Introduction:Free flap success rates have remained
stable in recent years ranging 93% to 98%. Historically, the causes of free
flap failures were attributed to the surgeon’s inexperience and technique.
However, there are factors beyond the surgical anastomosis that contribute to
flap failure. The purpose of this study is to review each case of total flap
loss in detail to develop a better understanding of complications. Methods:A retrospective study was performed
over eleven years in a single surgeon’s practice, a predominantly head and neck
reconstructive practice. All charts were independently reviewed.In patients who sustained total flap
loss, a review was conducted of patient comorbidites, anesthesia records,
perioperative and follow-up notes.Results:A total of 514 free flaps were
performed. 76% (392) of these flaps were for head and neck reconstruction.
There were 22 total flap losses (4%) and 26 partial flap losses (5%). Of the 22
total flap losses, four flaps were avulsed, five flaps were in patients later
found to have coagulation disorders (homozygous mutations of the MTHFR gene and
factor V Leiden), four patients were exposed to neosynephrine, two patients
remained hypotensive perioperatively, and four delayed flap losses were attributed
to pseudomonal infection. Five losses were technical or related to flap
inexperience. Several representative case scenarios are illustrated. Conclusion:Careful review
of free flap failures indicates that a thorough workup (particularly
coagulation disorders), flap selection, surgeon to anesthesia communication,
proper securing of the flap, and postoperative patient blood pressure and infection
control have a greater part to play in this new era of anastomotic success.
References
[1]
P. N. Blondeel, “One Hundred Free DIEP Flap Breast Reconstructions: A Personal Experience,” British Journal of Plastic Surgery, Vol. 52, No. 2, 1999, pp. 104-111.
doi:10.1054/bjps.1998.3033
[2]
R. J. Allen and P. Treece, “Deep Inferior Epigastric Perforator Flap for Breast Reconstruction,” Annals of Plastic Surgery, Vol. 32, No. 1, 1994, pp. 32-38.
doi:10.1097/00000637-199401000-00007
[3]
I. G. Taylor, P. Townsend and R. Corlett, “Superiority of the Deep Circumflex Iliac Vessels as the Supply for Free Groin Flaps Clinical Work,” Plastic and Reconstructive Surgery, Vol. 64, No. 6, 1979, pp. 745-759.
doi:10.1097/00006534-197912000-00001
[4]
I. A. McGregor and I. T. Jackson, “The Groin Flap,” British Journal of Plastic Surgery, Vol. 25, 1972, pp. 3-16.
doi:10.1016/S0007-1226(72)80003-1
[5]
W. M. Swartz, J. C. Banis, E. D. Newton, et al., “The Osteocutaneous Scapular Flap for Mandibular and Maxillary Reconstruction,” Plastic and Reconstructive Surgery, Vol. 77, No. 4, 1986, pp. 530-545.
doi:10.1097/00006534-198604000-00003
[6]
W. M. Swartz and D. C. Mears, “The Role of Free-Tissue Transfers in Lower-Extremity Reconstruction,” Plastic and Reconstructive Surgery, Vol. 76, No. 3, 1985, pp. 364-373. doi:10.1097/00006534-198509000-00005
[7]
R. M. Zuker, I. B. Rosen, J. A. Palmer, F. R. Sutton, N. H. McKee and R. T. Manktelow, “Microvascular Free Flaps in Head and Neck Reconstruction,” Canadian Journal of Plastic Surgery, Vol. 23, No. 2, 1980, pp. 157-162.
[8]
M. Godina, “Preferential Use of End-to-Side Arterial Anastomoses in Free Flap Transfers,” Plastic and Reconstructive Surgery, Vol. 64, 1979, pp. 673-682.
[9]
I. Fogdestam, “Experiences with Free Flap Surgery,” Annales Chirurgiae et Gynaecologiae, Vol. 71, 1982, pp. 38-43.
[10]
D. T. Bui, P. G. Cordeiro, Q. Y. Hu, J. J. Disa, A. Pusic and B. J. Mehrara, “Free Flap Reexploration: Indications, Treatment, and Outcomes in 1193 Free Flaps,” Plastic and Reconstructive Surgery, Vol. 119, 2007, pp. 2092-2100. doi:10.1097/01.prs.0000260598.24376.e1
[11]
M. Okazaki, H. Asato, A. Takushima, et al., “Analysis of Salvage Treatments Following the Failure of Free Flap Transfer Caused by Vascular Thrombosis in Reconstruction for Head and Neck Cancer,” Plastic and Reconstructive Surgery, Vol. 119, No. 4, 2007, pp. 1223-1232.
doi:10.1097/01.prs.0000254400.29522.1c
[12]
K. T. Chen, S. Mardini, D. C. Chuang, et al., “Timing of Presentation of the First Signs of Vascular Compromise Dictates the Salvage Outcomes of Free Flap Transfers,” Plastic and Reconstructive Surgery, Vol. 120, No. 1, 2007, pp. 187-195.
