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Published on: April 26, 2019
Long-term survival analysis of free flap reconstruction in patients with collagen vascular disorders
Maria Yan1, Sanjna Rajput2, Kuldeep Singh1
1Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
Insights
Free flap reconstruction is feasible in patients with collagen vascular disorders (CVD). Careful perioperative steroid management is crucial for minimizing complications like cellulitis and abscesses, ensuring better wound healing.
Area of Science:
- Plastic Surgery
- Immunology
- Vascular Surgery
Background:
- Collagen vascular disorders (CVD) present unique challenges for reconstructive surgery due to patient immunosuppression and hyper-coagulable states.
- Free tissue transfer in CVD patients requires careful consideration of potential complications.
- Understanding these challenges is vital for optimizing surgical outcomes.
Purpose of the Study:
- To evaluate the safety and outcomes of free flap reconstructions in patients diagnosed with collagen vascular disorders (CVD).
- To identify predictors of surgical complications in this challenging patient cohort.
- To inform perioperative management strategies for CVD patients undergoing free flap surgery.
Main Methods:
- A retrospective review of 78 patients (96 free flaps) with diagnosed CVD (rheumatoid arthritis, Raynaud phenomenon, SLE, scleroderma, sarcoidosis) from 2000-2020.
- Inclusion criteria focused on adult patients with confirmed CVD undergoing free flap reconstruction.
- Time-to-event analysis was employed to identify risk factors for surgical complications.
Main Results:
- The overall flap loss rate was 3.8%.
- Steroid treatment was significantly associated with an increased risk of major complications (HR 2.5, p=0.01), specifically cellulitis (OR 5.1, p=0.02) and abscess (OR 5.7, p=0.01).
- Common CVDs included rheumatoid arthritis (36 patients) and Raynaud phenomenon (9 patients).
Conclusions:
- Free flap reconstruction is a viable option for patients with collagen vascular disorders.
- Perioperative optimization of steroid therapy is critical for improving wound healing and managing disease activity.
- Proactive management of immunosuppression and coagulation status is essential for successful outcomes.
Background:
Collagen vascular disorders (CVD) are inflammatory diseases that can affect the blood vessels and soft tissues. Patients with CVD are often immunosuppressed, prone to hyper-coagulation, and represent a challenging patient cohort for free tissue transfer.
Methods:
A retrospective review of patients with CVD who underwent free flap reconstructions from 2000-2020 was performed at our institution. Inclusion criteria were patients 18 years old or older with the clinical diagnosis of CVD, including rheumatoid arthritis, Raynaud phenomenon, systemic lupus erythematosus, scleroderma, and sarcoidosis. A time-to-event analysis was performed to identify predictors of surgical complications.
Results:
A total of 78 patients and 96 free flaps were included. The most common CVD were rheumatoid arthritis (n=36) and Raynaud's phenomenon (n=9). Type of flap included abdominal-based flap (26%), trunk-based flaps (32.3%), and extremity-based flaps (19.8%). The mean age was 56.7±14.6 years, and the mean BMI was 27.5±5.9 kg/m2. Antibody positivity was present in 25.6% of patients; 59% were on chronic steroids, 6.4% were on chronic anticoagulation, 35.9% had radiation therapy, and 29.5% had chemotherapy. Nine percent of patients had a history of prior flap loss, and 11.5% had a history of DVT or arterial thrombosis. The flap loss rate was 3.8%. Steroid treatment was associated with an increased risk of major complications after adjusting for the type of flap HR 2.5(1.3-4.9), p= 0.01. Specifically associated with a higher risk of cellulitis, OR 5.1 (1.1-24.5), p=0.02, and abscess, OR 5.7 (1.2-27.1), p=0.01.
Conclusion:
Free flap reconstruction can be safely performed in patients with CVD. Perioperative optimization of steroids is important to promote wound healing and stabilize disease activity.
