title: Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps.
abstract: Loss of a breast free flap is a relatively rare but catastrophic occurrence. Our study aims to identify risk factors for flap loss and to assess whether different salvage techniques affect flap salvage. We performed a retrospective review of all breast free flaps performed at a single institution from 2000 to 2010. Overall, 2138 flaps were performed in 1608 patients (unilateral, 1120 and bilateral, 488) with 44 flap losses (2.1%). Age, body mass index, smoking, radiation, chemotherapy, and surgeon experience did not affect flap loss. Abdominal flaps based on a single perforator were at significantly higher risk for flap loss compared with flaps based on multiple perforators (P = 0.0007). Subgroup analysis of the subset of 166 compromised free flaps (flaps requiring a return to the operating room, an intraoperative anastomotic revision, or loss/partial loss of a free flap) demonstrated deep inferior epigastric perforator, and other flaps (superficial inferior epigastric artery and superior gluteal artery perforator) were significantly associated with flap loss [odds ratio (OR) 5.20; P = 0.03 and OR 6.91; P = 0.0004, respectively] compared with transverse rectus abdominis myocutaneous and muscle-sparing transverse rectus abdominis myocutaneous flaps. Although an intraoperative complication was not associated with a flap loss, the need for a reoperation was strongly predictive (P < 0.0001). Flap salvage was the highest within the first 24 hours (83.7%) and significantly less between days 1 and 3 (38.6%; P < 0.0001) and beyond 4 days (29.4%; P < 0.0001). Longer ischemia time was significantly associated with flap loss (P = 0.04). Salvage techniques (aspirin, heparinzation, thrombectomy, and thrombolytic) had no impact on flap salvage rates. Heparinization and thrombolytics were associated with higher loss rates (OR 3.40; P = 0.003 and OR 10.36; P < 0.0001, respectively). Free flap loss following breast reconstruction is multifactorial with higher losses in superficial inferior epigastric artery and gluteal flaps, single-perforator abdominal flaps, and longer ischemia times. Salvage rates are most successful within the first 24 hours, and the use of heparinization, aspirin, and thrombolytics does not improve salvage rates.
authors.affiliation: From the Department of Plastic and Reconstructive Surgery, MD Anderson Cancer Center, Houston, TX.
authors.forename: Edward I
authors.initials: EI
authors.lastname: Chang
authors.forename: Eric I
authors.initials: EI
authors.lastname: Chang
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Soto-Miranda
authors.forename: Hong
authors.initials: H
authors.lastname: Zhang
authors.forename: Naveed
authors.initials: N
authors.lastname: Nosrati
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Crosby
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Reece
authors.forename: Geoffrey L
authors.initials: GL
authors.lastname: Robb
authors.forename: David W
authors.initials: DW
authors.lastname: Chang
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000627:therapeutic use; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D058752:Free Tissue Flaps / Q000098:blood supply*; D006085:Graft Survival; D006801:Humans; D016015:Logistic Models; D016462:Mammaplasty / Q000379:methods*; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D012189:Retrospective Studies; D012307:Risk Factors; D016879:Salvage Therapy / Q000379:methods*; D017131:Thrombectomy; D013927:Thrombosis / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants