Journal of Plastic, Reconstructive & Aesthetic Surgery (2016) 69, 894e906

Identification of independent risk factors for

flap failure: A retrospective analysis of 1530
free flaps for breast, head and neck and
extremity reconstruction*
David E. Las, Tim de Jong, J. Michiel Zuidam,
Norbert M. Verweij, Steven E.R. Hovius, Marc A.M. Mureau*

Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam,
Rotterdam, The Netherlands

Received 14 April 2015; accepted 1 February 2016

KEYWORDS Summary Reconstructive microsurgery is a powerful method of treating various complex de-
Microsurgery; fects. However, flap loss remains a possibility, leading to additional surgery, hospitalisation
Free flap; and costs. Consequently, it is important to know which factors lead to an increased risk of flap
Reconstruction; failure, so that measures can be undertaken to reduce this risk. Therefore, we analysed our
Breast; results over a 20-year period to identify risk factors for flap failure after breast, head and neck
Head and neck; and extremity reconstruction.
Extremity The medical files of all patients treated between 1992 and 2012 were reviewed. Patient
characteristics, surgical data and post-operative complications were scored, and independent
risk factors for flap loss were identified.
Reconstruction with a total of 1530 free flaps was performed in 1247 patients. Partial and
total flap loss occurred in 5.5% and 4.4% of all free flaps, respectively. In all flaps, signs of
compromised flap circulation were a risk factor for flap failure. More specifically, the risk fac-
tors for flap failure in breast reconstruction were previous radiotherapy, venous anastomosis
revision, gluteal artery perforator (GAP) flap choice and post-operative bleeding. In head
and neck reconstruction, pulmonary co-morbidity and anastomosis to the lingual vein or super-
ficial temporal artery were risk factors, whereas a radial forearm flap reduced the risk. In ex-
tremity reconstruction, diabetes, prolonged anaesthesia time and post-operative wound
infection were risk factors.

*
This paper was presented at 1) the fall meeting of the Dutch Society for Plastic Surgery, 4 October 2014 and at 2) the annual meeting of
the American Society for Reconstructive Microsurgery, 24e27 January 2015.
* Corresponding author. Department of Plastic and Reconstructive Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box
2040, NL-3000 CA, Rotterdam, The Netherlands.
E-mail address: m.mureau@erasmusmc.nl (M.A.M. Mureau).

http://dx.doi.org/10.1016/j.bjps.2016.02.001
1748-6815/ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Identification of independent risk factors for flap failure
Independent pre-, intra- and post-operative risk factors for flap failure after microvascular
breast, head and neck and extremity reconstruction were identified. These results may be
used to improve patient counselling and to adjust treatment algorithms to further reduce
the chance of flap failure.
ª 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.
Introduction
Reconstructive microsurgery is a powerful tool for treating
various complex defects; however, it is predominantly used
to reconstruct postmastectomy, head and neck and post-
traumatic extremity defects. Even in experienced hands,
partial or total flap failure remains a true possibility, which
affects both patient and surgeon severely, leading to
additional surgery, hospitalisation, increased costs and
emotional stress. Thus, it seems important to know which
factors lead to an increased risk of flap failure, so that
measures can be undertaken to reduce this risk and to
improve patient counselling.
A number of variables have been demonstrated to be
associated with flap loss after free tissue transfer. The re-
ported preoperative risk factors are age, gender, tobacco
use, diabetes, hypertension, body mass index (BMI), prior
radiotherapy and recipient-site surgery. Intraoperative risk
factors are limited surgical experience, use of vascular
grafts and free flap choice. Little is known about post-
operative risk factors, but all re-explorations with or
without revision of an anastomosis are associated with
higher flap loss rates.1e17
Previous reports analysing risk factors for flap failure
have their methodological limitations, such as small sample
size (<150)1e6,8e11,13e17,18 and univariate analyses without
correction for possible confounders.1,9,10,12,14,16,18
Furthermore, the majority of these series only studied
preoperative variables1e3,5e10,12e17; however, intra-
operative as well as post-operative variables (complica-
tions) may also have an important effect on flap
survival.7,11
The primary objective of the current study was to assess
independent pre-, intra- and post-operative risk factors for
partial and total flap failure after the most common types
of microvascular reconstruction. The second objective was
to determine the occurrence of major complications lead-
ing to reoperations following these microvascular
reconstructions.
Patients and methods
All consecutive patients who received a free flap for breast,
head and neck and extremity reconstruction between 1
January 1993 and 31 December 2012 were included. Cases
were identified based on their operation codes, which have
been digitally recorded since 1993. Patient characteristics,
surgical data, post-operative complications and reopera-
tions were collected from the medical files. The
895
preoperative characteristics were sex, age, BMI, tobacco
use, co-morbidities, medication, free flap indication and
location, prior recipient-site surgery and previous chemo-
therapy and radiotherapy. The intraoperative characteris-
tics included flap type(s), number of free flaps, total
anaesthesia time, ischaemia time, recipient vessels, type
of anastomosis, number of venous anastomoses, use of vein
grafts and intraoperative revision of an anastomosis. The
venous coupler device was introduced in the last year of
this series, and it was used by only one microsurgeon for
autologous breast reconstructions. Thus, the number of
uses of this device was too low to include it as a variable in
the analyses. The post-operative characteristics included
use of unfractionated heparin and post-operative compli-
cations leading to reoperation, such as haematoma, infec-
tion, signs of compromised flap circulation and partial and
total flap loss.
Statistical analysis
Univariate analyses were performed using chi-squared and
Fisher’s exact tests for categorical variables and Student’s
t-tests for continuous variables. All free flaps performed in
each patient were analysed independently. All pre-, intra-
and post-operative variables were analysed for a possible
correlation with partial or total flap failure. Variables with
p < 0.10 at univariate analyses were included in the
multivariate regression analyses, using a backward model.
Two-sided p-values <0.05 were considered statistically
significant. Statistical analyses were performed using SPSS
(SPSS for Windows Version 21.0; SPSS Inc., Chicago, IL,
USA).
Results
Patient characteristics
A total of 1247 patients (566 male and 681 female) received
1530 free flaps for the reconstruction of postmastectomy,
head and neck or post-traumatic extremity defects.
Although this implies only an average of 77 flaps per year,
52% (n Z 795) of the flaps were used during the last 5 years
of this series, due to an increase in oncologic microvascular
breast and head and neck reconstructions (Figure 1). The
mean age at the time of operation was 50.4 years (range,
4e89 years). The mean body mass index (BMI) was 25.6 kg/
m2. The potential preoperative risk factors for flap failure
were smoking (25.8%), diabetes (5.7%), hypertension
(15.8%), cardiovascular co-morbidity (8.7%), pulmonary co-
896 D.E. Las et al.

