ARTICLE IN PRESS. Postoperative complications in 202 cases of microvascular head and neck reconstruction

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1 Journal of Cranio-Maxillofacial Surgery (2007) 35, r 2007 European Association for Cranio-Maxillofacial Surgery doi: /j.jcms , available online at ARTICLE IN PRESS Postoperative complications in 202 cases of microvascular head and neck reconstruction Philipp POHLENZ 1,, Marco BLESSMANN 1,, Max HEILAND 1, Felix BLAKE 1, Rainer SCHMELZLE 1, Lei LI 2 1 Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Rainer Schmelzle), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 2 Department of Oral and Maxillofacial Surgery (Head: Priv. Doz. Dr. Dr. Lei Li), Klinikum Oldenburg, Oldenburg, Germany Available online 14 September 2007 SUMMARY. Introduction: This retrospective study was intended to determine the incidence and causes of postoperative complications in patients following head and neck reconstruction using microvascular free flaps. Patients and methods: A total of 202 consecutive microvascular free flaps were performed for reconstruction of the head and neck by the same surgeon, 85% of the defects arose following the treatment of malignancies. Flap donor sites included latissimus-dorsi flap (n ¼ 83), radial forearm (n ¼ 35), fibula (n ¼ 31), iliac crest (n ¼ 36), TRAM flap (n ¼ 3), groin flap (n ¼ l), jejunal flap (n ¼ 13). The incidence of postoperative complications and patient-related characteristics (age, sex, diagnosis, comorbidity level, operation duration, defect site, history of radiotherapy/chemotherapy) were retrospectively analyzed. Results: Free flaps proved to be extremely reliable, with a 2.9% incidence of free flap failure. Postoperative medical complications occurred in 11.4% of cases, with cardiac, pulmonary and infectious complications predominating. Conclusion: The present study confirms that free flaps are extremely reliable in achieving successful reconstruction of the head and neck. The incidence of postoperative complications is related to the preoperative comorbidity. r 2007 European Association for Cranio-Maxillofacial Surgery Keywords: postoperative complications, free tissue transfer, microsurgical reconstruction, head and neck INTRODUCTION Surgical treatment of patients with head and neck cancer was revolutionized during the 1970s with the advent of microvascular free flaps for reconstruction of head and neck defects (Taylor et al., 1975). The microsurgical tissue transfer is a well-established concept. The use of microvascular free tissue transfer has allowed the reconstruction of increasingly complex defects following extensive resection in the head and neck. It facilitates not only the filling of defects but also allows functional rehabilitation, (Chick et al., 1992; Bridger et al., 1994; Malata et al., 1996). Although advanced age itself is not a contradiction for any type of surgery, diminished functional capacities of all vital organs in elderly patients and the presence of associated medical problems may increase perioperative and postoperative morbidity and mortality (Shestak et al., 1992; Coskunfirat et al., 2005). The aim of this study was to assess the incidence and causes of complications in patients undergoing microvascular free flap reconstruction for surgical defects of the head and neck. A retrospective study was conducted including 202 microvascular free tissue transfers performed for the reconstruction of surgical defects in the head and neck region. There These authors contributed equally. are several consecutive series which describe the outcome of free flap operations (Schustermann et al., 1994; Simpson et al., 1996; O Brien et al., 1998; Haughey et al., 2001; Suh et al., 2004; Eckardt and Fokas, 2003; Classen and ward, 2006). However, unique to this study was the fact that all surgical procedures were performed by the same surgeon, a rare feature in previous studies. PATIENTS AND METHODS Two hundred and two free flap procedures were performed on 188 patients (104 men and 84 women, ranging in age from 4 to 92 years) between 1998 and 2005 for reconstruction of defects in the head and neck region by the senior author (L.L.). Of the 188 patients, 174 received 1 free flap, 1 received 2 simultaneous free flaps, and 13 received 2 sequential flaps to treat recurrent cancer (7 cases) or cases of reconstructive failure (6 cases). Eighty five percent were the consequence of radical tumour resection. Forty percent of the reconstructions were performed after radiotherapy. Ten percent of the free flaps were used to reconstruct traumatic or congenital defects of the head and neck. Over 90% of the defects involved the oral cavity and/or the oropharynx, 5% were defects in the pharyngoesophageal segment, and 311

2 312 Journal of Cranio-Maxillofacial Surgery another 5% were defects involving the skull base. For anastomosis, cervical recipient blood vessels were used. All patients received low dose anticoagulation with heparin, given by continuous infusion for 1 week (200 I.U./KG bw/24 h). The free flaps selected for reconstruction are listed in Fig. 1. Data were analysed retrospectively including age, sex, co-morbidity level (ASA) according to the American Society of Anaesthesiology status, diagnosis, radiotherapy, chemotherapy, operative time and the free flap type. The main outcome measures were complications occurring within 30 days of surgery. Complications were further categorized as reconstructive or general medical complications. Reconstructive complications were defined as those having a direct impact on the flap donor or recipient site. General medical complications were categorised by affected organ systems, which are listed in Fig. 2. RESULTS Reconstructive complications occurred in 52 (25.7%) of 202 surgical procedures, the