Does “the More,the Merrier” Apply to the Free Flap Learning Curve? A Ten-Year Retrospective Review from an Emerging Single Institution

Abstract

Introduction: Microvascular reconstruction demands specialized and additional training beyond residency. This study investigates the free flap learning curve at a newly established microsurgery center by analyzing free flap viability rate over 10 years. Methods: A retrospective review of free flap procedures performed between 2014 and 2024 by a single microsurgeon at a National Referral Hospital, Indonesia, was performed to assess free flap viability rates, flap types, and the relationships between specific flap choices and defect locations. The correlation between cumulative flap procedures and flap viability was also analyzed. Statistical analyses, including bivariate and correlation tests, were conducted using SPSS v24. Results: A total of 700 free flap procedures were performed, with a female predominance (51.4%) and patient age of 39 (3-98) years. Sixteen different flaps were utilized, with the most employed being ALT (35.3%), FFF (39%), RFFF (12.6%), LD (3.2%), and DIEP (7.1%). The majority of reconstructions addressed head and neck defects (82.4%). The overall flap viability rate was 91.57%, with specific rates of 87.9% for ALT, 95.2% for FFF, 96.6% for RFFF, and 81% for LD. Chi-square analysis demonstrated significant differences in viability among flap types, particularly ALT and FFF. A negative correlation between procedure volume and flap viability was observed, which weakened after 100 procedures, transitioned to moderate until 300 procedures, became weak until 600 procedures, and uncorrelated entirely thereafter. Conclusions: An emerging microsurgery center will achieve stability after 200 free flap procedures, while prioritizing RFFF and LD flaps as basic or lifeboat options is crucial.