In the 1970's work by Buncke, Daniel and Taylor, O'Brien and others helped establish free tissue transfer as a powerful technique for the management of reconstructive problems. During this first decade of experience free tissue transfer was considered a complex and difficult form of reconstruction and occupied the very top rung of the reconstructive ladder. In this conceptual position free tissue transfer was used when other flaps would not suffice and only in major medical centers with microsurgical teams. During the second decade of our experience the equipment used was refined and improved and a wide variety of instruments, sutures and monitoring aids were developed. Anatomic studies defined the vascular territories of the body and numerous donor sites and flap types were identified and developed providing the reconstructive microsurgeon with an extensive selection of reliable options for addressing the most complex defects. Over the last decade techniques have been further refined. Optical loupes have largely supplanted the more cumbersome operating microscope in many cases, the cost effectiveness of this technique has been established, flap survival rates of 96% to 99% have become standard and these procedures have even begun to move into the comunity hospital setting as the number of surgeons comfortable with microsurgical techniques has increased. Despite these advances there remains hesitancy on the part of many surgeons in private practice to include free tissue transfer in their reconstructive armamentarium. Among the reasons for this are the time required, concerns over the possibility of anastomotic thrombosis, the potential need for urgent re-exploration and the specter of complete flap loss. This report presents the results in a series of 100 patients who underwent free tissue reconstruction in a single surgeon private practice setting. Over a period of 11 years 100 patients underwent free tissue reconstruction with a total of 106 free flaps. The most common indication was immediate and delayed breast reconstruction followed by lower extremity trauma and chronic wound management. Flaps used included the free TRAM (53%), the latissimus dorsi (22%), the rectus abdominus (13%), the fibula(3%) and the lateral arm (2%). Average patient age was 46 years with a range of 17 - 80 years. Average operating time was 8 1/2 hours. There were three total flap losses and three partial losses. One patient underwent re-exploration during the first week after surgery. Overall free flap survival was 97% and the three cases of partial loss were revised with reconstructive success. In the hands of any surgeon who is well-trained in and comfortable with free tissue transfer techniques this option need no longer occupy the highest rung of the reconstructive ladder. We have arrived at the point in the evolution of free tissue transfer where, even in the private practice setting, the free flap can be regarded as the flap of choice in managing many complex reconstructive problems.
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