Intraoperative Versus Postoperative Correction of Vascular Compromise: Comparison of Flap and Patient Outcomes in...

Although flap complications due to vascular compromise are rare with patent anastomoses, it can be devastating when it leads to flap failure, occurring in 3 to 5% of free flap breast reconstructions. The unpredictable nature of vascular compromise presents a significant challenge to microsurgeons. Preventative interventions such as revision of the vascular anastomosis can occur as early as intraoperatively, but how these actions impact postoperative outcomes has not been thoroughly investigated. This study assesses the efficacy of intraoperative microsurgical interventions for vascular compromise on outcomes in free flap breast reconstruction.

A retrospective review was conducted of patients who underwent free flap breast reconstruction at a single academic institution between January 2005 and June 2023. Flaps that underwent intraoperative repeat anastomosis due to vascular compromise were compared with those that did not undergo intraoperative intervention but returned postoperatively for anastomosis revisions.

Among 3,120 patients and 5,003 flaps reviewed, 182 flaps experienced intraoperative microsurgical revisions, and 79 flaps underwent postoperative repeat vascular anastomosis. Patient demographics, comorbidities, and flap types were not significantly different between the two groups. Multivariate regression analysis revealed that the intraoperative re-anastomosis cohort had significantly lower odds of surgical site infection, seroma, hematoma, skin necrosis, and flap loss rate due to vascular compromise. The rate of overall flap loss was 1.28%.

Proactive intraoperative management of vascular compromise is ideal as it optimizes clinical outcomes and flap success rate. The findings from our study promote refinement of both surgical skills and decision-making among surgeons for optimal patient safety in free flap breast reconstruction.