doi:10.1097/01.prs.0000264077.07779.50
[13]
I. Koshima and S. Soeda, “Inferior Epigastric Artery Skin Flaps without Rectus Abdominis Muscle,” British Journal Plastic Surgery, Vol. 42, No. 6, 1989, pp. 645-648.
doi:10.1016/0007-1226(89)90075-1
[14]
R. J. Allen and C. Tucker, “Superior Gluteal Artery Perforator Free Flap for Breast Reconstruction,” Plastic and Reconstructive Surgery, Vol. 95, No. 7, 1995, pp. 1207-1212. doi:10.1097/00006534-199506000-00010
[15]
R. K. Khouri, “Avoiding Free Flap Failure,” Clinics in Plastic Surgery, Vol. 19, No. 4, 1992, pp. 773-781.
[16]
M. Y. Nahabedian, B. Momen, G. Galdino, et al., “Breast Reconstruction with the Free TRAM or DIEP Flap: Patient Selection, Choice of Flap, and Outcome,” Plastic and Reconstructive Surgery, Vol. 110, No. 2, 2002, pp. 466-475. doi:10.1097/00006534-200208000-00015
[17]
M. Y. Nahabedian, B. Momen and P. N. Manson, “Factors Associated with Anastomotic Failure after Microvascular Reconstruction of the Breast,” Plastic and Reconstructive Surgery, Vol. 114, No. 1, 2004, pp. 74-82.
doi:10.1097/01.PRS.0000127798.69644.65
[18]
M. Siemionow and G. Agaoglu, “Allotransplantation of the Face: How Close Are We,” Clinics in Plastic Surgery, Vol. 32, No. 3, 2005, pp. 401-409.
doi:10.1016/j.cps.2005.02.003
[19]
L. Heller and S. L. Levin, “Lower Extremity Microsurgical Reconstruction,” Plastic and Reconstructive Surgery, Vol. 108, No. 4, 2001, pp. 1029-1042.
doi:10.1097/00006534-200109150-00036
[20]
R. K. Khouri, B. C. Cooley, A. R. Kunselman, et al., “A Prospective Study of Microvascular Free-Flap Surgery and Outcome,” Plastic and Reconstructive Surgery, Vol. 102, No. 3, 1998, pp. 711-721.
[21]
S. Vega, J. M. Smartt, S. Jiang, et al., “500 Consecutive Patients with Free TRAM Flap Breast Reconstruction: A Single Surgeon’s Experience,” Plastic and Reconstructive Surgery, Vol. 122, No. 2, 2008, pp. 329-339.
doi:10.1097/PRS.0b013e31817f45cb
[22]
S. S. Kroll, M. A. Schusterman, G. P. Reece, et al., “Choice of Flap and Incidence of Free Flap Success,” Plastic and Reconstructive Surgery, Vol. 98, No. 3, 1996, pp. 459-463. doi:10.1097/00006534-199609000-00015
[23]
C. S. Lin, H. C. Lee, C. T. Lin and H. C. Lin, “The Association between Surgeon Case Volume and Hospitalization Costs in Free Flap Oral Cancer Reconstruction Operations,” Plastic and Reconstructive Surgery, Vol. 122, No. 1, 2008, pp. 133-139.
doi:10.1097/PRS.0b013e3181773d71
[24]
S. Jandali, L. C. Wu, S. J. Vega, S. J. Kovach and J. M. Serletti, “1000 Consecutive Venous Anastomoses Using the Microvascular Anastomotic Coupler in Breast Reconstruction,” Plastic and Reconstructive Surgery, Vol. 125, No. 3, 2010, pp. 792-798.
doi:10.1097/PRS.0b013e3181cb636d
[25]
A. Keller, “A New Diagnostic Algorithm for Early Prediction of Vascular Compromise in 208 Microsurgical Flaps Using Tissue Oxygen Saturation Measurements,” Annals of Plastic Surgery, Vol. 62, No. 5, 2009, pp. 538-543. doi:10.1097/SAP.0b013e3181a47ce8
[26]
S. P. Davison, C. M. Kessler and A. Al-Attar, “Microvascular Free Flap Failure Caused by Unrecognized Hypercoagulability,” Plastic and Reconstructive Surgery, Vol. 124, No. 2, 2009, pp. 490-495.
doi:10.1097/PRS.0b013e3181adcf35
[27]
J. M. Serletti, J. P. Higgins, S. Moran and G. S. Orland, “Factors Affecting Outcome in Free-Tissue Transfer in the Elderly,” Plastic and Reconstructive Surgery, Vol. 106, No. 1, 2000, pp. 66-70.
doi:10.1097/00006534-200007000-00012
[28]
J. C. Selber, J. E. Kurichi, S. J. Vega, S. S. Sonnad and J. M. Serletti, “Risk Factors and Complications in Free TRAM Flap Breast Reconstruction,” Annals of Plastic Surgery, Vol. 56, No. 5, 2006, pp. 492-497.