250
No flap failure
Partial flap failure
Total flap failure

200

Total free flaps

150

100

50

0
1993 (20%)
1994 (13%)
1995 (0%)
1996 (16%)
1997 (8%)
1998 (9%)
1999 (7%)
2000 (19%)
2001 (3%)
2002 (14%)
2003 (7%)
2004 (10%)
2005 (12%)
2006 (6%)
2007 (8%)
2008 (16%)
2009 (11%)
2010 (9%)
2011 (8%)
2012 (10%)
Year (% flap failure)

Figure 1 Number of free flaps and flap failures annually.

morbidity (3.8%), prior chemotherapy (16.1%) and prior Post-operative complications

radiotherapy (20.3%). In the past, 372 patients (29.8%) had
undergone surgery at the recipient site, primarily those Post-operative haematoma occurred in 6.7% of all free flap
who underwent head and neck and lower extremity reconstructions, wound infection in 3.1% and signs of
reconstruction. Table 1 shows all preoperative patient compromised flap circulation leading to exploration in
characteristics in more detail. 6.7%. The overall success rate of a flap salvage procedure
The indications for free flap reconstruction were post- was 61.8% (see Table 4 for flap salvage rates per indica-
oncologic head and neck defects in 459 patients (36.8%), tion). Partial flap loss was encountered 84 times (5.5%) and
postmastectomy defects in 458 patients (36.7%) and post- total flap loss 67 times (4.4%), resulting in a complete flap
traumatic extremity defects, mainly of the lower extrem- survival rate of 90.1%. The post-operative complications for
ity, in 330 patients (26.5%). Head and neck defects typically each of the indications are summarised in Table 5.
resulted after resection of a squamous cell carcinoma of Following post-traumatic extremity reconstruction,
the oral cavity (75.6%), but also after treatment of post-operative haematoma occurred significantly less often
osteoradionecrosis (10.5%). Breast reconstruction was per- (p Z 0.004) and signs of compromised flap circulation were
formed either after prophylactic mastectomy in BRCA 1 or 2 noted more often (p Z 0.04). No statistically significant
gene mutation carriers or following mastectomy for breast differences in the prevalence of partial flap loss between
cancer. the three indications could be determined. By contrast,
significantly fewer total flap losses (p < 0.001) and local
Operation characteristics infections (p Z 0.011) were seen after breast
reconstructions.
The deep inferior epigastric perforator (DIEP) (85.4%) and
muscle-sparing transverse rectus abdominis myocutaneous Independent risk factors for free flap loss in breast
(ms-TRAM) (7.3%) flaps were most commonly used in breast reconstruction
reconstruction; the radial forearm (34.5%), fibula (35.0%)
and anterolateral thigh (ALT) (19.7%) flaps in head and neck Of the 631 free flaps used for breast reconstruction, 32
reconstruction; and the latissimus dorsi (29.6%) and gracilis (5.1%) experienced partial flap failure and 11 (1.7%) total
(21.9%) flaps in post-traumatic extremity reconstruction flap failure. All significant risk factors associated with
(Table 2). The operation characteristics in terms of indi- partial and total flap loss after univariate analyses are
cation are listed in Table 3. summarised in Table 6. For partial flap loss, preoperative
Identification of independent risk factors for flap failure 897

Table 1 Preoperative patient characteristics (N Z 1247). Table 2 Free flap type per indication (N Z 1530).
N MV Flap type Total (%) Breast (%) Head and Trauma (%)
Sex N Z 1530 N Z 631 neck (%) N Z 351
Male 566 (45.4%) e N Z 548
Female 681 (54.6%) e DIEP 539 (35.2) 539 (85.4)
Age ms-TRAM 46 (3.0) 46 (7.3)
65 year 1020 (81.8%) e SGAP/IGAP 18 (1.2) 18 (2.9)
>65 year 227 (18.2%) e SIEA 12 (0.8) 12 (1.9)
Mean BMI in kg/m2 ( SD) 25.6 (4.4) 171 TMG 10 (0.7) 10 (1.6)
Smokinga 312 (25.8%) 39 Gluteus 2 (0.1) 2 (0.3)
Preoperative medication maximus
Antihypertensive drugs 246 (20.2%) 33 RF 228 (14.9) 189 (34.5) 39 (11.1)
Anticoagulants 162 (13.3%) 33 Fibula 201 (13.1) 192 (35.0) 9 (2.6)
Tamoxifenb 77 (16.8%) e ALT 158 (10.3) 1 (0.2) 108 (19.7) 49 (14.0)
Psychiatric drugs 64 (5.3%) 33 LD 127 (8.3) 3 (0.5) 20 (3.6) 104 (29.6)
Anti-diabetics 49 (4.0%) 33 Gracilis 86 (5.6) 9 (1.6) 77 (21.9)
Corticosteroids 23 (1.9%) e Rectus 37 (2.4) 6 (1.1) 31 (8.8)
Insulin 11 (0.9%) 33 abdominis
Comorbidities Parascapular 7 (0.5) 5 (0.9) 2 (0.6)
Hypertension 192 (15.8%) 33 Serratus 5 (0.3) 4 (0.7) 1 (0.3)
Cardiovascular 108 (8.7%) e anterior
Diabetes 69 (5.7%) 33 Toe 22 (1.4) 22 (6.3)
Pulmonary disease 48 (3.8%) e Other 32 (2.1) 15 (2.7) 17 (4.8)
Other malignancy 20 (1.6%) e DIEP: deep inferior epigastric artery perforator. ms-TRAM:
Previous treatment muscle sparing transverse rectus abdominis myocutaneous.
Recipient-site surgery 372 (29.8%) e SGAP: superior gluteal artery perforator. IGAP: inferior gluteal
Radiotherapy 253 (20.3%) e artery perforator. SIEA: superficial inferior epigastric artery.
Chemotherapy 201 (16.1%) e TMG: transverse myocutaneous gracilis. RF: radial forearm.
Indications ALT: anterolateral thigh. LD: latissimus dorsi.
Oncology 952 (68.7%) e
- Head and neck 459 (36.8%) e
Location site the use of gluteal artery perforator (GAP) flaps (OR Z 9.08,
Oral cavity 347 (75.6%) e p Z 0.030), post-operative bleeding (OR Z 12.80,
Scalp/face 49 (10.7%) e p < 0.001) and post-operative flap circulation problems
Pharynx 33 (7.2%) e (OR Z 17.80, p < 0.001) were independent risk factors.
Midface 30 (6.5%) e
Tumour type Independent risk factors for free flap loss in head
SCC 354 (77.1%) e and neck reconstruction
BCC 20 (4.4%) e
Sarcoma 10 (2.2%) e
After head and neck reconstruction, 25 flaps (4.6%) showed
Blastoma 7 (1.5%) e
partial flap loss and 35 (6.4%) total flap loss. The results of
ORN 48 (10.5%) e
the univariate analyses are listed in Table 7. Subsequently,
Other 20 (4.3%) e
the multivariate regression analysis showed that pulmonary
- Breast 458 (36.7%) e
co-morbidity (OR Z 4.74, p Z 0.007) and anastomosis to
Unilateral 288 (62.8%) e
the lingual vein (OR Z 7.17, p Z 0.036) were independent
Bilateral 170 (37.2%) e
risk factors for partial flap loss. The use of a radial forearm
Trauma 330 (26.5) e
flap, however, was a protective factor (OR Z 0.24,
Lower extremity 242 (73.3) e
p Z 0.029) for partial flap loss. Anastomosis to the super-
Upper extremity 88 (26.7) e
ficial temporal artery (OR Z 4.4, p Z 0.001) and post-
MV: missing value. SCC: squamous cell carcinoma. BCC: basal operative flap circulation problems (OR Z 11.23,
cell carcinoma. ORN: osteoradionecrosis.
a
p < 0.001) remained independent risk factors for total flap
Smoking at the time of operation. loss.
b
Tamoxifen use was only scored for all 458 breast recon-
struction patients.
Independent risk factors for free flap loss in post-
traumatic extremity reconstruction
radiotherapy (odds ratio (OR) Z 2.88, p Z 0.006), intra-
operative revision of venous anastomosis (OR Z 5.75, Partial flap loss occurred 27 times (7.7%) and total flap loss
p Z 0.001) and post-operative flap circulation problems 21 times (6.0%) after post-traumatic extremity recon-
(OR Z 4.94, p Z 0.002) remained independent risk factors struction. Of the 25 flaps used within 24 h following trauma,
after multivariate regression analysis. For total flap loss, six (24%) had partial or total flap failure, 14% (6 of 43)
898 D.E. Las et al.

