Free Flap Failures: What to Do Next?

2000 ◽  
Vol 8 (1) ◽  
pp. 30-32 ◽  
Author(s):  
Nadia S Afridi ◽  
Jl Paletz ◽  
Sf Morris
Keyword(s):  
Success Rate ◽  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Success Rates ◽  
Complete Necrosis ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Split Thickness Skin Grafting ◽  
Microvascular Tissue Transfer

Over the past two decades, microvascular free tissue transfer has become a common procedure, usually with predictable results. The overall success rate of free flap surgery has gradually improved, and most recent reviews document an overall success rate between 90% and 95%. The goal of this study was to determine the outcome of those patients who underwent unsuccessful free microvascular tissue transfer. An extensive chart review was carried out on all those patients who underwent free microvascular tissue transfer at the Queen Elizabeth II Health Sciences Centre from 1988 to 1999. One hundred and forty-eight patients underwent free tissue transfer. A total of 164 free flaps were carried out, with an overall success rate of 92%. Free flap failure was defined as complete necrosis of the flap. There were 13 documented flap failures with complete necrosis of the flap requiring debridement. Seven patients underwent repeat free microvascular tissue transfer. These procedures were carried out by the same surgeon or surgical team 12 to 52 days after the first surgery. These secondary microvascular procedures were all successful. Of the remaining patients, five had either debridement and split-thickness skin grafting or regional flap coverage. One patient went on to lower limb amputation. This study reaffirms the success rates of free microvascular tissue transfer. In addition, the success rates of repeat free flaps were evaluated. It appears that patients undergoing repeat microvascular tissue transfers have no innate propensity for flap failure.

Free Flap Head and Neck Reconstruction with an Emphasis on Postoperative Care

2018 ◽  
Vol 34 (06) ◽  
pp. 597-604 ◽  
Author(s):  
Jacob D'Souza ◽  
Wendy King ◽  
Michael Bater ◽  
Daniel van Gijn
Keyword(s):  
Free Flap ◽  
Microvascular Complications ◽  
Free Tissue Transfer ◽  
Congenital Defects ◽  
Head And Neck Reconstruction ◽  
Functional Rehabilitation ◽  
Immediate Reconstruction ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring

AbstractMicrosurgical free tissue transfer represents the mainstay of care in both ablative locoregional management and the simultaneous reconstruction of a defect. Advances in microsurgical techniques have helped balance the restoration of both form and function—decreasing the significant morbidity once associated with large ablative, traumatic, or congenital defects—while providing immediate reconstruction enabling early aesthetic and functional rehabilitation. There are a multitude of perioperative measures and considerations that aim to maximize the success of free tissue transfer. These include nutritional support, tight glycemic control, acknowledgment of psychological and psychiatric factors, intraoperative surgical technique, and close postoperative monitoring of the patients' hemodynamic physiology. While the success rates of free tissue transfer in experienced hands are comparable to alternative options, the consequences of flap failure are catastrophic—with the potential for significant patient morbidity, prolonged hospital stay (and associated increased financial implications), and increasingly limited options for further reconstruction. Success is entirely dependent on a continuous arterial inflow and venous outflow until neovascularization occurs. Flap failure is multifactorial and represents a dynamic process from the potentially reversible failing flap to the necrotic irreversibly failed flap—necessitating debridement, prolonged wound care, and ultimately decisions concerned with future reconstruction. The overriding goal of free flap monitoring is therefore the detection of microvascular complications prior to permanent injury occurring—identifying and intervening within that critical period between the failing flap and the failed flap—maximizing the potential for salvage. With continued technique refinement, microvascular free flap reconstruction offers patients the chance for both reliable functional and aesthetic restoration in the face of significant ablative defects. The caveat to this optimism is the requirement for considered perioperative care and the optimization of those factors that may offer the difference between success and failure.

scholarly journals Cross-Leg as Salvage Procedure after Free Flaps Transfer Failure: A Case Report

2012 ◽  
Vol 2012 ◽  
pp. 1-3
Author(s):  
F. Contedini ◽  
L. Negosanti ◽  
E. Fabbri ◽  
V. Pinto ◽  
B. Tavaniello ◽  
...  
Keyword(s):  
Free Flap ◽  
Latissimus Dorsi ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Lower Leg ◽  
Salvage Procedure ◽  
Soft Tissue Defects ◽  
Vascular Thrombosis ◽  
Flap Failure ◽  
Tissue Defects

Posttraumatic wounds of the lower leg with soft tissue defects and exposed fractures are a reconstructive challenge due to the scarce availability of local tissues and recipient vessels. Even when a free tissue transfer can be performed the risk of failure remains considerable. When a free flap is contraindicated or after a free flap failure, the cross-leg flap is still nowadays a possible option. We report a case of a male with a severe posttraumatic wound of the lower leg with exposed tibia fracture firstly treated with two consecutive latissimus dorsi muscular free flaps, failed for vascular thrombosis; the coverage was then achieved with a cross-leg flap with acceptable results.

