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Etiology and Management of Intraoperative Free Flap Failure

Alexandria J Lichtl¹, Morgan A Terry¹, Matthew B Studer¹

¹Department of Otolaryngology, Oregon Health & Science University, Portland, Oregon, USA.

|February 6, 2026

Abstract

Background:

Intraoperative free flap failure necessitates prompt intraoperative decision-making on alternative reconstructive strategies. In this study, we investigate the etiology and management of intraoperative flap loss.

Methods:

Retrospective review between 2010 and 2024 at 6 institutions.

Results:

There were 7423 free flaps performed with 46 instances of intraoperative flap failure (0.62%). The most common recipient subsite was oral cavity (27/46, 57%). Anterolateral thigh (ALT) was the most common flap type to fail (18/46, 39%), followed by the fibula (15/46, 32%). The most common reasons for total failure were clotting without observable vessel abnormality (12/35, 34.3%), poor quality perforator (11/35, 31.4%), and vessel spasm or intimal abnormality leading to clotting (8/35, 22.9%). The most common acute management was converting to an additional free flap intraoperatively (28/46, 60.9%).

Conclusions:

Flap failure intraoperatively is rare. The majority of cases were acutely managed with an additional flap to provide defect coverage.

Keywords:

complications failure intraoperative microvascular reconstruction

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