Matthew M. Hanasono, M.D.
Department of Plastic Surgery
Prevention and Treatment of
Free Flap Thrombosis (and
What to do After the Flap Fails)
Kaiser Permanente Plastic Surgery Symposium
January 19, 2013
“To err is human…”
Alexander Pope
Flap Loss
10-12% thrombosis rate
50-85% flap salvage rate
1-5% flap failure rate
Prevention
Don’t leave the operating room if
you’re not happy.
Flap Monitoring
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Physical exam
Handheld Doppler ultrasound
Scratch/pin prick
Implantable Doppler ultrasound
Tissue oxygenation
Temperature
?Indocyanine green
?Transit time ultrasound
“New” Technology: Transit-Time
Doppler
Selber JC, Garvey PB, Clemens MW, Chang EI, Zhang H, Hanasono MM. A prospective study
of transit time volume (TTFV) measurement for intraoperative evaluation and optimization of free
flaps. Plast Reconstr Surg. In press.
Arterial Vs. Venous Congestion
Arterial
Venous
ƒ Pale or mottled flap
ƒ Cyanotic flap
ƒ Slow capillary refill (>2
seconds)
ƒ Brisk capillary refill
ƒ Decreased turgor
ƒ May be cool
ƒ Cool (>2°C lower than
surrounding tissues)
ƒ Rapid bleeding of dark
blood
ƒ Scant bleeding
ƒ No venous Doppler
signal but arterial signal
may be present
ƒ No Doppler signal
ƒ Increased turgor
ƒ Hematoma
Venous Congestion
Arterial Insufficiency
Prophylaxis
ƒ Aspirin: cyclooxygenase inhibitor,
decreases TxA2 (platelet aggregator
and vasoconstrictor) and PGI2
(platelet inhibitor and vasodilator).
ƒ Dextran: platelet inhibitor and volume
expander (risk of pulmonary edema)
ƒ Heparin: antithrombin III cofactor
inhibits clotting cascade (risk of
heparin-induced thrombocytopenia)
Dosages
ƒ Aspirin: 81 mg - 325 mg
ƒ Dextran 40 IV: 20 ml/hr (following test
dose of 20 mL of 150 g/mL)
ƒ Heparin
à Heparinized saline irrigation: 50-250
U/mL*
à Heparin IV: 2000-3000 U bolus followed
by 100-400 U/hr
*Irrigation may elevate PTT if it enters the circulation
Postoperative Care
ƒ Patient positioning
ƒ Mobility
ƒ Dressings & tracheostomy ties
Reasons for Flap Loss
(Besides the Anastomosis)
ƒ Pedicle kink, twist, compression, or
tension
ƒ Poor flap design or injury during
harvest
ƒ Infection
ƒ Hypercoagulability
ƒ Vasospasm
Uncontrollable Circumstances
ƒ Tracheostomy ties/alcohol withdrawl POD 3
ƒ Purulent infection POD 4
ƒ Necrotizing fasciitis POD 2
ƒ Seat belt POD 5
ƒ Carotid rupture POD 3
ƒ Rupture of vein graft pseudoaneurysm POD 5
ƒ Implantable Doppler POD 5
Pseudoaneurysm
Pseudoaneurysm
Implantable Doppler Kink
Implantable Doppler Kink
Implantable Doppler Kink
Flap Salvage
Keys to Flap Salvage
ƒ Early return to the operating room
ƒ Correct diagnosis
ƒ Ability to correct the problem
Preoperative Considerations
ƒ Explain the urgency of a
rapid return to the
operating room
ƒ Discuss alternatives with
the patient
ƒ Consider the most likely
problem(s)
ƒ Rehearse your steps
ƒ Consider calling for help
Reasons for Thrombosis
ƒ Pedicle kink, twist, compression, or
tension
ƒ Poor flap design or injury during
harvest
ƒ Anastomotic problem
ƒ Infection
ƒ Hypercoagulability
ƒ Vasospasm
Operative Treatment
ƒ Clot extraction, heparin irrigation,
thrombolysis
ƒ Anastomotic revision
ƒ Vein grafting
ƒ Relief of vasospasm
Thrombolysis
ƒ Streptokinase: group C ß-hemolytic
streptococci; indirectly activates
plasminogen to plasmin, which degrades
fibrinogen (20 min half-life; dose 50,000250,000 U)
ƒ Urokinase: derived from human kidney
cells; activates plasminogen (20 min halflife; same dosage)
ƒ Tissue plasminogen activator (rTPA):
specific for fibrin (5 min half-life; 2-25 mg
dose)
Venous Congestion
After Revision
5 Days Later
Arterial Insufficiency
After Revision
Arterial and Venous Thrombosis
After Revision (2 Weeks)
Hanasono MM, Butler CE. Prevention and treatment of thrombosis in microvascular surgery. JRM 2008;24:305-314.
