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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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Year : 2022  |  Volume : 27  |  Issue : 4  |  Page : 428-434

Evaluation of complication rates of free flap reconstruction in pediatric patients

1 Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
2 Department of Surgery, Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA

Date of Submission19-Jun-2021
Date of Decision16-Sep-2021
Date of Acceptance21-Oct-2021
Date of Web Publication26-Jul-2022

Correspondence Address:
Michael Alperovich
Department of Surgery, Yale School of Medicine, Section of Plastic Surgery, 330 Cedar Street, Boardman Building, 3rd Floor, New Haven, CT 06510
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.jiaps_129_21

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Introduction: While there is extensive literature investigating surgical outcomes in free flaps for adults, there is a dearth of information on the efficacy of flap use in the pediatric population. This study is the first to measure complication rates following pediatric free flap reconstruction on a national level.
Methods: All pediatric free flap cases between 2012 and 2018 were identified and stratified by type of flap using current procedural terminology codes assigned to the primary procedure in the National Surgical Quality Improvement Program database. Each entry included the recipient location of the flap, postoperative complications, and demographics. Chi-square analysis was used to compare complication rates across various flap groupings. In addition, univariate and multivariate analyses were used to identify independent predictors of flap complications or failure.
Results: Multivariate regression analysis demonstrated that compared to bone flaps, there is increased risk of nonbleeding complications in skin (Odds Ratio (OR) =7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018). Flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps. Regression analysis also showed that older age is associated with bleeding complications, with patients aged 5–11 years (OR = 38.5, P = 0.027) and 12–17 years (OR = 30.6, P = 0.038) having greater rates compared to patients under the age of 2. The pediatric flap reoperation rate was found to be 3.6%–4.7%, with the highest flap anastomotic complication rate in the head-and-neck region (6.9%–8.0%).
Conclusion: Free flap reconstruction across flap type, anatomic location, and age ranges are safe and efficacious in the pediatric population.

Keywords: Flap, free flap, pediatric, tissue transfer

How to cite this article:
Allam O, Shah R, Cadwell JB, Dinis J, Peck C, Junn A, Gowda A, Alperovich M. Evaluation of complication rates of free flap reconstruction in pediatric patients. J Indian Assoc Pediatr Surg 2022;27:428-34

How to cite this URL:
Allam O, Shah R, Cadwell JB, Dinis J, Peck C, Junn A, Gowda A, Alperovich M. Evaluation of complication rates of free flap reconstruction in pediatric patients. J Indian Assoc Pediatr Surg [serial online] 2022 [cited 2022 Aug 17];27:428-34. Available from: https://www.jiaps.com/text.asp?2022/27/4/426/352277

   Introduction Top

Autologous free tissue transfer is an essential reconstructive tool.[1] Indications, approaches, and outcomes of free flaps in adult populations have been extensively described. However, due to the relative rarity of microsurgical cases among children, the same parameters are not as thoroughly defined in children. Although pediatric free flap reconstruction has been shown to be both feasible and successful for various defects,[2],[3],[4],[5],[6],[7],[8],[9] a need exists for more objective evidence related to its efficacy.

Microsurgical procedures among pediatric patients have historically been considered more challenging and to have more complications attributed to increased technical complexity and decreased vessel diameter.[10],[11] However, pediatric patients also typically present with fewer comorbidities, which may promote flap viability and wound healing. While the handful of previous case series have reported outcomes comparable to adult populations, there remains little consensus on the safety of free flaps in the pediatric population. Flap failure following pediatric microvascular reconstruction has ranged from 0% to 12%, and rates of minor complications have been reported to be as low as 9% and as high as 67%.[10],[12],[13],[14],[15] The majority of these studies have been single-surgeon case reports or single-institution cohort studies.

Given the inconsistency in reported complication rates and the paucity of multisurgeon and/or broader analyses, this study sought to measure complication rates following pediatric free flap reconstruction across a national database.

