Increased salvage rates with early reexploration: A retrospective analysis of 547 free flap cases

J Plast Reconstr Aesthet Surg. 2021 Oct;74(10):2479-2485. doi: 10.1016/j.bjps.2021.03.001. Epub 2021 Mar 19.


Background: Free flap complications are generally rare, but not negligible since they may exert paramount impact on both patients and care providers. The aim of the study was to identify risk factors for reexploration and assess predictors associated with increased salvage rates.

Methods: A retrospective cohort study was conducted for free flaps performed between 2006 and 2015. Patient demographics, indications and flap types were analyzed together with complications and time to reexploration.

Results: Among 547 consecutive free flaps, 11.5% required acute reexploration. Hematoma together with vascular compromise was the main cause (41.9%) for reexploration, followed by hematoma only (19.4%), venous (16.1%) and arterial (6.5%) thrombosis. Hematoma was associated with an increased risk for concomitant vascular complication (p < 0.02). The incidence of total and partial flap necrosis was 3.5% and 3.7% respectively. There was an overall 71.4% salvage rate. The median time from detection of a compromised flap to reexploration was 3.0 h. Significantly higher salvage rates were observed for cases reexplored within (82.4%) compared to after (57.1%) 3.0 h (OR 3.50 (95% CI 1.10 to 11.13, p = 0.034)).

Conclusions: The current study highlights the importance of early intervention, including evacuation of hematomas that may lead to vascular compromise. Adequate monitoring of venous outflow was found necessary to improve flap salvage rates, whereas arterial complications were mainly related to persistent arterial injury in traumatized extremities with reduced salvage rates. Free flap surgery requires trained staff and immediate access to operating facilities to ensure high flap survival rates.

Keywords: Critical flap; Early reexploration; Free flap monitoring; Microsurgery; Time to reexploration.

MeSH terms

  • Early Medical Intervention / methods
  • Female
  • Free Tissue Flaps* / adverse effects
  • Free Tissue Flaps* / blood supply
  • Free Tissue Flaps* / classification
  • Free Tissue Flaps* / statistics & numerical data
  • Hematoma* / etiology
  • Hematoma* / prevention & control
  • Hematoma* / surgery
  • Humans
  • Male
  • Middle Aged
  • Plastic Surgery Procedures / adverse effects*
  • Plastic Surgery Procedures / methods
  • Postoperative Complications* / pathology
  • Postoperative Complications* / physiopathology
  • Postoperative Complications* / surgery
  • Regional Blood Flow
  • Reoperation / methods
  • Reoperation / statistics & numerical data
  • Retrospective Studies
  • Risk Adjustment / methods
  • Risk Factors
  • Salvage Therapy / methods
  • Sweden / epidemiology
  • Thrombosis* / etiology
  • Thrombosis* / prevention & control
  • Thrombosis* / surgery
  • Time-to-Treatment / statistics & numerical data