Transfusions in Autologous Breast Reconstructions: An Analysis of Risk Factors, Complications, and Cost

Effects of Preoperative Hemoglobin on Microsurgical Reconstruction and Perioperative Blood Transfusion Requirement: A Meta-Analysis and Systematic Review of the Literature

PURPOSE

Although blood loss in microsurgical reconstruction is rarely large enough to be life-threatening, preoperative anemia can be a particular issue in terms of postoperative morbidity, impaired wound healing, and compromised tissue viability. We seek to review the effect of preoperative hemoglobin (Hgb) levels on perioperative blood transfusion (PBT) requirements and complications to guide management of patients with preexisting anemia undergoing reconstruction.

METHODS

PubMed, Embase, and Scopus were queried for relevant articles. Inclusion criteria were as follows: original studies investigating outcomes and PBT requirements in flap-based reconstruction based on preoperative Hgb levels. Patient and study characteristics were analyzed using descriptive statistics. A meta-analysis was conducted to assess transfusion requirements across the included studies using Stata (version 18.0 Stata Corp, College Station, Texas, USA). The Fisher method was used to aggregate individual study p values into a single combined value to statistically assess the combined findings, where a p value of < 0.05 was set as statistically significant.

RESULTS

One thousand three hundred and eighty-nine studies were screened for title and abstract relevance, 14 of which met the inclusion criteria, including a total of 61,116 patients. Meta-analysis of the studies revealed a PBT requirement of 36.2% for anemic individuals, significantly higher than the 20.0% for those with normal preoperative Hgb levels (p < 0.001), with an average 4.9 versus 2.4 units of packed red blood cells being transfused (p < 0.001). The majority of studies concluded that preoperative anemia was associated with medical complications, such as myocardial infarction, stroke, and infection (p < 0.001). While six studies reported a significant relationship between low preoperative Hgb and flap morbidity (flap loss and partial flap necrosis), two studies found no correlation. The overall postoperative complication rate across the studies was 42.2% among patients with low preoperative Hgb levels, whereas the nonanemic group demonstrated a markedly lower rate of 13.9% (p < 0.001).

CONCLUSION

The existing evidence is strongly suggestive of increased PBT requirement in patients with anemia, highlighting the necessity for preoperative optimization of Hgb levels and intraoperative monitoring. While preliminary evidence demonstrates a relationship between anemia and medical complications, more research is warranted to characterize the specific association between preoperative Hgb levels and flap morbidity.

Risk of Bleeding Versus Venous Thromboembolism After Surgery for Breast Cancer: A National Surgical Quality Improvement Program Analysis

INTRODUCTION

Patients who undergo surgery for breast cancer are at risk for venous thromboembolism (VTE) and bleeding, which can lead to significant consequences on outcomes. This study examined factors related to VTE and bleeding risk in breast cancer surgery, with and without reconstruction. We also investigated the relationship between operative time and resident involvement on bleeding and VTE risk.

METHODS

Using the ACS-NSQIP database, patients who underwent mastectomy, implant, pedicled, or free flap reconstruction from 2005 to 2021 were identified. Resident involvement was available from 2007 to 2010. We fitted two logistic regressions to model the log odds of bleeding occurrence and VTE as linear functions of procedure type, controlling for age, body mass index, and comorbidities.

RESULTS

Implant reconstruction had significantly reduced 30-d incidence of bleeding, compared to those who underwent transverse rectus abdominus muscle flap (P < 0.001). Free flap was associated with a significant increase in bleeding but not VTE risk (P < 0.001; P = 0.132). Increase in operative time significantly increased the risk of bleeding and VTE (P < 0.001). For surgeries with resident involvement coded, there was no significantly increased risk of bleeding or VTE (P = 0.600; P = 0.766).

CONCLUSIONS

Implant reconstruction remains the procedure with the lowest risk of both bleeding and VTE. Free flap reconstruction did not show a significantly increased risk of VTE, potentially expanding reconstruction options for patients previously excluded from autologous reconstruction. Surgeons should be mindful of operative time, with re-evaluation of risk factors with each additional hour of surgery, irrespective of reconstruction type. Resident involvement in surgeries should continue to be encouraged by faculty.

