Figure 1
Clinical data for 35 free flaps (29 patients)
| Operations (No. flaps) | Injury cause (No. flaps) | Indications for surgery (No. flaps) |
|---|---|---|
| LD flap (5) | Traffic accident (21) | Soft tissue defect leg/foot (8) |
| Toe transfer (8) | Blast injury (3) | Soft tissue defect wrist/forearm (4) |
| Gracilis FFMT (7) | Electrical burn (2) | Soft tissue defect hand/finger (4) |
| Fibular graft (5) | Machine | Bone defect: tibia (3), femur (1), humerus (1) |
| Lateral arm (2) | Industrial (8) | Thumb loss (6) |
| Radial forearm (2) | Tumor resection (1) | Finger joint loss (2) |
| ALT flap (4) | Post-arm replantation (1) | |
| Venous-free flap (2) |
Factors associated with outcome of free flap surgery
| Factor | Group A: major complications Group A: free flap with major complications that required additional surgery (Categories 1 and 2) | Group B: minor/no complication Group B: free flap with minor or no complications that did not require additional surgery (Categories 3 and 4) |
|---|---|---|
| 1. Mean age (y) | 25.5 | 32 |
| 2. Sex (male:female) | 15:3 | 14:3 |
| 3. Injury cause (No. of flaps) | MCA (10), blast (1), electrical burn (2), industrial accident (4), tumor resection (1) | MCA (11), blast (2), industrial accident (3) |
| 4. Location of defect | ||
| Soft tissue upper extremity | 6 | 3 |
| Soft tissue lower extremity | 5 | 3 |
| Bone defect | 4 [tibia (3), femur (1)] | 1 (humerus) |
| Hand/finger | 2 | 5 |
| 5. Time to surgery (No. of flaps) | ||
| <14 days | 4 | 6 |
| 14–90 days* Indicates significant difference between Groups A and B (P = 0.028) | 9 | 2 |
| >90 days | 5 | 9 |
| 6. Type of flap (No. of flaps) | ||
| Soft tissue transfer | 9 [LD (5), ALT (2), lateral arm (1), venous flap (2)] | 5 [radial forearm (2), ALT (2), lateral arm (1)] |
| Fibular graft transfer | 4 | 1 |
| Toe to hand transfer | 2 | 6 |
| Gracilis free muscle transfer | 2 | 5 |
| 7. Artery:vein ratio (No. of flaps) | ||
| 1:1 | 13 | 9 |
| >1:1 | 5 | 8 |
| 8. Vessel anastomosis (No. of flaps) | ||
| End-to-end | 13 | 14 |
| End-to-side | 5 | 3 |
Complications and secondary operations after free flap surgery
| Complications | No. of flaps (N = 35) | % | Notes |
|---|---|---|---|
| Flap necrosis | 16 | 46 | |
| Total | 7 | 20 | |
| Partial | 9 | 26 | |
| Acute flap ischemia | 6 | 17 | 5/6 flaps had total flap loss |
| Wound swelling | 3 | 9 | Required STSG |
| Bleeding | 2 | 6 | |
| Infection | 5 | 15 | 2/5 flaps had total flap loss |
| Implant failure | 1 | 3 | |
| Donor-site wound dehiscence (toe) | 1 | 3 | |
| Rhabdomyolysis | 1 | 3 | |
| Sciatic nerve injury | 1 | 3 | |
| Total flaps with complications | 26 | 74 | |
| Total flaps without complications | 9 | 26 | |
| Secondary operations | |||
| Pedicle revision | 3 | 9 | 2/3 flaps had total flap loss |
| Second flap coverage | 7 | 20 | |
| Free flap | 3 | 9 | Coverage total flap loss |
| Local | 3 | 9 | Coverage partial flap loss |
| Regional | 1 | 3 | Groin flap |
| Debridement + antibiotic bead | 2 | 6 | |
| Debridement + VAC | 1 | 2.9 | |
| Amputation | 2 | 5.7 | 1 BK, 1 finger |
| STSG | 6 | 17.1 | |
| Stop bleeding in operation room | 1 | 2.9 | |
| Implant revision | 1 | 2.9 | Revision tibial plate |
| Total flaps requiring secondary surgery | 18 | 51.4 | |
| Total flaps not requiring secondary surgery | 17 | 48.6 |
