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DOI: 10.1055/a-2616-4861
Fortuitous Forty-Year Follow-Up of a Family's Free Flaps-a Fable
Funding None.

In this hustle-bustle futuristic world, today's free flap will be completed yesterday. Microanastomoses are meticulously crafted by a robot. There will be no anastomotic catastrophes on our shift, no take-backs, and no revisions—all done efficiently before the block time is over. Another out-patient surgery is done, soon discharged, often never to be seen again; our provider's responsibility is over and forgotten. After all, we are the microsurgeons—perfectionists (always), persistent (to the nth degree), pragmatic (reasonable), and only occasionally paranoid (usually).[1] But somehow is there a missing link that we the “Doctor” missed, or did we merely avoid?
Just yesterday a young man walked down our hospital corridor to retrieve his mother who had had a simple skin graft. He was last seen face-to-face over 40 years ago. A shotgun blast had blown away his face ([Fig. 1A]). To restore oral competence and appearance, a vascularized bone graft with concomitant significant soft tissues would be essential.[2]


No CD videos were available nor YouTube to guide us step-by-step on October 14, 1984, instead, all must be performed freehand, and still all survived. Only soon thereafter liposuction debulked the cheek adiposity, and scalp skin overgrafting provided a color match. ([Fig. 1B]).
He then vanished, never to be seen again. Taylor et al[3] have since reported their 40-year experience without any specific patient longevity regarding mandible reconstruction. Just now here was our own 40+ follow-up in the hallway to prove the point ([Fig. 1C, D])—a responsible adult, his family secure, and a professional—a lawyer—for some, a perfect ending!
As always there is more to a story. The mother who had worried so much about her young son remained in our community, with frequent scalp skin cancers until eventually her skull became exposed a decade ago ([Fig. 2A]). She knew well the ins and outs of a free flap informed consent ([Fig. 2B]). Following all the operative steps as had her son was never a concern ([Fig. 2C]). She routinely still visits us for any advice we can give her and her family. And fortuitously this last time her son came north to chaperone.


Today our approach would be different—from super thin flaps for coverage, functioning facial muscle transfers, osteointegration for dental rehabilitation, virtual surgical planning including computer-assisted surgery with a three-component surgical template system[4] or CAD/CAM[5] to precisely cut our bone graft now as a unicortical approach would undoubtedly have resulted in a more superior result. We just did not know the future, yet for us more important was this doctor-patient relationship, nay doctor-family relationship, we did build over four decades. This was not the typical brief encounter of today's universe, but a family connection who so long have trusted us, just because we knew a little about microsurgery.
Publication History
Received: 09 April 2025
Accepted: 12 May 2025
Article published online:
06 June 2025
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References
- 1 Hallock GG. The four P's that make a microsurgeon: perfectionist, pragmatist, persistent, and paranoid. J Reconstr Microsurg 2013; 29 (07) 425-426
- 2 Taylor GI. Reconstruction of the mandible with free composite iliac bone grafts. Ann Plast Surg 1982; 9 (05) 361-376
- 3 Taylor GI, Corlett RJ, Ashton MW. The evolution of free vascularized bone transfer: a 40-year experience. Plast Reconstr Surg 2016; 137 (04) 1292-1305
- 4 Zheng C, Xu X, Jiang T. et al. Deep circumflex iliac artery flap reconstruction in Brown Class I defect of the mandible using a three-component surgical template system. Plast Reconstr Surg 2024; 153 (01) 203-214
- 5 Hilven PH, Vranckx JJ. The Iliac crest osteomuscular flap for bony reconstruction: beast or beauty? A reassessment of the value and donor site morbidity in the CAD/CAM Era. J Reconstr Microsurg 2021; 37 (08) 671-681