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J Reconstr Microsurg 2011; 27(3): 157-162
DOI: 10.1055/s-0030-1268855
© Thieme Medical Publishers

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

Pierre Perrot1 , 2 , Anne-Laure Bouffaut1 , Christophe Perret3 , Jérôme Connault4 , Franck Duteille1 , 2
  • 1Service de chirurgie plastique et reconstructrice–Centre des brûlés, Hôpital Jean Monnet, CHU de Nantes, France
  • 2Inserm U957, Laboratoire de physiopathologie de la résorption osseuse, Université de Nantes, France
  • 3Service de radiologie, Hôpital Hôtel Dieu, CHU de Nantes, France
  • 4Service de médecine interne, Hôpital Hôtel Dieu, CHU de Nantes, Nantes, France
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Publication History

Publication Date:
23 November 2010 (online)

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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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 4 Godina M. Early microsurgical reconstruction of complex trauma of the extremities.  Plast Reconstr Surg. 1986;  78 285-292
    CrossrefPubMedGoogle Scholar
  • 5 Gürlek A, Kroll S S, Schusterman M A. Ischemic time and free flap success.  Ann Plast Surg. 1997;  38 503-505
    CrossrefPubMedGoogle Scholar
  • 6 Khouri R K. Avoiding free flap failure.  Clin Plast Surg. 1992;  19 773-781
    Google Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 16 Wax M K, Rosenthal E. Etiology of late free flap failures occurring after hospital discharge.  Laryngoscope. 2007;  117 1961-1963
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 22 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers.  Plast Reconstr Surg. 2008;  121 1725-1737
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 25 Colen L BSA, Stevenson A, Sidorov V et al.. Microvascular anastomotic thrombosis in experimental diabetes mellitus.  Plast Reconstr Surg. 1997;  99 156-162
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 27 Byrd H S, Spicer T E, Cierney III G. Management of open tibial fractures.  Plast Reconstr Surg. 1985;  76 719-730
    CrossrefPubMedGoogle Scholar
  • 28 Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S. Free flap reconstructions of 100 tibial fractures.  J Trauma. 1999;  46 1031-1035
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar

Pierre PerrotM.D. Ph.D. 

Service de chirurgie plastique et reconstructrice–Centre des brûlés

Hôpital Jean Monnet, CHU de Nantes, 44093 Nantes Cedex 01, France

Email: pierre.perrot@chu-nantes.fr