   Methods Top

The database

The National Surgical Quality Improvement Program (NSQIP) is a well-known multi-institutional database provided by the American College of Surgeons (ACS). Through a collaboration with the American Pediatric Surgical Association, the ACS developed a database specifically for pediatric patients with slightly modified variables to account for the risk factors and complications relevant to pediatric patients. The database aims to provide and improve upon the quality of care delivered to younger patients.[16]

Patient and variable identification

All cases of pediatric free flaps were collected from the 2012–2018 NSQIP Pediatric database using the following current procedural terminology (CPT) codes: 15756, 15757, 15758, 20955, 20956, 20957, 20962, 20969, 20970, 20972, and 20973. All CPTs assigned to the primary procedure, either by the primary or secondary surgical teams, were assessed for inclusion. The type of flap was identified using CPT codes. The recipient location of the flap was assessed by the CPT codes as part of the concurrent procedure. Demographics of the patients, including sex, age, race, height, weight, American Society for Anesthesiologists Physical Status (ASA-PS) classification, and medical comorbidities, were collected. Overweight and obese status were assigned using the calculated body mass index, age, and sex for all patients 2 years or older as per the Centers for Disease Control and Prevention guidelines.[17]

Identification of postoperative complications and graft failure

Complications within 30 days of surgery were identified, including unplanned return to the operating room (OR), unplanned readmission, surgical site infections, wound disruption, and numerous medical complications. Patients were assigned into groups based on whether they had a postoperative bleeding complication or required a blood transfusion within 72 h of surgery. In addition, patients were assessed for whether there was a nonbleeding-related postoperative complication. As the database does not have a category for flap failure, unplanned reoperations were tracked. Assigned CPT and ICD-9 or ICD-10-CM codes of the unplanned reoperation were used to determine the reason for the return to the OR.

Statistical analysis

The rates of complications were compared across age groupings, flap location, and flap type by Chi-squared analysis. Differences in demographic and flap characteristics were compared between the aforementioned groups by Chi-squared analysis. Univariate and multivariable analyses were used to identify demographic and flap variables associated with bleeding or nonbleeding complications. Multivariable analyses were controlled for all variables significant on univariate analysis. Statistical significance was assigned a threshold of P < 0.05. SPSS version 24.0 (Armonk, NY, USA: IBM Corporation) was used to conduct the statistical analysis.

   Results Top

Patient and flap characteristics

In total, 192 pediatric patients underwent a free flap during the study period. Mean age was 10.2, with a standard deviation of 4.8. The patients were primarily male (51.0%), white (76.7%), and not overweight (67.9%). The majority of flaps were bone (59.4%) while the others were cutaneous (10.9%), myofascial (14.6%), fascial (4.7%), osteocutaneous (8.3%), or mixed in composition (2.1%). Many of the flaps were in the head-and-neck region (47.5%), with the remaining flaps in the trunk (20.8%), lower extremities (29.5%), or upper extremities (2.2%).

Rates of complications

Of these 192 patients, 68 (35.4%) had at least one postoperative complication, with 58 (30.2%) suffering a bleeding complication and 17 (8.9%) with a nonbleeding complication. There was no significant difference between patients with or without a bleeding complication regarding patient age or flap type. Flaps of the trunk had higher rates of bleeding complications than the other locations (P < 0.001). Alternatively, there was no significant difference among patients who experienced a nonbleeding complication across age or flap location groups. However, nonbleeding complications were more common in skin, muscle, and osteocutaneous flaps (P < 0.001) [Figure 1]. There were no mortalities within 30 days of surgery.
Figure 1: Complication rates following pediatric free flaps by (a) recipient site and (b) graft type. **P < 0.001

