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AAPS 2007 Annual Meeting, May 19 - 22, 2007, The Coeur d'Alene Resort, Coeur d'Alene, Idaho.
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Analysis of 47 Cases of Fap Compromise in 1032 Free Flaps for Head and Neck Reconstruction
Peirong Yu, M.D., M.S., David W. Chang, M.D., Michael J. Miller, M.D., Gregory P. Reece, M.D., Geoffrey L. Robb, M.D..
University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA.

Purpose: To analyze the causes for vessel thrombosis and flap failure in head and neck reconstruction.
Methods: Retrospective review of 1032 free flap reconstructions for head and neck defects from 1995 to 2005 were performed and 47 cases of flap compromise were identified.
Results: The incidence of flap compromise was 3.4% (23/674) and 6.7% (24/358) for men and women, respectively (P = 0.016). There were 25 flap losses (2.4%) in which 10 were male (1.5%) and 15 were female (4.2%) (P < 0.00001). Flap loss was four times higher in women than in men for tongue and pharyngoesophageal reconstruction. A total of 21 surgeons were involved and their experience varied from 10 to 220 cases (mean 50.7, median 42). Their thrombosis rate varied from 0 to 14% and flap failure rate from 0 to 10%. There was no correlation between surgeon’s experience and thrombosis or failure rate. Twenty-four flap compromises occurred and were explored within 24 hours, 4 between 24 and 48 hours, 6 between 48 and 72 hours, 5 between 3 and 5 days, and 8 were recognized until one or several weeks later. Salvage rate was 62% within 72 hours and 8% after 72 hours. In the 34 cases occurred within 72 hours, 24 were venous occlusions and 10 were arterial occlusions. Causes for venous occlusion included 15 cases of thrombosis due to kinking (8), size mismatch (1), or unknown etiology (6); 3 cases of perforator compression or damage; 3 cases of main pedicle compression; 2 cases of inadequate drainage from the vena comitantes without cephalic vein anastomosis, and 1 case of internal jugular vein thrombosis. Six of the 10 arterial failures had experienced intraoperative thrombosis due to technical difficulties or vessel damage. Other causes included 1 compression, 1 kinking, 1 thrombosis in the pedicle artery (1), and 1 anastomotic thrombosis for unknown etiology. All 5 cases of flap compromise between 3 and 5 days were caused by compression and 4 of them presented as venous congestion. The causes for flap loss beyond 7 days included 3 unrecognized failures of buried flaps, 4 clinically missed failures due to a positive Doppler signal, and 1 delayed exploration due to an acute stroke. The highest rate of flap thrombosis and failure occurred in orbitomaxillary reconstruction (10.5% and 6%, respectively). Among these 14 cases, 9 (64%) were caused by compression or kink, most likely in the tunnel under the cheek skin.
Conclusion: Flap thrombosis and failure following head and neck reconstruction occurred more commonly in female patients for unknown reasons. Flap failure appears more surgeon dependent than experience dependent. Avoiding compression or kinking of the pedicle may prevent many flap failures.

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