What Happens After the Free Flap? Evaluation of Aesthetic and Functional Elective Revisions.

[BACKGROUND] Microvascular free flap reconstruction of a defect, as a single-stage procedure, does not always achieve the desired functional and esthetic result. Revisions may be necessary to achieve ideal contour, symmetry, and suspension of soft tissues, or to support dental rehabilitation.

[PURPOSE] The study purpose was to estimate the incidence and identify factors associated with elective free flap revisions.

[STUDY DESIGN, SETTING, SAMPLE] A retrospective cohort study of subjects who underwent free flap reconstruction was conducted to characterize the rate of elective free flap revision surgery. The study included subjects aged >18 years, who underwent head and neck microvascular free flap surgery for any etiology, and both primary and secondary reconstructions, between 2014 and 2021. Subjects were excluded if they had incomplete records.

[PREDICTOR VARIABLE] The predictor variable was composed of a set of variables, grouped into the following categories: subject demographic data, medical history, disease etiology, anatomical site, and postoperative complications.

[MAIN OUTCOME VARIABLE] The outcome variable was time to elective revision surgery measured as months from the date of the initial operation to date of elective revision surgery. Elective revision surgery was defined as a procedure to enhance esthetics or function, which directly modifies the original surgical site, not including procedures to correct a complication, treat the original disease process, or emergencies.

[COVARIATES] Not applicable.

[ANALYSES] Kaplan-Meier method was used to analyze the data, with P value < .05. Risk factors for elective revisions were analyzed with Cox hazard ratio.

[RESULTS] The sample was composed of 377 subjects who underwent free flap surgery, with a mean age of 55.9 ± 15.9 years. Of these, 67% were male and 33% female, and 62 had an elective revision surgery (16.4%), with median follow-up period of 17 months (interquartile range 9 to 28). In the Cox regression model, only type of free flap was associated with an elective revision (P < .05), where radial forearm had the lowest association with elective revision, and fasciocutaneous, latissimus dorsi, and scapula flaps had the highest.

[CONCLUSION AND RELEVANCE] Achieving basic wound coverage with free flaps can be a challenge; however, surgeons should prepare patients for the potential need for functional and esthetic revisions after free flap surgery to improve patient quality of life.