Table 3 Operation characteristics per indication (N Z 1530 free flaps).

Breast (%) N Z 631 MV Head & neck (%) N Z 548 MV Trauma (%) N Z 351 MV
Operation time (mean  SD) 9:20  2:42 e 10:27  3:11 e 10:09  3:52 e
Two simultaneous flaps 170 (26.9) e 80 (14.6) e 16 (4.5) e
Arterial anastomosis 3 46 52
ETE 628 (100) 481 (95.8) 138 (46.2)
ETS 0 (0.0) 21 (4.2) 161 (53.8)
Venous anastomosis 2 49 49
ETE 611 (97.1) 357 (71.5) 256 (84.8)
ETS 18 (2.9) 142 (28.5) 46 (15.2)
Multiple venous anastomoses 71 (11.3) 4 46 (9.2) 50 43 (13.5) 32
Vascular graft 9 (1.4) 2 17 (3.4) 41 34 (10.6) 30
Revision arterial anastomosis 34 (5.4) 4 41 (8.2) 46 30 (9.4) 32
Revision venous anastomosis 27 (4.3) 4 16 (2.9) 46 34 (10.7) 32
Innervated flap 0 (0.0) e 15 (2.7) e 50 (14.2) e
Nerve graft 0 (0.0) e 6 (1.1) e 8 (2.3) e
Trunk
Recipient artery 1
Internal mammary 624 (99.0)
Thoracodorsal 5 (0.8)
Thoracoacromial 1 (0.2)
Recipient vein 2
Internal mammary 612 (97.3)
Thoracodorsal 5 (0.8)
Thoracoacromial 1 (0.2)
Cephalic 11 (1.7)
Head and neck
Recipient artery 58
Superior thyroid 227 (46.3)
Facial 146 (29.8)
Superficial temporal 56 (11.4)
External carotid 32 (6.5)
Lingual 26 (5.3)
Other 3 (0.6)
Recipient vein 49
Internal jugular 142 (28.5)
Facial 68 (13.6)
Superficial temporal 52 (10.4)
External jugular 49 (9.8)
Superior thyroid 43 (8.6)
Lingual 6 (1.2)
Anonymous side branch 139 (27.9)
Lower extremity
Recipient artery e
Posterior tibial 137 (56.6)
Anterior tibial 56 (23.1)
Dorsal pedis 13 (5.3)
Superficial femoral 12 (5.0)
Popliteal 12 (5.0)
Peroneal 5 (2.1)
Other 7 (2.9)
Recipient vein e
Posterior tibial 128 (52.9)
Anterior tibial 51 (21.1)
Greater saphenous 18 (7.4)
Dorsal pedis 12 (5.0)
Superficial femoral 12 (5.0)
Popliteal 12 (5.0)
Peroneal 4 (1.7)
Other 5 (2.1)
Identification of independent risk factors for flap failure 899

Table 3 (continued )
Breast (%) N Z 631 MV Head & neck (%) N Z 548 MV Trauma (%) N Z 351 MV
Upper extremity
Recipient artery 13
Radial 46 (61.3)
Ulnar 18 (24.0)
Brachial 6 (8.0)
Other 5 (6.7)
Recipient vein 13
Cephalic 28 (37.3)
Concomitant radial 20 (26)
Concomitant ulnar 13 (17.3)
Brachial 6 (8.0)
Basilic 3 (4.0)
Other 5 (6.7)
MV: Missing value. ETE: end-to-end anastomosis. ETS: end-to-side anastomosis.

between days 1 and 7, 18% (11 of 85) between 1 and 6
weeks and 12.6% (25 of 198) after 6 weeks. There was no
statistically significant correlation between the time from
trauma to surgery and flap failure (p Z 0.291).
Table 8 summarises all significant risk factors for flap
loss after univariate analyses. After multivariate analysis,
the remaining independent risk factors for partial flap loss
were post-operative wound infection (OR Z 6.32,
p Z 0.005) and flap circulation problems (OR Z 3.60,
p Z 0.015). For total flap loss, diabetes mellitus
(OR Z 9.16, p Z 0.019) and a total anaesthesia time
exceeding 10 h (OR Z 6.49, p Z 0.005) remained inde-
pendent risk factors.
Discussion
Free vascularised tissue transfer has become a reliable,
effective surgical technique for treating complex defects.
To better understand the risk factors for partial and total
free flap failure, the pre-, intra- and post-operative vari-
ables were studied. In the current series of 1530 free flaps,
partial flap loss occurred in 5.5% and total flap loss in 4.4%.
Previous large microvascular breast reconstruction se-
ries reported partial flap loss in 1.6e0.6%12e14,18e22 and
total flap loss in 0.3e2.9%.14,18e25 This is similar to our re-
sults with 5.1% partial flap loss and 1.7% total flap loss. This
considerable difference between partial and total flap loss
indicates that these complications arose from different
sources. Total flap loss generally occurs after failure of the
anastomosis, which is relatively rare, whereas partial flap
loss usually is the result of an insufficient flap microcircu-
lation. This can occur after a very large part of Holm’s zone
III or IV of a DIEP or ms-TRAM flap was included,26 after an
additional venous anastomosis failed to treat intra-
operative venous congestion or after the dominant perfo-
rator(s) could not be selected.27
Our results in head and neck reconstruction (4.6% partial
and 6.4% total flap loss) are comparable to other large se-
ries, with partial flap loss rates of 1.0e7.7%2,7e10,27,28 and

Table 4 Salvage success rate of compromised flaps.

