The Impact of Intraoperative Microvascular Compromise on Outcomes in Microsurgical Breast Reconstruction

Abstract

Background In microsurgical breast reconstruction, the nature and fate of postoperative vascular compromise has been well studied, but limited data exist on intraoperative vascular compromise.

Methods A review of all breast free flaps between 2007 and 2012 was performed. Details of intraoperative vascular compromise were recorded. Patients who experienced intraoperative microvascular compromise (Group I) were compared with patients who experienced only postoperative microvascular compromise (Group P) and all other patients (Group N).

Results A total of 612 microsurgical breast reconstructions were reviewed. There were 73 (11.9%) flaps in Group I, 27 (4.4%) in Group P, and 512 (83.7%) in Group N. Compared with Group P, Group I more often involved arterial problems (p = 0.01), required supercharging for venous problems (p = 0.02), and was more likely to be salvaged (89.0 vs. 70.4%, p = 0.03). Group I had a similar overall complication rate compared with all other flaps (Group N + P) (31.5 vs. 27.1%, p = 0.49), but a higher flap loss rate (11.0 vs. 1.7%, p = 0.0003). The need to perform > 1 arterial revision was a risk factor for flap loss in Group I (p = 0.028). Total ischemia times > 175 minutes (p = 0.047) and reperfusion times > 80 minutes (p = 0.041) significantly increased the risk of flap loss to approximately 50%.

Conclusion Intraoperative vascular problems occur more frequently than postoperative vascular problems but are more frequently salvaged. They do not increase the likelihood of reoperation or total complications compared with all other flaps but do increase the risk of flap loss.

Keywords

breast reconstruction - free flap - microsurgery

Note

This work was presented at the 2015 Annual Meeting of the American Society for Reconstructive Microsurgery (Paradise Island, Bahamas).

• References

• 1 Eltahir Y, Werners LL, Dreise MM , et al. Quality-of-life outcomes between mastectomy alone and breast reconstruction: comparison of patient-reported BREAST-Q and other health-related quality-of-life measures. Plast Reconstr Surg 2013; 132 (2) 201e-209e
• 2 Yueh JH, Slavin SA, Adesiyun T , et al. Patient satisfaction in postmastectomy breast reconstruction: a comparative evaluation of DIEP, TRAM, latissimus flap, and implant techniques. Plast Reconstr Surg 2010; 125 (6) 1585-1595
• 3 Eltahir Y, Werners LL, Dreise MM, Zeijlmans van Emmichoven IA, Werker PM, de Bock GH. Which breast is the best? Successful autologous or alloplastic breast reconstruction: patient-reported quality-of-life outcomes. Plast Reconstr Surg 2015; 135 (1) 43-50
• 4 Chen KT, Mardini S, Chuang DC , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (1) 187-195
• 5 Mirzabeigi MN, Wang T, Kovach SJ, Taylor JA, Serletti JM, Wu LC. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg 2012; 130 (3) 579-589
• 6 Selber JC, Angel Soto-Miranda M, Liu J, Robb G. The survival curve: factors impacting the outcome of free flap take-backs. Plast Reconstr Surg 2012; 130 (1) 105-113
• 7 Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (7) 2092-2100
• 8 Kroll SS, Schusterman MA, Reece GP , et al. Timing of pedicle thrombosis and flap loss after free-tissue transfer. Plast Reconstr Surg 1996; 98 (7) 1230-1233
• 9 Lee KT, Lee JE, Nam SJ, Mun GH. Ischaemic time and fat necrosis in breast reconstruction with a free deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2013; 66 (2) 174-181
• 10 Gürlek A, Kroll SS, Schusterman MA. Ischemic time and free flap success. Ann Plast Surg 1997; 38 (5) 503-505
• 11 Chang SY, Huang JJ, Tsao CK , et al. Does ischemia time affect the outcome of free fibula flaps for head and neck reconstruction? A review of 116 cases. Plast Reconstr Surg 2010; 126 (6) 1988-1995
• 12 Fosnot J, Jandali S, Low DW, Kovach III SJ, Wu LC, Serletti JM. Closer to an understanding of fate: the role of vascular complications in free flap breast reconstruction. Plast Reconstr Surg 2011; 128 (4) 835-843
• 13 Chang EI, Chang EI, Soto-Miranda MA , et al. Comprehensive Evaluation of Risk Factors and Management of Impending Flap Loss in 2138 Breast Free Flaps. Ann Plast Surg 2014; . PMID: 25003429 ( e-pub ahead of print)
• 14 Chang EI, Mehrara BJ, Festekjian JH, Da Lio AL, Crisera CA. Vascular complications and microvascular free flap salvage: the role of thrombolytic agents. Microsurgery 2011; 31 (7) 505-509
• 15 Galanis C, Nguyen P, Koh J, Roostaeian J, Festekjian J, Crisera C. Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction. Plast Reconstr Surg 2014; 134 (1) 20-27