The fate of the failed second-attempt free flap.

The superiority of a free flap in many clinical situations is unparalleled and, fortunately, initial failure rates have become almost nonexistent. Nevertheless, failures do occur, and then often an attempt at a second free flap transfer is the only worthy alternative for the same reason. In the author's experience during the past two decades, a second attempt was indicated after the failure of 19 free flaps. There were two distinct groups. Intraoperative failure was recognized for eight flaps and a second free flap was attempted immediately, with a 50% success rate. The rest were redone on a delayed basis, with 63.7% successful-a rate that was not statistically different from the first group. There were eight second failures (42.1%) overall. The need for vein grafts was the only notable factor associated with a higher risk for second flap failure (seven of eight failed second flaps). The ultimate fate of failed flaps was dismal, in that three required limb amputations and two have had unstable wounds for more than 15 years. This morbidity vindicated the difficult decision to undertake a second free flap attempt, which never can be taken lightly. Because successful flaps avoided these problems, an aggressive approach is emphasized, including an immediate second free flap attempt if conditions are favorable.