Flap Loss
Abandoning the Flap
ƒ Late diagnosis
ƒ No response to
treatment
ƒ Recurrent
thrombosis
ƒ Medically unstable
No Reflow Phenomenon
ƒ Distal embolization
ƒ Ischemic injury: capillary blockage,
endothelial damage, cellular edema
ƒ Reperfusion injury: infiltration of
neutrophils and platelets, tissue and
endothelial damage, vasoconstriction,
coagulation
The Reverse Reconstructive
Ladder
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Second free flap
Regional flap
Skin graft
Conservative management (or VAC)
Implant (breast)
Amputation (extremities)
Head and Neck Free Flap Loss
2000-2012 (n=3090)
Cause of Flap Loss
No. of Pts.*
Infection
10 (25.0%)
Problem with flap design/harvest
6 (15.0%)
Pedicle compression
5 (12.5%)
Kinked pedicle
4 (10.0%)
Hemorrhage
3 (7.5%)
Hypercoagulable disorder
2 (5.0%)
Hypotension
1 (2.5%)
Internal jugular vein (recipient vein) thrombosis
1 (2.5%)
Unclear etiology
8 (20.0%)
*98.6% Success rate
Initial and Subsequent
Reconstruction
Reconstruction
Initial
Subsequent
Anterolateral thigh
15 (37.5%)
11 (27.5%)
Fibula osteocutaneous
12 (30.0%)
4 (10.0%)
Radial forearm fasciocutaneous
3 (7.5%)
6 (15.0%)
Rectus abdominis myocutaneous
3 (7.5%)
2 (5.0%)
Latissimus dorsi muscle
3 (7.5%)
4 (10.0%)
Jejunum
2 (5.0%)
‐
Groin
2 (5.0%)
‐
Scapula/latissimus dorsi muscle chimeric
‐
1 (2.5%)
Pectoralis major pedicled
‐
7 (17.5%)
Obturator
‐
3 (7.5%)
Primary Closure
‐
1 (2.5%)
Secondary Intention
‐
1 (2.5%)
Recipient Blood Vessels
Location
Artery (n=28)
Vein (n=28)
Ipsilateral neck
8 (29%)
15 (54%)
Ipsilateral neck reused
14 (50%)
8 (29%)
Contrlateral neck
4 (14%)
4 (14%)
Noncervical
2 (7%)
1 (4%)
Complications
Complication
Subsequent Free Flap (n=28)
Other Reconstruction (n=12)
Total (n=40)
Recipient Site
5
4
10 (25%)
1
‐
1 (2.5%)
Donor Site
5
1
6 (15%)
Medical
8
6
14 (35%)
Pneumonia
2
4
5 (13.5%)
CVA
1
1
2 (5%)
12 (42.9%)
7 (58.3%)
19 (47.5%)
Total flap loss*
Total Patients†
*96.4% free flap success rate.
†9 patients had more than 1 complication.
