Every microsurgeon knows that there is, inherent in what we do, a risk of failure. We, as surgeons, accept this, but for the patient, this is a potentially devastating complication which has left them with scars, pain, and nothing else to show for the ordeal.
So what happens when free flaps fail?
I (like most microsurgeons I presume) have spentsleepl the odd sleepless night worrying about this after a complex procedure. I think about the cases that have come to define the way in which I practice. I think about the failures and the near-misses. Those cases, and the lessons I have learnt, are invaluable to me but each one has come at a cost to a patient.
Fortunately, I (and my patients) have had to suffer only very few failures. Some of us are less lucky. Even the best surgeons lose flaps. I won’t go into the reasons that free tissue transfer and microsurgery can go wrong (it can get complex), but just like any procedure, this type of surgery has risks. Any surgery may run the risk of infection, or wound healing problems, or a bleeding. If microsurgery goes wrong however, then flaps fail. The opportunity for an ideal reconstruction is lost.
It is generally accepted that the risk of a flap like a DIEP flap failing is around 0.5%-2%. This means that anywhere between 1 in 200 to 1 in 50 free flaps will fail. Whether there is an identifiable reason for this is immaterial. These are the real numbers and the risk is unavoidable.
“every microsurgeon accepts that there is an inherent risk of failure in performing a DIEP flap”
Is it worth the risk? I think so. The potential benefits can far outweigh the risks. But ultimately, each patient must make a choice for herself.
Of course, that doesn’t answer the question of what we do in this worst-case-scenario?
There are actually several options. In the event of the flap not surviving and having to be removed from the breast, I tell my patients there are 3 common “life boats”.
In the first instance, we can place a tissue expander and then close the skin with sutures. This tissue expander is partially filled with air or water, and can subsequently be inflated further to preserve and stretch the skin of the breast and prevent skin shrinkage. In time this expander can be replaced with an implant, or a second free flap procedure can be performed down the track. I don't love this option, but it can at least preserve the breast skin envelope in an immediate reconstruction.
In the second scenario, an attempt can be made to immediately perform another free flap from an alternative site to reconstruct the breast. I typically don’t feel that this is the wisest choice, particularly if there is an unknown reason for the first flap failing, but in some cases it may be reasonable.
In the third scenario, the breast can be reconstructed with a latissimus dorsi flap taken from the back (with or without a small implant). The latissimus muscle is a large muscle with an amazingly robust blood supply. Skin from the back (the resulting scar sits almost horizontally in the line of the bra strap) can be moved with the muscle to create the circular disk (much as a DIEP flap does) which will subsequently allow the nipple to be reconstructed.
Which of these 3 options we try depends entirely on the patient. The situation can be challenging though, and making a decision like this may seem impossible: when a flap fails, the patient is often tired (having had sleepless nights since the original procedure), emotionally and physically drained, and wanting nothing more than to go home. I have seen women at the end of their tether asking for a failed DIEP flap to be removed and nothing further done apart from having the wound closed, because at that point it seems like the simplest solution.
This is precisely why a conversation about the risks and benefits of any surgical procedure, and especially complex surgery like a DIEP flap, is vital. And it includes talking about what happens when it all goes wrong.
It’s a difficult but essential discussion to have.