Background: Microvascular reconstruction is an integral part of Breast and Head/Neck cancer (HNC) treatment. Free tissue transfers have reported success rates of 95%.1
Aims: To document the rate of urgent re-exploration of compromised free-flaps at Hutt Valley DHB over a 5 year period; document salvage success rates; and identify any risk factors that may contribute to flap compromise.
Methods: We retrospectively analysed all free tissue transfers at HVDHB from 2011 - 2015 and analysed the following variables:-
Primary: Type of flap; recipient site; primary pathology; age; smoking; salvage attempts
Secondary variables: Failure rate post salvage; Intra-op concerns; adjuncts to salvage; time from surgery to salvage
Results: There were 227 free flaps in 211 patients. 47% were for reconstruction following major HNC surgery, 32% were for breast reconstruction and 15% were for lower limb defects. 28 free flaps underwent 38 salvage attempts. The salvage failure rate was 18%, acute failure rate was 3.5% and the overall failure rate was 4.8%. 11% of Head/Neck flaps and 14% of breast flaps required urgent re-exploration. Arterial compromise was most common in breast flaps. Venous/mixed congestion was common in Head/neck flaps. Breast flap compromise was most likely to occur in the first 48 hours, while head/neck flap compromise occurred up to 5 days post operatively. 50% of breast flaps that become compromised had intra operative concerns compared to 8% for Head/neck free flaps. Thrombolysis was used as an adjunct in 10 salvage attempts with an 80% success rate.
Conclusion: HVDHB has higher flap take-back rates and equivalent overall success rates compared to high volume centres.2-3 Breast flaps with intra-operative concern are more likely to need salvage, especially within the first 48 hours. Head and neck free flaps may become compromised at any time in the first 5 days irrespective of intraoperative concern.