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Strategy for Reoperative Free Flaps after Failure of a First Flap

Baumeister, Steffen M.D.; Follmar, Keith E. M.D.; Zenn, Michael R. M.D.; Erdmann, Detlev M.D., Ph.D.; Levin, L Scott M.D.

Plastic and Reconstructive Surgery: September 2008 - Volume 122 - Issue 3 - p 962-971
doi: 10.1097/PRS.0b013e3181811ca0
Special Topic

Background: Free vascularized tissue transfer is generally associated with high success rates, but failures do occur. After a flap failure, the decision is often made to perform a second, reoperative free flap.

Methods: A retrospective review of all microsurgical free tissue transfers performed at the authors’ institution identified 13 patients who underwent a second, reoperative free flap after a failed primary flap. The records of these patients were reviewed, with particular emphasis on identifying changes in treatment strategy between the initially failed and the reoperative free flap.

Results: Thirteen patients were identified as having undergone a reoperative free flap. In nine of 13 primary free flaps, at least one likely cause for the failure was identified (69 percent). In the approach to the second free flap, strategy changes were performed in 10 of 13 cases (77 percent); 11 were successful (85 percent). One of the two patients with a failed reoperative free flap underwent a third attempt at free tissue transfer, which also failed.

Conclusions: The authors’ overall approach to the failed free flap includes the following four steps: (1) reconsideration of the need for vascularized free tissue transfer, (2) a sensitive psychosocial approach to the patient and family, (3) analysis of the cause of the first flap failure, and (4) change in microsurgical strategy. Based on the authors’ experience, they consider two previously failed free flaps without an obvious cause to be a contraindication to a third attempt.

Durham, N.C.

From the Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center.

Received for publication May 28, 2007; accepted October 1, 2007.

Disclosure: The authors have no financial interest in any of the products or materials referenced in this article.

Detlev Erdmann, M.D., Ph.D., Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery, Duke University Medical Center, Box 3181, Durham, N.C. 27710,

©2008American Society of Plastic Surgeons