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Rate of flap failure

A total of 11 (5.7%) of patients had an unplanned reoperation. Two of these reoperations were not related to the flap, seven were related to the flap, and two had an unknown indication. This leaves an estimated overall amount of flap failures or salvage at 7–9, at an overall rate of 3.6–4.7%. The highest flap anastomotic complication rate was observed in the head and neck with an estimated 6.9%–8.0% anastomotic complication rate. The trunk region had had 0–1 failures for a 0.0%–2.6% complication rate, and the lower extremity had 1 failure out of 54 cases (1.9%). There were no anastomotic complications in the upper extremity [Table 1]. There were no significant differences in anastomotic complication rate by flap location.
Table 1: Details on unplanned reoperations following pediatric free flaps

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Comparison of patient and flap characteristics

Patients with a postoperative bleeding complication were less likely to be white (P = 0.016), and more likely to have a higher ASA-PS classification (P < 0.001), one of numerous medical comorbidities (P < 0.05), or receive a flap in the trunk region (P < 0.001). Patients who experienced a nonbleeding complication in the postoperative period were more likely to be male (P = 0.001), have comorbidities (P < 0.05), or receive skin, muscle, or osteocutaneous flaps (P < 0.001) [Table 2] and [Table 3].
Table 2: Comparison of demographic characteristics between patients who did or did not experience postoperative complications

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Table 3: Comparison of flap characteristics between patients who did or did not experience postoperative complications

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Predictors of complications

On multivariable regression adjusted for chronic comorbidities, older age was associated with bleeding complications, with patients aged 5–11 years (OR = 38.5, P = 0.027) and 12–17 years (OR = 30.6, P = 0.038), demonstrating greater odds risk for complications relative to patients <2 years old. Further, patients having a flap of the trunk (OR = 40.9, P = 0.003) and upper extremities (OR = 32.9, P = 0.041) had a higher odds of bleeding complications compared to head-and-neck flaps.

On multivariable regression for nonbleeding complications, male patients had a higher odds risk for complications than females (OR = 14.4, P = 0.014). Furthermore, as compared to bone flaps, a higher odds ratio of nonbleeding complications was seen in skin (OR = 7.7, P = 0.029), muscle (OR = 10.6, P = 0.012), and osteocutaneous flaps (OR = 10.8, P = 0.018) [Table 4].
Table 4: Multivariable analyses assessing the relationship between demographic and flap characteristics and postoperative complications

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   Discussion Top

Advancements in microsurgical technique and success rates have expanded the clinical application of free flaps with extended indications. Historically, hesitancy to perform free flaps in the pediatric population was related to small vessel diameter, concern for vessel size mismatch and spasms, and morbidity of the donor and recipient site in a growing patient.[18],[19],[20] However, in recent years, there has been a growing body of single-institution studies supporting the safety and efficacy of pediatric microvascular surgery. This paper is the first national cohort analysis of free flap complications in the pediatric population published to date, with 192 pediatric patients who underwent free flaps across a diverse array of indications.

The most common type of free flap was bone, which is consistent with the most common type of solid tumors in the pediatric population.[21],[22] The majority of microvascular reconstructions were in the head and neck, and only a small minority of free flaps were performed in individuals under the age of 5 [Table 2] and [Table 3].

When examining the safety profile of free flaps, nonbleeding complications occurred in 8.9% of patients. The most significant predictor of nonbleeding complications was free flap composition, with skin, muscle, and osteocutaneous flaps having a higher risk than bone and fascial flaps [Table 4]. Primarily driving the higher complication rates were unplanned readmissions and reoperations. Potentially, the higher vascular demands of composite flaps increase the risk of ischemia, congestion, and flap failure.

Bleeding or the perioperative transfusions were the most common perioperative event, occurring in about one-quarter patients, which is unsurprising given the routine perioperative use of blood products in pediatric patients.[18] Blood transfusion has inherent metabolic and infectious risks.[23],[24] Free flap reconstruction of the trunk had higher transfusion rates, which may be related to the large volume of blood loss during spinal surgeries and longer operative times. Interestingly, younger age was associated with less frequent bleeding or transfusion rates, supporting the safety of free flap reconstruction in the youngest cohorts.

