Suspected Free Flap Compromise
Change in flap colour, turgor, refill, temperature, pinprick bleeding or Doppler signal
All Pathways
Plastic SurgeryEmergency
Free Flap Failure Recognition and Salvage
Free Flap Failure Recognition and Salvage: Suspected Free Flap Compromise → Compare With Normal Flap and Last Check → Any Change: Call the Plastic Surge...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Action Compare With Normal Flap and Last Check
Normal: colour as at end of surgery, warm, soft, capillary refill 2-3 s, audible arterial Doppler
- Checks: commonly hourly for 24-48 h, then 2-hourly to 72 h, then per unit protocol
- Most pedicle thromboses occur in the first 48 h; salvage falls sharply after day 2
- Buried flap: implantable Doppler or other monitor
03Warning Any Change: Call the Plastic Surgery Registrar Now
Flap compromise is a surgical emergency. Inform the consultant; the surgeon decides on return to theatre.
- Signs: pale or dusky, cool, slow or very brisk refill, tense or swollen, change in pinprick bleeding, Doppler signal change or loss
- Look for haematoma: swelling, bruising, high drain output
- Do not wait for the next scheduled check
04Warning Neck Swelling or Stridor: Airway First
After head and neck surgery, a neck haematoma can block the airway. Call the MET team and the anaesthetist now.
- Signs: stridor, difficult breathing, fast neck swelling, difficulty swallowing, rising early warning score
- Sit the patient up; high-flow oxygen; tracheostomy: check the tube is in place and patent
- Airway threatened: open the neck wound at the bedside (cut sutures, open skin and muscle, pack); do not wait for theatre
05Decision Type of Compromise?
Venous: dusky, swollen, brisk refill. Arterial: pale, cool, no Doppler signal. Mixed, haematoma or unsure. All types: return to theatre now.
- Venous
06Warning Venous Congestion: Return to Theatre Now
Outflow problem (most common): dusky or purple, swollen, tense, brisk refill (under 2 s), rapid dark blood on pinprick
- Causes: venous thrombus, kinking, compression, haematoma
- Flaps tolerate venous occlusion worse than arterial occlusion: there is no safe waiting time
- An arterial Doppler signal can persist: it does not exclude venous congestion
07Action All Types: Book Theatre Now; Bedside Measures Meanwhile
Bedside measures must not delay theatre. Tracheostomy ties: keep the tube held or re-secured before you loosen them; never leave it unsecured.
- Loosen tight dressings and ties; surgeon to release tight sutures if needed
- Check pedicle position: relieve kinking or compression; adjust head or limb position
- Keep warm; correct hypotension, hypovolaemia and hypothermia
- Prepare for theatre: fasting status, consent, group and hold, anaesthetist
08Decision Re-exploration Appropriate? (Surgeon Decision)
Default is yes: return to theatre now. No only when the surgeon decides revision is not appropriate.
- If Yes
09Action Theatre: Explore Pedicle and Anastomoses
As soon as possible: salvaged flaps were re-explored sooner than failed flaps
- Evacuate haematoma; correct kinks, twists and compression
- Thrombus: thrombectomy (Fogarty catheter or milking) and revise the anastomosis
- Vein graft if the pedicle is short; add a second venous outflow if needed
- Vasospasm: topical vasodilator (for example papaverine). Thrombolysis into the flap: surgeon decision
10Action Drugs at and After Re-exploration: Surgeon Decision
Never delay theatre for drug treatment
- Heparin: surgeon decision, usually at re-exploration; IV heparin increases haematoma risk
- Thrombosis again after heparin (often day 5-10): check platelets for HIT; haematology advice
- Aspirin or other prophylaxis: per unit protocol; no regimen is proven to reduce flap loss
- Dextran 40: not advised; heart failure, pulmonary oedema and anaphylaxis risk, no flap benefit
11Decision Flow Restored in Theatre?
Surgeon assessment after revision
- If Yes
12End Flow Restored: Restart Close Monitoring
Restart hourly flap checks; re-thrombosis can occur. Any change: call the surgeon now.
If No13Decision Flap Still Compromised: Arterial Inflow Present?