Speech
Group*
Mostly Partially Normal (100% (approx. 80%) (approx. 50%) Unintelligible intelligible)
intelligible
intelligible Primary/secon
dary closure 1 (50.0%)
(n=2)
1 (50.0%)
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‐
Obturator (n=3)
‐
‐
‐
Pectoralis
major pedicled 1 (14.3%)
flap (n=7)
2 (28.6%)
3 (42.9%)
1 (14.3%)
Free flap†
(n=14)
4 (28.6%)
‐
‐
3 (100%)
10 (71.4%)
*Excludes 5 aphonic patients who had total laryngectomy.
†Pectoralis major flap vs. free flap patients, p=0.01
Speech
Group*
>80% Intelligible
50‐80% Intelligible <50% Intelligible Primary/secondary closure (n=2)
2 (100%)
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‐
Obturator (n=3)
3 (100%)
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Pectoralis major pedicled flap (n=7)
3 (42.95%)
3 (42.9%)
1 (14.3%)
Free flap† (n=14)
14 (100%)
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*Excludes 5 aphonic patients who had total laryngectomy.
†Pectoralis major flap vs. free flap patients, p=0.007
Diet
Pureed
Partial Tube Total Tube Feed
Feed
Primary/secondary 1 (50.0%)
closure (n=2)
1 (50.0%)
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Obturator (n=3)
2 (66.7%)
‐
‐
1 (33.3%)
Pectoralis major pedicled flap (n=8)
2 (25.0%)
2 (25.0%)
4 (50.0%)
Free flap (n=16)*
13 (81.3%)
1 (6.3%)
1 (6.3%)
Group
Soft/Regul
ar
1 (6.3%)
*Pectoralis major flap vs. free flap group, p=0.02
Note: in free flap group, the partial and total tube feed patients had severe trismus
limiting oral feeding.
Survival
Case: Maxillary Reconstruction
Venous Thrombosis
Unsalvageable Flap
Serial Debridement
A New Flap
A New Vessel
Postoperative Result
Case: Multiple Free Flap
Reconstruction
Venous Congestion Treated with
Leeches
Can Leeches Save Flaps?
Flap Salvage with Leech Therapy
Flap Type
Total Salvage
Partial Salvage
Total Loss
Native tissue (n=5)
100%
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‐
Local flap (n=6)
83%
17%
‐
Regional flap (n=14)
21%
43%
36%
Free flap (n=13)
46%
23%
31%
Total (n=38)
50%
26%
24%
Nguyen MQ, Crosby MA, Skoracki RJ, Hanasono MM. Outcomes of flap salvage with
medicinal leech therapy. Microsurgery 2012;32:351-357.
Morbidity of Leech Therapy
Factor
Total Salvage
Partial Salvage
Total Loss
P‐value
No. leeches
38
101
158
0.04
Days of treatment
4
7
5
0.16
Leeches per day
10
15
25
0.03
Units of blood
1.7
3.2
5.6
0.02
Hospital stay
12
12
14
0.45
Nguyen MQ, Crosby MA, Skoracki RJ, Hanasono MM. Outcomes of flap salvage with medicinal
leech therapy. Microsurgery 2012;32:351-357.
Leech Algorithm
Pectoralis Major Flap
Postoperative Result
Case: Osteoradionecrosis
Fibula and ALT Free Flap
Reconstruction
After Complication
Debridement
Scapular-ParascapularLatissimus Dorsi Muscle
Chimeric Free Flap
Immediate Result
Postoperative Result
Conclusions
ƒ Some flap losses are unavoidable
ƒ Salvage requires early intervention,
accurate diagnosis, and the ability to
correct the problem
ƒ The choice of salvage reconstruction
is often the reverse of the original
reconstruction
ƒ Appropriately selected, a second free
flap can be accomplished with good
success rates
“Good decisions come from
experience, and experience
comes from bad decisions.”
Author Unknown