The effect of learning curve on flap selection, re-exploration, and salvage rates in free flaps; A retrospective analysis of 155 cases.

The purpose of this study is to report our experience and learning curve in avoiding complications at both the recipient and donor sites as well in choosing the best flap for different anatomic locations. For this purpose 155 free flaps done between October 2005 and August 2012 were retrospectively examined. Patient demographics, flap types, etiology, re-exploration indications, timing of the re-explorations, and salvage rates were documented. In the first 60 cases, our re-exploration rate was 26.7% (16 flaps), and the rate decreased to 15.0% for the second 60 flaps (9 flaps). In correlation with this decrease, in the last 35 cases, only three flaps were re-explored (8.6%). This decrease in re-exploration rates over time was statistically significant (P = 0.021). Re-exploration rates for axial and perforator flaps were 14.6% and 22.7%, respectively. Salvage rates were 76.9% in axial flaps and 53.3% in perforator flaps. The total success rate for axial flaps was 95.5% and for perforator flaps was 89.4%. Besides, re-exploration rates were higher with lower salvage rates in perforator flaps compared to axial flaps causing lower overall success rates in the former group. The mean time of re-explorations was 21.4 hours. Salvage rates were significantly higher in re-explorations done within the first 12 hours after the initial surgery than in re-explorations done after 12 hours (83.3% vs. 47.3%) (P = 0.040). We can conclude that axial flaps have a steeper learning curve and are safer options for the inexperienced reconstructive micro-surgeons until they have adequate experience with the perforator dissection.