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
Further Information

Publication History

Publication Date:
23 January 2004 (online)

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.

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
  • 2 Disa J J, Cordeiro P G. Mandible reconstruction with microvascular surgery.  Semin Surg Oncol . 2000;  19 226-234
  • 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
  • 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
  • 5 Khouri R K. Free flap surgery. The second decade.  Clin Plast Surg . 1992;  19 757-761
  • 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
  • 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
  • 8 Synderman C. The pathogenesis of vascular thrombosis and its impact in microvascular surgery.  Head Neck . 1999;  21 355-359
  • 9 Wax M K, Quraishi H, Rodman S, Granke K. Internal jugular vein patency in patients undergoing microvascular reconstruction.  Laryngoscope . 1997;  107 1245-1248
  • 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
  • 11 Blackwell K E. Donor site evaluation for fibula free flap transfer.  Am J Otolaryngol . 1998;  19 89-95
  • 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
  • 13 Yaffe B, Cushin B J, Strauch B. Effect of cigarette smoking on experimental microvascular anastomoses.  Microsurgery . 1984;  5 70-72
  • 14 Towler J. Cigarette smoking and its effects on wound healing.  J Wound Care . 2000;  9 100-104
  • 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
  • 16 Campanile G, Hautmann G, Lotti T. Cigarette smoking, wound healing, and face-lift.  Clin Dermatol . 1998;  16 575-578
  • 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
  • 18 Sherwin M A, Gastwirth C M. Detrimental effects of cigarette smoking on lower extremity wound healing.  J Foot Surg . 1990;  29 84-87
  • 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
  • 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
  • 21 Esclamado R M, Carroll W R. The pathogenesis of vascular thrombosis and its impact in microvascular surgery.  Head Neck . 1999;  21 355-362
  • 22 Goldminz D, Bennett R G. Cigarette smoking and flap and full-thickness graft necrosis.  Arch Dermatol . 1991;  127 1012-1015
  • 23 Merli G J. Prophylaxis for deep venous thrombosis and pulmonary embolism in the surgical patient.  Clin Cornerstone . 2000;  2 15-20
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 39 Germann G, Steinau H U. The clinical reliability of vein grafts in free-flap transfer.  J Reconstr Microsurg . 1996;  12 11-17
  • 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
  • 41 Gurlek A, Kroll S S, Schusterman M A. Ischemic time and free flap success.  Ann Plast Surg . 1997;  38 503-505
  • 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
  • 43 Hirigoyen M B, Urken M L, Weinberg H. Free flap monitoring: a review of current practice.  Microsurgery . 1995;  16 723-726
  • 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
  • 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
  • 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
  • 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
  • 48 Davies M G, Hagen P O. The vascular endothelium. A new horizon.  Ann Surg . 1993;  218 593-609
  • 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
  • 50 Das S, Miller J. Current status of topical antithrombotic agents in microvascular surgery.  Microsurgery . 1994;  15 630-632
  • 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
  • 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
  • 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
  • 54 Conrad M H, Adams Jr P W. Pharmacologic optimization of microsurgery in the new millennium.  Plast Reconstr Surg . 2001;  108 2088-2096
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 66 Marder V J, Sherry S. Thrombolytic therapy: current status (1).  N Engl J Med . 1988;  318 1512-1520
  • 67 Marder V J, Sherry S. Thrombolytic therapy: current status (2).  N Engl J Med . 1988;  318 1585-1595
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 75 Al-Buhairi A R, Jan M M. Recombinant tissue plasminogen activator for acute ischemic stroke.  Saudi Med J . 2002;  23 13-19
  • 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
  • 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
  • 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
  • 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
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