Detail of complications and secondary operations following free flap surgery (Categories 1, 2, and 3)
| Category 1 | n | Operation | Indications for surgery | Detail of complications | Secondary procedures |
|---|---|---|---|---|---|
| LD flap | Exposed plate ankle | Flap ischemia (day 1) | Radial forearm flap | ||
| Total flap loss | 7 | LD flap | Soft tissue loss at tibia | Flap ischemia (day 1) | Radial forearm flap |
| Venous-free flap | Soft tissue loss at middle finger | Flap ischemia (day 1) | Finger amputation | ||
| Compartment with | Flap ischemia (day 1) | Debride + antibiotic bead insert | |||
| Lateral arm flap | exposed distal radius plate | LD flap | |||
| Blast injury with | Flap ischemia (day 2) | Pedicle revision | |||
| 2nd toe transfer | bilateral thumb loss | Groin flap | |||
| LD flap | Degloving skin at leg | Infection (day 21) | BK amputation | ||
| Compartment syndrome with | Infection (day 28) | Pedicle revision | |||
| ALT flap | exposed tibial plate | Debride and vacuum dressing | |||
| Category 2 | n | Operation | Indications for surgery | Detail of complications | Secondary procedures |
| 2nd toe transfer | Crash injury with finger joint loss | Soft tissue defect | Posterior Interosseous flap | ||
| Partial flap | 6/11 | Fibular free flap | Segmental tibial bone defect | Soft tissue defect exposed tibia | Gastrocnemius flap |
| necrosis | Fibular free flap | Segmental tibial bone defect | Skin necrosis, exposed tibia | Rotational flap | |
| Venous free flap | Electrical burn with defect at finger | Partial skin loss | Debridement + STSG | ||
| ALT flap | Degloved hand | Partial flap necrosis | Debridement + STSG | ||
| Fibular free flap | Tibial bone loss | Partial skin necrosis | Debridement + STSG | ||
| 2nd toe transfer | Crush injury with finger joint loss | Swelling | STSG | ||
| Postoperative swelling | 3/11 | Gracilis FFMT | Post-arm replantation | Swelling | STSG |
| Gracilis flap | Fx both bone leg with plate exposed | Swelling | STSG | ||
| Acute flap ischemia | 1 | Fibula free flap | Post-tumor resection | Flap ischemia (postop day 1) | Revision anastomosis |
| Postoperative bleeding | 1 | LD flap | Soft tissue defect forearm | Postoperative bleeding (day 4) | Explore pedicle + stop bleeding |
| Infection | 1 | LD flap | Compartment exposed radius plate | Chronic osteomyelitis | Antibiotic bead insertion |
| implant failure | 1 | Fibular free flap | Segmental tibial bone defect | Loosening screw fixation | ORIF with locking plate tibia |
| Category 3 | n | Operations | Indications for surgery | Detail of complications | Secondary procedures |
| Gracilis FFMT | Brachial plexus injury—total arm | Partial flap necrosis | No | ||
| Partial flap necrosis | 3/8 | ALT flap | Fx forearm (S/P fail lateral arm flap) | Tip of flap necrosis | No |
| Fibular free flap | AVN + COM proximal humerus | Superficial skin loss | No | ||
| Wound drainage | 2/8 | Radial forearm | Fx both bone left leg | Sinus drainage with COM | No |
| ALT flap | Soft tissue loss lateral side of foot | Postop sinus drainage | No | ||
| Bleeding | 1 | Radial forearm | Fx ankle with fail LD flap | Postop bleeding | No |
| Donor wound dehiscence | 1 | Wrap around | Failed thumb replantation | Wound at big toe | No |
| Rhabdomyolysis | 1 | 2nd toe transfer | Bilateral thumb loss | No | |
| Sciatic nerve injury | 1 | 2nd toe transfer | Bilateral thumb loss | No | |