Invited Discussion

These authors present their experience with 57 free flap transfers carried out in a well-organized unit, performed by senior surgeons or trainees under the control of senior surgeons, and they have tried to identify the parameters influencing outcomes.

First, Dr. Kelly and colleagues have encountered the same percentage of success when anastomoses were performed by trainees. That finding is not really surprising, since a strict control of trainees can result in as efficient a procedure as that performed by a senior surgeon. However, when approaching a parameter of mean ischemia times ranging from 86 to 102 minutes, this seems rather longer than what can normally be expected. Indeed, an arterial or venous anastomosis should not take more than 10 to 15 minutes. If the procedure is done with a one- or two-team approach, and if the flap is separated only when the recipient vessels have been correctly dissected and their patency judged adequate, nothing can explain such extended mean ischemia times except for the insufficient experience of the trainees. If a thrombosis occurs during the postoperative period, the second warm ischemia time could add a deleterious effect to the first one, and chances for saving a flap could theoretically be jeopardized. In our experience, this is why saving any ischemic time is important.

Second, the authors mention that perioperative systemic heparin or dextran given under unexpected and difficult circumstances was always followed by an uneventful outcome. If this is true, why did they not provide this prophylactic antithrombotic treatment to all patients?

Most of their free flaps were used in head and neck reconstructions (37). It is therefore not surprising that partial or total failures (8) were more numerous than those encountered at other recipient sites. Even so, free tissue transfers to the head and neck are usually followed by a statistically significant higher success rate than those performed in the lower extremity, where only an 80 percent success rate can be expected. This is not the experience of the authors, who have observed a 100 percent success rate in lower limb reconstruction.

When the parameter of radiotherapy was approached, no deleterious effect of this adjuvant therapy was noted. But the authors do not mention the timing relative to the free flap procedure. The effects of radiotherapy are exacerbated as time passes, since it can be responsible for vessel sclerosis and postoperative thrombosis.

Finally, the very low overall postoperative complication rate of 15.2 percent (6.7 percent complete flap failure vs. 8.5 percent partial failure) is quite remarkable. However, as mentioned previously, this study deals with the experience of only one team, and their findings and conclusions are not necessarily shared by every one. But that is also true in any surgical field.