Compromised microvascular free flaps; salvage using Fogarty vascular catheter thrombectomy

2020 ◽  
Vol 13 (12) ◽  
pp. e239251
Author(s):  
Santhosh Rao ◽  
Nitin Kumar Kashyap ◽  
Chinmaya Panda ◽  
Naveen Kumar
Keyword(s):  
Free Flap ◽  
Thrombus Formation ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Tissue Transfer ◽  
Microvascular Free Flaps ◽  
Flap Perfusion

Compromised free flap perfusion secondary to thrombus formation is a routinely encountered complication in microvascular free tissue transfer. Various modalities were tried out prophylactically to prevent thrombus formation, and likewise, various methods are tried for salvaging the flap with effective thrombectomy. We present the use of Fogarty vascular catheter for thrombectomy and effective salvage of the flap.

scholarly journals Microsurgical free tissue transfer as avaluable reconstructive procedure in foot reconstruction

2007 ◽  
Vol 40 (02) ◽  
pp. 141-146
Author(s):  
mohamed el-shazly ◽  
mohamed makboul
Keyword(s):  
Free Flap ◽  
Motor Vehicle ◽  
Donor Site ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Vehicle Accidents ◽  
Tissue Transfer ◽  
Scapular Flap ◽  
Radial Forearm ◽  
Foot Reconstruction

ABSTRACT Background: owing to the limited soft tissue donor sites in the foot area, the use of microsurgical tissue transfer is frequently becoming mandatory in this area, especially in cases of massive defects due to the common motor vehicle accidents in the territory of upper egypt. free flaps offer a great variety of available tissues to cover larger, multifocal or multistructural defects. they also improve the perfusion of the infected poorly perfused areas.Objectives: in this study, we tried to evaluate foot defects according to their size, shape and site and to determine the general and specific parameters of free tissue transfer to the foot area in concomitance with the patients needs.Materials and methods: eleven patients were included in this study. for each patient, complete history was taken, general and local examination, photographic documentation, laboratory investigations, imaging and other investigations were performed. free flap transfers were applied in all cases as follows: latissimus dorsi flap in five cases, rectus abdominis flap in three cases, scapular flap in one case, gracilis flap in one case and radial forearm flap in one case.Results: nine flaps survived. no infection or donor site complications were recorded. every patient had the optimum free flap as regards the defect size, site, depth, condition, shape, donor site availability and the recipient vessels′ condition.Conclusion: the study of the optimum free flap for foot reconstruction in relation to the defect present and patient conditions is crucial to have significant results.

Effects of Transfusion on Free Flap Survival: Searching for an Optimal Hemoglobin Threshold for Transfusion

2018 ◽  
Vol 34 (08) ◽  
pp. 610-615 ◽  
Author(s):  
Min Ji Kim ◽  
Kyong-Je Woo ◽  
So Ra Kang ◽  
Bo Young Park
Keyword(s):  
Risk Factors ◽  
Blood Transfusion ◽  
Free Flap ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Free Tissue Transfer ◽  
Control Group ◽  
Flap Failure ◽  
Tissue Transfer ◽  
The Impact

