The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.
To evaluate the value of routine preoperative angiographies of donor sites, 120 patients with free fibula osteoseptocutaneous flap transplantations were included in this prospective study, which consisted of preoperative evaluation of dorsalis pedis and tibial posterior artery pulsation and angiographies of the donor legs (120 patients) and contralateral legs (111 patients). Both pedal pulses were palpable in 114 patients, and only one pulse was palpable in six patients. The respective nonpalpable foot pulses were detectable with pencil Doppler in five patients, but they were not detectable in one patient. Intraoperatively, the latter patient had a relatively hypertrophied peroneal artery as compared with both the tibial posterior and tibial anterior arteries. The angiographic result was arteria peronea magna. The other five patients showed intraoperatively and angiographically normal-sized major arteries of the lower leg. In three patients with normal pedal pulses, hypoplasias of either the tibial anterior or tibial posterior arteries were found intraoperatively. These findings corresponded with the angiographical results. In all patients (n = 119), except one with peroneal artery hemangioma, free osteoseptocutaneous fibula flap was harvested from the originally planned leg without subsequent sequelae to the respective donor leg. In 231 leg angiographies, only 7 cases (3 percent) with abnormalsized major lower leg arteries were described. The diagnoses in these cases were hypoplasia of either the tibial posterior or tibial anterior artery (4 cases), arteria peronea magna (2 cases, one of which was a false positive), absence of peroneal artery combined with hypoplastic tibial posterior artery (1 case), and hemangioma of the peroneal artery (1 case). From this prospective study, it was determined that routine preoperative angiography of the donor leg before fibula transplantation is not justified. It does not add relevant new information about donor leg vascularity, provided that the clinical evaluation of the pedal pulses is well conducted. The only two conditions that may require a preoperative donor leg angiography are abnormal pedal pulses or significant previous lower leg trauma.
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