postoperative mortality was 0.49% (1 of 202 surgical procedures performed). This was a 75-year old patient with a history of cardiac disease who died 14 days after fibula flap transfer for mandibular reconstruction. The patient succumbed to a myocardial infarction. Twenty one cases required urgent surgical reexploration for clinical evidence of vascular flap compromise. In the study group there were 12 cases of venous thrombosis of flaps. Four flaps were salvaged either reanastomosis, additional venous anastomosis, or via hydrodilatation. Five flaps were salvaged on the 1st, 2nd or 3rd postoperative days. Nevertheless, 3 flaps were lost on the 2nd, 3rd and 5th post-op-day, resulting in 75% successful salvage in cases of venous Distribution of performed flaps Groin Tram Jejunal Fibula Radial forearm Iliac crest Latissimus dorsi Latissimus dorsi Iliac crest Radial forearm Fibula Jejunal Tram Groin No performed No. performed Fig. 1 Distribution of 202 free flaps used for head and neck reconstruction in 188 patients Medical complications No. (%) of occurences Respiratory Cardiac Infection Gastrointestinal Neurological Periopertive mortalitiy Fig. 2 Postoperative general medical complications in 202 surgical procedures.

3 Postoperative complications in 202 cases of microvascular head and neck reconstruction 313 complications. In 4 cases, arterial thrombosis occurred. Only one flap was successfully salvaged despite reexploration and thromobolytic therapy with heparin. Haematomas were (n ¼ 5) all resolved intraoperatively or on the following day. Overall, the rate of successful salvage of ischaemic free flaps by urgent surgical reexploration was 71.4% (15 of 21 cases). The overall rate of free flap failure due to microvascular thrombosis was 2.9% (6 of 202). One failure following iliac bone grafting has been secondarily resolved using a free fibula flap. In the cases of lost latissimus-dorsi flaps, in one patient a second free flap was harvested from the contralateral site and another repair was salvaged with a pedicled pectoralis major flap. All other patients refused further reconstruction, not least because of advanced age. The most common reconstructive complications are listed in Fig. 3. General medical complications occurred in 23 of 202 surgical procedures (11.4%). Specific medical complications are listed in Fig. 2. The cardiac, respiratory and infectious complications predominated among the group of medical complications. All other medical complications were less than 5%. The most common medical complications were pneumonia and supraventricular tachyarrhythmia. The analysis showed a significant relationship between the incidence of perioperative complications and the risk factors of ASA status. The incidence of postoperative reconstructive complications was associated with the risk factors of flap type, previous surgery, radiotherapy. The incidence of postoperative medical complications was associated with age, operation duration, ASA status and flap type. Other risk factors analysed, including sex, diagnosis, defect site, history of chemotherapy had no significant impact on the incidence of complications, reconstructive or general medical complications. DISCUSSION The use of microvascular free tissue transfer has allowed the reconstruction of complex defects in high risk patients (Khouri, 1992). In the present series, the incidence of free flap failure in 67 cases of vascularized bone-transfers was 5.9% (4/67) compared with two flap failures in 135 soft tissue flaps (1.48%). The 1.98% incidence of iliac crest flap failure (4/202) proved to be statistically higher than the 0.9% incidence of flap failure (2/202) seen with all other types of free flaps. In three of four cases of total flap necrosis involving the iliac crest, occlusion of the anastomosed vessels was caused by infection arising from partial necrosis of the skin that was used to reconstruct the intraoral defect. Similar observations were reported from Takushima et al. (2001). Other factors that have been reported as associated with an increased risk of free flap failure include flap diameter greater than 7 cm, operative time longer than 12 h, reconstruction following radiotherapy. The impact of comorbid conditions on outcome of patients with head and neck cancer has been demonstrated by many authors (Piccirillo et al., 1994; Singh et al., 1997, 1998, 1999). Similarly, the impact of comorbid conditions on surgical outcome has also been well appreciated (Concato et al., 1992; Piccirillo et al., 1994). Several authors have attempted to evaluate the impact of the baseline medical status on the outcome of patients treated with microvascular free tissue transfer (Shestak et al., 1992; Bridger et al., 1994). Chick et al. (1992), in a study of elderly patients, evaluated the individual impact of seven different medical conditions, reporting an increase in the complication rate with increasing number of comorbid conditions. Similarly, Bridger et al. (1994) evaluated four different conditions, including a fifth category for other significant diseases, reporting a correlation with increasing numbers of comorbid conditions and the development of complications. The present series showed a significant relationship between the incidence of postoperative complications and the risk factors of ASA status, flap type, previous surgery and radiotherapy. Similar results were reported from Schustermann et al. (1994). It has been reported that an increased risk of free flap failure in Postoperative reconstructive complications in 202free flap transfers Total free flap necrosis Partial free flap necrosis Cervical hematoma Salivary fistula formation Necrosisof facial/neck skin Delayed wound healing Occurences Fig. 3 Postoperative reconstructive complications in 202 free flap procedures.

