Plast Reconstr Surg . 1996;  98 459-463
    CrossrefPubMedGoogle Scholar
  • 25 Miller M J, Schusterman M A, Reece G P, Kroll S S. Microvascular craniofacial reconstruction in cancer patients.  Ann Surg Oncol . 1995;  2 145-150
    PubMedGoogle Scholar
  • 26 Schusterman M A, Miller M J, Reece G P, Kroll S S, Marchi M, Goepfert H. A single center's experience with 308 free flaps for repair of head and neck cancer defects.  Plast Reconstr Surg . 1994;  93 472-478
    CrossrefPubMedGoogle Scholar
  • 27 Urken M L, Vickery C, Weinberg H, Buchbinder D, Biller H F. Geometry of the vascular pedicle in free tissue transfers to the head and neck.  Arch Otolaryngol Head Neck Surg . 1989;  115 954-960
    CrossrefPubMedGoogle Scholar
  • 28 Chalian A A, Anderson T D, Weinstein G S, Weber R S. Internal jugular vein versus external jugular vein anastomosis: implications for successful free tissue transfer.  Head Neck . 2001;  23 475-478
    CrossrefPubMedGoogle Scholar
  • 29 Yamamoto Y, Nohira K, Kuwahara H, Sekido M, Furukawa H, Sugihara T. Superiority of end-to-side anastomosis with the internal jugular vein: the experience of 80 cases in head and neck microsurgical reconstruction.  Br J Plast Surg . 1999;  52 88-91
    CrossrefPubMedGoogle Scholar
  • 30 Katou F, Echigo S, Ito M, Shirai N, Ohtani H, Motegi K. Reliability of internal jugular vein in oral microvascular reconstruction.  Oral Surg Oral Med Oral Pathol Oral Radiol Endod . 1998;  86 529-533
    CrossrefPubMedGoogle Scholar
  • 31 Ueda K, Harii K, Nakatsuka T, Asato H, Yamada A. Comparison of end-to-end and end-to-side venous anastomosis in free- tissue transfer following resection of head and neck tumors.  Microsurgery . 1996;  17 146-149
    CrossrefPubMedGoogle Scholar
  • 32 Ahn C Y, Borud L J, Shaw W W. Analysis of suturing techniques in the microvascular anastomosis of vessels of unequal diameter.  Ann Plast Surg . 1994;  32 469-473
    PubMedGoogle Scholar
  • 33 Bas L, May Jr W J, Handren J, Fallon J. End-to-end versus end-to-side microvascular anastomosis patency in experimental venous repairs.  Plast Reconstr Surg . 1986;  77 442-450
    CrossrefPubMedGoogle Scholar
  • 34 Harris J R, Seikaly H, Calhoun K, Daugherty E. Effect of diameter of microvascular interposition vein grafts on vessel patency and free flap survival in the rat model.  J Otolaryngol . 1999;  28 152-157
    PubMedGoogle Scholar
  • 35 Kubo T, Haramoto U, Yano K. et al . Internal jugular vein occlusion in head and neck microsurgical reconstruction.  Ann Plast Surg . 2002;  49 490-494
    CrossrefPubMedGoogle Scholar
  • 36 Quraishi H, Wax M, Granke K, Rodman S. Internal jugular vein thrombosis after functional and selective neck dissection.  Arch Otolaryngol Head Neck Surg . 1997;  123 969-973
    CrossrefPubMedGoogle Scholar
  • 37 Prim M P, de Diego I J, Fernandez-Zubillaga A, Garcia-Raya P, Madero R, Gavilan J. Patency and flow of the internal jugular vein after functional neck dissection.  Laryngoscope . 2000;  110 47-50
    PubMedGoogle Scholar
  • 38 Miller M J, Schusterman M A, Reece G P, Kroll S S. Use of interposition vein grafts in head and microsurgery.  J Reconstr Microsurg . 1994;  10 133-134
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Germann G, Steinau H U. The clinical reliability of vein grafts in free-flap transfer.  J Reconstr Microsurg . 1996;  12 11-17
    Article in Thieme ConnectPubMedGoogle Scholar
  • 40 Bayramicli M, Tetik C, Sonmez A, Gurunluoglu R, Baltaci F. Reliability of primary vein grafts in lower extremity free tissue transfers.  Ann Plast Surg . 2002;  48 21-29
    PubMedGoogle Scholar
  • 41 Gurlek A, Kroll S S, Schusterman M A. Ischemic time and free flap success.  Ann Plast Surg . 1997;  38 503-505
    PubMedGoogle Scholar
  • 42 Shaw W W, Ko C Y, Ahn C Y, Markowitz B L. Safe ischemia time in free-flap surgery: a clinical study of contact-surface cooling.  J Reconstr Microsurg . 1996;  12 421-424