Cost analysis of a patient blood management program for patients undergoing gastric cancer surgery

Patient Blood Management (PBM) programs have probed to reduce blood transfusions and postoperative complications following gastric cancer resection, but evidence on their economic benefit is scarce. A recent prospective interventional study of our group described a reduction in transfusions, infectious complications and length of stay after implementation of a multicenter PBM program in patients undergoing elective gastric cancer resection with curative intent. The aim of the present study was to analyze the economic impact associated with these clinical benefits. The mean [and 95% CI] of total healthcare cost per patient was lower (-1955 [-3764, -119] €) after the PBM program implementation. The main drivers of this reduction were the hospital stay (-1847 [-3161, -553] €), blood transfusions (-100 [-145, -56] €), and post-operative complications (-162 [-718, 411] €). Total societal cost was reduced by -2243 [-4244, -210] € per patient. These findings highlight the potential economic benefit of PBM strategies.

Big data analysis of the risk factors and rates of perioperative transfusion in immediate autologous breast reconstruction

Patients undergoing autologous breast reconstruction (ABR) are more likely to require perioperative transfusions due to the increased intraoperative bleeding. In addition to the mastectomy site, further incisions and muscle dissection are performed at the donor sites, including the back or abdomen, increasing the possibility of transfusion. The purpose of this study was to evaluate perioperative transfusion rates and risk factors according to the type of ABR through analysis of big data. Patients who underwent total mastectomy for breast cancer between 2014 and 2019 were identified. The patients were divided into mastectomy only and immediate ABR groups. The transfusion rate was 14-fold higher in the immediate ABR group (16.1%) compared to the mastectomy only group (1.2%). The transfusion rate was highest with the pedicled transverse rectus abdominis myocutaneous flap (24.2%). Performance of the operation in medical institutions located in the provinces and coronary artery disease (CAD) were significant risk factors for the need for transfusion. The perioperative transfusion risk among patients undergoing immediate ABR was related to the flap type, location of medical institution, and CAD. Based on the higher transfusion rate in this study (16.1%) compared to previous studies, the risk factors for the need for transfusion should be determined and evidence-based guidelines should be developed to reduce the transfusion rates.

Is there any difference in perioperative characteristics or postoperative complications between overweight, normal-weight and obese patients in delayed DIEP reconstructions?

Increased number of overweight and obese women are seeking breast reconstruction. Studies have demonstrated that obese experience increased rates of complications, but less data is available considering overweight patients. We analyzed the impact of body mass index (BMI) on perioperative characteristics and complications in unilateral delayed deep inferior epigastric perforator flap (DIEP) reconstructions. The records of patients with DIEP reconstruction performed between 2014 and 2020, were retrospectively analyzed. Patients were categorized into obese (BMI ≥30), overweight (BMI 25.0-29.9), and normal-weight groups (BMI <25). Patient characteristics (age, comorbidity, radiation, abdominal surgery, ASA category, and smoking), perioperative characteristics (length of operation, blood loss, vasoactive drugs, fluid administration, and urine output), and postoperative complications were recorded. The study included 308 patients. Of these, 104 (34%) were normal-weighted, 142 (46%) overweight and 62 (20%) obese. Among patients with BMI ≥ 25, blood loss increased (p = 0.002) and the length of operation tended to be longer (p = 0.072). No between-groups difference existed in fluid administration (p = 0.319), urine output (p = 0.425), or use of vasoactive drugs (p = 0.815). There was no statistically significant difference in overall complications (p = 0.122) between BMI groups. Blood loss >150ml was associated with both minor and major complications (p = 0.022). Greater BMI moderated with the radiation therapy for higher risk of minor complications (OR 42.0, 95%CI 3.54-49.7, p = 0.003). We conclude that greater BMI alone is not associated with a higher overall complication rate, but both overweight and obesity may be moderators for other risk factors.

