Factors Influencing Free Flap Management

Abstract

Sir: We read with interest Dr. Nahabedian's discussion of “A Comparison between DIEP and Muscle-Sparing Free TRAM Flaps in Breast Reconstruction: A Single Surgeon's Recent Experience.”1 In this article, he discusses free flap management and factors influencing outcome. The points he raises are all very valuable for any microsurgeon and, in particular, for the starting microsurgeon, whether performing breast reconstruction or any other type of free flap surgery. In particular, it is important to keep a critical eye on one's own work by continuously auditing one's results. Our Taiwan unit, like Dr. Nahabedian, does not use any preoperative imaging other than Doppler imaging of the perforators, nor do we use any perioperative perfusion imaging. Postoperatively, we monitor our flaps only clinically and are of the opinion that early exploration is the key to high salvage success rates. In addition to Dr. Nahabedian's views, we would also like to add the need to defer raising a second free flap following complete flap loss. At this particular time point, the microvascular endothelium is likely to be affected by hypoxia-induced inflammatory mediators, free radicals, and growth factors,2 which could lead to a second free flap failure. For this reason, we advise waiting for at least 2 to 3 weeks before raising a second flap or using a different nearby recipient vessel. Should the situation occur where immediate coverage is of the essence, such as exposed bone in lower limb injuries or an exposed carotid artery in head and neck defects, we advise using free flaps supplied by cross-leg vessels3 or distant pedicled flaps (such as a pedicled colon flap), respectively. Anita A. Liem, M.R.C.S., F.R.C.S.(Plast.) Hung-Chi Chen, M.H.A., M.D. Department of Plastic Surgery China Medical University Hospital China Medical University Taichung, Taiwan, Republic of China