Wax Mark K, Rosenthal Eben
Department of Otolaryngology Head and Neck Surgery, Oregon Health Sciences University, Portland, OR 97201, USA.
Laryngoscope. 2007 Nov;117(11):1961-3. doi: 10.1097/MLG.0b013e31812e017a.
Vascular compromise of free flaps most commonly occurs in the immediate postoperative period in association with failure of the microvascular anastomosis. Rarely do flaps fail in the late postoperative period. It is not well understood why free flaps can fail after 7 postoperative days. We undertook a case review series to assess possible causes of late free flap failure.
Retrospective review at two tertiary referral centers: Oregon Health Sciences University and University of Alabama at Birmingham.
A review of 1,530 flaps performed in 1,592 patients between 1998 and 2006 were evaluated to identify late flap failure. Late flap failure was defined as failure occurring after postoperative day 7 or on follow-up visits after hospital discharge. A prospective database with the following variables was examined: age, medical comorbidities, postreconstructive complications (fistula or infection), hematoma, seroma, previous surgery, radiation therapy, intraoperative findings at the time of debridement, nutrition, and, possibly, etiologies.
A total of 13 patients with late graft failure were identified in this study population of 1,530 (less than 1%) flaps; 6 radial forearm fasciocutaneous flaps, 2 rectus abdominis myocutaneous flaps, 4 fibular flaps, and 1 latissimus dorsi myocutaneous flap underwent late failure. The time to necrosis was a median of 21 (range, 7-90) days. Etiology was believed to possibly be pressure on the pedicle in the postoperative period in four patients (no sign of local wound issues at the pedicle), infection (abscess formation) in three patients, and regrowth of residual tumor in six patients. Loss occurring within 1 month was more common in radial forearm flaps and was presented in the context of a normal appearing wound at the anastomotic site, as opposed to loss occurring after 1 month, which happened more commonly in fibula flaps secondary to recurrence.
Although late free flap failure is rare, local factors such as infection and possibly pressure on the pedicle can be contributing factors. Patients presenting with late flap failure should be evaluated for residual tumor growth.
游离皮瓣血管危象最常发生在术后即刻,与微血管吻合失败有关。皮瓣很少在术后晚期失败。目前尚不清楚为什么游离皮瓣在术后7天之后会失败。我们进行了一项病例回顾系列研究,以评估晚期游离皮瓣失败的可能原因。
在两个三级转诊中心进行回顾性研究:俄勒冈健康与科学大学和阿拉巴马大学伯明翰分校。
对1998年至2006年间1592例患者进行的1530例皮瓣手术进行回顾性评估,以确定晚期皮瓣失败情况。晚期皮瓣失败定义为术后第7天之后或出院后随访时发生的失败。检查了一个包含以下变量的前瞻性数据库:年龄、内科合并症、重建后并发症(瘘管或感染)、血肿、血清肿、既往手术、放射治疗、清创时的术中发现、营养状况以及可能的病因。
在这1530例皮瓣(不到1%)的研究人群中,共识别出13例晚期移植失败患者;6例桡侧前臂筋膜皮瓣、2例腹直肌肌皮瓣、4例腓骨皮瓣和1例背阔肌肌皮瓣发生晚期失败。坏死时间中位数为21天(范围为7 - 90天)。病因被认为可能是4例患者术后蒂部受压(蒂部无局部伤口问题迹象)、3例患者感染(脓肿形成)以及6例患者残留肿瘤再生长。1个月内发生的皮瓣坏死在桡侧前臂皮瓣中更常见,且吻合口处伤口外观正常,而1个月后发生的皮瓣坏死在腓骨皮瓣中更常见,主要原因是复发。
尽管晚期游离皮瓣失败很少见,但局部因素如感染以及可能的蒂部受压可能是促成因素。出现晚期皮瓣失败的患者应评估是否存在残留肿瘤生长。