    PubMedGoogle Scholar
  • 43 Hirigoyen M B, Urken M L, Weinberg H. Free flap monitoring: a review of current practice.  Microsurgery . 1995;  16 723-726
    CrossrefPubMedGoogle Scholar
  • 44 Disa J J, Cordeiro P G, Hidalgo D A. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases.  Plast Reconstr Surg . 1999;  104 97-101
    CrossrefPubMedGoogle Scholar
  • 45 Cho B C, Shin D P, Byun J S, Park J W, Baik B S. Monitoring flap for buried free tissue transfer: its importance and reliability.  Plast Reconstr Surg . 2002;  110 1249-1258
    CrossrefPubMedGoogle Scholar
  • 46 Swartz W M, Izquierdo R, Miller M J. Implantable venous Doppler microvascular monitoring: laboratory investigation and clinical results.  Plast Reconstr Surg . 1994;  93 152-163
    CrossrefPubMedGoogle Scholar
  • 47 Hirsh J, Salzman W, Marder V, Colman R. Overview of the thrombotic process and its therapy. In: Colman R, Hirsh J, Marder V, Clomes A, George J, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 3rd ed Philadelphia: Lippincott 1994: 101-193
    Google Scholar
  • 48 Davies M G, Hagen P O. The vascular endothelium. A new horizon.  Ann Surg . 1993;  218 593-609
    CrossrefPubMedGoogle Scholar
  • 49 Zinberg E M, Choo D I, Zotter L A. Effect of heparinized irrigating solutions on patency of experimental microvascular anastomoses.  Microsurgery . 1989;  10 103-107
    CrossrefPubMedGoogle Scholar
  • 50 Das S, Miller J. Current status of topical antithrombotic agents in microvascular surgery.  Microsurgery . 1994;  15 630-632
    CrossrefPubMedGoogle Scholar
  • 51 Braam M J, Cooley B C, Gould J S. Topical heparin enhances patency in a rat model of arterial thrombosis.  Ann Plast Surg . 1995;  34 148-151
    CrossrefPubMedGoogle Scholar
  • 52 Li X, Cooley B C, Gould J S. Influence of topical heparin on stasis-induced thrombosis of microvascular anastomoses.  Microsurgery . 1992;  13 72-75
    PubMedGoogle Scholar
  • 53 Kroll S S, Miller M J, Reece G P. et al . Anticoagulants and hematomas in free flap surgery.  Plast Reconstr Surg . 1995;  96 643-647
    CrossrefPubMedGoogle Scholar
  • 54 Conrad M H, Adams Jr P W. Pharmacologic optimization of microsurgery in the new millennium.  Plast Reconstr Surg . 2001;  108 2088-2096
    CrossrefPubMedGoogle Scholar
  • 55 Peter F W, Franken R J, Wang W Z. et al . Effect of low dose aspirin on thrombus formation at arterial and venous microanastomoses and on the tissue microcirculation.  Plast Reconstr Surg . 1997;  99 1112-1121
    CrossrefPubMedGoogle Scholar
  • 56 Rothkopf D M, Chu B, Bern S, May Jr W J. The effect of dextran on microvascular thrombosis in an experimental rabbit model.  Plast Reconstr Surg . 1993;  92 511-515
    PubMedGoogle Scholar
  • 57 Kitziger K J, Sanders W E, Andrews C P. Acute pulmonary edema associated with use of low-molecular weight dextran for prevention of microvascular thrombosis.  J Hand Surg [Am] . 1990;  15 902-905
    PubMedGoogle Scholar
  • 58 Hein K D, Wechsler M E, Schwartzstein R M, Morris D J. The adult respiratory distress syndrome after dextran infusion as an antithrombotic agent in free TRAM flap breast reconstruction.  Plast Reconstr Surg . 1999;  103 1706-1708
    CrossrefPubMedGoogle Scholar
  • 59 Ljungstrom K G, Renck H, Hedin H, Richter W, Rosberg B. Prevention of dextran-induced anaphylactic reactions by hapten inhibition. I. A Scandinavian multicenter study on the effects of 10 ml dextran 1, 15% administered before dextran 70 or dextran 40.  Acta Chir Scand . 1983;  149 355-360
    PubMedGoogle Scholar
  • 60 Ljungstrom K G, Renck H, Strandberg K, Hedin H, Richter W, Widerlov E. Adverse reactions to dextran in Sweden 1970-1979.  Acta Chir Scand . 1983;  149 253-262
    PubMedGoogle Scholar
