Letter to the Editor: Short Report
477
Vasopressor-Dependent Recipient Vessel Blood Flow in Head and Neck Free Tissue Transfer: A Report of Two Cases Edward W. Swanson, MD1 Srinivas M. Susarla, DMD, MD, MPH1 Georgia C. Yalanis, BS, MSc1 Hsu-Tang Cheng, MD1,2 Denver M. Lough, MD, PhD1 Owen Johnson III, MD1 Anthony P. Tufaro, DDS, MD1 Paul N. Manson, MD1 Justin M. Sacks, MD1 1 Department of Plastic and Reconstructive Surgery, The Johns
Hopkins University School of Medicine, Baltimore, Maryland 2 Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, China Medical University School of Medicine, Taichung City, Taiwan
Address for correspondence Justin M. Sacks, MD, Department of Plastic and Reconstructive Surgery, Suite 2114C, Johns Hopkins Outpatient Center, Baltimore, MD 21287 (e-mail: [email protected]).
The utility of vasopressors in free tissue transfer continues to be a point of debate among microvascular surgeons. Surveys of microsurgeons highlight their reluctance to treat hypotension and general avoidance of vasoactive medications.1,2 Despite the negative attitudes toward the use of vasopressors during free flap reconstruction, multiple studies have documented a high prevalence of their use intraoperatively (52– 82%), and overall lack of effect on ultimate flap outcomes.3–8 We report two cases of free latissimus dorsi flap reconstruction for scalp coverage, both requiring intraoperative and continuous postoperative vasopressor support to maintain adequate blood flow through the recipient artery. These cases add to the growing literature that vasopressors are safe in microsurgery, as they demonstrate vasoactive medications can be a useful tool to improve blood flow in recipient vessels in head and neck microsurgery, and not merely to maintain systemic pressures intraoperatively.
muscle flap was harvested for soft tissue coverage. Flow in the recipient superficial temporal artery could only be maintained intraoperatively when systolic blood pressure was kept above 180 mm Hg with the use of phenylephrine. The decision was made to continue phenylephrine infusion to sustain recipient artery perfusion. The latissimus dorsi flap was divided and anastomosed to the superficial temporal vessels successfully with continued phenylephrine infusion. The patient was kept in the surgical intensive care unit, where norepinephrine infusion (0.3–0.85 µg/kg/min) was continued until she could be liberated from vasopressor support on postoperative day (POD) 5. She was discharged on POD 7 with a systolic blood pressure of 130 to 150 mm Hg and viable reconstruction (►Fig. 4). Upon follow-up at 6 months postoperatively, her flap remains healthy with no signs of necrosis, infection, or hardware exposure.
Case 1
Case 2
The patient was a 73-year-old woman with an 8 8 cm fungating invasive squamous cell carcinoma of the right scalp who presented for resection (►Figs. 1 and 2). Of note, she was found to have uncontrolled hypertension in preoperative workup, with systolic blood pressure ranging from 200 to 220 mm Hg. The tumor was removed en bloc with neurosurgery, resulting in a 15 10 cm scalp defect and a 9 9 cm full thickness calvarial defect (►Fig. 3). Cranioplasty was achieved with titanium mesh (►Fig. 3). Latissimus dorsi
The patient was a 92-year-old man with a history of multiple basal cell carcinomas and melanoma of his scalp that had been previously resected and treated with radiation, who presented with a full-thickness scalp wound and osteoradionecrosis of the calvarium. The patient underwent resection of the wound to viable tissue and bilateral parietal midline craniectomy by neurosurgery, reconstructed with titanium mesh, and a resultant 15 12 cm soft tissue defect. A musculocutaneous latissimus dorsi flap was harvested simultaneously. Similar to case 1, superficial
received December 23, 2014 accepted after revision February 15, 2015 published online March 31, 2015
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1549008. ISSN 0743-684X.
Downloaded by: University of British Columbia. Copyrighted material.
J Reconstr Microsurg 2015;31:477–480.
Vasopressors in Head and Neck Free Tissue Transfer
Swanson et al.
Fig. 1 Case 1 preoperative 3D computed tomography reconstructions of frontal (A), posterior (B), and lateral (C and D) views showing right vertex tumor with surrounding vasculature, bone invasion, and soft tissue involvement. 3D, three-dimensional.
temporal artery perfusion was dependent on the systolic blood pressure remaining above 160 mm Hg with the aid of phenylephrine. Postoperatively, he was maintained on norepinephrine (0.1–0.24 µg/kg/min) and phenylephrine (1 µg/kg/min) to reach a systolic blood pressure goal of 150 to 160 mm Hg. He was eventually weaned from vasopressor support by POD 2. At 4 months postoperatively, he continues to do well with a stable reconstruction.
