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Methods: All reports describing free flap survival after postoperative vascular occlusion without revision of the microsurgical anastomoses were reviewed. The type of flap, recipient site, vessel of occlusion, postoperative occlusion day, and non-surgical treatment were analyzed.
Results: 19 reports (24 flaps) detailed 11 arterial, 5 venous, and 8 simultaneous arterial and venous (vascular pedicle) occlusions in 11 head and neck, 9 lower extremity, 1 breast, and 2 upper extremity free tissue transfers. 9 flaps survived without any intervention, 6 survived with conservative therapy (anticoagulation or leeches), and 9 survived despite pedicle ligation. The range of critical day of occlusion did not differ significantly among vessel types—6 to 19 days for arterial, 4 to 35 days for venous, and 8.5 to 35 days for vascular pedicle occlusions. The range of critical occlusion time that resulted in survival of jejunum, muscle, bone, and skin flaps was 12 to 35, 4 to 35, 7 to 12, and 4 to 19 days respectively. 75% of arterial occlusions occurred between 6 and 14.5 days. 75% of vascular pedicle occlusions occurred between 8.5 and 18.5 days. When compared to jejunal flaps, skin flaps survived after earlier postoperative occlusion. (20.8 vs. 10.5 days; p-value 0.01)
Conclusion: This analysis suggests that flaps compromised by vascular occlusion or pedicle ligation may still survive without surgical intervention when the event occurs after a minimum critical time period. Flap survival is more probable when arterial occlusion or pedicle ligation occurs after postoperative day 11, but this minimum critical period may be as low as 6 days for arterial occlusion.