Postoperative Antithrombotic Strategies in Head and Neck Free Flap Reconstruction: A Systematic Review and Network Meta-Analysis.

Abstract

The role of postoperative antithrombotic therapy in microvascular free flap reconstruction remains controversial, with no consensus on the optimal regimen. A systematic review and arm-based Bayesian network meta-analysis was conducted searching PubMed, Scopus, and Google Scholar databases. Aspirin (ASA), dextran, low-molecular-weight heparin (LMWH), intravenous or subcutaneous unfractionated heparin (IV UFH, SC UFH), prostaglandin E1 (PGE1) were compared with no prophylaxis. Primary outcomes were total and partial flap loss, vascular complications, hematoma, and reoperation. Fifty-four studies (17 773 patients) were included. IV UFH significantly increased hematoma risk (OR 4.18, 95% CI 1.36-13.22) and LMWH modestly raised reoperation rates (OR 2.25, 95% CI 1.00-5.01). No regimen consistently reduced flap loss or thrombosis compared with no prophylaxis. Antithrombotic agents showed limited benefit in reducing flap-related complications. These findings support individualized prophylaxis and highlight the need for prospective studies to inform evidence-based guidelines.