The Safety of Microvascular Free Tissue Transfer in the Elderly Population (original) (raw)
European Journal of Plastic Surgery, 1998
The aim of this study was to compare the influence of two different types of antithrombogenic medication and the technique of anastomosis on flap survival in free tissue transfer. In 81 patients, the postoperative medication was dextran and heparin (Group 1), in 123 patients heparin only (Group 2). After dextran and heparin medication arterial thrombosis occurred in six patients (7.4%), after heparin therapy only in eight patients (6.5%, p=0.79). In 154 patients an arterial end-to-end anastomosis, and in 50 patients an end-to-side anastomosis was performed. Arterial occlusion occurred in 8.9% after end-to-end anastomosis and in no case after end-toside anastomosis (p<0.02). Total flap necrosis occurred in 11 patients (5%), a partial flap necrosis occurred in three patients (2%). The results suggest that it is only the surgical method of anastomosis which has an influence on the survival rate of free flaps, the postoperative medication has no effect.
Microvascular tissue transfers in the elderly: Safety analysis for a challenging area
Now that we are in the fifth decade of free flap surgery, microvascular reconstruction has become an invaluable option among reconstructive methods. New techniques in microsurgery, shorter durations of operations, better handling of comorbid conditions by other practices, developments in anesthesiology, and better patient care in intensive care units (ICUs) all contributed to the widespread use of microsurgery. The adopted "reconstructive ladder" algorithm yielded a "reconstructive triangle" as the years passed. Nowadays the versatility of free flap use is not that burdensome on the patient's behalf. The developments in medicine that gave rise to microsurgery also contributed to other disciplines. As a result of the advances in medicine, now the average human life is longer. Due to aging populations, now there are more elderly people than ever before who have conditions that need microsurgical interventions. Diminished functional capacities of these patients with or without diagnosed illnesses are discouraging for the microsurgeon. To date, many studies have been done on microsurgical procedures in geriatric populations. These studies did not oppose these operations. Instead, they mainly tried to set criteria for patient selection. The goal was to minimize morbidity and mortality by careful patient selection using the right criteria. Age, preoperative comorbid conditions, preoperative American Society of Anesthesiologists (ASA) and Charlson Comorbidity Index (CCI) scores, preoperative platelet count, duration of operation, and hospital and ICU stays were all investigated as risk factors in the past. Due to infrequent numbers of microsurgical procedures performed in this age group, many studies failed to state statistically significant data or found contradictory results. Age was stated as an independent risk factor for morbidity in some studies (1-4), but others had opposite results (5-9). Preoperative comorbidities and tools for their assessment were also investigated. Many studies agreed that these conditions are risk factors for systemic complications, but some favored the ASA classification (4-6,8-10), some the CCI (3), and some the Kaplan Feinstein Index (KFI) (11), so there was no consensus on Background/Aim: Due to increased average life expectancy, the number of elderly patients requiring complex reconstructive microsurgical procedures is rising. Age, comorbid conditions, and location of operation are all possible risk factors. The aim of this study is to evaluate surgical outcomes to set the right criteria. Between 1996 and 2014, the data of 30 patients over the age of 70, who were treated with microsurgical techniques in our clinic, were extracted from patient records and analyzed retrospectively. In this patient population, flap success rate was 94%. Systemic and surgical complication rates were 40% and 48%, respectively. Complication rates were higher in head and neck cases but there was no statistically significant difference compared to reconstructions in other areas. Loss of oral lining, as a serious complication, had no effect on complications in head and neck reconstruction patients in our series. Conclusions: Flap success is comparable to younger age groups but procedures are associated with a high rate of complications Evaluating and controlling comorbid conditions is important. The American Society of Anesthesiologists scoring system is reliable in this patient population. Although complications are more common, these procedures can be performed safely in elderly populations with careful patient selection.
