Microvascular reconstruction of oro-facial defects; a review of one surgeon's experience

Introduction The practice of micro vascular surgery is currently limited to a few centres in Sri Lanka. This type of surgery requires specialist training and a dedicated team. A retrospective review of the micro vascular reconstructions carried out by one surgeon at the Dental Hospital, Peradeniya, Sri Lanka, was performed and the outcome has been analysed. The resection, neck dissections, the harvest of the flap and the reconstructions were performed single-handedly. Methods This is a retrospective study. Details were obtained from the theatre register, clinical notes and from the surgeon's personal data base. Patient identity, age, sex, diagnosis, type of surgery, reconstruction type, vein grafts, complications, anticoagulants used, type of anastomosis, tracheostomy, intubation period, flap salvage and final outcome were recorded. Results During the period from 2007 to 2010, 33 microvascular reconstructions were performed by the first author. Twenty two patients had resections for oral malignancies. The commonest flap was the fibula flap (16 cases), followed by the radial forearm flap (13 cases). There were four anterior lateral thigh flaps as well. The success rate was 82% with six failures. There were 21 males and 12 females. The average age was 44.7, ranging from 14 years to 64 years. The male to female ratio was 2.7:1. Seven patients (21%) were taken back to the theatre for exploration. Six patients developed thrombosis of the vessels. Only one flap thrombosis was identified in time and this was salvaged by re- anastomosis. No tracheostomies were performed electively. Patients were managed in the dedicated intensive care unit by keeping the endotracheal tube longer to secure the airway. Seventy five percent (75%) of patients were extubated within 48 hours. Conclusions Microvascular surgery is technically highly demanding. The success rate (82%) here is lower compared to more well-established units around the world. Three types of flaps have been used in this series. The commonest cause of flap loss was venous thrombosis. Proper training of nurses and junior doctors in recognising early signs of flap failure, close monitoring, prompt exploration when indicated and meticulous post¬operative management during the first 72 hours would have given better flap survival. Tracheostomies can be avoided despite major head and neck resections. Ideally, two teams should work together to save time and minimise surgeon fatigue. The Sri Lanka Journal of Surgery 2015; 33(4): 13-19