Discussion Necessity is often the mother of invention, or in our case forced us to challenge microsurgical dogma. The cases presented underscore the safety and potential utility of vasopressor medication in free tissue transfer. Each patient experienced relative hypotension intraoperatively compared with their baseline blood pressures, and there was no flow upon dissection of the superficial temporal vessels. Without
Fig. 2 Case 1 preoperative images of the fungating, bleeding squamous cell carcinoma.
Journal of Reconstructive Microsurgery
Vol. 31
No. 6/2015
Downloaded by: University of British Columbia. Copyrighted material.
478
Swanson et al.
Fig. 3 Case 1 en bloc scalp and tumor resection (A) and craniectomy (B) specimens with resultant scalp and cranial defect (C) reconstructed with titanium mesh cranioplasty (D).
the use of vasoactive medication, free tissue transfer would have been delayed or aborted, and alternative reconstructive options would have been pursued. The use of vasopressors allowed the surgical and anesthetic team to control the inflow pressure to the recipient vessels, leading to successful microvascular anastomosis. Furthermore, we wanted to avoid large volume fluid resuscitation in a 90-year-old man with an extensive cardiac history. Of note, cardiac monitoring should be used in patients receiving vasopressors due to risk of
cardiac ischemia. We are not advocating for routine protocol use of vasopressors in free flap reconstruction, but we urge microvascular surgeons to consider their use earlier during hypotensive episodes when recipient vessels are transected and prepared for anastomosis. Weak flow across an anastomosis can lead to thrombosis and higher probability of free flap failure. In addition, a recent literature review by Brinkman et al suggests that aggressive fluid resuscitation should be avoided in microsurgical reconstruction.9
Fig. 4 Case 1 posterior (A), right posterior oblique (B), and lateral (C) postoperative photographs demonstrating a healthy, viable latissimus dorsi muscle free flap scalp reconstruction. Journal of Reconstructive Microsurgery
Vol. 31
No. 6/2015
479
Downloaded by: University of British Columbia. Copyrighted material.
Vasopressors in Head and Neck Free Tissue Transfer
Vasopressors in Head and Neck Free Tissue Transfer
Swanson et al.
Conclusions
2 Vyas K, Wong L. Intraoperative management of free flaps: current
We report two successful cases of free latissimus dorsi scalp reconstruction requiring the use of vasopressors to elicit flow in the recipient superficial temporal arteries and throughout the postoperative period. The literature reveals a high rate of use and safety of vasopressors during free tissue transfer despite persistent negative impressions. This report highlights that vasoactive medications are not only safe in the setting of hypotension, but can be an effective tool for the microsurgeon to initiate or improve recipient vessel blood flow.
3 Monroe MM, McClelland J, Swide C, Wax MK. Vasopressor use in
practice. Ann Plast Surg 2014;72(6):S220–S223
Disclosure There are no personal or financial conflicts of interest to report for any author. The study was not funded.
References
5
6
7
8
9
1 Marsh M, Elliott S, Anand R, Brennan PA. Early postoperative care
for free flap head & neck reconstructive surgery—a national survey of practice. Br J Oral Maxillofac Surg 2009;47(3):182–185
Journal of Reconstructive Microsurgery
4
Vol. 31
No. 6/2015
free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142(2):169–173 Monroe MM, Cannady SB, Ghanem TA, Swide CE, Wax MK. Safety of vasopressor use in head and neck microvascular reconstruction: a prospective observational study. Otolaryngol Head Neck Surg 2011;144(6):877–882 Harris L, Goldstein D, Hofer S, Gilbert R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery 2012;32(1):15–19 Chan JY, Chow VL, Liu LH. Safety of intra-operative vasopressor in free jejunal flap reconstruction. Microsurgery 2013;33(5): 358–361 Chen C, Nguyen MD, Bar-Meir E, et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg 2010;65(1):28–31 Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg 2014;72(6): S135–S138 Brinkman JN, Derks LH, Klimek M, Mureau MA. Perioperative fluid management and use of vasoactive and antithrombotic agents in free flap surgery: a literature review and clinical recommendations. J Reconstr Microsurg 2013;29(6):357–366
Downloaded by: University of British Columbia. Copyrighted material.
