Psychological Sequelae and Support for Microsurgeons After Free Flap Failure

Background: Free tissue transfer is the standard for complex reconstruction, yet flap failure remains an inevitable reality of microsurgical practice. Beyond patient impact, these events can profoundly affect surgeons through psychological, physical, and professional sequelae. Comprehensive data on prevalence, risk factors, and support systems specific to microsurgeons remain limited. Methods: Following IRB approval, a 15-item REDCap survey was distributed to American Society for Reconstructive Microsurgery members. The survey assessed demographics, flap experience, psychological and physical symptoms following flap loss, symptom duration and impact, coping strategies, available institutional support, and desired support. Statistical analyses included descriptive statistics, Fisher's exact test, Spearman correlation, and logistic regression. Free-text responses underwent thematic content analysis. Results: Eighty-two microsurgeons completed the survey (63.4% male, 36.6% female; mean 12.2 years in practice). 67.1% experienced guilt, 61.0% fear of future poor outcomes, 58.5% difficulty sleeping, and 56.1% anxiety and questioning of surgical ability. While most experienced short-term symptoms, 17.1% reported prolonged duration (several months or longer). Female-identifying surgeons experienced prolonged symptoms significantly more often than male-identifying surgeons (30.0% vs. 9.6%, p=0.031). Having ≤5 microsurgical colleagues was associated with prolonged symptoms (27.3% vs. 5.3%, p=0.009). The most common coping strategy was discussing events with colleagues (72.8%). A substantial gap existed between available and desired support: only 25.9% had access to counseling services, while 51.9% desired peer support programs. Conclusion: Psychological sequelae after flap loss are nearly universal among microsurgeons, with female-identifying surgeons and those in smaller practices particularly vulnerable. Institutions and microsurgical societies should develop structured, psychologically safe support systems to improve surgeon well-being, promote professional sustainability, and strengthen a culture of reflection and learning.