Abstract
The commonest cause of microvascular free flap failure is thrombosis at the anastomosis.
Pharmacological antithrombotic therapies have been used to mitigate this risk, but
they carry the risk of bleeding and haematoma formation. To justify any intervention,
it is necessary to evaluate the benefits and balance of risks. This meta-analysis
aims to quantify the value of systemic anticoagulation during head and neck free tissue
reconstruction. We performed a systematic review on the impact of additional prophylactic
antithrombotic therapy on head and neck (H&N) free tissue transfer (on top and above
the use of low molecular weight heparin to prevent deep vein thrombosis). We carried
a PRISMA-guided literature review, following registration with PROSPERO. All studies
analysing the possible impact of prophylactic anticoagulants on free flap surgery
in the head and neck were eligible. The primary outcome was perioperative free flap
complications (perioperative thrombosis, partial or total free flap failure, thrombo-embolic
events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation
or bleeding complications requiring further intervention. We identified eight eligible
studies out of 454. These included 3531 free flaps for H&N reconstruction. None of
the assessed interventions demonstrated a statistically significant improvement in
free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated
an increased relative risk of free flap complications [RR 1.54 (0.73–3.23)] compared
to control albeit not statistically significant (p = 0.25). Pooled analysis from the
included studies showed that the prophylactic use of therapeutic doses of anticoagulants
significantly (p = 0.003) increased the risk of haematoma and bleeding requiring intervention
[RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure. Additional
anticoagulation does not reduce the incidence of free flap thrombosis and failure.
Unfractionated heparin (UFH) consistently increased the risk of free flap complications.
The use of additional anticoagulation as ‘prophylaxis’ in the perioperative setting,
increases the risk of haematoma and bleeding.
Keywords
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Article info
Publication history
Published online: September 16, 2022
Accepted:
July 18,
2022
Identification
Copyright
© 2022 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
