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Chen et al. Plast Aesthet Res 2023;10:24 https://dx.doi.org/10.20517/2347-9264.2022.136 Page 17 of 26

Special Considerations
Management of ischemia-reperfusion injury
Ischemia reperfusion injury is an important consideration for microsurgeons as tissue damage can persist
well after the flow is re-established. Restoration of blood flow to a flap promotes the release of
proinflammatory cytokines and reactive oxygen species (ROS), leading to tissue inflammation, coagulation,
and necrosis. This cascade can ultimately result in partial or complete flap loss and fat necrosis as well as
adverse patient outcomes and healthcare costs . The most dreaded outcome in this scenario is the “no-
[149]
reflow” phenomenon, whereby tissue damage is so severe that the flap does not perfuse despite the patency
of the anastomosis. Several factors have been implicated in an increased risk for ischemia-reperfusion
[150]
injury, including tissue type, surgical technique, temperature, and ischemia time .
Given the pathogenesis of ischemia-reperfusion injury, immunomodulators, antioxidants, and
anticoagulants have each been proposed as potential therapeutics. While these therapies have shown
promise in animal models, the data on their utility in human patients is unclear [151-157] . For example, while
statins have theoretical anti-inflammatory and antioxidant activity, Koolen et al. and van den Heuvel et al.
did not find such benefits in breast microsurgery [158,159] . Additionally, in a retrospective study, Coriddi et al.
found no significant difference in lost vs salvaged flaps and patients who received intra/postoperative
[103]
steroids or therapeutic anticoagulation for ischemia-reperfusion injury prophylaxis . Ultimately, more
research in this area, including randomized controlled clinical trials, is needed before further therapeutic
recommendations are made.

When flap salvage is not feasible
When considering approaches to tertiary reconstruction, Baumeister et al. recommend the following steps:
a sensitive psychosocial approach to the patient and family, an analysis of the cause of the first flap failure,
reconsideration of the need for vascularized free tissue transfer, and a change in microsurgical strategy .
[160]
An investigation into the cause of flap failure should include careful consideration of the following: the
preoperative preparations, the recipient vessels and anastomosis, the patient’s risk for hypercoagulability
and thrombosis, the postoperative care, and the surgeon’s individual expertise. Baumeister et al. provide a
thorough checklist to consider in [Table 2] .
[160]

Hamdi et al. broadly classify the causes of flap failure into “technical” (anastomosis errors, pedicle kinking,
anatomical variations, and quality and choice of recipient vessels and/or perforator of the nourishing
pedicle) and “nontechnical” (one or more hypercoagulability disorders) etiologies . In the event of
[161]
“nontechnical” flap failure, alternative options, including a pedicled flap, should be strongly considered,
given the high risk of another failure. However, for patients whose free flap failed due to a presumed
technical error, another free flap may be reasonably considered.

In the rare case of non-salvageable total flap failure, an in-depth and empathetic discussion with the patient
and family is essential. A description of possible alternative forms of breast reconstruction will provide
necessary reassurance. We recommend debriding all non-viable tissue in the operating room soon after the
diagnosis is assured. The mastectomy skin flaps should be closed if possible. If the skin flaps cannot be
closed primarily, a negative pressure therapy dressing may be used temporarily. In a case of partial flap
failure, debridement of the non-viable tissue should take place only after demarcation. The timing of future
efforts at breast reconstruction should be dictated by the patient’s preferences, psychosocial needs, and the
state of the wound after flap debridement.