The effect of learning curve on flap selection, re‐exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases

Abstract

The purpose of this study is to report our experience and learning curve in avoiding complications at both the recipient and donor sites as well in choosing the best flap for different anatomic locations. For this purpose 155 free flaps done between October 2005 and August 2012 were retrospectively examined. Patient demographics, flap types, etiology, re-exploration indications, timing of the re-explorations, and salvage rates were documented. In the first 60 cases, our re-exploration rate was 26.7% (16 flaps), and the rate decreased to 15.0% for the second 60 flaps (9 flaps). In correlation with this decrease, in the last 35 cases, only three flaps were re-explored (8.6%). This decrease in re-exploration rates over time was statistically significant (P = 0.021). Re-exploration rates for axial and perforator flaps were 14.6% and 22.7%, respectively. Salvage rates were 76.9% in axial flaps and 53.3% in perforator flaps. The total success rate for axial flaps was 95.5% and for perforator flaps was 89.4%. Besides, re-exploration rates were higher with lower salvage rates in perforator flaps compared to axial flaps causing lower overall success rates in the former group. The mean time of re-explorations was 21.4 hours. Salvage rates were significantly higher in re-explorations done within the first 12 hours after the initial surgery than in re-explorations done after 12 hours (83.3% vs. 47.3%) (P = 0.040). We can conclude that axial flaps have a steeper learning curve and are safer options for the inexperienced reconstructive micro-surgeons until they have adequate experience with the perforator dissection.

Free Flap Reconstruction Experience and Outcomes at a Low‐Volume Institution over 20 Years

“…It is known that microvascular surgeons have better outcomes with the higher number of cases they have performed 11,12 . This has also been shown with a statistically significant reduced reexploration rate from a center’s first 60 to the following 60 flaps 13 . A study at the Boston Eye and Ear Infirmary showed an improved failure rate from 13% during the first year with 29 flaps to a 2.5% failure rate 10 years later with 81 flaps 4 .…”

Cumulative Sum Analysis of the Learning Curve of Free Flap Reconstruction in Head and Neck Cancer Patients

“…Previous studies have used the flap failure rate, salvage rate, and complication rate to evaluate the learning curve. However, none have used CUSUM analysis to determine the learning curve in head and neck free-flap reconstruction surgery [16][17][18][19]. In addition to operation time, we tried to define the phases by risk-adjusted CUSUM analysis for flap failure.…”

A Structured, Microsurgical Training Curriculum Improves the Outcome in Lower Extremity Reconstruction Free Flap Residency Training: The Ludwigshafen Concept

“…6,7 Furthermore, in microsurgery, efforts on implementing standardized protocols for anticoagulation or objective tools for flap monitoring can also reduce postoperative complications for free tissue transfer. 10 Partial flap loss can be avoided by standardized intraoperative application of Indocyanine-Green Fluorescence Angiography or the Continuous Video-Rate Laser Speckle Imaging, and safely allows adapting the flap design to the defect as well as to the angiosom. 11,12 Unfortunately, this formal and consistent approach does not exist for continuous microsurgical education of the PGY.…”