Prevention and Treatment of Flap Congestion during Head and Neck Reconstruction with Respect to Onset Time

Background:

Circulatory failure in free tissue transfer surgery is a critical complication because an especially congestive condition damages tissue even more than does ischemia. Predicting the cause of flap congestion is important to ensure the immediate removal of the cause and the flap's survival. Here, we identified the causes of flap congestion with respect to onset time.

Methods:

We retrospectively analyzed 249 cases of free tissue transplant in the head and neck, including 15 congestive cases, conducted at the University of Tsukuba Hospital from August 2008 to June 2018. In all cases, microvascular reconstruction was performed. Eight factors were investigated: primary disease, flap type, onset time of congestion, thrombosis, flap condition at onset, cause of congestion, treatment, and flap survival. The primary and secondary causes of congestion were chosen from intraoperative and postoperative factors, assuming that flap congestion is caused by several factors. And the congestion was classified into 3 grades.

Results:

The most common primary diseases were tongue cancer (31.3%) and hypopharyngeal cancer (15.7%). Nine flaps were used, the most common being anterolateral thigh (36.9%) and rectus abdominis (21.7%) flaps. The overall flap congestion rate was 7.4%, and the venous thrombosis rate was 3.9%. As for the onset time of congestion, 93% of the congestions occurred within 3 days of surgery. Most of the congestions without thrombosis occurred within 12 hours of surgery. Venous thrombosis occurred in 9 cases and 3 areas (anastomosis area: 6 cases; distal area from anastomosis: 1 case; internal jugular vein: 1 case; external jugular vein: 1 case) (all within 3 days of surgery). The congestion caused by thrombosis at the anastomosis area was found within 12 hours of surgery, which was earlier than for the other areas. We classified flap congestion into 3 grades according to the purpuric appearance: grade 1: 5 cases; grade 2: 7 cases; grade 3: 3 cases. Grade-1 congestion was found in the early phase and worsened over time. The primary causes of the flap congestion were damaged endothelium (4 cases), flap volume (4 cases), flap positioning (3 cases), wound tension (1 case), recipient vessels (2 cases), swelling of the wound after surgery (2 cases), and rest of the wound (1 case). Seven kinds of treatment were performed: reanastomosis (7 cases), reduction of skin tension by stitch removal (7 cases), reconstruction with another flap (2 cases), medicinal leech therapy (2 cases), reduction of flap volume (2 cases), etc. The final result after congestion had 3 patterns: complete flap survival (5 cases), partial necrosis (3 cases), and total necrosis (7 cases).

Conclusion:

Within a 24-hour posttransplant window, damaged endothelium, excessive flap volume, tight sutures and swelling of the surgical site were factors influencing flap congestion during head and neck reconstruction. Thereafter, damaged endothelium was the main factor. In addition, failure of the flap arrangement and neck rest as well as recipient vessel troubles were crucial factors to prevent complications. Using the time of onset to categorize types of flap congestion allows for preventive and rapid responses to the congestion.