Reconstruction Compromised Salvage attempted (%) Salvage success (%) Partial flap failure (%) Total flap failure (%)
flap circulation
Breast 35 35 (100) 23 (63.8) 6 (17.1) 6 (17.1)
Head and neck 30 29 (96.7) 16 (55.1) 2 (6.7) 11 (36.6)
Trauma 37 36 (97.3) 24 (66.6) 6 (16.7) 6 (16.7)
Total 102 100 (98.0) 63 (61.8) 14 (13.7) 23 (22.5)

Table 5 Postoperative free flap complications leading to re-operation.

Total (%) N Z 1530 Breast (%) N Z 631 Head & neck (%) N Z 548 Trauma (%) N Z 351
Hematoma 103 (6.7) 48 (7.6) 45 (8.2) 10 (2.8)
Wound infection 47 (3.1) 8 (1.3) 24 (4.4) 15 (4.3)
Compromised flap circulation 102 (6.7) 35 (5.5) 30 (5.5) 37 (10.5)
Partial flap loss 84 (5.5) 32 (5.1) 25 (4.6) 27 (7.9)
Total flap loss 67 (4.4) 11 (1.7) 35 (6.4) 27 (7.9)
900 D.E. Las et al.

Table 6 Univariate analyses of statistically significant risk factors for flap loss in breast reconstruction (N Z 631).
Variable Total (%) Partial flap loss N Z 32 Total flap loss N Z 11
N (%) p-value N (%) p-value
Previous radiotherapy
- Yes 156 (24.7) 14 (9.0) 0.010
- No 475 (75.3) 18 (3.8)
Previous chemotherapy
- Yes 235 (37.2) 17 (7.2) 0.056
- No 396 (62.8) 15 (3.8)
Laterality
- Bilateral 340 (53.9) 12 (3.5) 0.056
- Unilateral 291 (46.1) 20 (6.9)
Revision of venous anastomosisa
- Yes 27 (4.3) 5 (18.5) 0.009
- No 600 (95.7) 27 (4.5)
DIEP flap
- Yes 539 (85.4) 7 (1.3) 0.060
- No 92 (14.6) 4 (4.3)
SGAP/IGAP flap
- Yes 18 (2.8) 3 (16.7) 0.003
- No 613 (97.2) 8 (1.3)
Internal mammary veina
- Yes 612 (97.3) 29 (4.7) 0.050
- No 17 (2.7) 3 (17.6)
Postoperative hematoma
- Yes 48 (7.6) 6 (12.5) 0.028 6 (12.5) <0.001
- No 583 (92.4) 26 (4.4) 5 (0.8)
Compromised flap circulation
- Yes 35 (5.6) 6 (17.1) 0.006 6 (17.1) <0.001
- No 596 (94.4) 26 (4.4) 5 (0.8)
DIEP: deep inferior epigastric artery perforator. SGAP: superior gluteal artery perforator.
IGAP: inferior gluteal artery perforator.
a
Sum of total is not 631 because of missing values.

total flap loss rates of 1.0e15.0%.2e10 However, the higher
flap failure rates were only reported in the smaller and
older series.
The total flap failure (6.0%) after post-traumatic ex-
tremity reconstruction is also in line with the reported per-
centages in the literature (3.2%e8.5%),15e17,29 but partial
flap loss was encountered less often (7.9%) than in the only
previous study that reported partial flap failure (12.7%).17
breast reconstruction. This could compromise the micro-
circulation of the partially buried flap, which may explain
the higher partial flap loss rate after previous radiotherapy
in our series. Therefore, it is important to resect all sub-
cutaneous fibrotic tissues from the elevated mastectomy
skin flap. When the skin flap remains tight, a back-cut must
be made laterally to minimise pressure on the buried part
of the abdominal flap.

Risk factors for free flap failure in breast Microsurgical revision

reconstruction
Intraoperative revision of the venous anastomosis
Radiotherapy increased the risk of partial flap failure in breast recon-
struction (OR Z 5.75). This increases ischaemia time,
which can be attributed to the post-ischaemia reperfusion
Previous radiotherapy increased the risk of partial flap loss
injury and, consequently, to partial necrosis. This may also
(OR Z 2.88), but not of total flap loss. In a series of 363 free
be due to the correlation between intraoperative vascular
flaps by Chang et al.,23 106 free flaps received preoperative
problems and post-operative venous thrombosis, which
and 45 post-operative radiotherapy. No significant differ-
could lead to partial flap loss, as was previously found by
ence in total flap failure was found between the two
Fosnot et al.31
groups, which confirmed our finding. Thus, preoperative
radiotherapy does not seem to affect the patency of the
anastomosis in microvascular breast reconstruction.30 Flap type
However, preoperative radiotherapy may tighten the
skin of the chest wall, which is used to cover the cranial, The use of superior gluteal artery perforator (SGAP) and
de-epithelialised part of the flap in delayed microvascular inferior gluteal artery perforator (IGAP) flaps led to an
Identification of independent risk factors for flap failure 901

Table 7 Univariate analyses of statistically significant risk factors for flap loss in head and neck reconstruction (N Z 548).
Variable Total (%) Partial flap loss N Z 25 Total flap loss N Z 35
N (%) p-value N (%) p-value
Pulmonary disease
-Yes 41 (7.5) 5 (14.6) 0.032
- No 507 (92.5) 20 (3.9)
Oral cavity
- Yes 423 (77.2) 15 (3.5) 0.036
- No 125 (22.8) 10 (8.0)
Midface
- Yes 35 (6.4) 4 (11.4) 0.067 5 (14.3) 0.063
- No 513 (93.6) 21 (4.1) 30 (5.8)
Revision of arterial anastomosisa
- Yes 41 (8.2) 5 (12.2) 0.038
- No 461 (91.8) 19 (4.5)
Radial forearm flap
- Yes 189 (34.5) 3 (1.6) 0.015
- No 359 (65.5) 22 (6.1)
Superior thyroid arterya
- Yes 227 (46.3) 8 (3.5) 0.026
- No 263 (53.7) 22 (8.4)
Facial arterya
- Yes 146 (29.8) 3 (2.0) 0.074
- No 344 (70.2) 20 (5.8)
Superficial temporal arterya
- Yes 56 (11.4) 9 (16.1) 0.004
- No 434 (88.6) 21 (4.8)
Extern carotid arterya
- Yes 32 (6.5) 4 (12.5) 0.055
- No 458 (93.5) 19 (4.1)
Superficial temporal veina
- Yes 52 (10.5) 8 (15.4) 0.008
- No 443 (89.5) 22 (5.0)
Lingual veina
- Yes 6 (1.2) 2 (33.3) 0.028
- No 489 (98.8) 21 (4.3)
Compromised flap circulation
- Yes 30 (5.5) 11 (36.7) <.001
- No 518 (94.5) 24 (4.6)
a
Sum of total is not 548 because of missing values.