While other studies have assessed complication profiles in either lower extremity or head-and-neck reconstruction, this is the first to evaluate surgical outcomes across all free flaps in the pediatric population. When excluding blood transfusions from the complication profile, <10% of free flap reconstructions resulted in complications and about 6% necessitated a return to the OR. Of those requiring reoperation between 7 and 9 were related to anastomotic complications – primarily in the head-and-neck flaps. Consistent with the adult population, the highest rate of flap failure was in the head-and-neck region.[25] Although trunk free flaps have higher bleeding complications, it does not impact flap survival.

Given the low complication and failure rates, our data support an acceptable safety profile and success rate for free flap reconstruction in pediatric patients. Overall, free flap success is likely attributable to a low prevalence of comorbidities, nonatherosclerotic vessels, and large vessel size to flap volume ratio in this population.[14] Based on our data, free flap tissue type is the primary predictor of complications while bleeding and transfusion is most closely associated with the trunk.

Limitations of this study include the retrospective nature of the NSQIP pediatric database, as well as the lack of operative notes and other details that may provide more granular detail regarding wound complications and flap failure. Further, the large confidence intervals in the multivariable regressions limit to use of specific odds ratios for interpretation.

   Conclusion Top

Free flap reconstruction across flap type, anatomic location, and age ranges are both feasible and largely successful in the pediatric population. Our study illustrates that pediatric free flaps are safe and effective in the largest cohort studied to date. Paralleling the adult population, free flap failure rates are highest in head-and-neck reconstruction.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Acar MA, Güleç A, Aydin BK, Erkoçak ÖF, Yilmaz G, Şenaran H. Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients. J Reconstr Microsurg 2015;31:225-32.  Back to cited text no. 2
Trojanowski P, Szymański M, Trojanowska A, Andrzejczak A, Szczepanek D, Klatka J. Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection. Eur Arch Otorhinolaryngol 2019;276:3487-94.  Back to cited text no. 3
Ghoneimy AM, Sherbiny ME, Kamal N. Use of vascularized fibular free flap in the reconstruction of the femur in pediatric and adolescent bone sarcomas: Complications and functional outcome. J Reconstr Microsurg 2019;35:156-62.  Back to cited text no. 4
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Serletti JM, Schingo VA Jr, Deuber MA, Carras AJ, Herrera HR, Reale VF. Free tissue transfer in pediatric patients. Ann Plast Surg 1996;36:561-8.  Back to cited text no. 9
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Gilbert A. Reconstruction of congenital hand defects with microvascular toe transfers. Hand Clin 1985;1:351-60.  Back to cited text no. 11
Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: A 10-year review. Plast Reconstr Surg 2005;115:1618-24.  Back to cited text no. 12
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Alkureishi LW, Purnell CA, Park P, Bauer BS, Fine NA, Sisco M. Long-term outcomes after pediatric free flap reconstruction. Ann Plast Surg 2018;81:449-55.  Back to cited text no. 14
Liu S, Zhang WB, Yu Y, Wang Y, Mao C, Guo CB, et al. Free flap transfer for pediatric head and neck reconstruction: What factors influence flap survival? Laryngoscope 2019;129:1915-21.  Back to cited text no. 15
About ACS NSQIP Pediatric. American College of Surgeons. Available from: https://www.facs.org/quality-programs/childrens-surgery/pediatric/overview. [Last accessed on 2021 Feb 06].  Back to cited text no. 16
About Child and Teen BMI. Centers for Disease Control and Prevention. Available from: https://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. [Last accessed on 2021 Feb 06].  Back to cited text no. 17
Roasa FV, Castañeda SS, Mendoza DJ. Pediatric free flap reconstruction for head and neck defects. Curr Opin Otolaryngol Head Neck Surg 2018;26:334-9.  Back to cited text no. 18
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Barcelona SL, Thompson AA, Coté CJ. Intraoperative pediatric blood transfusion therapy: A review of common issues. Part I: Hematologic and physiologic differences from adults; metabolic and infectious risks. Paediatr Anaesth 2005;15:716-26.  Back to cited text no. 23
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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