The Effect of Perioperative Blood Transfusions on Microvascular Anastomoses

Introduction: Perioperative transfusions are associated with complications of free flaps. The purpose of the present study was to find out whether there is a significant relationship between the risk of developing complications in vascular anastomoses and the history of transfusions. Methods: We studied 372 patients retrospectively with microsurgical reconstruction between 2009 and 2017 with regards to the number of red blood cell concentrates transfused. Complications were analyzed relative to flap loss and complications in microvascular anastomoses. Results: 130 patients (34.9%) received blood transfusions. Some 55% of them were transfused between the day of the intervention and the first postoperative day. Ninety-six patients were reoperated on (25.7%). Of those, thirty-six patients (37.5%) corresponded to anastomosis failure. The percentage of patients transfused among those who required reoperation was 55.2%. The percentage of patients transfused among those who were reoperated on within the first 72 h due to an alteration in the anastomosis was 60.6%, while it was 25.6% (Chi square P = 0.0001) for the rest of the patients. Conclusions: Although there is a strong association between transfusion and vascular anastomosis failure, it is not possible to establish the causation between the two.

Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching

BACKGROUND

 Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis.

METHODS

 The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications.

RESULTS

 A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications.

CONCLUSION

 Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.

Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck

Importance

Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking.

Objective

To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck.

Design, Setting, and Participants

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016.

Exposures

Microvascular reconstructive surgery of the head and neck.

Main Outcomes and Measures

Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality.

Results

A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16).

Conclusions and Relevance

Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery.

Level of Evidence

3.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives

The management of postoperative pain is of critical importance for women undergoing breast reconstruction after surgical treatment for breast cancer. Mitigating postoperative pain can improve health-related quality of life, reduce health care resource utilization and costs, and minimize perioperative opiate use. Multimodal analgesia pain management strategies with nonopioid analgesics have improved the value of surgical care in patients undergoing various operations but have only recently been reported in reconstructive breast surgery. Regional anesthesia techniques, with paravertebral blocks (PVBs) and transversus abdominis plane (TAP) blocks, and enhanced recovery after surgery (ERAS) pathways have been increasingly utilized in opioid-sparing multimodal analgesia protocols for women undergoing breast reconstruction. The objectives of this review are to 1) comprehensively review regional anesthesia techniques in breast reconstruction, 2) outline important components of ERAS protocols in breast reconstruction, and 3) provide evidence-based recommendations regarding each intervention included in these protocols. The authors searched across six databases to identify relevant articles. For each perioperative intervention included in the ERAS protocols, the literature was exhaustively reviewed and evidence-based recommendations were generated using the Grading of Recommendations, Assessment, Development, and Evaluation system methodology. This study provides a comprehensive evidence-based review of interventions to optimize perioperative care and postoperative pain control in breast reconstruction. Incorporating evidence-based interventions into future ERAS protocols is essential to ensure high value care in breast reconstruction.

Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients

BACKGROUND CONTEXT

Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study.

PURPOSE

This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients.

STUDY DESIGN/SETTING

This is a retrospective study.

PATIENT SAMPLE

The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis.

OUTCOME MEASURES

The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident).

MATERIALS AND METHODS

Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy.

RESULTS

Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually.

CONCLUSIONS

Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs.

Efficacy of the postoperative management after microsurgical free tissue transfer

INTRODUCTION

The physical and medical postoperative measures after free flap reconstruction vary substantially between surgical units. The objective of this review was to identify the postoperative measures which proved a significant positive effect on free flap survival.

METHOD

A review was conducted in the MEDLINE database on the English and French literature.

RESULTS AND DISCUSSION

Twenty-eight articles were retained. A meta-analysis of 4984 patients who were given antithrombotics (viz. antiplatelets and anticoagulants) postoperatively found that these treatments were of no significant benefit to free flap survival and increased the risk of postoperative hematoma. Postoperative transfusions did not favor free flap survival and were associated with a higher incidence of medical complications. Preoperative anemia was a risk factor for free flap failure. Blood pressure control, vasodilators, antioxidants, corticotherapy, oxygen therapy, and prolonged immobilization were of no proven benefit.

CONCLUSION

No postoperative therapy, whether drug-based or not, has been shown to have a significant positive effect on free flap survival.

