gms | German Medical Science

Objectives/Interrogation: To investigate the causes and classification of the congestion or stasis free perforator flap.

Methods: 187 compromised flaps were found in 1236 patients receiving the free perforator flap transfer, and divided into four types based on the size, the characteristics and the progress of ecchymosis which showing on the surface: Type 1 had no ecchymosis. Type 2 had slowly enlarged ecchymosis in a small area. Low perfusion was type 3. Type 4 had a high flap tension with larger ecchymosis size and deeper color in a short time. According to this classification, there were 37 cases in type 1, 68 in type 2, 39 in type 3, 43 in type 4. The conservative treatments,such as dressing change, removal of stitches, bleeding with small incisions, local flap massage and thrombolysis were applied to 109 cases including 37 in type 1, 68 in type 2, 4 in type 3. The other 78 cases underwent surgical revision including 35 in type 3 and 43 in type 4. After exploration, 35 in type 4 (44.9%, 35/78) were venous obstruction, 29 (37.2%, 29/78) in type 3 due to artery occlusion, and 14 (17.9%, 14/78) consisting of 8 in type 4 and 6 in type 3 were both of arterial and venous obstruction.

Results and Conclusions: After conservative treatment, 94 (86.2%, 94/109) flaps survived, 13 (12%, 13/109) were partial necrosis, and 2 (1.8%, 2/109) complete necrosis. After surgical revision, 29 cases (82.9%, 29/35) were venous obstruction, 17 (58.6%, 17/29) were arterial cause and 8 (57.1%, 8/14) because of both vessel problem survived finally. Partial necrosis were 4 (11.4%, 4/35), 3 (10.4%, 3/29) and 4 (28.6%, 4/14) respectively. Complete necrosis were 2 (5.7% 2/35), 9 (31%, 9/29) and 2 (14.3%, 2/14). 132 patients (70.6%, 132/187) were followed up from 3 to 21 months. The texture and color of the fully salvaged flap is similar to the non-crisis flap, but it looks like tougher and darker in the partial salvaged flap. Conclusion The stasis and congestion of venous blood in the flap always led to flap necrosis, which may result from either low artery perfusion or poor venous backflow. The clinical classification is objective and easy to observe, which contribute to an early accurate diagnosis and treatment for the compromised flap. The conservative methods are mainly used to save the crisis flap in type 1 or 2, and for the cases in type 3 or 4, the surgical revision is a preferred choice.