Etiology and Management of Intraoperative Free Flap Failure

BACKGROUND: Intraoperative free flap failure necessitates prompt intraoperative decision-making on alternative reconstructive strategies. In this study, we investigate the etiology and management of intraoperative flap loss. METHODS: Retrospective review between 2010 and 2024 at 6 institutions. RESULTS: There were 7423 free flaps performed with 46 instances of intraoperative flap failure (0.62%). The most common recipient subsite was oral cavity (27/46, 57%). Anterolateral thigh (ALT) was the most common flap type to fail (18/46, 39%), followed by the fibula (15/46, 32%). The most common reasons for total failure were clotting without observable vessel abnormality (12/35, 34.3%), poor quality perforator (11/35, 31.4%), and vessel spasm or intimal abnormality leading to clotting (8/35, 22.9%). The most common acute management was converting to an additional free flap intraoperatively (28/46, 60.9%). CONCLUSIONS: Flap failure intraoperatively is rare. The majority of cases were acutely managed with an additional flap to provide defect coverage.