Download PDF
J Reconstr Microsurg 2024; 40(09): 694-706
DOI: 10.1055/s-0044-1782671
Original Article

When a Good Flap Turns Bad: A Temporal Predictive Model for Free Flap Complications

Dylan K. Kim 
1   Division of Plastic and Reconstructive Surgery, Columbia University Irving Medical Center, New York, New York
,
Seth Z. Aschen
1   Division of Plastic and Reconstructive Surgery, Columbia University Irving Medical Center, New York, New York
,
Christine H. Rohde
1   Division of Plastic and Reconstructive Surgery, Columbia University Irving Medical Center, New York, New York
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Microsurgical cases are complex plastic surgery procedures with a significant risk of acute postoperative complications. In this study, we use a large-scale database to investigate the temporal progression of complications after microsurgical procedures and the risk imparted by acute postoperative complications on subsequent reconstructive outcomes.

Methods Microsurgery cases were extracted from the National Surgical Quality Improvement Program database by Current Procedural Terminology codes. Postoperative complications were collected for 30 days after surgery and stratified into four temporal periods (postoperative days [PODs] 0–6, 7–13, 14–20, 21–30). Postoperative complication occurrences were incorporated into a weighted multivariate logistic regression model to identify significant predictors of adverse outcomes (p < 0.05). Separately, a regression model was calculated for the time between index operation and reoperation and additional complications.

Results The final cohort comprised 19,517 patients, 6,140 (31.5%) of which experienced at least one complication in the first 30 days after surgery. The occurrence of prior complications in the postoperative period was a significant predictor of future adverse outcomes following the initial week after surgery (p < 0.001). Upon predictive analysis, overall model performance was highest in PODs 7 to 13 (71.1% accuracy and the area under a receiver operating characteristic curve 0.684); 2,578 (13.2%) patients underwent at least one reoperation within the first 2 weeks after surgery. The indication for reoperation (p < 0.001) and number of days since surgery (p = 0.0038) were significant predictors of future complications after reoperation.

Conclusion Prior occurrence of complications in an earlier postoperative week, as well as timing and nature of reoperation, were shown to be significant predictors of future complications.

