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Building a Successful High-Volume Free Flap Center: The Penn Experience
Theresa Y. Wang, M.D., Liza C. Wu, MD, Jennifer McGrath, MD, Richard Agag, MD, David C. Low, MD, Stephen J. Kovach, MD, Scott P. Bartlett, MD, Benjamin Chang, MD, Suhail Kanchwala, MD, Joseph M. Serletti, MD.
University of Pennsylvania, Philadelphia, PA, USA.

PURPOSE: Free flap reconstruction has become the standard of care in many areas of plastic surgery. However, there is always the inherent risk of flap thrombosis and many intricacies are involved in achieving a viable flap. From the surgeon to hospital staff, down to the technical details of flap harvest, microsurgery and postoperative care, many aspects of the reconstruction are subject to flap complications. We present our experience which details our team approach and intraoperative and postoperative protocols that have worked well in doing high-volume free flap cases successfully.
METHODS: A review was conducted on all free flap reconstruction cases within the University of Pennsylvania Health System between January 2005 and December 2009. A total of 1619 free flaps were performed in 1186 patients. Preoperative, intraoperative and postoperative records were analyzed for patient demographics, medical history, operative notes, hospital course as well as clinic follow-up data. Our standard free flap practice consists of dedicated OR teams specific for our microsurgical cases. Intraopera tively, an independent micro instrument stand is handled only by the surgeons, wide exposure of recipient vessels, minimal handling of all vessels, and an observation period for perfusion of the flap prior to insetting. Postoperatively, patients are monitored for 48 hours in an intermediate care unit with experienced free flap nursing staff.
RESULTS: Nine hundred fifty patients were female, 236 were male. Mean age was 51 years (17-96). The average BMI was 28.0 kg/m2(17.2-50.1). Average length of hospital stay was 4.5 days. Flap breakdown shows a wide variety performed including: 861 msTRAM/TRAM, 8 VRAM, 296 DIEP, 76 SIEA, 6 SGAP, 19 IGAP, 28 TUG, 62 RFFF, 135 ALT, 42 fibula, 4 DCIA, 29 latissimus, 24 vastus lateralis, 5 scapular, 13 gracilis, 2 jejunal, and 9 others. Seventy-nine percent or 1285 of the flaps had the venous anastomosis completed using a coupler. For the microsurgical portion of the case, 3.5 loupes were used an estimated 88% of the cases. The rate of intraoperative thrombosis was a total of 1.9% (1.6% arterial, 0.3% venous). The rate of intraoperative technical difficulties (including but not limited to re-do anastomosis, thrombosis, scarring, friable vessels/tissues) was 5.7%. The rate of postoperative thrombosis was 2.3% (1.2% arterial, 1.1% venous). The rate for takeback to the OR for exploration and salvage was 1.5%. The overall salvage rate was 60%. Total flap loss was 1.8% whereas partial flap loss was 0.8%. Complications included fat necrosis 5.2%, infection 6.4%, hematoma 2.8%, seroma 4.3%.
CONCLUSION: Established algorithms and approaches help to improve outcomes and lower failure rates. Notably, a dedicated team of surgeons and staff experienced with free flap cases are an important resource. However, of paramount importance is the detailed assessment of the flap intraop and ascertaining that all aspects are viable prior to leaving the operating room. Free flap reconstruction may have its unpredictable aspects. However, it is when we make it into a predictable course that allows us to pursue high-volume cases successfully.


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