Introduction:
Incidence of perioperative free flap compromise is low with successful salvage in up to 70%.  When the flap is compromised a second time, the value of intervening is unknown.  We assessed the outcomes of a second revascularization attempts for compromised free flaps.

Methods: Multi-institutional retrospective chart review 2000-2020. Of 3,510 flaps, 77 successfully salvaged once, became compromised a second time and underwent attempted salvage. Outcomes were analyzed

Results: Surgical indication: malignancy 80%, other 10.1%, osteoradionecrosis 8.9%.  Reconstructive site: oral cavity 48%, mandible 11%, other 9.0%, oropharynx 8.9%, scalp 8.9%, maxilla 8.9%, larynx 5.4%.  Flap types requiring second revision: RFFF 29%, fibula 26%, ALT 22%, scapula 9.1%, latissimus dorsi 6.5%, other 6.5%.  Cause of initial flap compromise: venous congestion 46%, arterial thrombosis 30%, other 24%.  Cause of secondary flap compromise: recurrent arterial thrombosis 47%, recurrent venous congestion 35%. Other 18%.  Heparin administered to 43% of patients after first successful salvage with 92% on heparin during second flap compromise.  64% of patients were on heparin after second salvage, they demonstrated a 57% survival rate versus patients not on heparin 43%, flap survival p=0.52.  Flap outcomes following second salvage: 66% partial or total necrosis, 34% survived.  Flap type did not impact survival after second salvage attempt.

Conclusions:  Second salvage surgeries successfully perfused 34% of flaps.  There was no correlation noted for the type of flap used and survival. Post-operative heparin did not appear to increase flap survival. Second salvage flap surgery may be valuable in patients with limited reconstructive options.