Background Microsurgical free tissue transfer is a popular technique nowadays. Because of its considerably exquisite procedure, various risk factors can affect surgical outcome. However, current key practices, especially those in blood transfusion, are in contention due to the lack of enough evidence. Therefore, the objective of this study was to investigate the impact of perioperative blood transfusion on microsurgical complication. Methods Data of a total of 168 patients who underwent microvascular free tissue transfer from 2013 through 2016 were retrospectively reviewed. Age, comorbidity, anatomical surgical site, preoperative and postoperative lowest hemoglobin (Hb) level, estimated blood volume loss, and final clinical flap outcome were compared between patients with and without transfusion treatment. Factors with a significance of p < 0.05 in univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. Results Of 168 patients, 72 (43%) were in the transfusion group. Cross analysis statistics showed that flap failure in the transfusion group was 3.6 times higher (p = 0.018) than that in the control group. Multivariable analysis revealed that age (p = 0.083) and perioperative lowest Hb level (p = 0.021) remained as significant predictors of flap failure. Receiver-operating characteristic curve analysis showed that the appropriate lower limit of transfusion commencement of Hb was 8.75 g/dL (area under the curve: 0.721). Conclusion A transfusion during perioperative period of free flap did not increase its failure rate. Rather than appropriate transfusion strategy, perioperative lowest Hb level, and age were significant predictors of flap failure. Therefore, transfusion can be confidently used in patients who undergo free flap without any hesitation. Results of this study provide practical evidence of performing perioperative transfusion for free tissue transfer patients.

Neurotized Free Tissue Transfer for Foot Reconstruction: A Systematic Review

2019 ◽  
Vol 36 (01) ◽  
pp. 032-040 ◽  
Author(s):  
Jacob R. Rinkinen ◽  
Shawn Diamond ◽  
Jonathan Lans ◽  
Curtis L. Cetrulo ◽  
Kyle R. Eberlin
Keyword(s):  
Systematic Review ◽  
Soft Tissue ◽  
Activities Of Daily Living ◽  
Free Flap ◽  
Daily Living ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Ulcer Formation ◽  
Soft Tissue Reconstruction ◽  
Tissue Transfer

Background Soft tissue reconstruction of the foot represents a complex reconstructive challenge given the unique anatomical properties of the glabrous plantar skin. For large soft tissue defects and/or complex injuries, free tissue transfer is often the optimal reconstructive modality. The decision to pursue a neurotized free flap remains controversial and an area of debate. Given the trend toward increasing use of neurotized free flaps, we performed a systematic review to determine if nerve coaptation is a beneficial adjunct to free tissue transfer. Methods A systematic search of the English literature using PubMed and Web of Science was performed. Studies were identified between 1985 and 2018. Manuscripts were eligible if they contained original clinical outcomes research of patients who underwent free tissue transfer to the foot or heel with neurotization. Results A total of 189 studies were identified with initial screening and 19 studies were included in our analysis. A total of 175 patients underwent free flap reconstruction to the foot; of these, 107 patients had a nerve coaptation performed. Patients who underwent neurotization had improved sensory characteristics (two-point discrimination, light touch, and pain sensation), quicker return to ambulation and activities of daily living, and decreased ulcer formation compared with those who did not. Overall complications were infrequent, with ulceration being the most common. Conclusion Neurotized free flaps appear to have an overall decreased rate of ulceration, improved sensory discrimination, and quicker return to ambulation/activities of daily living in comparison to nonneurotized free flaps. However, when examining free anterolateral thigh (ALT) and free medial plantar artery (MPA) fasciocutaneous flaps, durability (i.e., frequency of ulcer formation) and functionality (ambulation and return to activities of daily living) do not appear to be significantly different between neurotized and nonneurotized flaps.

scholarly journals Postoperative Free-Flap Monitoring Techniques

2019 ◽  
Vol 33 (01) ◽  
pp. 013-016 ◽  
Author(s):  
Scott Kohlert ◽  
Alexandra Quimby ◽  
Masoud Saman ◽  
Yadranko Ducic
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Potential Complication ◽  
Postoperative Monitoring ◽  
Monitoring Techniques ◽  
Flap Failure ◽  
Tissue Transfer ◽  
Free Flap Monitoring ◽  
Flap Monitoring

AbstractFree tissue transfer is commonly employed in the reconstruction of large or complicated defects. Postoperative flap failure from microvascular compromise is an uncommon but major potential complication of this procedure. As such, many postoperative monitoring techniques devices have been developed. This paper provides an overview of the wide variety of options available for surgeons today.

Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review

2021 ◽  
Author(s):  
Amanda Y. Shen ◽  
Sarah Lonie ◽  
Kaiyang Lim ◽  
Hannah Farthing ◽  
David J. Hunter-Smith ◽  
...  
Keyword(s):  
Free Flap ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Cochrane Library ◽  
Success Rates ◽  
Reliable Technique ◽  
Free Flap Monitoring ◽  
Vascular Compromise ◽  
Flap Monitoring ◽  
Meta Analyses

Abstract Background Microsurgical free tissue transfer has become a reliable technique with success rates around 99% and around 5% requiring exploration for vascular compromise. Protocols for flap monitoring between plastic surgery units vary. We aimed to elucidate the time period when monitoring is crucial for flap salvage. Methods A systematic search of literature was performed in PubMed, Cochrane Library, Medline, and Scopus databases from 1966 to July 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, identifying 3,844 studies with mention of free flap and monitoring or timing or salvage or compromise. Studies were screened for relevance according to predetermined inclusion criteria. Data was extracted from included studies relating to flap type, monitoring, timing and reason for failure, and success of salvage intervention. Results A total of 109 studies featuring 44,031 free flaps were included. A total of 2,549 (5.8%) flaps required return to theater for compromise; 926 (2.1%) were lost and 1,654 (3.7%) were salvaged. In the first 24 hours postoperatively 93.8% of explored flaps are successfully salvaged, by day 2: 83.33%, day 3: 12.1%, and beyond day 4: none were successful. Of the 355 flaps where the cause of failure was reported, 59.5% was venous, 27.9% was arterial, 2.3% was a combination of both, and 10.2% was hematoma or infection. The proportion of flap failures at various recipient sites was highest in the trunk/viscera (7%, 95% confidence interval [CI] 0.00, 0.36), followed by limbs (5%, 95% CI 0.02, 0.08), head and neck (3%, 95% CI 0.02, 0.04), and breast (<1%; 95% CI 0.00, 0.02). Conclusion Close flap monitoring is of most value in the first 48 hours postoperatively, facilitating rapid detection of vascular compromise, early salvage, and better outcomes. The location of the flap has implications on its success and certain recipient sites may need particular attention to improve chances of success.

scholarly journals Pedicle streaking: A novel and simple aid in pedicle positioning in free tissue transfer

2015 ◽  
Vol 48 (03) ◽  
pp. 274-277 ◽  
Author(s):  
Aditya Aggarwal ◽  
Hardeep Singh ◽  
Sanjay Mahendru ◽  
Vimalendu Brajesh ◽  
Sukhdeep Singh ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Success Rate ◽  
Single Case ◽  
Free Tissue Transfer ◽  
Free Flaps ◽  
Blue Dye ◽  
Methylene Blue Dye ◽  
Safe Method ◽  
Tissue Transfer ◽  
Novel Method

ABSTRACT Introduction: The pedicle positioning in free tissue transfer is critical to its success. Long thin pedicles are especially prone to this complication where even a slight twist in the perforator can result in flap loss. Pedicles passing through the long tunnels are similarly at risk. Streaking the pedicle with methylene blue is a simple and safe method which increases the safety of free tissue transfer. Materials and Methods: Once the flap is islanded on the pedicle and the vascularity of the flap is confirmed, the pedicle is streaked with methylene blue dye at a distance of 6-7 mm. The streaking starts from the origin of the vessels and continued distally on to the under surface of flap to mark the complete course of the pedicle in alignment. The presence of streaking in some parts and not in rest indicates twist in the pedicle. Observation and Results: Four hundred and sixty five free flaps have been done at our centre in the last 5 years. The overall success rate of free flaps is 95.3% (22 free flap failures). There has not been a single case of pedicle twist leading to flap congestion and failure. Conclusion: This simple and novel method is very reliable for pedicle positioning avoiding any twist necessary for successful free tissue transfer.

scholarly journals Flap Failure and Salvage in Head and Neck Reconstruction

2020 ◽  
Vol 34 (04) ◽  
pp. 314-320
Author(s):  
Weitao Wang ◽  
Adrian Ong ◽  
Aurora G. Vincent ◽  
Tom Shokri ◽  
Britney Scott ◽  
...  
Keyword(s):  
Head And Neck ◽  
Free Flap ◽  
Surgical Techniques ◽  
Free Tissue Transfer ◽  
Head And Neck Reconstruction ◽  
Success Rates ◽  
Neck Reconstruction ◽  
Flap Failure ◽  
Ablative Surgery ◽  
Reconstructive Option

AbstractWith advanced head and neck ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional and aesthetic outcomes. Contemporary microvascular reconstructive surgery with free tissue transfer has become the standard for complex head and neck reconstruction. With continued refinements in surgical techniques, larger surgical volumes, and technological advancements, free flap success rates have exceeded 95%. Despite these high success rates, postoperative flap loss is a feared complication requiring the surgeon to be aware of potential options for successful salvage. The purpose of this article is to review free flap failure and ways to optimize surgical salvage in the scenario of flap compromise.

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