BACKGROUND: Collagen vascular disorders (CVD) are inflammatory diseases that can affect the blood vessels and soft tissues. Patients with CVD are often immunosuppressed, prone to hyper-coagulation and overall represent a challenging patient cohort for free tissue transfer. In this report, we review our outcomes of free tissue transfer in patients with CVD.
METHODS: A retrospective review of patients with CVD who underwent free flap reconstructions from January 2010 to 2020 was performed at our institution. Inclusion criteria were patients 18 years old or older with clinical diagnosis of CVD including Rheumatoid arthritis, Raynaud phenomenon, Systemic lupus erythematosus, Scleroderma, Sarcoidosis, Psoriasis, Dermatomyositis, Polymyalgia rheumatica, Mixed connective tissue disease, Behcet’s disease, Sjogren’s syndrome, Ehlers-Danlos syndrome, Gardner-Diamond syndrome, and Systemic amyloidosis. Patient comorbidities and surgical outcomes were collected. Endpoints for analysis included flap loss, receipt and donor site wound complications, hematomas and return to operative room for flap complications.
RESULTS: A total of 51 patients (36 women and 15 men) with CVD underwent 67 free flap reconstructions. The mean age was 54.7 ± 14 years old and mean body mass index was 27.4 ± 5.6 kg/m2. Median follow-up time was 28.1 months (Q1–3, 9.6–44), and median length of hospital stay was 5.5 days (Q1–3, 3–11.80). In total, 64.7% of patients were on steroids preoperatively and 27.5% on other immune-suppressants, 41.3% had history of radiation, 31.7% had undergone neoadjuvant chemotherapy, 7.8% were current smokers and 7.8% of patients had a history of prior flap loss. CVD included Rheumatoid arthritis (n = 22), Raynaud phenomenon (n = 7), Systemic lupus erythematosus (n = 4), Psoriasis (n = 3), Scleroderma (n = 2), Sarcoidosis (n = 2), Dermatomyositis (n = 2), Mixed connective tissue disease (n = 2), Behcet’s disease (n = 2), Polymyalgia rheumatica (n = 1), Sjogren’s syndrome (n = 1), Ehlers-Danlos syndrome (n = 1), Gardner-Diamond syndrome (n = 1), and Systemic amyloidosis (n = 1). Flap reconstructions included transverse rectus abdominis musculocutaneous (n = 17), deep inferior epigastric perforator flaps (n = 14), latissimus dorsi muscle (n = 9), radial forearm (n = 7), gracilis muscle (n = 6), fibula (n = 6), anterolateral thigh (n = 4), jejunal (n = 1), scapular (n = 1), and rectus abdominis muscle flaps (n = 1). Reasons for reconstruction were oncologic (n = 45), infection (n = 11), wound healing problems (n = 8), facial paralysis (n = 2), and trauma (n = 1). The location of the reconstruction included the breast (n = 32), head and neck (n = 18), and extremity (n = 17). Of all flaps, 37.3% developed infection, 26.9% required wound debridement, 34.3% developed delayed wound healing, 23.9% developed recipient site wound dehiscence, 17.9% developed donor site wound dehiscence, 13.4% developed seroma, 9% developed full necrosis, 3% developed partial necrosis, 9% developed hematoma, 3% developed deep vein thrombosis, and 3% developed acute blood loss. Intraoperative complications due to venous congestions occurred in 6% of flaps and flap loss rate was 10.4%.
CONCLUSIONS: Connective tissue disorders appear to be an independent risk factor for flap loss, infection and wound healing complications and should be approached with caution after carefully evaluating the risks versus benefits in individual patients. This study will be helpful in patient education and informed consent for the procedure and may offer some guidance and caution to the reconstructive microsurgeon.