doi:10.1097/01.sap.0000210180.72721.4a
[29]
J. C. Selber, F. Samra, M. Bristol, et al., “A Head-toHead Comparison between the Muscle-Sparing Free TRAM and the SIEA Flaps: Is the Rate of Flap Loss Worth the Gain in Abdominal Wall Function,” Plastic and Reconstructive Surgery, Vol. 122, No. 2, 2008, pp. 348-355. doi:10.1097/PRS.0b013e31817d60b0
[30]
R. K. Khouri and W. W. Shaw, “Reconstruction of the Lower Extremity with Microvascular Free Flaps: A 10-Year Experience with 304 Consecutive Cases,” Journal of Trauma, Vol. 29, No. 8, 1989, pp. 1086-1094.
doi:10.1097/00005373-198908000-00005
[31]
F. C. Wei, F. Demirkan, H. C. Chen, et al., “The Outcome of Failed Free Flaps in Head and Neck and Extremity Reconstruction: What Is Next in the Reconstructive Ladder,” Plastic and Reconstructive Surgery, Vol. 108, No. 5, 2001, pp. 1154-1160.
doi:10.1097/00006534-200110000-00007
[32]
M. A. Schusterman, M. J. Miller, G. P. Reece, S. S. Kroll, M. Marchi and H. Goepfert, “A Single Center’s Experience with 308 Free Flaps for Repair of Head and Neck Cancer Defects,” Plastic and Reconstructive Surgery, Vol. 93, No. 3, 1994, pp. 472-478.
[33]
K. E. Blackwell, M. T. Brown and D. Gonzalez, “Overcoming the Learning Curve in Microvascular Head and Neck Reconstruction,” Archives of Otolaryngology—Head and Neck Surgery, Vol. 123, No. 12, 1997, pp. 1332-1335.
doi:10.1001/archotol.1997.01900120082013
[34]
M. F. Massey and D. K. Gupta, “The Effects of Systemic Phenylephrine and Epinephrine on Pedicle Artery and Microvascular Perfusion in a Pig Model of Myoadipocutaneous Rotational Flaps,” Plastic and Reconstructive Surgery, Vol. 120, No. 5, 2007, pp. 1289-1299.
doi:10.1097/01.prs.0000279371.63439.8d
[35]
B. T. Lee, A. M. Tobias, J. H. Yueh, et al., “Design and Impact of an Intraoperative Pathway: A New Operating Room Model for Team-Based Practice,” Journal of the American College of Surgeons, Vol. 207, No. 6, 2008, pp. 865-873. doi:10.1016/j.jamcollsurg.2008.08.016
[36]
B. T. Lee, J. H. Yueh, C. Chen, S. J. Lin, A. M. Tobias and S. A Slavin, “Establishment of Perforator Flap Programs for Breast Reconstruction: The New England Program Experience,” Plastic and Reconstructive Surgery, Vol. 124, No. 5, 2009, pp. 1410-1418.
doi:10.1097/PRS.0b013e3181b989a5
[37]
T. Nakatsuka, K. Harii, H. Asato, et al., “Analytic Review of 2372 Free Flap Transfers for Head and Neck Reconstruction Following Cancer Resection,” Journal of Reconstructive Microsurgery, Vol. 19, No. 6, 2003, pp. 363-368. doi:10.1055/s-2003-42630
[38]
C. Ayala and K. E. Blackwell, “Protein C Deficiency in Microvascular Head and Neck Reconstruction,” Laryngoscope, Vol. 109, No. 2, 1999, pp. 259-265.
doi:10.1097/00005537-199902000-00016
[39]
E. Olsson and P. Hoijer, “Activated Protein C Resistance Due to Factor V Leiden, Elevated Coagulation Factor VIII, and Postoperative Deep Vein Thrombosis in Late Breast Reconstruction with a Free TRAM Flap: A Report of Two Cases,” British Journal of Plastic Surgery, Vol. 58, No. 5, 2005, pp. 720-723.
doi:10.1016/j.bjps.2004.12.024
[40]
B. I. Labow, A. K. Green and J. Upton, “Homocystinuria: An Unrecognized Cause of Microvascular Failure,” Plastic and Reconstructive Surgery, Vol. 120, No. 1, 2007, pp. 6e-12e. doi:10.1097/01.prs.0000264079.39846.6f
[41]
S. Baumeister, K. E. Follmar, M. R. Zenn, D. Erdmann and L. S. Levin, “Strategy for Reoperative Free Flaps after Failure of a First Flap,” Plastic and Reconstructive Surgery, Vol. 122, No. 3, 2008, pp. 962-971.
doi:10.1097/PRS.0b013e3181811ca0
[42]
J. M. Serletti, “Discussion,” Plastic and Reconstructive Surgery, Vol. 124, No. 2, 2009, pp. 496-499.
doi:10.1097/PRS.0b013e3181adcfab
