Anatomy of Free Flap Failures: Dissection of a Series

Abstract

Introduction: Free flap success rates have remainedstable in recent years ranging 93% to 98%. Historically, the causes of freeflap failures were attributed to the surgeon’s inexperience and technique.However, there are factors beyond the surgical anastomosis that contribute toflap failure. The purpose of this study is to review each case of total flaploss in detail to develop a better understanding of complications. Methods: A retrospective study was performedover eleven years in a single surgeon’s practice, a predominantly head and neckreconstructive practice. All charts were independently reviewed. In patients who sustained total flaploss, a review was conducted of patient comorbidites, anesthesia records,perioperative and follow-up notes. Results: A total of 514 free flaps wereperformed. 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 22total flap losses, four flaps were avulsed, five flaps were in patients laterfound to have coagulation disorders (homozygous mutations of the MTHFR gene andfactor V Leiden), four patients were exposed to neosynephrine, two patientsremained hypotensive perioperatively, and four delayed flap losses were attributedto pseudomonal infection. Five losses were technical or related to flapinexperience. Several representative case scenarios are illustrated. Conclusion: Careful reviewof free flap failures indicates that a thorough workup (particularlycoagulation disorders), flap selection, surgeon to anesthesia communication,proper securing of the flap, and postoperative patient blood pressure and infectioncontrol have a greater part to play in this new era of anastomotic success.