Insufficient fibrinogen response following free flap surgery is associated with bleeding complications

Background: Microvascular tissue transfer has become a safe and reliable tool in the reconstructive armamentarium, yielding high success rates. However, little is known about the changes in coagulation after free tissue transfer and their potential impact on morbidity. Methods: Fibrinogen concentration and platelet count among other values were available and assessed in 139 undergoing free tissue transfer before, immediately after, and 1-3 as well as 8-11 days after surgery. In patients undergoing urgent revision for either bleeding or microvascular thrombosis, blood samples were drawn directly before re-exploration. Results: In the patients without any surgical revision and in those with thrombosis of the microvascular pedicle, both fibrinogen concentration and platelet count increased significantly during the early and late post-operative window. Patients that developed bleeding necessitating re-exploration showed an inadequate increase in fibrinogen levels, resulting in significantly lower concentrations compared to the other two groups. There were no significant differences in platelet count or PTT between these groups. Conclusion: Free flap surgery induces acute and subacute changes in coagulation, comparable to other major surgeries and severe injuries. This leads to an increase in platelet count and fibrinogen over the post-operative course. Patients that developed bleeding requiring surgical re-exploration showed an insufficient increase in fibrinogen, resulting in significantly lower fibrinogen levels. Therefore, monitoring and correction of fibrinogen levels might aid in preventing or treating bleeding complications following free flap surgery.

Restrictive use of perioperative blood transfusion does not increase complication rates in microvascular breast reconstruction

INTRODUCTION

With increasing appreciation of the possible adverse effects of peri-operative blood transfusion, restrictive policies regarding use of blood products have been adopted in many surgical specialties. Although microvascular breast reconstruction has become a routine procedure, high peri-operative transfusion rates continue to be reported in the literature. In this study we examine the impact of our restrictive approach on blood transfusion rates and postoperative complications in patients undergoing microvascular blood transfusion.

METHODS

A retrospective review of patients undergoing microvascular breast reconstruction with abdominal flaps at a single institution was performed. Patient age and body mass index as well as type, timing and laterality of reconstruction was recorded. Pre-operative and post-operative hemoglobin and hematocrit were recorded. Peri-operative blood transfusion rates were calculated. Post-operative complication rates were compared between patients with higher and lower post-operative hemoglobin levels.

RESULTS

Five hundred and twelve patients were included in this study. The peri-operative transfusion rate was 0.98% in this series. There was no significant difference between transfusion rates in unilateral and bilateral reconstructions (0.68 vs 1.36% p = 0.08) or immediate and delayed reconstructions (1.02 vs 0.51% p = 0.72 and 1.01 vs 1.60% p = 0.09 for unilateral and bilateral respectively). Lower post-operative hemoglobin levels were not associated with increased flap related, surgical or medical complications rates.

CONCLUSION

A restrictive approach to peri-operative blood transfusion can be safely adopted in microvascular breast reconstruction without compromising flap viability or overall complication rates.

Emerging paradigms in perioperative management for microsurgical free tissue transfer: review of the literature and evidence-based guidelines

BACKGROUND

Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management.

METHODS

A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation.

RESULTS

A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use.

CONCLUSIONS

Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.

Transfusion in head and neck free flap patients: practice patterns and a comparative analysis by flap type

OBJECTIVE

To characterize patterns of utilization and outcomes following transfusion in head and neck patients undergoing free flap reconstruction.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

Two hundred eighty-two head and neck patients undergoing free flap reconstruction from 2011 to 2013. Outcome parameters included post-transfusion hematocrit increase, length of stay (LOS), flap survival, and perioperative complications.

RESULTS

Of all head and neck free flap patients, 48.9% received blood transfusions. Average pretransfusion hametocrit (Hct) was 24.7%±0.2% with 2.5±0.1 units of blood transfused. Transfused patients were more likely to have been taken back to the operating room. Rates of transfusion were similar between flap types, although anterolateral thigh (ALT) and fibular free flap (FFF) patients had higher transfusion requirements compared to radial forearm free flap (RFFF) patients. Further, FFF patients trended toward receiving transfusions earlier. Transfusion did not influence flap survival but was associated with wound dehiscence, myocardial infarction, congestive heart failure, respiratory distress, and pneumonia. Subset analyses by flap type revealed that differences were significant among the RFFF and FFF cohorts but not ALT patients. When comparing patients who were transfused for Hct<21 to those transfused for Hct<27, there were no differences in LOS, flap survival, or postsurgical complications.

CONCLUSIONS

Among the different types of flaps, FFF and ALT are associated with higher transfusion requirements. Transfusion in patients undergoing free flap reconstruction does not significantly affect flap survival but was associated with perioperative complications. Our data support consideration of a restrictive transfusion policy in free flap patients.