When Free Flaps Fail Twice, Another Try Can Be Successful

DALLAS — A second revascularization attempt for compromised free flaps was successful in 30% of cases, according to a multicenter retrospective medical record review.

Among 79 patients with flaps undergoing second salvage attempts, 24 flaps survived, while 55 showed necrosis, reported Allison Slijepcevic, MD, of Oregon Health & Science University in Portland, and colleagues.

In addition, arterial or venous thrombectomy was performed in 71% of the flaps that survived and 42% of the flaps showing necrosis (OR 3.38, 95% CI 1.21-9.47), they noted in JAMA Otolaryngology – Head and Neck Surgery.

And in cases of venous compromise, changing the anastomotic vein was associated with reduced survival compared with not changing the vein. Vein revision to an alternative branch was completed in 4% of the flaps that survived and 35% of the flaps with necrosis (OR 0.08, 95% CI 0.00-0.60).

Though the incidence of perioperative free flap compromise is low, with successful salvage in about 70% of cases, “when the flap is compromised a second time, the value of intervening is unknown,” the authors wrote.

“Second salvage flap surgery may be valuable in patients with limited reconstructive options,” Slijepcevic said during a ‘Best of the Abstracts’ session at the annual meeting of the American Head and Neck Society, where the findings were also presented.

The key, though, is to find the right patients, Slijepcevic told MedPage Today. “I think it is worth trying if you have the right person. A key aspect of free flap survival following second salvage attempts was the identification and management of arterial and/or venous thromboses in the flap pedicle.”

“The present data suggest that if an identifiable anastomotic clot is the source of flap compromise, particularly in the arterial system, surgical revision has a greater chance of success when compared with flaps without an isolated identifiable intravascular pathology,” she added, noting that the overall health of the patient is also important.

In commenting on the results of the trial, the session co-chairs were cautious about whether a second revision was worthwhile. “The first redo attempt is 70% successful, so it makes sense to try that, but when the second attempt has a success rate of 30%, it may make more sense to let that flap die and do a new one,” Nicole Schmitt, MD, of Emory University School of Medicine in Atlanta, told MedPage Today.

She noted that there were another 80 patients who had unsuccessful first and second attempts to make the flap work, and that group was not considered for the third round of surgery. The researchers were selecting the best patients for the second redo, and they only had a 30% success rate in the best of the patients, she pointed out.

“When a free flap fails, often the option is to create another free flap taking tissue from another part of the body,” Schmitt said. “For example, if it is the fibula flap that fails, then you can use a flap from the other side of the body, such as the shoulder blade. Or you can use the pectoralis muscle, or even just let it heal. The decision is really patient dependent.”

Co-chair Thomas Ow, MD, of Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, told MedPage Today, “The question raised in the study was, is this worthwhile? This is very complex surgery and before we consider it, I think we need to be able to select people better who would be good candidates for these treatments. I think we should be incorporating the concept of frailty of the patients into how we select patients for these surgeries.”

For this study, Slijepcevic and colleagues examined data on patients with a history of head and neck defects from cancer, osteoradionecrosis, or other wounds, who were undergoing head and neck reconstruction with free flaps at six U.S. medical centers from January 2000 through December 2020.

Of 3,510 free flaps identified, 79 patients showed a second episode of compromise and underwent a second attempt at surgical revascularization. Among this group, mean age was 64, 77% were men, and 73% were former or current smokers.

The most common causes of initial flap compromise included venous thrombosis in 43 patients and arterial thrombosis in 22 patients. Blood vessel thrombosis — both venous and arterial — was the most common cause of the second episode of flap compromise.

Although heparin is often employed to improve perfusion in these compromised flaps, Slijepcevic noted that the use of heparin in her study did not appear to influence outcomes in this subset of patients.