Keywords

microsurgery - complications - plastic surgery

Supplementary Material



Publication History

Received: 25 September 2023

Accepted: 20 February 2024

Article published online:
28 March 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Dasari CR, Gunther S, Wisner DH, Cooke DT, Gold CK, Wong MS. Rise in microsurgical free-flap breast reconstruction in academic medical practices. Ann Plast Surg 2015; 74 (Suppl. 01) S62-S65
    CrossrefPubMedGoogle Scholar
  • 2 American Society of Plastic Surgeons; Plastic. Surgery Statistics Report. 2020. . Available at: https://www.plasticsurgery.org/documents/News/Statistics/2020/plastic-surgery-statistics-full-report-2020.pdf . Accessed on May 15, 2023
    Google Scholar
  • 3 Chang EI. Latest advancements in autologous breast reconstruction. Plast Reconstr Surg 2021; 147 (01) 111e-122e
    CrossrefPubMedGoogle Scholar
  • 4 Katsnelson JY, Tyrell R, Karadsheh MJ. et al. Postoperative complications associated with the choice of reconstruction in head and neck cancer: an outcome analysis of 4,712 patients from the ACS-NSQIP database. J Reconstr Microsurg 2022; 38 (05) 343-360
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Shen AY, Lonie S, Lim K, Farthing H, Hunter-Smith DJ, Rozen WM. Free flap monitoring, salvage, and failure timing: a systematic review. J Reconstr Microsurg 2021; 37 (03) 300-308
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Lo S-L, Yen Y-H, Lee P-J, Liu CC, Pu C-M. Factors influencing postoperative complications in reconstructive microsurgery for head and neck cancer. J Oral Maxillofac Surg 2017; 75 (04) 867-873
    CrossrefPubMedGoogle Scholar
  • 7 Mortada H, AlNojaidi TF, AlRabah R, Almohammadi Y, AlKhashan R, Aljaaly H. Morbidity of donor site and complication rates of breast reconstruction with autologous abdominal flaps: a systematic review and meta-analysis. Breast J 2022; 2022: 7857158
    CrossrefPubMedGoogle Scholar
  • 8 Patel VA, Dunklebarger M, Banerjee K, Shokri T, Zhan X, Isildak H. Surgical management of vestibular schwannoma: practice pattern analysis via NSQIP. Ann Otol Rhinol Laryngol 2020; 129 (03) 230-237
    CrossrefPubMedGoogle Scholar
  • 9 Wright T, Donato D, Veith J, Magno-Padron D, Agarwal J. Thirty-day outcomes following upper extremity flap reconstruction. J Hand Microsurg 2021; 13 (02) 101-108
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Ali B, Choi EE, Barlas V, Petersen TR, Menon NG, Morrell NT. Risk factors for 30-day mortality after head and neck microsurgical reconstruction for cancer: NSQIP analysis. OTO Open 2021; 5 (03) X211037257
    PubMedGoogle Scholar
  • 11 Yung AE, Wong G, Pillinger N. et al. Validation of a risk prediction calculator in Australian patients undergoing head and neck microsurgery reconstruction. J Plast Reconstr Aesthet Surg 2022; 75 (09) 3323-3329
    CrossrefPubMedGoogle Scholar
  • 12 Orr JP, Shammas RL, Thomas AB. et al. Bleeding after free flap-based breast reconstruction: A NSQIP analysis. J Reconstr Microsurg 2019; 35 (06) 417-424
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Massenburg BB, Sanati-Mehrizy P, Ingargiola MJ, Rosa JH, Taub PJ. Flap failure and wound complications in autologous breast reconstruction: A national perspective. Aesthet Plast Surg 2015; 39 (06) 902-909
    CrossrefPubMedGoogle Scholar
  • 14 Fassas S, Mamidi I, Lee R. et al. Postoperative complications after thyroidectomy: Time course and incidence before discharge. J Surg Res 2021; 260: 210-219
    CrossrefPubMedGoogle Scholar
  • 15 Goyal N, Bohl DD, Wysocki RW. Timing of complications following hand surgery. J Hand Microsurg 2020; 14 (01) 31-38
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Bohl DD, Webb ML, Lukasiewicz AM. et al. Timing of complications after spinal fusion surgery. Spine 2015; 40 (19) 1527-1535
    CrossrefPubMedGoogle Scholar
  • 17 Verbree-Willemsen L, Grobben RB, van Waes JA. et al. Causes and prevention of postoperative myocardial injury. Eur J Prev Cardiol 2019; 26 (01) 59-67
