Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 38:
  Survival of free-tissue transfer exceeds 90% in the several large reported series of assorted flaps and defects.8-10 Analyses of the circumstances of flap failure have produced some specific observations that merit continued clinical and experimental investigation. Three groups5,11,12 correlated their flap failures with classifications of lower extremity traumatic and osteomyelitic defects. Swartz et al.11 and Weiland et al.12 identified subgroups of patients with extensive, contaminated defects who had very poor results and for whom amputation still appears to be a more straightforward alternative. In a prospective study, Byrd et al.5 demonstrated better success in type III open tibial fractures (severe comminution or bone loss with skin loss and devitalized muscle) treated with early free flap closure than with prolonged dressing care and skin grafting. They also presented data suggesting that early flap closure (within five days of injury) was more successful than later flap closure, implicating progressive bacterial colonization and chronic inflammatory tissue changes (also discussed by Lidman and Daniel13) as explanations for their observations. Godina8 analyzed a large series of extremity reconstructions and showed decreased failure with early wound coverage and with increased experience with the procedures. Unfortunately, he did not clearly analyze these variables independently. A review of a portion of our free-tissue transfer experience suggested that preoperative thrombocytosis and local wound factors were associated with our failures.10

  The incidence of postoperative re-exploration for vascular pedicle complications varies widely between different groups. Eight to 34% of microvascular tissue transfer procedures reportedly require vascular pedicle exploration and revision. Flap salvage rates are generally high (75%10,13 to 100%7) following pedicle revision.

Other complications receive varying emphasis in different reports. Perioperative and anaesthesia complications 14,15 occur rarely, despite the length of time required to perform these procedures. Mean blood loss was 820 cc in our series of 72 flaps.10 Postoperative soft tissue infections occur in 5% or less9 of cases, except in series containing large numbers of severely compromised lower extremity wounds. Persistent postoperative osteomyelitis occurs in 11% 11 to 20% 12 of these patients. Minor soft tissue dehiscences and skin graft complications rarely cause significant morbidity.10 One group7 reported a 17% incidence of transient brachial plexus palsy after harvest of latissimus dorsi flaps. These palsies occurred early in the group's experience and emphasized the need for careful arm placement and gentle axillary retraction during this procedure. We found a 3.2% incidence of donor site complications, l0 but a meticulous analysis of 300 donor sites by Colen et al.16 revealed a 20% rate of complications, including a 7.7% incidence of secondary surgery performed to correct donor site defects.

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