As with any technique, there are disadvantages. One of the primary disadvantages of microvascular surgery is that it continues to be a technically challenging technique that requires expertise and experience. There is no debate about this issue, and it is clear that continuing surgical experience elevates the expertise and success rate. It is doubtful that the surgeon who occasionally performs microvascular surgery can achieve the proficiency of one who regularly makes use of these techniques. There is also no question that the surgeon who regularly performs tissue transfer techniques with the regional flaps also improves proficiency and success, although this is probably less impacted by frequency of utilization with the pedicled muscu-locutaneous flaps than it is for microvascular surgery.

Although not totally established, many would state that free flaps add operative time compared with some of the alternative tissue-transferring techniques.9 In addition, most free flap transfers are performed by a second operative team which is not necessary for reconstructions involving regional flaps.

Another potential disadvantage is that free flaps are often dependent on donor vessels that are within the field of treatment, whether that be surgery or radiation therapy. Both therapeutic modalities, whether performed before, during, or after the free flap transfer, have the potential to have an adverse impact on the flap's success or failure. Once again, this is in distinction to the regional flaps that are not reliant on donor vessels within the treated area. Free flaps are also limited more than the regional flaps by the patient's comorbid conditions. Any health problems that can affect the blood vessels have to be


viewed as a concern and possibly a contraindication for the use of microvascular surgery. Therefore, conditions such as diabetes mellitus or atherosclerosis, or both, can become relative, or even absolute contraindications to free flap transfer. The presence of such conditions, however, is not a contraindication to the use of regional flaps.

Another potential disadvantage is the reality that the failure of a free flap oftentimes results in total loss of the tissue that has been transferred. Once again, this differs from the regional flaps where partial failure can occur which does not always result in the need for another operation to transfer tissue.

Unfortunately, many of the advantages and disadvantages cited are based on opinions from experienced reconstructive surgeons, rather than facts. As a result, there continues to be a wide array of unresolved issues regarding which reconstructive technique is most appropriate for a given situation.

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