Collagen Vascular Disease in Reconstructive Microsurgery: A Review of 30 Free Flaps
Theresa Y. Wang, M.D., Joseph M. Serletti, M.D., Sharon Kolasinski, M.D., David W. Low, M.D., Benjamin Chang, M.D., Stephen J. Kovach, M.D., Liza C. Wu, M.D..
University of Pennsylvania, Philadelphia, PA, USA.
Collagen vascular or connective tissue diseases affect multiple organs by the deposition of immunoglobulins along vascular basement membranes. As a result, manifestations of vasculitis are common along with soft tissue pathology. The inherent risks for thrombosis and wound healing complications may deem these patients unsuitable candidates for free tissue reconstruction. We present our series of connective tissue disorder patients who underwent successful free flap reconstruction. This represents the first reported series in the literature.
A prospective review was conducted of all free flap reconstruction within the Division of Plastic Surgery at University of Pennsylvania. A total of 1251 free flaps were performed between February 2005 and February 2009. Twenty-four (2%) patients, who underwent a total of 30 free flaps, with the diagnosis of connective tissue disorders were identified with some having concomitant diseases. These included Sjogren’s (3), Raynaud’s (8), rheumatoid arthritis (7), systemic lupus erythematosus (4), sarcoid (3), CREST (1), and multicentric thrombocytosis (1). Data were evaluated based on operative, inpatient and outpatient clinic records.
All 24 patients were females (21 white, 3 black). Mean age was 51 years (37 to 72), and average BMI was 28.1 kg/m2 (16.6 to 38.8). Average length of hospital stay was 4 days (3 to 8). Seven patients (29%) were on chronic immunosuppression for their diseases. Three patients underwent and were cleared by a preoperative hematology evaluation due to their history of clotting and prior failed pedicled flaps. A total of 30 free flap reconstructions were performed which included 22 breast patients (7 DIEP, 19 TRAM, 1 gluteal) and 2 head and neck patients (1 ALT, 2 radial forearm). Six flaps were delayed reconstruction, and 24 were immediate. The fascia was closed primarily in 14 of the breast flap patients. All free flaps were performed with a single arterial and venous anastomosis. None had intraoperative or postoperative microvascular complications. Postoperatively, each patient received the standard anticoagulation according to independent surgeon protocol. There was 1 case of lower extremity deep vein thrombosis with readmission for calf swelling on postoperative day 15 that was managed with coumadin. There were 3 cases of wound dehiscence, all of which healed secondarily with local wound care. There was 1 case of ventral hernia that was repaired with permanent mesh.
CONCLUSION: Blood vessels and soft tissues are weakened and injured by inflammation as the primary target of collagen vascular diseases. The increased incidence for thrombotic events and flap loss and wound healing complications make them risky free tissue transfer patients. We demonstrate from our series, however, that it is safe, and there is no increased morbidity in vascular compromise and the types of postoperative complications in this population. Collagen vascular disease should not preclude patients from free flap reconstruction.