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RISK FACTORS ASSOCIATED WITH MICROVASCULAR FREE FLAP FAILURE: DATA FROM THE ACS-NATIONAL SURGICAL QUALITY IMPROVEMENT PROJECT (ACS-NSQIP)
JoAnna Nguyen, MD, Ahva Shahabi, MPH, Evan N. Vidar, MA, Linda S. Chan, PhD, Regina Y. Baker, MD, Wesley G. Schooler, MD, Mark M. Urata, MD, DDS, Alex K. Wong, MD, DDS.
Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Purpose - There are numerous factors that may influence microvascular free flap failure. The ACS National Surgical Quality Improvement Program (NSQIP) is a validated, risk-adjusted program used to establish national outcomes benchmarks. Using this multi-institutional database, we sought to identify factors associated with microsurgical free flap failure and return to the operating room.
Methods - We identified all patients who underwent free flap procedures in the NSQIP database from 2005-8. Univariate analyses were performed to determine associations of return to OR and flap failure with the following variables of age, BMI, amount of transfusion required, diabetes and smoking status, total intra-operative time, and type of flap procedure.
Results - From 2005-8, 320 patients underwent a microsurgical free flap procedure with 370 flaps. The mean age of the 320 patients was 52 years. Of the 370 flaps, 270 (73%) flaps were done for breast reconstruction, 57 (15.4 %) were myocutaneous flaps, 25 (6.8 %) were free cutaneous flaps, and 18 (4.9 %) were free fascial flaps. Overall, the incidence of returning to the OR was 15% (56/370), (95%CI 11%, 19%) and the incidence of flap failure within 30 days was 6% (22/370) (95%CI 4%, 8%).
Patients who received 3 or more units of packed red blood cells intra-operatively were 3 times more likely to return to the OR and over 5 times more likely to experience flap failure. For every hour of increased operative time, patients had a 10% increased risk of returning to the operating room and 22% increased risk of flap failure . Patients who underwent head and neck reconstructions had a 4 fold increased risk of flap failure .
Conclusions - We found that risk factors for flap failure include increased number of transfusion, prolonged surgery time, and head and neck reconstruction. The overall rates of flap loss was 6% and return to the OR was 15%. Based on the multi-institutional data derived from NSQIP hospitals around the country, this study offers for the first time, a true approximation of nationwide microvascular free flap outcomes in plastic surgery.
Disclaimer: American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.


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