Alexander Fiedler, Nesrin Ibrahim, Maria Füth, Tatjana Katharina Fricke, Sonja Verena Schmidt, Felix Reinkemeier, Flemming Puscz, Yonca Steubing, Marcus Lehnhardt, Christoph Wallner, Marius Drysch
In this cohort, pre-incision delays (arrival and OR preparation (prep)) were not associated with failure. Signals instead pointed toward patient and anesthetic complexity and technically challenging salvage procedures. Thus, quality improvement attempts should prioritize rapid recognition/decision pathways and anesthesia-surgery coordination rather than focusing solely on logistics between ward and incision.
BACKGROUND: Timely re-exploration is critical when free flaps show vascular compromise. However, the relative contribution of modifiable pre-incision delays after surgery registration and opportunities to shorten time to re-exploration within the recognition-to-incision pathway after flap ischaemia recognition remain uncertain. This study aimed to evaluate whether pre-incision delays are associated with free-flap salvage failure and to identify potential workflow targets for quality improvement.
METHODS: We conducted a retrospective, single-center analysis of 113 free-flap revision surgeries performed over the past 6 years. Time from registration to incision was partitioned into arrival latency (ward to operating room (OR)), anesthesia lead time, operating-room preparation, and surgery lead time. Operative duration was assessed separately. The primary outcome was salvage versus failure (total loss).
RESULTS: Total flap loss occurred in 14.2% of re-explorations. Median registration-to-incision time was similar between salvage and failure (78 min vs. 77 min, ±30 min, p = 0.89). Arrival latency (19 min vs. 20 min, ±17 min, p = 0.89), operating-room preparation (25 min vs. 22 min, ±12 min, p = 0.66) and door to incision (52 min vs. 53 min, ±23.5 min, p = 0.5) showed no difference. Failures trended toward longer anesthesia lead time (28 vs. 38 min, ±16.7 min, p = 0.48) and operative duration (83 vs. 109 min, ±75 min, p = 0.12). Night-time operations were not associated with failure, but weekend cases showed a higher proportion of failure (25% vs. 12%, p = 0.06, trend only).
CONCLUSIONS: In this cohort, pre-incision delays (arrival and OR preparation (prep)) were not associated with failure. Signals instead pointed toward patient and anesthetic complexity and technically challenging salvage procedures. Thus, quality improvement attempts should prioritize rapid recognition/decision pathways and anesthesia-surgery coordination rather than focusing solely on logistics between ward and incision.