480
477
Vasopressor-Dependent Recipient Vessel Blood Flow in Head and Neck Free Tissue Transfer: A Report of Two Cases Edward W. Swanson, MD1 Srinivas M. Susarla, DMD, MD, MPH1 Georgia C. Yalanis, BS, MSc1 Hsu-Tang Cheng, MD1,2 Denver M. Lough, MD, PhD1 Owen Johnson III, MD1 Anthony P. Tufaro, DDS, MD1 Paul N. Manson, MD1 Justin M. Sacks, MD1 1 Department of Plastic and Reconstructive Surgery, The Johns
Hopkins University School of Medicine, Baltimore, Maryland 2 Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, China Medical University School of Medicine, Taichung City, Taiwan
Address for correspondence Justin M. Sacks, MD, Department of Plastic and Reconstructive Surgery, Suite 2114C, Johns Hopkins Outpatient Center, Baltimore, MD 21287 (e-mail: [email protected]).
The utility of vasopressors in free tissue transfer continues to be a point of debate among microvascular surgeons. Surveys of microsurgeons highlight their reluctance to treat hypotension and general avoidance of vasoactive medications.1,2 Despite the negative attitudes toward the use of vasopressors during free flap reconstruction, multiple studies have documented a high prevalence of their use intraoperatively (52– 82%), and overall lack of effect on ultimate flap outcomes.3–8 We report two cases of free latissimus dorsi flap reconstruction for scalp coverage, both requiring intraoperative and continuous postoperative vasopressor support to maintain adequate blood flow through the recipient artery. These cases add to the growing literature that vasopressors are safe in microsurgery, as they demonstrate vasoactive medications can be a useful tool to improve blood flow in recipient vessels in head and neck microsurgery, and not merely to maintain systemic pressures intraoperatively.
muscle flap was harvested for soft tissue coverage. Flow in the recipient superficial temporal artery could only be maintained intraoperatively when systolic blood pressure was kept above 180 mm Hg with the use of phenylephrine. The decision was made to continue phenylephrine infusion to sustain recipient artery perfusion. The latissimus dorsi flap was divided and anastomosed to the superficial temporal vessels successfully with continued phenylephrine infusion. The patient was kept in the surgical intensive care unit, where norepinephrine infusion (0.3–0.85 µg/kg/min) was continued until she could be liberated from vasopressor support on postoperative day (POD) 5. She was discharged on POD 7 with a systolic blood pressure of 130 to 150 mm Hg and viable reconstruction (►Fig. 4). Upon follow-up at 6 months postoperatively, her flap remains healthy with no signs of necrosis, infection, or hardware exposure.
Case 1
Case 2
The patient was a 73-year-old woman with an 8 8 cm fungating invasive squamous cell carcinoma of the right scalp who presented for resection (►Figs. 1 and 2). Of note, she was found to have uncontrolled hypertension in preoperative workup, with systolic blood pressure ranging from 200 to 220 mm Hg. The tumor was removed en bloc with neurosurgery, resulting in a 15 10 cm scalp defect and a 9 9 cm full thickness calvarial defect (►Fig. 3). Cranioplasty was achieved with titanium mesh (►Fig. 3). Latissimus dorsi
The patient was a 92-year-old man with a history of multiple basal cell carcinomas and melanoma of his scalp that had been previously resected and treated with radiation, who presented with a full-thickness scalp wound and osteoradionecrosis of the calvarium. The patient underwent resection of the wound to viable tissue and bilateral parietal midline craniectomy by neurosurgery, reconstructed with titanium mesh, and a resultant 15 12 cm soft tissue defect. A musculocutaneous latissimus dorsi flap was harvested simultaneously. Similar to case 1, superficial
received December 23, 2014 accepted after revision February 15, 2015 published online March 31, 2015
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0035-1549008. ISSN 0743-684X.
Downloaded by: University of British Columbia. Copyrighted material.
J Reconstr Microsurg 2015;31:477–480.
Vasopressors in Head and Neck Free Tissue Transfer
Swanson et al.
Fig. 1 Case 1 preoperative 3D computed tomography reconstructions of frontal (A), posterior (B), and lateral (C and D) views showing right vertex tumor with surrounding vasculature, bone invasion, and soft tissue involvement. 3D, three-dimensional.
temporal artery perfusion was dependent on the systolic blood pressure remaining above 160 mm Hg with the aid of phenylephrine. Postoperatively, he was maintained on norepinephrine (0.1–0.24 µg/kg/min) and phenylephrine (1 µg/kg/min) to reach a systolic blood pressure goal of 150 to 160 mm Hg. He was eventually weaned from vasopressor support by POD 2. At 4 months postoperatively, he continues to do well with a stable reconstruction.
