The superiority of a free flap in many clinical situations is unparalleled
and, fortunately, initial failure rates have become almost nonexistent. Nev
ertheless, failures do occur, and then often an attempt at a second free fl
ap transfer is the only worthy alternative for the same reason. In the auth
or's experience during the past two decades, a second attempt was indicated
after the failure of 19 free flaps. There were two distinct groups. Intrao
perative failure was recognized for eight flaps and a second free flap was
attempted immediately, with a 50% success rate, The rest were redone on a d
elayed basis, with 63.7% successful-a rate that was not statistically diffe
rent from the first group, There were eight second failures (42.1%) overall
. The need for vein grafts was the only notable factor associated with a hi
gher risk for second flap failure (seven of eight failed second flaps), The
ultimate fate of failed flaps was dismal, in that three required limb ampu
tations and two have had unstable wounds for more than 15 years, This morbi
dity vindicated the difficult decision to undertake a second free flap atte
mpt, which never can be taken lightly, Because successful flaps avoided the
se problems, an aggressive approach is emphasized, including an immediate s
econd free flap attempt if conditions are favorable.