An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures

Angelica Hernandez Alvarez; Daniela Lee; Erin J. Kim; Kirsten Schuster; Iulianna Taritsa; Jose Foppiani; Lauren Valentine; Allan A. Weidman; Carly Comer; Bernard T. Lee; Samuel J. Lin

doi:10.1055/s-0044-1787776

Journal of Reconstructive Microsurgery, Table of Contents

J Reconstr Microsurg 2025; 41(02): 170-176
DOI: 10.1055/s-0044-1787776

Original Article

An Institutional Analysis of Early Postoperative Free Tissue Transfer Takeback Procedures

Angelica Hernandez Alvarez

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Daniela Lee

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Erin J. Kim

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Kirsten Schuster

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Iulianna Taritsa

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Jose Foppiani

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Lauren Valentine

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Allan A. Weidman

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Carly Comer

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Bernard T. Lee

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

,

Samuel J. Lin

¹Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

› Author Affiliations

Abstract

Background Postoperative free tissue transfer reexploration procedures are relatively infrequent but associated with increased overall failure rates. This study examines the differences between flaps requiring takeback versus no takeback, as well as trends in reexploration techniques that may increase the odds of successful salvage.

Methods A retrospective review was conducted on all free tissue transfers performed at our institution from 2011 to 2022. Patients who underwent flap reexploration within 30 days of the original procedure were compared with a randomly selected control group who underwent free flap procedures without reexploration (1:2 cases to controls). Univariate and multivariate logistic regression analyses were performed.

Results From 1,213 free tissue transfers performed in the study period, 187 patients were included in the analysis. Of the total flaps performed, 62 (0.05%) required takeback, and 125 were randomly selected as a control group. Free flap indication, flap type, reconstruction location, and number of venous anastomoses differed significantly between the two groups. Among the reexplored flaps, 8 (4.3% of the total) had a subsequent failure while 54 (87.10%) were salvaged, with significant differences in cause of initial flap failure, affected vessel type, and salvage technique.

Conclusion Free tissue transfers least prone to reexploration involved breast reconstruction in patients without predisposition to hypercoagulability or reconstruction history. When takeback operations were required, salvage was more likely in those without microvascular compromise or with an isolated venous injury who required a single exploratory operation.