increased risk of flap failure in our series (OR Z 9.08).
Fischer et al. found this risk in a series of 1303 free flaps
(OR Z 1.44, p Z 0.024).11 In our series, GAP flaps were
infrequently used (2.9%) and were usually chosen when
DIEP or ms-TRAM flaps were not feasible or had previously
failed. An unfavourable relationship between the short
pedicle length and thickness of the GAP flap could produce
excessive traction on the anastomosis, leading to throm-
bosis and flap failure. To ensure adequate pedicle length,
perforator dissection of a GAP flap deep to the gluteal
fascia is laborious and time consuming, due to extensive
branching and the presence of thin-walled veins.32 The
short pedicle length may be compensated for by dissecting
the internal mammary vessels more distally after removing
the cartilage of the caudal rib.
The higher total GAP flap losses in the present series may
also be explained by the lack of a preoperative CTA scan of
the donor site for the majority of these flaps, which
increased the risk of failure to select the best perforator.
Presently, all patients who are scheduled for a free perfo-
rator flap breast reconstruction at our centre receive a CTA
scan of the donor site for imaging of the perforators.
Post-operative haematoma
In the present study, post-operative haematoma appeared
to be a major (OR Z 12.80) risk factor for total flap loss in
breast reconstruction. Venous congestion due to venous
thrombosis or insufficient venous drainage may sometimes
be the cause of persistent bleeding post-operatively. The
resulting haematoma in its turn compresses the anasto-
mosis as well as the flap, further compromising flap
circulation.
Haemostasis must be achieved carefully before closing
the skin envelope; however, post-operative haematoma
902 D.E. Las et al.

Table 8 Univariate analyses of statistically significant risk factors for flap loss in posttraumatic extremity reconstruction
(N Z 351).
Variable Total (%) Partial flap loss N Z 27 Total flap loss N Z 21
N (%) p-value N (%) p-value
Diabetesa
- Yes 8 (2.3) 2 (25.0) 0.074
- No 315 (89.7) 17 (5.4)
Hypertensiona
- Yes 25 (7.1) 4 (16.0) 0.057
- No 299 (85.2) 16 (5.3)
Insulina
- Yes 1 (0.3) 1 (100.0) 0.063
- No 323 (92.0) 19 (5.9)
Two simultaneous flaps
- Yes 16 (4.5) 3 (18.7) 0.073
- No 335 (95.4) 18 (5.4)
Total anaesthesia time
- < 10 h 187 (53.3) 5 (2.7) 0.005
- > 10 h 164 (46.7) 16 (9.7)
Revision of arterial anastomosisa
- Yes 30 (9.4) 5 (16.7) 0.011
- No 289 (80.6) 11 (3.8)
Revision of venous anastomosisa
- Yes 34 (10.7) 4 (11.7) 0.078
- No 285 (89.3) 12 (4.2)
Vascular grafta
- Yes 34 (10.6) 5 (14.7) 0.024
- No 287 (89.4) 12 (4.2)
Latissimus dorsi flap
- Yes 104 (29.6) 13 (12.5) 0.046
- No 247 (70.4) 14 (5.7)
Fibula flap
- Yes 9 (2.8) 2 (22.2) 0.095
- No 342 (97.6) 19 (5.6)
Greater saphenous veina
- Yes 18 (5.7) 4 (22.2) 0.043 3 (16.7) 0.046
- No 299 (85.2) 21 (7.0) 12 (4.0)
Postoperative infection
- Yes 15 (4.3) 4 (26.7) 0.021
- No 336 (95.7) 23 (6.8)
Compromised flap circulation
- Yes 37 (10.5) 6 (16.2) 0.051 6 (16.2) 0.015
- No 314 (89.5) 21 (6.7) 15 (4.8)
a
Sum of total is not 351 because of missing values.

