Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.
Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.
Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).
This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.
Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

For patients undergoing microvascular free tissue transfer (MFTT), we evaluated risk factors and financial implications of operating room (OR) take-back procedures.
Retrospective review at a tertiary care center.
Patients who underwent MFTT for head and neck reconstruction from 2011 to 2018 were identified. We compared hospital length of stay and overall costs associated with OR take-back procedures. Multivariable regression analysis evaluated factors associated with OR take-backs during the same hospitalization.
A total of 727 free flaps were reviewed, and 70 OR take-backs (9.6%) were identified. Mean total length of stay (LOS) in the ICU was 3.4 days versus 6.7 days for non-take-back and take-back flaps, respectively (P < .001). Mean total LOS on the regular floor was 6.3 days versus 13.1 days, respectively (P < .001). This resulted in a cost differential of $33,507 (94.3% increase relative to non-take-back flaps). The total cost associated with an OR take-back was $39,786. Hematomas were the most common cause of take-backs and wound dehiscence was associated with the highest costs. On multivariable analysis, higher ASA class (OR, 2.06; 95% CI, 1.11-3.99; P = .026) and shorter ischemia times (OR, 0.52; 95% CI, 0.29-0.95; P = .030) were independently associated with increased risk of take-backs.
OR take-backs infrequently occur but are associated with a significant increase in financial burden when compared to free flap cases not requiring OR take-back. The large majority of the cost differential lies in a substantial increase of ICU and floor LOS for take-back flaps when compared to non-take-back flaps.
4 Laryngoscope, 131:E1821-E1829, 2021.

Extracorporeal perfusion is a promising new technique for prolonged preservation of free flaps and extremities; however, uncertainties on perfusion settings and efficacy still exist. No overview of literature is currently available. This review systematically appraised available evidence comparing extracorporeal perfusion to static storage.
An electronic systematic search was performed on June 12, 2016, in MEDLINE and EMBASE. Articles were included when evaluating the effect of extracorporeal perfusion of free flaps or extremities compared to that of a control group. Two independent researchers conducted the selection process, critical appraisal, and data extraction.
Of 3485 articles screened, 18 articles were included for further analyzation. One article studied discarded human tissue; others were studies conducted on rats, pigs, or dogs. Perfusion periods varied from 1 h to 10 d; eight articles also described replantation. Risk of bias was generally scored high; none of the articles was excluded based on these scores. Tissue vitality showed overall better results in the perfused groups, more pronounced when perfusing over 6 h. The development of edema was a broadly described side effect of perfusion.
Although tissue vitality outcomes seem to favor extracorporeal perfusion, this is difficult to objectify because of large heterogeneity and poor quality of the available evidence. Future research should focus on validating outcome measures, edema prevention, perfusion settings, and maximum perfusion time for safe replantation and be preferably performed on large animals to increase translation to clinical settings.

BACKGROUND: There is a general consensus among reconstructive surgeons that preoperative radiotherapy is associated with a higher risk of flap failure and complications in head and neck surgery. Opinion is also divided regarding the effects of radiation dose on free flap outcomes and timing of preoperative radiation to minimize adverse outcomes. Our meta-analysis will attempt to address these issues.
METHODS: A systematic review of the literature was conducted in concordance to PRISMA protocol. Data were combined using STATA 12 and Open Meta-Analyst software programmes.
RESULTS: Twenty-four studies were included comparing 2842 flaps performed in irradiated fields and 3491 flaps performed in non-irradiated fields. Meta-analysis yielded statistically significant risk ratios for flap failure (RR 1.48, P = 0.004), complications (RR 1.84, P < 0.001), reoperation (RR 2.06, P < 0.001) and fistula (RR 2.05, P < 0.001). Mean radiation dose demonstrated a trend towards increased risk of flap failure, but this was not statistically significant. On subgroup analysis, flaps with >60 Gy radiation had a non-statistically significant higher risk of flap failure (RR 1.61, P = 0.145).
CONCLUSIONS: Preoperative radiation is associated with a statistically significant increased risk of flap complications, failure and fistula. Preoperative radiation in excess of 60 Gy after radiotherapy represents a potential risk factor for increased flap loss and should be avoided where possible.