RECONSTRUCTIVE Timing of Presentation of the First Signs of Vascular Compromise Dictates the Salvage Outcome of Free Flap Transfers Kuang-Te Chen, M.D. Samir Mardini, M.D. David Chwei-Chin Chuang, M.D. Chih-Hung Lin, M.D. Ming-Huei Cheng, M.D. Yu-Te Lin, M.D. Wei-Chao Huang, M.D. Chung-Kan Tsao, M.D. Fu-Chan Wei, M.D. Taoyuan, Taiwan Background: Microsurgical free tissue transfer has become a reliable technique. Nevertheless, 5 to 25 percent of transferred flaps require re-exploration due to circulatory compromise. This study was conducted to evaluate the timing of occurrence of flap compromise following free tissue transfer, and its correlation with salvage outcome. Methods: Between January of 2002 and June of 2003, 1142 free flap procedures were performed and 113 flaps (9.9 percent) received re-exploration due to compromise. All patients were cared for in the microsurgical intensive care unit for 5 days. Through a retrospective review, timing of presentation of compro- mise was identified and correlated with salvage outcome. Results: Seventy-two flaps (63.7 percent) were completely salvaged and 23 (20.4 percent) were partially salvaged. Eighteen flaps (15.9 percent) failed com- pletely. Ninety-three flaps (82.3 percent) presented with circulatory compro- mise within 24 hours; 108 (95.6 percent) presented with circulatory compromise within 72 hours, and 92 flaps (85.2 percent) were salvaged within this period. One out of the three flaps presenting with compromise 1 week postoperatively was salvaged. Flaps presenting with compromise upon admission to the micro- surgical intensive care unit had significantly lower complete salvage rates as compared with those without immediate abnormal signs (40.9 percent versus 69.2 percent, p = 0.01). Conclusions: The time of presentation of flap compromise is a significant predictor of flap salvage outcome. Intensive flap monitoring at a special mi- crosurgical intensive care unit by well-trained nurses and surgeons allows for early detection of vascular compromise, which leads to better outcomes. (Plast. Reconstr. Surg. 120: 187, 2007.) F ree tissue transfer has become an important reconstructive option for a variety of de- fects. The success rate of free tissue transfer at the present time is reported to be in the range of 91 percent to 99 percent in large series from major microsurgical centers. 1–6 However, 5 per- cent to 25 percent of free flaps require re- exploration due to circulatory compromise. 5–12 The flap salvage rate in several series has been reported to be in the range of 33 percent to 81 percent, 3,9,10 and it could be influenced, to a significant degree, by the timing of detection of circulatory compromise and the timing of re- exploration. Early detection of circulatory com- promise allows for earlier re-exploration of the vascular anastomoses and for potential salvage of a failing flap before an irreversible no-reflow phenomenon occurs. Continued critical evaluation of flap outcomes is essential for the advancement of the field of microsurgery. As the percentage of free tissue transfer in most centers is relatively low, and the percentage of flap compromise requiring re- exploration is very low, it is difficult to gather large numbers of patients who have undergone free flap surgery followed by flap re-exploration due to compromise. Unfortunately, flap compro- From the Department of Surgery, Saint Paul’s Hospital, and the Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and University. Received for publication October 7, 2005; accepted March 23, 2006. Presented at the Annual Meeting of the American Society for Reconstructive Microsurgery, in Fajardo, Puerto Rico, Jan- uary 15 through 18, 2005. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000264077.07779.50 www.PRSJournal.com 187