may be an early sign of venous outflow problems, and thus
early re-exploration is recommended. This is all the more
important if intraoperative heparin is used, as this was
previously shown to significantly increase the risk of
bleeding and haematoma.33
Risk factors for free flap failure in head and
neck reconstruction
Co-morbidity
Patients with pulmonary co-morbidity showed a 4.7 times
higher risk of partial flap loss. Although pulmonary co-
morbidity remained an independent risk factor after
multivariate regression analysis, we assume that this
finding is confounded by long-term tobacco use. The
smoking history of current nonsmokers was not consid-
ered in our study. Seidenstuecker et al.12 concluded from
a review of previous studies that active smoking 1) ele-
vates platelet count, increasing the risk of thrombosis; 2)
activates the sympathetic nervous system, causing vaso-
constriction; and 3) causes hypoxia, due to binding of
carbon monoxide to haemoglobin. All three pathways
could compromise flap circulation. This could also be
caused by the lower O2 saturation levels in chronic
obstructive pulmonary disease (COPD) patients, due to
exacerbation or airway infections. This leads to
Identification of independent risk factors for flap failure
decreased oxygenation of the flap, ultimately resulting in
partial flap failure.
Radiotherapy
The effect of preoperative radiotherapy on increasing the
risk of flap failure in microvascular head and neck recon-
struction is debatable. In our study, 147 patients with head
and neck cancer (26.8%) received preoperative radio-
therapy, which was not linked to the incidence of flap
failure. These results corroborate the findings of previous
studies.3,4,8,34,35 However, other studies did show a signifi-
cant correlation between preoperative radiotherapy and an
increased risk of flap failure, specifically in delayed re-
constructions and at total doses exceeding 60Gy.6,36,37 To
reduce the risk of post-operative microsurgical complica-
tions, we also believe it is important to choose recipient
vessels outside the radiated field, such as from the
contralateral neck, the transverse cervical, thor-
acoacromial or internal mammary vessels.38
Flap type
The use of a radial forearm flap led to a lower risk of partial
flap failure (OR Z 0.24). The radial forearm flap was the
second most commonly used free flap in head and neck
(34.5%) reconstructions. In other series, the radial forearm
flap accounted for 13.7e69.0% of the free flaps
used.1,2,4,5,7e10,27,28,34,39e41 In a series of 2372 free flaps for
head and neck reconstruction, Nakatsuka et al.10 showed a
significantly better flap survival rate for their three con-
ventional free flaps (radial forearm, rectus abdominis and
jejunum flap). In addition, Pholenz et al.41 and Eckardt
et al.34 chose the radial forearm flap for reconstruction of
intra-oral defects, because of its high vascularity and thin
and pliable tissue. Thus, the free flap is easy to dissect and
its long and large-calibre vessels obviate the need for vein
grafts.
Recipient vessels
Anastomosis to the lingual vein increased the risk of partial
flap failure (OR Z 7.17) in head and neck surgery. Two
partial flap losses occurred after the use of the lingual vein
in six cases. In these cases, the lingual vein was the final
option for a local recipient vein without the use of vein
grafts after intraoperative failure of the anastomosis to the
facial and/or external jugular vein. Anastomosis to the
lingual vein may be rather difficult, especially with an
operating microscope, due to its cranial position under the
mandible.
Free flaps anastomosed to the superficial temporal ar-
tery had a 4.4 greater risk of total flap necrosis. Although
this artery is easily accessible because of its superficial
location, its diameter may be insufficient and it may easily
develop vasospasm. For scalp reconstruction, however, we
prefer superficial temporal vessels as recipient vessels,
because of their proximity. To prevent insufficient flow,
these vessels must be dissected further proximal into the
parotid gland in front of the tragus, where their calibre in
general is large.42
903
Risk factors for free flap failure in post-
traumatic extremity reconstruction
Diabetes mellitus
Diabetes was a significant risk factor for total flap loss
(OR Z 9.16) in post-traumatic extremity reconstruction.
Interestingly, this could not be found in previous studies on
post-traumatic extremity reconstruction,16,17,45 although it
has been reported in studies on microsurgical breast and
head and neck reconstruction.1,46 Not all patients with
diabetes may be at an increased risk of flap failure, except
those with atherosclerosis and/or renal impairment.47
Anaesthesia time
Anaesthesia time exceeding 10 h was associated with a
higher risk of total flap loss (OR Z 6.49). Prolonged
anaesthesia time was previously found to double the risk of
flap failure.45 This likely indicates increased intraoperative
difficulties, such as difficult recipient-site vessel dissection,
the need for venous interposition grafts or revision of an
anastomosis.
Wound infection
Post-operative wound infections were associated with
partial flap loss (OR Z 6.32). Post-operative wound in-
fections, which more often occur in post-traumatic,
contaminated wounds, may provoke venous stasis and
subsequent thrombosis. Alternatively, partial flap failure
itself may also be the cause of a local wound infection.
Wound infections should be limited by radical debridement
and appropriate antibiotics based on positive cultures.
Post-operative signs of compromised flap
circulation
Post-operative signs of compromised flap circulation were a
significant risk factor for flap loss in breast, head and neck
and post-traumatic extremity reconstruction. Bui et al.
studied post-operative complications in 1193 free flaps and
concluded that the timing of re-exploration of compro-
mised flaps has a significant effect on the flap salvage
rates.49 In our series, approximately 60% of the compro-
mised flaps were salvaged after reoperation, which is in line
with the previously reported series.49,50 Therefore, we
advocate early re-exploration of compromised flaps, to
determine a treatable cause, such as microvascular
thrombosis or kinking of the pedicle. If no cause can be
found, it suggests an intrinsic vascularisation problem of
the flap; even in the case of early exploration, partial or
total flap failure may be inevitable.
Methodological considerations
The weakness of the present paper is its retrospective
design, which resulted in missing data of several cases.
Furthermore, over the past 20 years, multiple
904
microsurgeons have performed the procedures in this study,
all with varying experience. This may have influenced the
results, specifically during the first years of the current
series when reconstruction with only few free flaps was
performed annually by fully trained plastic surgeons with
presumably limited microsurgical experience. The learning
curve of microsurgeons has been demonstrated several
times, specifically in older studies.51e54 However, in 1997,
Blackwell et al. already showed that surgeons with
adequate microsurgical training obtain good results even
within their first year of clinical experience, comparable
with results reported by experienced microvascular sur-