4 314 Journal of Cranio-Maxillofacial Surgery patients with previous surgery exist. Those increasing complication rates may reflect the complexity of reconstruction because of scarring and fibrosis secondary to previous surgery. The impact of previous radiotherapy on local tissue and vasculature and its negative impact on surgical outcomes in head and neck surgery are well established (Sams, 1965; Kiener et al., 1991). The role of radiation exposure in the outcome of microvascular free tissue transfer has also been evaluated. Tabah et al. (1984) reported an increase in both local complications and flap failures in previously irradiated patients. Recent reports have confirmed this association. However, Bengtson et al. (1993) studied 354 patients undergoing 368 microvascular free tissue transfers and did not find any relationship between preoperative radiation therapy and the development of complications. Similarly, Kiener et al. (1991) also did not find an association between preoperative radiation and the development of complication. In addition Smolka et al. (2005) noticed that associated radiation therapy had no marked influence on the occurrence of complications. In contrast, preoperative radiation therapy was one of the main factors associated with an increased risk of recipient site complications in our study. There are several factors that may explain the differences observed between these studies. The flap failure rates in Tabah s study (6 12%) from 1984 are higher than those reported in the 1990s, consequent to advances in techniques (Kiener et al., 1991; Singh et al., 1999). Furthermore, the outcome of microvascular free tissue transfer in patients after radiotherapy demands a greater surgical skill than in nonirradiated patients. The incidence of primary wound healing in the head and neck in patients after microvascular free tissue transfer has to be noted. In the present series, the incidence of complications associated with delayed recipient site healing proved very low (9.4% of all cases including patients after in irradiation). There was a 4.0% incidence of partial free flap necrosis and a 2.5% incidence of salivary fistula formation. These rates are in accordance with the literature. However, regarding the incidence of salivary fistula formation even higher rates have been reported (Ferri et al., 1999; Haughey et al., 2001). The question of what anticoagulation regime seems adequate is the basis for much debate in the medical literature and there are no evidence based recommendations currently available (Davies, 1982; Johnson and Barker, 1992). For example, Khouri et al. (2001) concluded that the use of recombinant human tissue factor pathway inhibitor (rh TFPI) as an intraluminal irrigant during free flap reconstruction is safe, well tolerated, and as effective as the use of heparin for preventing thromboembolic complications during and after operations. Furthermore, the lower dose of rh TFPI (0.05 mg/ml) may reduce the occurrence of postoperative haematoma and help prevent flap failure (Khouri et al., 2001). Moreover, no recommendation concerning the intraoperative blood pressure management, haemoglobin levels or the implementation of alpha sympathometic drugs exist. Due to the established surgical techniques, high success rates are currently achieved. Nonetheless, due to the dire consequences of flap loss, improved evidence-based strategies of intra- and perioperative management must be aspired to leading to a further improvement of the success rates. However, in view of the success rates that have been achieved with traditional donor sites, flaps harvested from other sites have been described with promising results as well, extending the surgical armamentarium (Wolff et al., 2006). CONCLUSION Microvascular surgery is a highly successful and reliable method for the reconstruction of large head and neck defects, associated with a low incidence of free flap failure, promoting primary wound healing. Irradiated patients have a significantly higher risk of developing complications at the recipient site. To identify patients who are at higher risk of experiencing postoperative complications, a careful preoperative assessment, with particular attention to the ASA status, previous surgery, age of patient, history of radiotherapy, are necessary. 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