Long term study into surgical re-exploration of the 'free flap in difficulty'

Background: Free tissue transfers must survive in order to achieve their surgical goals. There is little consensus about managing the 'failing' free flap, and practice is often guided by anecdote. Material and methods: We have prospectively collected data about all free flaps performed within our department between 1985 and 2008 (2569 flaps). We identified 327 flaps which were re-explored a total of 369 times . We analysed these flaps with regard to indication for re-exploration, operative findings and outcome . Results: Thirteen percent( 327) of free flaps were re-explored. Of these, 291( 83%) had a successful outcome. Successful re-explorations took place at a mean 19 h post-op and unsuccessful re-explorations at a mean 56 h post-op. Clinical diagnosis prior to re-exploration was confirmed operatively in 91% of cases. Conclusion: We have considered the factors that allowed us to achieve the salvage rates described over a prolonged period, and identified two key areas. Firstly, we favour a model for free flap monitoring with clinical judgement at it score. Secondly, we feel the facility to recover patients post-operatively in a specialised, warmed environment, and return them to theatre quickly should the need arise, is essential. These two simple, yet institutionally determined factors are vital for maintaining excellent success rates. (C) 2009 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.