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The Risk of Pre-Operative Covid-19 Infection on Microvascular Free-Flap Viability
Brielle E. Raine1, Kateryna Zelenova1, Rachel E. Williams1, Ricki Chen1, Anna E. Davis1, Thom R. Loree2, Mark S. Burke2, Michael Y. Nagai2, Jordan D. Frey2
1University at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY; 2Erie County Medical Center, Buffalo, NY

Background: Microvascular free-flap tissue transfer is the gold standard for complex reconstructive surgery. However, the impact of Covid-19 infection on free flap viability has not been evaluated.1-5 In this study, we examine outcomes in free flap reconstruction in patients based on pre-operative Covid-19 status.
Methods: A retrospective review of patients who underwent microvascular free-flap reconstruction, between August 2020 and January 2022, was performed at our institution. Exclusion criteria included patients with unknown status of Covid-19 infection prior to surgery. Patient demographics, operative details, and surgical outcomes were collected for analysis.
Results: Of the 107 flaps evaluated, 84 were included. The mean age at time of surgery was 52.6 13.4 and mean body mass index (BMI) was 30.2 6.4 kg/m2. Comorbidities of patients included hypertension (35.4%), tobacco use (22.0%), and diabetes (11.0%). Free flaps included ALT (n=11), DIEP (n=41), Fibula (n=9), Jejunum (n=1), MSAP (n=1), Omentum (n=2), PAP (n=5), Rectus (n=1), RFFF (n=12), and SIEA (n=1). Of the 84 flaps included in the study, 17 were in patients identified as having a documented Covid-19 infection prior to surgery. Of the 17 patients with a previous Covid-19 infection, 4 of the free flaps were ultimately not viable (76.5% viability). Of the 67 free flaps in patients without Covid-19 infection prior to surgery, 5 of the free flaps were not viable (92.5% viability). On Chi square analysis, flaps in previously infected Covid-19 patients were significantly more likely to experience flap failure (p=0.012).Moreover, the group with Covid-19 infection prior to surgery had a 3.82 (95% CI 0.9-16.174) times the odds of free-flap failure than the group without a known Covid-19 infection prior to surgery.
Conclusion: Based on our data, free flaps in patients with prior Covid-19 infection are more likely to experience microvascular flap failure. Additional studies are required to further elucidate this relationship as well as etiology. An early hypothesis is that Covid-19 infection results in a hypercoagulative state that may require adjustments to anticoagulation regimens in free flap patients.


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