Microvascular Free Tissue Transfer: Results in 57 Consecutive Cases
Veterinary Surgery, 1998
To evaluate the outcomes and complications in a consecutive series of animals undergoing microvascular reconstructive procedures at two veterinary institutions. Retrospective study. A total of 44 client-owned dogs and one red-necked wallaby. The medical records of all animals undergoing reconstructive microsurgical procedures at the Western College of Veterinary Medicine and Michigan State University were reviewed. Microvascular flap survival and related complications were described. Statistical analysis was performed to determine the significance of relationships between operative factors and outcome. A total of 57 microvascular procedures were performed on 55 animals. Reconstruction was required after trauma in 42 animals, after ablative cancer surgery in 11 animals and for correction of congenital tissue aplasia in I animal. Donor tissues included the superficial cervical cutaneous, medial saphenous fasciocutaneous or musculofasciocutaneous, caudal superficial epigastric cutaneous, trapezius muscle or musculocutaneous, caudal sartorius muscle, latissimus dorsi muscle or musculocutaneous, cranial abdominal myoperitoneal, carpal footpad, digital footpad, and vascularized ulnar bone flaps. A total of 53 of 57 flaps (93%) survived. There was a significant relationship between flap failure and level of assistant surgeon experience (P < .05). Latissimus dorsi flaps were significantly more likely to fail when compared with pooled data from all other flap types (P < .01). The success of microvascular tissue transfer in this case series compares favorably with those reported in human reconstructive microsurgery. Both the primary and assistant surgeon should be practiced in microsurgical technique. Failure of latissimus dorsi flaps was not likely caused by an inherently deficient flap design, but was more likely attributed to the location and severity of trauma at the recipient site, the difficulty in isolating suitable recipient vessels for anastomosis or the absence of a trained assistant surgeon during these procedures. Clinical Relevance-This retrospective study documents the successful application of microvascular technique in a series of clinical cases requiring tissue reconstruction.
Microvascular free tissue transfer in elderly patients: The Toronto experience
Head & Neck, 2003
Background. Microvascular free tissue transfer has become an accepted and versatile method of reconstruction in the head and neck region, offering a one-stage procedure and thus reducing the number and length of hospital stays. Many of the patients requiring head and neck free flaps are elderly, with concomitant medical problems, including respiratory and cardiovascular compromise, and are therefore potentially at higher risk of adverse outcomes. In addition, they frequently have a history of heavy alcohol and cigarette consumption, which can compound the risks.
Microsurgical reconstruction in patients greater than 80 years old
Microsurgery, 2016
Background: Demographic change implies that the human population is getting older and the elderly are living longer. Consequently, achieving good functional and aesthetic outcomes in microvascular procedures, especially in very old patients with higher incidence of atherosclerosis and vessel calcifications, constitutes a microsurgical challenge. This study evaluates the feasibility of microsurgical procedures in a very old patient cohort. Patients and Methods: Between 2009 and 2015, 754 patients underwent 838 free flap reconstructions. The patients were divided into two groups according to age in "middle-aged" (<80 years old; n 5 711) or "very old" (80 years old; n 5 43). The series was retrospectively analyzed regarding potential influence of medical comorbidities, surgical and medical complications and outcomes. Results: Between the groups, there was a significant difference regarding comorbidities with a higher prevalence of hypertension (P < 0.0001) and peripheral artery disease (P < 0.0001) in the very old group. However, there was no significant difference regarding the rate of surgical or medical complications, flap failure (middle aged group 43/791 flaps (5.44%) versus very old group 4/47 flaps (8.51%); P 5 0.328), and revision rate (117/791 flaps (14.79%) versus 6/47 flaps (12.77%); P 5 0.834) between the patient groups during our 3-months follow-up period. Conclusion: Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can also be achieved in a very old population with acceptable risk for complications.
Microvascular free-flap transfer for head and neck reconstruction in elderly patients
BMC Surgery, 2013
Background: With the increase in life expectancy, the incidence of head and neck cancer has grown in the elderly population. Free tissue transfer has become the first choice, among all the reconstructive techniques, in these cases. The safety and success of micro vascular transfer have been well documented in the general population, but its positive results achieved in elderly patients have received less attention. Methods: We retrospectively studied 28 patients over the age of 60 years. The aim of this paper was to study the success rate of free tissue transfer and investigate the complication incidence in this patient population. Results: Twenty-eight free flaps were performed to reconstruct medium to large cervico-facial surgical defects in six years. No difference was noted between success and complication rates observed between general and elderly population. Conclusion: This study indicates that free-flap technique for head and neck reconstruction could be considered a safe option in elderly patients when a good pre-operative general status is present.
