The aim of this study was to assess the effectiveness of early exploration of anterolateral thigh (ALT) free flap compromise in head and neck reconstruction and to correlate this with the salvage success rate. The perioperative data of 1051 patients with 1072 ALT flap reconstructions were reviewed retrospectively for the period January 2002 to December 2012. Outcome measures included ethnicity, defect type, incidence and timing of flap compromise, type of flap compromise, causes of vascular occlusion, and salvage rate. The success rate of free flap reconstruction was 97.3% (1043/1072). Of the 29 failures, 21 were complete and eight were partial failures (10–40% of the flap). Venous occlusions occurred in 39 flaps (83.0%) and arterial occlusions in five flaps (17.0%). Six cases were detected within 8 h postoperatively, 13 at 8–16 h postoperatively, seven at 16–24 h postoperatively, and 18 at 24–48 h postoperatively, with respective salvage rates of 66.7%, 61.5%, 28.6%, and 22.2%; three cases detected after 48 h failed. The salvage rate at ≤16 h (62.2%) was much higher than that at >16 h (21.4%, P = 0.0039). Early detection, re-exploration, and effective handling of the flap crisis increases the rate of flap salvage tremendously.
Anterolateral thigh (ALT) free flap transfers have become a classical tool in head and neck reconstruction following cancer resection, allowing greater diversity in complex reconstruction than local or regional flaps. This flap can be raised as a subcutaneous flap, fasciocutaneous flap, or myocutaneous flap and can cover large defects of the head and neck. One of its main advantages is its large and long vascular pedicle, which enables its harvest with a two-team approach. With advances in surgical techniques and instruments, ALT free flap success rates at most centres have reached 96%, and in some expert hands close to 99%, making it one of the most reliable procedures in reconstructive surgery. However, occasional flap failures still occur. In this particular study, our aims were to determine why microvascular crisis and subsequent flap failure still occurs in modern reconstruction surgery, to highlight the common mistakes leading to these events, and to identify how such outcomes can be prevented. We also suggest new techniques and provide advice regarding the management strategy for the novice surgeon who is interested in this type of operation.
Materials and methods
A retrospective review was done of 1072 ALT free flaps used for oral and maxillofacial reconstruction in 1051 patients between January 2002 and December 2012 at the university hospital. Cases of intraoperative thrombosis without further consequences were excluded. The following details were collected: patient age, gender, ethnicity, defect type, pathology of the neoplasm, and previous treatment. The timing of flap compromise, type of flap compromise (i.e. arterial or venous), causes of vascular occlusion, and salvage rate were noted and analyzed.
The 1051 patients ranged in age from 6 to 82 years, with a mean age of 51.6 years; 832 were males and 219 were females. Of the reconstructions performed, 1066 were done for the repair of defects resulting from the primary treatment of malignant neoplasms and six for defects from trauma and deformity. The procedures were performed with a two-team approach. Heparin was used during anastomosis to prevent vasospasm. Also, the temperature of the operating room was maintained at 25 °C to prevent vasospasm. Most flaps were anastomosed with two pairs of veins, unless only one vein was present. The free flap monitoring protocol was followed closely: 1072 ALT musculocutaneous flaps were monitored clinically every hour during the first 8 h after surgery; the frequency of flap monitoring was reduced to every 1.5 h in the consecutive 8–16 h after surgery and then to every 3–5 h from the end of the first day to the fifth postoperative day.