geons.55 In addition, Kreymerman et al. did not find a
correlation between the surgeon’s years of experience and
the outcomes measured (anastomotic failure, flap loss or
haematoma) for three young microsurgeons at a single
institution during their first 8 years in clinical practice.56
These young microsurgeons were exposed to microsurgery
during plastic surgery training at many programs, similar to
ours; consequently, residents often have already surpassed
the learning curve.
A microsurgical skills laboratory has been in operation at
our institution since 1976, and microsurgery courses have
been organised twice a year since the early 1970s. Since
then, all residents and reconstructive microsurgeons have
completed the microsurgery course during their training
and have had the opportunity to practice and improve their
microsurgical skills in the laboratory regularly. In addition,
with the increasing microsurgical experience and expertise
at our institution, less experienced surgeons are supervised
by their more experienced seniors. Therefore, we assume
that the correlation between surgeon experience and flap
failure might have been present only in the first years of the
present series. Unfortunately, we do not have the data to
prove this assumption, because the years of surgeon
experience could not be retrieved from the patient files.
Variables that could have been influenced by limited
microsurgical experience are flap choice, recipient vessel
choice and total anaesthesia time. Finally, the increase in
microsurgical experience and expertise at our unit during
the later years could have reduced the flap failure rates.
However, based on the flap failure rates over the past 20
years, the rates have not changed significantly, despite the
increasing number of patients and experience gained. This
may have been caused by the more complex case mix we
have been operating during recent years.
Conclusions
The present series confirms that microvascular breast, head
and neck and extremity reconstructions are reliable and
safe with relatively low flap failure rates. For all types of
reconstruction, we recommend early exploration for signs
of compromised flap circulation, because flap failure could
be prevented in 62% of these cases.
In the case of microvascular breast reconstruction after
previous radiotherapy, it is important to resect all subcu-
taneous fibrotic tissue from the elevated mastectomy skin
flap. When the skin flap remains tight, a back-cut must be
made laterally, to minimise pressure on the buried part of
the abdominal flap. It is hoped that this technique will
D.E. Las et al.
reduce the risk of partial flap failure. In patients undergo-
ing breast reconstruction with GAP flaps, we recommend
additional counselling of patients regarding the increased
risk of flap failure following these less common, difficult
perforator flap reconstructions.
In head and neck reconstruction, anastomosis to the
lingual vein or superficial temporal artery should be avoi-
ded whenever possible. The free radial forearm flap re-
mains one of the safest options for reconstruction and thus
the free flap of choice when a thin flap is indicated.
In post-traumatic extremity reconstruction, the timing
of free flap transfer did not seem to affect the risk of flap
failure. Hill et al. obtained similar findings,57 thus refuting
the effect of timing on flap survival. Furthermore, post-
operative wound infections should be avoided by radical
debridement and use of appropriate antibiotics based on
positive cultures.
Our results may be used to improve patient counselling
and treatment algorithms, to ultimately reduce free flap
failure rates.
Conflict of interest
This study was not supported by any external sources or
funds. The authors have no financial interest in any medical
device, product or procedure mentioned in this article.
References
1. Valentini V, Cassoni A, Marianetti TM, et al. Diabetes as main
risk factor in head and neck reconstructive surgery with free
flaps. J Craniofac Surg 2008 Jul;19(4):1080e4.
2. Frederick JW, Sweeny L, Carroll WR, Peters GE, Rosenthal EL.
Outcomes in head and neck reconstruction by surgical site and
donor site. Laryngoscope 2013 Jul;123(7):1612e7.
3. Yu P, Chang DW, Miller MJ, Reece G, Robb GL. Analysis of 49
cases of flap compromise in 1310 free flaps for head and neck
reconstruction. Head Neck 2009 Jan;31(1):45e51.
4. Bozikov K, Arnez ZM. Factors predicting free flap complications
in head and neck reconstruction. J Plast Reconstr Aesthet Surg
2006;59(7):737e42.
5. Vandersteen C, Dassonville O, Chamorey E, et al. Impact of
patient comorbidities on head and neck microvascular recon-
struction. A report on 423 cases. Eur Arch Otorhinolaryngol
2013 May;270(5):1741e6.
6. Benatar MJ, Dassonville O, Chamorey E, et al. Impact of pre-
operative radiotherapy on head and neck free flap recon-
struction: a report on 429 cases. J Plast Reconstr Aesthet Surg
2013 Apr;66(4):478e82.
7. Suh JD, Sercarz JA, Abemayor E, et al. Analysis of outcome and
complications in 400 cases of microvascular head and neck
reconstruction. Arch Otolaryngol Head Neck Surg 2004 Aug;
130(8):962e6.
8. Dassonville O, Poissonnet G, Chamorey E, et al. Head and neck
reconstruction with free flaps: a report on 213 cases. Eur Arch
Otorhinolaryngol 2008 Jan;265(1):85e95.
9. le Nobel GJ, Higgins KM, Enepekides DJ. Predictors of compli-
cations of free flap reconstruction in head and neck surgery:
analysis of 304 free flap reconstruction procedures. Laryngo-
scope 2012 May;122(5):1014e9.
10. Nakatsuka T, Harii K, Asato H, et al. Analytic review of 2372
free flap transfers for head and neck reconstruction following
cancer resection. J Reconstr Microsurg 2003 Aug;19(6):363e8.
Identification of independent risk factors for flap failure
11. Fischer JP, Sieber B, Nelson JA, et al. Comprehensive outcome
and cost analysis of free tissue transfer for breast recon-
struction: an experience with 1303 flaps. Plast Reconstr Surg
2013 Feb;131(2):195e203.
12. Seidenstuecker K, Munder B, Mahajan AL, Richrath P,
Behrendt P, Andree C. Morbidity of microsurgical breast
reconstruction in patients with comorbid conditions. Plast
Reconstr Surg 2011 Mar;127(3):1086e92.
13. Vega S, Smartt Jr JM, Jiang S, et al. 500 Consecutive patients
with free TRAM flap breast reconstruction: a single surgeon’s
experience. Plast Reconstr Surg 2008 Aug;122(2):329e39.
14. Andree C, Langer S, Seidenstuecker K, et al. A single center
prospective study of bilateral breast reconstruction with free
abdominal flaps: a critical analyses of 144 patients. Med Sci
Monit 2013;19:467e74.
15. ATt Culliford, Spector J, Blank A, Karp NS, Kasabian A,
Levine JP. The fate of lower extremities with failed free flaps:
a single institution’s experience over 25 years. Ann Plast Surg
2007 Jul;59(1):18e21. discussion-2.
16. Lorenzo AR, Lin CH, Lin CH, et al. Selection of the recipient
vein in microvascular flap reconstruction of the lower ex-
tremity: analysis of 362 free-tissue transfers. J Plast Reconst
Aesthet Surg 2011 May;64(5):649e55.
17. Wettstein R, Schurch R, Banic A, Erni D, Harder Y. Review of
197 consecutive free flap reconstructions in the lower ex-
tremity. J Plast Reconst Aesthet Surg 2008 Jul;61(7):772e6.
18. Hofer SO, Damen TH, Mureau MA, Rakhorst HA, Roche NA. A
critical review of perioperative complications in 175 free deep
