1. Flap Failure (it happens to us all)

2. Flap failure
How to
Prevent it
Recognise it
Treat it

3. Prevention of flap failure
Patient factors
Local
General
‘Surgeon’ factors
Technique
Team
Equipment
Anaesthetic factors
Post-op care
timing

4. Patient factors Local Radiotherapy Infection Inflammation
Khouri PRS 1998 survey of 23 surgeons and all their flap failures over 6 months 4.1% failure v 9.4%
Mullholland PRS 1993 >300 cases with 2/3 in irradiated tissue 3.5% v 2.8% but noted higher failure rate with increased time from DXR to surgery
Recommendations – pre DXR or as soon after as possible and anastamosis outside zone if possible
Infection
Inflammation

5. Surgeon factors Technique End to end or end to side?
Practise like your livelihood depended on it
Initial large number in simulated setting to overcome the learning curve
Ongoing practise – at least once a fortnight

8. Surgeon factors Technique
Meticulous attention to detail at every stage from
choice of flap,
size of flap,
choice of vessels
Size discrepancy
Pedicle length
Pedicle position – don’t relax too quickly after the anastamosis is finished or your pedicle will become kinked
Don’t be in a rush to finish
Any doubt – REDO IT

9. Surgeon factors Team Equipment Anaesthetic Define roles
Scrub staff training and cues
Flap time off and on
Equipment
Anaesthetic
What do you need from the anaesthetic team to make sure this is a safe procedure for the patient and the flap

10. Awake free flaps
52 osteomyelitis patients All combined orthoplastic reconstruction with free flap Central neuraxial anaesthesia (spinal / epidural) with continuous titrated IV sedation. Mean procedure duration 508 min ( ) All free flaps harvested from lower limbs All operations for chronic osteomyelitis No flap failures No ITU admissions 5 converted to GA during the procedure due to failure of the epidural

11. ‘Surgeon’ Factors Fearless debridement Post-op care Timing
Position of patient in recovery
Creating the perfect environment for a flap
Timing
The earlier the better
If late presentation don’t delay but ensure fearless debridement
Fearless debridement

12. Recognise it Team One to one care in PACU No place for denial
Use all methods of monitoring available to you and act immediately if any of them show signs of impending failure.
5% return to theatre of which 50% are salvaged
3% overall failure rate

13. Treat it Return to theatre Lift flap and check for haematoma
Flow check anastamosis
ANY DOUBT REDO