The survival curve: factors impacting the outcome of free flap take-backs

When vascular compromise is detected, a free flap is immediately taken back to the operating room for attempted salvage. Which factors predict the success or failure of a take-back is currently unknown.

A review of free flaps performed at a single institution over the last 10 years was performed. A total of 4965 flaps were identified, and an analysis of factors predicting salvage or failure of first, second, and third take-backs for microvascular complications was performed.

Of 4965 flaps, 517 (10.3 percent) required return to the operating room, 157 (3.34 percent) for vascular complications. There were 66 (1.41 percent) total flap failures. Of 157 take-backs, 102 required return once, 44 twice, and 11 three times, with salvage rates of 72, 34, and 27 percent, respectively (p < 0.01). Overall salvage rate was 58 percent. The probability of a flap going back for a second time was 35 percent. Risks for flap failure included thrombotic (35.1 percent) versus mechanical (8 percent) etiology (p = 0.01) and arterial (37.5 percent) or mixed (61.5 percent) versus venous only (25 percent) etiology (p = 0.06). Failure was more likely the greater number of days postoperatively the take-back occurred (p = 0.02).

The number of returns to the operating room is inversely proportional to flap salvage. Mechanical and venous etiologies tend to result in salvage and arterial and thrombotic etiologies in failure. Earlier take-backs are more likely to be successful. Knowledge of these predictors of salvage should guide clinical decision making and informed consent.

Risk, II.