Risk Factors and Therapeutic Strategy after Failure of Free Flap Coverage for Lower-Limb Defects

ABSTRACT

From 2004 to 2007, 148 limb free flaps were performed in a series of 138 patients at the University Hospital in Nantes, France. Flaps were successful in 127 instances (rate: 86%; group A) and failed in 21 (group B). An analysis of the various factors (pre-, intra-, and postoperative) in both groups that may have influenced the outcome of surgery identified the following: operating time, cold ischemia time, and the interval before reoperation. This report is based on our experience in managing 21 free flap failures during reconstructive surgery of the limbs. The causes of failure were analyzed, and possible therapeutic strategies defined (i.e., a second free flap procedure, a pedicle flap, coverage with artificial dermis, or amputation). In our opinion, careful analysis of the causes of flap failure is essential to an appropriate choice of subsequent therapeutic strategy.

KEYWORDS

Failure - free flap - limbs

REFERENCES

• 1 Bui D T, Cordeiro P G, Hu Q Y, Disa J J, Pusic A, Mehrara B J. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps.  Plast Reconstr Surg. 2007;  119 2092-2100
• 2 Cooley B CHD, Hanel D P, Anderson R B, Foster M D, Gould J S. The influence of diabetes on free flap transfer: I. Flap survival and microvascular healing.  Ann Plast Surg. 1992;  29 58-64
• 3 Duteille F, Lim A, Dautel G. Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients.  Ann Plast Surg. 2003;  50 344-349
• 4 Godina M. Early microsurgical reconstruction of complex trauma of the extremities.  Plast Reconstr Surg. 1986;  78 285-292
• 5 Gürlek A, Kroll S S, Schusterman M A. Ischemic time and free flap success.  Ann Plast Surg. 1997;  38 503-505
• 6 Khouri R K. Avoiding free flap failure.  Clin Plast Surg. 1992;  19 773-781
• 7 Nahabedian M Y, Momen B, Manson P N. Factors associated with anastomotic failure after microvascular reconstruction of the breast.  Plast Reconstr Surg. 2004;  114 74-82
• 8 Organek A J, Klebuc M J, Zuker R M. Indications and outcomes of free tissue transfer to the lower extremity in children: review.  J Reconstr Microsurg. 2006;  22 173-181
• 9 Yu P, Chang D W, Miller M J, Reece G, Robb G L. Analysis of 49 cases of flap compromise in 1310 free flaps for head and neck reconstruction.  Head Neck. 2009;  31 45-51
• 10 Pohlenz P, Blessmann M, Blake F, Li L, Schmelzle R, Heiland M. Outcome and complications of 540 microvascular free flaps: the Hamburg experience.  Clin Oral Investig. 2007;  11 89-92
• 11 Pohlenz P, Blessmann M, Heiland M, Blake F, Schmelzle R, Li L. Postoperative complications in 202 cases of microvascular head and neck reconstruction.  J Craniomaxillofac Surg. 2007;  35 311-315
• 12 Salama A R, McClure S A, Ord R A, Pazoki A E. Free-flap failures and complications in an American oral and maxillofacial surgery unit.  Int J Oral Maxillofac Surg. 2009;  38 1048-1051
• 13 Serletti J M, Higgins J P, Moran S, Orlando G S. Factors affecting outcome in free-tissue transfer in the elderly.  Plast Reconstr Surg. 2000;  106 66-70
• 14 Smit J M, Acosta R, Zeebregts C J, Liss A G, Anniko M, Hartman E H. Early reintervention of compromised free flaps improves success rate.  Microsurgery. 2007;  27 612-616
• 15 Suh J D, Sercarz J A, Abemayor E et al.. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction.  Arch Otolaryngol Head Neck Surg. 2004;  130 962-966
• 16 Wax M K, Rosenthal E. Etiology of late free flap failures occurring after hospital discharge.  Laryngoscope. 2007;  117 1961-1963
• 17 Baumeister S FK, Follmar K E, Zenn M R, Erdmann D, Levin L S. Strategy for reoperative free flaps after failure of a first flap.  Plast Reconstr Surg. 2008;  122 962-971
• 18 Basheer M H, Wilson S M, Lewis H, Herbert K. Microvascular free tissue transfer in reconstruction of the lower limb.  J Plast Reconstr Aesthet Surg. 2008;  61 525-528
• 19 Duteille F, Thibault F, Perrot P, Renard B, Pannier M. Salvaging limbs in cases of severe purpura fulminans: advantages of free flaps.  Plast Reconstr Surg. 2006;  118 681-685 discussion 686-687
• 20 Hidalgo D A, Disa J J, Cordeiro P G, Hu Q Y. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique.  Plast Reconstr Surg. 1998;  102 722-732 discussion 733-734
• 21 Lin C H, Mardini S, Wei F C, Lin Y T, Chen C T. Free flap reconstruction of foot and ankle defects in pediatric patients: long-term outcome in 91 cases.  Plast Reconstr Surg. 2006;  117 2478-2487
• 22 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers.  Plast Reconstr Surg. 2008;  121 1725-1737
• 23 Wei F C, Demirkan F, Chen H C et al.. The outcome of failed free flaps in head and neck and extremity reconstruction: what is next in the reconstructive ladder?.  Plast Reconstr Surg. 2001;  108 1154-1160 discussion 1161-1162
• 24 Sakurai H, Yamaki T, Takeuchi M, Soejima K, Kono T, Nozaki M. Hemodynamic alterations in the transferred tissue to lower extremities.  Microsurgery. 2009;  29 101-106
• 25 Colen L BSA, Stevenson A, Sidorov V et al.. Microvascular anastomotic thrombosis in experimental diabetes mellitus.  Plast Reconstr Surg. 1997;  99 156-162
• 26 Chen K T, Mardini S, Chuang D C et al.. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers.  Plast Reconstr Surg. 2007;  120 187-195
• 27 Byrd H S, Spicer T E, Cierney III G. Management of open tibial fractures.  Plast Reconstr Surg. 1985;  76 719-730
• 28 Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S. Free flap reconstructions of 100 tibial fractures.  J Trauma. 1999;  46 1031-1035
• 29 Pollak A N, McCarthy M L, Burgess A R. The Lower Extremity Assessment Project (LEAP) Study Group . Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia.  J Bone Joint Surg Am. 2000;  82-A 1681-1691
• 30 Bocchi A, Merelli S, Morellini A, Baldassarre S, Caleffi E, Papadia F. Reverse fasciosubcutaneous flap versus distally pedicled sural island flap: two elective methods for distal-third leg reconstruction.  Ann Plast Surg. 2000;  45 284-291
• 31 Rajacic N, Darweesh M, Jayakrishnan K, Gang R K, Jojic S. The distally based superficial sural flap for reconstruction of the lower leg and foot.  Br J Plast Surg. 1996;  49 383-389