Keywords

flap failure - breast reconstruction - flap takeback

Full Text

References

References
1 Ahmad FI, Gerecci D, Gonzalez JD, Peck JJ, Wax MK. The role of postoperative hematoma on free flap compromise. Laryngoscope 2015; 125 (08) 1811-1815
2 Ricci JA, Vargas CR, Ho OA, Lin SJ, Tobias AM, Lee BT. Evaluating the use of tissue oximetry to decrease intensive unit monitoring for free flap breast reconstruction. Ann Plast Surg 2017; 79 (01) 42-46
3 Lin SJ, Nguyen MD, Chen C. et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127 (03) 1080-1085
4 Selber JC, Angel Soto-Miranda M, Liu J, Robb G. The survival curve: factors impacting the outcome of free flap take-backs. Plast Reconstr Surg 2012; 130 (01) 105-113
5 Stranix JT, Lee ZH, Jacoby A. et al. Forty years of lower extremity take-backs: flap type influences salvage outcomes. Plast Reconstr Surg 2018; 141 (05) 1282-1287
6 Zhao R, Shammas RL, Broadwater G. et al. Assessing the influence of attending surgeon continuity on free flap outcomes following unplanned returns to the operating room. J Reconstr Microsurg 2020; 36 (08) 583-591
7 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (03) 579-589
8 Vijan SS, Tran VN. Microvascular breast reconstruction pedicle thrombosis: how long can we wait?. Microsurgery 2007; 27 (06) 544-547
9 Odorico SK, Reuter Muñoz K, JNicksic P. et al. Surgical and demographic predictors of free flap salvage after takeback: a systematic review. Microsurgery 2023; 43 (01) 78-88
10 Yim JH, Yun J, Lee TJ, Kim EK, Cho J, Eom JS. Outcomes of take-back operations in breast reconstruction with free lower abdominal flaps. Arch Plast Surg 2015; 42 (06) 741-745
11 Han M, Ochoa E, Zhu B. et al. Risk factors for and cost implications of free flap take-backs: a single institution review. Laryngoscope 2021; 131 (06) E1821-E1829
12 Pannucci CJ, Kovach SJ, Cuker A. Microsurgery and the hypercoagulable state: a hematologist's perspective. Plast Reconstr Surg 2015; 136 (04) 545e-552e
13 Paydar KZ, Hansen SL, Chang DS, Hoffman WY, Leon P. Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate. Plast Reconstr Surg 2010; 125 (04) 1129-1134
14 Kamali A, Docherty Skogh AC, Edsander Nord Å. et al. Increased salvage rates with early reexploration: a retrospective analysis of 547 free flap cases. J Plast Reconstr Aesthet Surg 2021; 74 (10) 2479-2485
15 Chiu YH, Chang DH, Perng CK. Vascular complications and free flap salvage in head and neck reconstructive surgery: analysis of 150 cases of reexploration. Ann Plast Surg 2017; 78 (3 Suppl 2): S83-S88
16 Hudson DA, Engelbrecht G, Duminy FJ. Another method to prevent venous thrombosis in microsurgery: an in situ venous catheter. Plast Reconstr Surg 2000; 105 (03) 999-1003
17 Saber AY, Hohman MH, Dreyer MA. Basic Flap Design. StatPearls Publishing;; 2022
18 Askari M, Fisher C, Weniger FG, Bidic S, Lee WPA. Anticoagulation therapy in microsurgery: a review. J Hand Surg Am 2006; 31 (05) 836-846
19 Wong AK, Joanna Nguyen T, Peric M. et al. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2015; 35 (01) 6-12
20 Carney MJ, Weissler JM, Tecce MG. et al. 5000 free flaps and counting: a 10-year review of a single academic institution's microsurgical development and outcomes. Plast Reconstr Surg 2018; 141 (04) 855-863
21 Kalmar CL, Drolet BC, Kassis S, Thayer WP, Higdon KK, Perdikis G. Breast reconstruction free flap failure: does platelet count matter?. Ann Plast Surg 2022; 89 (05) 523-528
22 Brady JS, Govindan A, Crippen MM. et al. Impact of diabetes on free flap surgery of the head and neck: a NSQIP analysis. Microsurgery 2018; 38 (05) 504-511
23 Piwnica-Worms W, Stranix JT, Othman S. et al. Risk factors for lower extremity amputation following attempted free flap limb salvage. J Reconstr Microsurg 2020; 36 (07) 528-533
24 Struebing F, Xiong L, Bigdeli AK. et al. Microsurgical strategies after free flap failure in soft tissue reconstruction of the lower extremity: a 17-year single-center experience. J Pers Med 2022; 12 (10) 1563
25 Slijepcevic AA, Young G, Shinn J. et al. Success and outcomes following a second salvage attempt for free flap compromise in patients undergoing head and neck reconstruction. JAMA Otolaryngol Head Neck Surg 2022; 148 (06) 555-560
26 Roostaeian J, Yoon AP, Ordon S. et al. Impact of prior tissue expander/implant on postmastectomy free flap breast reconstruction. Plast Reconstr Surg 2016; 137 (04) 1083-1091
27 Chang EI, Zhang H, Liu J, Yu P, Skoracki RJ, Hanasono MM. Analysis of risk factors for flap loss and salvage in free flap head and neck reconstruction. Head Neck 2016; 38 (Suppl. 01) E771-E775
28 Cho EH, Bauder AR, Centkowski S. et al. Preoperative platelet count predicts lower extremity free flap thrombosis: a multi-institutional experience. Plast Reconstr Surg 2017; 139 (01) 220-230
29 Hwang K, Son JS, Ryu WK. Smoking and flap survival. Plast Surg (Oakv) 2018; 26 (04) 280-285
30 Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia*. J Bone Joint Surg Am 2000; 82 (12) 1681-1691
31 Hess JR, Brohi K, Dutton RP. et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008; 65 (04) 748-754
32 Xiong L, Gazyakan E, Kremer T. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: a meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (06) 511-524
33 Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free flap monitoring, salvage, and failure timing: a systematic review. J Reconstr Microsurg 2021; 37 (03) 300-308
34 Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A single center comparison of one versus two venous anastomoses in 564 consecutive DIEP flaps: investigating the effect on venous congestion and flap survival. Microsurgery 2010; 30 (03) 185-191