Current techniques in the post-operative monitoring of microvascular free-tissue transfers
European Journal of Plastic Surgery, 2005
Accurate assessment of the perfusion of freetissue transfers has always been a challenge for surgeons undertaking microvascular reconstructive procedures. Microvascular free-tissue transfer today has a high success rate, which is partly due to the monitoring of flap circulation post-operatively. Recent advances in technology and improvements in surgical technique have led to reported success rates of between 95% and 98%. The aim of post-operative surveillance is the early recognition of flap compromise to improve chances of flap salvage and lower morbidity and mortality rates. There is extensive literature available on post-operative monitoring, and, although many techniques to assess flap perfusion have been described, a standard, reliable, universally accepted method, other than bedside clinical observation by the medical and nursing staff, remains elusive. This review outlines the current clinical and experimental flap monitoring methods available.
Is There an Association between Comorbidities and the Outcome of Microvascular Free Tissue Transfer?
Journal of Reconstructive Microsurgery, 2011
The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.
Factors Affecting the Risk of Free Flap Failure in Microvascular Surgery
Proceedings of the Latvian Academy of Sciences. Section B. Natural, Exact, and Applied Sciences., 2016
Microvascular free flap surgery, has become an important part of reconstructive surgery during the last decades, as it allows closure of various tissue defects and recovery of organs function. Despite surgical progress resulting in high rates of transferred tissue survival, the risk of pedicle vessels thrombosis still remains a significant problem. A total of 108 articles from Pubmed and Science Direct databases published in 2005–2015 were analysed. This review of the literature assessed the influence of patient-dependent risk factors and different perioperative management strategies on development of microvascular free flap thrombosis. Sufficient evidence for risk associated with hypercoagulation, advanced age and certain comorbidities was identified. Presently, rotational thromboelastometry allows early hypercoagulability detection, significantly changing further patient management. Identification of flap thrombosis promoting surgery-related aspects is also essential in preoperati...
Shift in the timing of microvascular free tissue transfer failures in head and neck reconstruction
The Laryngoscope, 2019
Objective: Analyze the cause and significance of a shift in the timing of free flap failures in head and neck reconstruction. Study Design: Retrospective multi-institutional review of prospectively collected databases at tertiary care centers. Methods: Included consecutive patients undergoing free flap reconstructions of head and neck defects between 2007 and 2017. Selected variables: demographics, defect location, donor site, free flap failure cause, social and radiation therapy history. Results: Overall free flap failure rate was 4.6% (n = 133). Distribution of donor tissue by flap failure: radial forearm (32%, n = 43), osteocutaneous radial forearm (6%, n = 8), anterior lateral thigh (23%, n = 31), fibula (23%, n = 30), rectus abdominis (4%, n = 5), latissimus (11%, n = 14), scapula (1.5%, n = 2). Forty percent of flap failures occurred in the initial 72 hours following reconstruction (n = 53). The mean postoperative day for flap failure attributed to venous congestion was 4.7 days (95% confidence interval [CI], 2.6-6.7) versus 6.8 days (CI 5.3-8.3) for arterial insufficiency and 16.6 days (CI 11.7-21.5) for infection (P < .001). The majority of flap failures were attributed to compromise of the arterial or venous system (84%, n = 112). Factors found to affect the timing of free flap failure included surgical indication (P = .032), defect location (P = .006), cause of the flap failure (P < .001), and use of an osteocutaneous flap (P = .002). Conclusion: This study is the largest to date on late free flap failures with findings suggesting a paradigm shift in the timing of flap failures. Surgical indication, defect site, cause of flap failure, and use of osteocutaneous free flap were found to impact timing of free flap failures.