  • 61 Hedin H, Richter W, Messmer K, Renck H, Ljungstrom K G, Laubenthal H. Incidence, pathomechanism and prevention of dextran-induced anaphylactoid / anaphylactic reactions in man.  Dev Biol Stand . 1980;  48 179-189
    PubMedGoogle Scholar
  • 62 Hidalgo D A, Jones C S. The role of emergent exploration in free-tissue transfer: a review of 150 consecutive cases.  Plast Reconstr Surg . 1990;  86 492-498
    CrossrefPubMedGoogle Scholar
  • 63 Macnamara M, Pope S, Sadler A, Grant H, Brough M. Microvascular free flaps in head and neck surgery.  J Laryngol Otol . 1994;  108 962-968
    PubMedGoogle Scholar
  • 64 Hoffmann J, Ehrenfeld M, Hwang S, Schwenzer N. Complications after microsurgical tissue transfer in the head and neck region.  J Craniomaxillofac Surg . 1998;  26 255-259
    PubMedGoogle Scholar
  • 65 Wheatley M J, Meltzer T R. The role of vascular pedicle thrombectomy in the management of compromised free tissue transfers.  Ann Plast Surg . 1996;  36 360-364
    CrossrefPubMedGoogle Scholar
  • 66 Marder V J, Sherry S. Thrombolytic therapy: current status (1).  N Engl J Med . 1988;  318 1512-1520
    PubMedGoogle Scholar
  • 67 Marder V J, Sherry S. Thrombolytic therapy: current status (2).  N Engl J Med . 1988;  318 1585-1595
    PubMedGoogle Scholar
  • 68 Schubert W, Hunter D W, Guzman-Stein G. et al . Use of streptokinase for the salvage of a free flap: case report and review of the use of thrombolytic therapy.  Microsurgery . 1987;  8 117-121
    PubMedGoogle Scholar
  • 69 Goldberg J A, Pederson W C, Barwick W J. Salvage of free tissue transfers using thrombolytic agents.  J Reconstr Microsurg . 1989;  5 351-356
    Article in Thieme ConnectPubMedGoogle Scholar
  • 70 Marder V, Hirsh J, Bell W. Rationale and practical basis of thrombolytic therapy. In: Colman R, Hirsh J, Marder V, Clomes A, George J, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice, 3rd ed Philadelphia: Lippincott 1994: 233-303
    Google Scholar
  • 71 Rooks M D, Rodriguez Jr J, Blechner M, Zusmanis K, Hutton W. Comparative study of intraarterial and intravenous anticoagulants in microvascular anastomoses.  Microsurgery . 1994;  15 123-129
    CrossrefPubMedGoogle Scholar
  • 72 Wein T H, Hickenbottom S L, Morgenstern L B, Demchuk A M, Grotta J C. Safety of tissue plasminogen activator for acute stroke in menstruating women.  Stroke . 2002;  33 2506-2508
    CrossrefPubMedGoogle Scholar
  • 73 Ahearn G S, Hadjiliadis D, Govert J A, Tapson V F. Massive pulmonary embolism during pregnancy successfully treated with recombinant tissue plasminogen activator: a case report and review of treatment options.  Arch Intern Med . 2002;  162 1221-1227
    CrossrefPubMedGoogle Scholar
  • 74 Dakik H A, Nasrallah A. Repeated doses of tissue plasminogen activator for failed thrombolysis: case report and review of the literature.  Heart Dis . 2001;  3 362-364
    PubMedGoogle Scholar
  • 75 Al-Buhairi A R, Jan M M. Recombinant tissue plasminogen activator for acute ischemic stroke.  Saudi Med J . 2002;  23 13-19
    PubMedGoogle Scholar
  • 76 Forster A, Wells P. Tissue plasminogen activator for the treatment of deep venous thrombosis of the lower extremity: a systematic review.  Chest . 2001;  119 572-579
    CrossrefPubMedGoogle Scholar
  • 77 Hergrueter C A, Handren J, Kersh R, May Jr W J. Human recombinant tissue type plasminogen activator and its effect on microvascular thrombosis in the rabbit.  Plast Reconstr Surg . 1988;  81 418-424
    PubMedGoogle Scholar
  • 78 Rohrich R J, Handren J, Kersh R, Hergrueter C A, May Jr W J. Prevention of microvascular thrombosis with short-term infusion of human tissue-type plasminogen activator.  Plast Reconstr Surg . 1996;  98 118-128
    PubMedGoogle Scholar
  • 79 Fudem G M, Walton R L. Microvascular thrombolysis to salvage a free flap using human recombinant tissue plasminogen activator.  J Reconstr Microsurg . 1989;  5 231-234
    Article in Thieme ConnectPubMedGoogle Scholar