Discussion Necessity is often the mother of invention, or in our case forced us to challenge microsurgical dogma. The cases presented underscore the safety and potential utility of vasopressor medication in free tissue transfer. Each patient experienced relative hypotension intraoperatively compared with their baseline blood pressures, and there was no flow upon dissection of the superficial temporal vessels. Without
Fig. 2 Case 1 preoperative images of the fungating, bleeding squamous cell carcinoma.
Journal of Reconstructive Microsurgery
Vol. 31
No. 6/2015
Downloaded by: University of British Columbia. Copyrighted material.
478
Swanson et al.
Fig. 3 Case 1 en bloc scalp and tumor resection (A) and craniectomy (B) specimens with resultant scalp and cranial defect (C) reconstructed with titanium mesh cranioplasty (D).
the use of vasoactive medication, free tissue transfer would have been delayed or aborted, and alternative reconstructive options would have been pursued. The use of vasopressors allowed the surgical and anesthetic team to control the inflow pressure to the recipient vessels, leading to successful microvascular anastomosis. Furthermore, we wanted to avoid large volume fluid resuscitation in a 90-year-old man with an extensive cardiac history. Of note, cardiac monitoring should be used in patients receiving vasopressors due to risk of
cardiac ischemia. We are not advocating for routine protocol use of vasopressors in free flap reconstruction, but we urge microvascular surgeons to consider their use earlier during hypotensive episodes when recipient vessels are transected and prepared for anastomosis. Weak flow across an anastomosis can lead to thrombosis and higher probability of free flap failure. In addition, a recent literature review by Brinkman et al suggests that aggressive fluid resuscitation should be avoided in microsurgical reconstruction.9
Fig. 4 Case 1 posterior (A), right posterior oblique (B), and lateral (C) postoperative photographs demonstrating a healthy, viable latissimus dorsi muscle free flap scalp reconstruction. Journal of Reconstructive Microsurgery
Vol. 31
No. 6/2015
479
Downloaded by: University of British Columbia. Copyrighted material.
Vasopressors in Head and Neck Free Tissue Transfer
Vasopressors in Head and Neck Free Tissue Transfer
Swanson et al.
Conclusions
2 Vyas K, Wong L. Intraoperative management of free flaps: current
We report two successful cases of free latissimus dorsi scalp reconstruction requiring the use of vasopressors to elicit flow in the recipient superficial temporal arteries and throughout the postoperative period. The literature reveals a high rate of use and safety of vasopressors during free tissue transfer despite persistent negative impressions. This report highlights that vasoactive medications are not only safe in the setting of hypotension, but can be an effective tool for the microsurgeon to initiate or improve recipient vessel blood flow.
3 Monroe MM, McClelland J, Swide C, Wax MK. Vasopressor use in
practice. Ann Plast Surg 2014;72(6):S220–S223
Disclosure There are no personal or financial conflicts of interest to report for any author. The study was not funded.
References
5
6
7
8
9
1 Marsh M, Elliott S, Anand R, Brennan PA. Early postoperative care
for free flap head & neck reconstructive surgery—a national survey of practice. Br J Oral Maxillofac Surg 2009;47(3):182–185
Journal of Reconstructive Microsurgery
4
Vol. 31
No. 6/2015
free tissue transfer surgery. Otolaryngol Head Neck Surg 2010; 142(2):169–173 Monroe MM, Cannady SB, Ghanem TA, Swide CE, Wax MK. Safety of vasopressor use in head and neck microvascular reconstruction: a prospective observational study. Otolaryngol Head Neck Surg 2011;144(6):877–882 Harris L, Goldstein D, Hofer S, Gilbert R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery 2012;32(1):15–19 Chan JY, Chow VL, Liu LH. Safety of intra-operative vasopressor in free jejunal flap reconstruction. Microsurgery 2013;33(5): 358–361 Chen C, Nguyen MD, Bar-Meir E, et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg 2010;65(1):28–31 Kelly DA, Reynolds M, Crantford C, Pestana IA. Impact of intraoperative vasopressor use in free tissue transfer for head, neck, and extremity reconstruction. Ann Plast Surg 2014;72(6): S135–S138 Brinkman JN, Derks LH, Klimek M, Mureau MA. Perioperative fluid management and use of vasoactive and antithrombotic agents in free flap surgery: a literature review and clinical recommendations. J Reconstr Microsurg 2013;29(6):357–366
Downloaded by: University of British Columbia. Copyrighted material.
480