    CrossrefPubMedGoogle Scholar
  • 18 Elmer NA, Araya S, Panichella J, Egleston B, Deng M, Patel SA. Timing of unplanned reoperation after lower extremity free flap reconstruction: What are the roles of procedure indication and defect etiology?. Ann Plast Surg 2023; 90 (03) 229-236
    CrossrefPubMedGoogle Scholar
  • 19 Lucas DJ, Sweeney JF, Pawlik TM. The timing of complications impacts risk of readmission after hepatopancreatobiliary surgery. Surgery 2014; 155 (05) 945-953
    CrossrefPubMedGoogle Scholar
  • 20 Elmer NA, Bustos VP, Veeramani A. et al. Trends of autologous free-flap breast reconstruction and safety during the coronavirus disease 2019 pandemic. J Reconstr Microsurg 2023; 39 (09) 715-726
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Veith J, Donato D, Holoyda K, Simpson A, Agarwal J. Variables associated with 30-day postoperative complications in lower extremity free flap reconstruction identified in the ACS-NSQIP database. Microsurgery 2019; 39 (07) 621-628
    CrossrefPubMedGoogle Scholar
  • 22 Python Software Foundation. Python Language Reference, version 3.9. Available at: http://python.org Accessed May 1, 2023
    PubMedGoogle Scholar
  • 23 Lee Z-H, Chu CK, Asaad M. et al. Comparing donor site morbidity for autologous breast reconstruction: Thigh vs. abdomen. Plast Reconstr Surg Glob Open 2022; 10 (03) e4215
    CrossrefPubMedGoogle Scholar
  • 24 Mohan AT, Saint-Cyr M. Recent advances in microsurgery: an update in the past 4 years. Clin Plast Surg 2020; 47 (04) 663-677
    CrossrefPubMedGoogle Scholar
  • 25 Shpigel M, Othman S, Cohn JE. et al. Special considerations in face transplantation: A systematic review. J Craniofac Surg 2022; 33 (05) 1352-1357
    CrossrefPubMedGoogle Scholar
  • 26 Zhu H, Wei X, Lineaweaver W, Li Q. Perioperative risk factors for vascularized composite allotransplantation: a systematic review and proposal of identity-defining VCA. Microsurgery 2014; 34 (03) 240-244
    CrossrefPubMedGoogle Scholar
  • 27 Soteropulos CE, Tang SYQ, Poore SO. Enhanced recovery after surgery in breast reconstruction: A systematic review. J Reconstr Microsurg 2019; 35 (09) 695-704
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Tan YY, Liaw F, Warner R, Myers S, Ghanem A. Enhanced recovery pathways for flap-based reconstruction: Systematic review and meta-analysis. Aesthetic Plast Surg 2021; 45 (05) 2096-2115
    CrossrefPubMedGoogle Scholar
  • 29 Martinez CA, Boutros SG. Outpatient microsurgical breast reconstruction. Plast Reconstr Surg Glob Open 2020; 8 (09) e3109
    CrossrefPubMedGoogle Scholar
  • 30 Martinez CA, Fairchild B, Secchi-Del Rio R, Boutros SG. Bilateral outpatient breast reconstruction with stacked DIEP and vertical PAP flaps. Plast Reconstr Surg Glob Open 2021; 9 (10) e3878
    CrossrefPubMedGoogle Scholar
  • 31 Kaoutzanis C, Ganesh Kumar N, O'Neill D. et al. Enhanced recovery pathway in microvascular autologous tissue-based breast reconstruction: Should it become the standard of care?. Plast Reconstr Surg 2018; 141 (04) 841-851
    CrossrefPubMedGoogle Scholar
  • 32 Lee HK, Kim DH, Jin US, Jeon YT, Hwang JW, Park HP. Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap for breast reconstruction. Microsurgery 2014; 34 (06) 434-438
    CrossrefPubMedGoogle Scholar
  • 33 Yuan P, Wu Z, Li Z. et al. Impact of postoperative major complications on long-term survival after radical resection of gastric cancer. BMC Cancer 2019; 19 (01) 833
    CrossrefPubMedGoogle Scholar
  • 34 Tebala GD, Gallucci A, Khan AQ. The impact of complications on a programme of enhanced recovery in colorectal surgery. BMC Surg 2018; 18 (01) 60
    CrossrefPubMedGoogle Scholar
  • 35 Torabi R, Stalder MW, Tessler O. et al. Assessing age as a risk factor for complications in autologous breast reconstruction. Plast Reconstr Surg 2018; 142 (06) 840e-846e
    CrossrefPubMedGoogle Scholar
