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Page 2 of 13 Myers et al. Plast Aesthet Res 2023;10:38 https://dx.doi.org/10.20517/2347-9264.2022.150

[3-9]
rates of success, estimated at > 96% in high-volume centers ; however, the consequences of flap failure can
[10]
still be devastating to patients and surgeons . Specific patient and non-patient related factors have been
identified that can PREDISPOSE PATIENTS to a greater risk for flap failures. Patient factors include
hypercoagulable conditions, prior radiotherapy, and obesity [11,12] . Beyond patient factors, flap failures can
also be IMPACTED by flap and perforator choices, and technical problems in all phases of the procedure
including the flap harvest, microvascular anastomoses, flap inset and postoperative incidents.

Breast reconstruction decision making following flap loss is a uniquely individualized process, contingent
upon considerations of safety, patient goals and preferences, as well as the surgeon’s skillset. The aims of
reconstruction salvage after flap loss are to excise unhealthy tissue and restore a breast mound of normal
[13]
anatomical shape . There are well-described management algorithms for other types of failed
microvascular reconstruction, such as for lower extremity or head and neck reconstructions , but there
[14]
[15]
is a paucity of information on this topic in breast reconstruction. We present an algorithm as a possible
approach to managing flap failures [Figure 1]. We also review the management of breast reconstruction
following free flap failure, including the role of hematologic investigation, anticoagulation
recommendations and secondary or tertiary reconstruction with both prosthetic and autologous techniques.

PATIENT COUNSELING IN THE SETTING OF FLAP FAILURE
However difficult the conversation may be, clear and thoughtful patient communication is imperative in the
event of a flap failure. Complications from surgery have a significant impact on quality of life, including
mental health conditions . This can be particularly devastating to women undergoing secondary
[16]
autologous reconstruction after failed alloplastic reconstruction, as there are potential feelings of losing the
[17]
breast twice . Having a complete preoperative discussion to set realistic expectations is the first step. This
is true for not only complete flap loss, but the range of breast complications as well as those that involve the
donor site. Informing patients of the likelihood of adverse events is necessary while also discussing
individual factors that place them at higher risk, such as obesity or hypercoagulability. It can be helpful to
discuss flap loss rates reported in the literature and, if available, failure rates at the specific treating
institution. It is also beneficial to educate patients on the secondary (or tertiary) options for reconstruction,
such as implant-based, and additional autologous reconstruction options. While knowledge of the
possibility of flap failure can cause some concern for patients, most are placed at ease knowing that alternate
options exist in the unlikely event of flap failure and that they will be supported and guided through each
step of the process. In patients who do not wish to undergo further reconstructive surgery, the option of an
[18]
aesthetic flat closure should be offered . In fact, Lineaweaver et al. found that nearly half of patients opted
to forgo further breast reconstruction following their flap failure .
[19]
Higgins et al. interviewed women who experienced complete flap loss for breast reconstruction to better
understand the psychosocial detriment of this outcome . Not surprisingly, women expressed difficulty
[10]
with body image and coping with emotions after flap loss. Another notable theme that emerged, however,
was the impact the relationship with the surgeon had on the patient’s overall experience. The study showed
that women who reported a strong relationship with their surgeon also reported easier acceptance and
coping with their flap loss. Similarly, patients who felt unsupported or dismissed by their surgeon expressed
[10]
greater emotional distress and questioning after flap loss . Many women suggested increasing emotional
support resources in the setting of flap failure, including social workers and psychiatrists. Given that a
multidisciplinary approach results in better outcomes in breast reconstruction a similar holistic approach
[20]
to the management of the patient who has experienced a flap loss may be beneficial. Li et al. found that with
dedicated nursing attention, surgical breast cancer patients reported lower depression scores and greater
[21]
satisfaction postoperatively . Even with ancillary support, the surgeon is ultimately responsible for the