The indications for free flaps have been more or less clarified; however, the course of reconstruction after the failure of a free flap remains undetermined. Is it better to insist on one's initial choice, or should surgeons downgrade their reconstructive goals? To establish a preliminary guideline, this study was designed to retrospectively analyze the outcome of failed free-tissue transfers performed in the authors hospital. Over the past 8 years (1990 through 1997), 3361 head and neck and extremity reconstructions were performed by free-tissue transfers, excluding toe transplantations. Among these reconstructions, 1235 flaps (36.7 percent) were transferred to the head and neck region, and 2126 flaps (63.3 percent) to the extremities. A total of 101 failures (3.0 percent total plus the partial failure rate) were encountered. Forty-two failures occurred in the head and neck region, and 59 in the extremities. Evaluation of the cases revealed that one of three following approaches to handling the failure was taken: (1) a second free-tissue transfer; (2) a regional flap transfer; or (3) conservative management with debridement, wound care, and subsequent closure by secondary intention, whether by local flaps or skin grafting. In the head and neck region, 17 second free flaps (40 percent) and 15 regional flaps (36 percent) were transferred to salvage the reconstruction, whereas conservative management was undertaken in the remaining 10 cases (24 percent). In the extremities, 37 failures were treated conservatively (63 percent) in addition to 17 second free flaps (29 percent) and three regional flaps (5 percent) used to salvage the failed reconstruction. Two cases underwent amputation (3 percent). The average time elapsed between the failure and second free-tissue transfer was 12 days (range, 2 to 60 days) in the head and neck region and 18 days (range, 2 to 56 days) in the extremities. In a total of 34 second free-tissue transfers at both localizations, there were only three failures (9 percent). However, in the head and neck region, seven of the regional flaps transferred (47 percent) and four cases that were conservatively treated (40 percent) either failed or developed complications that lengthened the reconstruction period because of additional procedures. Six other free-tissue transfers had to be performed to manage these complicated cases. Conservative management was quite successful in the extremities; most patients' wounds healed, although more than one skin-graft procedure was required in 10 patients (27 percent). In conclusion, a second free-tissue transfer is, in general, a relatively more reliable and more effective procedure for the treatment of flap failure in the head and neck region, as well as failed vascularized bone flaps in the reconstruction of the extremities. Conservative treatment may be a simple and valid alternative to second (free) flaps for soft-tissue coverage in extremities with partial and even total losses.

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Major replantation of a traction avulsion amputation is undertaken with the goal of not only the reestablishment of circulation, but also functional outcome. This type of amputation is characterized by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. Between 1985 and 1998, 27 cases were referred for secondary reconstruction following amputation of the upper extremity involving both arm and forearm. Replantation was performed by at least 12 qualified plastic surgeons using different approaches and management, resulting in different outcomes. Initial replantation management significantly affects the later reconstruction. For comparing studies and prognostic implications, the authors propose a new classification according to the level of injury to muscles and innervated nerves: type I, amputation at or close to the musculotendinous aponeurosis with muscles remaining essentially intact; type II, amputation within the muscle bellies but with the proximal muscles still innervated; type III, amputation involving the motor nerve or neuromuscular junction, thereby causing total loss of muscle function; and type IV, amputation through the joint; i.e., disarticulation of the elbow or shoulder joint. Some patients required further reconstruction for functional restoration after replantation, but some did not. Through this retrospective study based on the proposed classification system, prospective guidelines for the management of different types of traction avulsion amputation are provided, including the value of replantation, length of bone shortening, primary or delayed muscle or nerve repair, necessity of fasciotomy, timing for using free tissue transfer for wound coverage, and the role of functioning free muscle transplantation for late reconstruction. The final functional outcome can also be anticipated prospectively through this classification system.