Surgeon assessment: after failed revision, or when re-exploration is not appropriate
- If Yes
14Action Venous Congestion With Arterial Inflow: Consider Leeches (Surgeon Decision)
After failed revision, or when re-exploration is not appropriate. Not for arterial insufficiency. Do not use if the patient refuses blood transfusion or antibiotics.
- Do not use with bleeding disorder, severe anaemia, hypotension or sepsis
- Anaemia, anticoagulant, immunosuppressant or pregnancy: not advised; surgeon to weigh against flap loss
- Aeromonas prophylaxis for the whole course, per local protocol or infectious diseases advice
- Check haemoglobin often; group and hold; transfusion is often needed
15Decision Venous Congestion Resolving With Leeches?
Surgeon reviews the flap often. Reapply leeches as needed until venous outflow recovers.
- If Yes
16End Congestion Resolved: Stop Leeches, Continue Checks
Continue flap checks and haemoglobin checks. Complete Aeromonas prophylaxis per local protocol.
If No17End Flap Not Viable: Flap Loss
Surgeon decision. Stop leeches. Debride and plan further reconstruction
- Debride necrotic tissue; wound care (dressings or negative pressure)
- Options: second free flap, pedicled or local flap, skin graft
- Timing of reconstruction: consultant decision
If No18End No Arterial Inflow: Flap Loss
Surgeon decision. Leeches do not help. Debride and plan further reconstruction: second free flap, pedicled or local flap, or skin graft.
If No19Action Re-exploration Not Appropriate: Surgeon Plans Care Without Theatre
Surgeon assesses arterial inflow. Venous congestion with arterial inflow: leeches may be used. No arterial inflow: flap loss.
- Path rejoins step 13Shared downstream outcome
- Arterial
20Warning Arterial Insufficiency: Return to Theatre Now
Inflow problem: pale, cool, slow (over 3 s) or absent refill, little or no pinprick bleeding, no arterial Doppler
- Causes: arterial thrombus, kink, compression, vasospasm, haematoma
- Usually in the first 24 h; salvage rate is lower than for venous thrombosis
- Do not wait for bedside measures to work
- Path rejoins step 07Shared downstream outcome
- Mixed, haematoma or unsure
21Warning Mixed, Haematoma or Unsure: Treat as Compromise
Surgeon to assess now; if in doubt, explore in theatre. Neck haematoma: airway first.
- Haematoma can compress the pedicle: evacuate it in theatre
- Combined arterial and venous thrombosis: return to theatre now
- Path rejoins step 07Shared downstream outcome
Guideline Source
Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review. J Reconstr Microsurg 2021;37(3):300-308
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- No formal guideline exists: content is from systematic reviews and large cohort studies. Follow the unit microsurgery protocol.
- Buried flaps cannot be seen: rely on an implantable Doppler or other monitor.
- Antithrombotic and leech regimens vary by unit; no antithrombotic regimen has been shown to reduce flap loss.
- Salvage success depends on time to re-exploration and operative expertise.
Contraindicated Populations
Pedicled or local flaps and digit replantation: management differs; not covered by this pathway
Applicable Regions
AUUSEU
AU: Leech supply and Aeromonas prophylaxis follow the local hospital protocol.
Version 2Next review: 2027-09-30
Next steps
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Related Resources
Frequently Asked Questions
What is the Free Flap Failure Recognition and Salvage?
The Free Flap Failure Recognition and Salvage is a emergency clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review. J Reconstr Microsurg 2021;37(3):300-308.
What guideline is the Free Flap Failure Recognition and Salvage based on?
This algorithm is based on Shen AY et al. Free Flap Monitoring, Salvage, and Failure Timing: A Systematic Review. J Reconstr Microsurg 2021;37(3):300-308 (DOI: 10.1055/s-0040-1722182).
What are the limitations of the Free Flap Failure Recognition and Salvage?
Known limitations include: No formal guideline exists: content is from systematic reviews and large cohort studies. Follow the unit microsurgery protocol.; Buried flaps cannot be seen: rely on an implantable Doppler or other monitor.; Antithrombotic and leech regimens vary by unit; no antithrombotic regimen has been shown to reduce flap loss.; Salvage success depends on time to re-exploration and operative expertise.. Individual patient factors may require deviation from these recommendations.
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