inferior epigastric perforator flap breast reconstructions. Ann
Plast Surg 2007 Aug;59(2):137e42.
19. Damen TH, Morritt AN, Zhong T, Ahmad J, Hofer SO. Improving
outcomes in microsurgical breast reconstruction: lessons learnt
from 406 consecutive DIEP/TRAM flaps performed by a single
surgeon. J Plast Reconst Aesthet Surg 2013 Aug;66(8):1032e8.
20. Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A single
center comparison of one versus two venous anastomoses in
564 consecutive DIEP flaps: investigating the effect on venous
congestion and flap survival. Microsurgery 2010;30(3):185e91.
21. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective re-
view of 758 DIEP flaps for breast reconstruction. Plast Reconstr
Surg 2004 Apr 1;113(4):1153e60.
22. Langer S, Munder B, Seidenstuecker K, et al. Development of a
surgical algorithm and optimized management of complica-
tions - based on a review of 706 abdominal free flaps for breast
reconstruction. Med Sci Monit 2010 Nov;16(11):Cr518e22.
23. Chang EI, Liu TS, Festekjian JH, Da Lio AL, Crisera CA. Effects
of radiation therapy for breast cancer based on type of free
flap reconstruction. Plast Reconstr Surg 2013 Jan;131(1):
1ee8e.
24. Hamdi M, Andrades P, Thiessen F, et al. Is a second free flap
still an option in a failed free flap breast reconstruction? Plast
Reconstr Surg 2010 Aug;126(2):375e84.
25. Saint-Cyr M, Youssef A, Bae HW, Robb GL, Chang DW. Changing
trends in recipient vessel selection for microvascular autolo-
gous breast reconstruction: an analysis of 1483 consecutive
cases. Plast Reconstr Surg 2007 Jun;119(7):1993e2000.
26. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant
medial row perforator DIEP flap in breast reconstruction:
three-dimensional perforasome and clinical results. Plast
Reconstr Surg 2010 Sep;126(3):739e51.
27. Patel RS, McCluskey SA, Goldstein DP, et al. Clinicopathologic
and therapeutic risk factors for perioperative complications
and prolonged hospital stay in free flap reconstruction of the
head and neck. Head Neck 2010 Oct;32(10):1345e53.
28. Pohlenz P, Klatt J, Schon G, Blessmann M, Li L, Schmelzle R.
Microvascular free flaps in head and neck surgery: complica-
tions and outcome of 1000 flaps. Int J Oral Maxillofac Surg
2012 Jun;41(6):739e43.
905
29. Spector JA, Levine S, Levine JP. Free tissue transfer to the
lower extremity distal to the zone of injury: indications and
outcomes over a 25-year experience. Plast Reconstr Surg 2007
Sep 15;120(4):952e9.
30. Momoh AO, Colakoglu S, de Blacam C, Gautam S, Tobias AM,
Lee BT. Delayed autologous breast reconstruction after post-
mastectomy radiation therapy: is there an optimal time? Ann
Plast Surg 2012 Jul;69(1):14e8.
31. Fosnot J, Jandali S, Low DW, Kovach 3rd SJ, Wu LC, Serletti JM.
Closer to an understanding of fate: the role of vascular com-
plications in free flap breast reconstruction. Plast Reconstr
Surg 2011 Oct;128(4):835e43.
32. Baumeister S, Werdin F, Peek A. The sGAP flap: rare exception
or second choice in autologous breast reconstruction? J
Reconstr Microsurg 2010 May;26(4):251e8.
33. Chen CM, Ashjian P, Disa JJ, Cordeiro PG, Pusic AL, Mehrara BJ.
Is the use of intraoperative heparin safe? Plast Reconstr Surg
2008 Mar;121(3):49ee53e.
34. Eckardt A, Meyer A, Laas U, Hausamen JE. Reconstruction of
defects in the head and neck with free flaps: 20 years expe-
rience. Br J Oral Maxillofac Surg 2007 Jan;45(1):11e5.
35. Tan NC, Lin PY, Chiang YC, et al. Influence of neck dissection
and preoperative irradiation on microvascular head and neck
reconstruction-Analysis of 853 cases. Microsurgery 2014 Nov;
34(8):602e7.
36. Herle P, Shukla L, Morrison WA, Shayan R. Preoperative radia-
tion and free flap outcomes for head and neck reconstruction:
a systematic review and meta-analysis. ANZ J Surg 2015 Mar;
85(3):121e7.
37. Tall J, Bjorklund TC, Skogh AC, Arnander C, Halle M. Vascular
complications after radiotherapy in head and neck free flap
reconstruction: clinical outcome related to vascular biology.
Ann Plast Surg 2015 Sep;75(3):309e15.
38. Krijgh DD, Mureau MA. Reconstructive options in patients with
late complications after surgery and radiotherapy for head and
neck cancer: remember the deltopectoral flap. Ann Plast Surg
2013 Aug;71(2):181e5.
39. Halvorson EG, Cordeiro PG. Go for the jugular: a 10-year
experience with end-to-side anastomosis to the internal ju-
gular vein in 320 head and neck free flaps. Ann Plast Surg 2007
Jul;59(1):31e5. discussion 5.
40. Klug C, Berzaczy D, Reinbacher H, et al. Influence of previous
radiotherapy on free tissue transfer in the head and neck re-
gion: evaluation of 455 cases. Laryngoscope 2006 Jul;116(7):
1162e7.
41. Pohlenz P, Blessmann M, Blake F, Li L, Schmelzle R, Heiland M.
Outcome and complications of 540 microvascular free flaps:
the Hamburg experience. Clin Oral Investig 2007 Mar;11(1):
89e92.
42. van Driel AA, Mureau MA, Goldstein DP, et al. Aesthetic and
oncologic outcome after microsurgical reconstruction of com-
plex scalp and forehead defects after malignant tumor resec-
tion: an algorithm for treatment. Plast Reconstr Surg 2010 Aug;
126(2):460e70.
45. Wong AK, Joanna Nguyen T, Peric M, et al. Analysis of risk factors
associated with microvascular free flap failure using a multi-
institutional database. Microsurgery 2015 Jan;35(1):6e12.
46. Miller RB, Reece G, Kroll SS, et al. Microvascular breast
reconstruction in the diabetic patient. Plast Reconstr Surg
2007 Jan;119(1):38e45. discussion 6e8.
47. Kim BK, Lee YK, Park KY, et al. Analysis of multiple risk factors
affecting the result of free flap transfer for necrotising soft
tissue defects of the lower extremities in patients with type 2
diabetes mellitus. J Plast Reconst Aesthet Surg 2014 May;
67(5):624e8.
49. Bui DT, Cordeiro PG, Hu QY, Disa JJ, Pusic A, Mehrara BJ. Free
flap reexploration: indications, treatment, and outcomes in
1193 free flaps. Plast Reconstr Surg 2007 Jun;119(7):2092e100.
906
50. Wu CC, Lin PY, Chew KY, Kuo YR. Free tissue transfers in head
and neck reconstruction: complications, outcomes and stra-
tegies for management of flap failure: analysis of 2019 flaps in
single institute. Microsurgery 2014 Jul;34(5):339e44.
51. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstr Surg 1986;78:285e92.
52. Khouri RK. Avoiding free flap failure. Clin Plast Surg 1992;19:
773e81.
53. Schusterman MA, Miller MJ, Reece GP, Kroll SS, Marchi M,
Goepfert H. A single center’s experience with 308 free flaps for
repair of head and neck cancer defects. Plast Reconstr Surg
1994;93:472e8. discussion 479e480.
54. Urken ML, Weinberg H, Buchbinder D, et al. Microvascular free
flaps in head and neck reconstruction. Report of 200 cases and
D.E. Las et al.
review of complications. Arch Otolaryngol Head Neck Surg
1994;120:633e40.
55. Blackwell KE, Brown MT, Gonzalez D. Overcoming the learning
curve in microvascular head and neck reconstruction. Arch
Otolaryngol Head Neck Surg 1997;123:1332e5.
56. Kreymerman P, Silverman AL, Rebecca AM, Casey WJ. Contra-
dicting an established mantra: microsurgeon experience de-
termines free flap outcome. Plast Reconstr Surg 2012;130:
507ee12e.
57. Hill JB, Vogel JE, Sexton KW, Guillamondegui OD, Corral GA,
Shack RB. Re-evaluating the paradigm of early free flap
coverage in lower extremity trauma. Microsurgery 2013 Jan;
33(1):9e13.