Safety And Efficacy Of Microsurgical Pedicle Extension In Free Flap Reconstruction: A Systematic Review Of The Literature
Edgar Soto, BS1, Paxton W. Peacock, BS1, Ashlynn R. Clark, BS1, Sharon D. Lawson, MD2, Ali Kilic, MD MSHA2, René P. Myers, MD2, Jorge I. de la Torre, MD MSHA2.
1University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA, 2University of Alabama at Birmingham, Department of Surgery, Division of Plastics, Birmingham, AL, USA.
PURPOSE: Traumatic injuries that demand free tissue flaps for reconstruction may require vascular pedicle extension between the flap and recipient vessels to form a clear anastomosis. Reports in the literature conflict on the reliability of pedicle extension techniques in free flap surgery. The objective of this study is to systematically assess available literature about outcomes of pedicle extensions in free flap reconstruction.
METHODS: A comprehensive search was performed for relevant studies prior to January 2020. Using the Cochrane Collaboration risk of bias assessment tool, a total of 49 studies were identified for this investigation. Of these 49, those meeting inclusion criteria underwent data extraction focusing on demographics, conduit type, microsurgical technique, and postoperative outcomes.
RESULTS: The search ultimately yielded 22 retrospective studies totaling 855 procedures from 2007 to 2018 in which 159 (17.1%) complications were reported. Overall heterogeneity of articles was high. Free flap failure and thrombosis were the two most prevalent major complications. Vein graft extensions maintained the highest rate of complications (20%) in comparison to arterial grafts (12%) and arteriovenous loops (17%). Bone flaps had the most complications per tissue type at 21%. Overall success rate of pedicle extensions in free flaps was 91%.
CONCLUSION: This systematic review strongly suggests that pedicle extensions of free flaps in high-risk complex settings are practical and effective options. There may be a benefit to using arterial versus venous conduits, although further examination is warranted given the small number of reconstructions reported in the literature and the low quality of evidence available.
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