Management of the Failing Flap

Abstract

Free tissue transfer has become the reconstructive modality of choice for replacing composite tissue defects. While the success rate in high-volume centers is reported to be greater than 95%, up to 10% of patients will require revision of their vascular anastomosis secondary to thrombosis or compromise to flow. In the intraoperative setting, immediate revision is successful in the majority of cases. Rarely, the flap cannot be revascularized and a secondary option must be used. In the perioperative setting revision is successful if the patient can be brought back to the operating room in a timely fashion. Revision rates up to 70% are reported. A small number of these patients may then suffer a second episode of compromise where revision is less successful at 30%. In these cases, consideration should be given to secondary reconstruction rather than attempting salvage. Finally, there are a small number of patients whose flaps will fail following discharge from the hospital. These patients can rarely be salvaged and secondary reconstructive options should be explored.

Keywords: free flap compromise; free flap failure; salvage.

Fig. 1

This flap demonstrates the classic signs of venous congestion. A dark blue tinge of the tissue with dark blood on skin prick.

Fig. 2

The venous pedicle exhibits no flow and a vascular clot.

Fig. 3

The artery demonstrates a clot at the anastomotic site that proceeds distally down the flap pedicle.

Fig. 4

This flap was viable when the patient was discharged. They recall sleeping on that side and waking up with the flap appearing like this. Clearly, it is not salvageable on postoperative day 21.

Fig. 5

This patient developed a neck infection requiring washout and irrigation. The flap was nonviable and could not be salvaged on postoperative day 14.