The very high success rates for microvascular reconstruction at most major centers today is attributable to numerous factors, which are discussed at length in this chapter by Prof. Matthew Hanasono.
Exhaustive pre-operative evaluation to assess potential risk factors is crucial and includes obtaining a detailed past history that may reveal high risk factors (co-morbidities, smoking, uncontrolled diabetes, extreme old age with severe atherosclerosis, systemic conditions causing hypercoagulability and previous free flap loss), detailed physical examination and careful selection of the best alternative in a given case.
Pre-operative imaging is also essential, not only for optimal excision plans but also assessment of the neck for possible recipients, especially in previously treated, vessel depleted necks.
A very detailed plan is made to ensure tension-free anastomosis and absence of kinks and pressure points over anastomosed vessels.
The use of anti-platelet agents is considered helpful in selected circumstances, and a careful post-operative vigil is maintained in all cases. If microvascular thrombosis is suspected, immediate re-exploration is the only way out, as timing is crucial and the patient must be re-explored before the ‘no reflow’ phenomenon sets in, indicating microcirculatory failure. Salvage is generally successful if early (within the first 48-72 hours) rather than delayed (over five days) following initial surgery.
This is a preview of subscription content, log in to check access.
Grammatica A, Piazza C, Paderno A, Taglietti V, Marengoni A, Nicolai P (2015) Free flaps in head and neck reconstruction after oncologic surgery: expected outcomes in the elderly. Otolaryngol Head Neck Surg 152:796–802CrossRefGoogle Scholar
Wang TY, Serletti JM, Cuker A et al (2012) Free tissue transfer in the hypercoagulable patient: a review of 58 flaps. Plast Reconstr Surg 129:443–453CrossRefGoogle Scholar
Garvey PB, Chang EI, Selber JC et al (2012) A prospective study of preoperative computed tomographic angiographic mapping of free fibula osteocutaneous flaps for head and neck reconstruction. Plast Reconstr Surg 130:541e–548eCrossRefGoogle Scholar
Yazar S, Wei FC, Chen HC et al (2005) Selection of recipient vessels in double free-flap reconstruction of composite head and neck defects. Plast Reconstr Surg 115:1553–1561CrossRefGoogle Scholar
Hanasono MM, Weinstock YE, Yu P (2008) Reconstruction of extensive head and neck defects with multiple simultaneous free flaps. Plast Reconstr Surg 122:1739–1346CrossRefGoogle Scholar
Yu P (2005) The transverse cervical vessels as recipient vessels for previously treated head and neck cancer patients. Plast Reconstr Surg 115:1253CrossRefGoogle Scholar
Hanasono MM, Barnea Y, Skoracki RJ (2009) Microvascular surgery in the previously operated and irradiated neck. Microsurgery 29:1–7CrossRefGoogle Scholar
Jacobson AS, Eloy JA, Park E, Roman B, Genden EM (2008) Vessel-depleted neck: techniques for achieving microvascular reconstruction. Head Neck 30:201–207CrossRefGoogle Scholar
Urken ML, Higgins KM, Lee B, Vickery C (2006) Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck vessel-depleted neck. Head Neck 28:797CrossRefGoogle Scholar
Aycock JK, Senson KM, Gottlieb LJ (2008) The thoracoacromial trunk: alternative recipient vessels in reoperative head and neck microsurgery. Plast Reconstr Surg 121:88CrossRefGoogle Scholar
Horng SY Chen MT (1993) Reversed cephalic vein: a lifeboat in head and neck free-flap reconstruction. Plast Reconstr Surg 92:752CrossRefGoogle Scholar
Yu P, Chang DW, Miller MJ, Reece GP, Robb GL (2008) Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction. Head Neck 31:45–51CrossRefGoogle Scholar
Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ (2007) Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 119:2092–2100CrossRefGoogle Scholar
Rosenberg JJ, Fornage BD, Chevray PM (2006) Monitoring buried free flaps: limitations of the implantable Doppler and use of color duplex sonography as a confirmatory test. Plast Reconstr Surg 118:109CrossRefGoogle Scholar
Fang L, Liu J, Yu C, Hanasono MM, Zheng G, Yu P (2018) Intraoperative use of vasopressors does not increase the risk of free flap compromise and failure in cancer patients. Ann Surg 268(2):379–384CrossRefGoogle Scholar
Corbitt C, Skoracki RJ, Yu P, Hanasono MM (2014) Free flap failure in head and neck reconstruction. Head Neck 36:1440–1445PubMedGoogle Scholar
Hanasono MM, Butler CE (2008) Prevention and treatment of thrombosis in microvascular surgery. J Reconstr Microsurg 24(5):305–314CrossRefGoogle Scholar
Chang EI, Hanasono MM, Butler CE (2016) Management of unfavorable outcomes in head and neck free flap reconstruction: experience-based lessons from the MD Anderson Cancer Center. Clin Plast Surg 43:653–667CrossRefGoogle Scholar