By Michael A. Fritz, MD

Success rates and morbidity in microvascular reconstruction continue to increase and decrease, respectively. Free flap survival rates at most major institutions nationally now routinely exceed 97 percent. This success places less imperative on prolonged monitoring of free tissue transfers in those patients who otherwise have no significant postoperative risk. In addition, developments in free flap technique — particularly the growth in popularity of anterolateral thigh (ALT) free flaps — have allowed for free tissue transfer to be performed with negligible donor-site morbidity.

Expanding indications

Facial plastic surgeons at Cleveland Clinic’s Head & Neck Institute have been working on several fronts to deliver reliable, leading-edge facial reconstruction with less patient morbidity and at lower cost.

• First, aggressive adaptation of the ALT flap has led to an exponential increase in its use, by far surpassing in frequency the use of more traditional donor sites (e.g., radial forearm, rectus abdominis and pectoralis major grafts), which are associated with greater morbidity and a more visible harvest-site deformity. This has been accomplished with aggressive perforator flap tech-niques and flap thinning as well as novel uses of the ALT fascial or adipofascial flaps.
• Second, minimal access approaches to expose vessels form icrovascular anastomosis have been developed that minimize morbidity and surgical time while conferring the benefit of improved pedicle reach to palatal, nasal and skull base defects. These advances have allowed us to expand the indications for free tissue transfer. We now regularly use free flaps in complex nasal and palatal reconstruction, correction of large facial contour defects, and salvage of refractory osteoradionecrosis prior to full bone destruction.

This evolution in reconstruction has created a dichotomy in the free flap population, with traditional large tumor resections and reconstructions occupying one subset and more focused surgeries utilizing perforator flaps and minimal access approaches at the other.

Major reconstructions that confer functional morbidity as well as airway and fistula risk continue to require a hospital stay of one week or more to allow for appropriate management and observation.

However, the necessary length of admission for patients who undergo “minor” free flap reconstruction is less clear.

A test of early discharge

At the Head & Neck Institute, we discharge free flap patients as soon as postoperative care needs allow, provided that their medical comorbidities are acceptable and their risk of airway compromise or fistula formation is low. To assess the prudence of our policy, we retrospectively reviewed our initial experience with early discharge by assessing outcomes of those patients discharged within three days after surgery.

We reviewed the records of 50 patients who had undergone a total of 51 free tissue transfers for head and neck reconstruction and who had been discharged on or before postoperative day three; the average date of discharge was postoperative day two. The indications for free flaps were variable, the most common being reconstruction of a cutaneous defect. The vast majority of these reconstructions involved ALT free flaps that were vascularized primarily through minimally invasive approaches to facial, angular or superficial temporal vessels.

Only two of the 50 patients experienced a complication and had to return for revision. One patient who had been discharged home on postoperative day two returned two days later with signs of vascular compromise, and the free flap was successfully salvaged after vessel revision. Another patient who had been discharged on postoperative day two experienced a late flap failure between two and three weeks postoperatively. She eventually underwent an additional microvascular reconstruction (with early discharge), which was successful. As a result, our overall flap success rate in this cohort was 98 percent. No other postoperative complications were identified.

Expanding indications

Favorable free flap outcomes and low complication rates in our patients suggest that early discharge can be adopted in carefully selected patients without compromising safety or surgical success rates. Notably, the vast majority of these patients underwent ALT perforator free flaps and minimal access approaches for recipient vessels. In this subset of patients, our policy of early mobilization and early discharge not only decreases overall costs, but also avoids potential risks associated with prolonged hospital stays. With these factors in mind, indications for free tissue transfer to improve patient form and function in facial reconstruction will continue to expand.

Dr. Fritz is a specialist in facial plastic and reconstructive surgery in the Head & Neck Institute. He can be reached at 216.444.2792 or fritzm1@ccf.org.