  • 36 Oskar S, Nelson JA, Hicks MEV. et al. The impact of race on perioperative and patient-reported outcomes following autologous breast reconstruction. Plast Reconstr Surg 2022; 149 (01) 15-27
    CrossrefPubMedGoogle Scholar
  • 37 Heo YH, Yagi S, Toriyama K. et al. Relationship between BMI and postoperative complications with free flap in anterolateral craniofacial reconstruction. Plast Reconstr Surg Glob Open 2016; 4 (03) e636
    CrossrefPubMedGoogle Scholar
  • 38 Kim SW. Perforator free flap coverage of chronic lower extremity ulcers in patients with autoimmune diseases under immunosuppression. Int J Low Extrem Wounds 2021; 20 (04) 355-363
    CrossrefPubMedGoogle Scholar
  • 39 Hwang K, Lee JP, Yoo SY, Kim H. Relationships of comorbidities and old age with postoperative complications of head and neck free flaps: A review. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1627-1635
    CrossrefPubMedGoogle Scholar
  • 40 Prantl L, Moellhoff N, Fritschen UV. et al. Impact of smoking status in free deep inferior epigastric artery perforator flap breast reconstruction: A multicenter study. J Reconstr Microsurg 2020; 36 (09) 694-702
    Article in Thieme ConnectPubMedGoogle Scholar
  • 41 Irawati N, Every J, Dawson R. et al. Effect of operative time on complications associated with free flap reconstruction of the head and neck. Clin Otolaryngol 2023; 48 (02) 175-181
    CrossrefPubMedGoogle Scholar
  • 42 Kwok AC, Edwards K, Donato DP. et al. Operative time and flap failure in unilateral and bilateral free flap breast reconstruction. J Reconstr Microsurg 2018; 34 (06) 428-435
    Article in Thieme ConnectPubMedGoogle Scholar
  • 43 Crawley MB, Sweeny L, Ravipati P. et al. Factors associated with free flap failures in head and neck reconstruction. Otolaryngol Head Neck Surg 2019; 161 (04) 598-604
    CrossrefPubMedGoogle Scholar
  • 44 Arshi A, Lai WC, Iglesias BC. et al. Blood transfusion rates and predictors following geriatric hip fracture surgery. Hip Int 2021; 31 (02) 272-279
    CrossrefPubMedGoogle Scholar
  • 45 Walming S, Angenete E, Block M, Bock D, Gessler B, Haglind E. Retrospective review of risk factors for surgical wound dehiscence and incisional hernia. BMC Surg 2017; 17 (01) 19
    CrossrefPubMedGoogle Scholar
  • 46 Kolakowski Jr S, Dougherty MJ, Calligaro KD. Does the timing of reoperation influence the risk of graft infection?. J Vasc Surg 2007; 45 (01) 60-64
    CrossrefPubMedGoogle Scholar
  • 47 Rotholtz NA, Angeramo CA, Laporte M, Matzner Perfumo M, Schlottmann F, Bun ME. “Early” reoperation to treat complications following laparoscopic colorectal surgery: The sooner the better. Surg Laparosc Endosc Percutan Tech 2021; 31 (06) 756-759
    CrossrefPubMedGoogle Scholar
  • 48 Marquez JL, Sudduth JD, Kuo K. et al. A comparison of postoperative outcomes between immediate, delayed immediate, and delayed autologous free flap breast reconstruction: Analysis of 2010–2020 NSQIP data. J Reconstr Microsurg 2023; 39 (08) 664-670
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Yamada A, Narui K, Satake T. et al. Long-term outcomes of immediate autologous breast reconstruction for breast cancer patients. J Surg Res 2020; 251: 78-84
    CrossrefPubMedGoogle Scholar
  • 50 Dekerle L, Cortese S, Salleron J. et al. Long-term survival after head and neck cancer surgery with immediate free flap reconstruction. Ann Chir Plast Esthet 2021; 66 (05) 357-363
    CrossrefPubMedGoogle Scholar
  • 51 Ren Y, Deschler DG, Sajed D, Durand ML. Case of late-onset, relapsing surgical site infection related to a venous coupler placed during free flap reconstruction for major head and neck cancer. Head Neck 2018; 40 (04) E29-E32
    PubMedGoogle Scholar
  • 52 Reintgen C, Leavitt A, Pace E, Molas-Pierson J, Mast BA. Risk factor analysis for mastectomy skin flap necrosis: implications for intraoperative vascular analysis. Ann Plast Surg 2016; 76 (Suppl. 04) S336-S339
    CrossrefPubMedGoogle Scholar